It has often been said that no one knows what psychoanalysis is—whether it is a science, one of the humanities, a particular type of therapeutic art, a religion or a form of semantic theory (Ryecroft 1968). There are those who postpone judgement, waiting to see whether psychoanalytical theory is refuted or accepted. This raises the question of the nature of theories developed to explain human nature, as opposed to those designed for the purpose of explaining physical nature. Failure to distinguish between them leads to much confusion. Consideration of human nature leads to what is exclusively and most significantly human—human experience, so-called psychic reality, a phenomenon unique to human beings, but shared to a certain extent by them, and capable of communication between them. Physical nature, both organic and inorganic, is of a different order of abstraction. Psychic reality, which cannot be directly perceived through the physical senses, is only directly experienced in the self, but can be communicated by language—and can be inferred from observation. Physical reality can only be perceived through the physical senses.

Psychoanalytic treatment shares with other forms of psychotherapy the aim of bringing about lasting changes within the patient. In common with other ‘insight’ therapies it makes use of interpretations and other verbal interventions (Sandier, Dare and Holder, 1971). While these are aimed partly at making unconscious content and processes conscious, it has been maintained since the early days of psychoanalytic treatment that ‘making what is unconscious conscious' and the gaining of insight is not sufficient, in the ordinary course of events, to bring about a fundamental change in the patient. In contrast to procedures involving hypnosis and massive abreaction (catharsis), the psychoanalytic method is regarded as depending for its success on a number of additional elements. A number of these have been discussed in previous papers, particularly the elements of treatment alliance (Sandier, Holder and Dare, 1970a), transference (Sandier, Dare and Holder, 1970a, b) and the analysis of resistance (Sandier, Holder and Dare, 1970b). It is the purpose of the present paper to examine those further factors in the psychoanalytic treatment situation which have been encompassed under the heading of working through.

A cogent interpretation of the apparent average ineffectiveness of psychotherapy (e.g. Eysenck, 1960) has been proposed by Bergin (1966) and taken up by Truax and Carkhuff (1967). This explanation is based upon the suggestion that some therapeutic encounters harm patients and hence beneficial effects are cancelled out when the average results of large groups are considered. Rather than beginning with large miscellaneous samples treated in an unspecified variety of ways, our research programme involves detailed experimental and correlational studies of the therapy of a small number of patients with similar diagnoses. This paper is limited to a preliminary study of assessment of change in psychotherapy by means of the Personal Questionnaire (PQ,), (Shapiro, 1961, 1969).

Too few psychiatrists in Britain have received an adequate training in psychotherapy, and the teaching of human personality growth and development is often woefully inadequate at both undergratuate and postgraduate levels—a state of affairs sometimes justified on the basis that existing knowledge has not been scientifically validated. For some psychiatrists their only training in communication with their patients is in clinical interviewing and their only understanding of their patients emotional life is derived from a study of gross psychopathology.

Physicians and patients frequently assume a causal connection between life events and subsequent episodes of psychiatric illness. It seems to ‘make sense’ that an illness which is to some extent manifested by disordered emotions could be caused in part by emotion-producing events. But plausibility alone is no proof of the truth of such an assumption. Realizing this, several investigators have conducted systematic studies of the interrelationships of life events and illnesses, both psychiatric and medical. Such work has been reported by Adamson and Schmale (1), Holmes, et al. (3, 7, 9, 10) Brown and Birley (2) Clayton, et al. (4) Morrison, et al. (11) Murphy, et al. (12, 13) and Hudgens, et al. (8). These authors differed regarding the specific question of whether illnesses may be caused by emotion-producing stress. The first six of the above papers presented positive evidence for such a cause-effect relationship. The last four papers reported that psychiatric patients had significantly more interpersonal conflicts than did well persons or medically ill persons, at least while their psychiatric illnesses were in progress; but the latter authors were unable to find evidence that any type of stress, interpersonal or otherwise, played a causative role in the illnesses. Disagreements among all these workers may be traced to differences in both theoretical approach and methodology.

The process whereby neurotic symptoms are generated, and the degree to which they are linked to pre-existent personality traits, is still a matter of debate in psychiatric and psychological literature. On the basis of the medical model, symptoms may be thought of as intruding unaccountably (from the subjective point of view) into the individual's experience as part of a disease process. This standpoint, where it exists, must be accepted as an article of faith, since no convincing demonstration of how a phobia or an obsession, for example, can be accounted for in this way has yet been put forward. However, cogent arguments have been advanced (e.g. Foulds 1965) for regarding symptoms as distinct from personality traits; in part such arguments have been occasioned by the confusion in psychiatric diagnosis between concepts such as ‘hysteria’ and ‘hysterical personality’.

Hypnotic drugs are most commonly used with patients at home, yet with few exceptions (Ghernish, Gruber and Kohlstaedt, 1956) most trials of hypnotic drugs are carried out in hospitals. Studies on such patients by general practitioners are valuable, but they often rely on retrospective or other forms of delayed reporting and their validity is thereby somewhat limited. This preliminary study therefore compared four widely used hypnotics with a placebo when normal subjects were sleeping at home. Their impressions of the quality of their sleep and other information, including their dreams, were collected by telephone the morning after the drug had been administered. All subjects were healthy and did not complain of sleep disorders; neither before nor at the time of the trial were they taking either hypnotics or other medication.

Taste sensitivity may be a valid quantitative predictor of other kinds of reaction to the same drug by a given organism (Fischer and Griffin, 1963). Such a relationship in healthy subjects has been directly demonstrated for hyoscine butyl bromide (Joyce, Pan and Varonos, 1968), but the implications for the prediction of clinical response have apparently not yet been explored in a direct fashion. For example, in one group of female schizophrenics with a low taste threshold for quinine, a significantly lower dose of trifluoperazine elicited toxic effects than was the case in a group with a high taste threshold (Knopp, Fischer, Beck and Teitelbaum, 1966). But this study made, without testing, two important assumptions: first, that the dose necessary to produce toxic effects is positively correlated with the therapeutic dose; second, that the relationship between taste threshold and response to the drug is non-specific, so that the bitter substance quinine may serve as an indicator of response to any bitter-tasting centrally-active drug, or perhaps to any drug at all. The first of these propositions, though once fashionable, is certainly open to discussion; to accept the second would eliminate the interesting possibility of using differences in taste thresholds for a range of drugs to predict the drug to which the individual patient might best react.

Oral intake of amphetamine may cause the development of a schizophrenia-like paranoid psychosis (Monroe and Drell 1947, Connell 1958, Kiloh and Brandon 1962). Intravenous abuse of the drug causes more intense psychotic manifestations dominated by vivid visual and auditory hallucinations (Connell 1958, Kramer et al. 1967, Rylander 1967, Cohen 1968). In the present investigation a rating scale, was designed for the study of amphetamine psychosis in 15 intravenous abusers. A preliminary report of this work has been given earlier (Jönsson and Gunne 1969).

The excellent immediate response of many depressive states to ECT is well established, but unfortunately relapse is common. Pare (1968) noted that it was becoming increasingly common for anti-depressant drugs to be given concomitantly with and after ECT in order to prevent relapse, but there appear to be only two reports bearing on the value of this procedure. Seager and Bird (1962), in a blind trial, followed up 28 ECT treated depressives and found that the six month relapse rate was markedly lower in those who received imipramine after discharge (17 per cent) compared with those on placebo (69 per cent). Imlah et al. (1965), in a study of 124 patients, found that a relapse rate of about 50 per cent within six months of ECT when used alone was reduced by over one half when ECT was combined with and followed by either imipramine or phenelzine, but their trial was not conducted blind. The after-care of depressed patients is so important, particularly in view of the risk of suicide, that further evidence seemed desirable.

Published reports on sulthiame have been primarily concerned with its effects as an anticonvulsant. Some investigators have also examined behavioural changes brought about by its use. For example, Haran (1962) found that it reduced irritability and violent behaviour, and generally improved the sociability of epileptic patients. Ingram and Ratcliffe (1963) found that the hyperkinetic behaviour of 16 out of the 18 patients in their sample was either ‘abolished’ or improved. Working with a larger group, Liu (1966) noted ‘over-all clinical improvement’ in the behaviour of 32 out of 50 cases. Kneebone (1968) claimed that 12 out of a total of 18 hyperkinetic children had 'significantly improved behaviour’ with sulthiame.

Despite the views of many authors that migraine and epilepsy are unrelated phenomena, there is much evidence to the contrary. Davidenkov (1934) studied fifty parents with epilepsy, twenty-six of whose children had migraine. Barolin (1966) and Janzen (1969) also present evidence of a high incidence of migraine in epileptics. Owing to the success in treating migraine with anticholinesterases syntostigmin and nivalin (Ikonomoff, 1961, 1967, 1968), and the possible relationship between migraine and epilepsy, the same anticholinesterase drugs were administered to epileptics. Tentative and careful studies with syntostigmin and nivalin seemed to show that these anticholinesterases could be given with safety and apparent success. A study was therefore. undertaken of the effects of syntostigmin.

Pimozide is a new neuroleptic drug and is chemically described as bis-para-fluoro-phenyl-butylpiperidine. It is active after oral administration, with a 24 hour duration of action and a peak effect lasting four to six hours (1). Superiority over placebo has been demonstrated by Brugmans (2).

The classification of depressive illnesses continues to be a problematic and controversial issue (Kendell, 1968; Hope, 1969). The many statistical approaches applied to this complex question since Hamilton's original study (1960) have been reviewed by Kendell (1968). More recently, Pilowsky, Levine and Boulton (1969) have offered evidence (based on the application of information theory taxonomy to patients' questionnaire responses) which supports the validity of regarding ‘endogenous' depression as a clinical entity. Following on this study, Pilowsky and Boulton (1970) have developed a decision rule for the identification of depressive class members and have shown that class membership is related to the response to electroconvulsive therapy; patients in the ‘endogenous' Class B group having a better clinical outcome.

Recently increased interest has been shown in the physiological and behavioural consequences of DC polarization of the brain.

In 1964 Cutler et al. (1) reported on a family in which 11 members apparently had primary hyperparathyroidism. Seven cases were diagnosed at surgery; four other members had elevated serum calcium and other evidence of the disease. It was noted as an incidental finding that two of the affected members also suffered from severe psychiatric illness. The present study is a six-year follow-up investigation of the family from a psychiatric viewpoint, using non-hyperparathyroidism family members as controls to explore the possible relation of hyperparathyroidism to psychiatric illness.

It is known that pernicious anaemia is sometimes associated with mental symptoms which improve following vitamin B12 therapy (Eilenberg, 1960; Holmes, 1956; Smith, 1960). Further, it has been pointed out that such mental symptoms can occur years before the development of anaemia and no definite relationship exists between them and the severity of anaemia (Smith, 1960). Cases have been described with a variety of psychiatric symptoms and low serum vitamin B12 levels without any neurological manifestation or abnormality of peripheral blood and bone marrow. Since pernicious anaemia is due to vitamin B12 deficiency it is suspected that B12 deficiency is responsible for the mental symptoms, and serum B12 assays have been advocated routinely in psychiatric patients (Strachan and Henderson, 1965; Hunter and Matthews, 1965).

Narcolepsy is a syndrome characterized by recurrent sleep attacks and one or more of the following symptoms: cataplexy (transient loss of muscle tone), sleep paralysis (inability to move in the transition between sleep and arousal), and hypnagogic hallucinations (Sours, 1963). Polygraphic sleep studies indicate that narcoleptics have an abnormal sleep record. Normally, rapid eye movement (REM) sleep is preceded by 90 to 100 minutes of non-REM sleep, whereas narcoleptics often have an REM-period at the onset of sleep (Hishikawa and Kaneki, 1965; Rechtschaffen et al., 1963).

The studies to be discussed were carried out within the framework of the Personal Construct Theory, as proposed by G. A. Kelly (4) and summarized by Bannister (1), and follow the line that thought disorder in offspring may be related to some kind of thought disorder in parents (2,6).