Organizers: Cage Hall, MD PhD, Carl Fleisher, MD, Sonal Rana, MD
Classics Club is an opportunity to read and discuss one or two selections each session from classic papers and authors in psychiatry and related fields, with an emphasis on seminal papers in psychoanalysis. We will also read some classic papers from academic psychology, cognitive science, and anthropology, as they may illuminate or critique psychodynamic concepts.
We have been lucky during the past year to have clinical and theoretical insights during the lunches from psychoanalytically trained psychiatrists Dr. David Coffey, Dr. Angel Cienfuegos, Dr. David Leviadin, and from our program director Dr. James Spar. We look forward to hearing from other faculty during the coming year.
The journal club began during the 2008-2009 academic year and largely focused on readings that seemed fairly digestible on their own, applicable to situations that PGY2 and PGY3 residents encounter frequently, and not employing so much of the metaphor or terminology that one can get bogged down in. In practice, this meant several articles from George Vaillant and D. W. Winnicott, as well as Sigmund Freud's “Mourning and Melancholia” and an essay by Nancy Chodorow on female development. This year (2009-2010) we are trying to work through Freud's three major theoretical models (topographic, structural, and psychosexual development), with some applications to therapy in the spring. Next year (2010-2011) we plan to cover different aspects of object relations, one of the dominant strands of psychodynamic theory in psychiatry since the middle of the 20th century.
We are also trying to generate on online annotated bibliography for those who want to read further on their own. For residents interested in additional readings on their own, the following are good introductions to psychoanalytic theory:
See also our companion journal club, Cutting Edge topics in psychiatry.
Practical matters:
The reading group normally meets every second Friday of the month during regular resident lunches. Readings are normally distributed beforehand, along with an email briefly outlining the main concepts and their theoretical and historical context.
Please note: future readings are subject to change. This syllabus is a work in progress and responds both to the interests of the residents and suggestions from our faculty discussants.
2008-2009 year: basic elements of psychodynamic approaches in therapy
2009-2010 year: Freud's three models of mind, critiques, and applications to therapy (transference and counter-transference)
2010-2011 year: object relations and concepts of the self
Suggested additional readings:
Faculty discussant: Dr. Elizabeth Bromley
Faculty discussant: Dr. Angel Cienfuegos
Faculty discussant: Dr. David Coffey
This is the first of several readings planned on Donald W. Winnicott and his works. Initially trained as a pediatrician in Britain, Winnicott was one of the most influential of the Object Relations theorists, a prolific and provocative writer but not always one of the most transparent. He is famous for saying "there is no such thing as 'an infant'", emphasizing the intensely social nature of the infant-mother dyad and the fact that no human infant exists in a social vacuum. Though he did not develop a systematic theory of human development or psychic function as such, his work inspired many schools of psychologists and psychiatrists interested in child development and interpersonal relations. Many of his concepts have now become standard in these fields, so common-sensical that we tend to forget their origins. He is also perhaps the best known of the so-called "Middle Group" of British psychoanalysts, between Melanie Klein and her adherents on the one side and and the Ego Psychology of Anna Freud and her associates on the other.
In the readings for this session, Winnicott discusses the use of the teddy bear as a transitional object to establish a concept of self, explores the child's sense of play, and describes the "good-enough mother", a core idea in dealing with many personality disorders and in thinking of the therapeutic experience as re-parenting. The third article is a chapter from Arnold Modell outlining Winnicott in general.
Faculty discussant: Dr. David Coffey
Faculty discussant: Dr. David Coffey
Faculty discussant: Dr. David Coffey
For further reading:
Schachter, Stanley, and Jerome E. Singer. (1962) “Cognitive, social and physiological determinants of emotional state.” Psychological Review 69(5): 379-99.
Faculty discussants: Dr. David Coffey and Dr. Angel Cienfuegos
In this essay, Freud lays out some of the classic observations on the processes of repression, resistance, and acting out which occur in the context of therapy, and suggests why patients may appear to get worse in the short term as they begin the longer-term process of getting better.
Faculty discussant: Dr. David Coffey
Vaillant, George E. (1975) “Sociopathy as a human process. A viewpoint.” Archives of General Psychiatry 32(2):178-83.
Faculty discussant: Dr. David Coffey
Vaillant, George E. (1992) “The beginning of wisdom is never calling a patient a borderline; or, The clinical management of immature defenses in the treatment of individuals with personality disorders.” Journal of Psychotherapy Practice and Research 1:117-134.
We will again be reading a selection from George Vaillant. This paper is one of the most-recommended papers on syllabi for C/L psychiatry and frequently cited in discussions of clinical management of personality disorders. The paper describes most of the major types of primitive and maladaptive coping mechanisms, how they manifest in therapy or other clinical practice, and suggests strategies for dealing with them.
Faculty discussant: Dr. P. David Leviadin
The case that started it all: Sigmund Freud and Josef Breuer's early patient “Anna O.” (aka Bertha Pappenheim), was a woman with hysterical conversion symptoms. Her treatment, partly with hypnosis and partly with free association, sparked Freud's conception of repression as well as the primary technique of psychoanalytic treatment--free association--as a way of getting behind repression. This led in time to the development of early psychoanalytic method.
Faculty discussant: Dr. David Coffey
The earliest of Freud's models for how the mind works, the topographic model divides the mind into parts that are Conscious (Cs - things of which one is aware), the Preconscious (Pcs - things that you are not thinking of now, but that can be easily brought into consciousness, like remembering your dental appointment next week or what you had for breakfast), and the Unconscious (Ucs - note, not "subconscious" - made up of things that have been repressed or otherwise not allowed into consciousness). These lectures are part of a series of five that were delivered at Clark University in Worcester, MA, in 1909. (The full lectures are available on line at http://www.rasch.org/over.htm) In these lectures, he outlines his theory of mental functioning and psychopathology as he understood it at the time. The first lecture, which we are skipping, largely recapitulates the material from the case of Anna O., which we read last month. The second and third lectures continue with his discussion of conflicts, hysteria, psychoanalytic method, repression, and slips of the tongue and other unconsciously motivated "accidents"(parapraxes).
Faculty discussant: Dr. David Coffey
While our overall goal during the first half of this year is to cover Freud's three major theoretical models (topographic, structural, and psychosexual development), we will be taking a brief detour into attachment theory over the next two months in preparation for our illustrious guest speaker in September. Dr. Anthony Bateman is a psychiatrist at University College London who will be speaking to us during the third week of September. Together with Dr. Peter Fonagy, he has developed one of the main therapeutic approaches to treating borderline personality disorder and related conditions. Their approach, Mentalization-Based Psychotherapy, derives in part from attachment theory.
Attachment refers to proposed psychological and neurological systems in human beings that mediate particular social relationships, especially the parent-child relationship and possibly romantic relationships. These appear to develop during crucial periods in early childhood and affect aspects of temperament, emotional regulation, and interpersonal relations throughout life. The concept was developed initially by John Bowlby, arising in part from and in part in reaction to psychoanalysts in London such as Melanie Klein and Donald Winnicott. For the next two sessions, we will read first an overview of the history and concepts of attachment theory, and then an article by Bateman and Fonagy describing their (evidence-based) therapy and how it grows out of attachment theory and related offshoots of psychoanalysis. For the August session then, we will focus on an article by Bowlby and his colleague Mary D. S. Ainsworth, who developed the main technique for assessing attachment in infants, the Strange Situation.
One of the difficulties of reading about attachment theory is that most of it is either in very long books (Attachment and Loss, 3 vols, at 400-plus pages per book documenting the theory, clinical observations, and experiments with animals and humans), or in very technical ethology papers by researchers such as Harry Harlowe, whose work with baby Rhesus macacques interacting with wire vs cloth "mothers" you probably remember from human development or intro psychology courses. This article, in constrast, shows Bowlby and Ainsworth talking about their initial inspirations and challenges and places their theoretical insights in a historical context. The second paper is more for further reading for those who are interested. Mary Main is an American psychologist who explicitly extended attachment theory to adults, developing attachment style assessment instruments and carrying out further empirical research.
Faculty discussant: Dr. David Coffey
And for further reading, an interesting commentary on a case of borderline personality disorder by the proponents of three different (though overlapping) theoretical models: Anthony Bateman, John Gunderson, and Otto Kernberg: the case of "Ellen": Gunderson, John G., Anthony Bateman, and Otto Kernberg. (2007) “Alternative perspectives on psychodynamic psychotherapy of Borderline Personality Disorder: the case of 'Ellen'.” American Journal of Psychiatry 164:1333-1339.
Faculty discussant: Dr. Joshua Pretsky
In his earlier writings, Freud had assumed/posited that a major driver and motivator in the psyche is the desire to avoid pain/anxiety/conflict. He also implied some importance for a positive desire of pleasurable things. In this essay, he begins to work out two major driving factors, also ways of engaging with the world, that motivate behavior. The pleasure/unpleasure principle is the desire to achieve or reexperience pleasurable things while avoiding unpleasurable things. This is associated with a "childlike" or infantile disregard of reality, including consequences for oneself (if I eat chocolate and don't exercise, I'll get fat), consequences for others (if I take chocolate from my baby sister, she'll be unhappy and cry), physical reality (the chocolate is in the store and the store is closed and locked until tomorrow morning), and social reality (if I eat the chocolate before dinner, I'll get in trouble). Because the pleasure/unpleasure principle is childlike and ignores reality, its most basic mechanism for avoiding unpleasure (aside from physically avoiding it) is to deny it--the motive for repression. Alternatively, the mind can present itself with hallucinatory wish-fulfillments, pretending to itself that the world is as it wants. (This wish-fulfilling phantasy later becomes a major concept in the work of Melanie Klein.)
However, ignoring reality is not sustainable, and in time causes its own share of unpleasure and missed opportunities for pleasure. The reality principle develops partly as the psyche seeks to protect itself from the unpleasantness of butting up against physical and social reality; in developing a reality-testing function, becomes the mediating factor that seeks pragmatic compromise with the real world.
A significant feature in this, which allows us to understand much of the implicit framework of later writings, is Freud's use of contemporary homeostatic models from physiology. He postulates that the ego seeks ultimately to reduce tensions, to discharge emotional energy, and to avoid excitement of any kind (seeing hunger as seeking satisfaction of a deficiency state, and sexual desire to some degree as the discharge of a buildup of sexual energy). These homeostatic principles have since been heavily modified, to say the least, and most behavioral researchers currently do not explain motivation as primarily seeking drive reduction in these terms. However, understanding this aspect of drive theory is crucial to be able to translate much of later Freud and his mid-century successors into modern psychological terms.
A reminder of terminology: cathexis is the binding of psychic/emotional energy to an object (an internal representation of something in the world, usually another person or aspect of a person, but potentially also an idea).
This essay is part of a transition from Freud's early topographic model to his later structural model. The early division of the psyche into Conscious, Preconscious (essentially a holding area for the Conscious, more of a distinction between working memory/awareness and declarative memory/that which can readily be called into awareness), and Unconscious (that which is repressed or has never been allowed into consciousness), gave way to his structural a model, in which several agents/modules/functions in the psyche operate on different principles. The Id (the It) would be identified with the pleasure/unpleasure principle and its primary process, the Ego (the I) with the reality principle, and the Super-ego (the Above-me) comprising the internalized values (positive and negative) of one's parents and the larger society as well as one's aspirations (Ego-Ideal).
Faculty discussant: Dr. Shirah Vollmer
Faculty discussant: TBA
Looking at female psychosexual development and a feminist critique of Freud’s formulation of castration anxiety and the Oedipus complex.
For further reading: Schafer, Roy. (1974) “Problems in Freud’s psychology of women.” Journal of the American Psychoanalytic Association, 22: 459-485
Faculty discussant: Dr. Angel Cienfuegos
Faculty discussant: Dr. Stan Leiken
Faculty discussant: TBA
Faculty discussant: TBA (tentatively, Dr. Stephen Marmer)
Faculty discussant: TBA
Faculty discussant: TBA
Our goal over the course of this year, having surveyed some of the founding principles of psychoanalytic thought, is to look more at the two main streams of contemporary psychodynamic theory: Object Relations (looking at our need for connection with others) and Ego Psychology/Self Psychology (looking at ego defenses and identity).
Faculty discussant: TBA
Faculty discussant: TBA
We will be revisiting Freud's classic article that foreshadowed object relations.
Faculty discussant: TBA
Faculty discussant: TBA
Faculty discussant: TBA (tentatively, Dr. Van DeGolia)
Faculty discussant: TBA (tentatively, Dr. Joshua Pretsky)
For further reading: Rubens, Richard L. (1994) “Fairbairn's structural theory.” In: Grotstein, J. S. & Rinsley, D. B., Fairbairn and the Origins of Object Relations. New York: Guilford Press.
Faculty discussant: TBA
Faculty discussant: TBA
Faculty discussant: TBA
Faculty discussant: TBA
Irving Hallowell, one of the pioneers of psychological anthropology and trained as a lay analyst, developed some of the key concepts in understanding the role of cultural variation in psychodynamic processes. In this article, he demonstrates the importance of considering projection, phantasy, myth, religion, and cultural categories in understanding how persons relate to others. In particular, he argues that Ojibwa (Native Americans from the Upper Midwest) often participate in meaningful relationships with being we would consider spirits, and opens up the question of spiritual or religious beliefs in object relations.
Faculty discussant: TBA
Faculty discussant: TBA
Created 2008 July 30.
Last updated 2009 Nov 23.