Women and Children Last: Reflections on the History of Child Psychoanalysis.

From the very first efforts to analyze children and adolescents to the present day, child and adolescent analysis has been denigrated in the analytic community. It has been viewed as "women's work" and regarded as clinically inferior to the analysis of adults. It has been seen as less important for understanding the psyche and in the training of psychoanalysts. This attitude is rationalized by observations that children and adolescents engage psychological material differently than adults do, so that, it is claimed, child and adolescent analysis is severely limited compared to adult analysis with regard to the material available for analysis. Beliefs that children require socialization lead some child analysts to indoctrinate children and sacrifice a respectful exploratory and uncovering approach. The situation of child analysis reflects larger social phenomenona, namely childism and sexism, the prejudices against children and women, as these prejudices are elaborated in our culture. Like others, child analysts respond to being the objects of prejudice by both isolating ourselves, reacting against the prejudice, and internalizing the prejudice. This paper includes clinical and institutional illustrations of these prejudices in action.

Psychopathia sexualis: sexuality in old and new psychoanalysis.

The different conceptions of sexuality in classical and contemporary psychoanalysis are explored. Freud's misguided theories of sexual or libidinal drives and the Oedipus complex are shown to be defenses against his own traumatic attachment history. The evidence for this is found in a review of his childhood and self-analysis, and further illustrated with the cases reported in the Studies on Hysteria and elsewhere. Modern views of sex turn these old theories on their heads, demonstrating that sexual fantasies and actions are phenomena, unique to each individual, that are themselves in need of explanation. These radically different conceptions of sexuality are illustrated with 3 case histories.

How careproviders can acquire and apply greater wisdom.

In this issue of JCE, Baum-Baicker and Sisti present senior psychoanalysts' views of wisdom. Although views on wisdom differ widely, there is agreement that when ethical conflicts arise, wisdom may be critical in bringing about an optimal result. Here I will present recent empirical findings on wisdom and the ways careproviders may acquire and apply it, especially in ethical conflicts.The findings are not well-known and may seem counterintuitive; I selected them, in large part, for those reasons. A core challenge may be to decide when to give patients standard care and when to make exceptions. In this issue of JCE, Baum-Baicker and Sisti discuss exceptions and Bursztajn and colleagues consider how these exceptions may be further validated as evidence-based treatments.

Clinical wisdom in psychoanalysis and psychodynamic psychotherapy: a philosophical and qualitative analysis.

To precisely define wisdom has been an ongoing task of philosophers for millennia. Investigations into the psychological dimensions of wisdom have revealed several features that make exemplary persons "wise." Contemporary bioethicists took up this concept as they retrieved and adapted Aristotle's intellectual virtue of phronesis for applications in medical contexts. In this article, we build on scholarship in both psychology and medical ethics by providing an account of clinical wisdom qua phronesis in the context of the practice of psychoanalysis and psychodynamic psychotherapy. With the support of qualitative data, we argue that the concept of clinical wisdom in mental healthcare shares several of the key ethical dimensions offered by standard models of phronesis in medical ethics and serves as a useful, albeit overlooked, reference point for a broader development of virtue-based medical ethics. We propose that the features of clinical wisdom are pragmatic skills that include, but are not limited to, an awareness of balance, the acceptance of paradox, and a particular clinical manner that maintains a deep regard for the other. We offer several suggestions for refining training programs and redoubling efforts to provide long-term mentorship opportunities for trainees in clinical mental healthcare in order to cultivate clinical wisdom.

Response: Clinical wisdom and evidence-based medicine are complementary.

A long-debated question in the philosophy of health, and contingent disciplines, is the extent to which wise clinical practice ("clinical wisdom") is, or could be, compatible with empirically validated medicine ("evidence-based medicine"--EBM). Here we respond to Baum-Baicker and Sisti, who not only suggest that these two types of knowledge are divided due to their differing sources, but also that EBM can sometimes even hurt wise clinical practice. We argue that the distinction between EBM and clinical wisdom is poorly defined, unsupported by the methodology employed, and ultimately incorrect; crucial differences exist, we argue, not in the source of a particular piece of clinical knowledge, but in its dependability. In light of this subtle but fundamental revision, we explain how clinical wisdom and EBM are--by necessity--complementary, rather than in conflict. We elaborate on how recognizing this relationship can have far-reaching implications for the domains of clinical practice, medical education, and health policy.

Attending to clinical wisdom.

In response to the article by Baum-Baicker and Sisti, I will consider the kind of wisdom involved in therapeutic listening; the role of life wisdom; and the challenge of imparting clinical wisdom to young health professionals' education.

Some limits of the boundary concept.

A reexamination of the boundary concept and its applicability to different theoretical approaches to psychoanalysis reveals it to be of questionable usefulness in the present climate of psychoanalytic pluralism. In the light of clinical illustrations, it is suggested that an underlying problem with this concept may be a failure to discriminate between technical and moral dimensions. The necessity of separating the legal issues involved is also indicated. Recognizing the existence of separate domains and considering the rules that apply to each are offered as an alternative to focusing on boundary concepts.

The Efficacy of Psychoanalysis and the Analytic Therapies: Reflections of a Psychoanalyst and her Former Patients.

An informal statistical analysis of treatment modalities and succesful outcomes in the 55-year private practice of an experienced psychoanalyst is provided. Clinical examples in this personal account bring emphasis to value of the therapist-patient relationship.

Identification: psychoanalytic and biological perspectives.

In recent attempts to bring psychoanalysis into greater contact with other sciences, a number of works have explicated neural science concepts and phenomena--affect, memory, consciousness--for the psychoanalyst. These efforts have helped analysts build a more scientific foundation for their theory and practice. A related task remains--namely, to take psychoanalytic concepts and see how they relate to other sciences. The concept of identification has a long history in psychoanalytic theory. It is seen in parent-child interactions, in teaching and mentoring relationships, and in psychoanalysis and psychotherapy. Neuropsychology and evolutionary biology have explored the phylogenetic precursors of identification, while genetics and infant observation provide insights into individual processes of identification. Finally, neuroscience, particularly recent studies of mirror neurons, offers information about the biological mechanisms of imitation and the relationship of imitation to identification. Findings from these sciences are presented in an effort to further the psychoanalytic understanding of identification, especially its biological underpinnings.

The coming changes in psychoanalytic education: part I.

The author presents a critical overview of the literature on psychoanalytic education, focusing on criticism regarding structural aspects of our educational institutions. He then presents arguments for the need of radical changes in the organizational structure of institutes, and focuses on the problems of the training analysis system. He proposes concrete solutions for these problems, in the form of changes both in the assignment of responsibilities for the personal analysis of candidates and in the selection and function of supervisors.

[Psychiatry and psychoanalysis: a crazy dialogue]. / Psiquiatría y Psicoanálisis: diálogo de locos.

The relation between psychiatry and psychoanalysis has been and is complex and fertile, in the frame of coincidences and differences. The common sense will be the first point that will allow us to guide the reflection. The hermeneutic treatment of the sense and its opposite, the non sense, will open the way for enquiring a diversity of concepts: 1. A different use of the word. 2. The consequent destination between two ways of the truth. 3. It is extracted from the previous point two positions that I call: psychiatric volunteer and the psychoanalyst's desire. At the end of the article, we explore different positions, but not necessarily incompatible, referred to the suicide act risk.

The place of psychoanalytic treatments within psychiatry.

Psychoanalytic treatments may be necessary when other treatments are ineffective. An empirically grounded framework for the use of these treatments involves sources of evidence from both efficacy and effectiveness studies. Preliminary evidence suggests that psychoanalysis appears to be consistently helpful to patients with milder disorders and somewhat helpful to those with more severe disturbances. A greater number of controlled studies are necessary to confirm these impressions. A multisite process and outcome study is proposed.

The Emperor's clothes: some serious problems in psychoanalytic training.

The author discusses some of the key problems in psychoanalytic training, in particular those problems that stem from the power differential between training analysts and students in training. One effect of this differential can be that some students feel a pressure to comply with their teachers and supervisors, even their training analyst, in ways that can be seriously detrimental to their development. Further, when something goes wrong in a student's training, how is this to be viewed by those in charge of the training? Also, how are complaints dealt with? Is sufficient weight given to external reality? Too often training analysts, and training committees, get into pathologising a student in a process that should be recognised as 'wild analysis in committee', rather than considering more carefully the external realities that may be affecting a student's progress in the training. This 'analysis' in committee should never be allowed. There is an urgency for immediate changes to be made in psychoanalytic training so that the problems discussed, with more care being taken, should be prevented from happening. Too often, however, an institutional resistance to change dominates discussions in committee, and in society meetings, with the result that little or no change takes place even after years of debate.

The translational metaphor in psychoanalysis.

The translational metaphor in psychoanalysis refers to the traditional method of interpreting or restating the meaning of verbal and behavioral acts of a patient in other, presumably more accurate terms that specify the forces and conflicts underlying symptoms. The analyst translates the clinical phenomenology to explain its true meaning and origin. This model of analytic process has been challenged from different vantage points by authors presenting alternative conceptions of therapeutic action. Although the temptation to find and make interpretations of clinical material is difficult to resist, behaving in this way places the analyst in the position of a teacher or diagnostician, seeking a specific etiology, which has not proven fruitful. Despite its historical appeal, I argue that the translational model is a misleading and anachronistic version of what actually occurs in psychoanalysis. I emphasize instead the capacity of analysis to promote the emergence of new forms of representation, or figuration, from the unconscious, using the work of Lacan, Laplanche, and Modell to exemplify this reformulation, and provide clinical illustrations of how it looks in practice.

Sexual misconduct by psychiatrists: the ethical and clinical dilemma of confidentiality.

Psychiatrists have an ethical obligation to expose colleagues who sexually abuse their patients. However, this obligation often conflicts with the ethical obligation of confidentiality. The principled ethical dilemma is grounded in practical clinical considerations. The author suggests systematic use of consultation as a potential method to address both ethical and clinical responsibilities.

Psychoanalytic ecumenism and varieties of psychoanalytic experience.

Using the metaphor of ecumenism, the current status of psychoanalysis and the American Psychoanalytic Association is examined. The dialectical tendencies to oppose and to unify are noted in psychoanalytic theory, technique, and practice, as well as in the administrative and political life of our organization. Fostering tolerance for new hypotheses without sacrificing empirical discrimination, and promoting broad participation without lowering standards confront us as major tasks demanding continuing vigilance and effort.

The analyst's participation: a new look.

Over the past fifteen years or so, advocates of a relational theory of psychoanalytic process have developed a compelling challenge to the classical approach to clinical work. Their critique of a fixed "standard technique," applicable across the board to all analyzable patients, has been particularly effective. The new approach opens the possibility of tailoring technique to individual analysands, negotiating the best way of working within each unique analytic dyad. But despite the openness of relational theory, many of the most influential clinical vignettes in the recent literature emphasize the analyst's risk-taking, engaging patients in a highly personal way that breaks the traditional analytic frame. Various implications of the tendency of relational analysts to emphasize this sort of intervention are discussed, and questions raised about the way this may affect how relational thinking is received.

Countertransference, supervised analysis, and psychoanalytic training requirements.

Because psychoanalysts have an ever expanding appreciation for the many factors that contribute to the psychoanalytic treatment process, they no longer view themselves simply as the receiver of the patient's transferences. When patient and analyst meet in the consulting room, they bring along with them a blend of intrapsychic and external ingredients--including countertransference--that make up the analytic soup. Candidates in psychoanalytic training must contend with even more sources of indirect countertransference reactions (Racker 1968) than experienced graduate analysts, due to aspects of the training experience itself. The author contends that minimum graduation requirements for supervised analyses are one such source of indirect countertransference. Four clinical examples of control analyses demonstrate this form of indirect countertransference during the assessment, opening, middle, and termination phases. These examples are followed by implications and recommendations for didactic psychoanalytic training curricula, countertransference awareness, supervision of control cases, institute governance policies and procedures, publication of clinical material, and future research.

Speaking the unspeakable: institutional reactions to boundary violations by training analysts.

The work of a COPE study group on boundary violations is summarized, with particular focus on the impact on institutes and societies of sexual misconduct by training analysts. Difficulties in evaluating such situations are discussed, and the dynamics of institutional avoidance explicated. In addition, psychodynamic themes that are commonly observed in analysts who engage in sexual boundary violations with their patients are elaborated. Finally, suggestions are made for managing, through existing mechanisms, instances of boundary violations by training analysts.