Different origins and meanings of acute acting-out in an inpatient psychotherapeutic setting

In this paper I describe four different sources of acute acting-out behaviour as may be observed in long-term hospitalised patients suffering from severe personality disorders. I hope to demonstrate that acute psychological distress does not happen in a vacuum, but that specific intrapsychic and interpersonal dynamics within the hospital setting are at the root of what appears overtly as nonspecific emotional and behavioural disturbance. I argue that the hospital team's correct insight into the factors underlying acute acting-out is crucial to the implementation of therapeutic interventions aimed to decrease the patient's disturbed state of mind.     

Working with incest survivors

The purpose of this paper is to convey more widely the existence of this kind of specialist group in the NHS. We also wish to show some of the advantages and disadvantages in setting up such a group to other professionals who may be considering the possibility of starting an incest-survivors group. The paper describes the group which ran at the Psychiatric Day Hospital at the Whittington Hospital for forty weeks: how we adopted the group structure; some of the problems we faced; and some of the emotional issues generated in therapists and patients. Conclusions are drawn about the usefulness of such a group.     

Psychoanalysis and the political process

The Political Process is Society's mechanism for debating value systems. The term can also be used to describe a debate in a variety of other settings — subsystems of Society — about value systems. This paper is about the contributions that psychoanalysis, both as a theory and in its various applications, can make to the understanding of the process of debate and its setting. It is also about the implications for our conduct that arise from this understanding.     

When it is not the patient who pays

This paper looks at the question of third-party payments in psychotherapy and psychoanalysis. This is of particular relevance in Holland, where the Dutch government makes substantial payments for psychoanalytic treatment via a state insurance system. The literature concerning third-party payments is reviewed. Freud himself was inconsistent about this matter and cannot therefore be relied on to give a clear guideline. The majority of writers are heavily in favour of ‘personal sacrifice’ and show a strong bias, especially against insurance payments for fees. These arguments are examined in detail and the two main conclusions are explored, namely that (1) certain unconscious conflicts cannot be mobilised where there is external financing, and (2) that the absence of personal sacrifice engenders too much wish-fulfilment. Both these arguments are rejected as being biased and are found not to stand up to detailed scrutiny.

The effects that different types of payment have on the development of the therapeutic situation, and the different types of transference and countertransference problems that each engenders, are explored. There is some speculation as to the reason for the persistence of this view if it is so patently false. Finally there is some consideration of the positive effects third-party payments can have on psychoanalytic practice.     

Manic-depressive psychosis: Psychopathology and individual psychotherapy within a psychodynamic milieu

Manic-depressive patients are not usually regarded by psychiatrists as suitable subjects for psychotherapy, and there are many reasons for this view. Psychological support tends to take the form of helping the patient adjust to his disability, to become more aware of the life situations which may disturb him, of warning symptoms, of the need for appropriate medication, and perhaps to explore the most significant life conflicts. Psychoanalytic psychotherapy aimed at conflict resolution and personality development is widely regarded as impracticable, or ineffectual at best, or, at worst, as a potentially dangerous intervention. Considering the fact that the risk of suicide in the depressive phases may be so great, the problems of containing the disinhibited manic episode so serious, and the social consequences of such episodes so disastrous, it is not surprising that pharmacological control of pathological symptoms is so often regarded as the only therapeutic aim.

This paper is based on an account of a single patient suffering from a severe manic-depressive disorder with schizoid features, and a family history of manic-depressive illness, who was treated with individual intensive psychoanalytic psychotherapy in a context of a psychodynamic psychiatric ward, with encouraging results. Some implications of this experience will be discussed.     

Development of the concepts of transference and counter-transference

SUMMARY

This paper traces the development of the concepts of transference and counter-transference over nearly a hundred years, from the origin of the concepts to current understanding of them. Clinical material will be given to illustrate some of the ideas held today.     

A new look at the vulnerability of puerperal mothers — A clinical study of two inpatient families at the Cassel Hospital

SUMMARY

The paper reviews some previous writings by Dr. Tom Main and Dr. Peter Lomas about the work of the Cassel Hospital with puerperal mothers. It goes on to describe the case histories and treatment of two patients recently treated with their families. The emphasis is on actual material produced in therapy but with reference to other aspects of the much wider treatment structures employed by the Cassel, for example the nursing and the community. Important aspects focussed upon include the essential experience of good mothering in becoming a mother, how closeness to the infantile impulses and urges of a real baby can lead to profound measures of identification and projection, and the effects of motherhood on femininity and sexuality.     

“Hotspots” in trauma memories in the treatment of post-traumatic stress disorder: A replication

“Hotspots” refer to memories of detailed moments of peak emotional distress during a traumatic event. This study investigates hotspot frequency, and the emotions and cognitions contained in hotspots of memory for trauma, to replicate a previous study in this area (Holmes, Grey, & Young, 2005). Participants were patients receiving treatment for post-traumatic stress disorder (PTSD) at a specialist outpatient clinic after experiencing a range of traumatic events. The main finding was that, after fear, the most common emotions reported were anger and sadness. Cognitions related to psychological threat to the self were more common than those related to physical threat.     

Long-term memory for the emotional gist and the emotional essence of an experience

We investigated accuracy in recalling past emotional behaviours and emotionality. Male couples discussed the history of their relationship, and coders rated the extent to which each partner engaged in behaviours such as complimenting or criticising. These ratings were combined into dimensions representing the deeper, emotional essence of that partner's discussion (expressions of We-ness, Fondness, Negativity, and Disappointment). Four years later, participants accurately recalled some of their own and some of their partner's emotional gist-level behaviours, but their answers indicated that they also remembered the emotional essence of the conversation. We conclude that individuals can retain the emotional essence of an experience for a long time, and that they may use this memory to infer, in part, gist-level details of the experience.