Comparative anatomy and phylogenetic distribution of the mammalian cecal appendix.

A recently improved understanding of gut immunity has merged with current thinking in biological and medical science, pointing to an apparent function of the mammalian cecal appendix as a safe-house for symbiotic gut microbes, preserving the flora during times of gastrointestinal infection in societies without modern medicine. This function is potentially a selective force for the evolution and maintenance of the appendix, and provides an impetus for reassessment of the evolution of the appendix. A comparative anatomical approach reveals three apparent morphotypes of the cecal appendix, as well as appendix-like structures in some species that lack a true cecal appendix. Cladistic analyses indicate that the appendix has evolved independently at least twice (at least once in diprotodont marsupials and at least once in Euarchontoglires), shows a highly significant (P < 0.0001) phylogenetic signal in its distribution, and has been maintained in mammalian evolution for 80 million years or longer.

Borderline syndromes in childhood: criteria for diagnosis.

There is currently a great deal of confusion regarding the diagnostic status of children with borderline disorders and a tendency to apply criteria for borderline adults to the diagnosis of these children without allowing for developmental differences. On the basis of their experience with 24 latency-age children, the authors propose diagnostic criteria in an effort to establish a uniformity in the diagnosis of these children. Major areas of psychopathology include fluctuation of functioning, nature and extent of anxiety, thought content and processes, relationships to others, and lack of control. The authors also found a high frequency of organic impairment, physical abuse, and familial disturbance.

Diagnosis and management of major vascular injuries: a review of 200 operative cases.

In a series of 250 civilian vascular injuries, 85 per cent were due to firearms and 50 per cent involved the torso, both of which represent an increased frequency of occurrence over other reports. There were 40 deaths, 31 of which occurred during operation or in the recovery room and were due to irreversible shock or coagulopathy. Of the nine late deaths, failure of the vascular repair was responsible for only three. In 124 extremity artery injuries, there were 12 leg amputations (10%) with shotgun wounds responsible for nine and popliteal artery injuries involved in seven. In gunshot wounds of the aorta and iliac arteries, there were five suture line disruptions in nine primary repairs and no disruptions in 11 patients repaired by grafts. The evidence indicates that an antibiotic soaked dacron graft is the method of choice to repair gunshot wounds of the aorta and iliac arteries at this time.

The elephant on the fence: approaches to the psychotherapy of attention deficit disorder.

Attention Deficit Disorder (ADD) is understood in terms of a complex interaction between neurophysiological growth, environmental demand, and ego-development. Various therapeutic approaches have been recommended, including cognitive training and psychodynamic psychotherapy. Cognitive impairments demand modifications in the usual psychotherapeutic techniques to develop an effective integrated approach to treatment.

Aspects of the treatment of borderline children.

The authors review the history of the concept of borderline children and the criteria for diagnosis. They then outline the various stages of the treatment of these children, paying particular attention to the vicissitudes of the psychotherapeutic relationship and the multifaceted treatment approach, which is essential to their growth and development.

Creative misreading: why we talk past each other.

A close look at Gedo's recent paper on working through reveals a number of devices used in the development of competing psychoanalytic theories, devices which result in analysts talking past each other. Starting with the notion that all theorists "misread" their predecessors, the author examines how different views of the past create confusion in the dialogue between Gedo and his commentators. He then takes up the issue of how data emerging from the neurosciences can be used to support many different psychoanalytic theories and suggests that there will always be a "metaphorical leap" from one frame of reference to the other. Finally, he examines how the drawing of sharp dichotomies both within a theory and between one theory and another misrepresents analytic work and exaggerates differences between one point of view and another. Thus, various devices that are used to buttress one version of analytic theory make it more difficult to develop a more integrated theory and to correlate psychoanalytic data with those emerging from the neurosciences.

Hearing voices: the fate of the analyst's identifications.

Using detailed clinical examples, the author illustrates the function of conscious and unconscious identifications with former training analysts, supervisors, teachers, and theorists in the mind of the working analyst. As compromise formations, analytic identifications are the product of loving and aggressive wishes, defenses against those wishes, and self-punitive trends that accompany the analyst in the work. The analyst's stance at any given moment has an identificatory history that may become conscious at certain times with certain patients. While the analyst's identifications modify over time, following a predictable developmental path, they are never fully given up, but consciously and unconsciously remain an active part of the analyst's inner life. During the clinical hour they are responsive to both the analyst's and the patient's conflicts, and they coexist in a dynamic reciprocal relationship with the patient's inner life.

Subjectivity and objectivity in analytic listening.

Analysts use the concepts of subjectivity and intersubjectivity to support many different technical recommendations; this represents a misuse of theory. The dichotomy between subjectivity and objectivity is a false one. Arguing against the notion of objectivity, analysts conflate it with the idealized notion of pure objectivity and then eliminate various technical devices in its name. One cannot have a concept of subjectivity without a concept of objectivity, or an intersubjective perspective that does not include some agreed-upon concept of objectivity. The simplest definition of objectivity is a directional one. Objectivity is the perception or experience of the external; subjectivity is the perception or experience of the internal. Subjectivity and objectivity are both necessary pathways to knowledge and are dependent on each other. Any form of looking or listening does to some extent preclude another, but to speak solely from a subjective or an objective perspective represents a regression in thinking to a form of naive objectivism or naive subjectivism. Clinical examples illustrate how the forming and testing of hypotheses require the cooperation of both subjective and objective listening.

Introduction: Gedo and Freud on working through.

In this issue we begin an experiment. John Gedo has graciously given us permission to publish his plenary address with a series of brief commentaries, which are followed by a response ("Encore") from Dr. Gedo. You will note that some of the discussants take up an aspect of his point of view, while others elaborate on an aspect of the topic. The result might be called a "round table" on working through. We invite JAPA readers to join in the discussion with written comments. We would aim in this way to keep alive in the Journal a sense of the vitality of argument found at our meetings and so to advance the work and its theoretical basis. We are grateful to the discussants and especially to Dr. Gedo for his patience with our scrutiny and his engagement with our responses.

Countertransference, conflictual listening, and the analytic object relationship.

Analytic listening is an ongoing conflictual process, containing all the components of conflict and shaped in every moment by both the patient's and the analyst's conflicts. The mutual responsiveness that develops between analyst and patient stems from a complex conflictual object relationship, fundamentally no different from any other object relationship, in which countertransference at all times simultaneously facilitates and interferes with the analytic work. Detailed clinical process is used to illustrate these and related phenomena, including the use of signal conflict, the benign negative countertransference, the function of countertransference structures, and the analyst's use of projection. The analyst's affects, thoughts, and actions trace the shifting nature of the patient's transference and resistance, and the level of the object relationship continuously being created between patient and analyst.

Studies in listening: when patients talk about their patients.

The literature is curiously silent about special challenges in the analysis of psychotherapists, including the interactive tensions that result when analysands talk about their own patients. When analysands talk about their patients, the analyst may be deflected away from a focus on the analysand's intrapsychic experience by transient identifications with the analysand's patient and by multiple identificatory processes which press the material away from mutually observed metaphor toward enactment and actualisation. Using detailed illustrations of the clinical process when patients talk about their patients, the author illustrates the manner in which the analyst's listening itself may be drawn into the process of enactment and explores how transference-countertransference interactions alter both the analyst's and the patient's listening. These interactions and identifications are compared to the triadic identificatory processes that lead to what has been called the 'parallel phenomenon' in supervision. Because the challenges that arise when patients talk about their own patients may be of more general significance, they merit further study.

Cues: the perceptual edge of the transference.

In spite of Freud's recommendation in his postscript to Dora, analysts may neglect, as Schwaber has pointed out, the patient's perception of the analyst's participation in the analytic context. Examination of the patient's experience of the 'external', by attending to the patient's search for and use of perceptual cues, can lead to essential aspects of the patient's intrapsychic life. Beginning with the description of a particular analytic intervention, the author discusses the nature of cues, their origins developmentally, their role in the development of transference and in the generation of a particular form of resistance, and their place in the ongoing clarification of the transference, countertransference and the analyst's technique. The author then contrasts the approach described with positions taken by Langs, Gill and Sandler, and discusses why Freud's recommendations may have been neglected.

Towards an international dialogue. North American reflections on the Santiago Congress.

In this brief reflection on the Santiago Congress, an attempt is made to clarify some of our difficulties in international dialogue. The fantasy persists that there is only one psychoanalytic mother tongue; alongside is the wish that European, Latin American and North American approaches might be integrated. Is such integration possible or desirable? In making clinical observations are we all looking at the same phenomena and putting them into different words, or are our observations irreconcilable? It is suggested that common ground might exist more readily on some levels of abstraction than on others and that North American conceptualisations might coexist with European and Latin American conceptualisations on separate levels of abstraction. An argument is made for a reconsideration of quantitative and energic factors, especially in the realm of affect and representation, and a reintegration of such notions into structural theory. Because the tight linkage we habitually draw between theory and practice may not accurately reflect the analyst's mind at work, we cannot study too frequently the details of the clinical hour, including what we observe ourselves thinking and doing.

Analytic listening and the experience of surprise.

The analyst's experience of surprise, its relation to different models of analytic listening and its function in the analytic process is illustrated and explored through a series of clinical vignettes. Surprise is a crucial affective ingredient of the analyst's attention and data-gathering. It is multiply determined and inevitably reflects some discovery or rediscovery on the part of the analyst about both the patient and the analyst. In the dynamic tension of the analyst's listening there is always an interplay between expectation and surprise, as each new facet of the patient's conflictual organisation is revealed. Evenly-hovering attention entails the setting aside of conscious expectation and so maximises the potential for curiosity, surprise and discovery. The author describes the relation of surprise to transient identifications with the patient and to the interventions that result, the relation of surprise to the sense of the uncanny, and the shifts in the analyst's defensive organisation that allow for the experience of surprise. Several vignettes illustrate the interplay of the analyst's and the patient's psychologies and the manner in which surprise may alert the analyst to mutually-created resistances and enactments, which may appear to be discrete phenomena, but are in fact continuous processes, intrinsic to the work.

Time, reconstruction and psychic reality.

This paper illustrates certain relationships between the concepts of time, reconstruction and psychic reality as they appear in the clinical situation. A case example introduces the literature concerning the difficulty of knowing over time "what actually happened." Arlow's model of the two projectors, which has been used to describe psychic reality, is extended from a developmental point of view. Two further case examples then illustrate how attention to the patient's unique psychic reality can lead to different reconstructive problems and interventions. The two case examples raise certain questions about the nature of early experience and the role of external reality. The conclusion takes a broader view of the relationships between time, reconstruction and psychic reality utilizing two examples from contemporary Western literature.