International journal of psychoanalytic psychotherapy最新文献

This paper describes a defensive pattern, pathologic preoccupation, that is used to hide emotional absence under a mask of rationalization, in regard to loyalties outside the family. Observations and clinical data drawn from both individuals and families are used. The emphasis is on preoccupation as a transpersonal process of defense and on the resistances to treatment that result. The patient's struggle with the past against identification derives from representations of the family of origin in which the same-sex parent figures as an object of contempt or shame. Pathologic distance regulation must be understood through the manifest defensive operation of narcissistically vulnerable persons, that is, by the nature of binding and unbinding that occurs among real people, not just in fantasy.

The multifaceted syndrome of suicide is viewed as a symptom with a manifest and a latent content. An attempt is made to demonstrate a dynamic reciprocal relationship, in a continuum, among fantasy, masturbation, and suicide. Sadomasochistic phenomena, beating fantasies, and suicidal thoughts and acts are viewed as translations of underlying positive and negative oedipal fantasies. Attention is also paid to how suicidal phenomena are facilitated by immature concepts of death, that is, its perception as a transient and reversible phenomenon, as well as its erotization. Four cases highlighting aspects of these themes are presented and then discussed in terms of how they illustrate the varying vicissitudes and elaborations of the masturbatory and/or oedipal fantasy and act, along separate or simultaneous pathways. In conclusion, there is an exploration of interpretive differences, with special reference to an object relations approach to phenomena, with its emphasis on preoedipal determinants and its attempts to accommodate both the drive/structure and object-relational/structure theoretical orientations.

The ground rules of psychoanalysis define the nature and boundaries of the analyst-analysand relationship. This paper examines the classical tenet of the analyst's relative anonymity. Technical justifications for this precept, as well as the existing literature on the subject, are reviewed. The relevance of this ground rule in the context of psychoanalytic psychotherapy is explored. Potential sources of threat to the maintenance of appropriate anonymity are also discussed. Finally, two clinical examples in which there were modifications in the ground rule of anonymity are presented. Using a communicative perspective, the patient's unconscious reactions and perceptions regarding the therapist that emerged under such conditions are examined. The data support the conclusion that the far-reaching consequences of the manner in which the therapist establishes and sustains the ground rules of the therapeutic relationship usually have not been adequately appreciated.

Selected literature is reviewed, and clinical material is presented to discuss the phenomena of negative therapeutic reaction, interaction, and impasses in psychotherapy. It is suggested that certain seriously ill patients, in whose therapy an impasse develops, suffer from both the primitive superego pathology or other intrapsychic conflicts that have been described in the literature on negative therapeutic reaction and from a tendency to act so as to recreate these struggles in the external field, often in the form of negative therapeutic interactions. In some such cases, outside assistance for the therapist is necessary in order for the treatment to move beyond a stalemate. In seriously disturbed, hospitalized patients, interventions by the entire treatment team, not simply the therapist alone or the therapist and supervisor, are sometimes required to enable the treatment to proceed. This may be due to the primitive and extremely violent nature of such patients' conflicts, which may strain the limits of a dyadic relationship.

Much of this paper focuses on the psychoanalysis of Bert, a severely disturbed 9-year-old adopted boy. Constitutional factors, parents' personalities and parenting styles, and libidinal and aggressive zonal fixations all played a role in determining Bert's problems. Besides the normal developmental challenges, the adoptive child faces the unique developmental task of becoming the true adoptive child of true adoptive parents. Bert's case shows how this process can be facilitated in psychoanalytic treatment. After a brief introduction to the psychological implications of adoption at various stages of development, the paper elaborates on how and why Bert first came for treatment and describes three phases in the treatment, the first session, the period of transference developments, and the termination phase. The final section outlines special treatment issues and the implications for the psychoanalytic treatment of an adopted child.

Winnicott's concept of transitional phenomena is employed as a means of further understanding the effect of medicine and the medication-giving process itself. Particular facets examined include the "soothing" function of medication, the placebo effect, and medication compliance, as well as countertransference difficulties encountered in administering the medicine. Medication as a transitional object is viewed largely as a creation along the self-object interface, with the "potential space" between patient and therapist recapitulating aspects of the original dyad. This usage of medicine as a transitional object, or its ultimate abandonment as such, is presented in terms of the vicissitudes of internal object relations, with clinical case examples to clarify particular issues.

Prevailing psychoanalytic attitudes toward male homosexuality are predisposed to the treatment of it as a psychopathological disorder. This study proposes that the appearance of disorder follows from the distortions imposed on the personality during development. Superego conflicts ensue that are relieved rather than resolved in the analysis, if the analyst shares the patient's conviction that it is sexuality that is disordered. The study's second point is the suggestion that the unifying characteristic of male homosexuals is to be found in the particular form of body narcissism that leads to same-sex choice. Third, it is proposed that analysts reconsider the likelihood that biogenetic elements enter into the homosexual outcome.

There are two "psychotherapies." The first, very close to psychoanalysis, may be defined as that mental treatment whose central focus is the analysis of the patient's experience of the relationship with the therapist in the here and now, and whose goal is insight. This is psychoanalytic psychotherapy. The second is nonpsychoanalytic psychotherapy, which bypasses the patient's experience of the relationship with the therapist, and by so doing may be defined as that mental treatment based on suggestion, with the goal of subjective improvement or symptom relief. Each therapy has its appropriate role in human experience. The basis of nonanalytic therapy, suggestion, is antithetical to both the means (analysis) and ends (insight) of analytic therapy.

The significance of a visual dialogue between patient and therapist in assisting tension regulation for patients with severe narcissistic injury is proposed. Non-verbal interactions may unfold spontaneously and contribute to development of a "holding environment" in its broadest sense. There will be inevitably both countertransference and real elements in this bipersonal field. The development of a visual holding environment at a symbiotic level may be based on a counter-transference response by the therapist of an earlier need to "hold or be held." It has been suggested that it is difficult for the therapist to feel a "gleam in the eye" for patients who have missed early mirroring. Developmental stages of treatment involving active mutuality of eye contact, considered a "language of silence" beyond verbal interpretation, are suggested. These observations agree with Searles' paper that facial expressions form a bridge to personal relatedness.

Consultation is acknowledged to be a useful aid in the treatment of the suicidal patient. Consultation is, however, a deviation from the therapeutic framework, and there are potential dangers. A case example is used to illustrate the various phases of the consultation process--from the decision to consult, the way the consultation is arranged, the type of consultation, and the results of the consultation on the patient-therapist relationship. A brief examination of the intrapsychic and interpersonal dynamics of the suicidal patient highlights the patient's vulnerability to seeing the deviation in technique as a disruption. A preferred form of consultation for these situations is suggested.