The transference neurosis in Freud's writings

This paper reviews the evolution of the concept of transference neurosis in Freud's writings. It suggests that the language in which the concept of the transference neurosis is originally expressed by Freud includes an idea of the analyst as aggressively pursuing the analytic cure by waging a solitary battle against the patient's disease. With the representation of the death drive and the larger role accorded to sadism as its external manifestation in Freud's revised drive theory of 1920, the patient becomes the ally; resistance, in the sense of the conservative forces, not disease, in the sense of libidinal conflict, becomes the enemy. It is thus difficult to speak of a transference neurosis in the circumscribed way Freud originally meant it, and he ceased to use the term after 1926 rather than redefine it to fit his broader perspective. In this broader perspective, relative resolution of conflict replaced radical liberation of the patient from disease. That Freud did not redefine the term does not imply that he discarded it, or that we necessarily should. This paper suggests that Freud implied a functional distinction between transference as transforming agent and transference neurosis as result of that transformation. That distinction defines psychoanalytic cure in terms of the understanding of a symbolic transformation which is, through the transference neurosis, reexperienced as part of the psychoanalytic process.     

Evaluation and diagnosis of sexual abuse of little girls

In recent years, increasing evidence of sexual abuse of children has created a new field of medicolegal inquiry requiring a new expertise. In psychoanalysis, one of our specific tasks is to address the issues of diagnosis and of the pathogenic effect of sexual abuse as it is ultimately reflected in the intrapsychic dynamics of the developing ego. My hypothesis is that it may be possible to determine early in the treatment whether sexual abuse has taken place. The case of a two-and-three-quarters-year-old girl, suspected of having been molested by her father, is presented in depth. The evolution of material confirming the diagnosis is presented by way of documenting evidence of sexual abuse. Issues elaborating the difficulty in making the diagnosis are also explored. Finally, a synthesis of diagnostic considerations useful for arriving at a diagnosis of sexual abuse is presented in the hope that these factors will serve as diagnostic guidelines.     

Is agoraphobia harder to treat? A comparison of agoraphobics' and simple phobics' response to treatment

Agoraphobia is reputed to be more difficult to treat than simple phobia. In a test of this supposition, 38 agoraphobics and 19 simple phobics were each given 10 sessions of graduated in vivo exposure. They were assessed before and after therapy using a behavioral avoidance test, behavioral diaries, and self-report measures. Analysis of covariance revealed unequivocal posttest differences only on self-assessed disability level; agoraphobics had changed less in their report of global disability immediately following treatment but not at follow-up. Sixty-eight percent of the simple phobics showed clinically significant improvement on avoidance of the Main Phobia, compared with 34% of the agoraphobics. On three other outcome measures, including more precise behavioral measures of phobia, agoraphobics and simple phobics responded equivalently to treatment. Given clinicians' impression about the comparative difficulty in treating agoraphobic clients, fewer differences in treatment response were obtained than were expected. Several possible explanations for this discrepancy are discussed.     

Types and correlates of blood/injury-related vasovagal syncope

This study investigated by interview, the initial syncopal episode of 103 blood/injury-related vasovagal fainters in order to examine two competing hypotheses concerning their origins. Graham (Circulation, 23, 901-906, 1961) postulated that the faint resulted when sympathetic nervous system (SNS) activity ceased on termination of a threat, leaving parasympathetic nervous system (PNS) activation unopposed. Engel [Fainting (2nd edn), 1962; Annals of Internal Medicine, 89, 901-906, 1978] proposed that when in the face of threat with SNS activation, escape is blocked, the PNS becomes activated as the conservation-withdrawal response, leading to syncope. We found cases clearly conforming to each of these formulations as well as some with characteristics of both, and some who fainted in response to blood or injury but with no perception of threat. The Graham and Engel types did not differ in terms of fear or avoidance of blood, injury, or medically-related situations nor did they differ in the frequency with which their parents reported blood/injury-related syncopal episodes. It is proposed that both may be activated by a common psychological mechanism involving cessation of a defensive posture. In contrast, the non-threat fainters showed significantly less medically-related avoidance and had a greater percentage (94%) of parents with positive faint histories.     

Psychophysiological outcome of cognitive, behavioral and psychophysiologically-based treatments of agoraphobia

Psychophysiological process and outcome phenomena were analyzed to examine differential temporal patterns within and across cognitive, behavioral and physiologically-based treatments of agoraphobia. Eighty-eight severe and chronic agoraphobics with panic attacks (DSM-III) were randomly assigned to one of three treatments: Paradoxical Intention, Graduated Exposure or Progressive Deep Muscle Relaxation Training. Protocol therapists, whose treatment integrity was objectively monitored, conducted 12 two-hour weekly sessions. All subjects received programmed practice instructions concurrent with their primary treatment. Analyses revealed numerous significant reductions on in vivo psychophysiological measures for the relaxation condition, a few improvements for the exposure treatment and no effects for the paradoxical intention modality. The mediating role of pretreatment physiological reactivity in treatment outcome and follow-up status was examined and revealed no significant associations. Synchrony-desynchrony patterns were found to vary widely according to both treatment phase and the time interval between assessments. No between-group differences were observed on the proportion of synchronizers. However, synchronizers exhibited superior outcome and follow-up compared to desynchronizers on all domains except the physiological measures. Conceptual, methodological and clinical implications of these findings are discussed with recommendations for future research.     

Ethical and malpractice issues in hospital practice

Ethical and malpractice issues arising in hospital practice are reviewed. Topics include (a) preparation and authorization to carry out clinical responsibilities, (b) personnel procedures, (c) financial and political forces influencing hospital policies, (d) billing procedures, (e) clinical procedures for responding to patients' needs, (f) confidentiality, (g) discrimination, (h) internship and training issues, (i) sexual abuse of patients, and (j) staff conflicts influencing patient care.     

Processing distinctions between stems and affixes: evidence from a non-fluent aphasic patient

In this paper, we study the ability of a non-fluent aphasic patient, BN, to comprehend morphologically complex words when they appear in utterance contexts. We first establish that he is insensitive to the contextual appropriateness of both derived and inflected words. In a further experiment we show that he has no difficulty processing the stems of complex words and conclude that his problem is with the bound morphemes themselves. We then ask whether this problem is due to his inability to access either the phonological form of a morphologically complex word or its semantic and/or syntactic content. We find that only the access of semantic and syntactic content is impaired. We conclude from these six studies that: (a) BN presents a counter-example to the claim that non-fluent patients have particular difficulty with those aspects of morphology which have a syntactic function; (b) BN processes both derived and inflected words by mapping the sensory input onto the entire full-form of a complex word, but the semantic and syntactic content of the stem alone is accessed and integrated into the context. The semantic and syntactic implications of the suffix are never evaluated. This implies separate representation of the stems and suffixes of some types of morphologically complex words.     

Towards a theory of algorithm-determined cognitive test construction

A rationale for, and data from, a trial of a theory of item generation by algorithms whose origins are cognitive models of task performance are presented. Since Spearman (1904), intelligence has been operationally defined and assessed in human subjects by administering identical test items whose content and order have been fixed only after empirical iterations. In our approach, intelligence is ostensively defined by theoretically determined algorithms used for item construction and presentation. Knowledge of what cognitive factors limit human performance makes it possible to vary within tightly specified parameters those features of the tasks that contribute to difficulty, which we call radicals, to let those components of the tasks that do not contribute to difficulty vary randomly, and to counterbalance aspects of answer production that might induce biases of response. Empirical data are based on the generation of five different short tests demanding only functional literacy as a prerequisite for their execution. Four parallel forms of each test were administered to young male Army recruits whose scores were collated with their Army Entrance Test results, which were not previously known to us. Results show that the parallel, algorithm-generated item sets are statistically invariant, which item generation theory demands; and that the individual tests differentially predict Army Entrance Test scores. We conclude that IQ test performances are parsimoniously explained by individual differences in encoding, comparison and reconstructive memory processes.