Richard Q. Ford

MIXED ANACLITIC-INTROJECTIVE PSYCHOPATHOLOGY IN TREATMENT-RESISTANT INPATIENTS UNDERGOING PSYCHOANALYTIC PSYCHOTHERAPY

Utilizing data from the Riggs-Yale Project, 45 male and 45 female 18–29-year-old treatment-resistant inpatients undergoing intensive psychoanalytically ori-ented treatment were studied. Twenty-seven mixed-type anaclitic–introjectiveinpatients were compared with 29 “pure” anaclitic and 34 “pure” introjectiveinpatients. At intake, mixed-type inpatients were more clinically impaired (i.e.,were more symptomatic, cognitively impaired, and thought disordered) andmore vulnerable (i.e., less accurate object representations and more frequentlyused maladaptive defense mechanisms) in comparison with clearly defined ana-clitic and introjective patients. Mixed-type patients, however, improved signifi-cantly more in the course of psychoanalytically oriented treatment, in terms ofclinical functioning (i.e., symptoms, cognitive functioning) and psychologicalvulnerability (i.e., utilization of more adaptive defense mechanisms).Interpersonal relatedness and self-definition are two fundamental themes in many psy-choanalytic and nonanalytic personality theories. In “Civilization and Its Discontents,” forexample, Freud (1930/1961a) contrasted “the man who is predominantly erotic [and gives]first preference to his emotional relationships of other people” with “the narcissistic man,

VERBAL REPRESENTATION AND THERAPEUTIC CHANGE IN ANACLITIC AND INTROJECTIVE INPATIENTS

This study examined the relation between changes in clinical functioning and changes in verbal expression in 81 seriously disturbed and treatment-resistant young adults seen in a comprehensive, psychoanalytically oriented inpatient treatment. Clinical functioning was evaluated with a battery of clinical and social measures. Verbal representations were assessed using computer-assisted scoring of Thematic Apperception Test responses. Changes in the frequency of verbal content and style in the narratives of these patients covaried with changes in clinical functioning. Significantly different covariations of verbal and clinical change, particularly differences in covariates of referential activity, were found for patients with anaclitic versus introjective personality configurations. The implications of these findings for understanding and treating severe psychopathology are discussed.

The Prediction of Therapeutic Response to Long-Term Intensive Treatment of Seriously Disturbed Young Adult Inpatients

Most investigations of predictors of therapeutic change report that less seriously disturbed patients have greater capacity to benefit from treatment while other investigations indicate that more seriously disturbed patients have greater potential for change. The results of the present study indicate that the prognosis for seriously disturbed young adults to gain from long-term, intensive, inpatient treatment is indicated by an initial capacity to communicate disordered thinking and disruptive experiences as well as a capacity for establishing appropriate and constructive interpersonal relationships. Greater disordered thinking and the representation of more malevolent, unilateral interactions, as well as more differentiated and integrated representations of the human figure on the Rorschach early in treatment, related to less intense and frequent clinical symptoms and more intact and appropriate interpersonal relationships after approximately 15 months of treatment. While the relevance of these findings ...

Effectiveness of Long-Term, Intensive, Inpatient Treatment for Seriously Disturbed Young Adults: A Reply to Bein

Beins criticisms of Therapeutic Change: An Object Relations Perspective are based on a misreading of the book; on a confusion between two independent types of analysis that were conducted; on a lack of appreciation of the nature of severe psychopathology and of long-term inpatient treatment; and on an attempt to impose a methodology from studies of treatment efficacy onto the investigation of the effectiveness of a comprehensive, multifaceted, intensive, long-term, inpatient treatment program designed to assist severely disturbed, treatment-resistant patients. Thus, we still contend that our findings, across a wide range of independent measures derived from the evaluation clinical case records and several different psychological assessment procedures, indicate that severely disturbed patients made significant therapeutic gain in long-term, intensive, inpatient treatment. Beins Kritik der Arbeit “Therapeutische Veranderung: Eine Objektbezichungsperspektive” grundet aufeinem falschen Verstandnis des Buches...

Therapeutic Change in Clinical Case Reports and on the Rorschach

This chapter will consider the evaluation of therapeutic change as expressed in ratings of clinical behavior described in the clinical case reports prepared on each patient after the first 6 weeks of hospitalization and then again, on average, after 15 months of intensive treatment including psychoanalytically oriented individual psychotherapy four times weekly. The case records were rated for manifest clinical symptoms of psychosis, neurosis, and labile and flattened affect, as well as for the quality of social interactions with other patients and members of the clinical staff. In addition, Rorschach protocols administered at these same two times in the treatment process were independently evaluated for a variety of dimensions including thought disorder and the quality of the representation of the human figure and the nature of its interactions.

Therapeutic Change on Human Figure Drawings

There is considerable disagreement about the value of Human Figure Drawings (HFDs) in both clinical practice and clinical research. Adler (1970, p. 52) concluded that of all available psychological testing instruments, HFDs ... are second only to the Rorschach in frequency of use in hospitals and clinics in the U.S. [Sundberg, 1961]. At the same time, reviews of the HFD literature (Harris, 1963; Roback, 1968; Swensen, 1968) are almost universally pessimistic about the validity of this instrument as commonly used in clinical practice.

Theoretical and Methodological Issues in the Study of Therapeutic Change

The clinical research presented in this book was initiated with several goals. First, we sought to assess systematically the effects of the therapeutic process with seriously disturbed patients hospitalized in an intensive, long-term, open inpatient treatment facility that offered psychodynamically informed treatment, including psychotherapy four times weekly.

The Prediction of Therapeutic Change

One of the more fascinating and important questions in psychotherapy research is the prediction of who is likely to gain from the treatment experience. Still applicable today is Frank’s (1979) comment: After decades of research, the amount of well-established, clinically relevant knowledge about psychotherapeutic outcome still remains disappointingly meager. Although some relationships between determinants and outcome have attained statistical significance, few are powerful enough to be clinically relevant, and most of [these] ... are intuitively obvious. An example is the finding that patients who begin therapy at a high level of functioning terminate at higher levels than those who begin at lower levels. In other words, the healthier one is to start with, the healthier one is at the end (Garfield, 1978). ... [R]esearch ... to date suggest that the major determinants of therapeutic success appear to lie in aspects of patients’ personality and style of life (pp. 310, 312).

Illustrative Clinical Cases

In the research presented in this book, we have taken a binocular view. We have looked at the same patients through two separate lenses: (1) through the systematic evaluation of clinical observations presented in narrative case reports and (2) through the precise delineation of psychological test variables, especially from the Rorschach, whose reliability and validity have been documented in a number of prior cross-sectional research investigations. We rated data from each of these points of view without knowledge of the other, in order to demonstrate the validity of both approaches to clinical assessment.

Methods for Assessing Therapeutic Change in Psychological Test Protocols

Coordinated with the preparation of the clinical case reports after the first 6 weeks of hospitalization and again much later in the treatment process (after at least 1 year of treatment), all patients were administered an extensive battery of diagnostic psychological tests, including the Rorschach, the Thematic Apperception Test (TAT), a Wechsler Intelligence Test, and, in some cases, the Human Figure Drawing (HFD) test. This testing was conducted by advanced, postdoctoral fellows in clinical psychology who were committed to diagnostic psychological testing and supervised by senior clinical psychologists. The test procedures were administered using a standard, well-specified format and a consistent theoretical orientation (Rapaport, Gill, & Schafer, 1945). The test protocols were all recorded verbatim and parallel the quality of the clinical records in detail and thoroughness. These psychological test protocols provide the data for independent evaluations of a number of important psychological dimensions. In addition to regular scoring procedures, newly developed conceptual schemes were used to score various aspects of these protocols.