Money Matters in Psychiatric Assessment, Case Formulation, Treatment Planning, and Ongoing Psychotherapy: Clinical Psychoeconomics.

ABSTRACT: Trainees often receive little guidance concerning money matters in patients' lives and treatment, that is, clinical psycho-economics. Accordingly, this article considers: a) practical approaches to inquiring about intrapsychic and interpersonal influences of money matters pertinent to psychiatric assessment; b) how money matters should impact case formulation; c) how money matters realistically impact treatment planning; and d) money matters in ongoing psychotherapy affecting transference, countertransference, and clinical supervision. To supplement their clinical experiences, the authors conducted a limited narrative review via PubMed, followed by snowballing for articles of interest. Evidence suggests that money matters influencing intrapsychic and interpersonal lives commonly cause emotional distress, generating a range of dysfunctional behaviors. These reactions manifest as explicit conflicts, implicit issues, and unequivocal money-related pathologies. Clinical vignettes illustrate specific issues. By explicitly addressing money matters in patient's intrapsychic and interpersonal lives, trainees can enrich their assessments, case formulations, treatment planning, and ongoing psychotherapy.

When the Assessor's Limits Are Tested: Enactments and the Assessment Frame in Psychological Testing.

Limit testing in psychological assessment is understood typically as a unidirectional technique in which the assessor intentionally introduces a parameter(s) in the service of data gathering by modifying standard procedures. Other parameters are introduced as conflict-based enactments tied to projective identification processes, and represent modifications in the assessment framework. Such modifications, abstracted from the psychotherapy literature, include atypical shifts in the assessor's usual practices concerning fees, scheduling, confidentiality, privacy, anonymity, administrative and technical procedure, and intervention style. In this article, I suggest that most framework modifications, if analyzed, hold the promise of an incremental data yield. These points are illustrated through discussion of (a) the assessment frame, enactments, and projective identification; (b) transference-countertransference interplay in response to frame issues; (c) 2 Rorschach responses that symbolically reflect enactments and projective identification; (d) interaction with coding consultants; (e) configurational analyses of the Rorschach responses; (f) patient-assessor and assessor-consultant parallel processes; and (g) test feedback.

Augmenting Psychiatric Risk Management: Practical Applications of Transference- Focused Psychotherapy (TFP) Principles.

Risk management challenges in psychiatry are made more complicated when they involve the treatment of patients with primary or co-occurring personality disorder pathology. Principles of transference-focused psychotherapy (TFP), a treatment empirically validated for borderline personality disorder (BPD) and with utility for patients with varying personality disorder presentations, are practical, commonsense measures that can guide clinicians in these difficult matters. Applied TFP principles are useful in this area even when clinicians are not engaged in an extended individual psychotherapy. Central to the TFP approach are: (1) an openness to identifying personality disorder pathology; (2) a deliberate process to assess personality disorder diagnoses with attention to severity of illness; (3) an emphasis on the informed consent process, which includes sharing fully with the patient the clinician's diagnostic impression with germane psychoeducation; (4) an expectation for timely contacts at the outset of treatment with prior practitioners and with family members, when indicated; and (5) the development and maintenance of a treatment frame. TFP stresses the active monitoring of three channels of communication (what the patient says, how the patient behaves, and the clinician's countertransference) as a guiding precept that informs clinical decision-making. TFP principles can serve as a useful risk management "checklist" by organizing a clinician's approach to inherently confounding material.

The Economy of the Totalitarian Mind: the Case of the Immigrant Child.

Immigration in early childhood can be considered as a traumatic situation. It often goes unrecognized since children adapt to most conditions and conform to their environment with astonishing agility. Inspired by the sensitive work of Sándor Ferenczi, and Donald Winnicott, regarding the psychic economy of maturational processes, the author explores the concept of totalitarian functioning and its obstruction of the growing psyche. Before birth we are all totalitarian, one with the mother; this symbiotic, invincible state of survival mode is prolonged as the immature newborn child ignores the requirements of reality and enjoys omnipotent pleasure through hallucination. The loss of place in immigration often becomes the loss of identity-the question of "where am I?" becomes confused with "who am I?". Clinical practice exposes this fragility in adults torn from their home environment at an early age, forced into precocious maturity, never to grow up in reality. Through clinical examples, the author illustrates how totalitarian mental functioning of "all or nothing, right or wrong, black or white" is exposed in the transference and can be worked through within the psychoanalytical space.

["There can be no unnecessary risks"]. / « Il ne saurait y avoir de risque inutile ¼.

The psychoanalytical point of view regarding the notion of risks helps us to understand the concept of transference and counter transference. Practice analysis groups provide an opportunity for collective discussion and the sharing of experience of clinical situations. Interview with Didier Gauchy, a psychiatrist-psychoanalyst in Lyon.

External and internal reality: the impact of the current socio-economic crisis on the analytic dyad.

This paper addresses the impact of the current economic crisis on the psychic functioning of the patient and the analyst, their relationship and collaboration. This intrusion of 'external reality' is multidimensional, and thus with multiple meanings. The critical role of the economic factor brings various dimensions of money into play, such as self-preservation, power as well as aspects of psychosexual development. In addition, the crisis involves symbolic loss of basic ideals such as honesty and social responsibility. Patient and analyst are affected in similar and different ways in their respective roles as well as according to the specific intrapsychic functioning of each. Moreover, unique characteristics of the crisis often create a crisis in the analysis. In order to avoid deformation of the analytic relationship, the analytic dyad must examine and work through the multiple meanings of the crisis as well as the meaning of the impact of the crisis on the analytic relationship for both patient and analyst. This complex transference- countertransference interplay poses specific challenges to the analyst. After discussion of these issues, clinical material is presented that demonstrates how they appear in analytic practice today.

Political and clinical developments in analytical psychology, 1972-2014: subjectivity, equality and diversity-inside and outside the consulting room.

Utilizing Jung's idea of theory as a 'personal confession', the author charts his own development as a theorist, establishing links between his personal history and his ideas. Such links include his relationship with both parents, his sexuality, his cultural heritage, and his fascination with Tricksters and with Hermes. There follows a substantial critical interrogation of what the author discerns as the two main lines of clinical theorizing in contemporary analytical psychotherapy: interpretation of transference-countertransference, and the relational approach. His conclusion is that neither is superior to the other and neither is in fact adequate as a basis for clinical work. The focus then shifts to explore a range of political and social aspects of the clinical project of analytical psychology: economic inequality, diversity within the professional field, and Jung's controversial ideas about Jews and Africans. The author calls for an apology from the 'Jungian community' for remarks about Africans analogous to the apology already issued for remarks about Jews. The paper is dedicated to the author's friend Fred Plaut (1913-2009).

O dinheiro sacrifical / Sacrifice money

Neste artigo o autor aborda o dinheiro postulando-o como morto-vivo. Este tipo de objeto não é mero receptor passivo de projeção, e sim gerador de efeitos subjetivantes e dessubjetivantes nos indivíduos e na trama social. Com uma descrição sucinta do dinheiro se postula uma origem sacrifical do mesmo e se assevera que o dinheiro por si mesmo implica posições sadomasoquistas para o próprio sujeito e para o entorno social. Finalmente, mostra como o valor masoquista se faz presente no intercâmbio econômico durante os tratamentos analíticos.

In this paper it is said that the money is considered as a dead-living object. Such kind of objects are not passive recipients of projection but have subjectivism or de-subjectivism effects on the individuals and the social context. After a brief description of money as sacrificial source it is postulate that money carries itself carries violence and masochism. Moreover, money is thought of as the major vehicle of masochism that society has created. Finely it is shown how masochistic value is present in the economic exchange during the analytical treatments.

Effectiveness and cost effectiveness of Davanloo's intensive short-term dynamic psychotherapy: does unlocking the unconscious make a difference?

More than 20 years ago Habib Davanloo coined the term unlocking of the unconscious to describe how the psychodynamic concept of the human unconscious can become accessible using the technique of Intensive Short-Term Dynamic Psychotherapy (ISTDP). According to Davanloo, the possibility that unconscious material will be revealed is greatly increased when therapeutic efforts promote dominance of the unconscious therapeutic alliance over unconscious resistance. When these ingredients are present there is a psychic shift that allows unacceptable painful feelings to come to the surface. Toward adding further empirical support for the concept, in this article we compare outcomes between patients who experienced one or more major unlocking of the unconscious (N = 57) to those who did not experience major unlocking (N = 32) during ISTDP treatment. Significant and widespread differences were seen between these two groups, those with major unlocking had greater symptom reduction, interpersonal gains, and cost reduction for treatment. The relevance of this to clinical practice and healthcare utilization will be discussed.

Assessment of evaluation of transference support and training impact on the work of nurses.

OBJECTIVES: to assess the impact of the Training Course on Prevention and Treatment of PU, in width and depth; to observe and analyze the variables of transference support of training, offered by the organization and to verify the existence of the relationship between transference support and training impact. METHODS: this was a quantitative study, in which data were collected through the application of Likert-type instruments, conducted with 75 nurses participating in a training at a hospital organization in São Paulo city. Data were analyzed statistically. RESULTS: there was a positive impact in width and depth, and the variables of transference support were strongly related to the impact, and situational factors of support were the main predictors of impact. CONCLUSION: the results pointed toward pathways to redirect the practice of instructional actions in the work environment of individuals in the study scenario and in similar situations that occur in organizations.

Self-reflection in cognitive behavioural therapy and supervision.

OBJECTIVE: Supervision is a basic part of training and ongoing education in cognitive behavioural therapy. Self-reflection is an important part of supervision. The conscious understanding of one's own emotions, feelings, thoughts, and attitudes at the time of their occurrence, and the ability to continuously follow and recognize them are among the most important abilities of both therapists and supervisors. The objective of this article is to review aspects related to supervision in cognitive behavioural therapy and self-reflection in the literature. METHODS: This is a narrative review. A literature review was performed using the PubMed, SciVerse Scopus, and Web of Science databases; additional references were found through bibliography reviews of relevant articles published prior to July 2011. The databases were searched for articles containing the following keywords: cognitive behavioural therapy, self-reflection, therapeutic relationship, training, supervision, transference, and countertransference. The review also includes information from monographs referred to by other reviews. RESULTS: We discuss conceptual aspects related to supervision and the role of self-reflection. Self-reflection in therapy is a continuous process which is essential for the establishment of a therapeutic relationship, the professional growth of the therapist, and the ongoing development of therapeutic skills. Recognizing one's own emotions is a basic skill from which other skills necessary for both therapy and emotional self-control stem. Therapists who are skilled in understanding their inner emotions during their encounters with clients are better at making decisions, distinguishing their needs from their clients' needs, understanding transference and countertransference, and considering an optimal response at any time during a session. They know how to handle their feelings so that these correspond with the situation and their response is in the client's best interest. The ability to self-reflect increases the ability to perceive other people's inner emotions, kindles altruism, and increases attunement to subtle signals indicating what others need or want. Self-reflection may be practised by the therapists themselves using traditional cognitive behavioural therapy techniques, or it may be learned in the course of supervision. If therapists are unable to recognize their own thoughts and feelings, or the effects of their attitudes in a therapeutic situation, then they are helpless against these thoughts and feelings, which may control the therapist's behaviour to the disadvantage of the client and therapist alike. CONCLUSION: Training and supervision focused on self-reflection are beneficial to both supervisees and their clients. The more experienced the supervisor is, the more self-reflection used in therapy and supervision.

The cost-effectiveness of short-term psychodynamic psychotherapy and solution-focused therapy in the treatment of depressive and anxiety disorders during a one-year follow-up.

BACKGROUND: Mood and anxiety disorders are characterized by a high and increasing prevalence, they cause a lot of costs and human suffering and there are many treatment options with differing costs. The benefits of identifying the treatments with the most favourable cost-effectiveness ratios can be substantial. However, the number of randomized trials where psychological treatments are compared with each other and where economic aspects, too, are taken into account is still relatively small. AIM: To compare the cost-effectiveness of two short-term psychotherapies in the treatment of depressive and anxiety disorders during a one-year follow-up. METHODS: In the Helsinki Psychotherapy Study, 198 patients, who were 20--45 years of age and met DSM-IV criteria for anxiety or mood disorder, were randomized to short-term psychodynamic psychotherapy (SPP) or solution-focused therapy (SFT). Psychiatric symptoms were assessed at baseline and 4 times during the one-year follow-up from the start of therapy using the Beck Depression Inventory and the Symptom Check List Anxiety Scale, and 2 times using the Hamilton Depression Rating Scales and Hamilton Anxiety Rating Scales. Both direct costs (therapy sessions, outpatient visits, medication, inpatient care) and indirect costs (production losses due to work absenteeism, value of neglected household work, lost leisure time and unpaid help received) due to mental disorders were measured. Mean total costs were compared and incremental cost-effectiveness ratios analyzed. RESULTS: According to all 4 psychiatric outcome measures, symptoms of depression and anxiety were reduced statistically significantly in both therapy groups during the one-year follow-up. The relative changes were about the same size according to all four outcome measures. In both groups the reductions took place mainly in the first half of the follow-up. The reductions were somewhat greater with SPP, but the differences between the two groups were small and not statistically significant at any measurement point. The mean total direct costs were 1791 euros in the SPP group, being 346 euros (16%) lower than those of the SFT group, but this difference was not statistically significant either. Also the incremental cost-effectiveness ratio points calculated by 500 bootstrap iterations favoured SPP. The total indirect costs in the SPP group were, in contrast to direct costs, higher than those in the SFT group, but, again, the difference was not statistically significant. LIMITATIONS: The generalization of our results may be weakened by the fact that the patients included in our study were relatively young, and the follow-up period was restricted to one year. IMPLICATIONS: This study suggests that there are no notable differences in cost-effectiveness between SPP and SFT. If one were obliged to choose between these two therapies our results would support the choice of SPP. However, more research with extensive data about both costs and effectiveness, compiled over a period longer than one year, are needed before any firm conclusions can be drawn about the cost-effectiveness of the two therapies compared in this study.

Implications of attachment theory and research for the assessment and treatment of eating disorders.

In this paper, we review the research literature on attachment and eating disorders and suggest a framework for assessing and treating attachment functioning in patients with an eating disorder. Treatment outcomes for individuals with eating disorders tend to be moderate. Those with attachment-associated insecurities are likely to be the least to benefit from current symptom-focused therapies. We describe the common attachment categories (secure, avoidant, anxious), and then describe domains of attachment functioning within each category: affect regulation, interpersonal style, coherence of mind, and reflective functioning. We also note the impact of disorganized mental states related to loss or trauma. Assessing these domains of attachment functioning can guide focused interventions in the psychotherapy of eating disorders. Case examples are presented to illustrate assessment, case formulation, and group psychotherapy of eating disorders that are informed by attachment theory. Tailoring treatments to improve attachment functioning for patients with an eating disorder will likely result in better outcomes for those suffering from these particularly burdensome disorders.

Preparing for DSM 5 - assessment of personality pathology during psychoanalytic and psychiatric treatments.

BACKGROUND: Currently, the conceptualization and treatment of personality pathologies are mainly theory driven. The resulting categorical classification of personality disorders leads to inaccurate diagnoses and is therefore being criticized by many researchers and clinicians. A consensus exists that in the upcoming edition of the DSM (DSM 5), the classification of personality disorders should rather adopt a dimensional approach, where patients are assessed depending on their character traits, inner-defense mechanisms, and interpersonal functioning. However, the basis (theoretical or empirical) of this classification-system is still a topic of dispute. This study presents assessment methods based on both theoretical and empirical assumptions. OBJECTIVE: To determine whether psychodynamic instruments employed in psychoanalytic settings are also useful for measuring changes in personality pathology in psychiatric inpatient settings. METHODS: Matched pairs between two groups of patients, one receiving outpatient psychoanalytic care (n = 10; mean age 36 ± 11), the other inpatient social-psychiatric treatment (n = 10; mean age 27 ± 6), were created and subsequently analyzed (mean observation period 20 ± 11 days). Patients were assessed using psychodynamic instruments measuring changes in quality of object relations (QORS) and affect regulation and experience (AREQ). To allow conclusions concerning the respective mechanisms of change, the influence of the therapeutic relationship, measured by using instruments evaluating transference (PRQ) and countertransference (CTQ) patterns, was also assessed. RESULTS: The instruments aforementioned were shown to be suited for both psychoanalytic and psychiatric patients. Typical short-term developments of the distinctive therapeutic procedures were evident; however, in both settings a positive working alliance was shown to be crucial for therapeutic progress. CONCLUSION: The psychodynamic instruments introduced in this study proved to be effective in measuring personality pathology in psychiatric inpatients and in helping clinicians throughout the indication and recommendation process during transition from inpatient to outpatient treatment. Since components of such assessment methods are being considered for DSM 5, their practical utility is shown in this study.

Psychodynamic aspects of psychopharmacology.

This paper presents a framework for understanding the psychodynamic issues pertaining to psychopharmacology. It examines the treatment situation from three perspectives: the self-in-relation-to-others, the patient-prescriber relationship, and cultural attitudes. It discusses psychodynamic factors involved in clinical improvement and deterioration. The relevance of these issues is discussed and contrasted with the biomedical model of mental illness. It concludes by advocating the mindfulness of psychodynamic factors and the maintenance of dialectics in clinical practice.

Payment as perverse defense.

A case is discussed in which the patient's management of aspects of the payment process is seen as a focal point in a perverse defensive structure operating in the treatment. Detailed process material is examined with attention to transference and countertransference components of this defensive process. Recent literature on perverse thought and defense is reviewed in order to understand this case in the context of current thinking, to generate new ideas about the nature of perverse defenses, and to consider the potentially special role that money may play in the operation of such defenses in psychoanalysis.

Gateway health behaviors in college students: investigating transfer and compensation effects.

OBJECTIVE: There is a dearth of studies on the mechanisms of multiple risk behaviors, even though these behaviors are significant public health issues. The authors investigated whether health behavior interventions have transfer or compensatory effects on other health behaviors. PARTICIPANTS AND METHODS: The authors looked at transfer and compensation effects of 3 health behaviors (smoking, alcohol use, and physical activity) in a sample of college students aged 18 to 25 years (N = 973; 84% born in the United States; 50% female; 25% Japanese, 19% Caucasian, 16% mixed). RESULTS: The study revealed the following evidence for transfer effects: (1) nonsmokers consume less alcohol, (2) regularly active people smoke less, and (3) nondrinkers smoke less. The authors also found the following compensation effects: (1) regularly active people consume alcohol more frequently; and (2) alcohol drinkers are more active. CONCLUSIONS: Interventions involving college students' smoking, alcohol use, and physical activity need to take into account both transfer and compensation considerations to maximize health impacts.

The conversation group: using group psychoanalytic techniques to resolve resistances of recently immigrated Chinese students to learning English in a high school setting.

Does group psychoanalytic theory and technique have an application in an ordinary high school classroom? In this article, the writer describes a research project in which she attempts to answer this question by applying the techniques with a group of recently immigrated Chinese students who wished to improve their spoken English.