Brief communication: a comparison of the place of dreams in institute curricula between 1980-1981 and 1998-1999.

The analysis of dreams was central in demonstrating Freud's theory of mind and the power of unconscious forces. Many analysts informally comment that dreams no longer seem to hold the same centrality they had for analysts who were trained prior to the 1980s. This paper presents a brief study assessing whether there has been a change in the teaching of dreams in psychoanalytic institutes. Comparison of theoretical and clinical courses on dreams in 1980-1981 and 1998-1999 indicates that the actual number of hours devoted to teaching dreams has in fact decreased. However, there are indications that a renewal of interest in dreams may now be occurring, at least in some institutes. The relationship between views on the role of dreams and perspectives on psychoanalysis itself is discussed.

The role of the preconscious in psychoanalysis.

The analytic process inevitably involves the interdigitation of the intrapsychic structures of both patient and analyst. This interplay is expressed in transference-countertransference interactions. Drawing a dichotomy between intrapsychic and interpersonal factors as central agents of psychic change is a faulty construction. Affective, behavioral interchanges between patient and analyst reflect their individual intrapsychic organizations and their interplay, which influence the form and nature of psychological change. The safer both patient and analyst feel in relation to each other, the more freely will they relax their customary cognitive controls and permit the emergence of preconscious responses. Preconscious resonance between patient and analyst is likely to facilitate the lifting of repressive barriers and the emergence of unconscious material in both participants. The integration and reworking of old conflicts then becomes possible. The role of the preconscious in facilitating the analytic process is illustrated. Creative use of preconscious processes requires the analyst's self-discipline to preserve the analytic role and keep the treatment safe for both participants.

Pathways to self-knowledge. Private reflections and mutual supervision and other shared communications.

As part of a national survey of analysts in the American Psychoanalytic Association, analysts responding to the questionnaire reported the different ways in which they continued their self-explorations stimulated by their work with patients. Twenty-six of these analysts were interviewed about this process. Their responses clustered in four groupings; (1) analysts who revealed their self-reflections in writing; (2) analysts who used their self-discoveries in teaching; (3) analysts who communicated their self-discoveries to only a few people most often a spouse and one or two close friend-colleagues; and (4) analysts who participated in peer groups or had several friends and/or friend-colleagues with whom they were mutually self-disclosing. Subsequently, ten analysts were interviewed specifically about mutual supervision and self and other exploration in this process. This paper presents data about the frequency and methods of these reporting analysts' self-enquiry and their ideas about privacy and self-disclosure in relation to their self-reflections. The role of transference in self-revelation to peers is discussed in respect of its regressive and non-regressive aspects.

A different perspective on the therapeutic process: the impact of the patient on the analyst.

The therapeutic process is considered from the perspective of its impact on the analyst. Analysts undertake self-scrutiny, focusing on transference and countertransference reactions, in order to facilitate the treatment of their patients. However, this self-reflection also serves to continue and enhance the analysts own personal understanding. In the course of analyzing patients, an interactional process develops in which many of the therapeutic aspects of analysis affect the analyst as well as the patient. A clinical example is offered to illustrate this process.

The beneficial aspects of the patient-analyst match.

Attempts to define the central factors contributing to psychological change from psychoanalytic treatment have occurred throughout the history of psychoanalysis. Insight from interpretations and clarifications and the affective relationship to the analyst are agreed to be the crucial elements in analytic work as they play out in the transference and resistance. Each patient and analyst pair, however, has its own unique interaction. Even though patients potentially may have successful analyses with many different analysts, the experience of each patient-analyst dyad has its own non-replicable characteristics. The interdigitation of the particular characteristics of the analyst and the patient may be therapeutically beneficial and may determine the depth and range of work in any specific area. An illustration is offered where the positive impact of an interaction came from subtle, often non-verbal aspects of a particular patient-analyst pair. The author's thesis is that, in addition to the analyst's technical and empathic skill, the subtle aspects of character and conflict of both patient and analyst and their interplay constitutes a central therapeutic factor in analytic work.

The uniqueness of the patient-analyst pair: approaches for elucidating the analyst's role.

This paper describes ways in which patient-analyst interactions result in a unique creation in each psychoanalytic endeavour. The particular character of the analyst and analysand overlap in a manner that potentially influences both the depth and the limits of the analysis. Analysts, therefore, need to be alert to their impact on the analytic process. Three approaches for elucidating the analyst's role and its effect on the patient are described. Case examples illustrate the impeding effect of unrecognised similarities between patients and analysts. Once the analysts became aware of these similarities, there was a change in their behaviour, resulting in a deepening and expanding of the patients' analytic experiences.

Impasses in psychoanalysis: overcoming resistance in situations of stalemate.

Many impasses occur in treatment when the patient fears that analysis will repeat frightening or disappointing experiences. These stalemates result from the patient's conviction that the analyst has confirmed a preexisting belief that is central to the patient's primary conflict. Frequently, this belief involves an unacceptable or frightening self- or object representation. At these times, intense resistance and strong negative transference/countertransference reactions may develop. Impasses are differentiated from these strong negative reactions only by virtue of the fact that they remain unanalyzed. The factors that create these negative states can best be understood in instances where the potential impasse is resolved. When impasses persist, most often patients leave treatment. Under these circumstances, we can try retrospectively to understand what has gone wrong, but without the patient's confirmation, our conclusions must remain speculative. Four cases illustrate varying degrees of analysis and resolution of resistance and transference/countertransference binds.

The analyst's style and its impact on the analytic process: overcoming a patient-analyst stalemate.

Analysts have characteristic styles in working with their patients. At times of crisis or stalemate, an alteration in style may facilitate the progress of the treatment. To illustrate the impeding effects of an analytic style at a particular phase of analysis, I describe a stalemate in the analysis of a severely self-critical patient. Recognition of the limiting effects of style on the treatment became apparent in a countertransference enactment, influenced by the patient-analyst match. Self-analysis and alteration in the characteristic style of the analyst resolved the stalemate and enabled the analytic work to progress.

Followup of psychoanalysis five to ten years after termination: II. Development of the self-analytic function.

Thirteen of seventeen patients in followup interviews five to ten years after the termination of analysis reported the development or refinement of a self-analytic capacity. According to the accounts of these patients, there did not appear to be a direct relation between the attainment of a self-analytic function and the extent of resolution of the transference neurosis or the maintenance of therapeutic gains after treatment.

Followup of psychoanalysis five to ten years after termination: III. The relation between the resolution of the transference and the patient-analyst match.

As part of a long-term followup study of the outcome of psychoanalysis, we examined the relation between the extent of resolution of the transference at termination and the characteristics of the patient-analyst match. For twelve of the seventeen patients interviewed five to ten years after termination of psychoanalysis, the researchers found that the patient-analyst match played a role in the outcome of the analysis. Illustrations of the influence of the match in cases where the transference was resolved and those where it was not are presented.

Followup of psychoanalysis five to ten years after termination: I. Stability of change.

Seven out of 17 patients interviewed in a long-term followup of psychoanalysis showed either improvement in psychological functioning or a retention of psychological gains they had made during the course of psychoanalysis. Six patients deteriorated in their psychological functioning, but their gains were restored with subsequent treatment. Four patients deteriorated in psychological functioning without restoration, whether or not treatment was reentered. Neither analysts' assessments at the time of termination nor patients' assessments of themselves or assessments based on psychological tests one year after termination predicted which patients would improve or retain psychological change. No causal generalizations about factors related to psychological change can be made from these data. Different factors in interaction are suggested to account for the stability and instability of psychological change.

The patient-analyst match and the outcome of psychoanalysis: a pilot study.

This paper presents a pilot study in which we explore the possibility that the match between analyst and analysand is a factor of central importance in the analytic situation. It is an attempt to look at the issue of match across a large number of patients. The data we used were not collected for studying this topic; thus, the study has serious limitations. Nevertheless, certain patterns emerged which support our thesis that patient-analyst match plays a significant role in the outcome of psychoanalysis. We present this work as a first step in developing concepts and methods which will be pursued in a more systematic and rigorous fashion in a later study.

Changes in the level and quality of object relations in psychoanalysis: followup of a longitudinal, prospective study.

As part of a prospective, longitudinal study of suitability for and outcome of psychoanalysis, 22 patients were evaluated for changes in the level and quality of their object relations. These patients had been accepted for supervised analysis with candidates in training by senior analysts who had diagnosed them as neurotic. The majority of these patients reported difficulties in relationships as at least one of their reasons for originally seeking psychoanalytic treatment. Prior to beginning analysis, each patient was given a battery of psychological tests. One year after the termination of analysis, the test battery was readministered and a followup interview was conducted separately with each patient and analyst. Ratings of change based on patient and analyst interviews and comparisons of psychological tests before and after treatment all showed statistically significant improvement in the level and quality of object relations for this patient group. The results of this study support what is often observed in clinical practice, that psychoanalysis has a positive effect on the level and quality of a patient's object relations.

The role of reality testing in psychoanalysis: followup of 22 cases.

As part of a prospective, longitudinal study of psychoanalytic outcome, 22 patients were evaluated for changes in their level of reality testing. These patients had been accepted for supervised psychoanalysis with candidates in training by senior analysts who had diagnosed them as neurotic. Psychological tests given prior to the beginning of analysis indicated, however, that more than one third of our sample demonstrated serious distortions in their perceptions of reality. When psychological tests administered one year after the completion of analysis were compared with these pretreatment tests, no significant improvement was found in the level of reality testing for the group as a whole. However, when excluding two patients who had suffered major traumas in the year following psychoanalysis, significant improvement in reality testing was found for the remaining 20 patients. Post-treatment interviews with the treating analysts revealed that in the course of analysis itself, approximately one third of these patients showed some disturbance in reality testing; only three of these patients showed significant improvement in the level of their reality testing during treatment. These findings suggest that while patients may not present clinically with evidence of impaired reality testing, such evidence may be available in psychological testing, and may become apparent in the course of the treatment.

Early experience with the use of anti-inhibitor coagulant complex to treat bleeding in hemophiliacs with inhibitors to factor VIII.

Early clinical experience with anti-inhibitor coagulant complex in the treatment of bleeding in patients with factor VIII inhibitors is described. Sixty patients with a total of 120 bleeding episodes were studied. Satisfactory responses were obtained in 86.6% of bleeding episodes. Efficacy was slightly better in open bleeding than in closed bleeding. Higher doses were significantly better than lower doses in treating open bleeding. The incidence of adverse reactions was low. The results reported support the safety and efficacy of anti-inhibitor coagulant complex in the treatment of bleeding in patients with factor VIII inhibitors.

PROPLEX vs. PROPLEX SX: a controlled double blind study of the effectiveness in treating acute hemarthroses in hemophilia A patients with inhibitors to factor VIII.

A blinded randomized multicenter trial of two non-activated prothrombin complex concentrates was carried out to determine the clinical effectivity in the treatment of acute hemarthrosis in hemophiliac patients with inhibitors. The one product was prepared via DEAE Sephadex chromatography, while the second was fractionated via various precipitation procedures including polyethylene glycol. Equivalence of the two products was established with less than 15% difference in efficacy rates.

Affect availability, tolerance, complexity, and modulation in psychoanalysis: followup of a longitudinal, prospective study.

Evaluation of 22 patients in supervised psychoanalysis showed that affect availability and tolerance changed in a positive direction during the course of psychoanalysis. In this study, we have defined criteria of change that can be clinically observed. The changes observed were present one year following the completion of psychoanalysis. Ratings of analysts' and patients' interviews, and ratings of psychological tests all revealed that patients had derived "therapeutic benefit" in relation to affect experience and management. Discriminations were made among changes in affect modulation, which reflected both loosening and tightening of controls, changes in affect availability, changes in experience of painful affects, and changes in experience of affect complexity. Analysts' interviews and psychological test data reflected notable changes in affect modulation in the direction of increased control, while patients' interviews more often reflected changes in the direction of increased expressiveness.

Methodology for a prospective study of suitability for psychoanalysis: the role of psychological tests.

A methodology for the use of psychological tests in the evaluation for suitability for psychoanalysis is described. Four variables--Reality Testing, Level and Quality of Object Relations, Affect Availability and Tolerance, and Motivation--were chosen for study and are discussed in detail. Data indicating a high degree of reliability between raters are presented.