Dynamic psychotherapy: a 50-year perspective.

Dynamic psychotherapy is a method of treatment for psychiatric disorders and emotional problems that comprises a spectrum of approaches ranging between supportive and analytic peripheries. Although they are deployed in differing degrees and manners, all forms of dynamic psychotherapy derive their therapeutic powers from five components: support, hope, a certain kind of listening, insight, and guidance. Attentive listening is particularly important, while insight, although essential, is a complex phenomenon whose therapeutic value may be overestimated.

The changing role of dynamic psychotherapy in psychiatric practice.

The author reviews the range of accepted indications for dynamic psychotherapy when he first began practice after World War II and describes factors that have played a role in the current undervaluing of this treatment approach. He attributes much of the change to research that has produced a different understanding of many of the conditions treated by psychiatrists and has placed greater emphasis on their medical and biological aspects than on their psychological aspects. He also attributes many alterations in current practice to the change from a two-party to a three-party reimbursement system for psychiatric services.

Medical necessity and psychotherapy.

Managed care and, specifically, the need to conform to medical necessity requirements have had a dramatic effect on medical and psychiatric practice, especially on psychotherapy. The author describes the progression of the concept of medical necessity from a simple accounting of services reimbursable by insurance companies to an ambiguous term without definitional consensus. He describes its relationship to the medical model and discusses the incongruity between medical necessity and certain aspects of psychotherapy.

The AHCPR guidelines on heart failure: comparison of a family medicine and an internal medicine practice with the guidelines and an educational intervention to modify behavior.

Objectives: The objectives of this study were to apply the Agency for Health Care Policy and Research (AHCPR) guideline for heart failure to the measurement of quality of care in the ambulatory setting, to compare the results for two large practices and to design an educational intervention for the two practices being studied.

Methods: A retrospective chart review was conducted on a random sample of 50 patients with heart failure selected from each of two outpatient practices: the general internal medicine practice and the family medicine practice at a large academic medical center. Five medical review criteria were developed from the AHCPR guideline for heart failure to compare the two practices with each other and the guidelines.

Ethical dimensions of psychotherapy: a personal perspective.

A substantial increase in the interest devoted to ethical issues has been a defining feature of my 50 years in psychotherapeutic practice. Reasons include a shift from a paternalistic to a contractual model of the doctor-patient relationship, increased litigiousness, and greater emphasis on the business rather than professional aspects of practice. Many ethical violations stem from misuse of therapist power in the psychotherapeutic relationship.

Effects of the new economic climate on psychotherapeutic practice.

Psychotherapy, especially the intensive variety, has been put under considerable adverse pressure by changes in the economics of medicine and psychiatry. The dominance of third-party rather than out-of-pocket payment for services raises questions about the "medicality," and thus the eligibility for coverage, of some disorders treated with psychotherapy. Trends toward the "industrialization" of psychiatry threaten to curtail the independent, fee-for-service conditions that may be necessary for psychotherapeutic practice.

Fear of AIDS.

A specter is haunting our streets--the specter of AIDS, a remorseless and incurable disease whose nature, transmission and effects still contain elements of mystery. The fear of AIDS is pervasive. Most of us experience this fear as an uneasy but usually abstract awareness of its presence in the society.

Involuntary hospitalization of the mentally ill as a moral issue.

Conflict exists between medical model and civil liberties approaches to involuntary hospitalization for mental illness. The amassing and analysis of data will not resolve this conflict because the two sides view the problem from differing moral vantage points. Medical model adherents are influenced chiefly by utilitarian or consequentialist considerations, while the civil libertarians take more of a deontological or absolutist position.

Traumatic acute mitral regurgitation secondary to blunt chest trauma.

An 18-yr-old male involved in a motor vehicle accident developed acute traumatic mitral regurgitation with fulminant pulmonary edema and death. He had prominent V waves on his pulmonary arterial trace, a history of chest trauma, frothy pink pulmonary edema, and elevated pulmonary artery, wedge, and CVP. His ECG was normal and physical exam was negative for a typical murmur.

Assessment of psychotherapy: reflections of a practitioner.

Granting both the importance and the difficulty of assessing psychotherapy, I express my dissatisfaction with the relevance of large-scale controlled trials to the realities of outpatient clinical practice. I suggest that surveys of their psychotherapeutic experience by practitioners may have, at least, complementary value. It has been my impression that psychotherapy often is an effective modality for the symptoms and turmoil associated with emotional crises.

Hysteria and women.

Through the ages, hysteria has been considered to be a female disease. The author explores the historical record and concludes that the hysterical (histrionic) personality is a caricature of femininity. It develops under the influence of cultural forces, particularly male domination, and is not a natural attribute of women.

The effects of a fluctuating Fio2 on metabolic measurements in mechanically ventilated patients.

The determination of minute oxygen consumption (VO2) for metabolic studies on patients using either the Beckman Metabolic Cart (MMC) or the Respiratory Monitoring System (RMS) requires a stable fractional inspired oxygen concentration (FIO2). Measurement of VO2 on mechanically ventilated patients using the Bourns BEAR 1 and the Engstrom 311 and 312 was unsuccessful due to FIO2 variations greater than the acceptable limits. The inspiratory and expiratory O2 and CO2 waveforms were studied using various methods of supplying source gas to the ventilators.