The narrative and rhetoric of dreams: six literary fragments by a novelist.

Four of a novelist's dreams and two contemporaneous pieces of her fiction are examined through the lens of poststructuralism; thus viewed they display narrative coherence in form and content, a reciprocal interaction between dream and written day residue, and a rhetorical function in trauma resolution. Lacan's theories about the linguistic nature of the unconscious are particularly powerful in understanding these six works especially their recourse to figurative language in deconstructing and reconstructing the traumatized self. Dream narratology suggests the close relation of unconscious processes to creativity and the unity of storymaking and personal meaning. Narrative conventions in these dreams and related fiction illustrate the functions of metaphor and metonymy in traversing Lacan's "registers of experience" and his ideas about the "itinerary of the signifier," the way dreams and art capture the elusive object of desire. Creativity serves not only a wish-fulfillment function but also a self-fulfillment function. Dreams, then, as creative acts, claim a privilege unto themselves and support Lacan's argument for a therapeutic approach of "desirelessness."

Accidental injuries of hospitalized patients. A prospective cohort study.

Eight hundred and six medical and surgical patients who were hospitalized via the emergency ward were followed over their entire impairment stays and rated in anterograde, double-blind fashion for inpatient incidents (falls, medication errors, other). Injuries were minor but affected 2.2% of admissions, a figure which is strikingly similar to studies in other hospitals. There was a statistical trend toward a higher-than-normal risk of hazardous in-hospital incidents for males age 20 to 40 admitted because of injury and for medically ill females over 60 years old.

In-hospital injuries of medical and surgical patients: the predictive effect of a prior injury.

Four hundred three consecutive injury victims admitted via emergency ward over a 3-month period were tracked with 403 contemporaneous controls with medical illness and blindly assessed for in-hospital accidents. There was a high frequency of "incidents" (n = 161 in 107 patients, mainly falls and medication errors), but injury victim admissions resembled medically ill controls when compared by the Kaplan-Meier method for cumulative probability of occurrence of an in-hospital incident. Accelerated failure/time models using the Weibull method to compute average times from admission to incident showed little difference between groups. Admission type (injury victim vs. control) did not predict psychiatric consultation, incident type, or multiple incidents in hospital. Although the injury group had a larger proportion of males and lower mean age, stratification to control for age and sex did not significantly discriminate injury victims from controls in production of incidents: Over all risk of incidents was random. By studying patients during a hospital stay, the effects of differences in individual environment and drug and alcohol intoxication are largely factored out; under these conditions the predictive effect of a prior injury becomes insignificant. In-hospital injury is associated with host factors long known to promote falls: increasing age, debility-cum-mobility, and central nervous system depressant medication.

Teaching short-term psychotherapy with blind role playing.

This report describes the use of blind role playing to introduce the theory and techniques of the short-term psychotherapies in a combined "laboratory" and lecture course. "Therapist" and "patient" (but not instructor) are blind to each other's governing assumptions about therapy, yet must respond creatively to each other based on the algorithms of the "script" and on real-life experience as both doctor and patient.

Making society's groups more therapeutic.

This paper represents the author's Presidential Address to the American Group Psychotherapy Association, delivered at the annual meeting on February 11, 1988, in New York. The author poses a challenge: What can we teach society about how to make our groups more healing and productive? He suggests certain guidelines relating to effective communication, empathic understanding, willingness to assume responsibility, and, most importantly, recognition that groups exist for the individuals who comprise them. For groups to function well, individuals must play their role and sacrifice themselves for the good of the whole; yet for groups to function well, the needs of the individual must never be lost.

Emergence of hostility during alprazolam treatment.

Of 80 patients given alprazolam, eight became hostile early in treatment. The authors suggest that alprazolam-induced hostility may be more likely in patients with well-suppressed chronic anger and resentment and cite reports of hostility associated with other benzodiazepines.

Training supervision as a separate faculty role.

Training supervision is a longitudinal, nonclinically focused personal relationship between a faculty member and a resident for exploring the latter's professional development. In the authors' program the training supervisor meets with the supervisee monthly over the 3-year residency. The training supervisor's role is that of a nonevaluative senior colleague who orients and advises the resident and systematically reviews training progress and problems. The authors discuss the evolution of the training supervision concept, explore potential role conflicts for the training supervisor, who may serve other functions in the residency of the supervisee, and present positive and negative resident and faculty evaluations of their program.

Male genital self-mutilation.

Men who intentionally mutilate or remove their own genitals are likely to be psychotic at the time of the act, to have a number of goals and aims relating to conflicts about the male role, and to be vulnerable to sociocultural and psychological forces in a causal network as yet unknown. However, from a review of the cases of 53 male self-mutilators, it appears that a significant number involve individuals not psychotic at the time of the act but rather having character disorders and rageful feelings toward themselves or women, and transsexual males who premeditate their own gender conversion surgery. The psychiatric consultant's role in the management of such an individual in the general hospital setting includes not only care of a patient with a psychotic or impulse disorder but also involves support of the house staff, who are distressed by the fear, guilt, hopelessness, anger, and revulsion that the patient's act of genital self-mutilation causes.

Taking care of the hateful patient.

"Hateful patients" are not those with whom the physician has an occasional personality clash. As defined here they are those whom most physicians dread. The insatiable dependence of "hateful patients" leads to behaviors that group them into four stereotypes: dependent clingers, entitled demanders, manipulative help-rejecters and self-destructive deniers. The physician' negative reactions constitute important clinical data that should facilitate better understanding and more appropriate psychological management for each. Clingers evoke aversion; their care requires limits on expectations for an intense doctor-patient relationship. Demanders evoke a wish to counterattack; such patients need to have their feelings of total entitlement rechanneled into a partnership that acknowledges their entitlement--not to unrealistic demands but to good medical care. Help-rejecters evoke depression; "sharing" their pessimism diminishes their notion that losing the symptom implies losing the doctor. Self-destructive deniers evoke feeling of malice; their management requires the physician to lower Faustian expectations of delivering perfect care.

The so-called "inappropriate" psychiatric consultation request on a medical or surgical ward.

Seven cases of psychiatric consultations on medical and surgical wards are reviewed to show how intrapsychic conflicts in the staff may make the consultation request appear inappropriate. On deeper examination, such requests may signify staff dysfunction caused by arousal of conflictual feelings about the behavior of illness of the patient. Mutilated, mute patients appear to arouse fear of agression in their caregivers, who in turn reject such patients, see them as alien and violent, and become illogical in their management. Patients who publicly display sexual behaviors appear to arouse shame over exhibitionism, voyeurism, and masturbation; their caregivers become too passive to effect common-sense measures appropriate to the situation. Very sick and dying patients and ungrateful, demanding patients can arouse anger and despair. Their caregivers may become depressed about failure, feeling helpless and out of control; using projection, they can see such patients as evil or suicidal, and may eventually turn against themselves. The psychiatric consultant, recognizing the conflicts that make the requests seem inappropriate, seeks to substitute higher-level cognitive operations and coping behaviors in the staff (distancing, rationalization, intellectualization, undoing, and altruism) for distortion projection, over-identification, reaction formation, and turning against the self.

The long-acting phenothiazines.

Injected intramuscularly, the enanthane and decanoate esters of the phenothiazine fluphenazine are an effective treatment of the disordered behavior and thinking of schizophrenia. The decanoate preparation is not only slightly longer-acting but also has a smaller incidence of side-effects that the enanthate. The major adverse effect of these medications is the high frequency of extrapyramidal system disturbance. Since the 50% rate of failure of schizophrenic outpatients to take prescribed oral medications decreases treatment failure to about 20% with the use of long-acting injectable phenothiazines, this route of administration offers an advantage in patient management particularly applicable to community mental health systems. Moreover, parenteral administration of long-acting fluphenazine may be useful for patients who do not attain effective serum levels with medication taken orally because of metabolic or absorption difficulties.

Management of the borderline patient on a medical or surgical ward: the psychiatric consultant's role.

The patient with borderline personality hospitalized on a medical or surgical ward has a disorganizing effect on the house staff, who may regress in response to the patient's impulsivity, dependency, entitlement, and rage. The psychiatric consultant's role in the management of such a patient should consist of a specialized type of consultee-oriented approach in which countertransference hatred and fear, typically generated in the staff by the borderline, are drawn away from the patient and strategically metabolized within the staff-consultant relationship. The consultant should actively promote a behavioral management practicum, placed in the medical chart for reference and as a symbol of the psychiatrist's helping presence, which discusses: a) clear communication with the patient and among staff, b) understanding the patient's need for constant personnel, c) dealing with the patient's entitlement without confronting the patient's needed defenses, and d) setting firm limits on the patient's dependency, manipulativeness, rage, and self-destructive behaviors. The consultant should work to counteract feelings of helplessness in the staff, to neutralize punitive superego in the staff, and to diminish fearfulness toward the patient.