American Journal of Psychotherapy

Print ISSN: 0002-9564
Publications
This study explores the relationship between both classical and "masked" symptoms of depression with the discharge diagnosis of depression. The sample consisted of 10.412 impatient admissions to a child and adolescent psychiatric municipal hospital. The results indicate that "masked" symptoms are not associated with a diagnosis of depression.
 
This is a study of 1000 patients with severe agitated depressions who were treated with tranylcypromine on an ambulatory basis during a period of 13 years. It was administered in combination with tranquilizers, usually trifluoperazine. Tranylcypromine is a safe, rapidly acting, very effective antidepressant and appears to be the drug of choice in patients with agitated depressions.
 
The art and skill of psychotherapy supervision and its teaching have received relatively little attention compared to their importance in psychiatric education. Supervision is a complex task, requiring teaching and clinical skills, as well as an awareness of the numerous responsibilities of the position. We describe the responsibilities of the supervisor and group them to include those to the supervise, to the patient, to the training program and profession, and to the supervisor himself or herself. The core responsibility to supervise is teaching them how to be psychiatrists, which for supervisors requires a balance between a hierarchical and collaborative approach. The primary responsibility to patients is that of assuring satisfactory treatment. Evaluating supervise within an educational framework is the primary responsibility to the training program and profession. Finally, the responsibilities to the supervisors themselves include self-examination during the supervision process and general ongoing education. Several themes are highlighted. One theme, which is a central development in the understanding of supervision, is seeing the supervisor as a participant in the supervisory process, rather than an outside observer of the therapy process. Another theme is that these responsibilities are at times competing, requiring the supervisor to establish priorities. Vignettes are used throughout to illustrate the problems and subtleties of supervision.
 
Elvin Semrad was among the most influential and beloved teachers of psychotherapy in his generation. His legacy as a clinician, teacher, and mentor is still felt today, even among those who never knew him directly. What and how he taught remains as relevant as ever in the psychotherapeutic care of troubled individuals. His was primarily a psychiatry of affects and bodily feelings, and he focused uncannily and empathically on the patient's experience. The basis of his rich, heartfelt, wise, and inimitable approach was not just classically psychoanalytic, or existential, or ego-oriented, or self-psychological, or interpersonal-relational, or even humanistic or adaptational. Rather, it was all of these in a uniquely "Semradian" integration geared toward elucidating patients' experience that had arrested them during their life course and their avoidance of "acknowledging, bearing, and putting into perspective" what they were up against. This paper describes who he was and gives a personal perspective on his influence--how and what he taught and why he had such an effect on those who knew him.
 
Sixty studies, published between 1948 and 1995, on attitudes toward mental health professionals, particularly psychotherapists, were systematically content analyzed. Descriptive results concerning the topics status, expertise, personality attributes, physical appearance, sex/gender, psychotherapeutic settings, and interactions between therapists and clients are presented. Public-image problems of psychotherapists, research deficits, methodological problems, and sex/gender issues are critically discussed.
 
This article provides a brief overview of the changing nature of the concept of minor depression. It then discusses treatment studies conducted from 1980 to 1991 of patients diagnosed as neurotic depression, depressive neurosis or dysthymia, characterologic depression, "double depression" and minor depression or dysthymia, if there has been a full remission of a major depressive episode lasting at least six months prior to the development of dysthymia. Long-term treatment of chronic depression is also reviewed. Cognitive-behavioral intervention and marital therapy have been reported beneficial for patients diagnosed as having neurotic depression, characterological depression, or dysthymia. All studies of antidepressant drug treatment showed drugs to be efficacious and superior to placebo, with few differences found between drugs. In addition, they all showed the importance of analyzing the interactions between treatment and severity or diagnosis. Patients diagnosed as "double depression" also appear responsive to both psychosocial intervention and drug treatment; in general, however, these patients tend to have a poor long-term outcome and continued treatment is indicated. The most obvious finding to emerge from this review is that the diagnosis of minor depression is ambiguous, in large part because of the lack of defining criteria related to severity and course. The review also revealed that in addition to poorly defined subgroups, many studies lacked controls, had small sample sizes, inadequate and/or inconsistent measures of outcome, and limited follow-up. For these reasons, their findings cannot be considered conclusive. Finally, the literature revealed a dearth of controlled studies of psychosocial treatment for well defined subgroups of neurotic depression.
 
Psychoanalysis has passed through several dialectic steps of development. At present, it appears invigorated by social needs such as accountability and by object-relations theory and self-psychology. As the most rigorous application of causality to the understanding of human behavior, it is likely to endure into new social eras and outlive the various diluted and trendy fads.
 
The phenomenal rise that group psychotherapy has experienced during the last 30 years, is likely to continue. Short-term and more superficial group modalities will prevail, however, with long-term psychoanalytic group treatment becoming relegated to the private sector. The current trend toward pragmatism and eclecticism in group-psychotherapy theorizing and technical experimentation, is bound to persist. In research, the focus will need to be on the delineation of the therapeutic factors which are unique to the group method. Circumscribed outcome studies will also emerge, geared to specific patient categories, intervention models, patient-therapist fit, and especially session frequency and duration.
 
This paper identifies and discusses 10 broad-based themes or conclusions that could be drawn about the field of psychotherapy supervision now. These conclusions focus on various facets of clinical supervision theory, research, and practice; in so doing, they bring to light current supervision issues, problems, advances, and needs that seemingly merit our attention and consideration.
 
A survey conducted by America Online (AOL) in 2005 reported the startling finding that almost 50% of those posting entries on internet logs (weblogs or blogs), use them as a form of self-therapy. This finding went relatively unnoticed by psychotherapists and other mental health professionals. Given the rather significant global population of bloggers (those who post internet journal entries) and readers, and the seemingly intractable problem of mental illness worldwide (according to the World Health Organisation, the global burden of mental illness accounts for more than the burden of all cancers put together), the possibility of blogging as self-therapy deserves greater attention. Research investigating the health possibilities of blogs holds particular promise, at least for those disposed to writing and those working with patients who write. This paper addresses the question of how one might blog within a social network as a form of self-therapy. Based on an interview conducted with a blogger in May 2007, we construct a portrait of an individual who uses a blog as self-therapy.
 
The potential for countertransference complications in trauma work is generally known by now. "A priori" countertransference demonstrates that thoughts, emotions, and prejudices are evoked by preliminary information about a client even before the first meeting. Insufficient awareness is likely to put both therapists and clients at risk. The literature about therapy with Holocaust survivors amply illustrates this. Less is known about what happens to the therapeutic process at times of armed conflict. Must additional aspects of countertransference be taken into account? Can psychotherapy continue as normal? The outbreak of violence in Israel on Rosh Hashanah 2000, when peace seemed realistically near, provided an opportunity to explore the impact of therapists and clients sharing real-time, potentially (re)traumatizing conditions. This small qualitative study with therapists who work with clients traumatized by the Holocaust focuses on how they cope with the additional personal and professional challenges, and suggests answers to the above questions.
 
Many preindustrial cultures traditionally use certain psychedelic plants to enhance a procedure that resembles psychotherapy--an idea that was also tested in Western psychiatry in the 1950s and 1960s. LSD and related drugs were used to facilitate the production of memories, fantasies and insights and to enhance the therapeutic alliance. The results were inconclusive, and research was largely abandoned after the drugs became difficult to obtain. It may now be possible to revive this research, using new drugs that do not have some of the disadvantages of the old ones. The drug now of most interest is MDMA (3,4-methylenedioxymethamphetamine) a relatively mild and short-acting substance that is said to give a heightened capacity for introspection and intimacy without the perceptual changes, emotional unpredictability, and occasional adverse reactions associated with LSD. Therapists who have used the drug claim that it can enhance the therapeutic alliance by inviting self-disclosure and promoting trust. Whether MDMA fulfills this promise or not, other drugs may eventually prove useful in psychotherapy. Research on their potential should not be curtailed because of fear that they will be subject to illicit abuse.
 
Of 2,259 patients seen during 45 years of private practice, outcome data was produced for 1,599 cases. The mean (SD) number of sessions per case was 18.82 (29.89). The dropout rate was 18.76%. Of all treated cases with outcome data 4 (0.25%) were rated as Much Worse; 11 (0.69%), Worse; 497 (31.08%), No Change from Intake; 546 (34.15%), Improved; and 541 (33.83%), Much Improved. The mean (SD) pre-/post-treatment effect size (ES) was 1.90 (1.61), the median was 1.62, and the range was from -2.91 to +15.22. Patients and parents of minors rated outcomes more positively than the therapist did. Outcome varied significantly across diagnostic categories. There was a significant, positive relationship in length of treatment and outcome. The therapist's effectiveness did not improve across the years. Years with the largest patient caseloads or the greatest proportion of patients with managed-care insurance tended to show the poorest outcomes.
 
Genital hypoplasia (micropenis) and CNS impairments are among multiple anomalies of embryogenesis that are found in association in a syndrome for which the acronym CHARGE has recently been coined. The CNS anomalies are either peripheral or central or both. Their various manifestations are impaired hearing and vision; impaired motor performance and visual-motor coordination; IQ deficit either overall or specific to verbal reasoning or praxic reasoning; and social ineptitude consequent on impaired social maturation. These various impairments constitute a pedagogical handicap which, even though of major severity, is not refractory to clinical treatment and educational therapy.
 
Acute and chronic styles of suicidal behaviors require different psychotherapeutic approaches--the former needs a supportive-cognitive-focused approach, the latter (chronic or characterological) style needs an expressive insight-oriented psychotherapy with supportive elements to address the adolescent's developmental requirements for structure within the sessions. The psychotherapist needs to be appraised of the epidemiological, dynamic factors as well as the sources of external support the patient can count upon. It is interesting to note that psychodynamic factors alone or psychopathology alone are not sufficient to estimate the ebb and flow of the suicidal risk. A combination of all these factors must be taken into account in estimating suicidal risk at any point in treatment. It is advisable that an independent clinician's consultation be sought during treatment in the case of suicidal attempts as the therapist can easily overestimate or underestimate suicidal risks. Individual treatment requires family intervention from counseling to therapy. Particular problems addressed in the paper are countertransference reactions created by the suicidal behavior in the clinician such as rejection and withdrawal. The psychotherapy should address the resolution of aggressive, envious introjected images, issues of omnipotent control and interpersonal skills deficits. To transform suicidal behavior into reenactment of the aggression within the relationship to the therapist is the main immediate goal. A critical caveat; a patient who lies by commission or omission represents an obstacle for individual therapy on an outpatient basis as he will disguise his suicidal intentions and plans, excluding them from the therapeutic process.
 
Evidence has been presented supporting the existence of an emotional detachment effect caused by the deflection of both attention and affect toward the more demanding second language encoding tasks in bilinguals' communication across the language barrier. The bilingual patients' difficulty in integrating emotions and experiences, the displacement and blocking of affects, and the reinforcement of obsessive resistances may give rise to misinterpretations and distortions of their problems. Conversely, the language barrier may facilitate the verbalization of highly charged material by patients who feel 'protected' by the linguistic detachment. It is important that psychotherapists be sensitized to the consequences of these language barrier detachment factors in order to minimize their obstructing effects, as well as take advantage of the unique opportunities that they offer to the study of mental processes.
 
Studies have shown that men and women differ in their use of defense mechanisms (e.g. Cramer, 1991; Watson and Sinha, 1998). However, how and why this difference exists is still open to debate. The present study explores the relationship between gender and defenses using the Defense Style Questionnaire (DSQ-60; Trijsburg Bond, & Drapeau, 2003). As expected, no significant differences were found in Overall Defensive Functioning (ODF); however, men and women differed in their choice of defense style, defense level, and individual defense mechanisms. Evidence is provided to support the notion that while overall adaptivity of defenses is comparable, men and women rely on different defensive organizations during conflict-laden situations. We discuss the clinical relevance of these results in light of previous findings.
 
A nonclinical second-generation Holocaust survivor group of young adults is contrasted with a comparable North American Jewish control group. A discriminate analysis of questionnaire responses indicates specific differences between the functioning second generation (N = 68) and the control group (N = 51). Focus was on growth-producing rather than pathogenic factors. Sample characteristics, interview data, techniques of data analyses and results are presented and discussed; some literature and work in progress is noted. Recommendations regarding further research efforts are made.
 
Certain personality defects noted during psychoanalytic therapy are expressions of temperament. Using a 72-item temperament index, the author analyzed 101 patients with respect to depressive, irritable, manic, paranoid and shizoid subscales. At least one such "temperament" was present in two-thirds of the borderline and in one-third of the neurotic patients. The temperament-positive borderline patients usually had a close relative with a schizophrenic or primary affective disorder. Several cases exhibiting temperament abnormalities are presented and modifications of analytic psychotherapy to deal more effectively with them are outlined.
 
This article presents a case of self-induced diseases (Munchausen syndrome), among them a very dangerous cardiac condition. The psychotherapeutic process is described, through which the Munchausen behavior was effectively abolished. It is suggested that Munchausen syndrome may be a suicidal equivalent.
 
A case of obsessive-compulsive neurosis which developed in a young woman after she had viewed the fetus expelled during a therapeutic abortion with hypertonic saline is reported. The treatment, involving both psychodynamic psychotherapy and behavior therapy, illustrates the use and possible interaction of these therapies in the same patient.
 
This case study presents a young woman who developed a severe obsessive-compulsive disorder after a routine medical procedure. It is suggested that this procedure brought back repressed guilt from three abortions and thus led to the onset of symptoms. The case is discussed in relationship to available research and theory. PIP Although the majority of women experience no long-term significant psychopathology following an elective abortion, up to 5% exhibit severe psychiatric sequelae. Reported here is the case of a woman with an obsessive-compulsive disorder apparently related to abortions at ages 14 and 15 years of age. In her mid-20s, during her fourth marriage, the woman became convinced that she had been impregnated by a physician in the course of a pelvic exam and a proctosigmoidoscopy. At the time, she was obsessed that she would sabotage her marriage by becoming pregnant with a man other than her husband. The obsession later expanded to include a fear of contracting a sexually transmitted disease. In psychotherapy, the etiology of this disorder was linked to the patient's guilt and fear of punishment connected to her early abortions. The invasiveness of the sigmoidoscopy procedure triggered memories of these abortions and was subconsciously viewed as another pregnancy termination. A review of this woman's history revealed most of the factors considered to promote psychiatric problems after abortion, including young age, unmarried status, passivity, lack of social support, reservations about the abortions, parental pressure to abort, immaturity, and unstable relationships with the fathers. Counseling before and after abortion for women identified as having risk factors for emotional problems is recommended.
 
Metaphors are widely utilized in psychotherapy to effect change in patients. Psychotherapeutic metaphors, in their various versions, may offer new choices and ways of viewing oneself to the patient which are more palatable than straight discussions or sterile insights. By addressing resistances indirectly, metaphors can be an effective tool for the therapist to use, regardless of theoretical orientation. Abraham Lincoln, a master of metaphor, utilized this tool effectively in dealing with crises and the ultimate fragmentation, disunion of the national identity. The author argues that Lincoln was able to address complex issues (such as slavery, liberty, nationhood, union, and conduct of the war) with metaphors, much as a skilled psychotherapist addresses complex issues within his or her purview. Abraham Lincoln effectively disarmed his critics, established a means of communication with the people, and sought to make his points in an understandable nonconfrontational fashion. These are skills highly valued by psychotherapists. One might say that Abraham Lincoln conducted psychotherapy on a national scale. Without formal training, he was ultimately able to create a new and more stable sense of national self using a metaphorical approach.
 
It is widely known that people with schizophrenia have difficulty telling a coherent story of their lives and that this is linked to impoverished function. But what specifically has gone wrong in the narratives in schizophrenia? Is it the case that some elements of narrative remain intact in schizophrenia while others are uniquely affected? To address these questions, we qualitatively analyze the personal narratives of three persons with schizophrenia, which have emerged in psychotherapy. Based on this analysis we suggest that narratives in schizophrenia uniquely fail to situate agency within the narrator resulting in a story that is missing an agent-protagonist. While the narratives we present contain coherent accounts of how others are connected to one another, they fail to evolve into a story about the self as an agent that others could associate with the narrator. We speculate that this may reflect neuro-cognitively based difficulties maintaining the internal dialogue that propels agency as well as fears that any emergent subjectivity may be appropriated or objectified by others. Implications for psychotherapy are discussed.
 
Exploratory psychotherapy with alcoholics must address the problem of requiring abstinence. This depends upon the patient's capacity to abstain. In turn, this capacity is reflected in the specific transference issue of ability to introject the therapist's caring concern for the patient and for his wellbeing.
 
Top-cited authors
Augustus John Rush
  • Duke-NUS Medical School
Clifton Edward Watkins, Jr.
  • University of North Texas
Rudolf Hoehn-Saric
  • Johns Hopkins Medicine
Mardi Horowitz
  • University of California, San Francisco
Lester Grinspoon
  • Harvard Medical School