The Psychodynamic Diagnostic Manual (PDM) : An Overview: in This Issue

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VOL 24 NO 6
THE OFFICIAL NEWSLETTER OF THE SAN DIEGO PSYCHOLOGICAL ASSOCIATION
IN THIS ISSUE
The Psychodynamic Diagnostic
Manual (PDM): An Overview

Cover
The Evidence for Psychoanalysis
and the Psychoanalytic
Psychotherapies
p10
Reproductive Trauma and
Psychoanalytic Concepts

p11
AUGUST/SEPTEMBER 2009
The Psychodynamic Diagnostic

By Daniel Blaess, Ph.D.
hile the DSM-IV is largely considered our diagnostic bible, a

recent diagnostic framework, the Psychodynamic Diagnostic
Manual (PDM), may provide clinicians with a richer consideration of the patient, and indeed, a consideration that might
guide treatment in beneficial ways. My hope is to provide an overview of the

PDM, including the history and origins of its development, the PDMs approach
DANGEROUS CASES:
When treatment may not be the
best option
p16
to diagnosis, and its potential utility for clinicians.
A Contemporary Psychoanalytic
Understanding of Cure p21
among several psychoanalytic organizations, including the American Psycho-
THE WAYS WE LOVE: A

Developmental Approach to
Treating Couples
p23
[39] of the American Psychological Association, the American Academy of
Psychoanalytic Treatment of
Sexual Abuse Survivors

p27
Book Review: Immigration and
Identity: Turmoil, Treatment,
and Transformation p30
Committee Corner
p31
IN EVERY ISSUE
The Psychodynamic Diagnostic Manual was developed as a collaboration

analytic Association, the International Psychoanalytical Association, Division
Psychoanalysis, and the National Membership Committee on Psychoanalysis
in Clinical Social Work. The PDM
was created to complement, not
replace, the DSM-IV and ICD.
And while the DSM, at least after
DSM-2, is intended to provide
diagnostic clarity sans theory, the
PDM has considers diagnostics
from a psychodynamic perspective informed as much as possible
From the Editor
p3
by empirical research findings.
Letters
p4
A quick glance at the PDM will
Presidents Corner
p6
find that it provides a deeper and
New Members
p35
Calendar of Events
p36
more informed understanding of
Group Therapy
p37
Classifieds
p39
Directory
Back
the disorders that we see in clinical practice, and thus it goes well
beyond the descriptive stance of
the DSM.
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Continued on page 8
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AUGUST/SEPTEMBER
in the Behavioral Sciences
FROM the editor

San Diego
Psychologist
Jonathan Gale, Ph.D., Editor
Jonathan Gale, Ph.D.

jgalephd@gmail.com
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Jonathan Gale, Ph.D. PSY 206989
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San Diego Psychological Association
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elcome to our August/September issue. This issue has been guest edited by Felise Levine. Felise generated such an interest in this special
issue, there will be a second volume coming out in April/May 2010. Thank
you Felise for your hard work! Readers, please enjoy this wonderful collection of articles.
his special edition of The San Diego Psychologist features local psychologists who work from a psychoanalytic perspective. All of these writers
share basic beliefs in: the curative value of working with transference and
countertransference material; the impact of both conscious and unconscious
motivation on behavior; the significance of developmental tasks across the
lifespan; and the importance of understanding psychic structure in the assessment and treatment of
patients. In this issue, Dr. Lee
Jaffe updates us about
recent psychoanalytic research
and the growing evidence
for the efficacy of the psychoanalytic psychotherapies; and Dr. Daniel Blaess
introduces us to the PDM,
a manual for psychodynamic
diagnosis and assessment.
Several authors discuss how
psychoanalytic theory and
research informs their clinical
work: sexual abuse victims (Dr. Marti Peck); violent
sex offenders (Drs. Reed
Meloy and James Reavis); and
patients affected by reproductive trauma (Drs. David and Martha Diamond
and Dr. Janet Jaffe). Dr. Sheila Sharpe presents her developmental model for
understanding and treating couples. Writing about psychoanalytic theory, Dr.
Alan Sugarman discusses the curative factors in psychoanalytic treatment.
Lastly, in her review of Salmon Akhtars book, Dr. Azmaira Maker reminds
us of the importance of including a culturally sensitive perspective in psychodynamic theory and practice.
We hope this issue stimulates your thinking and provides you with both informative and enjoyable reading. If you are interested in submitting an article
for the second volume (Apr/May 10), please contact me. On behalf of SDPA,
we want to give special thanks to the authors who took time and energy from
their busy lives to contribute to our Newsletter. Thank you to the Board and
to Jonathon Gale for supporting this exciting project.
Dr. Felise Levine is a psychoanalyst and couples psychologist in private practice in La Jolla.
She is on faculty at the San Diego Psychoanalytic Institute
and is on the Board of SDPA.
You can email her at: fblevine@me.com or view her website
at www.feliseblevinephd.com
quote of the month

I dont know what it is about listening. I just
know when Im heard it feels damn good

-- Carl Rogers
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LETTERS
May 12, 2009
ello Jonathan. I think you have been doing a fabulous job putting together the Newsletter over the
years, and I know it is sometimes a thankless task! One
concern I have about the edition I just received: the
API article reads like an infomercial and is not really an
article that belongs in our Newsletter. Thats my two
cents. In contrast: I loved the article on narcissism by
Jason Camu. Hope all is well.

-David B Wexler, Ph.D.
May 31, 2009
heard with some dismay that the generally difficult

times have affected the SDPA. I have been a member
of the association for some time and continue to be so
mainly to belong to a greater community. I think we
could increase our membership if we could provide
even more tangible benefits to our members given the
difficult economic conditions. One idea would be to
have a weekly dinner meeting in which a volunteer
psychologist well respected by the community provides free CE to members over dinner. Psychologists
could be responsible for paying for their own dinner
and could receive their full complement of CE in a
convivial atmosphere. A two hour presentation by a
volunteer psychologist would not be that onerous and
the free CE would make the membership fee worthwhile.
The American Psychologist provides 1 CE credit per

issue by answering a quiz. Why dont we do the same
with the newsletter? Psychologists could pay a small
fee with their submitted quiz answers to defray the
publishing costs. An ad hoc committee to study how
to increase revenues for the association could also be
helpful. Perhaps the newsletter could be published
online, and those who wish a hard copy could pay an
additional fee.
-Richard W. Levak, Ph.D.
April 25, 2009 - Remembering Dr. Van der Veen: My

Father and His Work
The affirmation of myself as a person in
my first client-centered course contrasted so
sharply with the wasteland of the rest of my
school experience that it was like a window
had opened for my soul
-my father in a letter to Carl Rogers dated 10/12/73
My father was a psychologist involved in the clientcentered movement. He died in January. His name was
Ferdinand van der Veen.
A few months back I was presented with the opportunity to write something about him for this newsletter.
Given that I am not a psychologist, I felt hesitant. I
know about the field only from a laymans perspective.
But, certainly, I did know my father, and through him I
was exposed to the world he was a part of.
My fathers primary influence was Carl Rogers. He
was a student of Rogers at the University of Chicago.
He had a photograph of him, elderly, smiling and bespectacled, sitting on his dresser. Of all the psychology
books on my fathers shelves, the majority were either
by Rogers himself or somehow connected to the clientcentered model Rogers pioneered.
My father maintained a friendship with Rogers
through the years. He introduced me to him when
I was twelve years old. We met on the beach in La
Jolla. Rogers walked up shirtless, wearing only blue
Bermuda-style shorts and a matching blue golf-hat. He
was introduced to me as Carl. My father seemed very
happy. Carls demeanor was welcoming and inclusive.
I felt calm around them.
The three of us walked along the beach. Mostly, it was
a conversation between my father and Carl, but they
happily included me from time to time. The sun shone
down upon us, its intensity softened by a steady ocean
breeze. Waves crashed. Seagulls cried. The three of us
talked, laughed, dodged an occasional Frisbee. The
memory is entirely pleasant.
WWW.SDPSYCH.ORG
Years later, I read a quote of Carls in my high-school

psychology textbook. It went something like this: I
dont know what it is about listening. I just know when
Im heard it feels damn good.
My relationship with my father had most of the complications inherent in a father-son relationship. But,
one thing I remember fondly is his ability to listen.
He would fold his hands, sit back. His features would
soften, his eyebrows raise with attentiveness. As I
expressed myself, he would give an occasional nod,
maybe reflect a comment or two. Eventually, most of
the neurotic energy my feelings had generated would
dissipate. A calm sense of knowing would return. The
future would not seem quite as threatening as it had a
moment earlier. In short, it felt damn good.
I think thats what I got a taste of that day on the beach:
the calm centeredness that comes with the experience
of being heard.
Its probably impossible to measure the extent to
which the client-centered movement has benefited the
field of psychology and, in-turn, society as a whole. It
is probably equally impossible to measure the degree
to which my father contributed to the movement.
There was his work at the University of Chicago as
well as at the University of Wisconsin. There was the
Family Assessment test he developed, the research he
did at the Institute for Juvenile Research. There was
his involvement with The Center for the Studies of the
Person and the Association for the Development of the
Person Centered Approach. And there was the private
practice he continued until the time of his stroke in
May of 2008.
In the weeks that followed that event, and after having
conferred with some of his colleagues, I contacted his
clients to let them know hed had a medical emergency.
All expressed dismay, some even refusing a referral
number, instead preferring to wait in hopes that he
would recuperate enough for them to continue their
work together.
It did not happen. In June of that same year he was
diagnosed with advanced-stage lung cancer, and, as I
mentioned above, in January his body at last gave out

to the disease, and he embarked upon that new and
mysterious phase of his evolution.
On January tenth we had the funeral, and towards
the end of the services, as I made my way towards the
parking area, a woman approached me. I did not know
her. She wore dark glasses. She was crying. Your father helped me a great deal, she said. We stood there
for a moment, both awkward, sad. Then she turned
and walked away.
It is probably not possible to measure accurately the
contribution the client-centered movement has made
or to what extent my father contributed to that movement. But, I can say, in the humble terms of a layman,
that there was (and still is) a benefit and that my father
did make a contribution. There was the time the awkward twelve year old felt calmed and accepted during
his walk on the beach; there were the experiences of
a son knowing his father could hear him; there were
the clients one of whom appeared, with tear stained
cheeks, to express her gratitude in a memorial park.
In a way, the whole question of measurement strikes
me as absurd. For, who could quantify the balming of a
soul in distress? Who could quantify the touching of a
human heart? The healing, not absolute but unequivocal, of the profound wound we carry with us on our
sojourn from shore to shore?
I hold, through my own experience and observation,
a deep appreciation for the client-centered model, the
art of listening and the practice of unconditional positive regard. As well, I hold a deep appreciation for the
men and women who have carried that gift forward.
Among them, mixed in the crowd and perhaps a little
towards the front, walks my father.
A commitment to self-direction and mutuality,
and a special interest in empathic understanding for discovering the truth available within
our own experience, are at the heart of my
work in the person-centered approach.

WWW.SDPSYCH.ORG
- Ferdinand van der Veen

-Benjamin A. van der Veen
Presidents Corner: Maintaining Balance

Within Our Profession
Lori Futterman, RN, Ph.D.
his countrys birthday is July Fourth, Independence Day. It reminds us of the core values of our
democracy life, liberty and justice for all. The ultimate
dream is the pursuit of happiness. Research shows that
the creation and the construction of happiness is within
our power to fashion it for ourselves (Lyubirsky, Sonja,
The How of Happiness: A Scientific Approach to Getting the
Life You Want, 2007).
As psychologists our aim is to assist those we treat
to become healthy, balanced individuals. We live in a
country, currently facing a host of obstacles and profound cultural changes which impact how we live our
lives and provide professional services.
The current situation facing us in California is looking bleak. The rising unemployment, the significant
budget cutbacks for health services is drastic, falling
stock prices and rising foreclosures together with the
increase in the numbers of uninsured without health
care benefits give rise to a lack of balanced on the state
level which dramatically effect the individual psyche.
According to an APA survey, the economic climate is
a major stressor for eight out of ten Americans (APA
Practice Organization, March 26 2008).
Let us not forget that the governor has threatened to
shut down the state government if he and the legislature do not close the $24.3-billion deficit. In looking
at our mental health care alone we see the pending
reduction in outpatient programs and shift back to
inpatient and medication as a means to provide care
to the underserved Medi-Cal population and the cut
of the Healthy Families, Cal WORKS and CalGrants
program for savings of $1.3 billion. Reductions in these
health and welfare programs are attached to federal
funds and would lead to a decrease in outpatient mental health care and lower payments to hospitals and
substance-abuse treatment facilities. Added to this is
the commuting of jail and prison sentences giving rise
to the release of thousands of convicted inmates early
throughout the state. This will result in an increase in
6
the antisocial population within our state not to mention the ramifications of their antisocial behaviors and
lifestyle.
It is obvious that with the current climate of affairs we
could get lost in the crisis within our state or we could
adopt a broader perspective on mental health care by
looking closely at the up and coming national trends.
This view will provide us with avenues for opportunity both in the fields of psychology and mental health.
If we are actively involved in contributing to the field
of psychology in a reformed health-care system .the
benefits for all would be multifold, i.e. the individuals receiving the psychological care, their families, the
community and the profession.
Now more than ever it is vital that we take an active
role in the nations health care reform. We are at a
critical juncture in our nations history; a time when
sweeping change in health care is truly possible (Monitor on Psychology, May 2009, Vol.40, No.5, p.9) The
Stimulus package provides approximately $40 billion
for psychologically relevant health care and research.
This would create more employment and research opportunities as well as improved access to psychological
services for patients.
Mental Health can not be separated from Primary
Medical Care. I agree with the statement made by
the APA Chief Officer Norman B. Anderson, Ph.D.:
Psychology, as a science of behavior, has much to
contribute to improving the health status of our nation
(Clay, Rebecca, Monitor on Psychology, April 2009,
Vol.40, No.4, p.16). Research shows that when psychologists are members of interdisciplinary, integrated
health-care teams, patients have improved access to
care and are more likely to adhere to their treatment
plans (Monitor on Psychology, May 2009, Vol.40, No.5,
p.9). The goal is for psychology to be included in all
aspects of health care reform and transform the way
that health care is delivered within our country.
WWW.SDPSYCH.ORG
Our expertise in psychological assessment, behavioral

and psychosocial treatments put us in a prime position, to be primary care providers and to work with
acute and chronic diseases of all types. Health care
reform will have a greater emphasis on primary care
and prevention of chronic disease. Psychologists are
advocates for the unique interconnectedness between
the mind and body. In addition, we are collaborators
of integrated health care, can measure and improve
health outcomes and can be seen as health promoters.
It is not an uncommon scenario that patients that present with medical conditions often have an underling
psychological disorder or at least have some emotional
responses to the condition itself.
In looking closely at the outcomes generated by the
Presidential Summit of 2009 on the Future of Psychology Practice, leaders assembled to examine the
unique practice of psychology and related professions
from other practice associations, government entities,
training organizations, consumers, insurers and businesses.
Some issues that emerged were:
The need to collaborate in primary care

The need to be accountable
Health promotion and prevention
Creating and nurturing partners for change
APA continues its advocacy efforts through meetings
on Capitol Hill, working with congressional committees, advocating for psychology workforce legislation,
promoting psychological and behavioral research,
partnering with coalitions and sharing information
with the public through use of the media.
It is important for us to continue to build our profession with the issues put forth by the Presidential Summit and APA. As an organization and as individuals
we need to reflect on our advocacy efforts in contributing to the field of psychology. Dr. Brian Bray, President
of APA, stated at the Presidential Summit Let your
creative juices flow: dont be stopped by pragmatics...
Be solution focused: move beyond problems and look
for possibilities and opportunities. If we take this advice we can have an impact on the future of the mental
health care on the local, state level and national levels.
Psychologist will need to redefine training and

take advantage of new practice opportunities outside the traditional psychotherapy practice
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Continued from cover: The Psychodynamic Diagnostic

It might be noted that when the goal of a diagnostic
due to the lack of empirical evidence to support its inclusion in

a diagnostic framework.
scheme is strictly descriptive, the sheer volume of dis-
The PDM lays out a framework
orders can be problematic, as it is always possible to
for assessing the patients level of
add descriptive specificity in some beneficial manner.
personality organization. These
If I take a ruler and measure my copy of the DSM-2, it
criteria
measures about a third of an inch thick. In contrast, my
of the patients sense of self and
DSM-IV-TR, even in paperback, measures about two
others, relationships, affect, regulation of impulses and
inches! At that rate, I estimate that DSM-6 will be about
affects, moral sensibility, and reality testing. Any given
a foot thick! No one will be left out! Just kidding (sort
patient may have strengths or difficulties in some but
of).
not all of these areas. However, when a preponderance
The three Axis system of diagnosis in the PDM includes: the P Axis which pertains to personality
styles and disorders; the M Axis which entails a profiling of many clinically important aspects of mental
functioning, for example the patients capacity for
self regulation, attention, learning, relationships, their
experience of affect, and use of characteristic use of
defenses, to name a few; and finally, the S Axis detailing the patients symptom patterns, i.e., the patients
more subjective experience of their illness or difficulty.
The S Axis is very much like DSM-IVs Axis I, and the
disorders delineated in the S Axis reflect many that are
familiar to clinicians using the DSM.
consideration Daniel Blaess, Ph.D.
of data suggests one level of organization over another,

that assessment is made. For example, lets consider
assessment of regulation of affects and impulses. A
clinician might assess the ways that a patient regulates
impulses and affects by considering whether regulation is done in a way that is reasonably flexible. Does it
lead to reasonable adaptation to circumstances? Does it
provide for sufficient life satisfaction? In other words,
does the patient describe rigid controls that are unrelenting, or can the patient let his or her hair down from
time to time, when appropriate, and allow a bit more
expression and enjoyment? Can the very controlled
patient relax those controls and enjoy a sexual relationship or a playful hobby?
As I noted above, the first Axis in the PDMs diagnostic scheme is the P Axis. As might be expected for
a diagnostic approach championed by psychoanalytic
practitioners, the PDM begins with consideration of
personality patterns and disorders. The P Axis suggests
that assessment of the level of personality organization
should be a primary consideration in psychodiagnostics. This approach reflects well known ideas associated
with the work of Otto Kernberg (Kernberg, 1984), suggesting that an initial understanding of the patients
level of personality organization is key to approaching
case formulation and treatment planning. The P axis
points toward three levels of personality organization. These reflect Kernbergs Healthy, Neurotic, and
Borderline levels of organization. The PDM does not
include a psychotic level of personality organization
8
include
While limitations of space do not allow me to discuss at

length any particular personality disorder described in
the PDM, a brief listing of some of the particular disorders might be of interest. Some are identical to the DSMIV, but include specific subtypes, e.g., for Narcissistic
Personality Disorder, the PDM specifies Arrogant/
Entitled and Depressed/Depleted subtypes. These
subtypes may resonate with your clinician experience
with patients who are narcissistic. Other personality
disorders are unique to the PDM and reflect research
findings and clinical experience that support their inclusion. For example, the PDM includes a Depressive
Personality Disorder (with Introjective and Anaclitic
subtypes), Sadistic and Sadomasochistic Personality
Disorders, and Masochistic (Self-Defeating) Personal-
WWW.SDPSYCH.ORG
ity Disorder (with Moral Masochistic and Relational
well-known empirically supported treatments. Some
Masochistic subtypes). Again, hopefully, some of these
of these assumptions include: 1) the idea that psycho-
resonate with your own clinical experiences.
logical processes are highly malleable; 2) the idea that
I also appreciate that the PDM describes healthy personality functioning; it is not strictly skewed toward
pathology and whether a person meets a certain number of clinical criterion for diagnosis. The PDM defines
a healthy personality, i.e., the absence of personality
disorder, as when a person as one who: can engage
in satisfying relationships, can experience a full range
of age-expected feelings and thoughts, can function
fairly flexibly when stressed by external forces or
internal conflict, have a clear sense of personal iden-
most patients have one primary problem (they note

that co-morbidity is much more common; believed to
include 50 to 90% of patients); 3) that psychological
symptoms can be understood & treated in isolation
from personality; and 4) that controlled clinical trials
are the gold standard for assessing treatment efficacy.
These are readily questionable assumptions, and may
prompt a reconsideration of some of the research currently touted as authoritative when it comes to treatment outcomes studies.
tity, are well adapted to their life circumstances, and
In summary, the PDM should be seriously considered
neither experience significant distress nor impose it on
as an alternative and adjunctive approach for clinical
others (PDM, p. 18). Healthy functioning is a definite
diagnostics. I am very often struck by the lack of value-
subtext throughout the PDM, and may assist all of us
added by knowing a patients DSM-IV diagnosis. I am
in considering the range of ways our patients function,
equally impressed with the wealth of understanding
some very healthy, some not so much. For example,
that can be provided by the PDM and a diagnostic ap-
the M Axis, provides a way to rate various aspects of
proach grounded strongly in both theory and empiri-
mental functioning on continuum from Optimal Age-
cal research.
and Phase-Appropriate Mental Capacities, to Major
Note: The PDM is readily available online, including
Defects in Basic Mental Functions. Thus strengths, as

well as areas of concern, are reflected in the clinicians
assessment.
Another chapter in the PDM also bears mention. That
chapter, The Empirical Status of Empirically Supported Psychotherapies: Assumptions, Findings, and
Reporting In Controlled Clinical Trials, by Westen,
Novotny, and Thompson-Brenner, was first published
in Psychological Bulletin in 2004. Their article has
generated a great deal of discussion among researchers focused on psychotherapy outcome research, in
that they note many of the problematic assumptions
behind the so-called empirically supported treatments.
Those treatments are increasingly being embraced by
various powers that be (e.g., insurance companies,
graduate programs, legislative bodies) as the only
valid treatments to teach, reimburse, or authorize.
Westen and his colleagues (2004) do an excellent job of
questioning the assumptions behind many of the most
through Amazon.
References
Kernberg, O.F. (1984). Severe Personality Disorders: Psychotherapeutic Strategies. New Haven:
Yale University Press.
PDM Task Force. (2006). Psychodynamic Diagnostic Manual. Silver Spring, MD: Alliance of Psychoanalytic Organizations
Westen, D., Novotny, C., Thompson-Brenner, H.
(2004). The Empirical Status of Empirically Supported Psychotherapies: Assumptions, Findings,
and Reporting in Controlled Clinical Trials. Psychological Bulletin, 130(4), 631-663.
Dr. Blaess is in private practice in San Diego,
and serves as adjunct faculty at Alliant International
University. He is also on the adjunct staff of
The Center for Creative Leadership, and is an advanced
candidate in Adult Psychoanalysis at the San Diego
Psychoanalytic Institute and Society
drblaess@post.harvard.edu 619-804-1669
WWW.SDPSYCH.ORG
The Evidence for Psychoanalysis and the

Psychoanalytic Psychotherapies
By Lee Jaffe, Ph.D.
here is an increasing demand for proof of the effectiveness of all talking cures. In response to
this demand, there is a growing body of research that
demonstrates the efficacy of both psychoanalysis and
the psychoanalytic psychotherapies. Unfortunately,
this psychoanalytic outcome research has tended to
lag behind the research of other psychotherapies, and
it has been less publicized, contributing to the misperception that psychoanalytic treatments are less valid
and reliable than others. For this reason, it is critical
that both the public and the mental health community
appreciate the research findings exemplified by the following three recent publications, covering reviews of
numerous studies that demonstrate the effectiveness
of psychoanalysis and the psychoanalytic, exploratory
psychotherapies.
In 2002, the International Psychoanalytic Association
published An Open Door Review of Outcome Studies
in Psychoanalysis (www.ipa.org.uk). This publication
reports on 66 separate outcome studies of psychoanalytic treatment, covering a period over 75 years, with
careful consideration of the methodologies as well as
the conclusions of each study. Included are: methodological approaches to clinical research, findings of
process studies, follow-up studies, experimental studies, and studies of psychotherapy with relevance for
psychoanalysis. The earliest findings reported are from
the Berlin Study done by Otto Fenichel in 1930. The
editor summarizes the overall implications of the 66
studies as follows: In general, the findings underscore
the effectiveness of our work and should encourage us
to undertake further, even more rigorous, explorations
of psychoanalytic treatment outcome.
In 2008, the Journal of the American Medical Association published the Effectiveness of Long Term
Psychodynamic Psychotherapy. The authors analyzed
23 separate studies published between 1984 and 2008,
comprising 11 randomized controlled trials and 12
observational studies that included a total of 1053
patients. Long-term psychodynamic treatment was
10
defined, according to the definition of Gunderson

and Gabbard (1999), as a therapy that involves careful attention to the therapist-patient interaction, with
thoughtfully timed interpretations of transference and
resistance, embedded in a sophisticated appreciation
of the therapists contribution to the two-person field.
Treatment had to last for at least a year or a minimum
of 50 sessions. The authors concluded that the findings
of these 23 studies demonstrate: Long-term psychodynamic psychotherapy was significantly superior to
shorter-term methods of psychotherapy with regard
to overall outcome, target problems, and personality
functioningyielding large and stable effect sizes in
the treatment of patients with personality disorders,
multiple mental disorders, and chronic mental disorderswith an outcome that increased significantly between the end of therapy and follow-up (page 1563).
In 2009, the Harvard Review of Psychiatry published
The Effectivenss of Long-Term Psychoanalytic Therapy: A Systematic Review of Empirical Studies. The
authors reviewed 27 empirical studies of long-term
psychoanalytic therapy, with a total of 5,036 patients,
published between 1970 and 2008. A careful examination of success rates for symptom reduction and
personality change, over a range of severity of psychopathology, led them to conclude: Long-term psychoanalytic therapy is an effective treatment for a large
range of psychopathologies, with moderate to large
effectswith somewhat greater success in symptom
reduction than for personality change.
These three published reviews, together covering numerous scientific outcome studies of psychoanalysis
and psychoanalytic psychotherapy, demonstrate that
long-term psychoanalytic treatments are effective; in
some cases more effective than other, short-term psychotherapies. While the results clearly document that
psychoanalytic treatments work, it remains for us to
enlighten the general public, as well as our own colleagues who are unaware of the scientific findings.
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References
de Maat, S., de Jonghe, F., Schoevers, R., Dekker,
J. (2009) The effectiveness of long-term psychoanalytic therapy: A systematic review of empirical studies. Harvard Review of Psychiatry, 17(1),
1-23.
Fonagy, P. (Ed.). (2002) An open door review of
outcome studies in psychoanalysis (second revised
edition). Research Committee of the International
Psychoanalytic Association. Broomhills, London.
Gunderson, J.G., Gabbard, G.O. (1999) Making
the case for psychoanalytic psychotherapies in the
current psychiatric environment. Journal of the
American Psychoanalytic Association, 47(3), 679704.

Leichsenring, F., Rabung S. (2008) The effectiveness of long-term psychodynamic psychotherapy.
Journal of the American Medical Association, 300,
1551-1565.
Lee Jaffe is a Psychologist and a Training & Supervising Analyst at the San Diego Psychoanalytic Society and
Institute. He is on the faculty of the UCSD School of
Medicine, and he has a private practice in La Jolla.
Reproductive Trauma and

Psychoanalytic Concepts
By David J. Diamond, Ph.D., Martha O. Diamond,
Ph.D., and Janet Jaffe, Ph.D.
n our Center for Reproductive Psychology in San

Diego we have come to use the term Reproductive
Trauma to describe the psychological consequences
of a wide range adverse reproductive events. Such
experiences include infertility, miscarriage and other
perinatal losses, premature birth, medically complicated births, the birth of medically compromised or
disabled children, as well as postpartum disorders.
Scope of the problem
Medical technology related to the reproductive process
has advanced very rapidly since Louise Brown, the first
baby conceived through in vitro fertilization, was born
thirty years ago. There are now dozens of methods for
building a family, but understanding of the psychology of this phenomenal technology has lagged far
behind. Sensational examples such as the recent case
of the Octo Mom and her fertility-treatment-induced
octuplets make headlines, but the psychological implications of reproductive technology dont as often
get discussed. And the need for such understanding
is great. Currently, in the U.S., one out of six couples
experiences infertility, 20% of pregnancies end in
miscarriage, 15% of women experience a postpartum
disorder, and one out of eight pregnant women give

birth prematurely. As couples continue to delay childbearing into the late thirties and forties, these numbers
will continue to grow.
In our clinical practice and research on the impact of
traumatic reproductive events, we have developed
several concepts that have proven helpful in understanding how people experience them, and why their
impact can be so profound. We have found it useful
to look at these experiences from a psychoanalytic
perspective, because of the unconscious meaning that
parenthood and procreation has for the development
of adult identity. There is a large psychoanalytic literature on the meaning of parenthood (see Benedek, 1959;
Colarusso, 1990; Leon, 1992, 1996), so this article will
focus on the meaning of events when things go wrong
en route to parenthood.
Key organizing concepts that we have found helpful
One important concept is that peoples reactions to
adverse reproductive events can best be understood in
relation to the meaning of parenthood under normal
or optimal conditions -- conditions which sometimes
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11
seem all too rare to some of us who work in this area

and see the wide range of things that can go wrong.
This is like many aspects of psychoanalytic work, in
which we are always working back and forth between
our understanding of normal, optimal, or good
enough development, and pathological conditions
and troubles people encounter. In this case, the more
we understand about the normal transition to parenthood, the more effectively we can appreciate, and
help people with, what they experience when adverse
reproductive events occur. Therefore, part of what we
have tried to do over the past several years is to elaborate a model of what parenthood means to people.
A second basic concept is that adverse reproductive
events represent both traumas and losses. The losses
of babies through failed IVFs, miscarriages, stillbirths,
and so on are obvious, but many of the losses of hopes,
dreams, and expectations, of existential possibilities,
of opportunities for consolidating ones own sense of
adulthood, of the enriching feelings of generativity, and
of chances to repair a damaged past are much less
tangible. In the case of many reproductive traumas, the
seemingly intangible nature of the losses complicates
grieving. How do you grieve something that never
was? How do you grieve even as you must maintain
hope that the next procedure might be the one that
works? How do you find support for your grief when
friends and family may not have even known that you
were trying to get pregnant? With regard to trauma,
we know that its essence is the overwhelming of the
self or ego with more stimulation that can be effectively
mastered. Most often we think of trauma in terms of
sudden, dramatic events. Premature birth, for example,
which exposes new parents to the shock of the NICU
environment, or perinatal death, where the physical
experience of labor and delivery leaves parents holding a dead infant, easily meets the usual definition of
trauma. But it is important to keep in mind that there
are also cumulative traumas. The multiple invasive
procedures and progressive emotional wearing down
that occur with infertility treatment or from multiple
miscarriages may also create a trauma that often goes
unrecognized by medical professionals, or even by
the patients themselves. It is no surprise, then, that
12
people who come to our practices frequently present

with classic PTSD symptoms as well as issues of grief
and loss; the relief that they feel when their experience
is acknowledged as a trauma is often palpable.
To help us further understand the meaning of parenthood to people, the concept of parental identity has
proven helpful. (This is not a term we originated others have used it see Ross (1975), for example.) Here
are some important points about it:
1. It has a developmental line that begins in early
childhood.
2. It is based on internalized representations of
relationships in which we are parented, either
well or badly.
3. It encompasses many unspoken or unconscious
expectations, schemas, wishes, hopes, dreams,
fears, and plans, as well as conscious ones.
4. It can be thought of as an unconscious narrative that influences life choices and the meanings people attach to events in many aspects
of their relational lives and across many different phases of the life span. We have come
to call this narrative the reproductive story,
and have found the term itself to be useful in
speaking with our patients about their experiences with reproductive traumas ranging from
infertility to postpartum depression.
5. Both men and women have reproductive stories, whether or not they have children, or want
them.
The importance of the reproductive story
We started our research in this area by simply asking
patients to tell us the stories of the reproductive disruptions they had experienced, in as much detail as
they could. That is where we discovered the intensely
traumatic aspects of many adverse reproductive
events, which had been burned into the memories of
some people with the same intensity as the combat
experiences of Vietnam or Gulf War veterans we had
seen. But we also began to ask about prior fantasies
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and expectations regarding parenthood, and learned

that the reproductive story begins much earlier in
the earliest phases of life, as we now see it. Along the
way, we heard from people who had had vivid mental
pictures of their babies and their family lives, even
years before they married or tried to have their own
children. We have worked clinically with women who
had chosen names for their babies in their early teens
and had detailed images of them, but had forgotten all
this until the time of a painful miscarriage many years
later.
Parental identity, the reproductive story, and lifespan development.
There seems to be a need to actualize important elements of this partly-unconscious narrative about what
ones parenting life will be like. When this is not possible, there can be a profound disruption in the sense
of identity and progress through the important phases
of adult development. Of course, it is no surprise to
psychoanalytic thinkers that people tend to repeat, in
both good and bad ways, unconscious patterns laid
down through early experience.
Whether or not you want children or are able to have
them, you grew up, for better or worse, in a matrix
of relationships in which you were parented. You internalized, both in conscious and unconscious ways,
patterns and expectations about how parents and children relate. As a part of these schemas, you may have
imagined what you would not do, or how you would
repair or rework your past.
Of course, as psychoanalytic thinkers, our focus on
the vicissitudes of development allows us to understand that children do not simply internalize veridical
representations of their actual parents. Rather, the
childs internal representations of others and of his
relationships with them are colored by the childs own
powerful emotions and his consequent projections,
distortions, immature ego, and egocentric perceptions.
Nonetheless, whatever introjections, schemas, and
relationship paradigms are constructed are powerful
psychic realities that live on in the recesses of the inner
world as the child develop into an adult, and serve as
key organizers of subsequent interpersonal and self
experiences. In essence, they form the foundation of

parental identity or the reproductive story.
Psychoanalytic thinkers recognize that there is a profound tendency for these schemas and stories to play
themselves out across generations. When a person cannot have a baby, their parents cannot become grandparents. If a couple experiences a traumatic birth, it
may re evoke distressing reproductive experiences of
their parents or grandparents.
Clinical observations about the impact of reproductive traumas
We believe that many structures and functions in adult
life are tied to the ability to actualize ones parental
identity and the complex reproductive story that underlies it. An important part of the developmental line
of growing up involves acquiring what we can think of
as the capacity to be a parent to yourself something
else that you may do well or badly, and something that
you likewise learn and internalize from the ways in
which others parented you. You must gradually develop the capacity to do things for yourself such as:
self-soothing;
self-regulation of mood, anxiety, or other affect
states;
maintenance of self-esteem;
forming relationships with others and handling
these relationships productively;
continuing to progress through development,
without getting stuck;
finding meaning and purpose in life.
Psychologists have long known that even these basic
developmental achievements and capacities can be
disrupted in the face of severe trauma or overwhelming loss. We have certainly found this to be the case for
reproductive disruptions as well, perhaps even more
so than we would expect on the basis of the physical
nature of the events.
As people reach adulthood, there are additional developmental tasks to accomplish, including:
1.
Achieving the so-called Third Individuation (Colarusso, 1990) in relation to ones
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13
own parents and family of origin (this third

individuation follows the first individuation in early childhood (Mahler, 1968), and
the second in adolescence (Blos, 1962)). At
least in Western culture, people seem to seek
a sense of independence from and equality
with their own parents, in a way that allows
them to find their own rung on the ladder of
the generations. Other cultures sometimes
have an even clearer sense of this intergenerational continuity than western societies and
this fact can compound the sense of trauma
when developmental progress is stalled by
reproductive disruptions for people from
more collectivistic cultures, or cultures that
emphasize reverence for many generations
of ancestors.
2. Establishing the sense of generativity that
Erikson (1950) first described. Accomplishing this task enhances self esteem through
the capacity to offer something to others, and
helps people find meaning and purpose in
life. Existentially, offering something to the
next generation may also help people transcend the sense of their own mortality.
3. Another important adult developmental task
is related to the fact that most human beings arrive at adulthood with at least a few
significant scars from the slings and arrows
of outrageous fortune. Psychoanalysts call
this narcissistic damage, and hopefully,
individuals find ways in adulthood to repair
some of it, or to minimize its continuing impact. Having children, since they are naturally experienced as narcissistic extensions
of the self (and here we are talking not about
pathological narcissistic investment in children, but about normal processes of a less extreme degree), presents both an opportunity
to repair some of this old damage, and a risk
of worsening the problems.
The point of all this is that much is riding on the unfolding of the reproductive story, which begins to be
14
written early in life, and whose chapters continue into

adulthood.
Conclusion
The overall point we are trying to make here is that
many aspects of adult identity and personality are
connected, directly or indirectly, with the reproductive
story or parental identity, regardless of whether or not
we choose to have children. Of course, there are many
ways, besides having children, to accomplish the important developmental tasks of adulthood. In point
of fact, however, many people use the bearing of children to accomplish some of these things. The choice
of whether to have children or not often represents a
strongly motivated unfolding and actualization of the
reproductive story, and adult development can be propelled further by the processes set in motion as people
have children. Hence, when there are disruptions in
the reproductive process, the impact on individuals
can be profound and far-reaching. The losses are more
complex and the traumas are more intense than most
people including many medical and psychological professionals realize. The parental identity, the
sense that one is or will be a parent or that one will
choose not to be a parent is much closer to the core
of ones identity and sense of self than is commonly
understood. When unexpected changes occur in the
reproductive story, adult development can be at least
temporarily derailed, and functional capacities for
even the most basic forms of self-regulation and relating to others, capacities that an individual had taken
for granted, can be disrupted.
It is our hope that the concepts we have presented here
will be of use to clinicians in understanding the profound impact that adverse reproductive events have
on individuals who experience them. Thank you.
References
Benedek, T. (1959). Parenthood as a developmental phase a contribution to libido theory. J. Amer.
Psychoanal. Assoc. 7: 389-417.
Blos, Peter. (1962) On adolescence: A psychoanalytic interpretation. New York: Free Press.
Colarusso, Calvin A. (1990) The third individuation: The effect of biological parenthood on
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separation-individuation processes in adulthood.

Psychoanalytic Study of the Child, Vol 45, 1990.
pp. 179-194.
Erikson, Erik. (1950) Childhood and society. New
York: Norton.
Leon, Irving (1992) The psychoanalytic conceptualization of perinatal loss: A multidimensional
model. American Journal of Psychiatry, 149(11),
1464-1472.
Leon, Irving (1996) Revising psychoanalytic
understanding of perinatal loss. Psychoanalytic
Psychology, 13(2), 161-176.
Mahler, Margaret. (1968) On human symbiosis
and the vicissitudes of individuation. New York:
International Universities Press.
Ross, J.M. (1975). The Development of Paternal
Identity: A Critical Review of the Literature on
Nurturance and Generativity in Boys and Men. J.
Amer. Psychoanal. Assn., 23:783-817.
Together, Drs. David Diamond, Martha Diamond, and

Janet Jaffe are co-founders and Directors of the Center for
Reproductive Psychology (www.ReproductivePsychology.
org) and co-authors of Unsung Lullabies: Understanding
and Coping with Infertility. (St Martins Press, 2005).
All of them have presented nationally and internationally on the psychology of the reproductive process and the
things that go wrong with it.
Dr. David Diamond practices psychoanalysis as well as
a child and adult psychology. He also serves as Associate
Professor at the California School of Professional Psychology at Alliant International University..
Dr. Martha Diamond,has a private practice with adults,
adolescents, and children, and has served as adjunct faculty at CSPP.
Janet is a graduate of CSPP and has served on the adjunct
faculty there, and in addition to her work with the Center,
has a private practice in Mission Valley.
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15
DANGEROUS CASES: When treatment may

not be the best option
By J. Reid Meloy, Ph.D.

& James Reavis, Psy.D.
here are those who walk among us that have no

conscience. They mouth certain feelings, but have
no emotion. They do not bond to any living creatures.
Because of their chronic emotional detachment and
often sadistic impulse, they aggress without inhibition
when their desires are thwarted. Their sole relational
goal is to dominate their objects. They are the consummate intraspecies predators (Meloy & Meloy, 2002).
Although this sounds like fiction, it is not. Each of
these assertions is supported by abundant empirical
evidence. We are describing, of course, the psychopathic subject in his most severe form. Psychopathy
research is burgeoning, and over the past decade, the
world scientific literature has yielded over a thousand
studies. When psychopathy enters the consulting room
for the psychotherapist or psychoanalyst, it is a sign of
danger.
Psychopathy should concern clinicians for three reasons: when it is severe, treatment is a waste of time and
effort, and may make the character pathology worse;
the patient is likely to be emotionally dangerous; and
the patient may be physically dangerous and pose a
real threat to the clinician and others.
There is no body of controlled treatment outcome research for this character pathology, and there is, at present, no mental health treatment for psychopathy. These
findings do not preclude the eventual discovery of an
effective treatment regimen, but they do invite clinical caution and therapeutic skepticism if psychopathy
is identified in a patient seeking treatment. There are,
moreover, several research studies which suggest that
mental health treatment, when applied to the severely
psychopathic patient, may increase his risk of future
criminal behavior (Rice et al., 1992; Seto & Barbaree,
16
1999). In a large prospective study of offenders in

England and Wales, Hare et al. (2000) found that psychopaths with substantial interpersonal and affective
deficiencies recidivated at a much higher rate if they
had received treatment than if they had not. DSilva
et al. (2004) noted, however, that a negative treatment
effect has not been established. Nevertheless, clinicians
should keep in mind the absence of positive effects,
and the presence of some negative effects of mental
health treatment on psychopathy, and proceed with
great caution.
The emotional danger of the psychopathic patient is a
less obvious, but still a serious issue. It often emerges
from two inherently conflicted positions. On the one
hand, the psychopath wishes to dominate his objects,
and will use whatever interpersonal skills are at his
disposal to do so. On the other hand, the clinician assumes that a patient has the wish and the capacity to
form a therapeutic relationship based upon trust and
a motivation to get better. Dominance-submission and
reciprocal affection do not mix, and the clinician may
become deeply disturbed as she gradually, or suddenly
discovers the mendacity of her psychopathic patient.
The emotional life of the psychopath is developmentally
pre-oedipal and pathologically narcissistic. He does not
experience emotions such as sympathy, empathy, gratitude, shared joy, guilt, or remorse. Such feelings necessitate whole object relatedness: the ability to mentally
represent self and others as whole, real, meaningful,
and separate individuals. Although not yet empirically
measured in the childhood psychopathy literature, he
may not even develop the rudimentary skills of sharing and exchanging evident in young toddlers who are
just beginning to understand the presence of a separate
other (Meloy, 1988, 2001; Gacono & Meloy, 1994).
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His emotional life is instead characterized by part self

and object relations and accompanying feelings of
boredom, exhilaration, frustration, excitement, shame,
envy, and rage. Others are purely extensions of the self
(Meloy, 2001), only present intrapsychically and interpersonally as sources of immediate frustration or gratification. In other moments they do not exist, especially
as constant objects of gratitude or concern.
The clinical problem is that the psychopathic patient
will often imitate the more mature emotional states
that he observes the psychotherapist wants him to
feel. He does not identify the nuances of the clinicians
emotions and desires for him through empathy, but
through the vigilant activity of a predator studying
the behavior of his prey. Psychopaths in the laboratory
show enhanced orienting responses in certain reward
situations when compared to normals (Hare, 2003). We
also know through functional neuroimaging studies
that they do not process emotion the way normal individuals do (Kiehl et al., 2001), and clinically appear to
be limbically disconnected (Meloy, 1988).
Patient B, a severe psychopath, was misdiagnosed as a
narcissistic personality disorder and began intensive,
psychodynamic psychotherapy. As the weeks passed,
the clinician became aware that his assumptions that
patient Bdespite his grandiosity and sense of entitlement--experienced anxiety, formed attachments, and
had a conscience were wrong. These prerequisites for
successful treatment were absent. Instead, the patient
became irritated, evasive, or gave absurd statements
when asked to describe certain emotions he reportedly felt. The clinician sought supervision to address
his disturbing recognition that the perceived emotions
in his patient were only his wishful projections. Psychological testing done by a consulting psychologist
confirmed his suspicions.
The physical danger of the psychopathic patient should
not be underestimated, even in the absence of a history
of violence. There are many case studies which document both the affective (sudden, reactive, emotional)
and predatory (planned, instrumental, emotionless)
violence of psychopathic males who maintained a
veneer of familial bliss and occupational success for
several years prior to their murders (Cahill, 1986;
McGinniss, 1983; Rule, 1980). Often the motivation for

the first killing is quite banal. In a recent California
case, People v. Scott Peterson, a young man with many
of the hallmarks of the core personality characteristics
of psychopathy murdered his pregnant wife and attempted unsuccessfully to dispose of her body in the
San Francisco Bay. He killed for unknown reasons, but
was having an affair at the time. Peterson was eventually convicted and sentenced to death. The reporters
who covered the trial were perplexed and disturbed by
his complete absence of emotion throughout his court
appearances. When he arrived on death row at San
Quentin, he was overheard to remark, what a rush!
(first authors files). Both of these behaviors would be
consistent with a chronic emotional detachment and a
hunger for autonomic arousal noted in the clinical and
empirical psychopathy literature (Hare, 2003).
In forensic research the relationship between psychopathy and violence has been well documented. When
compared to nonpsychopathic criminal offenders,
psychopathic criminals are more likely to be violent
(Williamson et al., 1987), use a weapon (Hare et al.,
1988), target strangers, arouse to sadistic sexual and
nonsexual themes (Levenston et al., 2000), continue
to be violent as they age (Hare, 2003), violently fail
when conditionally released to the community (Hare,
1981), and escape from forensic hospitals (Gacono et
al., 1997). The presence of psychopathy is the strongest
predictor of violence in both forensic (Hare, 2003) and
civil mental health settings (Monahan et al., 2001), and
is the second strongest predictor of sexual reoffending
(Harris et al., 2001)the first being sexual arousal to deviant stimuli. Research on the so-called white collar or
successful psychopath, however, is in its infancy (Babiak and Hare, in press), and other nonviolent forms
of aggressive predation in this population, such as economic exploitation of others, have yet to be measured.
National and international events during the past year,
however, have given us a wealth of case examples of
psychopathy at work.
Countertransference phenomenon
The clinicians reactions to the psychopathic patient
often provide sensitive emotional indicators of his psychopathology, and do not necessarily indicate neurotic
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17
conflict in the psychotherapist. In fact, such reactions

may imply evolved adaptive strategies that have been
developed to protect ourselves against the predation
of such individuals (Meloy and Meloy, 2002). Such
reactions should not be documented in the clinical record since they will be viewed by others as admittedly
subjective, but they can provide an impetus for further
objective testing to measure the degree of psychopathy
in the patient of concern. We and others have identified
nine countertransference reactions to the psychopathic
characterthe intensity of these reactions will usually
covary with the degree of psychopathy in any one patient.
Therapeutic Nihilism. John Lion (1978) used this term
to describe the clinical rejection and condemnation
of all patients with any history of antisocial behavior
as being completely untreatable. Instead of carefully
evaluating the patient who has some psychopathic
traits for evidence of conscience, anxiety, attachment,
and conflict, the clinician sees him as a pariah and
devalues him, concordantly utilizing a psychological
defense that is very common in psychopathy (Racker,
1968). He does to the patient what the patient does to
others. Neville Symington referred to this same countertransference reaction as condemnation.
Illusory Treatment Alliance. The opposite reaction in
the clinician is the illusion that there is a treatment
alliance with the patient when, in fact, none exists.
Such perceptions are often a product of the wishful
projections of the clinician and the imitative skill of the
patient. Meloy (1988) called this malignant pseudoidentification. Behaviors during psychotherapy that
suggest such an alliance should be skeptically viewed,
especially if the patients psychopathy is moderate to
severe. The psychopath is a chameleon, and early psychoanalytic papers on his propensity to imposture are
elegant and insightful (Greenacre, 1958). Ben Bursten
(1973) described the manipulative cycle in the psychopathic patient wherein he successfully deceives
the other person and then feels contemptuous delight.
Such feelings serve to maintain his narcissistic homeostasis as he demonstrates to himself, once again, that
he is more clever than his psychotherapist. The clinician will be left feeling angry and humiliated.
18
Fear of Assault or Harm. Larry Strasburger (1986) wrote

that both reality-based and countertransference fears
may co-exist when attempting to treat the psychopath.
This particular reaction is an emotional defense in the
clinician that is often signaled by autonomic arousal
and visceral reactions, such as piloerection (he made
the hair stand up on my neck), even in the absence
of any actual violence or direct threat. Clinicians may
also react autonomically to the predatory stare of the
psychopath (Meloy, 1988), which is often a fear reaction to the absence of emotion in his eyes. Although
the visual communication of emotion is a quotidian
experience for most individuals, it appears to be absent in psychopathy, and may eventually be measured
in the laboratory. Meloy and Meloy (2002) found that
over three-quarters of a large sample of professionals
described such autonomic reactions when in the presence of a psychopathic subject, most commonly a dermatological event or somasthetic feeling (he made my
skin crawl). Such reactions may portend real danger
and should never be ignored.
Denial and Deception. Denial is most often manifest in
clinicians through their counterphobic responses to real
danger. It is a common defense against anxiety generated by violent patients, and has been documented in
those who witness mass murderers preparing for their
acts, yet do nothing (Meloy et al., 2004). Sometimes
clinicians will not believe that a patient has a criminal
history despite the presence of a rap sheet and extensive documentation to the contrary. Clinicians will be
heard referring to their patient as having allegedly
committed a crime despite the fact that he has been
tried and convicted by a jury.
Patient C was a psychopath and sexual sadist who
was committed to a forensic hospital for the torture,
rape and murder of several stranger females. During
a quality assurance peer review of the patients chart,
it was noted that the diagnosis of sexual sadism had
been removed from his Axis I DSM-IV-TR formulation.
When the treating psychiatrist was asked about this
omission, he said, oh, we dropped it since he hasnt
done anything sexually sadistic since hes been here at
the hospital.
Deception of the psychopathic patient is most often
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done by the clinician when she is frightened of him and

wishes to avoid his rage if she tells him the truth. It may
also suggest superego problems, passive-aggressive
behavior, or identification with the patients deceptive
skills. Rigorous honesty without self-disclosure is a
crucial treatment parameter with such patients.
Helplessness and Guilt. Clinicians beginning their careers may feel particularly helpless and guilty when
an antisocial or psychopathic patient does not change
despite their earnest efforts. It is difficult to accept the
immutability of certain personality traits, especially
when viewed through the prism of a treatment philosophy that endorses the basic goodness of human
nature. Psychopaths challenge our desire to order
and idealize the human experience. Sometimes such
feelings originate in the clinicians narcissistic belief
that he has an omnipotent ability to heal others, what
Annie Reich (1951) referred to as the Midas touch
syndrome. Psychopaths will exploit this narcissistic
vulnerability by imitating back to the psychotherapist
behaviors that confirm what he admires the most: his
ability to heal the patient, and perhaps unconsciously
defeat the therapists who had previously failed to help
the patient.
Devaluation and the Loss of Professional Identity. If
therapeutic competency is only measured through
genuine change in the patient, psychopathy will be a
source of continuous professional disappointment and
narcissistic wounding. In institutional settings where
contact with such patients is prolonged and controlled,
clinicians will often report symptoms of depression
and burnout due to their treatment failures and
marginal positions of power and authority when compared to the staff responsible for security. Despite the
adept management of the psychopaths contempt, it is
difficult not to feel despicable and devalued because
of the primitive, preverbal nature of the patients defenses, often behaviorally manifest through belittling
and aggressive gestures.
Subject D was the eighth individual to enter the young
female psychologists office on her first day of work
at a maximum security prison. She felt proud and
confident of her skills, establishing rapport with the
inmates and keeping her professional boundaries quite
clear and forthright. When subject D sat down, he ignored her questions, and began talking about how she
smelled. He speculated on the nature of her perfume,
looked her over, and made suggestions for improving
her smell and her appearance in the custody setting
so as not to sexually provoke other inmates. She felt
devalued and controlled, her lips and hands began to
tremble, and she could not stop the tears welling up in
her eyes. She abruptly ended the interview.
Hatred and the Wish to Destroy. Psychopathic patients
despise goodness itself, and often work hard to damage
the goodness they perceive in others to manage their
envious feelings. Paradoxically, a psychotherapist who
is devoted to being very competent and responsible
with such patients will often stimulate the most envy
in them. Some clinicians will identify with the psychopathic patients hatred and aggression to ameliorate
their impact upon him (Gabbard, 1996). If not acted
upon, such feelings in the clinician can be a source for
understanding the psychopathic individuals intensity
of aggression and the roots of such impulses. It is not
uncommon for psychotherapists or psychoanalysts
working with such patients to have spontaneous homicidal fantasies prior to an awareness of the affective
components of their aggression toward such patients.
Harold Searles (1979) explored the clinical awareness
of a wish to kill ones patient.
Assumption of Psychological Complexity. The most
subtle countertransference reaction to psychopathy is
the clinicians belief that the patient has the internal
structure and developmental maturity of a neurotically
organized individual, and it only has to be discovered
in treatment. Severely psychopathic individuals are
organized at a borderline level of personality, at best,
and they do not have the affective modulation, whole
object relations, and tripartite structure that is evident
in more treatable individuals (Gacono and Meloy, 1994;
Kernberg, 1984; Meloy, 1988). This misapprehension is
particularly common when evaluating a psychopathic
patient who has a substantially above average IQ and
no other Axis I diagnosis. Some clinicians still adhere
to the mistaken beliefs that all psychopathic patients
have low self esteem, developmentally mature affects
that are defended against (rather than nonexistent), and
a capacity for empathy and concern for others. There is
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19
abundant clinical and laboratory evidence that such is

not the case (Hare, 2003).
Fascination and Sexual Attraction. Our last countertransference reaction that heretofore has not been
discussed in the literature is fascination and sexual
attraction. Some clinicians are strongly drawn to such
patients, and provide for the psychopath an idealizing
countertransference through which he can regale others with stories of his prowess and exploits. Young
mental health professionals, especially women, will
often be enamored with criminal forensic work for the
sensation-seeking it delivers and the unconscious identifications with psychopathy which it invites. What is
forbidden is often what is most desired. If clinicians
come to understand the fantasized extremes of their
own aggression and hedonistic desires, this fascination
will often devolve into boredom, and then the clinical
task becomes maintaining interest in a patient who offers little hope for change.
When Treatment is Undertaken
In a perfect world, psychopathic individuals would be
easily identified, not referred for mental health treatment, and all energies would focus on the safety of the
unfortunate individuals living or working with or near
them. Such is not the case. In both public and private
treatment settings, prisons, jails, and outpatient practices, individuals with various degrees of psychopathy
will present for treatment, and sometimes the clinician
has no choice but to evaluate and attempt to treat them.
Psychopathy is an immutable trait in certain patients
which should give pause to the wise clinician before
treatment is undertaken. It can be reliably measured,

and depending upon its severity, will have a minimal
or massive impact on treatment outcome. We have focused in this brief paper on countertransference reactions; we believe such self understanding is central to
navigation through or around such character pathology. Clinicians bear the burden of responsibility when
deciding to treat such patients, since the psychopath,
true to his character, believes he bears no responsibility
at all.
References
(This is an abbreviated and revised portion of a
chapter first published in JB Van Luyn, S Akhtar, J
Livesley, eds., Severe Personality Disorders: Major
Issues in Everyday Practice. London: Cambridge
University Press, 2007. References are available
from the first author).
Dr. Reid Meloy is a diplomate in forensic psychology of the
American Board of Professional PsychologyHe is a clinical professor of psychiatry at the University of California,
San Diego, School of Medicine; an adjunct professor at
the University of San Diego School of Law; and a faculty
member of the San Diego Psychoanalytic Institute.
James A. Reavis, Ph.D. is the director of two treatment
programs in San Diego County, which together provide
offense-specific treatment, risk appraisal, and forensic
psychological evaluation to approximately 300 criminal
offenders. He was a founding member of the San Diego
Sex Offender Management Committee (SOMC), and, as a
private practitioner, received the sole San Diego contract to
treat Sexually Violent Predators.
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20
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A Contemporary Psychoanalytic
Understanding of Cure
By Alan Sugarman, Ph.D.
oo many psychologists these days have a view

of psychoanalysis as old fashioned and/or out of
touch with current day clinical realities. Some decry
the use of the couch and the need for patients to attend
sessions several days per week. Others believe that
psychoanalysis has no research upon which to base
its claims or think that it ignores current day developmental and neuro-scientific findings. Still others state
that it is overly reductionistic, explaining all problems
as due to childhood conflicts. And some assert that the
traditional psychoanalytic stance of neutrality makes
psychoanalysis cold, foreboding, and not user friendly.
It is impossible to dispel all these myths in one short
article, although I do believe they are all based on
outdated views of psychoanalysis as it was practiced
decades ago. In todays paper I will put forward a very
contemporary view of what psychoanalysts call mutative action and demonstrate that this view derives from
current developmental and neuro-scientific research.
This view of mutative action also requires a more flexible technical approach by the psychoanalyst that integrates different strands of psychoanalytic theory, most
notably the structural, relational, and Kleinian schools
of thought.
The term, mutative action, may cause some readers to
roll their eyes. They might be heard to mutter, Why
cant analysts write and speak in plain English? Although this complaint is legitimate, I will need to use
some jargon, hopefully minimal, to make my point.
Mutative action in psychoanalytic theory refers to the
mechanism of action thought to be curative in psychoanalytic technique. Traditionally psychoanalytic
thinkers have argued that their theory is one in which
their model of how the mind works leads directly to
a theory of pathogenesis (how it goes awry) that then
leads to a theory of mutative action.
And the theory of mutative action that has held sway

for much of the past century has been one based on
insight. That is, the psychoanalyst works with the patient in a way that provides the patient with insight
into the unconscious, past antecedents of his symptoms
or personality traits. The stereotype of the silent, aloof
analyst, sitting behind the couch, is a relatively accurate rendering of psychoanalytic technique as it was
practiced and taught from the 1950s to the late 80s,
with the caveat that certain exceptions always occurred
as new schools of psychoanalysis arose and gained
adherents. Nonetheless, American psychoanalysis,
in general, prioritized the provision of insight as the
main mutative factor. The prevailing theory of pathogenesis was that childhood experiences and conflicts
led to certain ideas, wishes, fantasies, or fears (generally sexual or aggressive) being repressed and made
dynamically conscious. By free associating while lying
on the couch, the patient provided the analyst with the
data necessary for the latter to interpret these repressed
mental contents and make them conscious. In this way
the patient gained cognitive and emotional insight into
the unconscious causes of his problems. This insight
was best attained when it involved the relationship
between the two parties--the patients transference.
The analyst needed to stay relatively silent in order to
provide enough frustration to cause the unconscious
mental contents about him to build up and force their
way into the patients associations.
In a series of papers (Sugarman, 2003a,b; 2006; 2007;
2008a,b; 2009; In press), I have pointed out that this
model of mutative action is outdated. It unwittingly
perpetuates a view of mental functioning and pathogenesis that Freud abandoned in 1923 when he published The Ego and the Id. My ideas have been stimulated by two other contemporary structural analysts,
Fred Busch (1995; 1999) and Paul Gray (1994) who
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21
point out that traditional American psychoanalysis has

maintained what they call a developmental lag in developing the clinical implications of Freuds structural
model. My expansion of their ideas takes as its starting
point the fact that the major function of the human
mind is to maintain a homeostatic equilibrium between
the multiple and conflicting mental functions (e.g. affect regulation, cognition, self and object constancy,
etc.) that comprise it. This equilibrium promotes selfregulation. Pathogenesis occurs, from this perspective,
when certain mental functions do not work optimally.
The goal of psychoanalysis, then, becomes improving
the working of these sub-optimal functions so that
equilibrium and self-regulation occur.
Recent developmental and cognitive research (BaronCohen, et al., 2000; Fonagy, et al., 2002) and research
into autism (Mayes, et al., 1993) suggests that self-regulation best occurs when individuals have the capacity
to mentalize or to utilize a theory of mind. These terms
refer to the same phenomenon: that is, (1) the realization that ones own and others behaviors are caused by
internal, mental phenomena, (2) the awareness that the
inner world is a mental construction, not a veridical imprint of the outer world, and (3)the ability to self-reflect
ones own internal world in order to understand it and
regulate ones behavior. This mental function develops,
arising out of a secure attachment between infant and
caretaker (Fonagy & Target, 1997), coming into clear
existence between ages 3 & 6 (Mayes & Cohen, 1996),
and evolving during latency (Jemerin, 2004), to the
point that it works optimally as the adolescent attains
formal operational thinking. All mental functions work
better when the individual can reflect on them in an
abstract verbal manner. For example, affect regulation
is best accomplished when one can put ones feelings
into words. Until then, behavioral action or psychosomatic discharge are the only modalities available for
experiencing and communicating emotions.
I have extrapolated from this body of work to suggest
that in psychoanalysis, we promote insightfulness
rather than insight into repressed content. That is, we
help our patients learn to mentalize in regard to the
mental functions that they have trouble regulating.
Although insight into repressed mental content does
22
occur, it is a by-product of our efforts at helping them

learn to reflect on their inner worlds. From this perspective, mutative action involves helping patients
attain a functional capacity that they either lost or
never developed fully. Such a shift of focus expands
the repertoire that the modern psychoanalyst has at his
or her disposal. Verbal interpretation is no longer prioritized. Any intervention by the analyst that promotes
insightfulness is functionally the same. Concepts on
the modern day psychoanalytic scene such as procedural knowledge and the embodied mind along with
more traditional ones like body ego or sensori-motor
thinking all indicate that mental functions originate
in the body and develop into more verbal, symbolic
ones. This holds true for mentalization also. To the
degree that patients mentalize in less developed ways
in certain area, the analyst must meet them at the level
at which they are doing so before helping them to do
so in more advanced ways. Hence, the analyst must,
at times, intervene via action (Sugarman, 2009). And,
because this mental function arises out of a secure attachment, sometimes the very relationship between
patient and analyst becomes essential for facilitating
insightfulness. Still other times, the analyst must self
disclose in order to make his or her mind available to
the patient in order to teach the value of self-reflection
(Sugarman, 2006; In press). All of this work is best
done in the here and now interaction with the analyst.
Reconstruction of the past is minimized, occurring
sometimes as the patient self-reflects; it is not curative
in its own right.
Hence, contemporary psychoanalysts work very differently than the ones of most stereotypes. And the
concepts they use are very much based on modern day
research. In other words, contemporary psychoanalysis is not your grandmothers psychoanalysis.
References
Baron-Cohen, S., Tager-Flusberg, H., & Cohen, D.J.
(2000). Understanding Other Minds: Perspectives
from Developmental Cognitive Neuroscience,
New York: Oxford University Press.
Busch, F. (1995). The Ego at the Center of Clinical
Technique. Northvale, NJ: Aronson.
Busch, F. (1999). Rethinking Clinical Technique.
WWW.SDPSYCH.ORG
Northvale, NJ: Aronson.

Fonagy, P. & Target, M. (1997). Attachment and
reflective function: their role in self-organization.
Development and Psychopathology, 9: 679-700.
Fonagy, P., Gergely, G., Jurist, E.L., & Target, M.
(2002) Affect Regulation, Mentalization, and the
Development of the Self. New York: Other Press.
Gray, P. (1994). The Ego and Analysis of Defense,
Northvale, NJ: Aronson.
Jemerin, J.M. (2004). Latency and the capacity to
reflect on mental states. Psychoanalytic Study of
the Child, 59: 211-239.
Mayes. L.C. & Cohen, D.J. (1996). Childrens developing theory of mind. Journal of the American
Psychoanalytic Association, 44: 117-142.
Mayes, L.C., Cohen, D.J. & Klin, A. (1993), Desire
and fantasy: a psychoanalytic perspective on
theory of mind and autism. In A. Martin & R.A.
King (eds.), Life is with Others: Selected Writings
on Child Psychiatry, pp. 49-64.
Sugarman, A. (2003a). A new model for conceptualizing insightfulness in the analysis of young
children. Psychoanalytic Quarterly, 72: 325-355.
Sugarman, A. (2003b). Dimensions of the child
analysts role as a developmental object: affect
regulation and limit setting. Psychoanalytic Study
of the Child, 58: 189-213.
ness, and therapeutic action: the importance of

mental organization. International Journal of
Psychoanalysis, 87: 965-987.
Sugarman, A. (2007). Whatever happened to neurosis? Who are we analyzing? And how? The importance of mental organization. Psychoanalytic
Psychology, 24: 409-428.
Sugarman, A. (2008a). The use of play to promote
insightfulness in the analysis of children suffering
from cumulative trauma. Psychoanalytic Quarterly: 77: 799-833.
Sugarman, A. (2008b). Fantasizing as process, not
fantasy as content: The importance of mental
organization. Psychoanalytic Inquiry, 28: 169-189.
Sugarman, A. (2009). The contribution of the analysts actions to mutative action: Adevelopmental
perspective. Psychoanalytic Study of the Child.
Sugarman, A. (In Press). Psychoanalyzing a
Vulcan: the importance of mental organization
in treating Aspergers patients. Psychoanalytic
Inquiry.
Dr. Sugarman is a Training and Supervising Analyst and
a Child and Adolescent Supervising Analyst at the San
Diego Psychoanalytic Society and Institute. He is also a
Clinical Professor of Psychiatry, University of California,
San Diego. He maintains a private practice in La Jolla.
Mumford2@cox.net
Sugarman, A. (2006). Mentalization, insightful-
THE WAYS WE LOVE: A Developmental

Approach to Treating Couples
By Sheila A. Sharpe, Ph.D.
Our culture has steeped us in two dichotomous ideals
of love and marriage. The first is the ideal of romantic
love. In this fairy tale, you fall in love, marry joyously,
and live happily ever after. The second is the ideal of
devoted love. The couple, in this saga, also falls in
love, but only as a brief interlude of madness before
getting down to the real business of loving, which is
to struggle side by side through years of hard work,
raising children, self-sacrifice, and compromise.
A tenacious myth keeps our understanding of marriage from advancing. It could be called the myth of
Athena, because Athena sprang from the head of Zeus
as a fully grown, perfectly formed goddess. We view
the marital relationship similarly, as springing into being, fully formed, when two people marry.
This lack of a developmental perspective can be attributed not only to the ideals of romantic and devoted love
but also to early psychoanalytic theory that viewed in-
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23
dividual development as essentially completed by late

adolescence. While psychoanalytic theory has slowly
integrated the concept of adult development, most
conceptions focus on the individual adults journey
through the life cycle and not on the marriage relationship as having a distinct evolution of its own.
Based on my work with couples over several decades,
I have formulated a theory of how love relationships
develop along with an allied treatment approach for
therapists working with couples (Sharpe, 2000). The
effectiveness of this developmental approach has
received support in recent research (Blair, 2006). In
this conception, marriages and other committed love
relationships are viewed as consisting of multiple patterns of relating that develop in parallel over time in
an interrelated fashion. I have identified seven central
relationship patterns that appear to be universally expressed in adult love relationships in our society. The
patterns promoting connection are: nurturing, merging, and idealizing.
The patterns promoting separateness within the relationship are: devaluing, controlling, competing for superiority, and competing in love triangles. Each of these
patterns has its own developmental course, subject to
certain derailments. These patterns reflect everyones
relational needs. We need to be nurtured and to nurture, to feel cared for, and to care for others. We need to
be able to merge, at times, to feel fundamentally connected and part of a greater whole. We need to idealize
our partners and to be idealized to stay attracted and
to feel cherished. We need to devalue at times of serious disappointment in our partners and ourselves, so
that necessary changes and greater acceptance can be
integrated. Sometimes, we need to control, dominate,
and oppose to feel powerful and independent. At other
times, we need to compete with our partners to define
and test our strengths and weaknesses. We also may
need to contend with outsiders (e.g., children, parents,
work) in order to preserve the priority of the bond with
our partners.
However, there is also a downside to each of these
patterns, a painful, potentially destructive aspect. A
relatively sturdy relationship that continues to grow
24
in spite of difficulties can usually tolerate the stress

of these negative potentials. However, when one of
these patterns dominates and rigidifies into a primarily defensive form, a couple relationship will become
stagnant or actively destructive.
The few previous contributions to a developmental
conception conceptualize marriage as one entity that
develops in a linear progression of stages, each stage
involving the partners mastery of certain psychological and interpersonal tasks. While building on these
contributions, my conception aims to capture the
greater complexity of couple relationships. Rather than
a single developmental progression evolving in serial
stages, I conceptualize multiple developmental lines
evolving in parallel, though interrelated, ways. Additionally, in contrast to the idea of a linear progression,
Ive observed that this evolution occurs in the form of
a spiral, wherein the steps are repeated, or recapitulated, at more mature levels throughout the life of the
relationship.
In earlier efforts (Sharpe, 1981, 1990, 1997), I applied
the stages in a childs development of object relations
described by Mahler, Pine, and Bergman (1975) to the
evolution of couple relationships. This conception
also incorporated the pioneering work of Henry Dicks
(1963) and other object relations theorists. Working
with this model for several years, I have found it to be
limited in its overemphasis on a single developmental
process, separationindividuation, with insufficient
regard for couples needs for varying kinds of connection. Viewing troubled couples solely in terms of
pathological syndromes also seemed to interfere with
the creation of a safe, growth-promoting environment.
Partners are more responsive to this approach which
emphasizes the positive, normal aspects of relationship development and incorporates a balanced view of
couples ongoing needs both to create a deeper connection and to be separate individuals.
Take mind reading, for example. Many therapists
view a couples wish to communicate in this fashion
as a symptom of pathological symbiosis. Directly or
indirectly, couples are prevailed upon to give up mind
reading. Many partners then feel criticized and pres-
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sured to correct this supposed flaw or risk disappointing the therapist. Many try to give up mind reading
for the therapists sake, but this kind of compliance in
sessions rarely advances a relationship, let alone the
partners self-esteem. Clinical approaches of this kind
reflect a singular emphasis on separationindividuation of the partners, without adequate understanding
of their equal or often greater needs for attachment.
In this developmental approach, mind reading and
merging are considered to be universal and normal
ways couples relate. These essential features of romantic love are fundamental to feeling deeply and
empathically connected. However, if such patterns
continue to dominate a relationship well beyond the
romantic phase, a disruption in development has likely
occurred, and these patterns have become defensive.
In treatment, I would initially seek to understand with
a couple the wishes and fears (often unconscious) that
motivate their mind reading.
Partners often reveal that mind reading and other forms
of merging are felt to be necessary to keep them safely
attached, rather than feeling abandoned and alone.
They preserve fantasies of oneness that seem vital to
feeling loved. When these needs and fears are understood and worked with to whatever depth is necessary,
a couple can usually move forward developmentally
and change the dysfunctional aspects of these patterns,
while improving the functional aspects.
The theoretical framework just described is summarized as follows:
A couple relationship is a system that develops
over time in a way that is distinct from, though related to, development of the individual partners.
A relationship consists of multiple patterns of relating that develop in an interwoven, interdependent fashion throughout the life of a relationship.
Seven universal patterns of intimate relating have
been identified: nurturing, merging, idealizing,
devaluing, controlling, competing for superiority,
and competing in love triangles.
Each pattern of relating has its origin in an individuals early relationship development and can
be viewed as an ongoing developmental theme
that is reworked in different ways throughout

life.
Each pattern expresses a distinctive facet of the
partners needs to be connected yet separate.
The optimal result of the developmental progression of these patterns is the couples increasing
ability to create a mutual relationship that also
supports individual development.
Each pattern thus undergoes a normative developmental progression that may become derailed
at any point in the couples life, causing temporary
or long-term problems.
These patterns become destructive when one or
more dynamics become too dominant or rigidly
fixed in form, so that development halts and a
functional balance is lost between the partners
needs to be connected and to be separate.
Effective couple therapy focuses on understanding the protective meanings of the couples
particular defensive patterns, as reflecting each
partners wishes for and fears of intimacy and
self-development. The general therapeutic aim is
to aid the couple in restoring an optimal developmental process and balance between relationship
and personal growth.
Through understanding the optimal development
and common pitfalls of each relationship pattern, the
therapist can more readily identify which pattern(s) is
causing difficulty for a couple and at what point in this
development the partners have become derailed, either
temporarily or more permanently. This assessment is
then helpful in determining treatment difficulty, where
and how to focus interventions, and the possibility of a
certain kind of relationship forming between therapist
and couple that may interfere with treatment progress.
Nurturing is a good example, since most couples who
come for therapy have difficulties in this area. One of
the most common complaints a couple therapist hears
is, My partner does not meet my needs. Marital
malnourishment is one of the most common problems
affecting couples today. This rampant condition is in
part the result of a society brainwashed by the myth of
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25
romantic love. Capacities of partners to nurture in the

particular ways each one needs are not usually present
at the outset of a relationship (as this myth leads us to
expect); they require development. Just the therapists
transmission of this basic understanding can reduce
the partners feelings of failure and shame, as well as
introduce the idea that meeting each others needs is
not an automatic given in a relationship, has little to
do with how much you love someone, but entails a
rather difficult developmental journey.
When a couples development becomes stalled or stuck
and one or more of the basic patterns become defensive, a certain kind of collusive role relationship can
rigidify between the partners. Sooner or later aspects
of this relationship will be transferred to the therapist
and evoke certain countertransference reactions. For
example, in the case of severe nurturing problems,
the collusive role relationship of caretaker and needful child is commonly seen. The therapist is likely to
be viewed by the partners as an all-giving mother and
may be drawn into the role of rescuing savior.
If the therapist has an understanding of the kind of
transference-countertransference constellations likely
to be induced by a certain relationship pattern, he or
she is in a much better position to utilize countertransference diagnostically, to recognize changes in the various transferences as therapy deepens, or work out of
an impasse (Sharpe, 1997).
Many years ago, I was trained to solve a couples
problems in twelve sessions. Then, I spent the next
decade trying to figure out how really to do couple
therapy. Today, there are treatment approaches that
purport to do the job in six sessions. Troubled partners
who need to be in treatment longer than the few sessions specified by their HMO or therapists approach
then feel even more like failures. Likewise therapists
who cannot fix a couple in six or twelve sessions begin
to wonder what is wrong with their skills.
couples needs, I also hope to encourage more enlightened views.

References
Blair, N. J. (2006). Patterns of connection and separateness in couples: an exploratory study of S. A.
Sharpes model. Doctoral Thesis: Alliant International University, California School of Professional
Psychology, San Diego.
Dicks, H. (1967). Marital tensions. New York: Basic
Books.
Mahler, M., Pine, F., & Bergman, A. (1975). The
psychological birth of the human infant. New
York: Basic Books.
Sharpe, S. A. (1981). The symbiotic marriage: A diagnostic profile. Bulletin of the Menninger Clinic,
45, 89114.
Sharpe, S. A. (1990). The oppositional couple: A
developmental object relations approach to diagnosis and treatment. In R. A. Nemiroff & C. A.
Colarusso (Eds.), New dimensions in adult development (pp. 386415). New York: Basic Books.
Sharpe, S. A. (1997). Countertransference and
diagnosis in couples therapy. In M. F. Solomon &
J. P. Siegel (Eds.), Countertransference in couples
therapy (pp. 3871). New York: Norton.
Sharpe, S.A. (2000). The ways we love: A developmental approach to treating couples. New
York: Guilford.
Sheila A. Sharpe, Ph.D. is in private practice in La Jolla,
California. She teaches in the Advanced Psychoanalytic
Psychotherapy Program of the San Diego Psychoanalytic
Society and Institute. She is also on the guest faculty of
New Directions in Psychoanalytic Thinking of the Washington Psychoanalytic Foundation.
I hope to counter these unhelpful attitudes by speaking to the difficulty of both creating a good marriage
and doing couple therapy. By offering an assessment
process and treatment approach grounded in the complexities of relationship development and tailored to a
26
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Psychoanalytic Treatment of Sexual

Abuse Survivors
By Marti Peck, Ph.D.
ith the tremendous amount of research findings and treatment approaches available to the
practicing psychologist in the past decade or more (e.g.
EMDR. TF-CBT, Dialectical Behavior Therapy, Mindfulness) for adults molested as children (AMAC), some
who read this may find they will translate the psychoanalytic language I use into their own terms of understanding. In my work with perpetrators, non-offending
partners and victims of sexual abuse I have found that
incorporating aspects of current attachment theory, cognitive, behavioral and psychodynamic understandings
work well. In this article, I hope to shed light on what I
view as the strengths of a psychoanalytic perspective.
For example, while I assume that all of us in our clinical
work recognize and value that thoughts, feelings and
behaviors interact and influence each other, I believe
that the emphasis which psychoanalysts place on the
unconscious, or the ability of thoughts, feelings, ideas,
and fantasies, to influence and affect behavior beyond
conscious awareness, is a distinct aspect that adds
value to any understanding of how the mind works
and what motivates human behavior.
Sexually abused patients often present with comorbid
disorders of depression, dissociative and anxiety disorders, substance abuse/dependence, chronic pain,
somatization, and poor self-esteem. However, while I
haveI have found it helpful to apply general guidelines
for assessing and treating this population, I have also
found it wise to balance this with the knowledge that
no two patients with a history of sexual abuse are alike,
and each will need a customized approach and treatment plan. An additional difficulty in the assessment
and treatment of this population is that AMAC patients
recall their sexual abuse in a variety of ways. Memories
can be distorted, repressed, serve as screen memories
for other memories, or may be remembered in detail or
in part detail. For example, some patients enter treatment having conscious memories of being molested in
childhood, when they actually were. Others have no
conscious memories, but later come to believe they
were molested (this being the bane of , and impetus for
the creation of the False Memory Syndrome Foundation), and still others believe they were molested, but
later in the therapy process come to believe they really
werent.
Freud himself grappled with the validity of memories
of sexual abuse, as he abandoned the original ideas of
seduction theory (that patients reports of molestation
were always true) to addressing the complexity and
spectrum of memories, ranging from actual to fantasized seduction and incest. Contemporary research
(Linda Meyer Williams, 1994, 1995) has provided
support for Freuds later ideas about the spectrum
of sexual abuse and memories. I have treated adults
whose experiences have ranged across this spectrum,
and have learned it is important to keep an open mind
throughout the therapeutic process to all possibilities
along this spectrum, allowing material to unfold and
be examined within the context of the totality of the
complex mosaic that is the patients life
In my private practice, I pay particular attention to
the phases of the therapeutic process (i.e. Assessment,
Beginning, Middle, End), including characteristics of
and guidelines for each phase.
1. Assessment Phase During the initial consultation
session, when patients report symptoms which could
potentially be an effect of childhood abuse (e.g. depression, eating disorder), I focus on getting more detailed
information about their complaints, what approaches
they have tried to deal with their concerns, and what
they have observed about the outcome of their attempts
to resolve them. I do this regardless of whether the patient has identified a sexual abuse history as relating to
the presenting problem. At the end of this first session,
we discuss their comfort level with me, if they have a
general sense that we would make a good match, and if
they would like to return. If they answer affirmatively,
I then propose that we meet several more times (usually 4-6), for the purpose of further assessment, for me
to obtain further background history, for us to evaluate
each other in terms of how we feel the process is going,
and to develop a more refined treatment plan.
Since I generally assume that one way the molested
child often dealt with their sexual abuse was by keeping it secret and not talking about it, I also assume that
at some level, talking therapy represents the opposite,
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27
and is a threatening way to start dealing with it. Therefore, AMAC patients are likely to enter treatment with
mixed feelings, and an approach/avoidance conflict,
about participating in therapy. It is partly for this reason that I present a time-limited trial in order for the
patient to feel safer, and to avoid feeling too afraid that
they are being trapped into a long-term commitment
(and a potential reenactment of their experience with
their perpetrator). This approach provides them with
an opportunity to begin developing a sense of safety
- that it can feel safe to talk about their internal world,
to talk about their thoughts, feelings, ideas, dreams,
fantasies, etc. During the first few sessions, if historytaking results in an understanding between myself and
the patient that sexual abuse did, or may have occurred
in their life and they express a desire to explore the
past-- I find it helpful to ask several more questions:
What is the reason you think you want to recover
(more) memories?, How do you hope recovering
memories will help you?, What problems in your
life do you hope will be changed by remembering the
abuse?. In this way we have an important conversation about their hoped for benefits and the potential
emotional costs for doing this work.
If at the end of the Assessment phase, the patient and
I agree to go forward, I try to communicate and outline some of the steps that might be involved in their
growth/healing process. This involves first of all establishing a sense of safety and stability in their body,
in their relationships and their life circumstances.
These goals are achieved by learning relatively more
constructive than self-destructive skills to manage
their feelings (e.g. stopping drinking/using drugs,
binging/purging) and by starting the practice of other
self-soothing measures less harmful to themselves. I
also emphasize to the patient the collaborative nature
of the treatment, as well as the likelihood of needing
longer rather than short-term treatment for addressing
the sexual abuse issues, especially with the existence of
a co-morbid condition.
Beginning Phase In this phase of treatment, I consistently encourage patients to seek out and participate
in whatever adjunctive interventions it takes to stop
self-harmful behavior and to start engaging in selfprotective behaviors. For example, I propose consulting with their medical doctor and a nutritionist for an
eating disorder, or attending A.A./Smart Recovery/
N.A. groups to help them maintain sobriety for drug/
alcohol abuse or dependence. This begins to help
them achieve stability in their life. Furthermore, this
28
approach contributes to an internal shift in their representations of themselves and others by seeing me role
model a protective stance a change which attachment
theorists (Siegel, 1999) might refer to as a change in
relational schema. This set of internal representations
differs from the representations of a non-protective
parent who likely existed in order for their childhood
molestation to have occurred. In sum, I would characterize the Beginning Phase as emphasizing a focus on
development and maintenance of resources and coping skills especially affect tolerance and regulation
skills - more than on their sexual trauma per se.
Middle Phase Once a foundation of stability in their
life has been established to a sufficient degree and the
patient begins to trust me as an advocate of their safety
and security, the Middle Phase of treatment begins to
emerge. I would characterize this stage as involving
a continual working and reworking of core issues related to victim/non-protective caregiver/perpetrator
relational dynamics. During this longest phase of treatment, attention to accessing and affectively processing
traumatic memories occurs more prominently and
requires basic levels of affect tolerance and regulation
skills. I presume that continual building on these levels
occurs throughout therapy, and that the therapist needs
to remain attuned throughout the process to evidence
of any ruptures or weaknesses in these skills, such as
relapse behavior, fragmentation, increased dissociation,
suicidal gestures or threats to terminate treatment prematurely. I have found John Brieres (1996) concept of
a therapeutic window helpful in conceptualizing the
challenge for the therapist. He emphasizes the need for
therapists to practice interventions that foster growth,
desensitization and cognitive processing, but do not
retraumatize the patient or trigger countertherapeutic
avoidance responses. It is necessary to continually
monitor and titrate the pace and intensity of therapeutic interventions, not only over the course of sessions,
but even within a session. This issue of titration speaks
to both the art and science of psychotherapy in that
overshooting the window can result in a flooding and
overwhelming of the patients defenses if the pace is
too fast, or undershooting the window if interventions
by the therapist remain only on a supportive level.
The value of the psychoanalytic concepts of transference/countertransference cannot be overestimated
in providing treatment to AMAC patients, and help
explain what it is in the psychoanalytic approach that
powerfully produces abiding change in the patients
approach to life and relationships. I am defining trans-
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ference as a type of re-activation of relational, implicit

memories in the interpersonal context of the therapistpatient relationship (Briere, 1996). Prominent in the
transference dynamics of sexually abused patients,
is the activation of fear which occurs (as it originally
did) in a context of a longing for attention and closeness. It is essential for the therapist to stay attuned to
the patients sense of terror associated with how that
longing got played out with their perpetrator, so that
it can be interpreted. In addition, interpretations by
the therapist connecting the patients history to the
patients fears of the longing for closeness with the
therapist helps prevent the AMAC patient from fleeing
the treatment prematurely. In the countertransference,
some of my experiences include wishes not to hear the
painful details of the AMAC patients story, and feeling the fear involved in their violation.
The relatively longer-term nature of and increased
meeting schedule of psychoanalytic psychotherapy
and psychoanalysis (2-5 time/weekly) more adequately meets the need to work & rework deeply engrained
patterns of interacting that have taken years for patients
to develop prior to entering treatment. The relatively
more frequent opportunities provided by this psychoanalytic structure and framework for therapist and
patient permits the emergence of repetitive activation,
processing and resolution of emotional and cognitive
triggers in the transference/countertransference.
Psychodynamic psychotherapy and psychoanalysis
provide increased opportunities for patient and therapist to talk through what the therapist said (or didnt
say), did (or didnt do) that triggered the patients
anger, disappointment, anxiety, etc. This process helps
to decrease the patients characteristic dissociation/
avoidance, promotes affect tolerance and an increased
capacity to act assertively in their life outside the therapists office. Thus, they are able to more effectively get
their needs met in other relationships. The relational
intimacy that is fostered by the increased meeting
frequency is also well-suited for the essential working
through needed by AMAC patients to address their
crippling difficulties in being genuinely intimate with
and trusting of others in their relationships
End Phase I see this stage of treatment I see as emerging when both therapist and patient see significant improvement in the patients self-esteem and confidence,
and in the patients relatively more developed ability
to maintain stability in their life and genuine intimacy
in their relationships. End phase characterized by a
summarizing of progress made and a grieving of the

important relationship with the therapist, who has
helped create a therapeutically safe environment that
emphasized self-awareness, self-acceptance and respectful processing of their sexual abuse.
Even among psychoanalytic psychotherapists, a range
of theoretical and technical positions can be found,
from those emphasizing a primarily intrapsychic
focus (e.g. contemporary ego psychology/structural,
object relations viewpoints) to those stressing a more
relational or interpersonal focus (e.g. intersubjectivity,
self psychology models). It has been my experience
that a relatively effective psychoanalytic approach
involves the practice of a balancing between the inner
and outer worlds of the patient, and allowing for some
flexibility depending on the responses of the patient
to the therapists interventions. I have come to believe
that successful treatment with AMAC patients very
basically depends on the nature of the therapist BEING
consistently reliable, honest, caring and noon-abusing
in every aspect of their own character, which will be
communicated to the patient in both verbal and nonverbal ways.
References
Bernstein, A.E. (1989). Analysis of Two Adult Female
Patients Who Had Been Victims of Incest in Childhood. Journal of the American Academy of Psychoanalysis and Dynamic Psychiatry. 17: 207-221
Briere, J. (1996). Therapy for Adults Molested as
Children: Beyond Survival (Second Edition). New
York: Springer Publishing Company, Inc.
Siegel, D. (1999). The Developing Mind. New York:
The Guilford Press.
Williams, L.M. (1994). Recall of childhood trauma:
A prospective study of womens memories of child
sexual abuse. Journal of Consulting and Clinical
Psychology, 62, 1167-1176.
Williams, L.M. (1995). Recovered memories of
abuse in women with documented sexual victimization histories. Journal of Traumatic Stress, 8,
649-673.
Marti Peck, Ph.D. completed pre- and post-doctoral internships at the County of San Diego Child Sexual Abuse
Treatment Program. She is certified in Adult Psychoanalysis by the American Psychoanalytic Association, and is a
Senior Faculty Member at the San Diego Psychoanalytic
Society and Institute. Dr. Peck welcomes feedback on her
article and can be contacted at martipeck@san.rr.com.
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29
Book Review: Immigration and

Identity: Turmoil, Treatment, and
Transformation, (Salman Akhtar. Jason, Aronson Inc., New Jersey, 1999)
By Azmaira Maker
r. Akhtar beautifully captures the kaleidoscopic

nature of an immigrants identity in this rich and
enlightening book. He systematically walks the reader
through a multidimensional understanding of the
immigrants unique experience, a complex task buttressed by theory and garlanded with poetry. By initially exploring the historical and panoramic reasons
for individual migration, he enables us to join the migrant at the beginning of his/her journey. Simultaneously, he clearly demarcates a multitude of immigrant
experiences to prevent the pitfalls of stereotypy. Dr.
Akhtars work largely focuses on the voluntary migr
seeking richer pastures, (vs an exile or a refugee), but
he is careful to also lay the framework for other forms
of displacement and varying psychosocial factors that
impact the psyche.
Before plunging into the depths of the immigrants
hybrid and fluctuating identity, the author provides
a solid review of developmental theory to ground the
reader. Dr. Akhtar creates a context of development
across the lifespan which I think is a crucial, but underlying thrust of his book. His conceptualization of
four fluid tracks of identity transformation crystallizes
the migrants intrapsychic and interpersonal struggle.
Vibrant issues of loss, nostalgia, hope, ecstasy, love,
hate, sorrow, and suspension of space powerfully depict the emerging and perhaps conflicting identities of
the immigrant across time. His poetry, especially for
the reader who understands Urdu, strums our deepest
sense of longing and belonging.
Fortunately, the author does not betray multiculturalism and immigrants by formulating a specific conclusion for the metamorphosis within each developmental
track. Instead, he leaves us suspended as are many
of his immigrant patients and perhaps him in a creative and hyper-cultural mode of multiple realities and
existential angst. Simultaneously, he does not permit
30
premature interpretations based on a cultural defense

the analysand must be analyzed within and beyond
his/her migrant identity conflicts. Dr. Akhtar thus
treads delicately to maintain a balance between sociocultural roots and more traditional psychoanalyses
in his poignant clinical vignettes. His clinical material
and contributions from immigrant friends and professionals further illuminate the myriad of unspoken and
potentially disruptive issues unique to immigrants
that permeate transference, countertransference, defenses, and language. The author provides an invaluable sketch of technical interventions and insights to
navigate any clinician through the intimidating task of
working with this ever-growing population.
Towards the end, Dr. Akhtar ventures into unchartered
waters as he applies psychodynamic theory in the nontraditional venue of parent guidance with immigrants.
I applaud him for doing so and for providing other immigrant psychologists permission and a guide to bridge
our Western analytic training with our non-Western
personal selves, culture, philosophy, and families. Perhaps the goal for the non-Western immigrant is not a
pure individuation and separation process to achieve
a monoidentity under the strict rules of analysis. Instead, as Dr. Akhtar himself suggests, we are hybrids
with multiple buds and roots, shifting in the sands, as
waves of past, present, and future perhaps lull us into
harmony.
This article has been previously published: Maker, A. (2001). Book
Review: Immigration and Identity: Turmoil, Treatment, and Transformation, Salman Akhtar. Journal of International Migration Review, 35,
(2), 606.
Azmaira H. Maker, Ph.D. has a private practice in Del

Mar/Carmel Valley, and she works with adults, adolescents, children, and families. Her clinical work and research focus on trauma and loss. She trained at the University of Michigan, Ann Arbor in adult psychodynamic
psychotherapy, and in child and family systems therapy.
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committee corner
rich variety of perspective embodied by local clinicians. Whether you are able to attend the event or not,
please consider donating money for students to join
this special evening.
Mens Issues
Committee: The
Odyssey Series 2009
By Mickey Suozzo, Ph.D.,
MIC Member
he concept for the Odyssey series arose from the

vision of Paul Pinegar. He wanted to celebrate and
acknowledge outstanding psychologists, individuals
who combine remarkable contributions to the field,
great character, and a special capacity to inspire others. The evening provides a venue for psychologists to
spend meaningful time together, to honor mentors, and
to share the personal stories of influential clinicians.
The Odyssey series has honored eight distinguished
psychologists since its initial event in March of 1996:
Erv and Miriam Polster, Tom McGee, Jim Chipps, Beverly Kilman, and Antonia and Julian Meltzoff, and Jon
Nachison. This year Odyssey will honor Hugh Pates.
The SDPA Mens Issues Committee has embraced the
concept of the Odyssey series because it is satisfying
on so many levels. An ongoing recognition carries a
rich sense of ritual that honors the recipient, the field,
and the deep meaning provided through performing
clinical work. By acknowledging the accomplishments
of the recipient, clinicians share their bond of psychology and enjoy the companionship of peers. In past programs, honorees shared warm, humorous, and serious
stories that placed their substantial professional accomplishments in a personal context. These programs
provide the opportunity for important bonds within
the local psychological community: students experience the personal stories of important psychologists,
established clinicians renew old friendships, and the
whole community honors wonderful people who have
given so much to the profession. In a very unique way,
the Odyssey invites local psychology students into the
community of local psychologists; by providing access
to generations of local clinicians, the event encourages
students to experience (in a very personal way) the
Because of my involvement on the Supervision Committee and Mens Issues Committee, Ive had the opportunity to get to know two of the past recipients,
Erv Polster and Jon Nachison. Both are amazing individuals; Ive felt really honored to get to know them
personally as I marvel at the wonderful things they
have given to psychology. I was curious about their
sense of the Odyssey I know what its like to attend,
but whats it like to be someone so admired by a large
body of peers?
Jon Nachison described his experience in the following
way: The Odyssey was an amazing adventure experienced with my family, friends, colleagues and students. It was an opportunity to debrief and explore the
meaning and motivation behind my lifes work and to
share more of my private self. I prepared by reviewing
my journey as a psychologist and constructing some
slides to guide my talk. But something else happened
during the event. It became a shared odyssey with the
audience, and my personal experience was that the
validation of peers is reciprocated by the speaker. I remember being struck by how lucky Ive been to be part
of this wonderful community and how the work we
all do is truly interdependent. The Odyssey series was
both affirming and humbling, a special moment in my
life that I try to live up to and will always remember.
Erv Polster also focused on the connection that binds
psychotherapists to each other: It has been a long time
since that Odyssey evening but I do still remember a
strangely familiar feeling of coming home. I have always loved coming home but it does seem odd to feel
like I was coming home when San Diego had already
been my home for 20 some years. But I had come here
fairly late in my life and it was my second home. I had
gone about my business here happily and loved many
people whom I had met and whom I had worked with.
But, not being very organizationally minded, I had
never felt as much rooted in the community of psy-
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31
chologists here as I felt that night. It was a pleasure

telling stories you would tell to a friend and being
incorporated into the community, the reverse of an
initiation rite, where I was completing what initiation
only begins.
The event heightened my professional reality as it
concretized and amplified what otherwise was a more
misty sense of contribution. There was, of course, some
measure of egoistic pleasure, the kind school children
get when they are called to show and tell, which kids
in my day never did. But I think the event went further
than my own pleasure. I think that such a celebration,
designating individual people, also serves as a celebration of the community itself, creating the opportunity to
feature particular people as temporary representatives
of us all, joined together in a common enterprise. For
me there was yet another and special high, enjoying
this role jointly with Miriam, a familiar bonding with
her, which I cherish even now. We did so much of our
professional work together, almost as though we were
one person. People thought of us as Erv and Miriam;
sometimes, even as Merv and Iriam.
The economy and its impact on individuals, clients,
and the field have taken their toll the last year or so.
SDPA has certainly been deeply affected. The Odyssey permits a time to refocus, a time to celebrate the
profound meaning psychology offers in todays world.
The Mens Issues Committee urges interested SDPA
members to save the date of Sunday, November 8, 2009
come share the common bond of psychology with
the Mens Issues Committee and all our friends. The
Sheraton in La Jolla remains the venue; please join us
in a special evening honoring Hugh Pates.
Early Career
Psychologists
Committee
By Lauren Woolly, M.A.
he Early Career Professional Committee (ECP)

is steadily growing and continuing to generate
programming and services to meet the needs of ECPs.
In June, Lindsey Alper, Ph.D. joined our meeting and
shared great strategies for building a successful private
practice. Many new ECPs attended this meeting. We
enjoyed meeting them and were glad many expressed
32
an interest in joining our committee. The ECP committee hopes to schedule several meet and greet events in
the upcoming months in order to widen and strengthen
ECPs professional networks. Please check the SDPA
events calendar for upcoming meet and greet events.
We hope that both ECPs and seasoned members of
SDPA will join us. We encourage ECPs to join our
upcoming meetings. Marc Murphy, Ph.D. will join
our meeting on September 12th to discuss supervision
issues, and Mary Herb-Sheets, Ph.D. will present on
private practice ethical issues during our November
14th meeting. These meetings will be held from 1:303:00 p.m. at the SDPA office. We look forward to seeing
you there!
BOP Representative
Quarterly Report
By Hugh Pates Ph.D.
Hughpates@yahoo.com
n May 8-9 I represented SDPA at the Board of

Psychology quarterly meeting held in Manhattan
Beach, CA. Linda Charles Ph.D., who has been our
very able and competent representative for the past
few years, has taken on new responsibilities and will
no longer be able to devote time to these meetings.
At the meeting, significant discussion took place
around a variety of topics.
I - CEs. The Board has proposed moving to an auditing system whereby psychologists would keep track of
their own 36 CE units over the two year time period.
There would be no reporting of these units. Each year
10% of psychologists would be audited to check their
compliance with the current mandate. LCSWs and
MFTs already have this system in place.
II - Supervsion. There is a proposal to develop a pool
of practicioners around the state who would serve as
supervisors for psychologists on probation due to an
ethics violation. If you are interested in such a postion,
just contact the Board.
III - Examination. During the past year 70% of psychologists sitting for the licensure exam passed the first
time they took the test. 75% of those taking the exam
for the second or more times also passed. Pass rates for
all graduate programs are posted on the Boards web
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site.
IV - Discipline. The most reported violations of the
ethics code were for unstable dual relationhips and
practicing outside ones expertise.
V - Retirees. Currently, there is only two catagories
of licensure - Active and non Active. A third category
Retired is being proposed that would allow retired
psychologists the opportunity to do pro bono work
and still be licensed. There would be adjustments to the
cost of renewing the license and the CEUs required to
continue practice.
VI - Child Custody. There is a strong desire to collaborate with the courts in order to get some form of
acceptable regulations for reports and decisions by
psychologists that would be acceptable to the courts
and lawyers in child custody disputes.
VII - Boards Future. An overarching concern during
the meeting was the future of the Board itself. Currently, the sunsetting of the Board is off the table until
2011. However, there is some trepidation about the
future of the Board depending upon the outcome of
the May 19th proposition ballot and the Governors
decision about budget cuts after this election.
VIII-

Disaster Response
Committee: When a
Loved One is in the
Midst of Danger
By Roberta S. Flynn, Psy.D., Chair
n May 28, 2009 I was visiting my older brother
and his wife in Albuquerque, New Mexico. My
sister-in-laws niece, Caroline, teaches on Roatan, an
island located off the Caribbean side of Honduras.
Caroline had contacted her mother to inform her she
had been caught in a 7.1 magnitude earthquake with
an epicenter near the islands of Roatan and Utila. The
quake was strongly felt in El Salvador, Guatemala and
northern Nicaragua, as well as Honduras. Caroline
2004 tsunami in the Indian Ocean Islands can be in extreme danger after earthquakes originate in the ocean.
The wave that begins as little more than a ripple gains
height and strength as it travels. The end result may
be a wall of water such as the December 26, 2004 9.3
tsunami that caused such widely spread death and destruction in Thailand, Sri Lanka, Indonesia and India
after a 9.3 magnitude earthquake. It released energy
equivalent to 23,000 Hiroshima-type atomic bombs according to the U.S. Geological Survey (USGS).
The 2004 tsunami traveled 3,000 miles to Africa, and
arrived with sufficient force to kill people and destroy
property. A tsunami may be less than a foot in height on
the surface of the open ocean, but it travels through the
ocean at hundreds of miles per hour. Once it reaches
shallow water near the coast it is slowed down. Since
the top of the wave moves faster than the bottom, the
sea rises dramatically. This tsunami caused waves as
high as 50 feet in some places. It destroyed thousands
of miles of coastline and even permanently submerged
entire islands.
At the end of that day, millions of people were struggling with the reality of tens of thousands of dead or
missing relatives, destroyed homes, and shattered
lives. Thousands of corpses started to rot in the tropical
heat. Since there was no food or clean water and many
people with open wounds, the risk of famine and
epidemic diseases was high. Health authorities feared
the death toll might reach 300,000. The U.S. Geological Survey initially recorded the death toll as 283,100
killed, 14,100 missing, and 1,126,900 people displaced.
However, analysis compiled by the United Nations
listed a total of 229,866 people lost, including 186,983
dead and 42,883 missing.
Contact information.
Board of Psychology
2005 Evergreen St. # 1400
Sacramento, CA. 95815 - 3894
916 - 263 - 2699
www.psychboard.ca.gov
was safe, house sitting in an elevated area of the island.

Roatan was under a tsunami watch at the time. The
watch was later cancelled.
In 1964, on Good Friday, a 9.2 earthquake and tsunami

hit Prince William Sound, Alaska. Not many lives
were lost in that one. However, on July 27, 1976 a 7.5
magnitude earthquake in Tangshan, China resulted in
an official death count of 255,000 with estimated death
counts as high as 655,000. The National Oceanic and
Atmospheric Administration (NOAA) through the
center for tsunami research now monitors two tsunami warning systems in the Pacific Ocean; the West
Coast/Alaska Tsunami Warning Center and the Pacific
Tsunami Warning Center. Unfortunately no warnings
were given after the earthquake that initiated the 2004
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33
tsunami.
First reactions
My first reaction to Carolines situation was, Thank
goodness shes on high ground. Caroline had been
able to contact her roommate at a lower elevation and
learned that people were pouring out onto the streets.
Great, as long as they headed to higher elevations, because of the tsunami watch.
What can we do in situations like this?
What could Carolines mother or aunt (my sister-inlaw) do to help Caroline? Well, nothing physically.
When a loved one is in the midst of danger, if you are
thousands of miles away, you obviously cant physically carry them out of the danger zone or even give
them a hug them to provide reassurance. Nonetheless,
there is a lot you can do emotionally and psychologically.
Emotional and psychological support
Our emotional support for someone in a dangerous
situation can go a long way towards keeping them
calm and able to function. We can also provide them
with a psychological edge. With the speed of todays
media we may already have useful information they
are unable to get at their location. If power has been
disrupted, we may provide some relief by giving them
updates on the scope and seriousness of the disaster
and possibly some recommendations the local authorities are trying to disperse. It is hard to get accurate
details at the epicenter of the disaster.
Sometimes just knowing we are thinking of them,
pulling for them and praying for them provides some
measure of psychological support. They can draw
upon this support to do whatever it is they need to do
to survive.
Perhaps we have taught them, modeled for them or nurtured in them a sense of resiliency and self-sufficiency.
These are helpful traits in dangerous situations.
So, our loved one is in danger and we are miles away;
maybe even thousands of miles away. What can prepare
us for this? Quite a lot can, actually - mental rehearsal,
having a plan, preparation and practice.
Mental rehearsal
Just as we need to engage in what ifs for our own
protection, such as, What if a client threatened me?
or What if a client hit me? or what if Im involved in a
traffic accident on the way home? or What if a loved
one suffers a heart attack and Im the only one around?
34
What does mental rehearsal do to prepare us for disasters, whether personal or widespread? By mentally
rehearsing what we would do if something happened,
we learn our weak spots, realize areas in which we are
not fully prepared and can make some decisions about
how we should act in certain situations. The military,
police, fire and other first responders train with mental
rehearsals before practical exercises. It is much safer to
have police officers practice in a simulated setting than
to initially use live ammunition.
For instance, I know if someone tried to kidnap me in
a parking lot, my least chance for survival would be
if I was forced into a vehicle and driven away from
populated areas. Ive studied car-jacking kidnap cases
and formulated plans of action. Part of my major plans
are related to not putting myself into situations where
I could become a victim.
Remember the What if a loved one suffers a heart
attack and I am the only one around? Do you know
how to perform cardiopulmonary resuscitation (CPR)?
Can you recognize the signs and symptoms of a heart
attack? How about the symptoms of stroke? Would
you know what to do if someone was choking? This
leads us to the next part of being able to help someone
in danger.
Planning
Do you have a plan? Bet youve heard that one before.
A good planning brochure utilizing information from
several organizations is available at meetings of the
Disaster Response Committee or through the American Red Cross. There are guidelines about developing
an emergency contact policy for you and your family/
loved ones. As mentioned above, there is often an interruption of communication services during/after a
disaster. You need to designate a contact person out of
the area; for instance, Aunt Mary in Chicago. Everyone involved in the disaster then calls Aunt Mary to
let her know they are safe and to leave messages for
others. Be sure to choose a secondary contact person
in case Aunt Mary is not available. Pick your contact
person carefully. If Aunt Mary is 95 years old and hard
of hearing, shes not a good choice for the designated
contact person. Now that you have a viable plan in
place, whats next?
Preperation
Now is the time to start preparations to enact your plan.
That just means getting all of the supplies you might
need. If you have done some of this preparation with
your loved ones, they will also have a sense of how
WWW.SDPSYCH.ORG
to become prepared. This preparation will be helpful

if they find themselves in a critical incident. We will
discuss how to determine what is necessary for you
and your loved ones at a later time.
The important thing is to remember that a great list
wont help much unless you have also gathered the
items on your list. Later is too late in a disaster! How
can you practice the plan?
Practice
Are you young enough to remember all the hours we
accumulated towards getting our license? I may not be
young enough but I still have some vivid memories of
all the places I worked to get the hours. That was practicing under supervision. I had some wonderful supervisors and really enjoyed many aspects of the process.
The manner in which we practice anything whether
it is driving or running a marathon is often the way
in which we perform the task at a later time. Disaster
response is the same. In addition to learning about
disasters, engaging in mental rehearsals, planning and
preparation, we still need to practice in disaster drills.
That is why some drills are mandated by law, such as
fire drills in schools. I have talked to many clients in
high rises that say they have never had a drill at their
location. That may or may not be true. They may have
missed a drill. If I worked in a high rise (above one
story), I would want to know what the disaster plans
were, are exits posted, necessary doors kept unlocked
for escape from the inside and probably several hundred additional questions. The same goes for one story
buildings.)
We can do a lot to assist our loved ones when they are
in the midst of danger. Perhaps the best thing we can
do for our loved ones is acquire training in several
areas related to disaster response. Then show by example that we are as ready as we can be for the disasters we are most likely to experience in our area. As it
turned out, Caroline, my sister-in-laws niece was safe.
Although there was a death toll of 6 persons, there was
not the wide-spread damage and death tolls that have
occurred with other 7.1 magnitude earthquakes.
and still be licensed. There would be adjustments to the
cost of renewing the license and the CEUs required to
continue practice.
San Diego Psychological

Association Welcomes Its
Newest Members
Full Members
Adrianne Ahern-Grundland Ph.D.
Shetal Patel, Ph.D.
Christina Wierenga, Ph.D.
Milton Brown, Ph.D.
Debra Kawahara, Ph.D.
Ramona Szczerba, Ph.D.
Pamela Toll, Ph.D.
Early Career
Delia Silva, Psy D
Bridget Ross, Psy.D.
Johanna Warchola, Ph.D.
Alicia Carpenter, Psy.D.
Kathleen Mc Chesney, Psy.D
Saurabh Gupta, Ph.D.
Student Members
Nancy Arzate
Latoya Brogdon, M.A.
Jason Bres
Jessica Buss
Raphaella Croccia, MFT-T
Jesse Little
Devon MacDermott
Leah Livesey
Emily Meier
Terese Skarra
Asal Azizi
Michelle Bailey
Janelle Anderson
Michael Irvin
Hannah Miller
Jenelle Anderson
Susan Orgera
Michelle Wright
Affiliate Member
Carole Meredith, MFT
WWW.SDPSYCH.ORG
35
CALENDAR OF EVENTS
Friday, August 21, 2009
Saturday October, 24,2009
Meet & Greet With Assemblymember Marty Block

Hosted by the SDPA Government Affairs Committee
Counseling Fathers
Presented by: Chen Z. Oren, Ph.D., &

Dora Chase Oren, Ph.D.
Time:
Place:

5:30 pm - 7:00 pm
Home of Mr. Howard Ernst &
Dr. Sallie Hildebrandt
4401 Braeburn Road
San Diego, CA 92116
Saturday August 22, 2009

Skills and Strategies to Improve Attention
Presented by: Dr. Lucy Jo Palladino
Time:
9:00 am 11:00 am
Place:

SDPA
4699 Murphy Canyon Road
San Diego, CA 92123
Cost:

Members:
$31
Non Members:
$43
Students:
$10

Student Non Members $15
2 CE Approval # Pending
Register online at www.sdpsych.org/calendar.cfm
Time:
1:00 pm 4:00 pm
Place:

SDPA
4699 Murphy Canyon Road
San Diego, CA 92123
Cost:

Members:
$43
Non Members:
$61
Students:
$15

3 CE Approval # Pending
Saturday October 31 ,2009
8- Hour Update Training for Custody Evaluators required
workshop - Lunch Included
Presented by: Neil Ribner, Ph.D. &

Russell Gold, Ph.D.
Time:
8:30 am 4:30 pm
Place:

Alliant University
10455 Pomerado Road
San Diego, CA 92123
Cost:
Members:
$103

Non Members:
$151

Students:
$40

8 CE Approval 09-1001-000
BOP Survey: Psychology to Improve Its Services to Psychologists

Progress Notes and your Editor are collaborating with the California Board of Psychology to help the Board
to improve its services to licensees and registrants.
If you have had contact with the Board, your Editor is encouraging you to fill out the survey to provide
feedback to the Board about the quality of the service you received from the Board. No psychologist who
responds to the survey will be linked to the survey that was submitted. In other words, any matter that an
applicant has before the Board will not be affected by completing the survey.
If you know of a colleague who has had a contact with the Board, please forward this message to your
colleague and encourage a response to the survey.
If California psychologists do not respond to this effort by the Board of Psychology to improve its services,
the Board will not have the best information it needs to raise the quality of its services.
The link to the survey is: https://app.dca.ca.gov/psychboard/licensing_survey.asp
36
WWW.SDPSYCH.ORG
group therapy directory

MIXED GROUPS
GROUP:
is now offering a 10-week CBT group for
Informational/educational meetings for
anyone looking to lose weight or maintain
adults with Attention Deficit Hyperactivity
weight loss. A terrific adjunct to individual
Disorder (ADHD/ADD). Mondays 6:30 to
therapy, groups are held every Monday
8:00 pm Call 619.276.6912 or check website
and Wednesday for 90 minutes and cost
www.learningdevelopmentservices.com
only $40 per session. For more information
for upcoming topics and to reserve a spot.
or to enroll, please contact Jill Stoddard,
Mark Katz, Ph.D. (PSY 4866), Learning
Ph.D. (PSY 21852) at 858.354.4077 or visit
ADULT CHILD SEXUAL ABUSE SURVI-
Development Services, 3754 Clairemont
us online at www.thinkthintobethin.com.
VORS GROUP: The group now forming is
Drive, San Diego, CA 92117.
ADDICTIVE
ADHD
BEHAVIOR
CHANGE
GROUP: Self-empowering (non-12-step)

approach,
multiple
groups
available
per week, $35 per group, paid by the

month. Tom Horvath, Ph.D. (PSY 7732),
858.453.4777 x 222.
open to women who are in recovery from

child sexual abuse in the family. This will
be a trauma-focused group, structured to
address topics including trust, self esteem,
sexuality and relationships.
Prospective
members should be in individual therapy

and well enough along in their healing to
be able to tolerate discussion of specifics
of abuse in group. This group will meet
on Monday evenings for 90 minutes in
ADULT
CAREER
SUPPORT
COGNITIVE BEHAVIORAL THERAPY
CONSULTATION
AND
FOR PERMANENT WEIGHT LOSS.
COACHING: Let me help your clients,
Group and individual therapy based on
friends, or family navigate career-related
the Beck Diet Solution. Clients will learn
issues such as career identification, career
to manage sabotaging thoughts and build
transition, job search, difficult job situa-
skills for long-term success. Contact Leslie
tions. Comprehensive approach, including
Miller, Ph.D. (PSY 16797) 858.414.9332 or
assessments as indicated. Contact Jacque-
drlsmiller@sbcglobal.net. Carmel Valley
line Butler Ph.D. (CA PSY 19513) jbphd@
and La Jolla.
aol.com 619.644.5750.
COUPLE THERAPY WORKSHOP: Bridg-
North Coastal San Diego County and will
CHRONIC PAIN: Migraines, fibromyalgia,
es for Healing: Personality Dimensions, the
require a 6-month commitment to attend.
and back pain are quite common and can be
Social Brain, and Couples Therapy. Led by
Contact Dr. Tania Davidson (PSY 16510) at
managed through psychotherapy. Learn
Roy Resnikoff, M.D. with live guest couples
760.729.5900 or drtaniadavidson@aol.com
techniques to reduce pain, depression and
consultation by Erving Poster, Ph.D. In La
for information and referral.
anxiety. Explore how existing coping skills
Jolla, Saturday, November 7, 2009, 9:00 A.M.
and schemas may be exacerbating pain and
5:00 P.M., $145.00 ($110 if attending as a
why it is so difficult to heal.
couple). 858.454.1650. Fax 858.454.0692. CE
Dawn S. Dilley, Ph.D. (PSY 21452), in Hill-
available for Ph.D.s, MFTs, Social Work-
crest: 619.255.7001 www.sdpaincenter.com
ers, and Nurses. License (G23495)
ADULT
GROUP
PSYCHOTHERAPY:
Ongoing, mixed, weekly process group.

Wednesdays 4-5:30. UTC/La Jolla location.
Cognitive-behavioral/psychodynamic.
$140 per month; Thomas Wegman, Ph.D.
COGNITIVE THERAPY GROUPS: Cog-
GRIEF SUPPORT GROUPS: Two new
(PSY 4228) 858.455.5252. 9255 Towne Cen-
nitive-behavioral treatment groups for: 1)
closed support groups for those who are
tre Drive, Suite 875, SD 92121.
Social Phobia/ Shyness, 2) Depression, 3)
grieving. One will be held on Wednesdays
Panic Disorder, 4) Permanent Weight Loss.
at 6:00 pm and the other on Mondays at
Education, skill building, experimental
12:00 noon. Each are 1 hours long and
exercises, cognitive restructuring, support
cost $25 per session. Each will be held
www.cognitivetherapysandiego.com Cog-
for 6 weeks. I do accept Tricare/Triwest,
nitive Therapy Institute, Inc., La Jolla. James
Medicare, Aetna, Schaller Anderson, Corp
Shenk, Ph.D. (PSY 11550) 858.450.1101.
Health, and any PPO insurance that cov-
ADULT
GROUP
PSYCHOTHERAPY:
Self-psychological/modern analytic process oriented groups available for selected

high functioning adults.
This approach
emphasizes the exploration of both current

and past relationships to self and others as
the primary vehicle for therapeutic change.
COGNITIVE
Contact Gil Spielberg, Ph.D., Fellow, Amer.
FOR WEIGHT LOSS AND WEIGHT
Group Psychotherapy Assoc. (PSY 6517) at
MANAGEMENT: The Center for Stress
858.456.2204.
& Anxiety Management in Mission Valley
BEHAVIOR
THERAPY
(www.anxietytherapysandiego.com)
WWW.SDPSYCH.ORG
ers groups.
Enrollment is limited to 8
participants per group and groups will

not begin until the maximum participant
number is met. For more information, contact Dr. Christina Zampitella, Psy.D. (PSY
20878) at doczamp@hotmail.com or call
37
858.268.9800.
information: 858.717.4200.
hood, divorce, anger, etc). The group meets
www.integrativepsychservices.com
PLAY
THERAPY
FOR
every other Wednesday for 90 minutes,

and perspective members are encouraged
CHILDREN:
to commit to attending for at least 6 con-
Evidence-based treatment for children
secutive months. For more information,
who struggle with a range of presenting
contact Danny Singley, Ph.D. (PSY 20995)
problems. Contact Oded R. Shezifi, Psy.D.,
at
RPT-S (PSY 21162). Registered Play Therapist Supervisor (S-941). 858.551.0518

www.shezifi.org
MARRIAGE
MENS LIFE TRANSITIONS SUPPORT GROUP - Mens group has some
meeting the right mate, and building
openings for men in mid-life (40s & 50s).
a healthy relationship. Proven method
Focus of the group will be navigating life
includes book, 8 sessions, and support
transitions: marital separation and divorce,
group. Great adjunct to psychotherapy and
loss of employment/ changes in financial
for psychotherapists, as well. www.how-
security, physical health issues, parent-
toimproveyourlife.com 2 sessions/month;
hood, death of family member, moving,
call for more information. Ginger Lipman
etc.. Group will address mens identity
Wishner, LMFT (MFC 19582) 858.454.8993
issues in these uncertain times. Good ad-
FOR
LOVE/
SOCIAL SKILLS GROUP FOR CHILDREN ages 6 -10 offered in Kearny Mesa
area beginning Oct 4th on Saturdays 10
-11:30 am. Group foci include social problem-solving, coping in social situations,
junct to individual or couples therapy.

Group meets the 1st and 3rd Tuesday of the
MALE SURVIVOR GROUP: This mens
Group also provides an opportunity for
adult males who have a history of abuse
the children to make friends and have fun!
and wish to participate in an ongoing sup-
Please call Kristen Bonwell, M.A., (PSB
port and psychotherapy group experience.
33490) (Supervised by Leslie Hovsepian,
This group is appropriate for men who are
PhD, (PSY 21538) ) at 858.277.6500.
already in individual therapy, in recovery
DREN WITH HIGH FUNCTIONING

AUTISM & ASPERGERS SYNDROME
Groups focus on: Social
language, conversation skills, empathy,

theory of mind, social reciprocity, social
awareness, negotiation, and understanding
from addictions/compulsions, are nonoffenders and currently not in crisis. The

group meets two Mondays monthly a minimum of one year commitment requested.
For a no charge screening interview please
call Paul R. Sussman, Ph.D. (PSY 13876) at
619.542.1335.
YOUNG-ISH MENS GROUP:
Please contact: Dr. Sandy Shaw (PSY 18351)
group is open to generally high-functioning
at 858.657.9117 or sshaw2@earthlink.net
adult men from 20-40 ish years old who are
and women in transition from separation.

divorce or loss of significant relationship.
Mondays 6 to 7:30 PM. Maryanne Cordahl
(PhD License # 21025) $50 per session. For
POSE a psychotherapy group for women

in transition from separation and divorce
or loss of significant relationship. Mondays
12:30 to 2 PM. $50 per session. Maryanne
Cordahl, PhD (PSY 21025). For Information: 858.717.4200.
interested in an ongoing therapy group. An

ideal adjunct to individual therapy, group
topics address interpersonal concerns with
a focus on mens issues (work-life balance,
stress management, relationships, father-
WWW.SDPSYCH.ORG
OTHER GROUPS
THERAPY GROUP FOR PARENTS OF
CHILDREN WITH SPECIAL NEEDS: In
the La Jolla area. Forming a group for parents to meet weekly. The group focuses on
dealing with issues related to their childs
diagnosis, coping strategies, education,
effects on the family (including sibling issues), and working with the school district.
Contact Sharon Lerner-Baron, Ph.D. (PSY
15644), 3252 Holiday Court #225 La Jolla.
Please call for information 858.457.4585.
This
inferences. Low cost, fun and educational.
MIXED ADULT GROUP forming for men
HEAL YOUR HEART: FIND NEW PUR-
to set up a 30 min. interview.
group is specifically for higher functioning
SOCIAL SKILLS GROUP FOR CHIL-
WOMENS GROUPS
Jeff Jones, Ph.D. (PSY 11466) at 858.793.4660
tive character traits/being a good friend.
38
singley@cognitive-
month from 7 -9 pm in Solana Beach. Call
socialization training, and discussing posi-
ages 3 to 18.
or
MENS GROUPS
GROUP: Learn the how tos of dating,
READY
858.380.4636
health.com
NON-THERAPY SERVICES
SOCIAL SKILLS GROUPS + PRIVATE
COMMUNICATION SKILLS SESSIONS
FOR ADULTS - MAKING CONVERSATION - Teens Ages 12-18. Three 2 hour ses-
sions: interactive practice; Empathy; DiSC
AEE5-
DF9C606B5D5/0/07Residential
858.481.8827 or at www.helprofessionals.
Communication Style; Making Conversa-
Survey.pdf for the resident satisfaction
com for application information. Annette
tion and Positive Attitude. INTERVIEW
survey. Dr. Holden 760.746.5857, send C.V.
Conway, Psy.D. (PSY 19997).
PREPARATION (Teens and Adults) and
to matth@nhcare.org, for job info go to
PRIVATE SESSIONS Adults with com-
www.nhcare.org
munication challenges). Audio and/or

Video-taped Sessions. Peggy Wallace, JD
760.803.2641
CLINICAL PSYCHOLOGISTS: The Dialectical Behavior Therapy Center of San Diego is seeking to hire clinical psychologists
www.makingconversation.com
who have received prior training in DBT or

ACT. At a minimum, solid training in CBT
and behavioral interventions is required.
Additional staff therapists are needed to
provide DBT for adults and adolescents.
License-eligible applicants will be given serious consideration. For more information
ANNOUNCEMENTS
OPPORTUNITIES
LICENSED PSYCHOLOGIST/LCSW: for
outpatient community clinic in central San
Diego. Flexible part-time to full-time with
excellent salary, benefits, and retirement
match. Immediate availability. High quality mental health team. Bilingual (Spanish)
preferred. Experience with children is necessary. Please fax vita to Kendra Weissbein,
Ph.D. at 858.279.0377.
TANT - I am seeking a position as a psychological assistant in San Diego County.

I have experience working with children
and adults and speak Spanish at a highintermediate level. I am available to work
starting in mid August. I will be graduating with my PsyD in Clinical Psychology
in July. Please contact me at mdetsch1@
yahoo.com # 619.370.1381. Thank you.
LICENSED
BILINGUAL
PSYCHO-
THERAPIST: Want to live close to work?

Consider relocating to beautiful Temecula
in Riverside County where property prices
are low, there are excellent schools, low
crime, and a small-town feel.
Go to
http://www.temecula.org/community.
html for a description of life in Temecula
and
http://www.cityoftemecula.org/
NR/rdonlyres/4329F560-402A-4A2C-
PSYCHOLOGICAL ASSISTANT POSITION: I am seeking a position as a psychological assistant in San Diego County.
I have experience working with children
and adults and speak Spanish at a highintermediate level. I am available to work
starting in mid August. I will be graduating with my PsyD in Clinical Psychology
in July. Please contact me at mdetsch1@
yahoo.com or # 619.370.1381 . Thank you.
or to submit an application, go to: www.
PART-TIME PSYCH ASSISTANTSHIP:
dbtsandiego.com
4th-year doctoral candidate at CSPP with
PSYCHOTHERAPY FOR GRADUATE

STUDENTS: Reasonable rates for students who need to meet their programs
psychotherapy requirements. Extensive
experience as therapist and supervisor
with graduate students. Editor of Humanistic Psychotherapies. Offices in Carlsbad
& San Marcos. Call David J. Cain, Ph.D.,
ABPP (PSY 6654). Free phone consultation
at: 760.510.9520.
SEEKING PSYCHOLOGICAL ASSIS-
LOOKING FOR:
competency spanning from crisis and

hospital settings (chronic pain/cancer at
UCSD), to long- term community health
care practice (more like private practice).
I have an interest in Mindfulness but use
an integrative approach tailored to each
patients level of change. I am very selfmotivated and am actively involved in the
psychological community at large. E-mail
or call for a CV, Jessica Evers Killebrew at
jbkbrew@gmail.com or 858. 353.8083. I am
PSYCHOLOGIST/SUPERVISOR:
The
Bayview/Paradise Valley Hospital Psychology Internship Program is seeking

a licensed psychologist to provide indi-
prepared to start immediately and can help

with the process!
OFFICE SPACE AVAILABLE
vidual/group supervision and training in
BANKERS HILL: Spanish style, one-
psychological testing. This part-time posi-
story building. Attractive, shared waiting
tion is for 7 hrs/wk and includes Monday
room/reception, courtyard. Full-time and
mornings. Please send resume and brief
per day office rental available. Cindy @
statement of interest to Jon Nachison, PhD,
619.785.5949.
ABPP at nachison@cox.net.
BANKERS HILL: Office space for rent in
HELP (Home-based Effective Living Pro-
a small psychological practice located in
fessionals) is recruiting licensed psychologists and social workers as independent

contractors interested in providing clinical
services to persons in their homes or care
facilities throughout San Diego County.
Medicare and bilingual providers are a
plus. Full or part time, flexible hours, 80%
reimbursement paid.
Contact HELP at
WWW.SDPSYCH.ORG
Bankers Hill. Flexible and part time hours

are available. The office unit is attractive
and centrally located, featuring a waiting
room, restroom, wireless internet, a fax and
copy machine, and a kitchen. Available now.
Please email or call Dr. Reyes at DrReyes@
psychsandiego.org or 858.361.1989.

39
CARDIFF BY THE SEA: Spacious office
services, file storage space, staff bathroom
parking. Contact Tom Hollander, Ph.D. at
with large ocean view window available
& kitchenette, clerical room w/fax & copy
858.755.5826.
full or part-time. Quiet and peaceful atmo-
machine. Well maintained building with
sphere in professional building with good
pharmacy and ample free parking. Office
soundproofing. Handicap access. Desir-
available Tuesday afternoons, and all day
able location near I-5, Highway 101 and
Wednesdays and Fridays. $824/month for
beach, across from Cardiff Town Center
2.5 days/week, $445/month for 1.5 days/
(Starbucks, Seaside Market). Contact Dr.
week, and $340 for 1 day/week. Please con-
Karen Helrich at 760.943.8686 or Khelrich@
tact Jody Saltzman, Ph.D. at 858.775.6364
aol.com.
or at jodypaige@sbcglobal.net.
CARLSBAD: Full or part time, furnished
CARMEL VALLEY: Part-time furnished
with nice waiting room in 4 office suite.
office available for sublease at the beauti-
Directly adjacent to I-5. $175/mo for 1 day
ful Hacienda Building. Rent 1, 2, or 3 days
per week. Dr. Woodburn 760.434.2242.
per week, flexible days. Newly renovated,
CARLSBAD: Office space for rent. Immediate availability. Full or part time, in an
established office with handicapped access
and WIFI connections.
Fully furnished,
kitchen space, ample free parking, internet

connection. One year lease. Contact: Deborah Pontillo, Ph.D. 858.692.4187 drpontillo@sdkidsfirst.com.
frigerator. Includes parking, utilities and
office.
janitorial service. Most days of the week
Contact Dr. Richard Sobel 858.467.0170
Ph.D. 760.729.6009.
available Monday, Tuesday and Wednesdays in a natural, garden setting located

in the heart of the village of Del Mar walking distance to the ocean. This is a unique,
enjoyable, casual environment to practice
sionals. Call 858.922.0732 for more details.
DEL MAR: Office on Carmel Valley Rd
across from the lagoon.
Beautiful, large,
newly renovated office available part

or full time, furnished or unfurnished.
Supportive environment with colleague
consultation welcomed, in a great location
with very reasonable rent. Contact drd-
CLAIREMONT: Ocean view, decorated
negotiable. Contact: John B. Mansdorfer,
Large spacious, fully furnished rustic office
among a diverse group of business profes-
private kitchen area, microwave and re-
are available either all day or half day. Rent
DEL MAR: Professional Office Rental.
Available Friday and Saturdays.
sweetland@aol.com or call 858.382.1137.

EL CAJON: Professional office space available in recently renovated and upgraded
CLAIREMONT: Therapy office available
El Cajon community mental health center.
for sublet. Professional Building at 5252
$200/month for one day/week, significant
Balboa Ave (corner of Genesee).
Large
discounts for multiple days. Professional
CARMEL VALLEY/DEL MAR: Turnkey
tastefully furnished office and waiting
Community Services (PCS) has openings
Established Mental Health office in medi-
room, 228 sq. ft. Plenty of sunlight, quiet
for full-time or part-time office space. Full
cal building. 275 sq ft office within 1900 sq
floor, refrigerator and microwave, copier,
office services offered, including furnished
ft suite. Attractive 3-story medical build-
internet service. Central location near the
office, office supplies, initial basic telephone
ing. Centrally located with easy access to
805, 163, 15 and bus stops; wheelchair ac-
screening and message taking, and use of
Interstate 5 near the Carmel Valley/Del
cessible. Restaurants and shopping areas
waiting room, photocopy equipment, tele-
Mar area. Current occupants all licensed
nearby. Available on Tue and/or Thu. Will
phone, fax and voicemail. Wireless internet
mental health practitioners; 2 psychiatrists,
sublet for 1 or 2 full days per week. Call
throughout building. Positive collegial
2 social workers, 1 psychologist, 2 MFCCs.
Anabel Bejarano, PhD at 619.410.5545.
working environment. Contact David B.
Includes furnished waiting room, utilities,

DSL access, janitorial services, file storage
space, staff bathroom and kitchenette,
clerical room w/fax & copy machine. Well
maintained building with pharmacy, ample
parking. Building open until 2 PM on Saturdays. $1650/month. Call 619.733.2541
CARMEL VALLEY/DEL MAR: Part-time
Office Available in Established Mental
Health Suite. 160 sq office within suite
of congenial mental health colleagues. Attractive 3-story medical building. Centrally
located with easy access to Interstate 5 and
Highway 56 in Carmel Valley. Includes
furnished waiting room, utilities, janitorial
40
CLAIREMONT/KEARNY MESA:
Rent
private two room office, one closed room
Wexler, Ph.D. at dbwexler@gmail.com or

619.296.8103 x 14
Part-time office space in
with bay windows, other room semi di-
ENCINITAS:
vided into two areas, entrance from sky
lovely two office suite w/ocean view. Ex-
lighted corridor. Balboa Ave/ Freeway 163,
cellent location, ample parking, inner office
easy access from all directions. Psycholo-
referrals. Suite has kitchenette & private
gist tenant moves out June 1st. 800/month.
bath. Call for details. Barbara Czescik,
858.449.4824.
Ph.D. 760.436.5570.
DEL MAR: Part-time office space avail-
ENCINITAS: Full or part-time, ocean view,
able in the Del Mar Medical Clinic, near
11x14 office available for lease or sublease
Ocean/I-5. Fully furnished, private en-
with three established psychiatrists. Con-
trance, waiting room, phone, excellent
veniently located close to highway 5 and
sound proofing, air conditioning, near
minutes from Scripps Encinitas. Includes
bus. Includes utilities, janitorial services,
free parking, wifi, common waiting room,
WWW.SDPSYCH.ORG
private entrance and bathroom. Contact

Dee Ann Wong at 760.753.7341 x 2.
Contact Betty Waldheim 858.452.1044.

GOLDEN TRIANGLE: Large office. Ocean
lished psychologists. Off-street parking,

intercom, shared waiting room, kitchen,
receptionist, copier/fax access. Near 5 and
ENCINITAS: 2 furnished offices-170 square
view. Suite constructed for therapists.
feet large windows. Use of Internet, wait-
Beautiful Class A building, contemporary
ing room, plenty of free parking. Suits
waiting room, advanced soundproofing,
psychologist, therapist, LCSW or similar
free local FAXing, free utilities, free gym-
KEARNY MESA: F/PT office space avail-
professional. Available Monday, Tuesday,
nasium. MANY amenities. Office projects
able. $350/month P/T $700/month F/T.
Friday and the weekend. 100 square feet
Success! Convenient I-5/805 access. Terrific
Waiting room, heating & AC, utilities in-
$550 per month full time part-time a
people. Restaurants close. Charlie Nelson
cluded. Access to fax, copier DSL. Large
possibility. Both offices are soundproofed
858.546.9255 or 858.442.6836. Igrateful1@
parking lot. Easy access to 163, 805, 15,
with new carpet and paint use of wire-
aol.com
public transportation. If interested please
less Internet, waiting room plenty of free

Parking. We also have a 100 square foot
part furnished or unfurnished office available for $500 per month. Prestigious and
convenient location in the beautiful North
Coast Business Park. 2 blocks from I-5 on
HILLCREST: 3636 4th Ave., Perfect for

psychology, Family Therapy, Approx 950-
in a beautiful, therapists-only building.
Contact: Hamid Mostofiat 858.354.8020.
Waiting room, kitchen, copier, fax, wireless
available within 3 Office Suite with 2 Ex-
alk@gmail.com
perienced Established Psychotherapists.
Weve been
here over 10 years and believe this is the

best location in the Golden Triangle. Its a
858.278.1089 or Rbelzer355@aol.com.
services, parking. Close to Freeway 5/163.
at: 760.632.7223 Ext. 3 or email: landacor-
and Wednesdays available.
contact Rosa Grunhaus Belzer, Ph.D.
KENSINGTON: Share a spacious office
HILLCREST/BANKERS HILL: 1 Office
a part time person to join us, with Fridays
Kilman, Ph.D. or Martha Hillyard, Ph.D.
1000 sq-ft for lease including janitorial
Encinitas Blvd. To view, please call Coral
GOLDEN TRIANGLE: Were looking for
163 freeways. Call 619.295.2749 for Beverly
modem. Available days are Wed, Fri, and

Sat. Contact Richard Jordan 619.303.5062,
drjordan@cox.net
Great Location ...Centrally located. Shared
LA MESA: Spacious, professional, fully
Kitchen area, Shared Large Waiting room,
furnished office in La Mesa Village. Loca-
Free parking for clients, Air Conditioning-
tion convenient to freeways and public
Please contact 858-429-8999 Melonie Gale
transportation. Accessible to persons with
MA LMFT
disabilities. Available one to five days per

week. Call David Slier, Ph.D., N.C.C.M.
well-designed suite in an intimate build-
HILLCREST/NORTH PARK: An afford-
ing with numerous amenities (including
able and attractive office in a park like
Starbucks) right across the street, access to
setting. One full time furnished private
LA JOLLA: Building out La Jolla offices
upscale clientele (UCSD faculty, corporate
office (including a s-roll top desk) $495.00/
now. Ready February 1st. Come see model
executives, scientists, engineers, etc) and
month and shared utilities. Rent includes:
and reserve your office now. All amenities,
its in an ideal spot with freeway access
Janitorial services, off street parking and
free parking, be apart of www.counsel-
from all over San Diego County. Friendly,
access to a group area. 3699 Park Boule-
ingsandiego.com Vince Huntington MFT
ethical, established colleagues.
vard. Contact Stan Lederman, Ph.D. (PSY
858.452.1199
Contact
5756) 619.296.0087.
Ain Roost at 858.552.0500.
619.992.7393.
LA JOLLA:
Windowed spacious office
Part-time fur-
HILLCREST: Spacious handicap accessible
with a view to courtyard in a suite of three
Excellent location, direct
office suitable for group and individual
offices.
I-805 and Governor
therapy. Free wireless internet, fax, outgo-
exits. Use of copier and fax. Ample park-
Drive (near 52). Large, bright office, secu-
ing local calls, waiting room with lights,
ing. Access to I-5 and I-805 across the street
rity system, free parking, private therapist
elevator, kitchenette, own desk space and
from UCSD in La Jolla Village Professional
restroom, highly professional friendly
file cabinet, window, fully furnished. One
Center. Evenings 4 pm 9 pm. Available
colleagues.
to two blocks from Balboa Park and coffee
now. $495. Dr. Diana Greg 858.552.1559.
GOLDEN TRIANGLE:
nished office.
freeway access off
Call Ellen Nemiroff
Ph.D
shops. All day Mondays, Wed mornings,
858.481.7755
GOLDEN TRIANGLE:
Office share.
Large comfortable windowed office, fully

furnished in University City.
Desirable
all day Thurs, and Fri available- $200/day

or $100 for half a day. Dawn Dilley, Ph.D.
619.255.7001 or drdilley@cox.net.
Classical separate entrance and
LA JOLLA: Available Now. Office share

w/options: Full day Wednesdays, Fridays,
Saturdays and Thursday mornings. Windowed with view. Spacious, beautifully
location with easy 805 freeway access, and
HILLCREST: Full-time beautiful 11x14 of-
furnished. Classic separate entrance/exit.
ample free parking. Congenial atmosphere.
fice with bay window available in historic
Copier/fax.
Available 1-2 days. Copier/Fax available.
Queen Anne Victorian house with estab-
parking/access to I-5 & I-805/near UCSD.
WWW.SDPSYCH.ORG
Open air complex, ample
41
Carole Meredith
(858) 646-9579; cmer-
days, evenings and weekends.

per month.
edith1@aol.com
LA JOLLA/GOLDEN TRIANGLE: Win-
$200.00
Call and leave message at
858.610.0570.
Saturdays, Sundays, and Mondays. Call

Lisa Petronis 619.787.2771.
SORRENTO VALLEY/MIRA MESA: At-
space
tractive psychotherapy offices in renovated
Class A building,
contemporary building, newly decorated,
fax, copier, free parking, lovely view. Call
shared waiting room. Sorrento Valley/
MISSION
Triangle/La Jolla/UTC area easily acces-
available on Fridays.
sible to UCSD and High Tech and Bio Tech

industries. ADA compliant. Available be-
Rosalie Easton at 619.294.9177.
Mira Mesa prime location, easy freeway
ginning April 1st for 4 days/week except

Wednesdays. For more information, call
Sallie Hildebrandt, PhD at 858.453.1800.
VALLEY:
Part-time
dowed office in Class A building in Golden
MISSION VALLEY: 14 X 17 furnished

windowed office space available all day
Monday, Wednesday, Saturday and Sun-
access,
furnished/unfurnished,
full
part-time. Must see, please contact Farnaz

Khoromi at 619.920.8892.
LA JOLLA/GOLDEN TRIANGLE: Thurs-
day. Rent 1, 2, 3 or all 4 days. Utilities and
UTC/LA JOLLA: One class A office for rent
days $175/month. Highly desirable loca-
janitorial services included.
Centralized
on Wednesdays. All amenities includes
tion, close to freeways, shops, restaurants.
location. Month-to-month. 3511 Camino
shady parking, 24 hr security, FAX, & Copy,
Free parking, copy/fax. Furnished interior
del Rio South, Suite 302.
private rest room. Some referrals. $300 a
office, shared waiting room, call lights, pri-
858.792.6060.
vate exit, wheelchair access.

professional setting.
Pleasant,
Call Mary Squire
Call Patti at
month. 2nd office available hourly any day
OCEANSIDE: Full time or part time office
of week. Vince Huntington 858.452.1199.

Professionally appointed office
space available. Modern large office suite
VISTA:
with other psychologists. The office has an
for sublet. Access off the 78 Freeway, bus
LA MESA office space available. Various
ocean view. Includes waiting room, plenty
lines, and across from the Vista Main Court
days available. Fully furnished, pleasing
of storage, computer, fax, and other ame-
House on South Melrose Drive, this office
environment. Secure professional building
nities are available.
space is equipped with waiting room call
with easy access to highway 8. Handicap
Samko at 760.721.1111.
858.452.5535 or Sharon Weld 858.452.4243.
access. Includes parking, waiting room,

copier and refrigerator. Please call Kate
Bennett, MFT at 619.491.3638 or Ron Cornett 619.462.6720.
RANCHO
Please call Michael
BERNARDO:
lights and music, refrigerator, microwave,

500
sq.
ft.
Freeway close. 2 office suite also includes

waiting room and copy/file room. Larger
office boasts windows with mountain/lake
Work
views. Smaller office approx 8x10. New
closer to where your patients live! Great
paint, clean, quiet & professional building.
location serving Scripps Ranch, Rancho
Please call w/inquiries. 619.298.8722 x 101
MIRAMAR/SCRIPPS
RANCH:
Bernardo, Rancho Penasquitos, Poway,

Mira Mesa, and the Miramar Marine Corps
Air Station.
One block to 15 freeway.
Part-time furnished office.
Opportunity
for referrals. Professional building with

artwork. Large windows, waiting room
with signal switches and music, excellent
soundproofing, designer lighting. Private
exit. Break area with fridge/microwave.
Free parking.
Contact Michael Reider,
Ph.D. toll-free 1.888.293.3182

MIRAMAR/SCRIPPS RANCH AREA:
Shared professional office available beginning April 1 on Thursdays, evenings and
weekends.
Comfortable office suite has
new carpet/pain, windows, ample parking, separate waiting area and private exit.
Near 1-15/Miramar exit. Available Thurs-
42
SAN MARCOS: Office space for sublet-in

beautiful professional building near restaurant row, near I-5, and local banks in quiet
street. Handicap access, elevator, janitor
service, immediate availability. Window
office, copier machine and waiting room.
Several days available, Flexible and part
time hours available now. Please call 760815-5470 or email drlily2003@yahoo.com .
separate room for testing, and copy

machine amenities. Shared office is available for rent on Mondays, Tuesdays, and
Wednesdays. Surrounded by many eateries. Large windowed office in professional,
Class A building with many opportunities
for referrals. Please contact Robin Bronstein, Ph.D. at 760.643.4043.
VISTA: Newly renovated professional office suite for lease. (Hurry and choose your
own color.) Lovely Spanish style building
with courtyard and fountain. Easy freeway
access. Office includes; waiting room, call
lights, kitchenette, casement windows, and
French doors. Bldg has shower, plenty of
parking, and is across from soon to be built
Civic Center. Single offices range from
SCRIPPS RANCH/SAN DIEGO: Central-
$525-$675 a month. Contact: Craig Carlson
ly located. Easy freeway access. Relaxed
Ph.D. 858.755.2359.
setting looking out into horse ranch. Large

eucalyptus trees enclose the suite giving it a
off the beaten path feel. Plenty of parking
steps from office. Fax, utilities and bottled
water included. Professional atmosphere
with well established psychologists. Office
is fully furnished and available Fridays,
WWW.SDPSYCH.ORG
WWW.SDPSYCH.ORG
43
SDPA STAFF
Director of Administration
Administrative Staff

STANDING COMMITTEES
Susan Farrar
Keny Leepier
BOARD OF DIRECTORS
President
President-Elect
Past President
Secretary
Treasurer
Members at Large

CPA Representatives

Lori Futterman, RN, Ph.D.

Mary Harb-Sheets, Ph.D.
Sallie Hildebrandt, Ph.D.
Lindsey Alper, Ph.D.
Rosalie Easton, Ph.D.
Sue Hoffman, Ph.D.
Felise Levine, Ph.D.
Bapsi Slali, Ph.D.
David Tweedy, Ph.D.
Anabel Bejarano, Ph.D.
ASSOCIATION SERVICES
Colleague Assistance
Legal Counsel
Newsletter
Psychologist Referral and
Information Service (PIRS)
Psychology 2000
Karen Fox, Ph.D.

David Leatherberry, J.D.
Jonathan Gale, Ph.D.
Vanja Gale, Psy.D.,
Adriana Molina, Ph.D.
Ain Roost, Ph.D.
SDPA REPRESENTATIVES
Board of Psychology
Adult System of Care
Childrens System of Care
Mental Health Board
Mental Health Board
Mental Heath Coalition
Older Adult Systems of Care
TERM Advisory Board
U.B.H. Credentialing Committee
U.B.H. Peer Review Committee
44
Hugh Pates, Ph.D.

Lori Futterman, Ph.D.
Karen Zappone, Ph.D.
Katherine DiFrancesca, Ph.D.
Gloria G. Harris, Ph.D.
Mary Ann Brummer, Ph.D.
Ken Dellefield, Ph.D.
Marilee Wasell, Ph.D.
Hugh Pates, Ph.D.
Steve Tess, Ph.D.
Community Mental Health

Continuing Education

Ethics and Standards
Government Affairs

Membership
Mary McGuinn Clark, Ph.D.

Steve Tess, Ph.D.
Christina Zampitella, Psy.D.
Vic Frazao, Ph.D
Mary Harb Sheets, Ph.D.
Bruce Sachs, Ph.D.
Mary Harb Sheets, Ph.D.
FORMAL COMMITTEES
Cultural Diversity
Disaster Response

Early Career Psychologist

Forensic

Mens Issues
Psychologist Retirement,
Incapacitation or Death (PRID)
Public Education & Media

Science Fair
Student Affairs

Supervision
Womens Issues
Azmaira Maker, Ph.D.

Roberta Flynn, Ph.D.
Aleksandra Marinovic, Psy.D.
Vanessa Weinbach, Ph.D.
Shaul Saddick, Ph.D
Preston Sims, Ph.D.
Danny Singley, Ph.D.
Joel Lazar, Ph.D.
Annette Conway, Ph.D.
Katherine Moore, Ph.D.
Richard Schere, Ph.D.
Clark Clipson, Ph.D.
Jessica Evers-Killebrew
Ruth Samad, Ph.D.
Shoshana Shea, Ph.D.
SPECIAL INTEREST COMMITTEES

Aging
Arts
Lesbian, Gay, Bisexual &
Transgender
Past Presidents
Sports Psychology
Hugh Pates, Ph.D.

Toni Ann Cafaro, Psy.D.
Paul Sussman, Ph.D.
Greg Koch, Ph.D
Brenda Johnson, Ph.D.
Sharon Colgan, Ph.D.
TASK FORCE GROUPS

Children & Youth
Neuropsychology
Mindfulness

WWW.SDPSYCH.ORG
Sharon Weld, Ph.D.

Michael Kabat, Ph.D.
Regina Huelsenbeck, Ph.D.
Steven Hickman, Ph.D.

The Psychodynamic Diagnostic Manual (PDM) : An Overview: in This Issue

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$5.

THE OFFICIAL NEWSLETTER OF THE SAN DIEGO PSYCHOLOGICAL ASSOCIATION

The Psychodynamic Diagnostic

By Daniel Blaess, Ph.D.

hile the DSM-IV is largely considered our diagnostic bible, a

guide treatment in beneficial ways. My hope is to provide an overview of the

to diagnosis, and its potential utility for clinicians.

among several psychoanalytic organizations, including the American Psycho-

THE WAYS WE LOVE: A

[39] of the American Psychological Association, the American Academy of

The Psychodynamic Diagnostic Manual was developed as a collaboration

From the Editor

by empirical research findings.

A quick glance at the PDM will

find that it provides a deeper and

more informed understanding of

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The format of the CPSE has changed!

Call OR viSiT OUR WEBSiTE TO ENROll:

| Offer Expires: 9/30/09

Association for Advanced Training

FROM the editor

Jonathan Gale, Ph.D.

Newsletter may be purchased for $5 per individual copy, or

$46 for 40 words or less

$6 for each additional 10 words

Display Ads: Dimensions for display ads are in real inches.

Inserts: A full page flyer may be submitted as an insert to the

$250 for full page insert (B&W)

$800 for full color copy

The Newsletter is published 6 times per year in bi-monthly

quote of the month

heard with some dismay that the generally difficult

The American Psychologist provides 1 CE credit per

April 25, 2009 - Remembering Dr. Van der Veen: My

Years later, I read a quote of Carls in my high-school

mentioned above, in January his body at last gave out

- Ferdinand van der Veen

Presidents Corner: Maintaining Balance

Our expertise in psychological assessment, behavioral

The need to collaborate in primary care

Psychologist will need to redefine training and

Continued from cover: The Psychodynamic Diagnostic

due to the lack of empirical evidence to support its inclusion in

scheme is strictly descriptive, the sheer volume of dis-

The PDM lays out a framework

orders can be problematic, as it is always possible to

for assessing the patients level of

add descriptive specificity in some beneficial manner.

personality organization. These

If I take a ruler and measure my copy of the DSM-2, it

measures about a third of an inch thick. In contrast, my

of the patients sense of self and