http://exhibits.library.stonybrook.edu/mfp/files/original/1e8c795fb4f587faa06c7827a2d53d1f.pdf 8dbcc77f9a018fd443642f4f0191daf3 PDF Text Text \Lz. MODIFICATION OF PSYCHOTHERAPEUTIC TRANSACTIONS BY ALTERED BRAIN FUNCTION J. JAFFE, M.D., H. ESECOVER, M.D., R. L. KAHN, and M., FINK, M.D. Glen Oaks, N. Y. PHD. This report is derived from a supervisory seminar in which the effects of convulsive treatment upon psychotherapeutic transactions were studied. The therapist’s observations have been described in a previous publication (1) . The present paper describes the process from the frame of reference of the supervisor and supervisory group. It is intended as a complementary set of observations of this combined therapy. In addition, concurrent neurophysiologic data are included, of which both therapist and supervisor were unaware. This additional frame of reference may broaden the understanding of certain phenomena in the patient-therapist, and therapist-supervisor interactions. Our purpose is to demonstrate that the introduction of a measurable physiologic variable is a useful method for the investigation of the psychotherapeutic process. The histories of the patients under study were given in the above-mentioned publication (1). In the following report, a detailed analysis of one of the cases" discussed in that paper is presented as most illustrative of the modification of interpersonal transactions by altered brain function. The patient, a 44—year-old widow and mother of a 12-year-old son, had been admitted to the hospital with symptoms of depression, anxiety, anorexia, varied physical complaints, and feelings of unreality and isolation. In her psychotherapeutic sessions she would reiterate her difficulties in a complaining pattern, repetitiously illustrating her inadequacy. During a three-month-period no improvement occurred and a course of electroshock therapy was recommended. At this juncture the patient was included in the present study. From the Department of Experimental Psychiatry, Hillside Hospital. Aided, in part, by the Foundations’ Fund for Research in Psychiatry (56151) and grant M-927 of the National Institute of Mental Health, National Institutes of Health, U.S. Public Health Service. The assistance of Miss Esther Sanders and Mrs. Anita Bellow, who participated actively in the seminars, is gratefully acknowledged. : * Case #3, G. C. 46 Reprinted from AMERICAN JOURNAL OF PSYCHOTHERAPY, Vol. pages 46—55. January, 1961. XV, No. 1, �MODIFICATION OF PSYCHOTHERAPEUTIC TRANSACTIONS 47 The setting was a weekly multi-disciplinary supervisory conference. Included in the group were: (a) the therapist (H.E.), (at the time a senior resident in psychiatry), who presented the case material; (b) a social worker who reported the response of the patient’s family; (c) a psychoanalyst (J .J .), Who dealt mainly with the didactic aspects of psychotherapeutic technique; (d) a psychologist (R.K.), who studied the cases independently; and (e) a neuropsychiatrist (M.F.), who coordinated the discussion. The last two members were aware of the concomitant changes in physiologic measures, and although this information influenced their questions, the data were not introduced at these conferences. The actual somatic treatment was performed by a physician who was not a participant at the meetings. The procedure was informal, with the therapist taking the lead in presenting his verbatim notes of the psychotherapeutic sessions. The order of the case reports and the amount of time devoted to each was not prescribed. Following the spontaneous case presentation, more directive questioning was introduced, aimed at clarifying and relating the information presented by therapist and social worker. Observations made during the period of somatic therapy are depicted in the accompanying chart. During the 94 days of supervision, two different forms of somatic treatment were utilized. This procedure was part of a hospital-wide convulsive-subconvulsive control study then in progress, in which therapists were unaware of the introduction of subconvulsive phases of treatment. . For the first treatment period (27 days) the patient received subconvulsive electro-stimulation with pentothal premedication. Twelve such treatments were given at the rate of three per week. No changes in the quantitative measures of EEG slow wave activity (2) were manifest during this time. This period served to establish a baseline for the behavioral observations and the expectancies of the staff. In the second treatment period (29th to 59th day), grand mal convulsions were induced three times weekly for a total of 14 treatments. In that period, minimal degrees of EEG change were recorded on the 37th day, and moderate degrees were shown on three subsequent recordings. Twelve days after the termination of convulsive therapy, EEG slow wave activity was considerably diminished. This information was not available tothe therapist or the supervisor until after the conclusion of the study. �‘ arr-fir». 48 AMERICAN JOURNAL OF PSYCHOTHERAPY EFFECT OF CHANGING BRAIN FUNCTION ON PSYCHOTHERAPY SUPERVISORS REPORT OF DISCOURAGEMEHT. AVOIDINCE FRUSTRATION. EXHORTATION APlST'S ATTITUDE TNEFMPIST'S REPORT 'SLIGNT CHANGE' (MINIMIZEDI DEPRESSED. couPanmG. SELF—REPROACHFUL, OF FATIENT'S A" ITUDE HELPLESS, HEW COMPLAINTS PARTICIPATION IN ACTIVITIES I I mnznlon } DEPRESSION I I "ORE COMFORTABLE, EASIER TO RELATE. POSITIVE FEELINGS CAUTIOUS, SOLICITOUS CHEERFUL, PRIMPING, SELF- CONVERSATIONALJRUSTING. AFFECTIONATE. ADULATING I I I I “APPRAISAL. SUPPORTIVE, DETACHED ASSERTIVE. OBJECTIVE. INDEPENDENT; ANXIOUS I I ANXIOUS .. .— I __ __ 20~ PAGES nous Unaware 5553101: m 10' 0 WW ......... 26EE 6 ". nu: nun) scum TREATMENT °"""°°""‘ I-COWULSIVE n'0- :— - _-.. B_|—|_I____J__J_l—J_L_'.l—L—L——L—J—-l——I—-—J___ 85 70 75 80 55 0 5 DAYS l0 [5 20 FROM 60 40 45 50 ONSET OF SOMATIC THERAPY 25 30 35 The patient was seen in psychotherapeutic sessions three times weekly throughout her hospitalization. While the therapist was he somatic was unaware that of treatment, the concurrent aware subconvulsive stimulation was given initially, and of the change to convulsive therapy on the 29th day. Changes in the patient-therapist relationship as reported in the supervisory meetings are summarized in the chart and are detailed below. Supervisors’ Notes Ist to 19th day: During the first three weeks the therapist did not discuss this patient in the supervisory group. Other patients occupied the allotted time, in spite of a resolution to consider each patient weekly. In retrospect, the failure to report this patient’s progress canstituted a pattern of avoidance. Somatic therapy had not modified the patient ’3 ward behavior or the doctor-patient relationship. Both were the same as in the initial months of hospitalization. The neurophysiologic indices were unchanged. 20th to 33rd day: The case history was first presented in the meeting on the 20th day. The therapist reported no alteration in �MODIFICATION OF PSYCHOTHERAPEUTIC TRANSACTIONS 4:9 the patient ’3 clinging, whining, helpless attitude throughout the preceding three months. Efforts to explore her problems in living were blocked by physical complaints and by recitals of guilt, selfreproach, and feelings of failure. He was left little opening for comment. In the three supervisory meetings during this period the group atmosphere was one of discouragement whenever this case was presented. The therapist reported impulses to exhort the patient to participate in ward activities, and reacted to her professions of helplessness with the feeling that “she wasn’t trying.” The family reported that the patient considered her doctor “too young,” reflecting her attitude of reproach toward those who were unable to help her. He, in turn, felt that she was “throwing up her hands and giving up.” The therapeutic impasse was empathically communicated to the group by the case report. The transactions during this period were typically those leading to referral of depressed patients for somatic (i.e., nan-verbal) treatment. They may be characterized as follows. Verbal methods of therapy are incompatible with the affective mode of communication adopted by such patients (3'). The doctor’s efforts to help are not met by a collaborative response, and he feels frustrated. The insatiable quality of the patient’s demands also calls forth defensive reactions in the therapist. During this period the mode of somatic treatment was changed from subconvulsive to convulsive. The clinical status and therapeutic relationship, however, continued unaltered. Perhaps the lack of the expected response of somatic treatment contributed to the therapist’s discouragement. He assumed that convulsions had been induced from the outset, and his past experience had led him to anticipate a clinical response by the fourth week of treatment (2). 34th to 42nd day: In the meeting that took place on the 38th day, a “slight change” was reported. Although the patient was still “crying, ranting, raving” in therapy sessions, it was also noted that “she participates in activities a little bit more, but not much.” The therapist and the group discounted this change in social relationships. The first spontaneous complaint of memory difficulty was also reported. The first evidence of neurophysiologic change appeared at this time. The EEG taken the day prior to this meeting showed a significant increase in slow wave activity. �50 AMERICAN JOURNAL OF PSYCHOTHERAPY 43rd to 63rd day: In the meeting on the 45th day the therapist reported a full psychotherapeutic session for the first time. He described the patient as “brighter,” “with a little more rouge and lipstick” and “smiling.” Two days later her mood was noted as “euphoric.” Physical complaints ceased and were replaced by complaints of forgetting. The therapist described this as a “cessation of complaining.” Concomitantly, the affective mode of expression was replace-d by a more intellectualized pattern. Instead of stating “I have to cling to my mother,” the patient said “I’m dependent on my mother for many things.” This was described as “talking about her dependency in a different way.” Another change in communication pattern evoked ‘ ‘uncanny’ ’ feelings in the therapist. He stated that the patient “mentions things we had talked about as if it were new information.” With these changes, there was a concomitant increase in the patient ’s sociability and participation in hospital activities, and a diminution of her clinging to the family and therapist. The supervisory group atmosphere also changed— from one of hopelessness to well-being, with increased joking, smiling, and animated participation. On the 52nd day the therapist reported that the patient dressed seductively and applied fresh make-up for her sessions. She expressed feelings of trust and enjoyment of the meetings. The doctor experienced similar emotions, and was eager to report the progress of this patient. She was now “upset” because she couldn’t recall her problems, and the therapist noted that he was inclined to a directive “remembering” role. She complained of memory loss and attempted to relate in a friendly, realistically gratifying way to prevent further psychologic exploration. A greater detachment from her family was expressed. Social improvement continued. The family stated that she no longer considered the doctor “too young,” but rather a “guiding angel.” The abrupt, gross change in the clinical picture paralleled the development of maximum physiologic change. The three EEG- records during this period showed a moderate degree of slow- wave activity. The advent of positive feelings elicited reciprocal emotions in the therapist which were cammunicated in the supervisory sessions. The aflect was empathically reflected in members of the conference group. (The clinical picture resembled that of a “transference cure.” ) It is of interest that a change from “ physical” to “memory” �MODIFICATION OF PSYCHOTHERAPEUTIC TRANSACTIONS 51 complaints was described as a “cessation of complaining.” Perhaps the memory deficit, an expected concomitant of convulsive therapy, is more acceptable to the staff because it is understandable. They feel a responsibility for this symptom and can authoritatively reassure the patient that it will be transient. An afiectionate dependency may also be more tolerable than a hostile one, especially when accompanied by gratifying social improvement. The language changes are indicative of a more detached, intellectualized cammunication of familiar content (4). The patient now “talked about” rather than emoting or “acting out.” This new language pattern was more in keeping with her background of college education, and the therapist’s implicit expectations (5‘). In contrast to her prior mode of communication it seemed to be more compatible with a psychoanalytioally-oriented approach. The concomitant development of memory difiiculty, however, perpetuated the essentially non-insightful therapeutic situation. 64th to 72nd day: This period followed the termination of somatic treatment. The patient reported a “sudden feeling of selfawareness.” Euphoria and memory difficulty were no longer Observed, and an anxious state supervened. Psychotherapeutic sessions were characterized by more critical appraisal of her life situation. For the first time the doctor gave the patient extra time in the sessions. The group voiced some concern that she was “slipping back.” When the patient occasionally talked positively about career, emancipation from mother, and so forth, the therapist felt called upon to respond optimistically, rather than to explore. There was a revival of Old complaints. At this point, the supervisor and therapist reviewed a tape-res corded therapy session. A recurrence of the earlier verbal patterns could indeed be identified. However, these occurred in circumscribed fashion rather than throughout the interview. The events antecedent tO such periods were examined and the adaptive nature of the recurrent affective patterns became apparent. The EEG record during this period showed a considerable decrease in slow wave activity. There was a concomitant reestablishment of some of the communication patterns which preceded the period of altered brain function. The conference group responded with anxiety, reflected in the solicitousness of the therapist in prolonging the sessions. The phenomenon observed in the supervisory group, for lack of �52 AMERICAN JOURNAL OF PSYCHOTHERAPY Statedependency.” “electroshock be called better term, may a ments were made in the meeting such as “she’s slipping back,” “needs more treatments” and “improvement not holding up.’ These statements imply that the hostile- dependent pattern was being rather depression,” “a nosologic entity, as a thought of primarily than a mode of human relatedness. Perhaps because behavioral it now alone, means psychologic been by effected had not change seemed totally dependent upon the alteration in cerebral function. The change in interaction was conceptualized as the result of the brain syndrome, and not as a function of the doctor-patient relationship. Hence the group’s uneasiness on the sporadic reappearance of preconvulsive patterns. The detailed examination of a taperecorded session revealed the adaptive function of this more circumscribed occurrence of the complaints, and the phenomenon of “electroshock dependency” was not observed in subsequent group meetings. 73rd to 94th day: During this period a more stable psychotheraindebecame The more patient apparent. was relationship peutic assertiveselfand of compliance discussed problems and pendent ness. Although her attitude remained positive and collaborative, her adulation of the therapist diminished. In one session she said She was at you.” I unless won’t better get I angry get “Maybe less elated. She moved from the closed ward to an open cottage, and began to work in the hospital library. Occasional episodes of overt disturbance were treated by the therapist without solicitude. His attitude was one of interest, support and detachment. They discussed plans for discharge and outpatient treatment. Subsidence of the changes in brain function resulting from convulsive therapy permitted a new integration of the doctor-patient relationship. The pattern of a conventional psychotherapeutic situation appeared, which differed both from the original negative and the artificially induced positive relationships. Therapist’s Notes as an Index of Relatedness Following the conclusion of the study, another index of the psydescribed Rioch has investigated. was relationship chotherapeutic stafiof index notes staff of as an volume of the the use progress in his notes a had The kept therapist interaction (6). patient standard stenographic notebook throughout the treatment. A gross count of the number of pages of notes per session was made, and �MODIFICATION OF PSYCHOTHERAPEUTIC TRANSACTIONS 53 is represented graphically on the chart. No written notes were taken during occasional tape-recorded sessions, and these are omitted from the chart. The change in the relationship is apparent from the abrupt and persistent increase in note-taking from the 44th day. This coincided with the first gross change in the electroencephalogram. The notes taken by the two other psychiatrists in the supervisory meetings followed a similar pattern (not illustrated), although with peaks of note-taking at the onset and again at the waning of induced neurophysiologic change. DISCUSSION This report describes an investigation of psychotherapy when somatic therapy is introduced as an adjunctive procedure. One difficulty in the objective study of psychotherapeutic transactions is the absence of a quantifiable and controllable variable. Adjunctive therapies, somatic and pharmacologic, provide such a variable. They produce alteration in behavior as well as measurable neurophysiologic changes (2, 7). This opportunity has been utilized in the present project. For example, one mode of adaptation to altered brain function is a euphoric type of relatedness (8). The occurrence of the phenomenon in this case permitted us to observe how induced alternation of positive and negative attitudes call forth similar attitudes in therapist and supervisor. Another illustration was the discounting of the earliest clinical change during the 34th to 42nd day of treatment. The electroencephalogram indicated the significance of this beginning change in the relationship. The fact that it was minimized demonstrates the obscuring effects of stalf expectancies. Finally, the alteration of brain function was accompanied by a change in complaint pattern, that is, from physical symptoms to memory difficulty. This resulted in a new form of the dependency relationship (43rd to 63rd day) which was experienced differently by the supervisory staff, with resultant change in their feelings about the patient. This effect was also observed in the patient ’s family group. The observations also illustrate a phenomenon peculiar to supervision in group settings. We have called attention to the emotional atmosphere of the group, which seemed to fluctuate in accordance with the therapeutic relationship being described. Hora (9) suggests that the supervisee may communicate the affective aspects of his experience with the patient non-verbally in the supervisory meet- �54 AMERICAN JOURNAL or PSYCHOTHERAPY ing. His formulation is that “The supervisee unconsciously identifies with the patient and involuntarily behaves in such a manner as to elicit in the supervisor those very emotions which he himself experiences while working with the patient, but was unable to convey verbally.” He also describes the diflusion of this affect in the other participants of a supervisory seminar. Thus he reports that “This observation has been subjected to repeated tests in seminars where it was possible to verify the supervisor’s emotional perceptions by matching them with the emotional reactions of the other participants present.” Our work supports such observations and suggests the potential fruitfulness of studies of group dynamics in supervisory seminars. We have noted one change in relatedness resulting from the somatic therapy that had a disjunctive effect upon the relationship (45th day). The patient mentioned familiar topics “as if it were new information.” The “uncanny” quality produced in the therapist and supervisor resulted from the temporary feeling that the therapeutic relationship had no history. Rapport in intensive psychotherapy depends to a great extent upon an accumulated body of shared information. Both doctor and patient take this for granted, and the inability to rely upon it may affect rapport adversely. Other patients in the study, not discussed in this paper, showed different patterns of response. These included transient paranoid episodes, hyperactivity, erotic, exhibitionistic, and other forms of “acting-out” which were disruptive to the concurrent psychotherapy. In each case the induced behavioral change was related to the personality of the individual patient and occurred at the time of changing brain function (2). Also in each case there were concomitant changes in behavior in the supervisory group. Our experience also highlights some of the difliculties that may develop when the two modes of treatment are used concurrently. Intensive psychotherapy is based upon the conviction of the eflicacy of verbal communication for improvement of the patient ’s adaptation. In the case reported, a trial period of psychotherapy had been ineffective in altering clinical behavior. The introduction of somatic treatment represented a decision against exclusive reliance upon interpersonal communication as the therapeutic instrument. When cerebral change was maximal, a “social recovery” occurred, apparently unrelated to interpretation of psychodynamic factors. When the induced neurophysiologic changes subsided, a recurrence �[MODIFICATION OF PSYCHOTHERAPEUTIC TRANSACTIONS ' 55 of earlier communication patterns led the therapist to doubt that the improvement could be perpetuated by interpersonal means alone. To some extent this phenomenon was an expression of differing conceptual and linguistic systems inherent in the two modes of therapy. It is related to the philosophical dichotomy described by Hollingshead and Redlich (10) between practitioners using somatic and analytically-oriented therapies. SUMMARY A study of concurrent somatic therapy and psychotherapy is reported, in which simultaneous observations of serial changes in brain function, the psychotherapeutic relationship and social adaptations were made. The observations in a group supervisory seminar reflected the pattern of neurophysiologic alteration. It is concluded that the introduction of a measurable physiologic variable is a useful method for investigation of interpersonal relationships. 1. 2. 3. BIBLIOGRAPHY Eseeover, H., Jaffe, J. and Kahn, R. L.: Psychotherapeutic Techniques with Electroshock Patients. J. Hillside Hosp, 7: 17, 1958. Fink, M. and Kahn, R. L.: Relation of EEG Delta Activity to Behavioral Resp0nse in Electroshock. Quantitative Serial Studies. A.M.A. Arch. Neurol. & Psychiat., 78: 516, 1957. Cohen, M. 8., Baker, G., Cohen, R. A., Fromm-Reichmann, F., and Weigert, E.: An Intensive Study of Twelve Cases of Manic-Depressive Psychosis. Psychiatry, 17: 103, 1954. Kahn, R. L. and Fink, M.: Changes in Language During Electroshock Therapy. In Psychopathology of Communication, P. Hoch and J. Zubin, Eds., Grune & Stratton, 1958. Kahn, R. L., Pollack, M. and Fink, M.: Sociopsychologic Aspects of Psychiatric Treatment in a Voluntary Mental Hospital. A.M.A. Arch. Gen. Psychiat, 1: 565, 1959. Rioch, D. McK.: Research in Psychiatry: Certain Problems and Developments in Multi-Disciplinary Studies. T. W. Salmon Lecture, New York ' 4. 5. 6. Academy of Medicine, 1957. 7. Fink, M.: A Unified Theory of the Action of Physiodynamic Therapies. J. Hillside Hosp, 6: 197, 1957. 8. Fink, M., Kahn, R. L. and Green, M.: Experimental Studies of the Electroshock Process. Dis Nero. Sys., 19: 113, 1958. 9. Hora, T.: Phenomenology of the Supervisory Process. Am. J. Psychother., 11: 769, 1957. 10. Hollingshead, A. B. and Redlich, F. 0.: Social Class and Mental Illness. J. Wiley & Son, New York, 1958. ��Modification of Psychotherapeutic and Supervisory Relationships by Altered Brain Function J. Jaffe, M.D., B. Esecover, M.D. R.L. Kahn, Ph.D. a M. Fink, M.D. the Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, L.I., N.Y. From Aided, in part, by the Foundations' Fund for Research in Psychiatry (56-151) and grant M-927 of the National Institute of Mental Health, National Institutes of Health, U.S. Public Health Service. assistance of Miss Esther Sanders and Mrs. Anita Bellow, caseworkers in the Department of Social Services, who participated actively in the seminars, is gratefully acknowledged. The VII: 11-15-58 �Modification of Psychotherapeutic and Supervisory Relationships by Altered Brain Function seminar from a supervisory derived is psychotreatment upon convulsive of which the effects in The studied. therapist's were communication therapeutic observations have been described in a previous publication (2), and are based mainly upon his personal experiences with the patients. The present paper describes the process intended as is of frame reference. It from the supervisor;s combined complex of this observations of a complementary set data is neurophysiologic concurrent In addition, therapy. unaware. were and supervisor both which of therapist included, This additional level of observation seems to account for and the in patient-therapist, certain clinical phenomena This report therapist-supervisor interactions. Our purpose is to demonstrate that the introduction method a useful is variables of measurable physiological for the investigation of the psychotherapy process. �METHOD: setting was a weekly multi-disciplinary conference composed of five people, and thus departed from the conventional supervisory situation. The group included: a) the therapist (H.E.), at the time a senior resident in psychiatry, who presented the case material; b) a social worker assigned to The the cases selected for study, who reported the on-going response of the patient's family; c) a psychoanalyst (J.J.), who dealt mainly with the didactic aspects of psychotherapeutic technique; d) a psychologist (R.L.K.), who had studied the cases independently; and e) a neuropsychiatrist (M.F.), who coordinated the discussion. The last two members were aware of concomitant changes in the physiologic measures, and although this information influenced their questions, the data was not introduced at these conferences. The actual somatic treatment was performed by a physician who was not a participant at the meetings. procedure was informal. The therapist took the lead in presenting verbatim notes of his psychotherapy sessions with five patients receiving combined therapy. The order of The the case presentations and the amount of time devoted to each was not prescribed. Following the spontaneous case reports, directive questioning was introduced, aimed at clarifying and relating the information presented by the therapist and the social worker. Although roles were defined, the atmosphere was one of inquiry in which no participant claimed a definitive answer to the problem under investigation. more . �m SUBJECT: case histories of the subjects of this study were In a this (2). report in a publication previous reported most #3 as Case clearly of is presented detailed analysis illustrative of the modification of interpersonal transactions The widow old year by patient, and mother of a 12 year old son, had been admitted to the hospital because of depression, anxiety, anorexia, multiple somatic complaints, and feelings of being "unreal" and isolated. In therapeutic sessions she would reiterate her difficulties 'in a persistent complaining pattern, as illustrations of her altered brain function. This a hh After a three month period of psychotherapy without alteration in the clinical condition it was decided co utilize a course of electroshock therapy. At this time the patient was included in the present project. More detailed description of the psychotherapy sessions is included under "Observations" below. failures and inadequacies. SOMATIC THERAPY: during the intercurrent somatic therapy are depicted in the accompanying chart. During the 9b days of supervision two different forms of somatic treatment 'Serial observations made This procedure was part of a convulsivesubconvulsive control study then in progress, in which the therqmd.was unaware of the introduction of the subconvulsive were utilized. phase of treatment. �-hFor the first period the patient received subconvulsive electrostimulation with pentothal premedicaticn. Twelve such treatments were given at the rate of three per week. No manifest changes in quantitative analyses of the degree of the EEG (3) were observed during this time: in delta activity This period established a baseline for the behavioral observations and the staff eXpectancies. Grand mal convulsions were induced from the 29th to the 59th days of somatic treatment, also at a rate of three per week for a total of 1h treatments. In this convulsive period, minimal degrees of electroencephalographic delta activity appeared on the 37th day, and moderate degrees were shown on three subsequent recordings. On a follow-up record 12 days after the termination of convulsive therapy the delta activity had decreased considerably. This information was not available to the therapist or the supervisor until after the conclusion of the study. The patient was seen in psychotherapy sessions three times a week throughout her hospitalization. While the therapist was aware of the concurrent somatic treatment, he was unaware of the fact that subconvulsive stimulation was given initially, and of the change to convulsive therapy on the 29th day. The changes in patient-therapist relationship as reported in the supervisory meetings is summarized in the chart and is detailed in the following observations. -~‘ -------Figure I 27 day �OBSERVATIONS: let to 19th day: During the first three weeks of somatic treatment the therapist did not discuss this patient in the supervisory in the time, allotted occupied Other all patients group. the in about hear to patient every of resolution our spite study each week. The case histories presented during this time were those of patients undergoing gross day-to-day changes in clinical behavior. Comment: retrospect, we consider the omitted presentation A communication. pattenlof avoidance to be a significant characterized this period. The neurophysiologic indices during this time were unchanged. Similarly, the patient's clinical status and the doctor-patient months the three in same the as were relationship In preceding somatic treatment. 20th to 33rd day: The case history was first presented in the meeting on the 20th day. Over a three month period the psychotherapeutic unable to the being been had unchanged, therapist relationship discern any alteration in the patient's clinging, whining, in her living problems to explore Efforts attitude. helpless of and by long recitals complaints blocked by were physical In three the of and failure. feelings self—reproach, guilt, supervisory meetings during this period the group atmosphere �-6was one of discouragement when this case presented. The therapist reported impulses to exhort the patient to participate in ward activities, and reacted to her professions of helplessness with the subjective feeling that "she was'nt trying." The reproach against those who were unable to help her was reflected in the family's report that the patient considered her therapist "too young." was Comment: therapeutic impasse was empathically communicated to the group by the therapist's report. The interaction during this period may be characterized as follows: After prolonged, unsuccessful efforts at verbal communication the psychotherapist is realistically frustrated (I). The affective mode The patient rendered essentially verbal techniques useless. The doctor's efforts to help were not met by a collaborative response, while the insatiable quality of the patient's demands may also have called forth defensive reactions in the therapist. Such interactions are typically those that lead to the referral of psychotically depressed patients for somatic, 3,3. nonof communication adopted by the verbal forms of therapy. During this period the mode of somatic treatment was changed from subconvulsive to convulsive. The clinical status and therapeutic relationship however, �-7continued unaltered. Perhaps lack of the expected response to somatic treatment contributed to the therapist's discouragement. He assumed that convulsive therapy had begun at the outset, and his past experience had led him to anticipate a clinical response by the fourth week of treatment (3). Bhth to h2nd day: In the meeting that took place on the 38th day, a "slight change" reported. Although the patient was described as still "crying, ranting, and raving“ in therapy sessions, it was reported that "she participates in activities a little bit was more, but not much." The therapist and the tended to minimize the social improvement. The first group spontaneous complaint of memory difficulty was also reported in this meeting. Comment: retrospect, the first evidence of neurophysiologic change had appeared at this time. The electroencephalogram on the day prior to this meeting showed a significant increase in delta activity. The In group discounted the concomitant observation of clinical change in view of a persistent hostile- dependent transference, and negative counter- transference feelings. �23rd to 63rd day: In the meeting on the hSth day the therapist spontaneously reported a full verbatim psychotherapy session for the first time. The patient was described as "brighter," "with a little more rouge and lipstick," and "smiling." Within the next two days he described her mood as ”euphoric.” Physical complaints ceased and were replaced by complaints of forgetting. The therapist, however, described this change as a cessation of "complaining." There was a change in the form of verbal expression although the content remained the same. Her affective mode of expression was replaced by an intellectualized pattern. For example, instead of complaining mother" the patient said, "I'm "I have to cling to my dependent on my mother for many things." The therapist described this change as "talking about her dependency in a different way." Another of his observations, however, was reported with "uncanny" feelings which were shared by the supervisor. He stated that the patient "mentions things we had talked about as if it were new information." With these changes, there was a concomitant increase in her sociability participation in hospital activities, and a diminution of her overt dependency upon family and therapist. The supervisory group atmosphere at this time changed from one of discouragement to a feeling of well-being, with increased Joking, smiling and animated participation. and �-9the 52nd day the therapist reported that the patient dressed seductively and applied fresh make-up for her therapy meetings. She expressed feelings of trust and enjoyment of the sessions. The doctor experienced similar emotions, and was eager to report the progress of this case. The patient was now "upset" because she could'nt remember her problems, and the therapist noted that he was being continually led into a directive "remembering" role. He felt the patient used her memory loss as a defense against further psychologic exploration, and that she preferred to maintain the relationship on a 0n friendly, realistically gratifying level. A greater detachment from her family was also expressed. Indicafima of social improvement were prominent. The family' stated that she no longer considered the doctor "too young," but rather a "guiding angel." Comment: abrupt and gross change in the clinical picture paralleled the development of maximum physiological change in this case. The three electroencephalograms during this period showed a moderate degree of delta activity. The advent of markedly positive feelings elicited reciprocal emotions in the therapist. These were communicated in the supervisory sessions, and were empathically reflected in members of the conference group. The clinical pattern resembled that of a "transference cure." The �-10- It is of interest that change from "physical" to "memory" complaints was described as an overall "decrease in complaining." Perhaps a memory deficit, expected concomitant of convulsive therapy, was ;MOre acceptable to the staff because it was understandable. They felt some responsibility for this Syphon and could authoritatively reassure the patient that it would be transient. It is also probable that an affectionate dependency is more tolerable than a hostile dependency, especially when accompanied by obvious and gratifying social an improvement. The language changes were indicative of a more detached, intellectualized'communication of familiar content (8). The patient at this time "talked about“ rather than emoting or "acting out." These new language patterns were consistent with her college education and, in contrast to her prior mode of communication, appeared to be more compatible with a psychoanalytically-oriented approach. However, there was the concomitant development of memory difficulty, exemplified by her introduction of previously discussed topics as new information. The ne.t effect thus a non-communicative situation with regard to interpretive insight therapy. was �-116hth to 72nd day: This period followed the termination of somatic treatment. The patient reported a "sudden feeling of selfmemory The awareness." euphoria and difficulty were no longer observed, and an anxious state supervened. The content of the psychotherapy sessions changed to a more critical appraisal of her life situation. For the first time the therapist gave the patient extra time in the sessions. The group voiced some concern that she'was "slipping back." When the patient occasionally talked positively about such problems as her emancipation from mother, the therapist was inclined to respond optimistically, rather than to explore. She reacted to this with a revival of old complaints. At this point, supervisor and therapist reviewed a tape recorded therapy session. A recurrence of the earlier pattern could indeed be identified, although in circumscribed fashion rather than throughout the interview. It was possible to examine the antecedent events in the session and to clarify the pattern as an adaptive response to stressful content. Comment: electroencephalogram during this period showed a considerable decrease in slow wave activity. There was a concomitant reestablishment of some of the communication patterns which preceded the The period of altered cerebral function. group responded with uneasiness which The supervisory was reflected �.12in the solicitousness of the therapist in prolonging the sessions. At this point a phenomenon was observed in the supervisory group which, for lack of a better term, may be called "electroshock dependency." Statements were made in the meeting such as, "she's slipping back," "needs more treatments," and "improvement not holding up." These statements imply that the hostile-dependent pattern constituted a nosologic entity - ”a depression" - rather than relatedness. Perhaps because therapeutic change could not be a effected by interpersonal means alone, its persistence seemed dependent upon the alteration in cerebral function. The change in interaction was thus being conceptuala mode of human ized as the result of the brain syndrome, and not as a function of the doctor-patient relationship. Hence the group's uneasiness on the sporadic reappearance of the pre-convulsive interaction pattern. The detailed examination of a tape-recorded session revealed the adaptive function of this more circumscribed occurrence of the complaints, and the phenomenon of "electroshock dependency" was not observed in subsequent group meetings. �-13. 23rd to 9hth daz: During relaionship this period stable psychotherapeutic patient became more independent a more apparent. The and discussed problems of compliance and self-assertiveness. Although her attitude remained positive and collaborative, her gross adulation of the therapist diminished. In one session she said, "Maybe I won't get better unless I get angry was at you.“ She was less elated. She moved from a closed ward to an open cottage, and began to work in the hospital library. Occasional episodes of overt disturbance were handled by the therapist without solicitude. His attitude was one of interest, support and detachment. Patient and therapist discussed plans for discharge and outpatient treatment. The patient was discharged six weeks later. Comment: Subsidence of the changes in brain function resulting from convulsive therapy permitted a new integration of the doctor-patient relationship. The pattern of a conventional psychotherapeutic situation appeared. This differed both from the original negative and the artificially induced positive transference relationships. �WW Therapist's notes as an index of relatedness: Following the conclusion of the study, another index of the psychotherapeutic relationship was investigated. Rioch (9) has described the use of the volume of staff progress notes as an index of staff-patient interaction. The therapist had kept his notes in a standard stenographic notebook throughout the treatment. A gross count of the number of pages of notes per session could be made. This is represented graphically on the chart. As no written notes were taken during the occasional tape-recorded sessions, these were omitted from the chart. The change in the therapeutic relationship is apparent from the abrupt and sustained increase in note-taking from the hhth day on. This coincided with the first gross change in the electroencephalogram. The notes taken by the two other psychiatrists in the supervisory meetings followed a similar pattern, although with peaks of note-taking at the onset and again at the waning of induced neurophysiologic change. �DISCUSSION: primary purpose of this report is to demonstrate the value of a detailed investigation of psychotherapy when somatic therapies are temporarily introduced as adjunctive procedures. One of the difficulties in the objective study of transference and countertransference phenomena is the The absence of a quantifiable and controllable variable. Adjunctive therapies, somatic or pharmacological, provide such a variable. They produce alteration in behavior as well as concomitant, measurable neurophysiologic changes (3, h). This opportunity has been utilized in the present project. For example, one of adaptation to altered brain function is a euphoric type of relatedness (5). The occurrence of the phenomenon in this case permitted us to observe how the induction of mode positive and negative transferences called forth similar countertransference attitudes in therapist and supervisor. Another illustration of this technique was our discounting of the earliest clinical change during the Bhth to h2nd day of somatic treatment. The electroencephalogram gave evidence in favor of the significance of this beginning change in the relationship. The fact that it was minimized demonstrates the obscuring effects of staff expectancies. Finally, the alteration of brain function in this course of psychotherapy was accompanied by a change of the pattern of complaints i;g. from physical symptoms to memory difficulty. This resulted in a modification �-16.. of the dependency relationship (h3rd to 63rd day). The new form of the relationship was experienced differently by the staff, with resultant change in their feelings about the patient. This effect was observed in the patient's family group as well as in the supervisory group. observations illustrate several other phenomena of interest. One is peculiar to supervision in group settings. We have called attention to the emotional atmosphere of the group, which seemed to fluctuate in accordance with the therapeutic relationship being described. Hora (7) believes that the supervises may communicate the affective aspects of his experience with a patient by non-verbal means. His formulation is that "the supervises unconsciously identifies with the patient and involuntarily behaves in such a manner as to elicit in the supervisor those very emotions which he himself experiences while working with the patient, but was unable to convey verbally." He also describes the diffusion of this effect in the other participants of a supervisory seminar. Thus he reports that, "This observation has been subjected to repeated tests in seminars where it was possible to verify the supervisor's emotional perceptions by matching them with the emotional reactions of the other participants present." Our work supports such observations and suggests the potential fruitfulness of studies of group dynamics in supervisory seminars. We have noted one change in relatedness resulting from the somatic therapy that had a disjunctive effect upon the The �-17- relationship (hSth day). The patient mentioned familiar topics "as if it were new information." The "uncanny" quality produced in the therapist and supervisor resulted from the temporary feeling that the therapeutic relationship had no history. Rapport in intensive psychotherapy depends to a great extent upon an accumulated body of shared information. Both doctor and patient take this for granted, and the inability to rely upon it may affect rapport adversely. Other patients in the study,nct discussed in this paper, showed different patterns of response. These included transient paranoid episodes, hyperactivity, erotic, exhibitionistic and other forms of "acting-out," which were disruptive to the concurrent psychotherapy. In each case the induced behavioral change was related to the personality of the individual patient and occurred at the time of changing brain function (3). Also, in each case, there were concomitant changes in behavior in the supervisory group. The limited scope of this study does not warrant general conclusions as to the efficacy of concurrent somatic treatment and psychotherapy. We have confined the discussion, therefore, to the presentation of methodology and description of the types of observations that can be made in such interdisciplinary approaches. Our experience does highlight, however, some of the difficulties that may develop when the two modes of treatment are used concurrently. Intensive psychotherapy is based upon �-18a conviction as to the the improvement of the efficacy of verbal communication for patient's adaptation. In the case reported a trial period of psychotherapy had been ineffective in altering clinical behavior. The introduction of somatic treatment represented a decision against exclusive reliance upon interpersonal communication as the therapeutic instrument. When cerebral change was maximal a "social recovery" occurred. This was apparently unrelated to interpretation of psychodynamic factors. No increase in awareness of psychological relationships was verbalised. When the induced neurophysiologic changes subsided, there was a partial recurrence of earlier communication patterns. This was accompanied by a brief period of doubt that the modification of behavior could be perpetuated by interpersonal means alone. To some extent this phenomenon was an expression of the different conceptual and linguistic systems inherent in the two modes of therapy. It is related to the philosophical dichotomy described by Hollingshead and Redlich (6) between practitioners using somatic and analytically-oriented therapies. These considerations also arise in the use of psychopharmacologic agents during the course of psychotherapy (h). �SUMMARY: study of the effects of concurrent somatic therapy on psychotherapy is reported, in which simultaneous observations of serial changes in brain function, the psychotherapeutic relationship, and social A adaptation were made. The observations in a group supervisory seminar reflected the pattern of neurophysiolcgical alteration. It is concluded that the introduction of a measurable physiological variable is a useful method for investigation of the psychotherapy process. �REFERENCES l. Cohen, M.B., Baker, 6., Cohen, R.A., Fromm-Reichman, F., and Weigert, E.: An Intensive Study of Twelve Cases of Manic—Depressive Psychosis, Psychiatry $1: 103, 195k. 2. Esecover, 8., Jaffe, J. and Kahn, R.L.: Psychotherapeutie Techniques with Electroshock Patients, J. Hillside Hosp. 1: 17, 1958. Fink, M. and Kahn, R.L.: Relation of EEG Delta Activity to Behavioral Response in Electroshock:Quantitative Serial Studies,A.M.A. Arch. Neurol. & Psychiat. 1Q: 516, 1957. 3. Fink, M.: A Unified Theory of the Action of Physiodynamic Therapies, J. Hillside Hosp.g: 197, 1957. Fink, M., Kahn, R.L. and Green, M.: Experimental Studies of the Electroshock Process, Dis. Nerv. 81 . $2: 113, 1958. Hollingshead, A.B. and Redlich, F.C.: Social Class and Mental Illness, J. Wiley & Son, N.Y. T953. Hora, T.: Phenomenology of the Supervisory Process, Am. J. Psychother. $1: 769, 1957. Kahn, R.L. and Fink, M.: Changes in Language During Electroshock Therapy, in Pa cho atholo of ZuSEn, P. 3. §§3., Grune and Communication, Hoch, & Stratton, 1958. Rioch, D. McK.: Research in Psychiatry: Certain Problems and Developments in Multi-Disciplinary Studies, T.W. Salmon Lectures, 1957 (in press). N.Y. Acad. Med. �noditiaation at Pnynhothornputtta frannaettonu By tltnrod Drain Junction "tt‘, H.B.. E. 3.00.7.7, K.D., R. L. “hn, Phonu ‘fid fl. link, 8.D. ‘0 Iron thy aspartulnt a: Bxportuonsal Psychiatry, £111.16. loupttal, 61.“ O‘k.’ L.I., ‘1’. Aided. in part, by tho Foundationn' thud tar Research in Puyehiutry (SénlSl) and grant 3-927 of the rational Inu‘itutc o: nuntnl lualth, laticntl Inutitflna of nculth, v.5. Public loalth aarvtoo. Tho aunt-tango or 31:: 83th.: sander: :nd Hrs. Anita DCIIOI, who participated auttvoly in tho tcatnnra, 1. gratitully acknavludgod. III 10/30/59 �this rlport ta darivnd from a luporvinory suntan: in which thn affect. at convultivc trontncnt upon p;y¢ho~ thornptut1e trananotxanu war. studiud. rho thornpist'u abrcrvntinnl havo boon douoribod in u previous publicattou (2). in: proaoat pups: accorthcu thn pronoun tr.u tho franc at ratcrcaco at tho atporvisor and ouporvinory group. It 1! intondod an n aonplonontnry hot or obaorVItioua at thin nonbinud therapy. In addition, ouncurront neurophyulalogia ant: arc includad, of vhich both thornpiat and supervisor var. unnuuro. this udditiouul tram. of xutorenoo may broaden the underutnndiug or eurtnin phonononu 1n the pattcnt-thcrapint, and therapiltulnparvitcr tatcraottona. to don-natratt that the intraduction a: a unanurablo phyuiologiaul variablo 1: a ncctul Itthod for the turoatixatinn a: tho payehothcrapy pronoun. Our purpaao 13 �xxggan: tho ootttag too o uookhr oulttodiooaplioory ooporvtoovy oontorouoo. Ioalndod in tho group rotor o) tho thoroptot (3.8.), (at tho ttno o senior rootdont in poynhiotrr), who proooutod tho enoo uotortol; h) o ooatol worhor who roportod tho rooponoo at tho yotiont'o fonily; a) o poyoho~ onolyot (3.5.), who doolt mainly with tho d1doct1e oopocto of psychothoropoutte toohniquo; d) o poychologiot (3.3.). who studiod tho eoooo indopondontly3 and o) o nonrepoyohiotrtot (8.!t). who coordinotod tho diocuooion. rho loot tot nooboro wart ovoro of tho connooitont chouxoo 1: phyoioloxtc honouroo, one olthough thlo intorlotton infloouood thotr quoottouo, tho doto woo not introdtcod ot thooo toaforonooo. rho octuol oo-otlo trootoout woo porforood by o phyoioion who not o porticipont ot tho nootingo. Tho pronodoro woo intoruol, with tho thoroptot toktnx tho lood 1a prooonttnx hto vorbotto uotoo of tho poyohothoropy Tho ooootoao. ordor of tho aooo roporto and tho ooount o: tiuo dovotod to oath woo not prooorihod. Iolloring tho opoutohoouo oooo pronoutotion, morn dironttvo quootiouiag II! Introdoood, otood ot choritytnx and rolottns tho intoraotioa proooutod by thoroptot ond ootiol vortor. woo �803130?! the hintertee e! the enhaeate at thte study were reported in e previeee publication (2). In thie report e detailed enelyeie of Gate #3 (0.0.) 1- presented es meet illustretive or the nodixieation of interpereomel trenaeetiene by extered hrein function. This petieut, e hh your old vitae end nether of e 12 yeer old eon, bed been ednitted to the hoepxtel with eyaptone of depreeeion, enxiety, enorexie, varied phyeicel complaints, end feelings é: unreelity end isoletien. In psychotherapy eeeeione she would reiterete her difficultiee in e cenpleining pattern, repetitiouely illustretinx her inedequecy. During e three nonth period an ilpreveaent occurred end A couree at electroehoek therepy wee reeoeeended. At thte Junotute the patient wee included in the preeent study. vsg§;!:c_rnxnarr: cheervetiene eede dertn; the period of eenetxe therepy ere depleted in the euconpenying ehert. During the 9k deye of supervision tee different levee e: eoeetie treetleut were utilieed. This procedure wee pert e: e heepitel-wide eonvuleiveoeubeeavuleive control etedy then in progreee, in which therepiete were enewere at the introduction or enheonvuleive pheeee e: treetnent. Fer the tit-t treeteent period (21 deye) the patient received eebeenvuleive electra-etlaeletiou with pentethel �‘h. pronodiootiou. roolvo oooh trootnonto ooro givon ot tho roto or throo por rook. lo ohonxoo in tho ooohtitotivo looooroo o: 336 olov oovo ootivity (3) woro monitoot during thio tins. fhio poriod oorvod to ootobiioh o booolino for tho hohoviorol oboorvotiooo and tho oxpootonoioo of tho otott. In tho oooond trootnoht porioo (29th to 59th doyo), grand nol oonvoloiono uoro ihduood thrioo wookly for o totol o: 1h trootnonto. In thio ported, nioiaol dogrooo of EEG ohongo ooro rooordod on tho 37th doy, ond uodoroto dogrooo. woro shown on throo oohooqoont rooordingo. foolvo doyo ottor tho toroiootino o: oonvuloivo thoropy, EEG slow wovo ootivity ooooidorohly dioioiohoo. this intoruhtioo woo not ovoilohlo to tho thoropiot or tho ooporvioor until ottor tho ooholuoioa of tho otooy. woo -fi.‘.‘....‘..0fld.fl. Pic. 1 about horo -DO“-....‘..O-.... rho potioot woo ooon in poyohothoropy ooooiono throo tiloo vookly throughout hor hoopitoliootion. Hhilo tho thoropiot II! ovoro of tho ooooorront oonotio trootnoot, ho woo nnovoro that oohoohvoloivo oti-olotion woo givon initiolly, ohd of tho ohonso to convoloivo thoropy on tho 29th doy. thongoo in tho potiont—thoropiot rolotionohip oo roportod in tho ouporvioory lootiogo oro oonnorisod in tho ohort ond oro dotoilod in tho following ohoorvotiooo. �0188371 ;tt ,IS! 2: 12th dgz; firot throo vookl tho thoropiot did not dioeuoo thio potiont in tho ooporvioory group. othor potionto oooupiod tho allottod tino, in opito o: o rooolutioa to ‘ Daring tho conoidor oaoh potiont vookly. Gounonts In totroppoot, tho toiluro to roport this potiont 'o pragrooo coaotitutod o pottoru or ovoidoneo. sonotiu thoropy hod' not Iodiriod tho potiont'o word bohovior or tho doctor-potiont rolotioaohip. Both voro tho onto to in tho initiol Iontho a: hospital- iootion. rho nonrophyoiologio indieoo voro unohonxod. 20th to 22:4 dog: rho oooo history firot prooontod in tho looting on tho 20th doy. rho thoropiot roportod no oltorotion in tho potiont'o clinging, whining, holplooo ottitudo throughout tho proooding throo uontho. Errorto to oxplorovhor problouo in 1171:; uoro blookod by phyoieol oonplointo and by rocitolo of woo Ho woo loft of toiluro. tooling: guilt, oolt-roprooch, littlo oponiag £0» counont. In tho throo ouporvioory nootingo during thio poriod tho group otnoophoro woo ono of diluenrogonoat thou thio eooo too prooontod. the thoropiot roportod inpulooo to oxhort tho oud �.6patient to participate in ward activitiee, and reacted to her prereeeieue e: helpleeeneae with the feeling that *ehe eaan't trying.‘ eoneidered The taniiy reported that the patient her doctor "tee reung,' retleetiac he: attitede e: repreaoh toearde theee who were unable to help her. He, in turn, felt that eke wee 'threeiuc up he: hende and giving up.“ I gelnenta the therapeutic iayaeee eae eapathieaiiy oeuaenicated to the creep by the cane repert. The transactiene during thie peried were typically theee leading to referral of depreeeed patiente for eeaetia (i.e. noncverbel) treataent. they nay be toileee. Verbal nethede ee eharaeterieed er therapy are inceepatible with the affective made at cannunieetien adapted by each patiente (1). The deetor'e atterte to help are not eat by a eellaheretive reepenee, and he feels treetratea. the ineatieble qeaiifiy er the patient“ dean“ a1" «11. berth deteueive veeetiene in the therapiet. Baring thin period the node or eeaatie treetaent wee chanced tree eaheenveieive to eeafileive. The elinieal etatne and therapeutic relatienehip, hetever, eentiaaed unaltered. Perhaps the lack of the expeated reapenee to �.7. eenetie treetnent eentributed te the thereptet'e dieeeuregeuene. le eeee-ed thet cenvuleteue nee been induced from the euteet, end hie peet experienee bed led hie te entteipete e elinieel reepenee by the fourth week e: teeetlent (3). to ytnd 63!. In the aeetinx thet teak pleee en the 38th day, e “alight chenlef wee reverted; Although the,pet1ent tee etill revinxi 1n therepy eeeeiene, it wee elee renting, 'eryinc, neted thet 'ehe pertteipetee 1a eetivlttee e 11$t1e bit note, but net naeh.’ {he therepiet end the group discounted ehie ehenge an eeeiel relet30nehtpe. the tiret eyeateueoee oonpleint at eeeery dittieelty'vee elee reported. «age: cennent: the Sir-t evidenee er eeurephyetelegte eheuge ep’eered et thie tine. the 3E6 teken the any prter ‘0 thin leetlng eheued e Wm eixuitteent inereeee in slew wave eettvxty. In the neeting en the hSth day fine therepiet reyerted e full perehetherepy eeeelee fer the rivet tine. Re deeertbed the pettent ee 'brighter,’ ”with e little eere reuse end lipetteh' end 'eetltng.‘ rue deye lefier her need wee meted ee 'eupheric.‘ Phyeteel eonpleinte eeeeed end were replaced by aenpleinte of forgetting. The therepiet deeeribed thie ee e *oeeeetteu e: ceapleintng.‘ concomitantly, the effective �.8. expreeeien wee repleeed by e eere intelleeteelieed e: pettern. Ineteed e: etetiux “I here to cling to I: nether“ the petieet eeid '1': dependent en ey nether ter may thus" Thie eee deeerihed ee 'telhina ehent her dependency in e different eey.‘ Another cheese in eeneenioetion pettern eveked 'enoenny‘ reeliuge in the therepiet. fie eteted that the petient 'eentiene things we hed telhed ebout ee it it were nee in:ereetien.' With theee ehenzee,there wee e ceneeeitent iaereeee in the petient'e eeeiehility end perthipetien in heepitel eetiritiee, end e dieieetien er her clinging to the teeily end therepiet. whe euporrieory group etueephere eleo changed free one e: hepeleeeneee te well-being, with increeeed aching, eniling end enineted participation. 0n the 52nd dey the therapist reported thet the petient are-led seductively end epplied treeh rehe-up for eede l V her eeeeiene. She expreeeed toelinge or treat end enjoyment e! the neetinge. the doctor experienced einiler eeetiene, end ere eexer to repert the pregreee of this oeee. fhe patient wee new 'upeet' beeeaee ehe couldn‘t resell her prehlene, end the therapiet noted that he wee inclined to e directive “re-ether. He end she of leee coupleined memory role. ettenpted felt in:' to relete in e triendly, reelieticelly gratifying we: to prevent further peyuhologie exploration. A greater deteehlent from her family wee expreeeed. Seeiel ilpreve-eet continued. the felily eteted thet ehe no ' �.9. long-r onunidorud the doctur 'tao 1033;,” but rnihor a 'guiding nasal.“ Gunnontt Eh: ubrupt, groi- ahnngo in tho picturu parnnllud tn. duvolopttnt or anxiaun physiological change. The 61131031 rayorda during this poriod uhovcd u nodcratl ducts. of slaw wavo activity. Tho udvunt or pcn1tsvo tooling: olicitod -ruciprocnl elation: in thn thordpist which 1n thu supervinery cautions. caununicntad utrt tho attoat was alpsthic:11y rotluctod in nonbiru at the conxcrcuoo group. (rho clinical pioturc roaonbltd that at a 'trtunforonac auro.') throo EEO It 10 .! iattraut that I chant. tron "physical“ to *nnncry’ eonplnintt was dolarlbea 1: I ‘uoaustton at oonpluiulnx.’ Pcrhupa the notary dottctt, an expootnd oonconittnt or oonvulntvc thurnpy, 1. nova acacptablo to the lint: becauau 1t 1- underatundablo. Thu: £001 a rnaponaibility for this tynptoa tad nun tuthorttativoly r033Iuro thu putlatt that it will be transiant. in lifteticnuta dapcndoncy any .100 be more tolorah1c thin a hastilt out, when ucconpnniod bi erutifyinz oaeinl oupccinlly improvonant. Tho langungo change: 3:. indicative of a nor. definah‘d, intqlleotnnltacd ooununicntioa �~10» of taniltar content (8). Th. patinat nor ”talked abaut' ruthor thnn cunting or “acting out.“ This nav 1:33:33. patttrn can nor. in kooping with hat background or oulloau uduaataoa, and the thcrtyint's inplioit unpoetutions (9). In contrast to her prior node of cuuuuntcntton 1t canned ta to nor. noipgtiblo with a purchaauulytically-oriontcd approach. The concomitant dovslopnant of honor: difficulty, howovur, perpetuated thc cantnttully nonninalghtrul thorapuutic nitnnticn. 65th to 12nd gig! than ported followod tho termination a: sciatic trontannt. fhe patiout Inverted a ”auddoa £90115: ’1 3011‘ cvnrouuuo.“ Euphorta and gentry attticulty wit! a. 19:10: tbscrvud, tad an amnion. ltlt. :uportcnod. Payohothortpy toutinnu worn nhnrtctor1s¢d by morn crittcal appruisal at hot 11:. uitunttnn. tar tho first txun tho doctor 3:10 tho Thu tho in auctions. tine group voiced ton. txtra pattont unacorn that aha wt. "olippiuc back.9 thn thd patient. .ccactoually talkud positivolr nbout euro-r, cutncipttiou tron lather, 333., the tharnpist tolt called upon to rospond optiniutically, rather thug to explore. Thurs vs; I rtvivul or old canplnintn. At thin paint, tha supervilar tad thortpist roviovod A nuonion. recurrence of tho ourltor a tnruvroeordcd thtrupy �vorbal putt-run could indeed be tdcntitiod. nauuvur, than. coourrod 1n airuuunoribad fashion ruthor than throughout $30 intervinv. The «wont: nutcccdunt to Inch parlodn worn attainad Ind tha adaptivh nature at the racnrront n£tocttvo pnttornu haunt. apparant. coununt: tundra during this patina showed a considorlbla duoranau in slow The EEG activity. tn: : cauconitant rocntabllihnant at IOII of tho connunieutlon pattorna which pracedod tau period or altered brain function. Th0 coutarsnco group responded with nnxtoty rotlootod in the solicitouunnul of tho thortpiat in pralongtnz in: sonoi¢ns. the phononunan obsorvoa ta ta. nnpcrvitory stain, for luck at a bottnr turn, may be callcd 'alcetronhack dupcndoaoy.‘ statoncntn were lid. in tha matting such us 'cho'u slipping buck,” "no.4. ucr- troutnonts* and ”taprovanont not holding up.“ In... Itatcnonts inyly that the hoitilcodcycndaat panama mm being thought a: primarily as a nonalcgie flntity, ”a dopraauiun,‘ rtthor than a node or Bantu ralatodnunn. Porhapa hcuuuac hohuviorul chnngo had not boon attcctod by psychologic Incas a1930, it new conned tottlly dopondout upon thc alteration in acrcbrul function. yaw. Thurs �1-1 a. rha chins. 1n intoraction was «Qneoptltltibd as th: roanlt of the brain syndroan, find not an a function of tho doatcrupntiont relation. Edna. tho graup'h «acacia... on 6h. ahip. sporadic rcappcaranco or praeouvrloivc puttornt. Thu dotatlcd oxnuinattou of I t‘po~racordud caution rqvualod ti. ndqfitvo functtun or this not. circumacribod occurrcnon of the canvlaiatt, tad the phnnancnon of “electroshock dupnndunay' Vt! not obnorvod in Inblcqucnt group nactinga. 12rd to 25th 4:13 baring this ported a not. stubln yuyvhothorupcntxc rtlatitnlhip was upparont. the ptticnt boots. nor. tndcpnndcnt and d£lcnalad prohlcno a! euupltauoo and uolt~aalurtavoucla. Although hot at$1tudo rousinod petitivo and eollnborutivo, hi! tdlllttin a: the thcrapiat diniutuhod. In on. 3.3.1.: ch. :31! *luyho I vantt xnt buttor union. I get that: at run.“ an. ant lens olntad. 5h. ncvcd troy eh. cloned ward so an upon 00:113., and bugnn *u Ibrk_1a the hospittl library. Occulionll Ipinodul of ownrt disturbance war. ‘run‘cd by tho thcrapiut washout salinituda. n1- attitude us: an: of intorant, tappart sud datuchnont. 1a.: dtnouusod plan: tar dischargo and .u‘pntlunt ‘ruutnnnt. �-13. Gemnentz Suhaidanaa at tha chances in brain fanation raaulting tron_cénvulaiva thorapy permittad a not iatagration or the doatnrfi patiant ralationahip. Thu pattern or a céhvanttanal paychotharapaatic attuatiau appeared, which airfarad both fro: the crazinal negative and the artificially induced poaitiva relatianahipa. rharantat'a nataa an an ands: a: relatedness: Following tha cancluaian of tho study, anathar 1ndax at tho payehotharapautie ralattouahip was invaatigatad. flinch baa daaaribad the use of tha volume or stat: pragraaa nataa aa an 134a: at ata£t«patxant intavactian (10). Tha thorapiat had kapt ht. natal in a standard atanoxraphic notahoak thranzho out tha troatnant. 1 grant count or the aunbar of vagaa or nataa par tau-ion vaa mafia, and in rapraaantcé graphically an aha chart. lo written meta. vara takan daring occasional tapa¢raaardad aaaaioaa, and thaaa ara anittad from tho chart. Tho chance in tha ralatienahip is apparant from tha abrupt and paratatant incraaaa finnota taking from tho hhth day. this aoiuuadad with tha tirat groan changa in tha alaatraanoaphalogran. Tho nut-a takon by aha two ethar psychiatriata in tho unparviaory naatinga rallauad a aiuilar pattorn (not illuatratad), although with peaks 6! actoatakinz at tha onaat and again at the waning or inducad naurophwrialagta changa. �.1h. Iscusa I!hso vaport dasnrlbts an tnvonttgatian at vlrrhat&orapy adjunc$1vu procuauru. an intracuucd as to aauugio thcrupy than and dtftiuulty in fiho fbj.¢$1V! Itudy of puyuhotharupcuttc centrallfiblu ana traanaatttaa it tho abnsncn a: I quanttraablt pharnnool¢gtanl. Ind tauntia thurapton. variablo. ,gdduncttvo bohuvior in altorgtioa product gravid. tank 1 varinblo. racy was. h). (3. change: tn wall I! uniqurablu naurophyaiolauic prudent. «#111334 an. in hula In pnunt urw‘utty 1. tunntluu brain altcrud ta Ixtnpln, oat Iona a! tduyta‘ion tho Eh. at coaurrauco (5). r.1ato¢ncsu 0t typo tuphurio I haw %o inducud obicrv. an phfinanouun in this 0:30 purai‘tcd 9511 forth uttifludto ‘nd accltivo altnrantioi .1 pontttv. Anetta: 5nd uupcrviuor. ‘hcruplut tn llnilnr uttitudca 011n1¢:1 unrlxunt 0: tho discounting ti. alluatrnfitoa wt; The Ilcutroa hand or truntlnut. fihth «:1 to ahnauo during thi beginning this .1 an. :tgnatteuueu instantad ouctphnllarun miniutsud 1t thut Th. tau! fill 13 tho ralnttonuhip. chnng. dcnnunfirt‘oo tho intestine «(Stats 0: uttxt .xpcotancicc. by «coup-uni“ um mum.» brain of ”3.111,”: from uyaptcns phywicul 1n fiulplaznt 5¢3,, puttarn. oh‘nxt : the of 3 tern Thin in ruaultcd ant t0 nounxydtstiauzty. which oxportonocd was 63rd day) to (hjrd dcp¢n¢¢u¢y rtlatlonahlp shuns. rcuul‘nnt with tun supervinary otatt, atttortntly hr nine was rhtu 0:3:ct thy p&t1ant. ubant in thoir :nolinsa w unfit“: �pstient'e resily group. The oheervstions else illnetrete e phenoeeaeh supervieion we heve celled in to settings. greep peculiar sttention to the emotional steoephere or the are up, which seemed to fleateste in eoeerdenue with the therepeetie rea Here the (7) described. thst suggests being istieaehip observed in the supervises say eoanunisete the effective sepsete or his experience with the pstient nenaverhsliy in the eupervisevy nesting. his ternaletien is thet *The supervises unconsciously identities with the petient end invelentsriiy hehevee in such s esnner es te elicit in the supervisor theee very esstiens which he himself experiences ehile working sith the petieat, but use unehle to convey verbally.” He elso describes the diffusion at this extent in the other psrtioipenta or e supervisory sesiner. thus he reports that 'rhis ehservetien hse been suhaeeted to repented tests in eeniners where it use possible to vsrit’ the euyervieor'e enetiohel perceptions by sstehinx thee with the eeotiehsl resctiens or the other psrtieipents present.” Our work supports such observetiene sud suggests the patentiel truitrhlnees or studies or group dynsnies in supervisory eeeiuers. we he's noted one ehenss in reletednese resulting tree the seentie therspy that hsd e disasuetive effect upon the rsletiehship (age dsy). the petieet mentioned teeilier tepiee ”es it it were new infatuation.” the 'nnoenny‘ queiity predeeed in the therepiet end supervisor resulted from the �.16. had no the relationship that therapeutic temporary feeling history. Rapport in intensive psychotherapy depends to a great extent upon an accuaulated body of shared inforaatien. loth doctor and patient take this for granted, and the inability to rely upon it nay affect rapport adversely. Other patients in the study, not discussed in this paper, showed different patterns of response. These included transient paranoid episodes, hyperactivity, erotic, exhibitionistic and other forns of 'acting-out' which were disruptive 1 to the concurrent psychotherapy. In each case the induced the behavioral change was related to personality of the individual patient end occurred at the time of changing brain function (3). Also in each case there were conconitant changes in behavior in the supervisory group. Our experience also highlights some of the difficulties that nay develop when the two nodes of treatment are used concurrently. Intensive psychotherapy is based upon the conviction as to the efficacy of verbal communication for iaproveaent of the patient's adaptation. In the case reported a trial period of psychotherapy had been ineffective in altering clinical behavior. The introduction of somatic treatment represented a decision against exclusive reliance upon interWhen communication the instrunent. as therapeutic personal cerebral change was aaxinal a “social recovery“ occurred, apparentlr unrelated to interpretation of psychedynanic factors. When the induced neurophysiologic changes subsided, a recurrence of earlier oonnnnication patterns led the therapist to doubt ‘ , �.17- that in. iapravaaant oeuid ha parpatuatad by intarparaoual aaana aloha. to can. extant thin phanauanan was an expraaaioa a: difllrint aancaptual and linguiatic ayataaa ink-rant in in. two node: a: thorapy. It in ralatad to tho philaaaphiaal dichotomy daacriboi by Haliiaxahaad and nadlieh (6) batwaan practitionara using aoaatic and analyticallyariaatad Sharapiaa. I 8931‘!!! i atady a: concurrant aquatic and payohatharapiaa ia taperiad, in which ainnitanaoua obnorvationa of atrial ”in. brain in function, omgu paychothanpaatio ralatiouahip and social adaptation var. Iada. rho ohaarvationa in a afonp aaparviaory salinar ratlaatad tha yattarn or natty; phyaiologia altaratiou. It ia canciudad that tho introduction or a aaaaarabia phyaialosio variable in a aaatul aathod for investigation at intarparaonai ralaiionahipa. �-13. BEIEREIGES 1. count, 1.1., frusn~801¢hn&un, 3iklf, 0., x.n., and Roigzrt, 3.: A: latch-ido‘stugy c§£r:01vo 1., cases .1 Han ouncprunl vs Pay: as a, Ila a g; 103' 1951‘ cohon, u, o queovor, 3., Jntfo, J. and Kuhn, R.L.¢ Payehnthcrnpoutic foehniquoo with Eloctroahook Pattontl, logz.‘1u 17.>1958. 3. rink, J, Hill-1d. l:hn, R.L.a Relation a: nun bolt: Activity Quantitativo to Inhaviorti Responao in Electronhoak. Soraul stadium, A.H.A. Arch. laurel. & Pnzchtat.lgu H. and 516, 1957. h. rink, Emailed Theory of the nation or Phystodynaaic l l.: ibtrnpiufi, J, Hillside 30.2. g; 197. 1957. 5. Pink, l.‘hxnhn, R.L. and aroon, H.c Bxporinnntnl Studio: of I nloctroahoek Fractal, Bin. Not. all. 32: 113, 1958. 6. lalliaglhand, 1.]. and lodlieh, 1.0.: Social Olunl tad flinttl Illnuln, J. U110: & Son, . ., . 7. Kora, 2.: Phononsnology 0! ‘ho Supurvisory Precast, “O J. chhothor. E" 769, 1957. 8. tuba, 8.L. and rink, x.s chanson 1n Lungnngo During Eltatronhock rhor‘py, 1n Palahgfathologi or connnnieatl n, Inch, P. an I a, . o 3., Gran. E 3!:35‘33, I956. (aha, 3.1.. Polltck, H. and rink, K.: sociopuycholocic Aspects a: Psychiatric rroatnnnt 1a a Volunttry xcntal noupital, 1.3.5. Arch. Gen. Pazehiu . (1n proul). 10. Hal-I ROI-arch 1n Pcyuhiutryt curtain Prohlonu sud Dovclepncntn in Hulttufiiaaiplinary studion, 2.8. Stlnon zocturor, l.!. laud. lad., 1957. kiosk, D. � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Modification of psychotherapeutic transactions by altered brain function. Am J Psychother. 1961 Jan; 15:46-55. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-003-49-015 Date A point or period of time associated with an event in the lifecycle of the resource 1961 Creator An entity primarily responsible for making the resource Jaffe J.; Esecover, H., Kahn, R. L.; <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource Reprint and two [preprints]. Reprint from AMERICAN JOURNAL OF PSYCHOTHERAPY, Vol. XV, No. 1, pages 46—55. January, 1961. Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Published