The role of ethical principles in health care and the implications for ethical codes.

A common ethical code for everybody involved in health care is desirable, but there are important limitations to the role such a code could play. In order to understand these limitations the approach to ethics using principles and their application to medicine is discussed, and in particular the implications of their being prima facie. The expectation of what an ethical code can do changes depending on how ethical properties in general are understood. The difficulties encountered when ethical values are applied reactively to an objective world can be avoided by seeing them as a more integral part of our understanding of the world. It is concluded that an ethical code can establish important values and describe a common ethical context for health care but is of limited use in solving new and complex ethical problems.

A brief history of the International Psychoanalytical Association.

Originally prepared as part of the background material for an International Psychoanalytical Association Symposium devoted to a critical consideration and review of the structure and functioning of the IPA in 1988, this paper uses sources within the IPA's Archives to trace the key developments in their history since their foundation in 1910. An addendum provides some details of similar developments from 1985 to the present.

Creativity and the third age.

The paper discusses aspects of the creative process in the elderly and, indeed, in the old. After a definition of the third age, the writer goes on to discuss the nature and aims of creativity. Particular attention is paid to the roles of sexuality, regression in the service of the ego, narcissism, sublimation, the depressive position and reparation. There follows discussion on therapeutic work with creative elderly individuals.

Neglected fathers in the aetiology and treatment of sexual deviations.

Current researches in sexual deviations have rightly stressed deficiencies and faults in the mother/child relationship, fears of annihilation and an inability to achieve separation and independence. As a result of this the role of the father in the patient's family structure and in their psychotherapies and psychoanalyses has been somewhat neglected, also because the fathers are usually described as cold, distant, uninvolved, etc. The author believes that the obliteration of the father figure, whether accidental or deliberate, is an important part of the psychopathology. It follows that in the late stages of a therapy there should be a careful examination of the original establishment of the father as a second object, as its internalization is essential for a healthy sexual development. The obliteration of the father figure can cause serious problems in terms of the understanding of the transference and countertransference. The paper includes a clinical description of a case where such problems were much in evidence.

[The psychoanalytic movement during the years of the war (1939-1941) according to the archives of the I.P.A]. / Le mouvement psychanalytique dans le monde durant les année de guerre (1939-1941) selon les archives de l'A.P.I.

This is an overview of the activities and developments within the twelve component Societies of the International Psychoanalytic Association from the outbreak of the Second World War to its end in 1945. The author describes how the war had deeply affected the activities of the societies within Europe, as compared with other parts of the world. He notes how in the United States of America psychoanalysis was in a comparatively bouyant state, to some extent owing to migration of psychoanalysts from Europe, whilst in South America and Australia new societies were formed. In view of the scarcity of material to be found in the Archives of the I.P.A., the author has made full use of relevant literature whenever it was concerned with contemporary world affairs, and the manner in which the war situation affected individuals and groups in various countries.

Toward a unified conception of the origins of sexual and social deviancy in young persons.

This paper is based on the empirical evidence that social and sexual deviancy in young persons often succeed on one another, alternate repeatedly, or occur concomitantly. The role of the superego and the relationship of acting out and symptomatic acts to both conditions are explored. States of excitement, tension, and discharge in young persons are described. The scanty but important literature on excitement is reviewed, and the role of this affect in the causation of both deviances is examined in some detail. The occurrence of early fantasies associated with (primary) excitement on a background of early psychic disturbance and environmental failure, common to both deviations, is compared with excitement in later stages of development. The fantasies that accompany physiological and psychological changes at puberty and adolescence provoke arousal and excitation, which is defended against with boredom and depression, which in turn leads to a search for (secondary) excitement. This process is illustrated by several clinical examples drawn from case material of patients treated with psychotherapy and psychoanalysis. Finally, the implications for treatment of a unified approach to the problem of social and sexual deviancy in young people is briefly explored.

Do patients who move to a new town consult their doctor more often?

A study was conducted to measure any difference in the consultation rate of patients from two new town housing estates compared with patients from the rest of the practice. Patients from the new estates consulted 15% to 20% more than those in other areas, but newly registered patients showed no difference compared with the indigenous population. It is suggested that patients who chose to move to new town rented accommodation bring with them a more casual attitude to the general medical services.

From denial to self-awareness: a 20 years' study of a case of childhood delinquency evolving into adult neurosis.

This is a study of the evolution of delinquency into adult neurosis in a girl whose analytic psychotherapy began in pre-puberty. With some interruptions the treatment was extended over nearly 20 years. The antisocial tendency, which was serious enough to lead to appearance in juvenile courts, continued until late adolescence when the first signs of a fully fledged neurosis made their appearance. The psychodynamics of the case are followed through from the overwhelming use of denial, splitting and omnipotence, as seen in most cases of delinquency, to the development of a sufficient degree of insight linked with self-awareness. Considerable difficulties were experienced in view of the severity of the psychopathology and the limitations of the psychotherapy as only once-a-week sessions could be offered to the patient. Although the therapeutic result was short of a full recovery, the therapy provided the patient and the therapist with the opportunity of gaining a fair understanding of the origins and nature of the delinquency as well as of the later neurotic features.

On some positive aspects of the negative therapeutic reaction.

The development of the concept of the Negative Therapeutic Reaction (N.T.R.) is followed through from the original description by Freud to that of later and contemporary psychoanalysts, revealing a considerable divergence of opinions as to the causes of the condition. It is suggested that in the more chronic forms the reaction is a special kind of acting out of the transference in the psychoanalytic situation, when it is also a particularly stubborn defence against the re-experiencing of pain and psychic suffering associated with early trauma. It is generally agreed that the N.T.R. is a challenge to the analyst's countertransference. On the other hand, it is also of positive value as an indicator of the state of the transference and the possibility that an especially painful area in the patient's psychopathology has been reached, requiring a further working through and better integration. Two clinical illustrations are presented in support of these theoretical considerations.

An outbreak of hepatitis B from tattooing.

An outbreak of 34 cases of hepatitis B not all of them notified, is described. 31 was tattooed by one artist; 3 were secondary infections. All primary infections occurred in males aged 16-28 years. Several defects in hygiene in the tattooing procedure were noticed. Recommendations are made for the licensing and routine inspection of all tattoo parlours.

The differential diagnosis of homosexuality.

The treatment of homosexuality presents serious difficulties owing to its multifactorial aetiology and variety of psychopathological views. It is suggested that the combined use of psychiatric and psychoanalytic models can contribute to the establishment of a satisfactory differential diagnosis. Out of the innumerable clinical types seen in practice and described in the literature, three major groups can be isolated. The homosexuality which occurs on the background of hysterical, obsessional and other neurotic personality types and related psychiatric conditions, tends to be linked with latent heterosexuality and responds well to all forms of psychotherapy. On the other hand, true homosexuality is often the major presenting symptom of borderline states, narcissistic disorders, psychopathy and the schizo-affective psychoses and carries an unfavourable prognosis with any form of treatment. Cases of actual bisexuality form the third group with its own specific psychopathology. The homosexual solution is seen as a defence and is regarded as a matter of survival for many individuals. It should be treated with the utmost caution by anyone who attempts to remove it.

Object choice and actual bisexuality.

Actual bisexuality is to be distinguished from homosexuality in a latent state and from conscious bisexual fantasies. Contemporary social changes have caused an increased demand for help for those men and women capable of engaging in protracted heterosexual and homosexual relations. Among such people narcissistic and borderline states are common. Clinical material is presented in some detail. The author suggests that the condition is associated with a tendency to be caught up between the anaclitic and narcissistic types of object choice. The concurrent involvement with a male and female love object against a background of pseudogenitality creates the illusory appearance of two objects being involved, covering up the fact that there is splitting of the original love object together with severe preoedipal disturbance.