Starting from scratch: Developing clinical psychology training and services in Bangladesh

Abstract

This paper outlines the author's personal experience of contributing to the development of the first ever training in clinical psychology in Bangladesh. This was part of a link project between University College London and Dhaka University. It examines the challenges posed by such an enterprise through the author's experience of teaching and assessing patients in the local psychiatric wards. It questions the validity of exporting Western models of psychotherapy – psychoanalysis in particular – to a non-Western culture.     

A trainee psychotherapist’s heuristic exploration of losing a mother to suicide

ABSTRACT

Suicide bereavement is a newly developing field of research in the UK, yet over 6,600 people take their own lives here every year. This heuristic inquiry aims to explore the lived experiences of trainee psychotherapists bereaved by maternal suicide. It examines the lived experiences of the researcher and two participants, with data collected through interviews, dreams and journalling. The findings revealed five themes: 1) It’s not just about the suicide, 2) The pain continues – attachment, abandonment and fear, 3) Left with all the unprocessed feelings – “the shit”, 4) Trigger after trigger – complicated experiences of psychotherapy training, 5) A catastrophic loss that no one “gets”. Implications for the counselling and psychotherapy profession are discussed.     

Pete the diesel: Psychotherapy with a severely disturbed five-year-old boy

The psychic significance of the figure of the grandmother in psychodynamic psychotherapy has received scant attention. This paper develops the concept of the ‘grandmaternal transference’ in parent–infant psychotherapy and explores its identification, its possible functions and its therapeutic significance. The grandmaternal transference has special relevance to parent–infant psychotherapy since the grandmother often represents both the mother’s mother and the child’s grandmother and offers a unique third position between mother and child. Three clinical vignettes illustrate how the grandmaternal transference may operate in this third position. In the first vignette, the therapist becomes in the transference a containing grandmother thereby facilitating maternal containment. In the second case, the therapist may be experienced as a differentiating grandmother able to help mother and infant with separation and individuation. In the third one, the therapist is transferentially experienced as a paternal grandmother who acts as a pseudo-father able to embody the paternal function. In each of these positions, the transference and countertransference – whether positive or negative – require that the therapist responds to rather than enacts the grandmaternal role. The three configurations of the grandmaternal transference have different clinical manifestations and offer different therapeutic ports of entry.     

The history,origin, and meaning of Nietzsche’s slave revolt in morality

Abstract

While it is uncontroversial that the slave revolt in morality consists in a denial of the nobles as objects of value, Nietzsche’s account in the Genealogy’s first essay invites ambiguities concerning its origin, ressentiment’s relationship to value creation, and its meaning. In this paper, I address these ambiguities by analyzing the morality of good and evil as an historical artifact of Judeo-Christian tradition, and I argue for a two-stage, non-strategic interpretation of the slave revolt, according to which Judaism and Christianity each made essential and different contributions. The inversion of values began with the Jewish prophets, who claimed the poor were holy and ‘good’ and the rich ‘evil’ (BGE 195), and it was sustained throughout the Second Temple period by the Jewish priests in relation to a ‘priestly-noble’ (GM I 7) conception of the virtuous person as holy and pure. Christ, through his espousal of egalitarianism (A 27), negated the pathos of distance essential to noble values, thus beginning the second phase of the slave revolt where goodness became associated with a distinctly slavish conception of virtue.     

Monitoring the effects of adult psychotherapy in routine practice in Switzerland: A feasibility trial

Background: Several studies have been published on the effects of psychotherapy in routine practice. Complementing traditional views summarised as ‘dose‐effect models’, Stiles et al. put forward data consistent with the responsive regulation model underlining the importance of the client's active participant role in defining length of treatment. One may ask what level of change reached by a patient is considered to be the ‘good enough level’ (GEL) and if it is related to the duration of psychotherapy. Aims: The main objective of the present feasibility trial was to monitor the patient's session‐by‐session evolution using a self‐report questionnaire in order to define the GEL, i.e. the number of sessions necessary for the patient to reach significant change. Method: A total of N=13 patients undergoing psychotherapy in routine practice participated in the study, completing the Outcome Questionnaire – 45.2 (OQ‐45), which assesses the symptom level, interpersonal relationships and social role after every psychotherapy session. The data was analysed using multi‐level analyses (HLMs). Results: High feasibility of fine‐grained assessment of effects of psychotherapy in routine practice in Switzerland was shown; response rates being acceptable; however, detailed analysis of the GEL was not feasible within the short study time‐frame. Conclusions: Reflections on the political context of monitoring in the specific case of routine psychiatric practice in Switzerland are discussed.     

Psychoanalytisch-orientierte Fokaltherapie der Depression bei Krebskranken

Emotional distress connected to a cancer disease may result in comorbid mental and especially depressive disorders. Although psychodynamic therapy is one of the most frequently applied forms of psychotherapy of depression in cancer patients there is a lack of empirical studies which meet the criteria of evidence-based psychotherapy research. This is especially true with regard to randomized controlled trials of psychodynamic psychotherapy. As far as we know no manual for psychodynamic treatment of cancer patients has yet been published. In this article a manual for a 20-session short-term psychodynamic treatment is presented. The treatment is based on Luborsky’s supportive-expressive (SE) therapy. The SE treatment manual of depressions in cancer patients presented here is an adaptation of the general SET manual as well as the SE manual for depression. In the first part the general principles of SE therapy are presented. In the second part a manual specifically adapted to the treatment of depressive cancer patients is described. The treatment manual is presently being used in a large-scale randomized controlled multi-centered study comparing short-term psychodynamic psychotherapy and treatment as usual.     

Ardent realism without referential normativity

ABSTRACT

This paper addresses a central positive claim in Matti Eklund’s Choosing Normative Concepts: that a certain kind of metaphysically ambitious realist about normativity – the ardent realist – is committed to the metasemantic idea that the distinctive inferential role of normative concepts suffices to fix the extension of those concepts. I argue first that commitment to this sort of inferential role metasemantic view does nothing to secure ardent realism. I then show how the ardent realist can address Eklund’s leading challenge without appeal to distinctively metasemantic commitments.     

A Randomized Controlled Trial of the Say Yes to Life (SYTL) Positive Psychology Group Psychotherapy Program for Depression: An Interim Report

An RCT was conducted to evaluate the effectiveness of the Say Yes to Life (SYTL) positive psychology group psychotherapy program compared with treatment as usual (TAU). The current interim report is based on data from the first 82 cases recruited into the trial. There were 57 trial completers at post-treatment. At pretreatment on demographic and clinical variables, there were no significant differences between trial completers and dropouts in SYTL and TAU groups. There were two main significant (p < .01) findings. Compared with TAU treatment-completers, more than twice as many SYTL treatment-completers (28 vs. 72 %) were recovered 3 months after therapy using stringent recovery criteria (no longer meeting DSM-5 diagnostic criteria for major depressive disorder and scoring below clinical cut-off scores on the Beck Depression Inventory II, the Hamilton Rating Scale for Depression, and the Montgomery–Asberg Depression Rating Scale and showing reliable change on these three measures of depressive symptom severity). Second, the overall average service use cost per case in the SYTL group was significantly lower than that of the TAU group (€726 vs.€1187). This was largely due to the lower cost of the SYTL group therapy program compared with TAU which involved individual therapy. The pattern of results in an intention-to-treat analysis was similar to that in the completer analysis, though group difference did not reach significance due to inadequate statistical power and conservative missing data imputation procedures. It is planned to collect data on 100 trial completers, based on a power analysis.     

The Good of Friendship at the End of Life

Abstract

This article attempts to explain the value that we assign to the presence of friends at the time when life is ending. It first shows that Aristotle’s treatment of friendship does not provide a clear account of such value. It then uses J. L. Austin’s notion of performativity to supplement one recent theory of friendship – given by Dean Cocking and Jeanette Kennett – in such a way that that theory can then account for friendship’s special value at our time of death.     

Exploring In-Session Process with Qualitative and Quantitative Methods in Psychotherapy with an Adolescent

ABSTRACT

There is emerging evidence for the effect of psychotherapy in adolescents with depression. Research indicates that therapists often use techniques from different theoretical models when working with adults. Research on the therapy process in adolescents is scarce. We explore the therapist’s interventions in a time-limited psychodynamic adolescent therapy with Susanna suffering from major depression. Susanna quite suddenly became worse at mid-treatment, with self-harming and suicidal ideations. Rating scales for analyzing in-session relational processes included the Structural Analysis of Social Behavior (SASB), the Adolescent Psychotherapy Q-set (APQ), and the Transference Work Scale (TWS). Self-reports on symptoms, interpersonal problems, and working alliance were obtained before, during, and at the end of and one year after treatment. Different tools seemed to expose different aspects of the process and the patient’s development. Only patient-rated questionnaires revealed the mid-treatment crises. Combining different and pan-theoretical rating scales on here-and-now interventions (TWS and SASB) and whole sessions (APQ), as well as clinician-rated measures and a variety of self-reports, indicated that different psychotherapeutic techniques were integrated in the therapy and seemed beneficial to patient’s outcome. The therapist adhered to the treatment manual. This way of exploring the therapy process may be used for different treatment modalities.     

Addicts to artists: The ‘good enough mother’ in the substance abuse clinic

Psychodynamic psychotherapy has had a bad reputation in substance abuse circles. Despite widespread use of behavioral interventions, outcomes remain relatively poor. The emerging trend is to incorporate relational and other psychodynamic approaches into addiction treatment. The article describes use of Winnicott's concepts of the ‘good enough mother’ and ‘play space’ in an outpatient ‘art group’.     

The Big Sleep

ABSTRACT

This paper illustrates the link between creativity and psychotherapy as an art. Clinical examples are given first, followed by significant events that affected this therapist's creative activities. Then personal views of creativity arc described with the conclusion showing different aspects of creativity as applicable to psychotherapy.     

Cognitive-Behavioral Versus Supportive Psychotherapy for Intermittent Explosive Disorder: A Randomized Controlled Trial

Few clinical trials have evaluated the efficacy of psychotherapy for Intermittent Explosive Disorder (IED). The present study tested the efficacy of a cognitive behavioral intervention (versus supportive psychotherapy) among adults with IED. In this randomized clinical trial, 44 participants with IED (22 men and 22 women) aged 20–55 years completed twelve 50-minute individual sessions of either a multi-component cognitive behavioral intervention for IED (n = 19) or a time equated supportive psychotherapy (n = 25). At baseline, posttreatment, and 3-month follow-up, all participants received the Overt Aggression Scale–Modified, which was conducted by an interviewer who was blind to the participant’s study condition. During these visits, participants also completed self-report measures of relational aggression (Self-Report of Relational Aggression and Social Behavior), anger (State-Trait Anger Expression Inventory-2), cognitive biases (e.g., Social Information Processing Questionnaire Attribution and Emotional Response Questionnaire), and associated symptoms (e.g., Beck Depression Inventory). Primary study outcomes were aggressive behavior and anger. Though participants in both treatments tended to improve over time, the cognitive behavioral intervention was superior to supportive psychotherapy in decreasing aggressive behavior and relational aggression. These findings support the efficacy of a multicomponent cognitive behavioral intervention in treating aggression in IED.     

Psychoanalytisch-orientierte Fokaltherapie der sozialen Phobie

Although psychodynamic therapy is one of the most frequently applied forms of psychotherapy to treat anxiety disorders in clinical practice, evidence for the efficacy of psychodynamic therapy in anxiety disorders is unsatisfactory. This is especially true with regard to randomized controlled trials of psychodynamic psychotherapy in anxiety disorders. Psychodynamically oriented treatment manuals for anxiety disorders presently exist for generalized anxiety disorder and panic disorder. For social phobia (or social anxiety disorder), however, no manual for psychodynamic treatment has yet been published. Social phobia is a very frequent mental disorder characterized by an early onset, a chronic course, severe psychosocial impairments and high socio-economic costs and at the same time in spite of these facts one of the mental disorders which are scarcely diagnosed and treated. In this article, a manual for a 30-session (5 exploratory and 25 therapy sessions) short-term psychodynamic treatment of social phobia is presented. The treatment is based on Luborsky’s supportive-expressive (SE) therapy. In the first part, the general principles of SE therapy are presented. In the second part, a manual specifically adapted to the treatment of social phobia is described. This manual includes specific additional treatment elements that have clinically proved to be useful in the therapy of social phobia. The treatment manual is presently used in a large-scale randomized controlled multi-center study comparing short-term psychodynamic psychotherapy and cognitive-behavioral therapy in the treatment of social phobia.     

No Empathy for Empathy: An Existential Reading of Husserl’s Forgotten Question

ABSTRACT

Empathy is a term used to denote our experience of connecting or feeling with an Other. The term has been used both by psychologists and phenomenologists as a supplement for our biological capacity to understand an Other. In this paper I would like to challenge the possibility of such empathy. If empathy is employed to mean that we know another person’s feelings, then I argue that this is impossible. I argue that there is an equivocation in the use of the term ‘empathy’ which conditions the appropriation of the Other as we think that we know how the Other feels. To claim that we do know an Other’s feelings – or any kind of their intentional experience – means to appropriate their experience through our own. I will first reveal the equivocal use of the term ‘empathy’ and, then, I will explore Husserl’s use of the term. In Husserl, the understanding of an Other as empathy is only partial. I shall conclude by reiterating a thesis from philosophy of existence and feminist theory according to which to know another person comes from creating a community with them and not because we have a biological structure that can mirror each other’s feelings.     

Jean Baker Miller,MD, Visionary Pragmatist

ABSTRACT

Jean Baker Miller’s 1976 book, Toward a New Psychology of Women, was an overnight success. It struck a deep chord in many women because it was based on listening to women’s stories. Instead of seeing women through the lens of male psychology with its emphasis on separation and autonomy, Jean suggested that relationships are central to women’s experience of themselves and the world. Traits that were typically pathologized (needing other people, attending to the messages of emotions, wanting to participate in growth fostering relationships for all involved) were revisited by Jean and her colleagues who discovered strengths where others had seen weakness. The resulting work is known as Relational-Cultural Theory (RCT) and has offered new understandings of women’s and men’s development with a special emphasis on the impact of power and marginalization on personal and collective wellbeing. Jean’s work is carried forward by members of a collaborative group with whom Jean worked for many years. RCT theorists have written and edited over 20 books, 115 works in progress, and numerous chapters and articles that continue to elaborate on Jean’s groundbreaking work. RCT is applied to both clinical and social justice settings. Jean was devoted to contributing to the creation of a more just society.     

Enduring Perfectionism: Seeing Through Eating Disorder Recovery and America’s Cultural Complex

ABSTRACT

Contemporary research in brain science and evidenced-based practices such as Cognitive Behavioral Therapy (Ellis, 1961; Beck, 1976), Dialectical Behavior Therapy (Linehan, 1993), Acceptance and Commitment Therapy (Hayes, Wilson, & Strosahl, 2011), and Family Based Therapy (Lock & LeGrange, 2013) offer salient knowledge and skill for the treatment of eating disorders, yet the intractable nature of eating disorders persists, begging the question: Is our current mode of perception of treatment the most fitting for the goal of the full development of the personality and a sustainable recovery? Archetypal psychologist James Hillman challenges that a new sensibility is required in psychotherapy, a quality of knowing that opens up the imagination in order to “see through” suffering. This article deconstructs the fantasy of eating disorder recovery by moving into the metaphorical roots beneath the rigid and unyielding behaviors, including America’s cultural complex of perfectionism. Depth psychological principles are applied to a case study of anorexia nervosa in an adolescent girl, arguing that a full recovery requires the presence of soul as integral to identity development. Fundamentally, a person with an eating disorder is hungering for soul in a culture that does not cultivate this form of nourishment.