THE ‘OTHER 23 HOURS’: SPECIAL PROBLEMS OF PSYCHOTHERAPY IN A ‘SPECIAL’ HOSPITAL

In this paper, I describe and discuss the complexities of being a therapist in a maximum security forensic psychiatric hospital, working with patients who have committed acts of serious violence, and who also suffer from severe mental illness and personality disorders. I suggest that profound disturbances in the patient's inner world get played out in triangular disputes between the patient, the therapist and other professionals working in the hospital. I also describe how real events in the life of the institution impact on the therapeutic process, and the importance for the therapist of reflection on the ‘other 23 hours’ that the patient lives outside of therapy. Finally, I raise some ethical dilemmas that arise for therapists working in such settings, where the stated therapeutic aim is not only treatment but also the containment and prevention of future violence.     

Psychoanalytic treatments and empirical research on their efficacy: A commentary

Abstract

The author summarizes the problems inherent in nomological approaches examining the efficacy of psychoanalysis as a form of treatment. He argues that nomologically oriented research operates with assumptions lacking empirical foundation and, moreover, that studies of this type merely give the impression of the effectiveness of psychoanalytic therapies while overlooking the specificity of the psychoanalytic method. He suggests that research into psychoanalytic treatments should not be subjected to a nomological conception of science, and that structural analysis of treatment courses should be examined and systematized within the frame of psychoanalytic treatment theory relative to their outcome. Given this approach, and provided that the theory of treatment is based on conceptual common ground, such studies would enable a prognostic conclusion that psychoanalytic treatments are successful, providing that the sequences generalized in the treatment theory do actually take place in treatments that take patients’ individuality into account.     

Curriculum and training reform in clinical psychology: Improving the integration of science and practice

Current graduate curricula do not fully grapple with and take advantage of the dialectical interplay of science and practice that is at the core of the scientist—practitioner (Boulder) model. This article addresses factors that interfere with the realization of the Boulder model and offers suggestions for curriculum reform. It emphasizes the importance of both science and practice, as well as the merit of both nomothetic and idiographic approaches to clinical training. The article discusses how academic politics often interfere with the incorporation of empirically supported treatments or assessment methods into training programs. Even when evidence-based approaches are a part of the curriculum, the challenges continue. Because empirically supported treatments are almost always associated with treatment manuals that rely on categorically defined diagnostic categories, they may inadvertently discourage idiographic functional analyses and the appreciation of underlying change principles. In addition, in light of the fact that many, if not most, students eventually pursue applied careers and because science-based interventions and assessment methods are currently underused by clinicians in the field, it is argued that clinical training should receive more recognition in scientist—practitioner programs. Programs should be mindful of the need to prepare a certain subset of interested students for scientifically based careers in applied settings. This article also highlights the importance of educating and training students in communicating and disseminating science-based clinical psychology to nonacademic psychologists and health professionals from other disciplines.     

Learning at the Margin: New Models of Strength

SUMMARY

This article was originally presented at the April, 2000 Learning from Women Conference sponsored by the Harvard Medical School and the Jean Baker Miller Training Institute. It explores the ways in which marginalization and the use of power-over maneuvers and privilege contribute to disconnection at a personal and societal level. Strength in vulnerability is proposed as an alternative to strength in isolation. The author suggests that courage is created in connection and the distorting effects of the myth of the separate-self must be challenged in order to appreciate the power of connection. This article examines specific ways to resist the disconnecting and disempowering effects of hyper-individualistic values both in and out of therapy.