Splitting in hospital treatment.

Splitting is a concept that is used in a variety of ways to describe several different phenomena commonly seen in hospital treatment. As defined in this paper, it should be reserved for situations in which intrapsychic and interpersonal splitting occur simultaneously, recreating the patient's internal object world in the milieu. Through projective identification, staff members unconsciously identify with projected aspects of the patient and behave accordingly. A clearer conceptual understanding of splitting in the hospital allows for its differentiation from common variants of splitting and for the development of strategies to manage splitting.

Psychodynamic psychiatry in the "decade of the brain".

OBJECTIVE AND METHOD: To illustrate the continued relevance of psychodynamic thinking in the practice of contemporary psychiatry, the author reviews a number of studies that demonstrate the intimate connection between psychosocial and neurophysiological factors in the etiology and pathogenesis of psychiatric disorders. A survey of three specific anxiety disorders illustrates the complex interaction between mind and brain in these disorders. RESULTS: Research on both primates and humans suggests that psychological influences result in permanent alterations of a neurobiological nature. Similarly, psychological interventions in a treatment context may have a profound impact on neurophysiology. Clinical case examples demonstrate that "biologically based" disorders may be rich in unconscious meaning. Clinical understanding of the meaning of symptoms may be instrumental in ensuring patients' compliance with pharmacotherapy regimens and in the removal of other resistances to treatment. CONCLUSIONS: In contemporary psychiatry, a psychodynamic perspective must be preserved. Without it, meaning will be lost, and both diagnostic understanding and informed treatment planning will suffer as a result.

The fate of integrated treatment: whatever happened to the biopsychosocial psychiatrist?

OBJECTIVE: The authors suggest that pharmacotherapy and psychotherapy, the major treatment modalities in psychiatry, have become fragmented from one another, creating an artificial separation of the psychosocial and biological domains in psychiatry. METHOD: After a brief discussion of the economic factors influencing this trend, the authors provide a selective overview of recent research. In the absence of systematic empirical data regarding which patients and which conditions might benefit from integrated treatment by one psychiatrist, the authors propose specific clinical situations that call for such integration and also discuss concerns about cost-effectiveness. RESULTS: Recent research suggests that combining psychotherapy and pharmacotherapy may have advantages over either treatment alone in certain clinical situations involving specific disorders. While few of the studies on combined treatment have tested whether a one-person or two-person model of treatment provision is more effective, there are a number of advantages to the one-person treatment model in which a psychiatrist conducts the psychotherapy and prescribes medication for the same patient. CONCLUSIONS: The authors suggest that further research is needed to clarify the optimal situations for the one-person model of integrated treatment and also propose systematic teaching of integrated treatment in all residency training programs.

Misuses and misunderstandings of boundary theory in clinical and regulatory settings.

OBJECTIVE: This paper outlines a number of misapplications of boundary theory in both regulatory settings and clinical situations. METHOD: The authors review clinical vignettes that illustrate the difference between boundary crossings, which lead to productive work in psychotherapy, and boundary violations, which are harmful to the patient and exploit the patient's vulnerable position. They also discuss developments in the field that have led to an excessively rigid and defensive posture on the part of some clinicians that may lead to less than optimal psychiatric treatment. They survey recent developments in the wording of state statutes that broadly define sexual misconduct in psychotherapy. RESULTS: This review of the current status of boundary theory in both the law and clinical practice suggests that an overreaction has occurred that requires corrections. CONCLUSIONS: The critical role of context must be considered whenever a boundary problem has been alleged, and boundaries must be regarded as flexible standards of good practice rather than lists of generically forbidden behavior.

The concept of boundaries in clinical practice: theoretical and risk-management dimensions.

The authors systematically examine the concept of boundaries and boundary violations in clinical practice, particularly as they relate to recent sexual misconduct litigation. They selectively review the literature on the subject and identify critical areas that require explication in terms of harmful versus nonharmful boundary issues short of sexual misconduct. These areas include role; time; place and space; money; gifts, services, and related matters; clothing; language; self-disclosure and related matters; and physical contact. While broad guidelines are helpful, the specific impact of a particular boundary crossing can only be assessed by careful attention to the clinical context. Heightened awareness of the concepts of boundaries, boundary crossings, and boundary violations will both improve patient care and contribute to effective risk management.

Sources of conflict in the medical marriage.

The authors surveyed a sample of 134 physicians and 125 physicians' spouses regarding marital satisfaction, sources of marital conflict, and complaints about their spouses. Contrary to conventional wisdom, the number of hours at work did not relate to the degree of marital satisfaction. The chief sources of conflict in the medical marriage appear to revolve around differences in the partners' needs for intimacy, perceptions of the problems in the marital relationship and in each other, and communication styles. Lack of time due to the demands of practice seems to be a complaint that serves the function of externalizing the conflicts in the marriage onto factors outside the marriage.

The out-of-body experience: a phenomenological typology based on questionnaire responses.

The authors review the few surveys that have been made of the incidence of out-of-body experiences. They then present data on 339 respondents to questionnaires who reported having had out-of-body experiences and 81 who had not. They analyze these data according to the conditions existing at the time of the experience, phenomenological features, and the long- and short-term impact of the experience. Finally, they raise questions about the etiology of out-of-body phenomena and their meaning to individuals who have such experiences.

The economic impact of psychotherapy: a review.

OBJECTIVE: The authors reviewed data involving the impact of providing psychotherapy for psychiatric disorders on costs of care. METHOD: In a search of the MEDLINE database limited to peer-reviewed papers published from 1984 through 1994, 686 articles were identified. Forty-one articles, covering 35 studies, were found in which the intervention tested was psychotherapeutic and the study included measures of outcome that had some implications for cost. The exclusion criteria for reviewing these studies included absence of a comparison group, a focus on medical disorders instead of psychiatric illnesses, and outcomes that did not include cost data or measures from which costs could be inferred. On this basis, 18 of the 35 studies were selected for analysis. The studies were categorized according to whether or not subjects were randomly assigned to study groups. Two reviewers independently read each study to identify the following characteristics: inclusion criteria, exclusion criteria, types of interventions, main outcome variables, sample size, and statistical tests for significant differences between treatments. Outcomes had to include actual cost accounting or data on medical care utilization or work functioning. RESULTS: The findings of eight (80%) of the 10 clinical trials with random assignment and all eight (100%) of the studies without random assignment suggested that psychotherapy reduces total costs. CONCLUSIONS: Psychotherapy appears to have a beneficial impact on a variety of costs when used in the treatment of the most severe psychiatric disorders, including schizophrenia, bipolar affective disorder, and borderline personality disorder. Much of that impact accrues from reductions in inpatient treatment and decreases in work impairment.

A psychodynamic perspective on the clinical impact of insurance review.

The rise of managed care and concurrent utilization review has had a profound impact on the practice of inpatient psychiatry. Little has been written, however, on the clinical impact of the review process itself. The actions of insurance reviewers often result in their being incorporated into the psychopathology of individual patients and into the dynamics of families and institutional settings. The authors apply psychodynamic understanding to a series of case examples to illustrate how concurrent review may promote splitting, impede the patient's ability to separate from the hospital, and paradoxically reinforce the patient's illness. They also explore a number of typical responses of treatment staff and families to the review process. A case vignette demonstrating a sincere effort at mutual collaboration between payers and providers is also presented. This spirit of compromise is proposed as the solution that best serves patient care.

Treatment of borderline patients in a multiple-treater setting.

For all the problems and challenges inherent in a multiple-treater setting, there are great advantages in being part of a treatment team. Colleagues provide a holding and containing function for each other in the treatment of these extraordinarily difficult patients. Marcus observed that "the problem with the sickest patients is that the affects are uncontainable by a single individual. The affects are more easily containable by the group, because at any one moment some members are not under direct threat and, therefore, can maintain an observing ego" (p 251). The different treatment relationships offer the borderline patient numerous opportunities to internalize new modes of object relatedness through the process of reintrojecting what they have projected into others. The cumulative effect of a group of caring professionals who are doing their best to process and understand what is happening can be highly therapeutic.

Transference interpretation in the psychotherapy of borderline patients: a high-risk, high-gain phenomenon.

The effectiveness of transference interpretation in the psychodynamic psychotherapy of patients with borderline personality disorder has been highly controversial. Both highly expressive approaches that stress the value of transference interpretation and supportive strategies that eschew transference work have been advocated in the literature. We review this literature and identify three emerging trends in thought: (1) Primarily interpretive approaches should be reserved for patients with greater levels of ego strength. (2) Whichever technique is used, a strong therapeutic alliance is the foundation of treatment. (3) Expressive and supportive techniques should not be juxtaposed as polarized opposites; supportive interventions often pave the way for transference interpretation. Our psychotherapy process study revealed that transference interpretations tended to have greater impact--both positive and negative--than other interventions made with patients with borderline personality disorder. We conclude that such factors as neuropsychologically based cognitive dysfunction, a history of early trauma, patterns of object relations involving interpersonal distance, masochistic tendencies, and anaclitic rather than introjective psychopathology are among the patient characteristics that influence the impact of transference interpretation on the therapeutic alliance. Bias toward expressive technique and countertransference issues appear to be relevant to the therapist's difficulty in shifting to a more supportive approach when indicated.

Evaluation of intensive inpatient treatment of patients with severe personality disorders.

OBJECTIVE: The purpose of this study was to determine whether severe personality disorders improve or deteriorate with intensive inpatient treatment. METHODS: Overall 216 patients diagnosed as having personality disorders by DSM-III-R criteria were prospectively monitored at two private psychiatric hospitals from admission through discharge to one-year follow-up. RESULTS: Substantial positive change in the sample was recorded at discharge, and the improvements held up at one-year follow-up. The proportion of patients with scores of 50 or more on the Global Assessment Scale was 3.7 percent at the time of admission. By discharge the proportion had increased to 55.1 percent, and by one-year follow-up it had risen to 66.3 percent. CONCLUSIONS: These results suggest that patients with severe personality disorders benefit from intensive inpatient treatment. We found no evidence that hospitalization of such patients is associated with regression or deterioration of function.

The unwed pregnant teenager and her male relationship.

A group of 100 primiparas, 17 years of age and younger, were interviewed one to three days postpartum. From these interviews, the quality of the relationship between the patient and the father of the newborn child was scored in three categories. Contrary to popular opinion about illegitimacy, it was found that in the majority of cases a good, continuing relationship was maintained throughout the pregnancy, despite the fact that 97% of the patients were unmarried. Fully 84% of the fathers of the unborn children has ongoing contacts with the patients; 68% of the fathers reported that they liked the idea of having the baby, whereas only 9% disliked the pregnancies. The relationship scores were compared with the occurrence of complications in the patient's labor and delivery. Statistical analyses revealed that the relationship between the teenage obstetric patient and the father of her child was not associated with the occurrence of complications in the patient's labor and delivery. However, trends indicate a possible association between these two variables.

Patients who hate.

Few experiences in the life of the mental health professional are more unpleasant than being intensely hated by a patient he is trying to help. In most cases the hatred is mitigated by periods where the patient sees the treater as more helpful and less malevolent, a shift that makes the treatment process more tolerable. However, there are patients who hate relentlessly, presenting a challenge that taxes the therapist's emotional and intellectual resources to an extraordinary degree.

Differential diagnosis of altered mind/body perception.

Considerable confusion exists in the psychiatric literature concerned with states of consciousness in which there is an altered perception of the mind/body relationship; related but different terms are often used interchangeably, with a lack of definitional rigor. The purpose of this paper is to bring clarity to this group of related phenomena by differentiating out-of-body experience (OBE) from depersonalization, autoscopic phenomena and schizophrenic body distortions (such as boundary loss), which are the principal entities with which the syndrome may be confused. The problem of variable definition of the syndromes is compounded by the fact that some studies deal with psychiatric or medical patients, others focus on nonpatients, and still others deal with both groups. The fact that some groups of persons with experiences of altered mind/body perception do not define themselves as patients, do not seek treatment, and may not need treatment underscores the need for clarification. Following an explication of the different syndromes and their characteristics, we will briefly consider treatment implications.

Reconsidering the American Psychological Association's policy on sex with former patients: is it justifiable?

This article invites reconsideration of the American Psychological Association's policy permitting sexual involvement between therapists and their former patients under certain conditions. The article (a) restates 5 major concerns about sex after termination that have not been adequately addressed; (b) examines 9 major arguments set forth in support of allowing posttermination sexual relationships, all of which appear ill-founded, fallacious, or misleading; and (c) describes 6 obstacles that seem to hinder attempts to create sound legal and professional policies in this area.

Dynamic therapy in the decade of the brain.

Data from diverse sources suggest that psychotherapy works by changing the functioning of the brain. This observation is part of a larger phenomenon involving neural plasticity. An extraordinary amount of research is demonstrating that neither gene expression nor the anatomy or physiology of the brain is static. Environment and genetics are in an ongoing interaction with one another, and this mutual influence informs our latest understanding of how psychotherapy appears to affect brain functioning. Research on disorders such as schizophrenia, obsessive-compulsive disorder, cancer, and panic disorder provide convincing data in this regard. For a full understanding of the etiology and pathogenesis of mental illness, as well as its treatment, the psychodynamic dimension of meaning must be incorporated.

Lessons to be learned from the study of sexual boundary violations.

The study of sexual boundary violations, through the actual evaluation and treatment of therapists who have engaged in sexual misconduct, reveals that all of us are potentially vulnerable to violations of this nature. A number of lessons can be learned from the detailed examination of these cases. These lessons include the following: (1) There is a difference between the conscious and unconscious intent of the therapist. (2) "Love" in the therapeutic setting is fraught with problems, including the fact that it is often used as a defense against the therapist's own aggression. (3) Supportive therapy and boundaryless therapy often become confused when a therapist switches from an expressive to a supportive approach. (4) The thoughts, feelings, and behaviors that a therapist would most like to keep secret from a supervisor or consultant are the most important issues to discuss with that supervisor or consultant. These observations have a number of implications for prevention. Matters of technique are inevitably conflated with issues of ethical principles so that the teaching of ethics must include discussions of transference, countertransference, and the use of third parties, such as supervisors or consultants, to assist the therapist in the monitoring of professional boundaries.

Obstacles to the dynamic understanding of therapist-patient sexual relations.

Several dynamic resistances appear to interfere with rational and empirically based discourse about therapist-patient sexual misconduct. These resistances include the lure of reductionism and a longing for simplicity; wishes for "political correctness"; gender bias; and confusion about the nature of the trauma in sexual misconduct. We conclude that (1) empirical study may produce unpleasant results; (2) "politically incorrect" models of misconduct merit study with care equal to "politically correct" ones; and (3) those reenactments we call transference-countertransference should be viewed in all their human complexity. Only then will our increased understanding of misconduct offer hope of prevention.

On love and lust in erotic transference.

Intense erotic transference is one of the most powerful and challenging phenomena in clinical psychoanalysis. Powerful longings for love and for sexual gratification are likely to elicit enactments in the analytic setting that interfere with the analyst's ability to maintain a dual state of awareness in which he or she is both a participant in and an observer of the immediate experience with the patient. These enactments occur on a continuum from frank love affairs between patient and analyst to subtle forms of partial transference gratification. Moreover, the two primary elements in the manifest content of erotic transference--love and lust--may be dissociated from one another and may produce significantly different reactions in the analyst.