Charismatic leadership, boundary issues, and collusion.

The authors suggest that a charismatic leadership style has an impact on the maintenance of boundaries and standards of practice within a department of psychiatry. They also underline the need for all members of a self-regulated professional group to assume responsibility for the maintenance of standards within the group. An overview of leadership tasks and styles, with particular emphasis on the qualities of charismatic leadership, is provided, and the impacts of boundary violations committed by members of a psychiatric department or institute on the integrity of the professional group are also elaborated. The authors then develop several hypotheses regarding the phenomenon of emotional collusion that occurs in departments in which a charismatic leader becomes sexually involved with patients. The individual internal psychological mechanisms and companion group dynamics that may allow the leader to be supported at the cost of ethical standards, principles of practice, and the ultimate creativity and viability of the group are then discussed. The authors conclude that the maintenance of standards within a self-regulating professional group must be the shared responsibility of all members. The example of boundary violations by a charismatic leader is used to illustrate the need for open debate regarding fundamental principles required to maintain a healthy functioning of critical checks and balances within the psychiatric profession.

Enactments: an evolving dyadic concept of acting out.

Unspoken actions between the therapist and the patient have major and often unconscious influences on the psychotherapeutic situation. Mutual transferences can bring about acting-out behaviors that portray transference wishes and defenses within both parties. Such actions tend to replace or overshadow verbalizing intrapsychic strife and in that sense can function as formidable resistance to therapeutic introspection. They also may represent behavioral attempts to communicate significant earlier experiences. Reflection on this dyadic interplay has led to contemporary treatment concepts. Enactment, actualization, and treatment misalliances are behavioral manifestations of urges, conflicts, and identifications and they appear most frequently during regressive periods in psychotherapy. Initially an enactment may include a component of the therapist's reciprocal behavior as a necessary feature of the process, prior to a fuller dynamic understanding and eventual definitive interpretation. Collusion by the therapist, through mutual and continuing acting out or through attempts to re-parent, will encourage antitherapeutic misalliances that can lead to continuing symptomatic behaviors and boundary violations. Continuing self-inquiry is essential to facilitate therapeutic change and we need to be aware that the principal analyzing device available to bring about positive change in our patients, is to be found within ourselves.

Assessment factors associated with premature psychotherapy termination.

Characteristics of patients accepted for both intensive psychotherapy and psychoanalysis were rated during their initial assessments. Twenty cases that terminated prematurely (most within the first month) were compared with twenty cases that continued in therapy. While neither specific diagnosis, type of insight therapy, nor gender of the patient or therapist was a reliable predictor of premature termination, it was found that psychodynamic and environmental assessment factors significantly differed between these two groups. In those patients who eventually dropped out, specific ego deficits, primarily introspection, frustration tolerance, impulse control, and motivation, were rated as significantly more impaired. The therapists' negative feelings toward their prospective patients and the patients' hostility toward past caretakers and present life circumstances were also associated with premature termination.

The incidence and significance of perceptual qualities in the reported dreams of patients with anorexia nervosa.

The dreams of anorexic patients' were recorded using a standardized sleep questionnaire concerning the perceptual qualities and affects remembered from their dreams. The anorexic subjects consistently had less frequent dream recall, fewer dreams in colour and fewer pleasurable themes than was noted in the normal controls. Anorexics frequently saw themselves in their dreams as having a distorted body (especially an enlarged belly), a younger appearance, and experienced food and hunger dysphoria. The evaluation of an anorexic patient's dreams and their subsequent changes in both sensations and the frequency of reported dreaming may have diagnostic and as well as prognostic importance for the therapeutic assessment of anorexia nervosa.

Supervising the supervisors: the evolution of a psychotherapy supervisors' group.

Three distinct psychotherapy supervision group formats developed over a fourteen-year period. The most consistently successful format was having a proposed psychotherapy supervision topic but with the primary emphasis being placed on free group discussion. The more inexperienced psychotherapy supervisors initially seem to want a more structured didactic approach, e.g., teaching seminars, while senior members favor a spontaneous and personal exploration of specific therapeutic and supervisory relationships. Psychotherapy supervisors in a group situation can explore and promote a deeper understanding of the supervisor-therapist relationship. They can function as a didactic study group and at the same time offer a useful interpersonal learning experience without the group having a therapeutic format. Group member interactions highlight the importance of the intersubjective nature of transferences and alliances, beginning with how the group leader responds to the other supervisors which then can be a model for the subsequent supervisor/supervisee processes. The leader of such a supervisors' group can be more helpful if he will see himself as a facilitator of essentially peer group observations rather than a transference interpreter or group teacher. Psychotherapy training programs should consider the introduction of a psychotherapy supervisors' group to improve the teaching and learning of psychotherapy skills. The efficacy of such supervisors' groups cannot be easily measured although it is suggested that patient outcome and supervisee satisfaction is significantly related to the quality of psychotherapy supervision provided.

Intersubjective processes in psychotherapy.

An intersubjective field is created by the interplay between the subjective inner worlds of the patient and therapist. The study of intersubjective processes has been based loosely on the paradigm of infant and caregiver interactions with subsequent empathic appreciation of each others' subjective realities. This approach is not necessarily dependent on an acceptance of a self-psychology model. Dyadic interactional dynamics can be explored and understood using different theoretical models. It may be therapeutic to be able to communicate and clarify significant moments of shared mutuality and affects, which when put into words often uncover previously repetitive and frustrating misunderstandings and expectations.

Regressive transferences--a manifestation of primitive personality organization.

Regressive transferences are but one manifestation of dynamic infantile and frequently unconscious fantasies seen in patients with a primitive personality organization. Such transference relationships may vary from an apparent profound unrelatedness to intense symbiotic dependencies. These transferences are primarily preoedipal and may include grandiose, persecuting, somatizing and dehumanized object experiences as well as narcissistic idealizing and denigrating selfobject formations. Three types of regressive transferences in patients with primitive personalities are described: primitive libidinal, transference automatism, and somatization. All three demonstrate symbolically meaningful but primarily unconscious primitive transference reenactments. Regressive transferences not only represent impulses seeking gratification but are also restitutive attempts for earlier losses and lack of self-cohesion. Patients with a primitive personality organization often have suffered early deprivations that bring about the formation of unstable internal representations. This makes acceptance of ambivalence and mourning difficult due to fear of ego dissolution caused by the aggression toward the self and others. Identification and exploration of shared intersubjective phenomena may facilitate conscious reconstruction and eventual interpretation of these regressive transferences.

An analyst's regressive reverie: a response to the analysand's illness.

A psychoanalytic session is described where both the analyst and analysand experienced a dream-like state associated with the theme of childhood illness. The analyst's countertransference took the form of a hypnogogic reverie concerning a dying boy's plea for his help, while the analysand's transference reaction was to re-experience the analyst as the negligent anaclitic father and himself the neglected child. The analyst's frustrated reverie and the patient's frightened angry response was a regressive expression of what previously had been unconsciously shared, but not totally congruent, fantasies. Although this was initially disillusioning experience in the analysis, with attempts at working through, the analysand was subsequently freer with his associations and positive feelings. There was also recovery of associated childhood illness experiences. It is suggested that these transient periods of altered consciousness provided a shared experience that was eventually analysable and therefore therapeutic. This paper considers the interaction between latent transference and countertransference fantasies during analyses. A clinical vignette illustrating the vicissitudes of empathy is explored primarily from an intersubjective point of view.

Erotic transferences.

Erotic transferences occur on a spectrum reflecting the ease or difficulty of their management. They represent sexualized re-enactments of important childhood relationships. This phase in psychotherapy may be a transient developmental feature or in some instances, assume a formidable resistance to further insightful work. Two case illustrations are given to indicate the breadth of this spectrum. Reasons are discussed for such differences in erotic transferences and their resolutions.