ABSTRACT
This article focuses on two components of psychodynamic psychotherapy with suicidal patients. First, the value and importance of establishing and maintaining a clearly defined therapeutic alliance is noted and explored. A carefully negotiated alliance can become an edge or boundary across which the survival of the therapy, as well as the patient, can be negotiated. Attention to the vicissitudes of the alliance is hypothesized to be the central initial therapeutic action with suicidal patients. Second, the author explores the importance of "taking" rather than "refusing" the transferences offered by the suicidal patient, particularly negative and erotic transferences. Case examples are offered as illustrations.
Subject(s)
Professional-Patient Relations , Psychotherapy , Suicide/psychology , Transference, Psychology , Humans , Treatment OutcomeABSTRACT
Sexual misconduct remains a significant problem in the behavioral health professions. Although it is tempting to view sexual misconduct as perpetrated by "bad" clinicians against patients who are "victims," this is an oversimplification of a complex problem. In this article, the author explores the psychoanalytic concept of enactment as a mechanism that can lead well-meaning clinicians to engage in sexual misconduct; defines enactment and differentiates it from near neighbor phenomena; uses case examples to illustrate how enactments may lead to sexual misconduct or may offer opportunities to deepen and enhance psychotherapeutic work; and offers recommendations for prevention of sexual misconduct.
Subject(s)
Professional-Patient Relations , Sexual Behavior/psychology , Adult , Female , Humans , Psychotherapy/methods , Transference, PsychologyABSTRACT
Regardless of the approach employed, treatment of patients with histories of sexual or other abuse is a formidable challenge. One reason for this is the vulnerability to "enactment" inherent in therapeutic work with such patients. Enactment is a recently elaborated psychoanalytic notion, defined as a pattern of nonverbal interactional behavior between the two parties in a therapeutic situation, with unconscious meaning for both. It involves mutual projective identification between therapist and patient. This paper clarifies the nature of enactment (conceptualized here as involving either refusal or actualization of the transference by the therapist) and its treatment implications. Transference-countertransference enactment paradigms encountered in work with survivors of abuse are presented. The therapeutic consequences of failing to recognize and respond to such enactments in work with these patients are explored. Unrecognized enactments may lead therapists unwittingly to abdicate the therapeutic role by becoming abusive, abused or vicariously traumatized, excessively guilty, seductive, overinvolved, and/or exhortatory or to implant false memories. Ways of utilizing enactment to advance treatment are also described and illustrated.
Subject(s)
Child Abuse/psychology , Psychoanalysis/methods , Transference, Psychology , Adult , Child , Child Abuse, Sexual/psychology , Female , Humans , Psychoanalytic Theory , Psychotherapeutic ProcessesSubject(s)
Health Resources/economics , Insurance, Psychiatric/economics , Managed Care Programs/economics , Patient Participation/economics , Personality Disorders/therapy , Adult , Combined Modality Therapy , Cost Control , Cost-Benefit Analysis , Female , Humans , Male , Middle Aged , Patient Admission/economics , Personality Disorders/economics , Personality Disorders/psychology , Psychoanalytic Therapy/economicsABSTRACT
Patients with borderline personality disorder often exhibit lethal or nonlethal self-destructive behavior. The author offers seven principles for establishing and maintaining a therapeutic alliance in the insight-oriented psychodynamic psychotherapy of borderline personality disorder patients with self-destructive behavior serious enough to threaten the continuity of the therapy.
ABSTRACT
Seventeen former inpatients with NPD were retrospectively compared to 19 patients with schizophrenia, 26 with MAD and 33 patients with BPD in terms of longitudinal course and outcome, exploring the validity of the NPD diagnosis. Two illustrative cases were presented. Results suggest that NPD is a valid diagnostic entity, more distinct from schizophrenia than MAD. NPD probably differs from BPD in terms of equal sex distribution in NPD; poor social functioning, especially in the low level of satisfaction with heterosexual relationships in NPD at follow-up; more rehospitalization in NPD; probably poorer global functioning in NPD at admission; and probably poorer overall follow-up functioning in NPD.
Subject(s)
Borderline Personality Disorder/diagnosis , Narcissism , Personality Disorders/diagnosis , Adult , Borderline Personality Disorder/psychology , Female , Follow-Up Studies , Humans , Male , Patient Readmission , Personality Disorders/psychology , Psychiatric Status Rating Scales , Psychoanalytic Therapy , Schizophrenia/diagnosis , Schizophrenic Psychology , Suicide, Attempted/psychologyABSTRACT
Admission and mean 14-year follow-up Global Assessment Scale functioning were studied in 237 inpatients meeting DSM-III criteria for borderline (BPD) and schizotypal (SPD) personality disorders and compared to major affective disorder, schizophrenia and other diagnoses. BPD patients also meeting criteria for SPD functioned more poorly than other BPD or SPD patients at admission but improved their functioning at follow-up. Two BPD and SPD criteria which were associated with good follow-up functioning in BPD with SPD patients were found to predict poor admission functioning but good follow-up functioning in 18 of 237 former inpatients regardless of diagnosis.
Subject(s)
Borderline Personality Disorder/diagnosis , Hospitalization , Personality Disorders/diagnosis , Schizotypal Personality Disorder/diagnosis , Adult , Borderline Personality Disorder/psychology , Depressive Disorder/diagnosis , Depressive Disorder/psychology , Diagnosis, Differential , Female , Follow-Up Studies , Humans , Male , Manuals as Topic , Psychiatric Status Rating Scales , Retrospective Studies , Schizophrenia/diagnosis , Schizotypal Personality Disorder/psychologyABSTRACT
Inpatients diagnosed as having borderline personality disorder (BPD) by DSM-III criteria who were admitted to 11 Central Neuropsychiatric Hospital Association (CNPHA) hospitals in 1982 and 1983 are described in terms of 28 clinical-history and demographic characteristics. This study statistically compared 181 BPD inpatients to 1,121 non-BPD inpatients admitted to the same hospitals during the same period as part of the broader CNPHA prospective outcome study. These BPD inpatients were also compared to other BPD samples described in the literature. The 1982-83 CNPHA BPD inpatients exhibited clinical and demographic characteristics significantly different from their non-BPD counterparts. These BPD inpatients, mostly female, may have had particularly difficult living situations, had extensive treatment histories that began early, were frequently self-destructive, and had a distinctive medication pattern, among other characteristics. Comparison to other BPD samples in the literature showed similarities, supporting the generalizability of the CNPHA prospective outcome study.
