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.     

The Longitudinal Impact of a Family-Based Communication Intervention on Observational and Self-Reports of Sexual Communication

Parents can play a vital role in shaping teenagers’ sexual attitudes, behavior, and contraceptive use through communication, however, less is known about how to modify parent–adolescent communication among youth with mental health problems. The impact of a family-based sexual risk prevention intervention on both observational and self-report of parent–adolescent sexual communication was examined at 12 months among adolescents with mental health problems. Of the 721 parent–adolescent dyads recruited for the study, 167 videotapes of sexual discussions between parents and adolescent were coded for the family-based intervention and 191 videotapes for the active comparison. Longitudinal analyses examined differences between conditions (family-based vs. comparison) in self-reported and observed parent–adolescent sexual discussions and also examined the impact of gender on intervention response. More parent I-statements, healthier parent body language, and fewer adolescent Negative Vocalizations were detected for family-based intervention participants 12 months after participating in the brief intervention (11?h of total intervention time) relative to those in the comparison condition. Parents in the family-based intervention also self-reported better sexual communication at 12 months. The current study provides supporting evidence that a relatively brief family-based intervention was successful at addressing parent–adolescent sexual communication among a mental health sample.     

WHAT IS EFFECTIVE IN PSYCHOANALYTIC PSYCHOTHERAPY? SOME THINGS CHANGE,SOME STAY THE SAME

As a reflection on two roundtable discussions published in the American Journal of Psychoanalysis in 1957 and 1965, the author seeks to provide historical context for what has taken place within the culture, within the profession, and within himself over this period of time. The struggle to define “effectiveness” is addressed and an argument made for the inclusion of empirical research into our work, but with simultaneous appreciation for the difficulty in objectively defining and measuring what takes place within the therapeutic relationship. This difficulty is hypothesized, in part, to be a function of the non-verbal and preverbal experiences of both patient and therapist.     

Contacting a 19 month‐old mute autistic girl: A clinical narrative

Conveying that psychoanalysis offers rich opportunities for the very early treatment of autistic spectrum disorders, this clinical communication unfolds the clinical process of a 19 month‐old ‘shell‐type’ encapsulated mute autistic girl. It details how, in a four‐weekly‐sessions schedule, infant Lila evolved within two years from being emotionally out‐of‐contact to the affective aliveness of oedipal involvement. Following Frances Tustin's emphasis on the analyst's ‘quality of attention’ and Justin Call's advice that in baby–mother interaction the infant is the initiator and the mother is the follower, it is described how the analyst must, amid excruciating non‐response, even‐mindedly sustain her attention in order to meet the child half‐way at those infrequent points where flickers of initiative on her side are adumbrated. This helps attain evanescent ‘moments of contact’ which coalesce later into ‘moments of sharing’, eventually leading to acknowledgment of the analyst's humanness and a receptiveness for to‐and‐fro communication. Thus the ‘primal dialogue’ (Spitz) is reawakened and, by experiencing herself in the mirror of the analyst, the child's sense of I‐ness is reinstated. As evinced by the literature, the mainstream stance rests on systematic early interpretation of the transference, which has in our view strongly deterred progress in the psychoanalytic treatment of autistic spectrum disorders.     

Impact of current grief on memory for past grief in spousal bereavement

This study examined the impact of changes in level of current grief over time on changes in memory for past grief. Following from previous work on the impact of current affective state on memory for past affectively salient events, bereaved individuals who underwent a greater reduction in grief over time were expected to show a similar pattern of changes in memory for past grief. A sample of conjugally bereaved participants completed measures of current grief and memory for past grief at the time of the loss of their spouse at each of the 2, 6, 13, and 30 month post-loss time periods. As predicted, those who reported greater reduction in grief over the course of the study were more likely to remember their past grief as progressively less severe relative to those who underwent less reduction in grief over time. A nonrecursive causal model analysis verified that changes in memory for past grief were explained by changes in current grief. These results were discussed in terms of contemporary reconstructive memory accounts of the effect of affective state on memory.     

Impact of current grief on memory for past grief in spousal bereavement

This study examined the impact of changes in level of current grief over time on changes in memory for past grief. Following from previous work on the impact of current affective state on memory for past affectively salient events, bereaved individuals who underwent a greater reduction in grief over time were expected to show a similar pattern of changes in memory for past grief. A sample of conjugally bereaved participants completed measures of current grief and memory for past grief at the time of the loss of their spouse at each of the 2, 6, 13, and 30 month post-loss time periods. As predicted, those who reported greater reduction in grief over the course of the study were more likely to remember their past grief as progressively less severe relative to those who underwent less reduction in grief over time. A nonrecursive causal model analysis verified that changes in memory for past grief were explained by changes in current grief. These results were discussed in terms of contemporary reconstructive memory accounts of the effect of affective state on memory.     

Factor structure of the mobility inventory for agoraphobia: A validational study with australian samples of agoraphobic patients

This study examines the factor structure of the Mobility Inventory for Agoraphobia and attempts to validate the inventory, using an Australian sample of agoraphobic patients, by comparison with other scales. One hundred twentyfour panic disorder with agoraphobia patients were studied. Factor analysis showed that a two-factor solution was the most suitable both when subjects were accompanied (accompanied condition) and when alone (alone condition). Factor I represented public, crowded, or social situations including department stores, supermarkets, restaurants, theaters, and panics and social gatherings. Factor II reflected enclosed or riding situations such as elevators, parking garages, enclosed spaces, and riding in subways or airplanes. These two factors accounted for 46.6% and 44.3% of the variance on the accompanied condition and the alone condition, respectively. The Mobility Inventory was significantly correlated with the Agoraphobia factor of the Fear Questionnaire and the Social Avoidance and Distress scale. These results indicated that the Mobility Inventory is a valid instrument to measure agoraphobic behavior.