Informed Outcomes: Self-rating measures and their use in psychodynamic therapy with adolescents

I am currently engaged in an A Space ¹ 1. A Space for Creative Learning and Support was set up as a research and development project in 1997 by The Glass-House Trust (a Sainsbury Family Charitable Trust), the Social Science Research Unit (Institute of Education, University of London) and Hackney Education. A core aim is to deliver psychodynamic therapies in the school setting, adapting and evolving current models of child and adolescent psychotherapy, where necessary, both in response to the educational context and to ensure that the needs of children and adolescents are best met. In 2010, A Space and The Centre for Psychoanalytic Studies, University of Essex, began a formal study into school-based therapy. Funded by The Glass-House Trust, this research will run through to 2013. A conference will be held in 2013, so that the findings can be more widely disseminated. /University of Essex research study looking at the ways in which psychodynamic counselling can best meet the needs of young people accessing therapy in the school setting. As part of the study, I have looked at the main outcome measures used in work with adolescents in clinics, the community and voluntary sector and in education settings. In this article, I look at the process of assessment, including the use of written self-rating outcome measures with young people. I critically review a selection of these and reflect on their application in practice. I go on to consider how collaborative written assessment procedures may be more appropriate for use by psychodynamic therapists working with school-based clients, given the challenges of delivering therapy in the education sector.     

Nachtraglichkeit

In this brief introductory essay, Harris and Bass consider the historic correspondence between Merton Gill and Philip M. Bromberg (1979–1981 Bromberg, P. M. 1979. Interpersonal psychoanalysis and regression. Contemporary Psychoanalysis, 15: 647–655. [Taylor & Francis Online], [Web of Science ®] , [Google Scholar]) in light of psychoanalytic developments over the past 30 years, which have included the emergence of Relational Psychoanalysis. The authors consider the ways in which the issues engaged by Bromberg and Gill in the correspondence stimulated by the publication of Bromberg's (1979) Bromberg, P. M. 1979. Interpersonal psychoanalysis and regression. Contemporary Psychoanalysis, 15: 647–655. [Taylor & Francis Online], [Web of Science ®] , [Google Scholar] “Interpersonal Psychoanalysis and Regression” helped shape the development of Relational Psychoanalysis as it emerged, and how the development of Relational Psychoanalysis has provided a new vantage point from which to view these early discussions.     

Pragmatic Psychodynamic Psychotherapy—Bridging Contemporary Psychoanalytic Clinical Practice and Evidence-Based Psychodynamic Practice

Pragmatic psychodynamic psychotherapy (PPP; Summers & Barber, 2009 Barber, J. P. 2009. Toward a working through of some core conflicts in psychotherapy research. Psychother. Res, 19(1): 1–12. [Taylor & Francis Online], [Web of Science ®] , [Google Scholar]) describes the therapeutic principles and approaches found in many forms of manualized psychodynamic psychotherapies, which are being used in research studies with the aim of building an evidence-based psychodynamic practice. This article focuses on one such treatment, Supportive-expressive psychotherapy (SEP; Luborsky 1984), which employs the Core Conflictual Relationship Theme (CCRT) method to formulate core interpersonal problems and treatment goals and identify therapeutic interventions. To illustrate SEP, we describe the 40-session treatment of a patient who met diagnostic criteria for several personality disorders. The case illustrates how complex ego-syntonic character pathology is expressed in CCRT terms and worked through in the transference, gradually becoming ego-dystonic and amenable to modification. In this case, the patient became more aware of his interpersonal wishes and vulnerability. Although his anxiety increased somewhat, he had an improvement in psychosocial functioning.     

‘Beyond forgetfulness’: How psychoanalytic ideas can help us to understand the experience of patients with dementia

We must cast ourselves forwards to a time when words must fail (Samuel Beckett, Happy days, 1961 Beckett, S. 1961. Happy days, London: Faber & Faber.  [Google Scholar]).

This paper approaches dementia and its care from a psychoanalytic perspective. It recognizes both the psychoanalytic literature on dementia and a biological understanding of neuro‐degenerative processes. Using neuro‐psychoanalysis to synthesize the two views, meeting points are found that may take the theoretical understanding of dementia processes a small step further, introducing the death instinct as one example. The mind and the brain are distinct entities which are also intimately related. A mind/brain model was proposed by Freud in his ‘project’ (1895). It pre‐dated his psychoanalytic work but was abandoned. None the less it runs as a rich vein throughout his work.

Although other causes exist there are two main types of dementia. Alzheimer's and vascular dementia have distinct differences and similarities in their respective clinical presentations. This paper explores the complex deterioration of brain and mind in both diseases and explains these in psychoanalytic terms. Developmental models of the mind are helpful, however dementia patients are adults, and are losing their minds in a non‐linear fashion. Dementia is not infant/child development in reverse order.

Three broad stages of dementia are proposed and psychoanalytic models of patient experience are suggested, as well as potentially offering ameliorating interventions. The first stage of dementia is dominated by anxiety and depression; also repression and denial and behavioural problems that may be akin to hysterical states. These seem to be amenable to analysis and psychoanalytically informed therapy. In the intermediate stages reality principle versus pleasure principle issues are patent, as are shame and humiliation (particularly around sexuality). Art and music therapies informed by psychoanalysis can be helpful as they depend less on words. In the final stages of extreme dependency, projective identification may be the most common method of communication. Understanding this phenomenon can assist sufferers and help carers to cope with unbearable states of mind. Some psychoanalytic ideas are already in use in some enlightened dementia services; there is room for more.     

Time and again: Intermittent Brief Dynamic Therapy

Abstract

The author notes that in many of the settings in which Brief Therapy takes place that a client may return after the ending for a further series of sessions. Time-limited therapy has placed an emphasis upon the termination phase of the therapy and linked this to the process of individuation and separation. Such an approach, as articulated by Mann (1973 Mann, J. 1973. Time-limited psychotherapy, Cambridge, MA: Harvard University Press.  [Google Scholar]), which draws conceptually from the work of Winnicott (1965 Winnicott, D. W. 1965. The maturational processes and the facilitating environment, London: Hogarth Press.  [Google Scholar]) and the notion that the infant achieves unit status from the original undifferentiated merger with the mother, is not easily compatible with Intermittent Brief Dynamic Therapy. The work of attachment theorists and Stern (1985 Stern, D. N. 1985. The interpersonal world of the infant, New York: Basic Books.  [Google Scholar]) provide an alternative basis upon which to conceive of the development of the infant. While emphasizing the importance of attending to affects at points of separation and ending, as is evidenced in the work of Della Selva (2004 Della, Selva P. C. 2004. Intensive short-term dynamic psychotherapy, London: Karnac.  [Google Scholar]), such a framework is more readily compatible with the development of Intermittent Therapy, and with the realities of the settings in which much brief work takes place. The author also comments upon the flexibility inherent in Winnicott's own practice of brief consultations, and the implications of this for the development of Intermittent Brief Dynamic Therapy. The paper includes a case study that illustrates this debate and which provides evidence for the therapeutic potency of a form of Brief Dynamic Intermittent Therapy where a dynamic focus maintains a structuring pattern to the narrative over a sequence of several periods of Brief Therapy, spread over a number of years.     

Pooled Peer Ratings,Self-Ratings,and Estimated Ratings of Therapeutic Communication and Popularity: A Relational Analysis

Two studies of therapeutic communication and popularity were conducted in the framework of Dialogic Action Therapy (Ho & Wang, 2009 Ho , D. Y. F. , & Wang , H. L. ( 2009 ). Interpersonal perceptions and metaperceptions in Dialogic Action Therapy: A relational methodological approach to theory construction . Humanistic Psychologist , 37 , 79 – 100 .[Taylor & Francis Online] , [Google Scholar]) that accords centrality to the bidirectional nature of interpersonal perceptions. Pooled peer ratings, self-ratings, and estimates of peer ratings were collected from 88 Chinese students in psychology who knew one another well. Self-inflation was operationally defined as the self-rating minus the peer rating, and overestimation as the estimated rating minus the peer rating, for each participant; negative values would be indicative of self-deflation or underestimation. Major results are: (a) Pooled peer ratings have superior validity over self-ratings of therapeutic communication; (b) bias effects (above-average and self-deflation) are found in ratings of popularity; (c) self-inflation and overestimation decrease as pooled peer ratings of therapeutic communication increase and, similarly, self-inflation decreases as pooled peer ratings of popularity increase. These results strengthen the case for a relational methodological approach that includes assessing how one views oneself and others, how one is viewed by others, and discrepancies between perceptions.     

Parental Bullying,Aggression, and Assertion: A Philosophical and Psychoanalytic Revisioning of Frank Summers' Case of Anna

Historically, psychoanalysis has failed to differentiate adequately between aggression and assertion. It is uncontroversial to state that bullying is a form of aggression. However, if aggression and assertion are not adequately distinguished, bullying could also be viewed as a form of assertion. Some psychoanalysts have attempted to resolve this by using the terms aggression and assertion as synonyms but introducing the notion of nondestructive aggression. Bullying, then, is understood to be hostile aggression or hostile assertion. In this article, I aim to prepare psychoanalytic and philosophical groundwork for a meaningful differentiation between aggression and assertion, and, at the same time, to shed light on the nature of bullying, parental bullying in particular. To achieve these aims, I critique an aspect of the case material presented by Frank Summers in his (2005) Summers, F. 2005. Self Creation: Psychoanalytic Therapy and the Art of the Possible, Hillsdale, NJ: The Analytic Press.  [Google Scholar] book, Self Creation: Psychoanalytic Therapy and the Art of the Possible. I also critique Parens' (2008) Parens, H. 2008. The Development of Aggression in Early Childhood, Lanham, MD: Jason Aronson.  [Google Scholar] notion of nondestructive aggression as used by him and by Summers. Additionally, I discuss some of the philosophical notions Summers introduces and discusses relevant to a critique of his notion of the analyst's vision of the patient's development in its relevance to his case of Anna.     

Min(d)ing Michael Shoshani (Rosenbaum's) Dare to be Human: Introduction

This introduction describes several of the unique features of Michael Shoshani (Rosenbaum's) (2009 Shoshani, M. (Rosenbaum). 2009. Dare to be human: A contemporary psychoanalytic journey, New York, NY: Routledge.  [Google Scholar]) Dare to be Human, a book that features the exceptionally broad and detailed case presentation of the psychoanalytic treatment of Daniel. Access is provided to the overall course of the analysis, samples of process and dialogue, biographical background information about the analyst, and two chapters authored by the patient posttreatment. A summary of the case is provided for those not familiar with the book, and four commentators take up varying aspects of this case presentation.     

Interpersonal Subtypes in Social Phobia: Diagnostic and Treatment Implications

Interpersonal assessment may provide a clinically useful way to identify subtypes of social phobia. In this study, we examined evidence for interpersonal subtypes in a sample of 77 socially phobic outpatients. A cluster analysis based on the dimensions of dominance and love on the Inventory of Interpersonal Problems–Circumplex Scales (Alden, Wiggins, &; Pincus, 1990 Alden, L. E. and Phillips, N. 1990. An interpersonal analysis of social anxiety and depression. Cognitive Therapy and Research, 14: 499–513. [Crossref], [Web of Science ®] , [Google Scholar]) found 2 interpersonal subtypes of socially phobic patients. These subtypes did not differ on pretreatment global symptom severity as measured by the Brief Symptom Inventory (Derogatis, 1993 Derogatis, L. R. 1993. Brief Symptom Inventory: Administration, scoring, and procedures manual , (4th ed.), Minneapolis, MN: NCS Pearson Assessments, Inc.  [Google Scholar]) or diagnostic comorbidity but did exhibit differential responses to outpatient psychotherapy. Overall, friendly-submissive social phobia patients had significantly lower scores on measures of social anxiety and significantly higher scores on measures of well-being and satisfaction at posttreatment than cold-submissive social phobia patients. We discuss the results in terms of interpersonal theory and the clinical relevance of assessment of interpersonal functioning prior to beginning psychotherapy with socially phobic patients.     

The Plague of Bullying: In the Classroom,the Psychoanalytic Institute,and on the Streets

This article addresses the social epidemic of bullying that impacts our schools, workplaces, and communities from a psychoanalytic perspective. It has been estimated by the American Academy of Child and Adolescent Psychiatry (2008 American Academy of Child and Adolescent Psychiatry. 2008. Facts for Families (online); #80 http://www.accap.org [Google Scholar]) that nearly half of our children are bullied at some point during their school years. Bullying has increased with use of the Internet and social networks, with cyber-bullying having become a new concern of parents and educators. Clinical examples will be drawn from an individual psychoanalytic treatment, a school setting, and a psychoanalytic organization. As a social issue, bullying behavior comes in many forms and, at worst, can become the foundation of cyclical violent and suicidal behavior, creating childhood trauma and severe psychological symptoms in children, adolescents, and adults. Psychoanalysis has much to offer conceptually, with clear implications for solutions. A theoretical section describes one dynamic of bullying, utilizing a self-psychological perspective. This approach emerged from the Analytic Service to Adolescents Program (ASAP), an in-school treatment and research program of the Chicago Institute for Psychoanalysis and Morton Alternative High School. I argue that the applications of psychoanalytic ideas beyond our consulting rooms can, in turn, inform and enrich the clinical experience in our consulting rooms as well.     

Reviving and Refining Psychodynamic Interpretation of the Wechsler Intelligence Tests: The Verbal Comprehension Subtests

The Wechsler intelligence tests (currently Wechsler, 2008 Wechsler, D. (2008). Wechsler Adult Intelligence Scale–Fourth Edition (WAIS–IV). San Antonio, TX: Psychological Corporation. [Google Scholar], 2014) have traditionally been part of the multimethod test battery favored by psychodynamically oriented assessors. In this tradition, assessors have used Wechsler data to make inferences about personality that transcend cognition. Recent trends in clinical psychology, however, have deemphasized this psychodynamic way of working. In this article, I make a conceptual and clinical case for reviving and refining a psychodynamic approach to inference making about personality using the Wechsler Verbal Comprehension subtests. Specifically, I (a) describe the psychological and environmental conditions sampled by the Wechsler tests, (b) discuss the Wechsler tests conceptually in terms of assessing vulnerability to breakdowns in adaptive defensive functioning, (c) review a general framework for inference making, and (d) offer considerations for and illustrate pragmatic application of the Verbal Comprehension subtests data to make inferences that help answer referral questions and have important treatment implications.     

MASTER OF THE UNIVERSE: SCORSESE’S “THE WOLF OF WALL STREET” THROUGH A PSYCHOANALYTIC LENS

In this essay I wish to present some reflections on Jordan Belfort, the protagonist of the movie “The Wolf of Wall Street” from a psychoanalytic prism. The movie, “The Wolf of Wall Street”, is a 2013 black comedy film directed by Martin Scorsese and adapted by Terence Winter from Belfort’s memoir (2007) of the same name. This movie has already been analyzed from cultural and historical perspectives, with the protagonist representing American culture of the 1980s. I will first summarize some of these views, and then present my psychoanalytic perspective of Jordan’s wish to become “Master of the Universe” (Wolfe, 1987; Grunberger, 1993), as expressed through his abuse of drugs, hyper-sexuality, and his aggressive and self-destructive behavior. As the craving for omnipotence and immortality is a universal wish that has existed from time immemorial, I will draw an analogy between certain aspects and symbolic elements in “The Wolf of Wall Street” and Wagner’s (1848–1872) four epic operas “Der Ring des Nibelungen.” I will conclude with a brief reference to the charismatic appeal of a man like Jordan to the general public.     

Understanding,respecting and integrating difference in therapeutic practice

The purpose of this paper is to promote thought and discussion around how and why we treat patients in chosen ways. In the present climate practitioners are required to treat patients following NICE guidelines in which cognitive behavioural therapy (CBT) is the treatment of choice in the majority of diagnoses. This paper raises concerns that this may lead to an homogenization of treatment, loss of invaluable skills and understanding from other treatment approaches, and loss to the patient who may be best cared for by a combination of treatments and approaches, most notably patients presenting with complex pathology. This paper aims to present this as a general principle, and by way of example, will focus on coupling two specific treatment orientations, cognitive behavioural therapy with psychodynamic psychotherapy, with the specific diagnosis of obsessive compulsive disorder (OCD).

Methods: Clinical material is drawn from case studies from practice in secondary adult mental health care services within the NHS. All patients were referred to the psychological services for treatment for OCD and provided with 1:1 therapy with UKCP‐registered therapists. Details have been anonymized by describing fictitious cases re‐constructed from clinical material. A theoretical understanding is included which provides both an overview for integrating treatment for the specific example of OCD and is intended by extension to other diagnoses.

Results: Working with the commonalities of therapeutic approaches, and integrating specific skills of CBT and psychodynamic psychotherapy, appears to offer a viable mode of treatment for cases resistant to single‐orientation therapies.

Conclusions: Coupling the skills of different therapies can be effective in treating complex patients that are referred to the secondary mental health services. Conversely, restricting practice to single orientation therapies can lead to an impoverished care for patients and diminution of invaluable therapeutic skills which may become underused, undervalued and lost in the practice of mental health care within the NHS. Acknowledgement of the skills of others, valuing these and learning from each other can help to avoid the defensive reactions of practitioners, where each may defensively retreat to their corners of specialism. Respecting and sharing skills from different orientations, and acknowledging this in the NICE guidelines, is good for both mental health services and patient care and addresses the concerns raised by practitioners exemplified by Bateman (2000 Bateman, A. 2000. Integration in psychotherapy: An evolving reality in personality disorder.. British Journal of Psychotherapy, 17(2): 147–156.  [Google Scholar], p. 147) that ‘psychotherapy continues to be bedeviled by ideological schisms with practitioners apparently ignoring alternative conceptualizations and potentially superior interventions’.     

Identification of the People and Critique of the Ideas in Meyer’s Philosophy of Occupation Therapy

This article identifies the people Meyer mentions in his article, “Philosophy of Occupation Therapy,” published in Archives of Occupational Therapy (Meyer, 1922c Meyer, A. (1922c). Philosophy of occupation therapy. Archives of Occupational Therapy, 1(1), 1–10. [Reprinted in American Journal of Occupational Therapy, 31(10), 639–642]. [Google Scholar]) and critiques the ideas discussed. Because there is no list of references provided within the article itself, the researcher selected the methodology of source criticism to identify the names of individuals appearing in the text—locating each person’s publications and analyzing the publications for influential ideas. Twenty-one names were found and publications were located for 15. Ideas were identified and analyzed. Finally, Meyer’s ideas were compared to current models of practice and a proposed reference list was created.     

Assessing Reflective Parenting in Interaction With School-Aged Children

The aim of this study was to examine whether it was possible to develop a reliable and valid assessment of reflective parenting implicit in interaction with school-aged children using an adaptation of the Squiggle paradigm developed by Winnicott (1968 Winnicott, D. W. (1968). Playing: Its theoretical status in the clinical situation. International Journal of Psycho-Analysis, 49, 591–599.[PubMed], [Web of Science ®] , [Google Scholar]) and a manualized coding system (Normandin, Leroux, Ensink, Terradas, &; Fonagy, 2015 Normandin, L., Leroux, A., Ensink, K., Terradas, M. M., &; Fonagy, P. (2015). Reflective Parenting Assessment coding manual (Unpublished manual). University Laval, Québec City, QC, Canada. [Google Scholar]). A total of 158 mother–child dyads participated when children were age 5 to 12. Of this group, 89 children had experienced sexual abuse. Interrater reliability using the manualized coding system was excellent. The factor analysis identified a reflective parenting stance factor, in addition to an affectionate support factor and a negative parenting factor. Furthermore, there was a medium strength relationship between the mother's reflective parenting stance evident in her interactions with her child and parental reflective functioning assessed using the Parent Development Interview (Slade, Aber, Bresgi, Berger, &; Kaplan, 2004 Slade, A., Aber, J. L., Bresgi, I., Berger, B., &; Kaplan, M. (2004). The Parent Development Interview–Revised (Unpublished protocol). The City University of New York, New York, NY. [Google Scholar]), suggesting the parental reflective stance is a good indicator of parental reflective functioning in interaction. With regard to parent reports of child internalizing and externalizing behaviors, the reflective parenting stance was the only predictor of internalizing difficulties and a significant predictor of externalizing difficulties in addition to sexual abuse.     

What is IPT? The Basic Principles and the Inevitability of Change

Interpersonal Psychotherapy (IPT) is an empirically validated treatment for a number of psychiatric disorders. Like all psychotherapies, IPT can be described by its theoretical foundations and its primary targets, tactics, and techniques. The need for continued creativity in IPT and other treatments is reviewed, and several specific proposals for change in IPT based on clinical observations and theoretical considerations are discussed. A paradigm for collaboration between academic research and clinical observation required for continued creativity is offered. Change is inevitable, and the empirically validated therapies such as IPT will be even more effective as they incorporate and test new and creative elements.

HOMELESSNESS AND CONTAINMENT – A PSYCHOTHERAPY PROJECT WITH HOMELESS PEOPLE AND WORKERS IN THE HOMELESS FIELD

A high percentage of homeless people suffer from a severe degree of personality disorder that causes them to fall through the net of psychiatric and caring services. Their persistent inability to maintain an actual dwelling‐place as a location of stability and meaning, is also reflected in an inner state of fragility, and in relationship difficulties that lead to destructive behaviours that inevitably alienate others. In this paper, the relationship between homelessness, the maternal body, buildings and containment is explored, using clinical material which illustrates how the claustro‐agoraphobic dilemma (Henri Rey 1994 Rey, H. 1994. Universals of Psychoanalysis in the Treatment of Psychotic and Borderline States, Edited by: Magagna, J. London: Free Association Books.  [Google Scholar]), intrinsic to the state of homelessness and to borderline conditions, impacts on vulnerable individuals and on care workers in this field. Examples drawn from staff consultations demonstrate how psychodynamic thinking can help to provide containment within systems of care.     

Religious fundamentalism and primitive projective processes

In her book on the origins, nature and contemporary global significance of religious fundamentalism, Karen Armstrong cites the example of an early twentieth-century, ultra-Orthodox Jewish spirituality1 ¹Such a spirituality may be characterized as ‘fundamentalist’ inasmuch as it appeals to the inerrancy of sacred texts to legitimize conceptions of the purity of the ‘Holy Land’ as exclusively a place for prayer and the study of Scripture and not as a site for the erection of a nation state. For a brief account of the history of ultra-Orthodox, anti-Zionist spirituality from 1900 to the present, see Armstrong 2000 Armstrong K 2000 The Battle for God. Fundamentalism in Judaism, Christianity and Islam (London: Harper Collins)  [Google Scholar], pp.?201–217. vehemently opposed to the creation of the state of Israel. Armstrong suggests that

This rejectionist vision is utterly incomprehensible to Jews who regard the Zionist achievement as wondrous and salvific. This is the dilemma that Jews, Christians and Muslims have all had to face in the twentieth century: between the fundamentalists and those who adopt a more positive attitude to the modern world there is an impassable gulf. Rational arguments are of no avail, because the divergence springs from a deeper and more instinctual level of the mind (Armstrong 2000 Armstrong K 2000 The Battle for God. Fundamentalism in Judaism, Christianity and Islam (London: Harper Collins)  [Google Scholar], pp.?204–205 [my highlighting]).

This paper will try and show that Melanie Klein's depiction of primitive mental processes serves to elucidate both the nature of this ‘impassable gulf’ and the ‘deeper’ levels of psychic functioning from which it originates. By shedding a specifically Kleinian psychoanalytic and object relations light on what appears to both warrant and inform the discourse on fundamentalism, it hopes to show how individual and group formation, and the interaction between them, are profoundly influenced by unconscious processes. Such processes are shown to be characterized by mechanisms of defence against anxieties – mechanisms induced by changes that threaten existing social relationships (Jaques 1955 The Guardian (2001) (London and Manchester) 13 October  [Google Scholar], p.?479).