目前形势下临床教学问题的探讨与改革

当前医疗大环境的改变,社会评价的影响及病人的维权、自我保护意识等使临床教学工作发生了很大变化.需要我们采取相应的变革,注重病历的书写,基本功的培训,语言能力的指导和改变查房的方式,以完成培养新一代合格医生的任务.     

Exploring counsellor perceptions of the impact of counselling supervision on clients

This qualitative study explores counsellors’ experiences and perceptions of how counselling supervision impacts upon their clients. Data collection combined open‐ended questionnaires (n = 13) and semi‐structured interviews (n = 6). The findings indicate that supervision impacts client work both helpfully and unhelpfully. Areas that emerged as having the most direct impact on client work were the counselling relationship dynamics and self‐awareness, professional development, emotional support, clients not discussed in supervision and the quality of the supervisory relationship. Congruence and confidence were the most direct link between supervision and client work.     

New interpretative styles: Progress or contamination? Psychoanalysis and phenomenological psychopathology1

Psychoanalysis has started to recoup, often quite implicitly, a more phenomenological stance, ever since psychoanalysts have started working with borderline and psychotic patients. As many of these patients have commonly been through traumatic experiences, psychoanalysts have been using an approach that questions the role of traditional psychoanalytical interpretation and pays more attention to the patient's inner conscious experiences; this approach is characteristic of a specifi c form of contemporary psychiatry: phenomenological psychopathology, founded by Karl Jaspers in 1913 and developed into a form of psychotherapy by Ludwig Binswanger, with his Daseinsanalyse. If what we could call a phenomenological ‘temptation’ has been spreading over psychoanalysis, so too has a psychoanalytical ‘temptation’ always been present in phenomenological psychopathology. In fact, even though this branch of psychiatry has led us towards a deeper understanding of the characteristics of psychotic being‐in‐the‐world, its therapeutic applications have never been adequately formalised, much less have they evolved into a specifi c technique or a structured psychotherapeutic approach. Likewise, phenomenological psychotherapy has always held an anaclitic attitude towards psychoanalysis, accepting its procedures but refusing its theoretical basis because it is too close to that of the objectifying natural sciences. Psychoanalytic ‘temptation’ and phenomenological ‘temptation’ can thus be considered as two sides of the same coin and outline a trend in psychoanalytic and phenomenological literature which points out the fundamental role of the patient's inner conscious experiences in the treatment of borderline and psychotic patients.     

The basic traumatic situation in the analytical relationship1

The author attempts to develop a concept of psychic trauma which would comply with the nucleus of this Freudian notion, that is, an excess of excitations that cannot be processed by the mental apparatus, but which would also consider the functions and the crucial role of objects in the constitution of the psychism and in traumatic conditions, as well as taking into account the methodological positioning according to which the analytical relationship is the sole possible locus of observation, inference and intervention by the psychoanalyst. He considers as a basic or minimal traumatic psychoanalytical situation that in which a magnitude or quality of emotions exceeds the capacity for containment of the psychoanalytical pair, to the point of generating a period or area of dementalisation in the psyche of one or both of the participants, of requiring analytical work on the matter and promoting a signifi cant positive or negative change in the relationship. Availing himself of Bion's theory about the alpha function and the metapsychological conceptions of Freud and Green concerning psychic representations, he presents two theoretical formulations relating to this traumatic situation, utilising them according to the ‘altered focus’ model proposed by Bion. He presents three clinical examples to illustrate the concept and the relevant theoretical formulations.     

Los Degradados: Out,down, dead: Transmitted and inflicted trauma as encountered in the analysis of a 6‐year‐old girl1

The author presents the analysis of a precocious traumatized little girl, which reveals the ways in which historical trauma is transmitted and intrafamilial trauma is both disguised and represented. The play as it evolves is seen to simultaneously communicate what the child struggles with and to resolutely try to hide what has actually happened. Analyst and child together participate in play which utilizes displacement, enactment and interactive enactment, the latter play mode being the very hallmark of profound traumatic experience. Carlotta, the child, helps the analyst to follow her quest for meaning making even as the interaction between them adheres to and departs from the deepening pentimenti of traumatic experience, which needs to be unraveled and reconstructed in order that her own developmental progression can be rejoined. The analysis facilitates Carlotta's capacity to play in a more unfettered fashion and to assist her family's recovery as well.     

Contextual Influences on Marriage

Abstract— Current proposals to promote and strengthen marriage among low-income populations focus on values and behavioral skills as primary targets of intervention. Marital research that examines contextual influences on marriage calls these emphases into question. Ethnographic and survey research reveal no evidence that populations experiencing higher rates of divorce value healthy marriages any less than other populations do. Longitudinal and observational research reveals two mechanisms through which the environment of a marriage may enhance or constrain effective relationship maintenance. First, some environments contain fewer sources of support and pose more severe challenges than others, presenting marriages in those environments with greater burdens than marriages in more supportive environments are faced with. Second, when demands external to the marriage are relatively high, even couples with adequate coping skills may have difficulty exercising those skills effectively. Together, such findings suggest that successful policies and interventions to strengthen marriages need to acknowledge the environments within which marriages take place.     

关于临床实践教学中患者隐私权的调查与分析

临床实践教学中患者隐私权的界定与保护一直是舆论界和学术界争论的问题之一.通过发放调查问卷,综合分析患者、医学生及带教医生对这一问题的观点,为解决这一争议进行了理性的思考,并给出了合理的建议.     

解析心理冲突的新角度--评介凯根的结构-发展理论

本文介绍了自我发展研究领域中罗伯特凯根提出的结构-发展理论及其特点,简析它与其它自我发展阶段论的异同。探讨了该理论在抚育、学校教育和临床咨询等方面的实践意义。     

“One Size Fits All”: An Existential-Constructivist Perspective on the Crisis Intervention Approach with Suicidal Individuals

The empirical data on the relationship between suicide and suicide attempts are interpreted as suggesting that the contemporary assessment and intervention approaches to suicidal individuals are, by and large, ineffective. In support of our argument, we focus on the crisis intervention model as one example and suggest that the crisis intervention approach to responding to suicidal individuals is at best, ineffective and, at worst, can be viewed as exacerbating suicidal risk through its distancing, marginalizing, and stigmatizing effects. Additionally, we hypothesize that the mechanics of the crisis intervention model contribute to the societal message that a meaning and contextual-based discussion of suicidality is taboo and that this message tends to continue into more long-term psychotherapeutic approaches. Along these lines, we present an alternative to the crisis intervention model grounded in an existential-constructivist theory of suicidal behavior and the principles of therapeutic and feminist assessment philosophies as an heuristic intended to stimulate the development of new and innovative approaches to working with suicidal individuals.     

Dynamic Psychotherapy and the Problem of Time

This paper examines the dilemmas psychodynamic clinicians face in dealing with the challenges of the current clinical climate. We look to our theories, to the evolution of psychodynamic technique and to the collaborative nature of the therapeutic endeavor as they relate to the goals of psychotherapy. A case illustration is provided, and guidelines are offered for current professional practice.