The author traces the history of the development of DSM-III within the larger context--intellectual, economic, scientific, and ideological--of the development of American psychiatry since World War II. Data were obtained through a literature review, investigation of archival material from the DSM-III task force and APA, and interviews with key participants. This research indicates that from the end of World War II until the mid-1970s, a broadly conceived biopsychosocial model, informed by psychoanalysis, sociological thinking, and biological knowledge, was the organizing model for American psychiatry. However, the biopsychosocial model did not clearly demarcate the mentally well from the mentally ill, and this failure led to a crisis in the legitimacy of psychiatry by the 1970s. The publication of DSM-III in 1980 represented an answer to this crisis, as the essential focus of psychiatric knowledge shifted from the clinically-based biopsychosocial model to a research-based medical model. The author concludes that while DSM-III, and the return to descriptive psychiatry which it inaugurated, has had positive consequences for the profession, at the same time it represents a significant narrowing of psychiatry's clinical gaze.
The ways in which the analyst's desire for particular experiences with patients is inevitable and often leads to narcissistically based resistances are considered. Five propositions are examined: (1) that the analyst cannot help but have desires and want them recognized by the analysand; (2) that these desires frequently underwrite the analyst's theoretical beliefs and technical interventions; (3) that narcissistic desires and their influence are ubiquitous among practicing analysts; (4) that the patient is often on the lookout for the analyst's various agendas; and (5) that the patient often hopes the analyst will put his or her desire aside and listen so the patient can further his or her own interests. Lacan's concept of the "dual relation" is central to this discussion. The neo-Kleinian position on narcissistic resistances is explored, as is the idea of the "analytic third" as a potential solution to the problem they pose. An extended case description illustrates the main points.
The analyst's desire expressed in impactful wishes and intentions is foundational to countertransference experience, yet undertheorized in the literature. The "wider" countertransference view, associated with neo-Kleinian theory, obscures the nature of countertransference and the analyst's contribution to it. A systematic analysis of the logic of desire as an intentional mental state is presented. Racker's (1957) talion law and Lacan's (1992) theory of the dual relation illustrate the problems that obtain with a wholesale embrace of the wider countertransference perspective. The ethical burden placed on the analyst in light of the role played by desire in countertransference is substantial. Lacan's ethics of desire and Benjamin's (2004) concept of the moral third are discussed.
It is an oft-noted clinical phenomenon that the analyst's mistakes are beneficial to the analytic process. Although the analyst's mistakes, misunderstandings, and faulty functioning have been described by psychoanalysts of various theoretical persuasions, no overall theory has been advanced to account for this clinical phenomenon. To address this theoretical lacuna the central Lacanian notions of lack and desire are brought to bear. In particular, lack, or nothing, is presented as an essential working condition of the analyst, one that if understood, recognized, and tolerated can positively inform the analyst's attitude. By contrast, theoretical biases that privilege presence can obscure lack as an important contributor to the analyst's attitude. A clinical case demonstrates that both analyst and patient struggle with deep anxieties generated by lack, and that both are repeatedly tempted to solve these struggles by settling for obsessional solutions.
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