The effect of psychotherapy in improving physical and psychiatric symptoms in patients with functional dyspepsia.

Objective: Functional Dyspepsia (FD) is a common symptom of upper gastrointestinal discomfort. Few data are available on the role of psychotherapy in the treatment of dyspeptic syndromes. This study assesses whether brief core conflictual relationship theme (CCRT) psychoanalytic psychotherapy improves gastrointestinal and psychiatric symptoms in patients with functional dyspepsia.

A randomized controlled trial of brief psychoanalytic psychotherapy in patients with functional dyspepsia.

Functional dyspepsia (FD) is a common cause of upper gastrointestinal symptoms and discomfort. The present study aimed to assess the effectiveness of brief core conflictual relationship theme (CCRT) psychoanalytic psychotherapy on changing gastrointestinal symptoms, alexithymia, and defense mechanisms in patients with FD. In a randomized controlled trial study, 49 patients with FD were randomly assigned to medical treatment with brief psychodynamic therapy (24 subjects) or medical treatment alone (25 subjects).

The "erotic transference": some technical and countertransferential difficulties.

This paper highlights dynamics that may interfere with the therapist's identifying and addressing the erotic transference: (1) deficient training; (2) theoretical orientations that devalue the transference while espousing a "real" relationship including self-disclosure; (3) countertransference responses to the erotic transference; and (4) clinical errors of focusing on the manifest erotic transference while overlooking significant but latent pre-oedipal, oedipal, aggressive, or selfobject issues. Inattention to these dynamics may render the therapist vulnerable to sexual acting out with his patient.

When the system is the problem, don't blame the patient: problems inherent in the interdisciplinary inpatient team.

Organizational theory used in conjunction with the transference/countertransference paradigm enables members of the interdisciplinary team to look at treatment problems from two perspectives and to intervene at the appropriate level. Common problems of the team are poorly defined accountability, a lack of leadership, communication breakdowns, and boundary violations. Suggested interventions are education of team members about organizational theory, open discussion of contentious issues, and reinforcement of boundaries.

Is empathy cost efficient?

In an attempt to constrain rising health-care costs, third-party payers are currently encouraging psychiatrists and other physicians to focus on the financial aspects of their treatment approaches. This paper has attempted to address the impact of this cost-efficient attitude on our empathy and by tracking the evolution of our health-care-delivery system since the turn of the century. I have described three overlapping phases: the humanist, the scientific, and the current corporate phase, and emphasized the importance or trivialization of an empathic practice-style associated with each stage.

Empathy: misconceptions and misuses in psychotherapy.

The frequent misconceptions and misuses of empathy that occur during psychotherapy are related to confusion about the definition of empathy, misunderstanding of the difference between the process of empathy and the therapist's response of being empathic, countertransference exploitation of empathy to act out the therapist's needs, the therapist's unawareness of the "layering" phenomenon, and overlooking the patient's level of self-other differentiation. These misuses result in the patient's feeling misunderstood and damaged, with a subsequent weakening of the therapeutic alliance and, at times, a breakdown in self-other differentiation. Once identified, misuses should be addressed and explored in psychotherapy to offset disruptions in treatment.

The resident's countertransference: approaching an avoided topic.

The resident's countertransference to his/her patient may offer essential information about certain denied processes within that patient. It may also signal the existence of countertherapeutic scotomas within the resident. This paper offers a clinically based approach for directly identifying, exploring, and utilizing the information emerging from the resident's countertransference.

Some psychodynamics of non-compliance.

With up to 50% of psychiatric patients refusing medication at some time during therapy, non-compliance can become a major treatment difficulty. This problem is compounded by the countertransference responses evoked within the therapists, and their tendency to react solely with information and exhortation rather than attempting to view non-compliance psychodynamically. When exploring with empathic concern, a number of common dynamic issues can be seen as playing a major role in drug refusal.

Soft clinical research on an inpatient unit: effect of findings on treatment.

This paper describes the value of identifying and processing intuitive hunches and impressionistic ideas that arose amongst psychiatrist/clinicians on an inpatient unit. Through semistructured meetings, these hunches generated psychodynamic formulations and therapeutic approaches that were integrated into already existing models of treatment to yield a better understanding of, and a more tailored approach to, the borderline patient and his/her impact on staff.

Case report of de Clerembault syndrome, bipolar affective disorder, and response to lithium.

De Clerembault identified a syndrome associated with delusional loving, and it has since been described in association with various diagnoses including paranoia, schizophrenia, affective disorder, and mental retardation. The authors document its coexistence with bipolar disorder and its response to lithium.

Analysis of emotional status during the hospital treatment of a borderline patient.

This single case study illustrates a methodology for identifying recurrent pathological emotional states in a hospitalized, borderline patient. Parallel therapeutic inputs are delineated and examined in terms of patient-specific responses. The results indicate that ratings of nursing notes recorded across three periods of hospitalization can reliably isolate the patient's most salient and debilitating emotional states.

The characterologically difficult patient: a hospital treatment model.

A treatment model for the hospitalized borderline patient has evolved from the long-term, intensive treatment of these patients in a psychodynamically oriented setting. Four stages are identified and described. Each has a therapeutic goal and strategy, and repeatedly observable patient responses and staff counter-responses.

Psychotherapy and the inpatient unit: a unique learning experience.

This paper describes the advantages of an inpatient setting for the teaching and learning of psychotherapy. Contributions to this process derive from the continuous and intense expressions of conscious and unconscious dynamics, transferences, and object relationships by the patients, the obligation on residents to therapeutically engage in a relatively exposed way with all the patients under their care, the availability and familiarity of the staff supervisors who participate in assessments and decisions regarding patient management and psychotherapy, and the collaborative work of all the other team members. Conditions of the setting which make this possible are the strong psychodynamic orientation of all the staff, the resident's role as manager and psychotherapist, the staff psychiatrist's role as supervisor and team leader, and the completely open communication among all the treating personnel.

The teaching and learning of psychotherapy in a general hospital.

A general teaching hospital provides an excellent setting for the teaching of psychiatric residents. The Canadian model for a teaching network, including general and specialty hospitals, allows for special interests to develop within given hospitals. A department of psychiatry which chooses the teaching of psychotherapy as a special interest is examined.

The resident and the borderline in-patient: a supervisor's perspective.

The problems of residents working intensively with borderline inpatients in a general hospital psychiatric unit area described. The resident feels pressure because of inexperience with intensive psychotherapy, and the high visibility of working in a closely supervised team setting. The border line patient baffles the resident with his defensive activity characterized by splitting, erotization, idealization, and negative therapeutic response.

Negative responses of the borderline to inpatient treatment.

The intense therapeutic encirclement maneuvers possible in long-term inpatient therapy of the borderline patient frequently stimulate emotional flooding and intense negative therapeutic reactions. Such reactions have understandable precipitants: a mixture of therapeutic goals, treatment methods, and defensive structures of the patient best conceptualized within an object-relations model.

Staff countertransference to borderline patients on an inpatient unit.

Borderline patients evoke unique countertransference responses among members of the treatment team: pejorative behavior, undue optimism, and pessimistic nihilism to these patients, along with difficulties in limit-setting, and fragmentation of the treatment team are common. Frequent meetings and open communication within the treatment team are recommended in order to minimize the splitting that is central to these countertransference constellations.