The role of personal therapy in psychiatric residency training: a survey of psychiatry training directors.

Objective: The authors examine the current place of personal therapy for residents in U.S. training programs.

A view from Riggs: treatment resistance and patient authority--X: from acting out to enactment in treatment resistant disorders.

Abstract Patients with treatment resistant disorders pose a major problem to clinicians of all theoretical perspectives, including psychodynamic therapists. Treatment of such patients often results in stalemates and impasses, and acting out is a frequent phenomenon. This paper addresses the value in work with such patients of looking beyond the concept of acting out, which is a one-person definition of a problem, toward the concept of enactment, which recognizes the roles both therapist and patient play in the phenomenon of treatment resistance.

Working with a patient claiming a direct relationship with god: encountering otherness.

Although we expect to encounter otherness in the consulting room, some types of otherness are more difficult to encounter than others. Differing ethnicities, religions, lifestyles, or other aspects of worldview can bring us into uneasy alliance with the other, as we also encounter disowned or unclaimed aspects of self in this process. I will discuss some of my difficulties working with a man who was born into my own religion-thus offering some common heritage of world view-but subsequently adopted another religion with such intensity that his faith seemed to have psychotic aspects.

A view from Riggs: treatment resistance and patient authority-IX. Integrative psychodynamic treatment of psychotic disorders.

Psychotic spectrum disorders present treatment challenges for patients, families, and clinicians. This article addresses the history of the dualism in the field between biological and psychological approaches to mental disorders, and surveys the contemporary literature about the etiology and treatment of psychotic spectrum disorders. An integrative approach to treatment derived from work at Austen Riggs with previously treatment refractory patients with psychotic spectrum disorders is described that combines individual psycho- dynamic psychotherapy, psychopharmacology, family systems approaches, and intensive psychosocial engagement.

A view from Riggs: treatment resistance and patient authority--VIII. Standards of care and patient autonomy.

The therapeutic community at the Austen Riggs Center relies on patient authority to preserve the open setting. Patients' willingness to take on the challenges and responsibilities of citizenship makes it possible to work without bars or locks. Most patients arrive having been labeled "treatment resistant," a label that can connote noncompliance but can also mark the complexity of the trouble and a resistance to being objectified in ways that are dehumanizing.

"Am I going crazy, doc?": a self psychology approach to therapeutic assessment.

In this case study, we explore the effectiveness of Therapeutic Assessment with a severely disturbed 25-year-old man, referred by his therapist, following Finn's (2007; Finn & Tonsager, 1992, 1997) model. This patient-therapist pair had been working together for approximately 2 months, but the therapy had ceased to progress. The therapist requested a clearer picture of his patient's affective functioning, interpersonal functioning, and self-functioning that might facilitate more effective treatment.

A view from Riggs: treatment resistance and patient authority--VII. A team approach to treatment resistance.

Treatment resistant patients frequently require treatment modalities beyond combined psychopharmacology and individual psychotherapy. They often require a team effort to manage crises, contain anxiety, and create a psychological space for examining the impact and meaning of behavior. The use of a treatment team as an adjunctive therapeutic modality helps individual team members understand regressions as repetitions of family dynamics, unearths the underlying meaning of behavior, engages patients' authority, and prioritizes the importance of relationships in effecting change.

A view from Riggs: treatment resistance and patient authority--VI. Working with family resistance to treatment.

Resistance to treatment is not only seen in the therapeutic dyad of patient and therapist. It can also be manifest in the interaction between the family, the patient, and the clinicians providing treatment. Psychodynamic and family systems perspectives can be useful in understanding the systemic and unconscious dynamics that comprise this form of resistance.

A view from Riggs: treatment resistance and patient authority - III. What is psychodynamic psychopharmacology? An approach to pharmacologic treatment resistance.

The authors explore the phenomenon of treatment resistance in relation to medications. They also propose and define a discipline of "psychodynamic psychopharmacology," describe its philosophical underpinnings and make technical recommendations for the psychodynamic treatment of pharmacologic treatment resistance. The authors review the recent literature suggesting a major role for interpersonal and meaning effects in positive pharmacologic treatment outcomes, and suggest that many patients are "treatment-resistant" to medications because an appreciation of the patient's dynamics is not incorporated into an understanding of repeated treatment failures.

A view from Riggs--treatment resistance and patient authority: I. A psychodynamic perspective on treatment resistance.

Treatment resistance has emerged as a significant issue in our era emphasizing biological treatments for psychiatric disorders. This article suggests that, particularly when Axis II disorders are part of the clinical presentation, a subset of treatment refractory patients responds to a psychodynamic treatment approach that includes careful attention to the meaning of treatment resistance, and to the importance of relationships and of patient authority in recovery. The importance of engaging the negative transference and countertransference in treatment is also emphasized.

Silent scream: the cost of crucifixion--working with a patient with an eating disorder.

In working with individuals who have experienced extreme deprivation in early relationships, the pain is often depicted silently and repetitively. There can be a tension between the need for validation and an avoidance of growth. The analyst, then, can find herself caught between her empathic resonance to the silent scream and the need to keep in mind the "cost of crucifixion.

Clinical tasks of the dynamic interview.

We examined psychodynamic interview tasks and techniques to identify clinical actions that improve or impede exploration of subjects' emotional responses, conflicts, defenses, and central relationship themes. This article extends previous quantitative studies (Perry, Fowler, & Greif, unpublished; Perry, Fowler, & Semeniuk, 2005) by examining interview vignettes in 50-minute psychodynamic research interviews. We conducted qualitative analyses on 72 dynamic research interviews given by 26 subjects to delineate categories of tasks and interventions.

Psychodynamic Trojan horses: using psychopharmacology to teach psychodynamics.

Concurrences of scientific, cultural, and economic developments in the past decade have changed psychiatric practice and psychiatric training. The explosion in neurobiological sciences has left residents with an overwhelming amount of neurobiology to master at the same time that managed care has led to a de-emphasis on psychiatrists providing psychotherapy. Consequently, many residents are left questioning the relevance of psychodynamics for psychiatry, given that the majority will function primarily as prescribers.

Assessment of Rorschach dependency measures in female inpatients diagnosed with borderline personality disorder.

The psychometric properties and predictive validity of the Dependency Index (DI; Hilsenroth & Bornstein, 2002) and the Rorschach Oral Dependency Scale (ROD; Masling, Rabie, & Blondheim, 1967) were examined to determine if these implicit measures of dependency predict observable attachment-seeking behavior in 66 female inpatients diagnosed with borderline personality disorder. Results indicate that both scales produce excellent reliability estimates. The DI and ROD yield adequate base rates, and the distributions of scores approximate normal distributions.

Teaching the prescriber's role: the psychology of psychopharmacology.

Objective: The author examines one aspect of the psychopharmacology curriculum: the psychology of psychopharmacology.

Method: Drawing from his experience teaching this subject to trainees at many different levels and from an emerging evidence base suggesting that psychosocial factors in the doctor-patient relationship may be crucial for medication effectiveness, the author explores the importance of this often overlooked aspect of pharmacotherapy. Several methods for teaching the integration of meaning and medication are examined.

Joining a group's task: the discovery of hope and respect.

When engaged with others in tension-filled dialogue, the temptation is for us to treat the other disrespectfully by unconsciously choosing an exclusive subgroup in our minds to belong to, and assigning the other to a devalued group. Unconsciously asserted exclusive membership allows us to deny the ways in which, by disconnecting the other, we are also alienating parts of ourselves. Using three stories, the author explores the notion of unconscious group membership and raises the possibility of discovering a shared membership in the midst of conflict.