Clinical wisdom, science and evidence: The neglected gifts of psychodynamic thinking
Australian & New Zealand Journal of Psychiatry, 2022
We review five key areas of contemporary psychodynamic practice and research to highlight the con... more We review five key areas of contemporary psychodynamic practice and research to highlight the contributions psychodynamic concepts can make to clinical psychiatry. These areas are as follows: (1) Contributions to understanding the development of subjectivity. (2) The psychodynamic understanding of the effects of early childhood trauma and their consequences in adult life. (3) The vital importance of the psychodynamic notion of the ‘holding environment’ based on an understanding of the dynamics of the development of subjectivity and trauma which, if applied, might improve the quality of psychiatric care in the public mental health system and enhance both the clinical competence and morale of clinicians in the system. (4) The emerging scientific disciplines of Neuropsychoanalysis and Affective Neuroscience, which illustrate the importance of seriously studying the mind as well as the brain. (5) A brief summary of some research into the clinical effectiveness and efficacy of psychoanal...
Whose evidence? Lessons from the philosophy of science and the epistemology of medicine
To demonstrate the inadequacies of empiricism as a scientific foundation for evidence-based appro... more To demonstrate the inadequacies of empiricism as a scientific foundation for evidence-based approaches to psychiatry. The principles of empiricism are reviewed in the light of developments in the philosophy of science and phenomenology. Case studies are selected from the history of physical sciences, biological science and clinical sciences (pathology, neuroscience, psychosocial science and psychopathology), paying particular attention to the role of observation in theory construction. The principles of empiricism, particularly its view of the nature of observation as the basis of evidence do not reflect the historical reality of scientific theorizing and practice. Science has constructed alternative models of its own activity that do justice to the complexities of its subject matter, including the world of human experience and mental illness. A failure to recognize both the limitations of empiricism in science and the conceptual richness of alternative formulations that accord more closely with the complexity of psychiatry's domain will result in a naïve model of science and inadequate understanding of the limitations of 'evidence' that guide the training, clinical practice and research in our profession. The consequences will be the intellectual, clinical and ethical impoverishment of psychiatry.
Ghost Busting: re-introducing psychotherapy for the psychiatrist
Australasian psychiatry : bulletin of Royal Australian and New Zealand College of Psychiatrists, 2014
The purpose of this paper is to provide a clinically relevant historical and conceptual overview ... more The purpose of this paper is to provide a clinically relevant historical and conceptual overview of psychotherapy as an introduction to a forthcoming series of papers on specific models of psychotherapy. The author offers a selective review of some key ideas in the history and practice of psychotherapy. The principles of psychotherapy should inform all psychiatric practice, including the doctor-patient relationship, multidisciplinary teams caring for patients with complex or 'treatment resistant' problems, and patients who are non-compliant with psychotropic medication.
In this paper, we have examined that ethical aspect of working with families which stresses the r... more In this paper, we have examined that ethical aspect of working with families which stresses the relevance of values. Given that values are at the heart of both the family's and the therapists's view of the world, we see it as crucial for them to be addressed in the course of assessment and treatment. A variety of approaches have been adopted by clinicians ranging from those who regard ethics as a cornerstone of therapy to more compartmentalized positions, whereby specific sociopolitical themes like racism, poverty, and sexism are highlighted. Whatever model is preferred, the essential task is to accept that values are a necessary feature of therapeutic work and require negotiation. Failure to do so may have adverse repercussions on the therapist-family relationship, even to the point of jeopardizing therapy. Guidelines can be articulated to forestall such unfortunate consequences. We have attempted to identify these in the hope of clarifying for therapists the necessary step...
Psychiatric aspects of drug overdose in adult suicide and suicide attempts are reviewed. Particul... more Psychiatric aspects of drug overdose in adult suicide and suicide attempts are reviewed. Particular reference is given to studies reported from Australia. The findings of a recent study from the Royal Melbourne Hospital with regard to age-sex distribution, drugs ~tsed in self-poisonings, clinical state of the patient on admission and psychiatric diagnosis are presented and discussed.
The aim of this article is to describe the principles of supportive psychotherapy. The author ill... more The aim of this article is to describe the principles of supportive psychotherapy. The author illustrates the principles of supportive psychotherapy with a case vignette. Supportive psychotherapy is an important clinical skill for all psychiatrists.
With the exception of Self Psychology, empathy has not been a major theoretical concept in psycho... more With the exception of Self Psychology, empathy has not been a major theoretical concept in psychoanalysis. Freud's (1921) definition of empathy implies it is a necessary condition for an analytic process to develop (p. 110, n. 2). Most psychoanalytic theories have side-stepped this issue by including empathy under various assumed names. We have discussed some of these in the theories
Book Review: Philosophy: FREUD AMONG THE PHILOSOPHERS: THE PSYCHOANALYTIC UNCONSCIOUS AND ITS PHILOSOPHICAL CRITICS. By Donald Levy. New Haven: Yale University Press, 1996, 199 pp., $25.00
Journal of the American Psychoanalytic Association, 1999
This article focuses on a specific aspect of consultation in contemporary family therapy, namely,... more This article focuses on a specific aspect of consultation in contemporary family therapy, namely, problems that arise in the context of a consultation that simultaneously serves as a demonstration of a particular model of therapy. The demonstration-consultation interview is used widely in family therapy, but has received little attention in the literature. We use a case example of the apparent persistent deterioration in the clinical state of a patient following such a family interview with a visiting expert, and examine the possible contribution to the patient's deterioration that the demonstration-consultation context creates for the various participants. We offer provisional guidelines to minimize the risk of negative effects of the demonstration-consultation interview, pending empirical research into this phenomenon. Fam Proc 30:363-371, 1991 One of the features of family therapy, which differentiates it from most forms of psychotherapy, is its openness to scrutiny: the use of a team behind a one-way mirror; team and therapist discussions observed by an audience of trainees and other interested observers; the extensive application of videotaping; and the use of "outside" opinions from consultants who are not members of the regular team but invited to observe a session in order to help resolve difficulties in treatment or in the team itself. Beyond these therapeutic and consultation practices, family therapy has popularized live interviews and videotape demonstrations of therapy for professional audiences, often consisting of several hundred people. Thus, family therapy is taught and practiced in an atmosphere of open inquiry and critical scrutiny of the work of therapists. After a quarter of a century of such practices, their popularity remains undiminished, and their usefulness in training widely acclaimed. Recently, however, the complexities and potential risks of the consultation interview have become a topic of interest, particularly when such consultation occurs in a context different from that in which the regular therapy is conducted (7, 8). The aim of the demonstration interview is to show an audience how a particular model of therapy is applied, whereas the aim of the consultation interview is to help a family therapy team resolve the difficulties it is having in its attempt to help a family. While these two aims are not incompatible, there are differences between the context of a demonstration interview and that of a consultation interview. Such differences in contexts may create difficulties for the participants (the family members, the host institution and its family therapy team, the workshop audience, and the visiting expert) when a single interview tries to provide both a consultation and a demonstration. Our interest in this matter was prompted by the observation of the entirely unexpected deleterious effects of what appeared to be a highly skilled, sensitively conducted interview by a distinguished practitioner, enthusiastically received by the observing audience, helpful to the team seeking consultation, and apparently rewarding for the patient and his family at the time of the interview. This pattern has been briefly noted by Byng-Hall (1), but the prevalence of this phenomenon in family therapy awaits empirical study. We will describe the impact of a demonstration-consultation interview on a family. The family had been selected for a consultation-demonstration interview on the basis that all family members were capable of and willing to participate and had provided informed consent, and that an impasse in treatment or other management difficulty had been experienced by the therapy team so that the opinion of a visiting expert was deemed to be potentially advantageous. Under these circumstances, the negative outcome of the interview came as a surprise to us. Upon subsequent reflection, we have tried to explicate the possible factors involved in this phenomenon of "demonstration-related deterioration" by briefly considering the issues relevant in the specific family, and then, in more general terms, in our ensuing discussion. THE ALBERT FAMILY When John Albert, aged 19, was admitted to hospital for investigation of persistent headache, he was noted to be morose and burdened by an immense concern for his family. It soon emerged that their lives had been dominated for a decade by the father's recurrent paranoid illness. Although several psychiatrists had contributed to his care, he had required hospitalization several times each year, usually with intensification of his paranoid thinking. In the ensuing family assessment, it was noted that all members were distressed: Mr. and Mrs. Albert, both in their mid-50s, and their two childrenMark, aged 24, a science student, and John. John had recently dropped out of a carpentry
Clinical wisdom, science and evidence: The neglected gifts of psychodynamic thinking
Australian & New Zealand Journal of Psychiatry, 2022
We review five key areas of contemporary psychodynamic practice and research to highlight the con... more We review five key areas of contemporary psychodynamic practice and research to highlight the contributions psychodynamic concepts can make to clinical psychiatry. These areas are as follows: (1) Contributions to understanding the development of subjectivity. (2) The psychodynamic understanding of the effects of early childhood trauma and their consequences in adult life. (3) The vital importance of the psychodynamic notion of the ‘holding environment’ based on an understanding of the dynamics of the development of subjectivity and trauma which, if applied, might improve the quality of psychiatric care in the public mental health system and enhance both the clinical competence and morale of clinicians in the system. (4) The emerging scientific disciplines of Neuropsychoanalysis and Affective Neuroscience, which illustrate the importance of seriously studying the mind as well as the brain. (5) A brief summary of some research into the clinical effectiveness and efficacy of psychoanal...
Whose evidence? Lessons from the philosophy of science and the epistemology of medicine
To demonstrate the inadequacies of empiricism as a scientific foundation for evidence-based appro... more To demonstrate the inadequacies of empiricism as a scientific foundation for evidence-based approaches to psychiatry. The principles of empiricism are reviewed in the light of developments in the philosophy of science and phenomenology. Case studies are selected from the history of physical sciences, biological science and clinical sciences (pathology, neuroscience, psychosocial science and psychopathology), paying particular attention to the role of observation in theory construction. The principles of empiricism, particularly its view of the nature of observation as the basis of evidence do not reflect the historical reality of scientific theorizing and practice. Science has constructed alternative models of its own activity that do justice to the complexities of its subject matter, including the world of human experience and mental illness. A failure to recognize both the limitations of empiricism in science and the conceptual richness of alternative formulations that accord more closely with the complexity of psychiatry's domain will result in a naïve model of science and inadequate understanding of the limitations of 'evidence' that guide the training, clinical practice and research in our profession. The consequences will be the intellectual, clinical and ethical impoverishment of psychiatry.
Ghost Busting: re-introducing psychotherapy for the psychiatrist
Australasian psychiatry : bulletin of Royal Australian and New Zealand College of Psychiatrists, 2014
The purpose of this paper is to provide a clinically relevant historical and conceptual overview ... more The purpose of this paper is to provide a clinically relevant historical and conceptual overview of psychotherapy as an introduction to a forthcoming series of papers on specific models of psychotherapy. The author offers a selective review of some key ideas in the history and practice of psychotherapy. The principles of psychotherapy should inform all psychiatric practice, including the doctor-patient relationship, multidisciplinary teams caring for patients with complex or 'treatment resistant' problems, and patients who are non-compliant with psychotropic medication.
In this paper, we have examined that ethical aspect of working with families which stresses the r... more In this paper, we have examined that ethical aspect of working with families which stresses the relevance of values. Given that values are at the heart of both the family's and the therapists's view of the world, we see it as crucial for them to be addressed in the course of assessment and treatment. A variety of approaches have been adopted by clinicians ranging from those who regard ethics as a cornerstone of therapy to more compartmentalized positions, whereby specific sociopolitical themes like racism, poverty, and sexism are highlighted. Whatever model is preferred, the essential task is to accept that values are a necessary feature of therapeutic work and require negotiation. Failure to do so may have adverse repercussions on the therapist-family relationship, even to the point of jeopardizing therapy. Guidelines can be articulated to forestall such unfortunate consequences. We have attempted to identify these in the hope of clarifying for therapists the necessary step...
Psychiatric aspects of drug overdose in adult suicide and suicide attempts are reviewed. Particul... more Psychiatric aspects of drug overdose in adult suicide and suicide attempts are reviewed. Particular reference is given to studies reported from Australia. The findings of a recent study from the Royal Melbourne Hospital with regard to age-sex distribution, drugs ~tsed in self-poisonings, clinical state of the patient on admission and psychiatric diagnosis are presented and discussed.
The aim of this article is to describe the principles of supportive psychotherapy. The author ill... more The aim of this article is to describe the principles of supportive psychotherapy. The author illustrates the principles of supportive psychotherapy with a case vignette. Supportive psychotherapy is an important clinical skill for all psychiatrists.
With the exception of Self Psychology, empathy has not been a major theoretical concept in psycho... more With the exception of Self Psychology, empathy has not been a major theoretical concept in psychoanalysis. Freud's (1921) definition of empathy implies it is a necessary condition for an analytic process to develop (p. 110, n. 2). Most psychoanalytic theories have side-stepped this issue by including empathy under various assumed names. We have discussed some of these in the theories
Book Review: Philosophy: FREUD AMONG THE PHILOSOPHERS: THE PSYCHOANALYTIC UNCONSCIOUS AND ITS PHILOSOPHICAL CRITICS. By Donald Levy. New Haven: Yale University Press, 1996, 199 pp., $25.00
Journal of the American Psychoanalytic Association, 1999
This article focuses on a specific aspect of consultation in contemporary family therapy, namely,... more This article focuses on a specific aspect of consultation in contemporary family therapy, namely, problems that arise in the context of a consultation that simultaneously serves as a demonstration of a particular model of therapy. The demonstration-consultation interview is used widely in family therapy, but has received little attention in the literature. We use a case example of the apparent persistent deterioration in the clinical state of a patient following such a family interview with a visiting expert, and examine the possible contribution to the patient's deterioration that the demonstration-consultation context creates for the various participants. We offer provisional guidelines to minimize the risk of negative effects of the demonstration-consultation interview, pending empirical research into this phenomenon. Fam Proc 30:363-371, 1991 One of the features of family therapy, which differentiates it from most forms of psychotherapy, is its openness to scrutiny: the use of a team behind a one-way mirror; team and therapist discussions observed by an audience of trainees and other interested observers; the extensive application of videotaping; and the use of "outside" opinions from consultants who are not members of the regular team but invited to observe a session in order to help resolve difficulties in treatment or in the team itself. Beyond these therapeutic and consultation practices, family therapy has popularized live interviews and videotape demonstrations of therapy for professional audiences, often consisting of several hundred people. Thus, family therapy is taught and practiced in an atmosphere of open inquiry and critical scrutiny of the work of therapists. After a quarter of a century of such practices, their popularity remains undiminished, and their usefulness in training widely acclaimed. Recently, however, the complexities and potential risks of the consultation interview have become a topic of interest, particularly when such consultation occurs in a context different from that in which the regular therapy is conducted (7, 8). The aim of the demonstration interview is to show an audience how a particular model of therapy is applied, whereas the aim of the consultation interview is to help a family therapy team resolve the difficulties it is having in its attempt to help a family. While these two aims are not incompatible, there are differences between the context of a demonstration interview and that of a consultation interview. Such differences in contexts may create difficulties for the participants (the family members, the host institution and its family therapy team, the workshop audience, and the visiting expert) when a single interview tries to provide both a consultation and a demonstration. Our interest in this matter was prompted by the observation of the entirely unexpected deleterious effects of what appeared to be a highly skilled, sensitively conducted interview by a distinguished practitioner, enthusiastically received by the observing audience, helpful to the team seeking consultation, and apparently rewarding for the patient and his family at the time of the interview. This pattern has been briefly noted by Byng-Hall (1), but the prevalence of this phenomenon in family therapy awaits empirical study. We will describe the impact of a demonstration-consultation interview on a family. The family had been selected for a consultation-demonstration interview on the basis that all family members were capable of and willing to participate and had provided informed consent, and that an impasse in treatment or other management difficulty had been experienced by the therapy team so that the opinion of a visiting expert was deemed to be potentially advantageous. Under these circumstances, the negative outcome of the interview came as a surprise to us. Upon subsequent reflection, we have tried to explicate the possible factors involved in this phenomenon of "demonstration-related deterioration" by briefly considering the issues relevant in the specific family, and then, in more general terms, in our ensuing discussion. THE ALBERT FAMILY When John Albert, aged 19, was admitted to hospital for investigation of persistent headache, he was noted to be morose and burdened by an immense concern for his family. It soon emerged that their lives had been dominated for a decade by the father's recurrent paranoid illness. Although several psychiatrists had contributed to his care, he had required hospitalization several times each year, usually with intensification of his paranoid thinking. In the ensuing family assessment, it was noted that all members were distressed: Mr. and Mrs. Albert, both in their mid-50s, and their two childrenMark, aged 24, a science student, and John. John had recently dropped out of a carpentry
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Papers by Edwin Harari