Sigourney Award for distinguished contributions to the field of psychoanalysis. He is the editor with Lori C. Lori C.
Ebook Understanding And Coping With Failure: Psychoanalytic Perspectives
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Safe and Secure Payments. Easy returns. You might be interested in. We continue to ask ourselves, "For this specific individual, with this problem, what type of treatment, administrated by who, at what point in time and under which conditions will lead to how great an extent of benefit in over how long a period? The present text raises certain considerations on the relationship between analysis-oriented psychotherapy and the approach to cases of "difficult-to-treat depression", reviewing certain psychoanalytic contributions to the subject and proposing that another point-of-view, in addition to the biological one, be tried in these cases.
Difficult-to-treat depression can be each and every situation that results in an unsatisfactory response to treatment. This is an exercise built upon a non-systematic bibliographic review of a given practical situation, and the expression "difficult-to-treat depression", which, while vague, non-specific and unfamiliar to current classifications, is the best way that the current author has found to describe the situation.
A clinical example is described and commented on based on contributions found in the psychoanalytic literature on depression. The scientific question must be faced in psychotherapy. This, however, is not an easy task. Furthermore, certain assumptions must be made in order to achieve clinical applicability in our current, but not eternal, "scientific truths" While psychiatrists, we are much more clinicians than we are scientists and we must apply a humanist focus to our work that takes into account the scientific knowledge of several different areas, but which goes beyond this and constitutes an art.
In psychotherapy research is becoming a serious scientific field, but certain obstacles that have already been overcome by the biological sciences have not been overcome in the field of psychotherapy. Although the value of case histories is being reaffirmed, 1 it is no longer enough to confirm form colleague to colleague that someone is performing good therapeutic work. There are many difficulties, including the fact that we cannot achieve homogenous samples if such are possible , we do not have placebo and do not even have a common language.
According to Thomas Kuhn, 3 the first stages of development of the majority of sciences have been characterized by continuous competition between a number of different concepts of a distinct nature, each one of the partially derives and all of them only approximately compatible with the dictates of observation and the scientific method. In psychiatry, we are still talking about lines of thought, we are still at the pre-paradigmatic stage or, as Drob puts it, 4 multiparadigmatic.
While this may be discouraging, it is better than prematurely establishing a truth, a dogma, as a defense against uncertainty.
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Lipowsky 2 warns us of the problems of reductionism in psychiatry and states that no focus that does not take into account the mind nor one that ignores the brain can do justice to the complexity of mental disease. Eclecticism is understood to mean, not that which is described as a pragmatic posture in which the therapist uses whatever they think will help the patient, something ingenuous and without criticism, but the integrative sense, in which theoretical purity can be preserved and differences respected.
Wallerstein 8 postulates that, in order to be as effective as possible, every approach must be matched to the patient for which it is most appropriate. According to Yager, 9 the eclectic focus involves approaching every clinical situation by way of multiple theoretical perspectives and establishing that which is most in accordance with what the patient wants and needs, without discarding the best available information. For this author eclecticism is necessary due to the properties of our cognitive and perceptive apparatus, because of the manner subject to errors with which we organize our reality.
He states that a theoretical perspective, at the same time as it organizes inquiries, observations and understanding, also limits the field of vision and that the two elements are necessary because without an appreciation system data becomes confused. He observes that we, psychiatrists, process "reality" via our own prejudices in order to see things that correspond to our usual form of appreciating human behavior and disease, including depression.
Although depression has been described phenomenologically in a very clear manner within the current classifications, it presents in the most varied range of psychological, biological and social contexts. There are thousands of situations in which depression may be difficult to treat. Examples would be conditions that fulfill the criteria for resistant depression, cases of refraction to initial treatment, cases in which compliance is difficult, in which comorbidity or syndromal groups on axes I or II interfere with treatment, or, even in situations in which there is a risk of suicide.
Furthermore, a variety of atypical living conditions and an infinity of situations which, in general, we attempt to include within the biopsychosocial model may also interfere with treatment. In a study of patients with mental disease who had not exhibited a response to 6 months' routine treatment, and of whom The IPP method was based of the interpersonal psychoanalysis school of Sullivan, on studies of mourning by Freud and the attachment theory of Bowlby; PCB was represented by the ideas of Beck.
When an exploratory assessment was made of severity, it was observed that, for more severely depressed patients there was some evidence for the efficacy of IPP and strong evidence for IMI-CMC. Furthermore, in an observation on compliance, the author, interested in the clinical significance of the findings, commented that more patients on IPP than on PLA-CM remained in treatment long enough to achieve improvement.
Among the conclusions of the authors, is the statement that, overall, the final judgment on the effectiveness of psychotherapy for the most depressed patients should be withheld and that, perhaps, if the patients were studied for a greater period of time and other characteristics of the sample were evaluated for example, factors such as personality , the result would be different. Scott et al. Scott, 15 reviewing psychological treatments for depression, observed that the attitude of the patient, by believing in the treatment model and the possibility of improvement, would significantly improve the clinical response.
Kendler et al.
Understanding and Coping with Failure: Psychoanalytic Perspectives by Brent Willock
The authors observed that a recent stressor event was, in isolation, the factor of greatest risk for the development of the condition. Furthermore, the authors called attention to the multiplicity of possible interactions between factors, with an additive effect, such as the existence of certain characteristics that could predispose to a stressor, in addition, naturally, to "bad luck".
Zavaschi et al. The occurrence of depression in parallel with other axis I or II diagnoses appears to be more the rule than the exception. Schestatsky, 20 studying depression and comorbidity, state that the presence of an associated personality disorder increases the probability of suicide, reduces the response to treatment, reduces the number of remissions and interferes with social readaptation. Marcus 21 proposes that, depending on the personality structure, depression has diverse presentations and should be approached technically with this in mind. These authors studied the participation of certain circumstances in difficult-to-treat depression and concluded that there is a need for individualized approaches.
The circumstances studied included pregnancy, motherhood and possible subsyndromes of panic, social phobia and posttraumatic stress that influence presentation and response to the treatment. For Hendin, 23 psychotherapy also contributes to the approach to patient at risk of suicide. The author alerts to the fact that the therapist should not reduce treatment to simple management and control of the patient, but should also understand the extent to which the patient is using their potential death as part of their adaptation, avoiding countertransferential traps and working psychodynamically.
Situations that might occur, for example, are the therapist's avoidance of getting closer to the patient in order to reduce guilt in the face of a possible suicide or concern at having their competence checked. Furthermore, the therapist may see themselves imprisoned narcissistically, in their desire to get to know and to cure everyone, while the patient may have chosen them as executioner and not savior.
The author 23 concludes that the best chance of helping the patient lies in understanding and helping with the problems that make them suicidal, including the way in which they are using the threat of death, because it is only through psychotherapy that the nature of suicidal involvement becomes apparent. Summing up, studies demonstrate, although with limitations with respect of specificity, that psychotherapy is an essential component in the response to treatment for depression and that the combined approach, for example, pharmaceuticals with psychotherapy is a common and positive practice, 24 in particular for patients with the more chronic and complex forms of the disease.
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In Mourning and melancholia , Freud 25 compares melancholy to mourning, describing a sensation of painful sadness resulting from an objective loss. He said that the distinctive mental traces of melancholy are a discouragement that is profoundly painful, an end to interest in the outside world, the loss of capacity to love, the inhibition of all and every activity and a reduction in feelings of self-esteem to the point of finding expression in self-recrimination and self-vilification, culminating in a deluded expectation of punishment.
In addition to sharing certain characteristics with mourning, melancholy involves a regression to the oral, still narcissistic phase of the libido, when an identification with the lost object occurs, Freud also said that in mourning it is the world that becomes worthless and empty; in melancholy it is the ego. In relation to the regressive identification he said that the shadow of the object falls over the ego. Since it is judged as if it were an object, part of the ego places itself against the other, judging it critically.
The self-recriminations seen clinically are recriminations made of a loved object that have been displaced. Object and ego succumb to the judgment, the so-called, 'critical agent'. Freud also highlights ambivalence as a predisposing factor to the condition, where the relation between the object is characterized by love and hate. The self torture that is seen clinically is explained by means of tendencies towards sadisms and hate related to the object and which return on the "I" of the individual. Here there is a correction of the earlier assumption about the destiny of the object-cathexis, in other words it is only a part of the object-cathexis that is displaced to identification.
The other part, due to the ambivalence, finds itself in sadism. Suicide also harbors murderous impulses towards others. The ego can only kill itself if, as a result of a return to the object-cathexis, it can treat itself as an object. According to Abraham, 26 in a consideration of the libidinal development phases proposed by Freud, the unconscious sees the loss of an object as an anal process, and the introjection of one like an oral process.
On the sadistic-anal phase of the libido, the author discourses on the instinctive component of sadism, showing two tendencies opposed to in action. One of these is to destroy the object or the external world ; the other is to control it. While referring to melancholy and neurosis in a single chapter, Abraham proposes that the sadistic-anal phase should be analyzed in two stages.
At the posterior level, conservative tendencies predominate, to retain and control, and at the more ancient level are the tendencies more hostile to the object, to destroy or lose it. The obsessive neurotic regresses to the posterior of these two planes and is capable to maintain contact with its object.
The melancholic, however, as soon as the ego enters into conflict with the love object, abandons relations with this object, acting on the tendencies of the more ancient level. Abraham 26 postulates on the importance of the oral phase to melancholy. He considers an especial fixation of the libido in the oral phase as one of the factors implicated in the etiology of the disease. The process of introjection in the melancholic, the representative of the oral phase, rests on a severe conflict of ambivalent sentiments.
Other factors implicated in the etiology, according to this author, are the occurrence of the first disappointment with the love object before the oedipal desires are overcome and a repetition of this first disappointment in later life, in addition to a great injury to infantile narcissism. On the subject of the psychogenesis of melancholy, Abraham 26 reminds us that melancholic patients are inaccessible to any criticism of their mode of thinking.
In them can be seen the narcissistic character of thought and disregard for people who confront them with reality. Summing up, Abraham says that when melancholic people suffer an unbearable disillusionment caused by their love object, they tend to expel this object as though it were feces, and destroy it. Soon after they will perform the act of introjection and devouring it, as act which is a specifically melancholic form of narcissistic identification.
Their sadistic thirst for vengeance then finds satisfaction, tormenting the ego, an activity which, partly, gives pleasure". Melanie Klein 27 postulates that depressed individuals do not establish good internal objects and do not feel safe in their internal world as a result of the external loss.
In , 27 with A contribution to the psychogenesis of manic depressive states , the author develops the concept of the depressive position, defined as a phase of development in which a baby recognizes an entire object and relates to it. Here, she observes that new sentiments appear, of lack of and desire for the good object which, in the fantasy, was destroyed and lost, in common with the guilt resulting from this.
In the work Mourning and its relation to manic depressive states , 28 less is said about oral regression and more focus is given to the concept of the depressive position as an event that modifies development and through which the changes necessary to adaptation occur. It is as though the child passes through something similar to mourning, and that the satisfactory negotiation of this moment, with the establishment of good internal objects, determines the future course of mental disease and, in particular, vulnerability to depression in the face of future losses.
The essence of the concept of the depressive position is to contain the start of the process of internalization of good internal objects, something that never ends, staying with the individual throughout life. If narcissism predominates, the psychic mechanisms will not take the object into account and will go in search of increased self value.