The Role of Psychoeducation in Psychodynamic Psychotherapy.

Psychoanalysts have generally avoided discussion of psychoeducational interventions in the context of psychodynamic psychotherapy, despite education being a component of many psychoanalytic techniques. This wariness stems from Freud's early concerns about interventions that could be deemed "suggestion," and a misunderstanding of various aspects of neutrality, including viewing psychoeducational comments as over-gratifying or siding with the ego. Although potential pitfalls exist, the authors review clinical evidence and research that indicate the value of psychoeducational approaches for engaging patients in psychodynamic psychotherapy, considering alternative treatments, providing a psychodynamic formulation, and enhancing the therapeutic alliance. In this context there has been increasing inclusion of psychoeducational interventions in clinical descriptions and manuals of psychodynamic psychotherapy. Various aspects of psychoeducation are described, including education about the patient's problems, how the treatment works, how the mind works, relevant information from other areas of psychology and neuroscience, and how the world works. A case example is provided that further demonstrates the value of psychoeducation in the clinical setting.

New Developments of the Therapeutic Alliance (TA): Good News for Psychodynamic Psychiatry.

Clinicians have long known that successful psychotherapy, including successful psychodynamic psychotherapy, depends upon the interaction between therapist and patient. In other words, it is important to have a strong therapeutic alliance. This article presents the history of the concept of the therapeutic alliance (TA). It also explores three areas of research that have bearing on the TA. The importance of the TA and the extensive research work that pertains to it hold promise for psychodynamic psychiatry, both in terms of understanding, and in the treatment of mental suffering.

Transference-focused psychotherapy training during residency: an aide to learning psychodynamic psychotherapy.

Competency in psychodynamic psychotherapy is a requirement for residency training in psychiatry. However, for a variety of reasons, learning psychodynamic psychotherapy is difficult for residents. In this article, we share our experience in an elective in Transference-Focused Psychotherapy (TFP), a manualized treatment for severe personality disorders. Originally, this elective was conceptualized as an advanced component of training, offering specialized training in treating a subgroup of patients with severe personality disorders with a specific type of psychodynamic psychotherapy. However, contrary to the expectations of the residents and the training director, the elective in TFP strengthened understanding of core components of basic psychodynamic psychotherapy with all patients, not just those with severe personality disorders. We discuss various challenges in learning psychodynamic psychotherapy and how TFP served to address them. Two case vignettes illustrate several key points.

The challenge of treating (and supervising) patients with borderline pathology in a residents' clinic.

Outpatients with borderline personality disorder (BPD) comprise up to 20% of psychiatry clinics, to which they are usually referred for treatment, not of their Axis II pathology but for comorbid Axis I conditions. The complex and intense transference and countertransference dynamics that patients with even "secondary" BPD evoke in psychotherapy treatments require careful handling and supervision. Cases can quickly lose focus, with resultant morbidity for both patient and treater alike. Little literature exists to guide supervision of psychiatry trainees treating outpatients with BPD and Axis I illness. We describe a case of a young woman with BPD with a comorbid major depressive episode (MDE) who was treated by a third-year psychiatry resident with a mixture of supportive and dynamic psychotherapy and medication management. The treatment rapidly became chaotic, with escalating levels of patient acting out and resident dissatisfaction. We outline suggestions for supervision of resident treatment of patients with comorbid or primary BPD, including importance of careful intake assessment and treatment formulation, the establishment of a clear-cut frame and/or treatment contract, and the need for contextualizing expectable transference and countertransference reactions. Last, we discuss the pros and cons of mixing psychotherapy techniques within the same treatment.

Psychoanalytic lexicography: notes from two "harmless drudges".

The co-Editors in Chief of the American Psychoanalytic Association's new edition of Psychoanalytic Terms and Concepts (previously edited by Moore and Fine and last revised in 1990) recount their lexicographical adventures. Editing a dictionary at the turn of the twenty-first century is a daunting, some might say foolhardy, undertaking. The most obvious challenge faced by the editors was the growing pluralism within psychoanalysis. However, a more fundamental challenge was that the object of psychoanalytic study, the mind and its processes, can be known only by putting words to our observations, inferences, and interpretations. Psychoanalytic thinkers, starting with Freud, have wrestled with this challenge in ways that define the history of psychoanalysis itself. Long gone are the days when Freud could commend the "correctness" of Sterba's lexicographical efforts. Today postmodern critics, at the opposite extreme, argue that terms and concepts are best understood as "verbal gestures" in the "language-game" of psychoanalysis. Some go so far as to assert that dictionary-writing is obsolete. The co-Editors in Chief of Psychoanalytic Terms and Concepts have not succumbed to such nihilistic views, but have instead struggled to establish a reasonable stance within contemporary debates over the nature of psychoanalytic language.

A reassessment of psychoanalytic education: controversies and changes.

To understand the many controversies surrounding psychoanalytic education, it is necessary first to understand the unique role played by education in our field where control of educational structures remains the most important measure of professional success for the majority of psychoanalysts. To keep debate about educational policy focused on the task of strengthening the intellectual basis of psychoanalysis, it is also necessary to understand that forces affecting education arise from at least three different domains which can too easily become confused with one another: 1) the domain of knowledge--intellectual, scientific and clinical; 2) the domain of the organized professional community; and 3) the domain of local institutional politics. The authors explore controversy arising within and among each of these domains. They also explore the major alternatives proposed to the Eitingon model of psychoanalytic education, arguing that excessive authoritarianism in education arises not from the existence of hierarchical structures per se (as suggested by the 'French model'), but from two other factors: the condensation of all important professional functions into the single 'monolithic' position of the training analyst, and the lack of agreed upon methodology for determining the validity of theoretical propositions. The solution lies not in obliterating all gaps in expertise and status by doing away with hierarchical structures altogether, but rather in strengthening the intellectual, scholarly and research context within which psychoanalytic education takes place. We must attempt to relocate our experience of a gap where it belongs: not between those who are training analysts and those who are not, but between what we feel we already know about mental life and what we do not yet know.