When is it time to stop? When good enough becomes bad enough.

This article draws on Winnicott's concept of the good enough mother to discuss how to know whether a therapeutic situation is good enough to continue or bad enough to end. This dilemma is explored in terms of clinical syndromes, such as anorexia and pathological gambling, but focuses mainly on analyst-initiated endings, which are termed the 'Casablanca dilemma', based on an amplification of the ending of the film Casablanca. The author goes on to discuss such one-sided endings, drawing on interviews with 40 analysts and therapists about their clinical experience. A typology of bad enough endings is presented. The psychological differences between a good enough analysis as opposed to a bad enough one are explored through the ideas of Winnicott and Neumann.

Cet article s'appuie sur le concept de Winnicott de la mère suffisamment bonne afin de discuter de comment savoir si une situation thérapeutique est suffisamment bonne pour poursuivre ou suffisamment mauvaise pour arrêter. Ce dilemme est étudié du point de vue de syndromes cliniques tels l'anorexie ou l'addiction aux jeux d'argent. L'article se concentre principalement sur les terminaisons initiées par l'analyste, pour lesquelles on parle du « dilemme de Casablanca ¼ en amplification de la fin du film Casablanca. L'auteur explore de telles terminaisons - décidées unilatéralement - s'appuyant sur des entretiens avec 40 analystes et thérapeutes au sujet de leur expérience clinique. L'article présente une typologie des terminaisons suffisamment mauvaises. Il examine les différences entre une analyse suffisamment bonne et une analyse suffisamment mauvaise, à travers les idées de Winnicott et de Neumann.

Este artículo se basa en el concepto de la madre suficientemente buena, de Winnicott, para analizar cómo reconocer cuándo una situación terapéutica es suficientemente buena para continuar o suficientemente mala para concluir. Se explora este dilema en síndromes clínicos, como anorexia y juego patológico, pero se focaliza principalmente en el analista - iniciador de finales, llamado 'el dilema Casablanca', en base a la amplificación del final de la película Casablanca. El autor continúa analizando semejantes finales unilaterales, a partir de entrevistas a cuarenta analistas y terapeutas acerca de su experiencia clínica. Se presenta una tipología de finales suficientemente malos. Se exploran las diferencias psicológicas entre un suficiente buen análisis en oposición a uno suficientemente malo, a través de las ideas de Winnicott y Neumann.

Daniel: psychological development of a master biblical dream interpreter.

This article describes the growth and development of Daniel as a master Biblical dream interpreter. In his clinical use of dreams, he is compared to a contemporary Jungian analyst who faces difficult clinical dilemmas such as interpreting a dream that is forgotten, understanding the difference between a 'big dream' and a personal dream, as well as the situation when a dream is interpreted within a dream. Daniel's technique is compared to traditional Jewish dream rituals. Although the Book of Daniel is usually considered as a series of disconnected episodes, the author argues that the sequence of chapters reveals the process of Daniel's individuation as described by Neumann's concept of centroversion.

Cet article décrit la croissance et le développement de Daniel en tant qu'interprète biblique spécialiste du rêve. Dans son utilisation clinique des rêves, il est comparé à un analyste Jungien contemporain, face à de difficiles dilemmes cliniques tels qu'interpréter un rêve qui est oublié, comprendre la différence entre un « grand rêve ¼ et un rêve personnel, ainsi que la situation dans laquelle un rêve est interprété dans un rêve. La technique de Daniel est comparée aux rituels traditionnels juifs concernant les rêves. Bien que le Livre de Daniel soit généralement considéré comme étant une suite d'épisodes décousus, l'auteur soutient que la séquence des chapitres révèle le processus de l'individuation de Daniel telle que décrite par Neumann par le concept de centroversion.

El presente artículo describe el crecimiento y desarrollo de Daniel como maestro Bíblico intérprete de sueños. En su clásico uso de los sueños, es comparado con un analista Junguiano contemporáneo quien se confronta con difíciles dilemas clínicos, tales como, la interpretación de un sueño que es olvidado, comprender la diferencia entre un 'gran sueño' y un sueño personal, así como también la situación en la que un sueño es interpretado dentro del sueño. La técnica de Daniel es comparada con el ritual tradicional Judaico de los sueños. Si bien el Libro de Daniel es considerado usualmente como una serie de episodios desconectados, el autor argumenta que la secuencia de los capítulos revela el proceso de individuación de Daniel tal como es descripto por Neumann y su concepto de centroversión.

Supervising away from home: clinical, cultural and professional challenges.

This paper explores some challenges of supervising clinical work of trainees, known as 'routers', who live in countries with diverse cultural, social and political traditions, and the analysts who travel to supervise them. It is written as an evolving dialogue between the authors, who explore together the effects of their own culture of origin, and in particular the legacy and values of their own training institutes on the styles and models of analytic supervision. Their dialogue is framed around the meaning of home and experiences of homesickness for analysts working away from home in an interactive field of strangeness in countries where analytical psychology is a relatively new discipline. The authors outline the findings from their own qualitative survey, where other supervisors working abroad, and those they have supervised, describe their experiences and their encounters with difference. The dialogue ends with both authors discussing what they have learned about teaching and supervising abroad, the implications for more flexible use of Jungian concepts, and how such visits have changed their clinical practice in their home countries.

A European consensus on learning objectives for a core communication curriculum in health care professions.

OBJECTIVE: To develop learning objectives for a core communication curriculum for all health care professions and to survey the acceptability and suitability of the curriculum for undergraduate European health care education. METHODS: Learning objectives for a Health Professions Core Communication Curriculum (HPCCC) in undergraduate education were developed based on international literature and expert knowledge by an international group of communication experts representing different health care professions. A Delphi process technique was used to gather feedback and to provide a consensus from various health care disciplines within Europe. RESULTS: 121 communication experts from 15 professional fields and 16 European countries participated in the consensus process. The overall acceptance of the core communication curriculum was high. 61 core communication objectives were rated on a five-point scale and found to be relevant for undergraduate education in health care professions. A thematic analysis revealed the benefits of the HPCCC. CONCLUSIONS AND PRACTICE IMPLICATIONS: Based on a broad European expert consensus, the Health Professions Core Communication Curriculum can be used as a guide for teaching communication inter- and multi-professionally in undergraduate education in health care. It can serve for curriculum development and support the goals of the Bologna process.

An anatomy of conflicts in primary care encounters: a multi-method study.

BACKGROUND: Medical consultations are replete with conflicts, particularly in the current era of explicit and implicit rationing practices in health care organizations. Although such conflicts may challenge the doctor-patient relationship, little is known about them or their consequences. AIMS: To systematically describe the nature of doctor-patient conflicts in medical encounters and the strategies physicians use when faced with conflicts. METHODS: Analysis of 291 videotaped routine encounters with 28 general practitioners, using a novel adaptation of the Roter interaction analysis system software, provided quantitative empirical data on the conflicts and on the communication process. Seven focus groups (56 GPs) provided qualitative insights and guided the analysis. RESULTS: Conflicts were identified in 40% of consultations; 21% of these were related to the rationing of health care resources. In conflictual encounters, both the opening and closing phases of the encounter were shorter than in non-conflictual encounters. In coping with resource rationing, the commonest strategy was to accept the dictates of the system without telling the patients about other options. When conflict of this type occurred, doctors showed more opposition to the patients rather than empathy. CONCLUSIONS: Doctors often face conflicts in their routine work, but resource-related conflicts are especially difficult and expose the dual loyalties of the doctor to the patient and to the system. Insights derived from this research can be used to design training interventions that improve doctors' efficacy in coping with conflicts and ultimately allow them to provide better patient care.

Stimulating ethical awareness during training.

This paper argues for a preventative approach to ethical violations through developing and maintaining ethical awareness in training and in the group life of each society. Rather than teaching ethics as a theoretical subject, a method is proposed that encourages direct personal confrontation with ethical dilemmas through the consideration of key examples, in the Talmudic manner. This develops ethical 'muscles' and allows candidates to explore the dilemmas of what Primo Levi called the 'grey zone' where the boundaries between good and bad are unclear. Several illustrations of such ethical dilemmas are described, as used in workshops that the author has run in several societies and developing groups. In this way, ethical awareness becomes part of the group life of the society so that analysts become an ethical resource for each other.

The Jewish heritage of Ludwig Wittgenstein: its influence on his life and work.

This article discusses two aspects of Wittgenstein's Jewish heritage. First, we try to show that Wittgenstein was acutely aware of his own Jewish heritage and especially concerned about its potential influence on his work. Second, we suggest that the form of his work, specifically, his method of inquiry and the peculiar literary character of his work, bear a striking resemblance to that of Hebrew Talmud. Like other assimilated Jews of Central Europe, Wittgenstein may have been directly or indirectly exposed to Hebraic culture and Talmudic logic. An understanding of Wittgenstein's Jewish heritage provides an important and neglected perspective on his work.

Medical students' ethical, legal and cross-cultural experiences during their clinical studies.

BACKGROUND: Many medical school curricula include training for ethical considerations, legal comprehension, implementation of patients' rights, awareness of cultural differences, and communication skills (ELCE). OBJECTIVES: To explore medical students' perceptions of their ELCE training during the clinical phase as well as the relationship between humanistic practice skills' experiences and the quality of clinical training. METHODS: A cross-sectional survey was carried out in two cohorts during their clinical year period at Tel Aviv University's Sackler Faculty of Medicine at the end of their Internal Medicine and Surgery clerkships in the 2002 academic year. The research tool was an 18 item Likert-type questionnaire (ELCEQ), based on the literature of biomedical ethics, legal aspects and behavior of practice skills. The content validation of the questionnaire was established by consulting experts among the school's faculty. It was circulated among the students by representatives of the Unit of Medical Education. RESULTS: The response rate was 88%. Students reported only a few opportunities for gaining experience in humanistic practice skills. A weak correlation was found between students' assessment of the quality of clinical training and their experiences in humanistic practice skills. CONCLUSIONS: A wider and more relevant range of active experiences in humanistic practice skills should be available to students during the clerkships. Correspondingly, there is a need for the clinical faculty to find innovative ways to internalize their task as role models and ensure that students acquire and are able to practice those skills.

A new approach to developing cross-cultural communication skills.

The need for cross-cultural training (CCT) increases as physicians encounter more culturally diverse patients. However, most medical schools relegate this topic to non-clinical years, hindering skills development. Some residency programs have successfully addressed this deficit by teaching cross-cultural communication skills in a teaching objective structured clinical examination (tOSCE) context. The authors developed and evaluated a CCT workshop designed to teach cross-cultural communication skills to third-year medical students using a tOSCE approach. A 1 and 1/2-day workshop incorporating didactic, group discussion and tOSCE components taught medical students cross-cultural awareness, interviewing skills, working with an interpreter, attention to complementary treatments, and consideration of culture in treatment and prevention. Six standardized patient cases introduced various clinical scenarios and the practical and ethical aspects of cross-cultural care. Student evaluation of the workshop was positive concerning educational value, skills advancement and pertinence to their clinical activities. Survey of students before and after the workshop demonstrated improvement in students' abilities to assess the culture and health beliefs of patients and negotiate issues regarding treatment. CCT in the context of medical student clinical training can be carried out effectively and efficiently using a dedicated multi-modal workshop including standardized patients.

Temenos regained: reflections on the absence of the analyst.

The importance of the temenos as a metaphor to conceptualize therapeutic containment is discussed. Jung drew the analogy between the consulting room and the temenos, at the centre of the Greek Temple as a sacred and inviolate place where the analysand might encounter the Self. Although Jung believed that whether called or not, the gods would appear, under certain conditions, patients may experience 'temenos lost', the loss of the holding function of the analytic space. Two cases are presented in which temenos issues played a central role. In one case, an unorthodox method was used to preserve the analytic container during the absence of the analyst and in the other, the impact of an extra-analytical encounter had a dramatic effect on the holding function of the temenos. A discussion is presented of the appropriate circumstances in which analysts may deviate from traditional analytic practice in order to preserve the temenos and transform a 'temenos lost' into a 'temenos regained'.

A tale of two exposures: a comparison of two approaches to early clinical exposure.

PURPOSE: Early Clinical Exposure (ECE) programs are an increasingly widespread component of undergraduate medical education. Little systematic research exists on the topic. This report compares the approach and cost/benefits of two parallel ECE programs at the Sackler School of Medicine, Tel Aviv University. METHOD: The two ECE programs were compared using student questionnaires, faculty questionnaires, focus groups and participant-observations. RESULTS: ECE for American medical students in Israel was based upon a semi-structured mentoring relationship with a hospital-based specialist, in which students were able to practice interviewing skills. ECE for Israeli students emphasized structured exposure to a wide variety of primary care settings and informal patient contact. Both ECEs were supplemented by campus-based small group discussion. Students, preceptors and group leaders in both ECEs all reported very high levels of satisfaction and perceived impact on medical training. CONCLUSION: There appears to be no "best" way to conduct ECE. The ECE should be tailored to the specific needs and goals of the student population. Further research and international comparison is needed.