The Primary Care Prescribing Psychologist Model: Medical Provider Ratings of the Safety, Impact and Utility of Prescribing Psychology in a Primary Care Setting

Family medicine providers at a large family medicine clinic were surveyed regarding their impression of the impact, utility and safety of the Primary Care Prescribing Psychologist (PCPP) model in which a prescribing psychologist is embedded in a primary care clinic. This article describes the model and provides indications of its strengths and weaknesses as reported by medical providers who have utilized the model for the past 2 years. A brief history of prescribing psychology and the challenges surrounding granting psychologists the authority to prescribe psychotropic medication is summarized. Results indicate family medicine providers agree that having a prescribing psychologist embedded in the family medicine clinic is helpful to their practice, safe for patients, convenient for providers and for patients, and improves patient care. Potential benefits of integrating prescribing psychology into primary care are considered and directions for future research are discussed.     

Talking about medication

With the increasing use of psychotropic medication concomitant with psychoanalysis, attention must be given to the challenges created by complaints of medication side effects. When confronted with these side effects, analysts may experience specific, uniquely actualized countertransference anxieties that can prompt the abandonment of transference analysis. Particular countertransference fantasies that arise in combined treatments are examined, as are the reasons for the analyst's suspension of curiosity and openness and its clinical consequences. In these situations, effective analysis requires the analyst to be "bilingual," to hold in mind both the analytic and the pharmacological model.     

Thoughts on medication and psychoanalysis: a lay analyst's view

The issues involved in split analytic treatments-where a second person manages the patient's medication-are discussed from the point of view of a developmentalist and lay analyst. Case material is presented to illustrate the interplay of medication with other elements of the psychoanalytic situation. Medication and its effects, it is argued, should be accorded no special status apart from other interventions and enactments in an analysis. Some see medication and psychoanalysis as parallel processes, two separate and unintegrated theoretical systems, and recommend shifting back and forth between models of the mind or becoming "bilingual"; against this view, it is argued that anything the analyst does will affect the patient's thoughts, fantasies, and even physiology in individual ways, and only attention to analytic material can reveal what an intervention means in a specific case. Success in split treatment depends on a collaborative therapeutic alliance among patient, analyst, and consultant. Because there is as yet no theory that bridges psychoanalysis and psychopharmacology, analysts must talk of these matters as incompletely synthesized and regard them as part of the challenges that make psychoanalysis the exciting, impossible profession it is.     

Medication as object

People experience and treat medication as though it were a person: in other words, as an object. Among the many symbolic meanings attributed to medication, this sort of personification, or object representation, is a meaning that medication is uniquely positioned to contain and convey: imbued with intentionality and influence, medication moves beyond the sphere of static, iconic representation and enters the changeable, dynamic object world of action, aim, and agency. Unlike more generic or stereotypic meanings, object representations attributed to medication may reflect the patient's specific dynamics and object relations. These representations are many and mutable, and take on shifting and overlapping forms that evolve with the analytic process. Medication may represent a third person within the framework of an analytic treatment, expanding the analytic dyad into a triad and offering new transference paradigms to explore. The defensive displacement of transferential qualities and attitudes, or split-off parts thereof, from the analyst onto medication can serve as a powerful resistance to the awareness of the transference to the analyst. Clinical examples illustrate the utility and importance of the analysis of medication as object, for both patient and analyst, with particular attention to the transference.     

Striving Towards Empowerment and Medication Adherence (STEP-AD): A Tailored Cognitive Behavioral Treatment Approach for Black Women Living With HIV

In the U.S. Black women with HIV face numerous psychosocial challenges, particularly trauma, racism, HIV-related discrimination, and gender role expectations, that are associated with negative HIV health outcomes and low medical treatment adherence. Yet many of these factors are unaddressed in traditional cognitive behavioral approaches. This study presents a case series of a tailored cognitive behavioral treatment approach for Black women living with HIV. Striving Towards EmPowerment and Medication Adherence (STEP-AD) is a 10-session treatment aimed at improving medication adherence for Black women with HIV by combining established cognitive behavioral strategies for trauma symptom reduction, strategies for coping with race- and HIV-related discrimination, gender empowerment, problem-solving techniques for medication adherence, and resilient coping. A case series study of five Black women with HIV was conducted to evaluate the preliminary acceptability and feasibility of the treatment and illustrate the approach. Findings support the potential promise of this treatment in helping to improve HIV medication adherence and decrease trauma symptoms. Areas for refinement in the treatment as well as structural barriers (e.g., housing) in the lives of the women that impacted their ability to fully benefit from the treatment are also noted.     

On Psychodynamic Meanings of Psychiatric Treatment: Discussion of “From Dyad to Triad”

Dr. Bar-Haim has covered vast territory in her contribution “From Dyad to Triad: On Psychodynamic Meanings of Psychiatric Treatment,” (this issue) and I welcome the opportunity to offer my thoughts on her contribution and this important topic more generally. The issues touched upon include the various meanings of psychiatric treatment for patient and therapist; factors that impact compliance; resistances to suggesting medication consultation on the part of the therapist; challenges of the prescribing therapist; the role of a “disease” model in mental suffering; the overdetermined meaning of “symptom”; and, most important, recommendations for establishing effective treatment when a treatment triangle exists. I address some of these issues and comment on two clinical vignettes to illustrate my way of thinking.     

Introduction to Panel: When Relatedness is Damaged or Undeveloped: A New Consideration of the Link between Relational Psychoanalysis and the Object Relations Tradition

In this panel, we introduce two new conceptualizations of the analyst’s role and function designed for work with patients outside the reach of customary modes of engagement. Our approaches to the challenges of such patients draw on the insights of object relations theorists but rely on the relational school’s emphasis on the analyst’s subjectivity and differing forms of engagement. We believe that together our approaches contribute to a broadened bandwidth of relational practice.     

Out of nothingness: rhythm and the making of words

Abstract: This contribution describes some aspects of the work with a four‐year‐old autistic child who was treated for many years with four times weekly sessions of psychotherapy. The fluctuations between the symbolic and non‐symbolic use of external objects are described, as well as the ever changing quality of the child's object relations. The rhythmical element in the analysand‐analyst interplay is of great importance: the construction of the temporal shapes (Alvarez) and the modulation of presence and absence are relevant as regards the progressive capacity to name aspects of external reality and subjective experience. From a theoretical point of view, the contributions of both the post‐Jungian, including Michael Fordham, and the post‐Kleinian traditions are outlined. The notions of pre‐conception (Bion) and of archetype (Jung) are immensely helpful in working with autistic children as they actually help the analyst in assuming that some proto‐trace of representational potential is always present in the individual.     

External and internal reality: The impact of the current socio‐economic crisis on the analytic dyad

This paper addresses the impact of the current economic crisis on the psychic functioning of the patient and the analyst, their relationship and collaboration. This intrusion of ‘external reality’ is multidimensional, and thus with multiple meanings. The critical role of the economic factor brings various dimensions of money into play, such as self‐preservation, power as well as aspects of psychosexual development. In addition, the crisis involves symbolic loss of basic ideals such as honesty and social responsibility. Patient and analyst are affected in similar and different ways in their respective roles as well as according to the specific intrapsychic functioning of each. Moreover, unique characteristics of the crisis often create a crisis in the analysis. In order to avoid deformation of the analytic relationship, the analytic dyad must examine and work through the multiple meanings of the crisis as well as the meaning of the impact of the crisis on the analytic relationship for both patient and analyst. This complex transference‐ countertransference interplay poses specific challenges to the analyst. After discussion of these issues, clinical material is presented that demonstrates how they appear in analytic practice today.     

Infertility in the age of technology

Rapid advances in medical and biological technologies are changing the ways we are born, live, and die. Biotechnology is pushing us in our notion of what is possible, and tapping into our most primitive omnipotent fantasies. For the most part these new techniques have not yet been integrated into a shared social consciousness. This paper examines, in a case study of a woman who eventually got pregnant with a donor egg and in a shorter case vignette, how the new technology impacts upon the analytic process. Attention is focused on the permeability of the boundaries between analyst and patient and between fantasy and action. The study shows how analyst and patient, together and often for the first time, must face the difficult moral and ethical issues stimulated by such procedures, as well as the anxieties and underlying fantasies they evoke. It is the uniqueness and the intensity of this experience that permeates boundaries, stimulates emotion in patient and analyst alike, and has the potential to deepen the analytic bond. The study underlines the need for the analyst to be flexible, moving back and forth between interpreting and creating a needed holding environment. Finally, the paper points out the tension between the traditional roles of motherhood, fatherhood, and family and those being created in this high-tech world.     

The Analyst in the Pharmacy

The merging of medication and analysis has been more widely endorsed in recent years. However, the issue of the analyst needing pharmacotherapy and how its use presses on the analytic frame has not been considered. This essay will look at how the analyst's need for medication threads into the structure of treatment. Issues of stigma and shame triggered by medication use are discussed, as well as the treatment consideration of self-disclosure as an intervention. The author offers both objective and subjective data on this subject, and includes a clinical case example to illustrate how self-disclosure of medication status can offer greater degrees of freedom in a patient's analysis.     

Accompaniment in Jazz and Psychoanalysis

The author explores a fundamental role of the analyst as improvisational accompanist. This role requires a dedicated attention to the shared rhythmic dimension of the interaction, a mode of psychoanalytic attention of embodied self-awareness and sensitivity–that is, embodied attunement to the pulse of the interaction. Directed action follows by providing various forms of accompaniment that depend on the nature of the patient’s needs and emotional state. By refining our accompaniment to meet clinical situations and challenges, we enlarge the range of analytic engagement. Using examples from jazz, the way the rhythm section finds the right form of accompaniment to support the soloist’s creativity and unique voice, the analyst similarly accompanies his or her patient, providing a temporal framework, a pulse that affirms emotionally shared states, recognition, differentiation, and creative expression. Various forms of analytic accompaniment include steady and present beat, an unobtrusive and loose presence, an interactive and conversational presence, or disruptive rhythms. From experiences of solid support and recognition, accompaniment can fuel the patient’s improvisations, allowing him to move away from the analyst and create a clearer differentiated voice. As the patient separates, he ventures out into new or difficult territory, the analyst’s presence is there following.     

On gratitude and gratification

Expressions of gratitude from the patient may be regarded by the analyst as a much-needed validation or affirmation of competence. The analyst's need for gratitude may be a relatively silent presence when things are going smoothly or when the analyst's efforts are openly appreciated by the patient. Ungrateful patients, however, are likely to force the analyst to confront his or her unconscious background wish to enact a longed-for mode of relatedness as part of the daily work of psychoanalysis. The analyst's wish for a specific form of object relationship involving a selfless, devoted helper and an appreciative patient who acknowledges having been helped may be thwarted by certain patients at every turn, knowing they are depriving the analyst of a particular form of gratification in their work. For patients of this type, failure may mean success. The implications of this particular form of clinical stalemate are outlined, and a clinical example illustrates some of the challenges encountered in psychoanalytic work with ungrateful patients.     

The Analyst’s Generous Involvement: Recognition and the “Tension of Tenderness”

I define the analyst’s generous involvement as inherent to human encounter and a necessary element of therapeutic process. When the analyst’s generous involvement goes missing, it can be read as a sign of disengagement and disconnection. Using as metaphor H. S. Sullivan’s concept of the “tension of tenderness,” I argue that the analyst’s recognition of a need or affect state in the patient evokes an internal tug constituting the analyst’s need to provide for what has been recognized. I elaborate on what the analyst’s generous involvement is, and what it is not, including countertransference pitfalls and corruptions that may masquerade as generosity. I engage a relational conversation with the radical ethical ideas of Emmanuel Levinas. An extended clinical vignette illustrates the challenges and conflicts entailed in the analyst’s finding an analytically useful form of expressing the tug of generous involvement in the immediate moment.     

Witch-mother is which? The potential role of the analyst in facilitating authentic motherhood

Abstract

This paper explores challenges in the treatment of women suffering from disturbances in maternal identification. A review of the psychoanalytic and developmental literature focuses on the frequent finding of early-onset mother–daughter relational disturbance involving maternal narcissistic fragility and exaggerated dependency needs, intergenerational trauma, and related psychopathology including mutual affect dysregulation. A case example of a young woman with a severe anxiety disorder is presented and discussed to illustrate the challenges to the traditional psychoanalytic technique. This patient avoided pregnancy into her late thirties and entered analysis with feelings of inauthenticity, characterological masochism, and a “secret mission” to unmask the witch recurring in her dreams. Through an elaborate working-through of negative maternal transference, the analyst and patient saw through the birth of the patient’s authentic self, a new approach to her career, her relationships with men, and her anticipation of the birth of a child by the sixth year of treatment. The author posits that psychoanalytic technique benefits from contemporary, attachment, and trauma research that supports the analyst’s playing a more active role in approaching, co-regulating, tolerating, and integrating avoided affects and memory traces that are associated with early-onset relational disturbances worsened by the effects of violence, maltreatment, and loss.     

Infantile Trauma,Therapeutic Impasses and Recovery

Throughout his writings Ferenczi examines the role of the mother–infant relationship in healthy development as well as the difficulties that occur when that relationship is problematic. This paper using Ferenczi and Bion as theoretical background explores the clinical development of impasse in the treatment of hard to reach patients. These patients present special difficulty for analysis because they are not self reflective although they can be addicted to “processing,” which is in lieu of emotional connection. Impasse occurs when the analyst does not detect the mimicry involved in processing. The paper offers the idea of recovery, rather than repair, in that such patients have “gone missing” in infancy. Recovery of lost potential can be found in relationship with the analyst and with significant others.     

Treatment of the older adult: the impact on the psychoanalyst

Work with the elderly challenges analysts in special ways. The author presents clinical material from her practice and from investigative interviews with nine treating analysts who report personal reactions and countertransferences to analytic work with twelve elderly patients. She concludes that the major challenges in work with the elderly come more from the analyst than from the patients. Issues arising from the analyst's unresolved feelings about aging, parents, loss, and death are revived in the treatment of the elderly in an especially intense form. In this paper many aspects of transference are considered, especially those relating to illness, loss, and the problems that flow from identifications of the older analyst with the patient. The affective reverberations in younger and older analysts with regard to the initiation of analytic treatment, the inevitability of moving in and out of real life crises, the sustaining of loss, and, particularly, the impending termination, are presented in the paper.     

加入WTO对我国医药卫生科学研究的影响及对策

中国加入WTO,不仅对我国经济和社会的发展带来机遇和挑战,而且对我们的医药卫生科学研究的发展,产生巨大的影响。这就需要我们采取积极的措施,变压力为动力,加速我国医药卫生科学研究和学科建设的发展。     

The Analyst’s Private Space: Spontaneity,Ritual, Psychotherapeutic Action,and Self-Care

The contemplation, containing, and linking that circulate within the analyst’s private space are positioned as key to states of psychic equivalence (the melding of psychic reality and material reality) and to sustained states of unknowing, which are held to be necessary for analytic work and fantastic spontaneity. These modes of practice are considered as they relate to rituals that promote the analyst’s self care. An account of a psychotherapy with a 5-year-old electively mute girl is offered to illustrate the work undertaken in the analyst’s private space, as he seeks to build and sustain potential space and the possibilities borne through play.