Anthony D. Bram

Potential space and reflective functioning : Towards conceptual clarification and preliminary clinical implications

The authors propose that although the psychoanalytic constructs ‘reflective functioning’ and ‘potential space’ overlap and are sometimes used interchangeably, a knowledge of their distinctions and the ways in which they interface have important clinical implications. These concepts are similar in that both are capacities considered (1) to originate in the caregiver‐child relationship, (2) to involve playing with ideas and symbolic thought, (3) to facilitate the therapeutic process and (4) to represent a desirable treatment outcome. The terms diverge in three important ways. First, potential space is a broader concept that can be applied not only to thinking about internal states but to aspects of human experience (e.g. art, religion) involving a sense of aliveness. Reflective functioning is more circumscribed to representations of mental states and their implications for interpersonal functioning. Second, potential space has more of a conscious introspective element, whereas reflective functioning is based in procedural memory. Third, reflective functioning operates intrapsychically, whereas potential space tends to be thought of as occurring in an interpersonal field. The authors hypothesise and illustrate a possible bi‐directional, dialectic relationship between the two constructs. It is suggested that this new understanding might, in some cases, facilitate productive reformulations of clinical formulations, such as working with a perceived resistance.

The relevance of the Rorschach and patient-examiner relationship in treatment planning and outcome assessment.

In this era of evidence-based mental health care, traditional forms of depth-oriented psychotherapy and psychological assessment have been marginalized in graduate training in clinical psychology. As a counterpoint, this article presents the evaluation and treatment of an adolescent client, along with an outcome assessment, and illustrates ways that aspects of traditional psychological testing, including the Rorschach (Exner, 1986) and the patient–examiner relationship, can enhance psychodiagnosis and treatment planning. Additionally, this case illustrates ways that test data can illuminate the concept of underlying disturbance and its utility in diagnostic formulation, treatment planning, and outcome assessment.

Psychological Testing and Treatment Implications: We Can Say More

Psychologists invest considerable time and labor in psychological testing and report writing. Patients and families expose vulnerabilities and make a significant financial and time investment in the hope that testing will make a difference in treatment. Frequently, though, handling of treatment implications in reports is generic, which might not justify the time, expense, and emotional investment involved in the evaluation. As diagnosticians, we have the responsibility and potential to contribute more meaningfully to the work of our referring colleagues and the treatment of the patients we assess. I review the psychotherapy research literature to highlight evidence-based findings that can serve as guideposts in formulating treatment implications. Subsequently, I illustrate how we can use test data to make nuanced inferences about therapeutic alliance, potential resistances, likely transferences and countertransferences, and conceptualizing treatment on the supportive–expressive continuum.

Quantifying Complexity: Personality Assessment and Its Relationship with Psychoanalysis

The fields of personality assessment and psychoanalysis have an entwined history and share much in common, notably an appreciation of the importance of understanding a person with complexity and depth, including the role of unconscious (or implicit) psychological processes. Personality assessment (or diagnostic psychological testing) offers a complement to psychoanalysis’ primarily idiographic approach by integrating it with a nomothetic one; that is, applying quantitative methods to determine in what ways and to what extent a person is similar or different relative to normative data. It is surprising, then, that contemporary psychoanalysts are largely unfamiliar with the field of personality assessment and seldom refer their patients for evaluation to assist with diagnostic formulation and treatment planning. In this article, we offer practicing analysts (1) a general description of the ways that testing can assist diagnostically, (2) an introduction to categories of psychological tests that sample functioning under varying conditions or from different vantage points, (3) a survey of assessment research that has provided empirical validation of key psychoanalytic concepts, (4) a window into the assessment process as it is applied clinically, and (5) cases to illustrate when and to what benefit analysts might consider referrals for testing. Examples include use of testing in instances when a new patient reports a history of repeated treatment failures; when patient and analyst are embroiled in a protracted impasse; and when a fine-tuned assessment of analyzability is warranted.

Effects of batting performance feedback on motivational factors and batting performance in youth baseball.

The effects of batting feedback on motivational factors and batting of young baseball players were investigated. Hypotheses were that, compared to participants receiving feedback or no feedback on their batting average, those receiving contact average would exhibit (a) a greater increase in batting efficacy, (b) more enjoyment, satisfaction, and persistence, and (c) superior batting performance. Participants were 78 children from nine teams. Although analyses did not support the hypotheses, performance-to-efficacy correlations as well as other data provided tentative evidence for the premise that contact average may be more appropriate feedback for young players because (compared to batting average) it is less ambiguous and is based on a more realistic definition of success. Limitations and implications for coaches were discussed.

Emotional Regulation in Women with Chronic Fatigue Syndrome and Depression: Internal Representations and Adaptive Defenses

Chronic fatigue syndrome (CFS) presents challenges in differential diagnosis and treatment. Complicating diagnosis is that its symptoms overlap with those of depression. This study applies psychoanalytic concepts to understand emotional regulation (ER) in women with CFS and/or depression. One hundred eighty-six women were assigned to four groups and compared: (a) CFS plus high er depression (CFS-HD); (b) CFS plus lower depression (CFS-LD); (c) depressive disorder (DD); and (d) healthy controls (HC). ER was operationalized by measures of capacity to form internal representations and adaptive defenses. The study’s premise was that difficulties metabolizing emotions psychologically would be associated with their greater somatic expression. Some support was found for the hypothesis that CFS participants would exhibit more impairment in representing emotions and in adaptive defenses compared to the DD and HC groups, but this held only for the CFS-HD group. Although CFS-LD participants were expected to be more purely somatizing than the CFS-HD group, they instead showed more sophisticated capacities for ER than that group and recalled less distressing early relationships, revealing more resilience. Still, however, we found support for somatization in some CFS sufferers: Within both the CFS-HD and the CFS-LD groups, weaknesses in representing emotions and in defensive functioning were associated with more severe physical symptoms. Clinically, the heterogeneity of CFS and those who suffer from it indicates the need for individual assessment and depression treatment.

Chronic fatigue syndrome and the somatic expression of emotional distress: Applying the concept of illusory mental health to address the controversy: BRAM et al.

OBJECTIVE The process of somatization in chronic fatigue syndrome (CFS) was investigated using the concept of illusory mental health (IMH). IMH involves self-reporting low emotional distress alongside performance-based assessment of distress. METHOD We studied IHM and physical symptoms in 175 women across four groups: (a) CFS plus depression; (b) CFS with no depression (CFS-ND); (c) depressive disorder without CFS; and (d) healthy controls (HC). IMH was assessed using a self-report measure plus the performance-based Early Memory Index (EMI). RESULTS CFS-NDs were no more likely to have IMH compared with HCs. Among the CFS-NDs, IMH was associated with more physical symptoms. For CFS-NDs, EMI added meaningfully beyond self-reported mental health in predicting physical symptoms. CONCLUSION Findings refute reducing CFS to somatization, but there is a subgroup of CFS whose lacking access to emotional distress is associated with heightened physical symptomatology.

Reviving and Refining Psychodynamic Interpretation of the Wechsler Intelligence Tests: The Verbal Comprehension Subtests

ABSTRACT The Wechsler intelligence tests (currently Wechsler, 2008, 2014) have traditionally been part of the multimethod test battery favored by psychodynamically oriented assessors. In this tradition, assessors have used Wechsler data to make inferences about personality that transcend cognition. Recent trends in clinical psychology, however, have deemphasized this psychodynamic way of working. In this article, I make a conceptual and clinical case for reviving and refining a psychodynamic approach to inference making about personality using the Wechsler Verbal Comprehension subtests. Specifically, I (a) describe the psychological and environmental conditions sampled by the Wechsler tests, (b) discuss the Wechsler tests conceptually in terms of assessing vulnerability to breakdowns in adaptive defensive functioning, (c) review a general framework for inference making, and (d) offer considerations for and illustrate pragmatic application of the Verbal Comprehension subtests data to make inferences that help answer referral questions and have important treatment implications.

To Resume a Stalled Psychotherapy? Psychological Testing to Understand an Impasse and Reevaluate Treatment Options

Clinical wisdom holds that psychological testing is a useful tool for consultation when there is a need to untangle and resolve a psychotherapeutic impasse. However, there has been a lack of empirical research in this area, and only a few cases have been published demonstrating how psychological testing can be used toward this end. In this article, the author offers a case illustration of the application of testing with a patient who sought to resume psychotherapy following a previous impasse and premature termination. Specific referral questions for the evaluation are explicated followed by discussion of the test data that answered each of them. The findings pointed not only to intrapsychic and object relational characteristics of the patient that contributed to the impasse but, importantly, alerted the author-therapist to his contributions as well. Treatment implications of the findings are also highlighted.