The Social Construction of PTSD: The Case of the 'Old Guard' Policemen After South African Democracy.

Often, we assume the traumatic nature of first response work has inevitable repercussions. This can lead to assumptions about trauma being the reason for distress, resulting in fixed ideas about diagnosis and treatment, without the complex socio-political and psychodynamic implications being fully considered. This paper challenges such assumptions by exploring the presentation of PTSD in 'old guard' police officers at the cusp of the post-apartheid era in South Africa. Focusing on long serving 'white' Afrikaner policemen, an argument is advanced that, while a diagnosis of PTSD may have enabled the old guard to legitimately access care and support for distress, at another level it served to displace core conflicts related to masculinity (and other aspects of identity) triggered by adjustment difficulties inherent in the transition from apartheid to post-apartheid South Africa. A case study is used to illustrate these observations.

Autistic defenses in agoraphobic syndrome: "flat" objects and the retardation of projective identification.

The function of autistic defenses in the generation of agoraphobic symptoms is explored in the case of a patient treated in psychoanalytic psychotherapy. The therapist's growing awareness of autistic modes of relating in the case facilitated various changes in the transference relationship. Although oedipal concerns are seen as important, a formulation is presented whereby autistic modes of generating experience are viewed as fundamental to an understanding of agoraphobic experience. Clinical findings in the transference-countertransference relationship led to the additional observation that the retardation of defensive forms of projective identification further contributed to the patient's agoraphobic difficulties. This formulation is tied theoretically to the idea that agoraphobic experience occurs when the dialectic between paranoid-schizoid and autistic-contiguous modes of generating experience collapses. The treatment implications of these observations are briefly explored.

Anticipatory interpretations: addressing "cautionary tales" and the problem of premature termination.

This article explores the use of anticipatory interpretations early in the therapeutic process as a means of addressing the problem of premature termination with some patients. The author argues that emerging transference references, detected through a close attention to "cautionary tales" or derivative communications, should be used in early interpretive interventions. It is suggested that such transference references form a "template of intention" that help determine future difficulties in the therapeutic alliance. Being able to communicate these observations in a future-orientated way lays the groundwork for "thinking about" actions that threaten the therapeutic alliance when they occur, in turn curtailing the possibility of acting out through termination. The author uses two case examples to illustrate his observations and goes on to suggest that anticipatory interpretations involve: (1) isolating derivatives and underlying anxieties, (2) future-orientated transference references, and (3) an affirmation of difficulty.

The psychoanalytic research interview: preliminary suggestions.

Psychoanalytically informed interview techniques and interview analysis can yield useful psychoanalytic insights about a particular research subject within the space of a few interviews. Basic hermeneutic principles, often used to understand the research interview, are not sufficient for understanding unconscious meaning and intrapsychic processes; they pay little attention to the particular theoretical and technical aspects of the interview needed to create the best conditions for understanding unconscious meaning. The portability of psychoanalytic concepts and their applicability outside the therapeutic setting are considered, after which four epistemological principles are outlined, derived mainly from the narrative tradition in psychoanalysis, that can inform interview technique and the analysis of the interview. Careful attention to feeling states, the search for core narratives, and the exploration of identifications and object relations are isolated as key analytic tasks in the interview analysis. A brief verbatim interview is used to illustrate this process, and methods are suggested to prevent the "wild analysis" of the interview encounter.

Working with HIV/AIDS sufferers: "when good enough is not enough".

The authors begin by examining the intrapsychic implications that HIV/AIDS presents after knowledge of infection. Using examples drawn from two cases, they explore how knowledge of infection precipitates an insidious traumatizing process that comprises a number of key defensive strategies and dynamic processes. Particular kinds of defensive splitting, projective dynamics, and key identifications, as well as the collapse of the symbolic function, are isolated as being central to understanding the traumatizing process. With this in mind, the role and aim of the insight-oriented therapist is considered. The authors argue that much of the therapeutic work in this area revolves around a central organizing fantasy about the limitations of "good enough" objects in helping them with their diagnosis and its implications. This is linked to a number of technical dilemmas that the therapist will inevitability have to face if he or she chooses to work analytically. Particular technical problems explored include: 1. the management of frame deviations, 2. the therapist's role/s, 3. the use of interpretation, and 4. countertransference experience and enactment.

The narcissistic exoskeleton: the defensive organization of the rage-type murderer.

After outlining the characteristics of rage-type murder, the author reviews possible psychodynamic explanations of the predisposing personality and the act itself. He argues that more recent contributions, using an object relations perspective, best account for the complexity of the internal world of these offenders. Using a single case to illustrate observations drawn from his work with nine offenders, the author sets out to develop an understanding of the defensive organization present in these apparently normal murderers. He isolates a defensive system comprising a set of split object relations that correspond with a split between internal and external reality, which he calls the "narcissistic exoskeleton." Projective and introjective processes that support the defensive organization are discussed. It is suggested that such a profile typifies a particular kind of stable borderline personality organization.