Comparing Psychoanalytic Process in Consulting Room and Teleconference: A Naturally Occurring Controlled Experiment.

BACKGROUND: In response to COVID-19, clinicians migrated psychoanalyses to videoconference platforms, creating an opportunity for a controlled empirical study in which only the site varied. HYPOTHESES: There will be no differences in the quality of the psychoanalytic process (QAP) in the consulting room (CR) and in videoconference (VC). Individuals' defensive functioning (adaptive style) will be associated with their capacity to maintain the analytic process when treatment moves from CR to VC. Underlying was the concept that empirical research of clinical psychoanalysis is possible. PARTICIPANTS AND METHODS: Forty psychoanalysts of all ranks in the Accreditation Council for Psychoanalytic Education, Inc., accredited programs contributed 50 cases. Participants scored QAP at each site on a 0-to-100 scale. They reported patients' characteristic defense mechanisms using the Defensive Functioning Scale (DFS). DATA ANALYSIS: To minimize bias, investigators calculated median DFS scores from data provided by clinicians. They compared QAP scores in CR and VC for the entire group without and with DFS scores, and for each DFS level (when feasible) using the related-samples Wilcoxon signed-rank test. FINDINGS: There was no difference in QAP between CR and VC for the group as a whole; but QAP of the Minor Image Distorting group degraded significantly from CR to VC. This was the only group showing a significant difference. CONCLUSIONS: While statistical significance may not reflect clinical significance, individual differences in adaptation to telepsychoanalysis warrant further study. Empirical research of phenomena occurring naturally in clinical psychoanalysis appears feasible.

Assessing Patients Who Seek Help Ending Their Lives.

As a result of end-of-life movements in a number of states, psychiatrists may be drawn into the capacity assessment of patients requesting assistance to end their lives. Such assessments cannot follow the mere technicalities of common clinical interviews, not simply because of the finality of the choice, but also because of the limitations of common cognitive assessments. The Committee on Professionalism and Ethics of the Group for the Advancement of Psychiatry consequently proposes an interview for such purposes that explores a patient's emotional capacity through a narrative inquiry about the patient's life, past coping, and reversible emotional states. It is a neutral approach that seeks to understand the patient rather than judge the appropriateness of an end-of-life request.

Challenges presenting in transference and countertransference in the psychodynamic psychotherapy of a military service member.

Complicating the management of the transference-countertransference set for the military psychiatrist is the dilemma of dual agency. This can be a hidden force in the work of most psychiatrists but it is continuous in the field of military health care. The military clinician must candidly engage with this dilemma as it is intrinsic to the mission, "to conserve the fighting strength." In the conduct of a dynamic psychotherapy, the military psychiatrist must craft ways simultaneously to attain both the needs and interests of the individual patient and those of the organization of which he or she is a member. Presented in this article is a case in which the dual agency dilemma manifested itself between the patient and military therapist within the transference-countertransference set. The discussion will center around (a) how this ubiquitous dilemma may present and affect the progress of a psychotherapy, and (b) interventions that will help resolve the conflict. Time honored psychoanalytic principles guiding these interventions include maintenance of therapeutic neutrality, recognition of the therapist's bright and blind spots, and awareness of patterns in the patient's current and past relationships.

Delineating prototypes of training psychotherapy.

Abstract There is no reported research comparing psychotherapy for trainees to psychotherapy for clinical patients. This preliminary study examines similarities and differences between the Training Psychotherapy Experience (TPE), an elective offered to residents in a large psychiatry training program, and psychotherapy conducted by the same clinicians in their private practices (TAU). We used the Psychotherapy Process Q-set (PQS; Ablon & Jones, 1988; Ablon, Levy, & Katzenstein, 2006). All program consultants who perform TPE were offered their standard fee to complete one PQS while envisioning a typical TPE session and another while envisioning a typical TAU session, using their own assessment of what happens in such sessions. These data were subjected to factor analysis to develop prototypes (TAU and TPE) that could be compared with each other and with validated prototypes developed by Ablon and Jones (1998, 2002). Twenty-two of the 25 clinicians who perform TPE (88%) responded to the study. We found two distinct prototypes in both TPE and TAU. One correlated significantly with Ablon and Jones' Cognitive-Behavioral and Interpersonal prototypes, and the other with their Psychodynamic prototype. There was no significant difference between corresponding TPE and TAU prototypes. We conclude, first, TPE offers trainees an experience of psychotherapy that is very similar to psychotherapy of actual patients. Second, experienced clinicians integrate a broad array of useful interventions into both TPE and TAU.

Nonresponse and dropout rates in outcome studies on PTSD: review and methodological considerations.

Post-traumatic stress disorder (PTSD) represents a frequent consequence of a variety of extreme psychological stressors. Lists of empirically supported treatments for PTSD usually include cognitive behavioral therapy (CBT) and eye movement desensitization and reprocessing (EMDR), but nonresponse and dropout rates in these treatments often are high. We review the treatment dropout and nonresponse rates in 55 studies of empirically supported treatments for PTSD, review the literature for predictors of dropout and nonresponse, discuss methodological inconsistencies in the literature that make comparisons across studies difficult, and outline future directions for research. Dropout rates ranged widely and may have depended, at least in part, on the nature of the study population. It was not uncommon to find nonresponse rates as high as 50%. Standard methods of reporting dropout and nonresponse rates are needed for reporting outcomes. We suggest guidelines for collecting data to help identify characteristics and predictors of dropouts and nonresponders.

Contributions of psychodynamic approaches to treatment of PTSD and trauma: a review of the empirical treatment and psychopathology literature.

Reviews of currently empirically supported treatments for post-traumatic stress disorder (PTSD) show that despite their efficacy for many patients, these treatments have high nonresponse and dropout rates. This article develops arguments for the value of psychodynamic approaches for PTSD, based on a review of the empirical psychopathology and treatment literature. Psychodynamic approaches may help address crucial areas in the clinical presentation of PTSD and the sequelae of trauma that are not targeted by currently empirically supported treatments. They may be particularly helpful when treating complex PTSD. Empirical and clinical evidence suggests that psychodynamic approaches may result in improved self-esteem, increased ability to resolve reactions to trauma through improved reflective functioning, increased reliance on mature defenses with concomitant decreased reliance on immature defenses, the internalization of more secure working models of relationships, and improved social functioning. Additionally, psychodynamic psychotherapy tends to result in continued improvement after treatment ends. Additional empirical studies of psychodynamic psychotherapy for PTSD are needed, including randomized controlled outcome studies.

Franklin Delano Jones, M.D., and war psychiatry.

Through a long career that spanned three wars and important changes in patterns of health care, Franklin Delano Jones (1935-2005) provided medical and psychiatric care to the most vulnerable members of our society, civilian as well as military. Recognizing that individuals tend to forget lessons learned in stressful situations, he compiled and codified the essential practices of wartime psychiatry into comprehensive and accessible texts. His neutrality, persistence, and sharp intellect stabilized and strengthened American military psychiatry in the post-Vietnam era. His culminating achievement, War Psychiatry, which is the codified clinical intelligence of several generations of military psychiatrists, is an essential foundation for clinical practice and for research. This article explores Jones'ss contributions, particularly the variations in the presentation of combat stress, the efficacy of the principles of forward treatment, and a comprehensive understanding of posttraumatic stress disorder.

Association of a training psychotherapy, experience with deployment stress in military physicians.

This study examines whether an elective Training Psychotherapy Experience (TPE) confers any specific benefit for those who must engage in military operations. A questionnaire and an Impact of Event Scale--Revised (IES-R) were sent to military physicians who had graduated from the F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences (USUHS) after 1980 and completed residencies in psychiatry, internal medicine, or a combination of the two. Those who participated in TPE and those who did not were compared in respect of demographics and whether they chose to remain in or leave the military after obligation. There was no difference in retention between the two groups. We suggest that this may be due to their medical education having taken place in a military-oriented environment. The IES-R scores confirm earlier findings that deployed medical personnel have fewer psychiatric sequellae than deployed combat troops (Kolkow, Grieger, Morse, & Spira, 2005).

The body remembers: somatic symptoms in traumatized Khmer.

UNLABELLED: Cambodians experienced genocide from 1975 to 1979 and ensuing civil war until 1993. PURPOSE: Are Khmer with a history of trauma who present to a general medical clinic with unexplained physical symptoms more likely than the general population to harbor psychiatric symptoms? METHODS: Subjects were drawn from a Phnom Penh clinic and the surrounding neighborhood. All subjects completed the Stressful Life Events Screening Questionnaire (SLESQ) and the PRIMEMD. Clinic patients with unexplained physical complaints were compared with neighborhood nonpatients. All individuals reporting trauma during the Pol Pot regime were compared to those reporting no such trauma; and those reporting exposure to domestic violence were compared to those without such exposure. FINDINGS: There is an increased incidence of traumatic events, depressive symptoms, general anxiety symptoms, and panic symptoms in the clinical group as compared to the control group. Survivors of genocide-associated trauma reported more somatic complaints and panic symptoms, while survivors of domestic violence had an increased incidence of depressive symptoms, general anxiety symptoms, and panic symptoms. CONCLUSION: Clinicians should consider the possibility of trauma-related psychological distress in patients who present with undiagnosable physical complaints.

A training psychotherapy elective for military psychiatry residents.

A Training Psychotherapy Elective (TPE) was developed to meet the special requirements of military medical education; but the model is generally applicable to all psychiatry training programs. It aims to demonstrate the technique of individual medical psychotherapy by offering residents and fellows an experience of this procedure in a patient role. It affords trainees an opportunity to address healthy curiosities about their mental functioning without the requirement of endorsing a complaint related to a mental disorder. Training psychotherapy follows the technical model that residents learn in their outpatient rotations. Transparent interventions allow trainees both to experience the impact of clarification and interpretation and to see how the therapist derived them from their associations. This facilitates the application of these interventions to work with patients. It also affords trainees an emotionally sheltered environment in which to explore attitudes and concerns associated with their service in military operations, fostering readiness for such assignments.

The contributions of Kenneth Leslie Artiss, M.D.

Kenneth Leslie Artiss (1913-2001) was an Army psychiatrist who did significant investigative work in schizophrenia and milieu therapy and whose broad scholarship led to decisively important and enduring contributions to operational psychiatry. After retirement from military service, he developed a bold approach for teaching psychodynamic theory and its applications, and he led seminars for psychiatry residents and other physicians for over four decades. He was among the first to apply psychodynamic ideas to improve oncology practice. His death in 2001 motivated a group of his military students to memorialize his life and contributions and to demonstrate why they merit continuing consideration.

Evidence-based psychotherapeutics.

Evidence-based medicine requires clinicians to base treatment of their patients on the findings of systematic clinical research. In recent years EBM has become linked with appropriate but also inappropriate efforts at cost containment. Organized psychiatry responded by developing evidence-based practice guidelines and launching a range of clinical research initiatives to determine the effectiveness and efficacy of current psychiatric practices. Psychoanalysis is particularly challenged because it has for most of the 20th century been based on conviction alone. Investigators have now identified the obstacles to research into psychoanalysis and dynamic psychotherapy and are developing techniques to overcome these and to study not only outcomes but also the internal processes of these treatment modalities. We may look forward to an evidence-based psychoanalysis in the 21st century.