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OBJECTIVE: The authors suggest that pharmacotherapy and psychotherapy, the major treatment modalities in psychiatry, have become fragmented from one another, creating an artificial separation of the psychosocial and biological domains in psychiatry. METHOD: After a brief discussion of the economic factors influencing this trend, the authors provide a selective overview of recent research. In the absence of systematic empirical data regarding which patients and which conditions might benefit from integrated treatment by one psychiatrist, the authors propose specific clinical situations that call for such integration and also discuss concerns about cost-effectiveness. RESULTS: Recent research suggests that combining psychotherapy and pharmacotherapy may have advantages over either treatment alone in certain clinical situations involving specific disorders. While few of the studies on combined treatment have tested whether a one-person or two-person model of treatment provision is more effective, there are a number of advantages to the one-person treatment model in which a psychiatrist conducts the psychotherapy and prescribes medication for the same patient. CONCLUSIONS: The authors suggest that further research is needed to clarify the optimal situations for the one-person model of integrated treatment and also propose systematic teaching of integrated treatment in all residency training programs.

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While psychoanalysis has generally been regarded as "the talking cure," written communication from patient to analyst commonly appears within the analytic setting. In our electronic age, e-mail communications from patient to analyst have become commonplace. This paper describes a case of erotic transference conveyed primarily through e-mail messages, and discusses their multiple meanings as an enactment. The unique features of e-mail communication are explored and contrasted with verbal discourse in the analytic dyad.

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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.

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The work of a COPE study group on boundary violations is summarized, with particular focus on the impact on institutes and societies of sexual misconduct by training analysts. Difficulties in evaluating such situations are discussed, and the dynamics of institutional avoidance explicated. In addition, psychodynamic themes that are commonly observed in analysts who engage in sexual boundary violations with their patients are elaborated. Finally, suggestions are made for managing, through existing mechanisms, instances of boundary violations by training analysts.

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Over the last 100 years, countertransference has evolved from a narrow construct referring to the analyst's transference to the patient to a jointly created phenomenon that is ever-present in the psychotherapeutic situation. In recent years, a myriad of theoretical perspectives have begun to converge around the view that countertransference is partly determined by the therapist's preexisting internal object world and partly influenced by feelings induced by the patient. Countertransference is now regarded as inevitable, and minor enactments of countertransference may provide valuable information about what is being recreated in the therapist-patient dyad. Self-disclosure of countertransference may be useful in some situations, but the sharing of some feelings will overwhelm patients and burden them in a way that may be destructive to the therapeutic process.

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Recent trends in the economics of mental health care threaten to undermine the use of psychodynamic psychotherapy for the treatment of patients with borderline personality disorder. These trends are driven in part by the assumption that such treatment of these challenging patients is very expensive. The author highlights empirical research that supports both the usefulness and the cost-effectiveness of this treatment approach. He also reviews some effective clinical strategies with borderline patients.

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Expressions of gratitude from the patient may be regarded by the analyst as a much-needed validation or affirmation of competence. The analyst's need for gratitude may be a relatively silent presence when things are going smoothly or when the analyst's efforts are openly appreciated by the patient. Ungrateful patients, however, are likely to force the analyst to confront his or her unconscious background wish to enact a longed-for mode of relatedness as part of the daily work of psychoanalysis. The analyst's wish for a specific form of object relationship involving a selfless, devoted helper and an appreciative patient who acknowledges having been helped may be thwarted by certain patients at every turn, knowing they are depriving the analyst of a particular form of gratification in their work. For patients of this type, failure may mean success. The implications of this particular form of clinical stalemate are outlined, and a clinical example illustrates some of the challenges encountered in psychoanalytic work with ungrateful patients.

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BACKGROUND: Polarisation of biological and psychosocial aspects of psychiatry has promoted a form of Cartesian dualism. Current knowledge of the interaction between biology and psychology makes it possible to consider a truly integrative approach to treatment. AIMS: The aim of this overview is to consider conceptual models of how psychotherapy may affect the brain. METHOD: The literature discussing the mutual influence of genes and environment is surveyed. Relevant data involving the influence of psychotherapy on the brain are also reviewed. RESULTS: Research findings suggest that the brain responds to environmental influence through the alteration of gene expression; that psychotherapy has specific measurable effects on the brain; and that implicit memory may be modified by psychotherapeutic interventions. CONCLUSIONS: Advances in neuroscience research have led to a more sophisticated understanding of how psychotherapy may affect brain functioning. These developments point the way towards a new era of psychotherapy research and practice in which specific modes of psychotherapy can be designed to target specific sites of brain functioning.

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OBJECTIVE: The purpose of this study was to determine whether severe personality disorders improve or deteriorate with intensive inpatient treatment. METHODS: Overall 216 patients diagnosed as having personality disorders by DSM-III-R criteria were prospectively monitored at two private psychiatric hospitals from admission through discharge to one-year follow-up. RESULTS: Substantial positive change in the sample was recorded at discharge, and the improvements held up at one-year follow-up. The proportion of patients with scores of 50 or more on the Global Assessment Scale was 3.7 percent at the time of admission. By discharge the proportion had increased to 55.1 percent, and by one-year follow-up it had risen to 66.3 percent. CONCLUSIONS: These results suggest that patients with severe personality disorders benefit from intensive inpatient treatment. We found no evidence that hospitalization of such patients is associated with regression or deterioration of function.

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The author argues that the use of clinical material for educational purposes or for publication presents the analyst with a conflict of interest between the protection of the patient's privacy and the educational and scientific needs of the field, and also that it places analysts in the position of using confidential patient material in the service of their own professional advancement. The strategies of dealing with this dilemma can be classified as follows: (1) thick disguise, (2) patient consent, (3) the process approach, (4) the use of composites and (5) the use of a colleague as author. Some of these options may, of course, be used in combination with one another. All of these methods have a place, and the author argues against a uniform approach. Each of these strategies is discussed in terms of its advantages and disadvantages. While no choice is without various risks, some guidelines are offered to assist analysts who wish to present or write about clinical cases.

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Although personality disorders are often regarded as "untreatable" by third-party payers, there is actually a growing empirical literature suggesting that Axis II conditions may be eminently treatable by psychotherapy. This literature is critically reviewed, the implications for length of treatment are discussed, and cost-effectiveness issues are examined.

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A variety of political, economic, and scientific forces have caused psychoanalytic therapies to become marginalized in psychiatry. These therapies are given short shrift in recently developed treatment guidelines, which are based largely on notions of empirical validation narrowly construed. Questions about the efficacy of psychoanalytic therapy can be meaningfully addressed by systematic assessment of available knowledge and potential data bases and by explicit efforts to locate the role of psychoanalytic therapies alongside other modalities. Several steps that might lend the psychoanalytic therapies greater credibility are proposed: (1) define the distinguishing features; (2) identify clear indications and contraindications; (3) systematically collect case histories of successfully treated mentally ill (diagnosable) patients; (4) increase vigilance (together with the patient) toward assessing progress in treatment.

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