Bertram P. Karon

Pathogenesis: A New Therapist Personality Dimension Related to Therapeutic Effectiveness

Summary The pre-project TATs of ten therapists were rated for “pathogenesis” and these ratings later correlated with their patients level of functioning after six months of treatment. Outcome was measured in a variety of data modalities: intellectual tests, thought disorder measures, projectives, clinical status interviews, and hospitalization. Significant correlations were obtained on five of eight outcome measures. Patients of more benign (or less pathogenic) therapists demonstrated greater foresight, less schizophrenic thought disorder, greater intellectual functioning, were rated as healthier in the Clinical Status Interview, and spent less time in the hospital than patients of more pathogenic therapists.

A direct analytic contribution to the understanding of postpartum psychosis.

SummaryThe deficiencies in our present knowledge of postpartum psychosis seem to be due to the inadequate consideration which has been given to the fantasy structures which underlie the traumatic impact of childbirth.Through the direct analysis of a schizophrenic woman with a postpartum psychosis, certain fantasies came to light which shed new light on the problem. Pregnancy had the significance to her of the final gratification of unresolved oral fantasies. The patient felt the increase in girth as caused by the bodys filling up with semen, which was equated with milk. The delivery was then viewed as a sudden castastrophic loss of this gratification.Such unconscious fantasies seem to account for many of the unexplained characteristics of postpartum disorders.

Reliability: Paradigm or Paradox, with Especial Reference to Personality Tests

Abstract Conventional reliability theory is inapplicable to many domains, including personality and projective tests. Repeat reliability, or temporal stability, is a matter to be investigated, not assumed; it is obvious that measures of some personality characteristics, e.g., mood, if temporally stable cannot be valid. As for internal consistency, classical mental test theory holds that an unreliable test cannot be valid. It is demonstrated mathematically that the maximum validity of a test with zero internal consistency (reliability) is one. The supposed limitation of validity follows only from the assumption of a random error component, uncorrelated with anything, to test scores. This often useful assumption leads us astray. A physical example is given as well as that of projective tests. Some consideration is given to the nature of these measurements. The largest validity squared is a conservative reliability estimate from classical test theory which may be used without being hurt by the theorys inapp...

Systematic studies of dreams: Relationship between the manifest dream and associations to the dream elements

Summary The relationship between the manifest dream and associations to the dream was investigated by the following method: one dream and its corresponding associations were selected from the data on each of 19 hospitalized psychiatric patients. The dreams and associations were rated independently and blindly on scales constructed to measure various emotional factors. It was found that the ratings of the manifest content of the dream correlated highly with the ratings of the associations with respect to: Degree of Hostility, Roots of Hostility, Dominance of Hostile Theme, Genitality, and Bodily Mutilation as defined in the scales. The scales by which the manifest dream and associations were correlated are described and some evidence for their validity is presented.

The Fear of Understanding Schizophrenia and Iatrogenic Myths

Empirically, psychotherapy with a competent therapist is the optimal, but rarely offered treatment, for schizophrenia. Medication or ECT produces less disturbing, lifelong cripples. Within 25 years one-third spontaneously recover completely (unless they stay on medication), and another third socially recover. Nazi Germany sterilized and annihilated patients without decreasing mental disorders in the next generation. Schizophrenia is a terror syndrome. The therapist must create a therapeutic alliance by creating hope and tolerating not understanding. Hallucinations are waking dreams. Delusions are transferences, defenses against pseudohomosexuality, family-specific meanings, or attempts to make sense out of strange experiences.

Brain Damage is Better than Having to Understand Schizophrenia: Medication and Other Organic Treatments

Abstract It is generally believed that a treatment that is more effective than its alternatives will be used, but psychological treatments for schizophrenic and other psychotic reactions have been avoided despite the evidence for their effectiveness from the time of “moral treatment” to the present. Less effective (or even destructive) treatments have been seized upon, in part, because they do not require understanding these patients. The problems with medication are described, including neurological damage. Evidence for genetic factors is weak. Only 20% of children raised by their schizophrenic parent ever become schizophrenic. Thirty percent of schizophrenics fully recover within twenty-five years spontaneously and another 30% have social recoveries. Medication may prevent full recovery. But better treatments, psychotherapies, are available.

Problems of Validities

In this chapter, I shall not attempt to review all the issues of validity of projective tests and the evidence relevant thereto. (That would take several volumes, rather than a chapter. One can summarize the literature briefly as follows: There are hundreds of articles on projective techniques which show them to be valid and hundreds of articles demonstrating them to be invalid.) Rather it is my intention to discuss some issues of validity both in clinical and research uses, to point out some of the considerations in the appropriate use of projective techniques in both settings, and to describe some of the common misconceptions which have led to confusion, conflicting evidence, and inappropriate conclusions.

Introduction to the special section treatment of psychoses by psychotherapy

At the end of the 18th century, a number of psychological treatments for psychoses (for which the term moral treatment was used) were begun in Europe and in the United States. Although they differed from each other, they all incorporated certain elements: (a) the use of physical force only to prevent patients from harming someone else or themselves, not for punishment; (b) avoidance of humiliation of patients; (c) encouraging work and social relationships; (d) obtaining as careful a case history as possible; and (e) doing one’s best to understand the patient as an individual human being. Despite some obviously untrue claims (‘‘Dr. Cure-All,’’ who cured every patient), the data showed that 60% to 80% of patients were discharged. For a number of reasons, the most important of which were economic, these treatments were abandoned for exclusively physical treatments, which were claimed to be more scientific and certainly were cheaper in the short run. However, patients stopped getting better (discharge rates in the same hospitals were now 10 /30%), but no one looked at the discharge or recovery data or investigated their determinants. Professionals, politicians, and the general public were happy about the supposed scientific and humanitarian advances in treatment. We are again in an age of controversy. A disturbing but accurate account of the facts concerning the treatments and mistreatments of schizophrenia in the United States from 1750 to the present has been put forth by Whitaker (2003). Read, Mosher, and Bentall (2004) present a good overview of the controversies and the current state of our knowledge relevant to these controversies. A number of psychotherapies seem to be useful. However, at least in the United States, psychotherapy and rehabilitation are largely being abandoned, primarily for shortterm economic reasons. Exclusively physical treatments are being substituted. Thus, the Patient Outcome Research Team (PORT) recommendations (Lehman, Steinwachs, & Co-Investigators of the PORT Project, 1998), supposedly on the basis of the empirical literature, concluded (admittedly by the authors on the basis of ‘‘expert opinion,’’ not research studies) that psychoanalytic therapy should not be used with schizophrenic patients and that no form of family therapy should be used that implies a relationship between events in the family and symptoms. This prompted a special issue of the Journal of the American Academy of Psychoanalysis and Dynamic Psychiatry (Silver & Larsen, 2003) presenting the opposing view and the clinical and research evidence for the psychotherapy of schizophrenia. In response, the PORT standards were revised to eliminate these negative recommendations, but no positive statements about psychotherapy were added. Fortunately, we are in an era in which data can be gathered, examined scientifically, and shared. The controversies about the benefits and shortcomings of different treatments and the interactions of treatments can and are being investigated. (Some researchers, however, have reported unusual difficulty publishing their results, unless they emphasize the value of medication regardless of whether it is in keeping with their actual findings.) It is important that there be a place in which carefully gathered empirical data about the process and outcomes of treatments, and the interaction of treatments, can be reported irrespective of what those findings might be and where the only relevant criteria are the care with which the study was designed and carried out. Psychotherapy Research is such a place, and these three articles*/by Yotis; Zgantzouri, Vallianatou, and Nestoros and Seikkula, Alakare, Aaltonen, and Haarakangas*/are a good beginning. These researchers are from different countries and evaluate different therapeutic approaches. Yotis, from Greece, describes and evaluates dramatherapy, a far more sophisticated treatment than the older psychodrama, and provides empirical data. Zgantzouri, Vallianatou, and Nestoros, from Crete, evaluate synthetiki psychotherapy by drawing the logical conclusion that, if there are positive changes within single sessions, these must accumulate during the total process, and the study of changes within a single session will clarify what is truly helpful. Seikkula, Alakare, Aaltonen, and Haarakangas, from Finland, describe and evaluate the open dialogue approach. In Finland they had already found that providing competent family therapy and individual therapy in addition to medication and hospitalization led to a decrease in hospitalization and medication, a cost savings, and better and more human outcome compared with the previous system, which (similar to that in the United States) had relied primarily on medication and hospitalization without meaningful psychotherapy. However, they Psychotherapy Research, March 2006; 16(2): 188 /189

Who Am I to Treat This Person? What It Feels Like to Treat a Seriously Disturbed Patient

Who am I to treat this person? That is what came to mind every time I treated a seriously disturbed patient. I do not know enough, and I have hang-ups. But no one knows enough, and every therapist has hang-ups, although our own analysis helps. We may feel confused, frightened, angry, or hopeless because these are the patient’s feelings. Discussed are creating rational hope, dealing with feelings (including terror), depression, delusions, hallucinations, and suicidal and homicidal dangers. Theory is helpful, but it is not enough. Tolerating not knowing often leads to effective improvisations. Best results were obtained with psychoanalysis or psychoanalytic therapy without medication. Next best was psychoanalytic therapy with initial medication withdrawn as rapidly as the patient can tolerate. Electroconvulsive therapy is discouraged.

Adolescent Hostility toward Therapists

Many therapists avoid working with adolescents. One of the reasons is that many adolescents are unreasonably hostile to therapists and express this hostility in ways that are hard to take. This is particularly difficult if you take their hostility at face value. But there is something ironic about adolescent hostility toward therapists. Although it would be bad therapy to laugh at them, it is funny (ironic): If you take their hostility at face value, you cannot tolerate them. If you do not take it at face value, you can tolerate their hostility, and if you keep working with them, they will get better. You will notice this even though they will tell you that you are not helping them. Theoretically, this is related to the unreasonable hostility of adolescents toward their parents and its basis in the need of the adolescent to prove to himself or herself that they do not want to still be a child even though a part of them does want to be a child. Several cases are presented, where taking the hostility seriously would have led to therapeutic failure, and where not taking it seriously led to therapeutic success. There was nothing funny, however, about the hostility of one adolescent patient who was a serial killer.