Clients’ experiences of dynamic interpersonal therapy (DIT): opportunities and challenges for brief,manualised psychodynamic therapy in the NHS

Dynamic interpersonal therapy (DIT) is a brief manualised psychodynamic intervention for depression. This is a first study exploring clients’ experiences of DIT specifically and brief, manualised psychodynamic psychotherapy (PP) in general. Interpretative phenomenological analysis was the methodology employed. Five participants completed a semi-structured interview, three weeks to ten months after completing DIT. The scores of pre- and post-therapy outcome measures of depression and anxiety were also available. Two emerging superordinate themes are presented here: (1) ‘The Distinct Features of DIT’, referring to how its therapeutic style and time limitations were experienced and (2) the ‘Impact of Therapy’, referring to perceived outcomes. While previous findings showed that therapist’s perceived limited activity in long-term PP was experienced as hindering/unhelpful, the perceived sense of direction in DIT appeared adequate to most participants. Secondly, the time limitations provoked complex responses. Reactions to the distinct elements of DIT are to be treated both as therapeutic opportunities and as challenges. Further, in line with psychoanalytic theory, most participants described relational changes that went beyond symptom relief and remained in progress after therapy ended. Intriguingly, there was no consistency between participants’ qualitative accounts of change and the scores of the outcome measures.     

Postmodernism versus psychotherapy

‘Postmodernism’has made a substantial impact on various schools of psychotherapy, including family therapy.‘Postmodern’therapists tend to focus on the productive capacities of language, developing narrative styles for their work.‘Postmodern’family therapy is differentiated from modernist approaches by its disavowal of truth claims and its encouragement of alternative‘voices’or narratives. In this paper, it is argued that this represents too narrow an approach to psychotherapy and to postmodernism. Postmodernism takes as a central concern the limits of symbolization, so a postmodernist therapy would deal primarily with failures of language. Language-based therapeutic procedures such as those to be found in family therapy are consequently not postmodernist. This state of affairs should be welcomed, as a truly‘postmodern’mode of therapy would probably celebrate irrationality.     

Editorial: Culture and religion

Based on theories of category formation (Baird) and genealogy (Foucault and Asad), and writing myself reflexively into the field, I question the consensus view that there is (or ever was) a viable social or religious ‘movement’ called ‘New Age’. Through a brief review of secondary sources, I disaggregate and historicise the field, drawing attention to signs of incompleteness, heterogeneity and cultural diffusion in preference to the dominant argument for a sui generis phenomenon. Within the field, I trace connections between Alice Bailey's discourse and Findhorn colony practice to illustrate one particular ‘New Age’ genealogy. I argue that ‘New Age’ is better represented as an expression of contemporary Anglo-American ‘popular religion’, a (re)conceptualisation that encourages more fruitful comparative historical and ethnographical analyses. Finally, I identify an emergent ‘second wave’ of ‘New Age’ studies, characterised by a concern for localised and contextualised representations.     

Family work for schizophrenia: some issues for Chinese immigrant families

This paper discusses some specific issues relevant to immigrant Chinese families in the context of family work for schizophrenia. The issues include shame and guilt, isolation and mistrust of officials, the importance of negotiation before details of problem-solving are worked out, high academic ambitions for children, and apparent ‘overprotectiveness’ in the Chinese culture. It is argued that cognitive-behavioural, goal-orientated family work could be adapted well for immigrant Chinese families with a member suffering from schizophrenia. A case study is presented to illustrate how such a family was helped.     

Alcohol problems and relapse: Can the clinic combat the community?

Despite over a decade of research and debate into the issue of relapse the majority of people in treatment for alcohol-related problems still relapse. In this paper the results of an innovative relapse prevention and management programme are reported. It was found that a cognitive-behavioural package of strategies reduced the likelihood of relapse. On average, clients receiving this experimental package took four times longer to return to any alcohol use and seven times longer to return to ‘heavy drinking’ than did a conventional treatment control group. However, notwithstanding these results, 60 per cent of the experimental group did return to harmful drinking. The authors question whether further refinement of these procedures is possible, and suggest that if relapse rates are to be further reduced then greater attention needs to be given by counsellors to clients' social environment.     

Target setting,self-reinforcement pattern and locus of control orientation as predictors of outcome in a behavioural weight-loss programme

High levels of unexplained variance have been reported in the outcome of weight-loss attempts by the obese using dietary and behavioural procedures to lose weight. The present study examined the effects of varying the short-term ‘target’ expectations of weight-loss and the degree of delay of self-reinforcement procedures. Contrary to expectation a significantly greater weight-loss was achieved under ‘unrealistic’ high target levels than under ‘realistic’ lower levels. Delay of self-reinforcement showed no differential effect. Hypothesized interactions between the experimental conditions and an external locus of control orientation were not found but there was a tentative indication that internally controlled individuals do significantly better under the ‘High’ than the ‘Low’ target expectations. The data suggest that more systematic attention should be paid to these cognitive-behavioural variables in planning weight-loss, programmes.     

Family therapy in Macau: development,challenges and opportunities

Family therapy in Macau is in its early stages of development. The Satir model and structural family therapy were the first two therapies introduced. Later on, solution‐focused brief therapy and narrative therapy were also introduced. Macau has been undergoing dramatic socioeconomic changes since the relaxation of the gambling licenses. In sociocultural terms this has led to significant changes: the so‐called ‘dealer's complex’, gambling, drug abuse and youth deviance have become more prevalent. To address complicated family problems, various counselling institutes and training centres were established to conduct family therapy. However, there are still some limitations and challenges that must be addressed in order to have a thriving family therapy profession in Macau.     

An eight-eyed version of Hawkins and Shohet's clinical supervision model: the addition of the cognitive analytic therapy concept of the ‘observing eye/I’ as the ‘observing us’

This paper proposes incorporating the concept of the ‘observing eye/I’, from cognitive analytic therapy (CAT), to Hawkins and Shohet's seven modes of supervision, comprising their transtheoretical model of supervision. Each mode is described alongside explicit examples relating to CAT. This modification using a key idea from CAT (in the form of the addition of a Mode 8 ‘observing us’) enhances the model's utility in supervisory practice. With this adaptation, the model could also be used, with greater breadth and depth, in therapies where the primary focus is not relational. The collaboratively reflexive ‘observing us’ ensures that the very process of supervision is effectively monitored and attended to. The inclusion of this eighth level leads to more formal emphasis on the meta communication and meta commentary levels in supervision.     

Some considerations about personality structure in child psychosis

This paper begins by describing the three main areas that can be addressed in seeking to bring about change in parent?–?infant work, and questions the extent to which a brief therapy model may be generally effective. Following a clinical example, there is a discussion of the nature of the process of change with this particular population. Drawing on ideas from Paula Heimann and others it is suggested that the ‘ghost in the nursery’ described by Fraiberg represents an ‘unassimilated object’ that may frequently be projected on to the infant but is also likely to appear elsewhere. It is argued that, especially if therapy relieves the infant of this projection, it will most often manifest its presence in the couple's relationship. In consequence, it is this relationship that should be a primary focus for our interventions, particularly as this also provides the essential context for the infant's psychological development.     

‘A preparation for practice?’ Students experiences of counselling training within departments of higher education

The literature has identified a gap between the education and practice in the education and training for the practice based professions based within traditional Departments of Higher Education. In the education and training in counselling it is suggested that this gap is primarily between those who view practice as the rigorous application of formal ‘science’ and those who see it as more holistically embedded in ‘tacit knowledge’ and artistry of the practitioner. This paper reports on a small scale qualitative study (Scanlon, 1993) which investigated the experience of students undertaking Counsellor training courses within Departments of Higher Education. Analysis of interview data revealed three main categories of concern. The first categoy describes the adverse effects of the theory-practice gap on the students. The second catego y describes the importance of clinical supervision in acquiring practice skills and the third catego y describes the participants' concerns about the quality of outcome for such training, particularly in relation to the perceived lack of ngour in the assessment of clinical competence. In the light of these findings a number of suggestions about how the professional education and training of counsellors could be better integrated into a more ‘practice led’ curriculum model are discussed.     

Coming to an end: A case study of an ambiguous process of ending psychotherapy

Aim: When the duration of therapy is not preset and the outcome is a matter for negotiation, the decision to end psychotherapy will be an experiential concern for the two participants. This case study draws attention to how ambiguities may be settled in a process where ending is initiated by the therapist and resisted by the client. Method and analysis: The actual case was strategically selected as exceptional owing to a combination of circumstances. The client and the therapist had developed a ‘good enough’ alliance (WAI) and reached a ‘good enough’ outcome (OQ‐45), and still the client felt she was far from finished. A close inspection of interactional data in sessions together with both clients' and therapists' reflections in post‐therapy interviews elicited information about both substantial content and structural aspects of this complicated process of ending. Findings and discussion: The discrepancy between therapist and client was not addressed, but rather postponed and revisited again later. Structural elements like preparations for a break for vacations and reducing the frequency of sessions were used to test experiential qualities, such as how the client managed life without therapy. Carefully preserving a ‘good enough’ emotional bond through the negotiations seemed important to both parties. Significantly, the client's autonomy was interpreted as the final proof of improvement and the client came to a point where she could affirm that she had got better only by accepting that treatment was coming to an end.     

Dilemmas in brief therapy

This paper examines three central concerns for the short-term therapist at a time when therapy is widely available free of charge in the community, in a model that has been called ‘ serial life-span therapy’. Issues of referral-on, topping-up or extending contracts are experienced as dilemmas or as temptations, depending on what therapists believe their clients need and what their clients may demand of them. Short-term therapy has become accepted in many contexts, with therapy no longer used as a once-and-for all solution to clinical problems, but as a serial method over time which includes topping up and re-contracting. After an initial agreement of brevity, depending on the client's disturbance levels at assessment and on availability, there may be the need for referral-on at the end of a brief contract, when clients may be offered a different, long-term service, or they may be recommended to return later in life for more, if and when this becomes necessary. Flexible contracts rather than rigid rules about the termination of therapy are being practiced in many contexts, depending on ‘what works’ and how methods can be adjusted to new evidence. There is danger of collusion or control, and this can lead to therapeutic dilemmas, which involve taking acceptable risks, or to therapeutic temptations, which are due to the desire for narcissistic gratification, benefiting the therapist rather than the client in terms of power or Eros. Being able to let go of clients and manage issues of loss, grief and greed requires a measure of maturity in the therapist that aims for good-enough results rather than striving for perfect endings.     

Robert Burns in the counsellor's chair: A socio-cultural analysis of the Burns myth

To illustrate how difficult endings are, this paper first cites an Italian therapist's experience of the use of time with university students in Naples and then associates to contrasting examples in the novel, art, music and the cinema. It uses a dialogue about ending in the film Brief Encounter as a possible paradigm for what is needed in brief therapy. It then refers to the work of James Mann on different experiences of time which underlie the resistance to brief work. How can brief therapy contain the paradox between finite and infinite time? Incorporating another model of therapeutic intervention with the use of Milton Erickson's attitude to time and the unconscious, the paper then moves on to a clinical example, where treatment consisted of an assessment and five sessions. Here the practice of not interpreting the transference is challenged, along with an exploration of the concept of transference to the organization and the use of pre-treatment ‘maternal reverie’ associations. Using the combination of informal trance-like states with a clear focus on the ‘here and now’, the process of the therapeutic relationship is then worked with in the case material.     

The effects of brief cognitive-behaviour therapy for pathological skin picking: A randomized comparison to wait-list control

Thirty-four college students suffering from pathological skin picking were randomly assigned to a four-session cognitive-behavioural treatment (n = 17) or a waiting-list condition (n = 17). Severity of skin picking, psycho-social impact of skin picking, strength of skin-picking-related dysfunctional cognitions, and severity of skin injury were measured at pre-, post-, and two-months follow-up assessment. Participants in the treatment condition showed a significantly larger reduction on all measured variables in comparison to the waiting-list condition. The obtained effect sizes for the outcome measures were large, ranging from .90 to 1.89. Treatment effects were maintained at follow-up. In conclusion, cognitive-behavioural therapy, even in brief form, constitutes an adequate treatment option for pathological skin-picking behaviour.     

Conceptualizing ‘social capital’ for health promotion in small local communities: a micro‐qualitative study

This paper reports on a micro‐qualitative case study of peoples' experiences of local community life in a south‐east English town. This material is used as the basis for a critical discussion of the suitability of Putnam's notion of social capital as a conceptual tool for the design and evaluation of ‘community strengthening’ policies and interventions. The study was motivated by a concern that too much debate about social capital has been conducted by academics and policy‐makers in a top‐down manner, with inadequate attention to the realities of life in the local communities that they refer to. Three‐hour semi‐structured interviews were conducted with 37 residents in two less affluent wards in our town of interest. Informants—half men and half women, and spread across the 15–75 age group—were encouraged to talk about their personal experiences of local community life. Interview findings are presented within the ‘norm’ categories of trust, neighbourliness and reciprocal help and support, and the ‘network’ categories of participation in informal networks, voluntary groupings and community activist groupings. Our case study points to a number of ways in which Putnam's concept needs to be refined if it is to inform ‘community strengthening’ policies and interventions in England. Far more notice needs to be taken of the role played by informal networks of friends and neighbours in the construction of local community life. Attention also needs to be given to the complex and shifting geographical spread of peoples' significant social networks. Putnam's conceptualization of cohesive local communities and his unitary notions of trust and local identity may also be unduly essentialist. In our particular communities of interest, they failed to capture the fluidity of local community norms and networks in a rapidly changing society. They also failed to do justice to the extent to which social distinctions—such as age, gender, ethnicity and housing tenure—shape and constrain the way in which people create, sustain and access social capital. Copyright © 2001 John Wiley & Sons, Ltd.     

Sexually abused children and post-traumatic stress disorder

Sexually abused children often develop post-traumatic stress disorder, a distressing and debilitating condition that is typically unresponsive to non-directive counselling. Empirically supported abuse-confronting, structured interventions are urgently required for use by counselling psychologists responsible for the management of this challenging clinical population. Given the success of cognitive-behavioural interventions with adult trauma victims, it has been suggested that this treatment approach be applied to sexually abused children. This paper presents a cognitive-behavioural treatment framework comprising two levels of intervention: child therapy and parent training. We selectively review emerging empirical support for the efficacy and acceptability of this treatment approach.     

PSYCHOANALYSIS AND COGNITIVE BEHAVIOUR THERAPY ‐ RIVAL PARADIGMS OR COMMON GROUND?3

The author suggests that contemporary enthusiasm for cognitive‐behavioural therapy reflects our longing for swift, rational help for psychological suffering. Competition for funding threatens the psychoanalytic presence in the public sector. The psychoanalytic and cognitive‐behavioural models are contrasted, and the relative richness of the psychoanalytic paradigm outlined. The author suggests that a cognitive model is commonsensical, but less complex, with less potential explanatory and therapeutic power. She discusses how the analytic stance is always under pressure to ‘collapse’ into simpler modes, one of which resembles a cognitive one. This also occurs inevitably, she argues, when attempts are made to ‘integrate’ the two models. Cognitive and ‘integrated’ treatments nevertheless have the advantage that they are less intrusive and hence more acceptable to some patients. Selected empirical process and outcome research on cognitive and psychoanalytic therapies is discussed. Brief psychotherapies of either variety have a similar, modestly good outcome, and there is some evidence that this may be based more on ‘dynamic’ than ‘cognitive’ elements of treatment. Formal outcome studies of more typical psychoanalytic psychotherapy and of psychoanalysis itself begin to suggest that these long and complex treatments are effective in the more comprehensive ways predicted by the model.     

Some thoughts on moving West

Abstract

This paper outlines an application of psychoanalysis in the tradition of Donald Winnicott in the clinical practice of paediatric diagnostic radiography. A practical way in which psychoanalytic theory may be employed in the care of essentially ‘normal’ children and their parents in the ‘abnormal’ setting of a district general hospital is demonstrated. The themes of holding and the effect of impingements, transitional phenomena and creative apperception and experiencing are addressed. A brief case study of one 15-month-old child is presented.     

Panic disorder: A cognitive-behavioural approach to treatment

The present study investigated the relationship between panic disorder and cognitive-behavioural therapy in a sample of 27 panic disorder patients who were randomly assigned to either a Treatment (six weeks of cognitive-behavioural therapy) or a Control group. Panic disorder was operationalized using three subjective and three physiologic indices. Results indicated that six weeks of cognitive-behavioural therapy were effective in decreasing panic disorder, as measured by three report measures: the Anxiety Sensitivity Index (catastrophic thoughts), State-Trait Anxiety Inventory (trait anxiety), and number of panic attacks, for the Treatment group relative to the Control group. In contrast, cognitive—behavioural therapy was ineffective in decreasing physiologic arousal as defined by blood pressure, pulse rate, and finger temperature. Implications of these results are discussed.     

A quantum approach to visual consciousness

A theoretical approach relying on quantum computation in microtubules within neurons can potentially resolve the enigmatic features of visual consciousness, but raises other questions. For example, how can delicate quantum states, which in the technological realm demand extreme cold and isolation to avoid environmental ‘decoherence’, manage to survive in the warm, wet brain? And if such states could survive within neuronal cell interiors, how could quantum states grow to encompass the whole brain? We present a physiological model for visual consciousness that can accommodate brain-wide quantum computation according to the Penrose–Hameroff ‘Orch OR’ model. In this view, visual consciousness occurs as a series of several-hundred-millisecond epochs, each comprising ‘crescendo sequences’ of quantum computations occurring at ∼40 Hz.