Toward Holistic,Compassionate, Professional Care: Using a Cultural Lens to Examine the Practice of Contemporary Psychotherapy in the West*

The author describes work undertaken in New Delhi with two young Indian women and their families from 1995 to 1999. Both presented with depression and suicidal ideation. One was severely cerebral palsied, the other was diagnosed with endogenous depression. As an integrative therapist, the author looks at her work from several perspectives. The debates highlighted here focus on the optimal usefulness of each of these perspectives in different situations, both the benefits and the limits and the very limits of contemporary psychotherapy itself. The author uses a cultural lens to explore the use of the self of the therapist and issues around boundaries, continuity, ethics, and compassion in psychotherapy.*Part of this work has been published in N. Hutnik (1999). An unusual intervention: Disability and abuse. Psychological Foundations - The Journa1, 1, 81–84, and is reproduced here with the permission of Psychological Foundations, New Delhi.**My heartfelt thanks are offered to Reenee Singh, friend of many years and very competent family therapist, who offered me her comments on an earlier draft of this paper.     

Blind mothers of suffering babies

Abstract

In this paper, the author presents case material related to a patient who asked for psychotherapy as she was having difficulty managing her problems within the family. This clinical vignette reveals how some mothers have difficulties being, as Winnicott said, “ordinary devoted mothers.” These mothers are “psychologically blind,” in that they not able to psychologically “see” or feel the pain of their babies or children. The author discusses the case material using Winnicott and Bion’s essential concepts of how the patient is deprived of maternal functioning.     

A psychoanalytic interpretation of bipolar disorder

Abstract

The author proposes viewing mania as a form of defense against the state of depression resulting from “narcissistic overidentification with the depressive object” (i.e., the object in relation to which the depressive state developed), rather than as a periodic rebellion against such an internalized object. An account of the analytic psychotherapy of a clinical case of bipolar depression serves to illustrate this point of view, linked to the author’s specific conception of the dynamics of depression.     

Successful treatment of the mother-infant relationship in a mother suffering from severe postpartum depression

This paper discusses the treatment of severe postpartum depression in home-based infant-parent psychotherapy. Severe postpartum depression is examined as a psychiatric disorder in which childbirth is a necessary but insufficient cause. Home-based treatment that involved both mother and infant permitted a more comprehensive approach. By facilitating assessment of the risks to the infant from the mother's impairment by direct observation of the mother-infant relationship, infant-parent psychotherapy helped to avoid an unnecessary hospitalization of the mother in the case example. Instead, treatment helped to build on the ego strengths of the mother in order to stabilize precarious defenses and to support her bonding with her baby.     

Complexity of referrals to a specialist psychotherapy service

Consecutive referrals to a specialist psychotherapy service were analysed for complexity. Some 71% had a severe enduring mental illness or personality disorder. Two-thirds of the rest had added psychosocial or behavioural complexity. Only 9% had no severe enduring mental illness, personality disorder, or added complexity; nearly half of these had somatoform disorder. Only 2% of the patients had uncomplicated depression or anxiety disorders.

Patients treated in this psychotherapy service are substantially different from those on whom NICE bases its guidance for the treatment of depression and anxiety, and for whom IAPT was conceived, it functions as a de facto complex case service.     

A Mother,A Baby,and Two Treatment Approaches: Discussing A Switch Case from CBT and Mentalization Perspectives

ABSTRACT

As the literature on perinatal depression and anxiety grows, there is an increased need for dialogue among theoretical approaches for mother-infant mental health. This article describes a community mental health program incorporating a range of treatment models for pregnant and postpartum women experiencing issues during the transition to parenthood. Perinatal distress can affect parenting practices, from breastfeeding to health care access, creating the need for targeted, practical, and concrete interventions. Interventions that aim to foster secure attachment relationships and mentalization capacities can also help increase maternal sensitivity and attunement and joy in caregiving, and reduce withdrawn/hostile behaviors that may be associated with perinatal distress. The article describes psychotherapy with a mother and her newborn that began from a cognitive-behavioral approach and transitioned to a psychodynamic mentalization-focused treatment. Working principles and examples of two additional components of treatment, a group psychotherapy and research measures, are discussed. The case helps demonstrate how attachment theory can inform treatment and build a bridge between alternative approaches.     

Transference and the idea of God

While many factors influence the course of therapy, based on empirical evidence a strong case can be made for the importance of religious beliefs influencing the process of transference. During a ten-year period of private psychiatric practice, the senior author saw 353 patients suffering from anxiety and neurotic depression. The form of treatment was individual, dynamic, psychoanalytically oriented psychotherapy with occasional use of psychotropic drugs. Forty percent of the patients who were seen were Catholic; forty percent were Protestant; and twenty percent were Jewish.Protestants, Catholics, and Jews bring differing conceptions of God to the transference phenomenon in individual psychotherapy. Basing findings on extensive clinical evidence, this study seeks to explain why this occurs, and the need for the psychotherapist to be aware of religious factors that influence the course of psychotherapy.He is Associate Clinical Professor of Psychiatry at the Medical College of Wisconsin in Milwaukee and Associate Professor at the Institute of Psychology of the Pontifical Gregorial University in Rome, Italy.     

案例概念化在临床上的应用

随着心理治疗方法的发展, 案例概念化作为治疗工作的重要组成部分, 日益成为临床关注的热点。案例概念化主要指在一定治疗理论的基础上, 就来访者的问题成因和维持因素提出假设, 为构建治疗方案提供指导蓝图。西方的临床研究表明案例概念化能有效地促进咨询师和来访者对于问题的认识和理解, 提高治疗效果。以认知行为治疗理论为基础, 具体地介绍案例概念化技术在焦虑症和抑郁症的临床应用。     

Chatbot-Delivered Psychotherapy for Adults With Depressive and Anxiety Symptoms: A Systematic Review and Meta-Regression

Although psychotherapy is a well-established treatment for depression and anxiety, chatbot-delivered psychotherapy is an emerging field that has yet to be explored in depth. This review aims to (a) examine the effectiveness of chatbot-delivered psychotherapy in improving depressive symptoms among adults with depression or anxiety, and (b) evaluate the preferred features for the design of chatbot-delivered psychotherapy. Eight electronic databases were searched for relevant randomized controlled trials. Meta-analysis and random effects meta-regression was conducted using Comprehensive Meta-Analysis 3.0 software. Overall effect was measured using Hedges’s g and determined using z statistics at significance level p < .05. Assessment of heterogeneity was done using χ² and I² tests. A meta-analysis of 11 trials revealed that chatbot-delivered psychotherapy significantly improved depressive symptoms (g = 0.54, 95% confidence interval [−0.66, −0.42], p < .001). Although no significant subgroup differences were detected, results revealed larger effect sizes for samples of clinically diagnosed anxiety or depression, chatbots with an embodiment, a combination of types of input and output formats, less than 10 sessions, problem-solving therapy, off-line platforms, and in different regions of the United States than their counterparts. Meta-regression did not identify significant covariates that had an impact on depressive symptoms. Chatbot-delivered psychotherapy can be adopted in health care institutions as an alternative treatment for depression and anxiety. More high-quality trials are warranted to confirm the effectiveness of chatbot-delivered psychotherapy on depressive symptoms.PROSPERO registration number: CRD42020153332.     

Mentally ill or mentally handicapped? A longitudinal study of severe learning disorder

SUMMARY

In the course of some eighteen months of psychoanalytic psychotherapy, a young woman of twenty-seven once deemed braindamaged at the age of seven years, has shown herself capable of sustaining once weekly psychotherapy. Against all expectations she has taken responsibility for her own attendance, travelling by public transport alone to her sessions. She has also taken initiatives in relation to finding work for herself.

Psychotherapy has disclosed a significant component of autism in the personality which is resorted to regularly and which seems to drag the patient into a passive acceptance of half-life which she tries not to mind. In the course of her sessions the patient has come to take more notice of her predicament and to mind more about the dissatisfactions which she experiences.

The case presented here is considered to have the characteristics of a particular group of adolescents. These are often described as “just slow” and are brought for psychiatric or psychological attention by desperate parents urgently concerned about the working future of their children.

These are individuals of whom the original definition of mental handicap contained in the Mental Health Act 1913 “a state of arrested or incomplete development of mind” would seem to offer as honest, appropriate and meaningful an assessment as the formal I.Q. score introduced in 1959. Unlike the latter, it is an assessment based on a concept of mental development. Assessment by I.Q. score has led to emphasis on training to compensate for the supposed loss of functioning and also to notions like “training for development” and “education from birth”.

In the case described here it was the abandonment of training aims and approaches which produced a dramatic improvement in the well-being of the patient and her family. Treatment is now fostering the potential in this woman to bring her own mind into action and to support in her, her own wish for personal development.     

Children's understanding of physical illnesses and psychological states

Abstract

The present study set out to compare 5.7, and 9-year-old children's understanding of a physical illness (chicken pox) with their understanding of a psychological state (depression). In addition, information about personal experience of the illnesses and external sources of information was elicited, in order to assess the effects of both age and experience. Children at all ages showed a basic intact knowledge of both chicken pox and depression, although older children had a more sophisticated understanding of depression, and had acquired this knowledge from a greater number of sources. The clinical implications of the findings, and their relationship to both neo-Piagetian and more recent theories of conceptual development in childhood are discussed.     

Great Men: Psychoanalytic Studies by Edward Hitschmann. Foreword by Ernest Jones

Abstract

This study examined the effectiveness of an integrated model of brief group psychotherapy for treatment of fibromyalgia syndrome, using cognitive behavioral and supportive expressive techniques. In the context of an outpatient, multidisciplinary fibromyalgia treatment program, group psychotherapy was provided to 35 patients with 21 control patients. Pre–post treatment measures of depression, anxiety, fibromyalgia impact, pain, fatigue, and morning tiredness were obtained. Using a quasi–experimental design with validated psychometric instruments, the results showed a significant decrease in pre-versus post treatment measures of depression, fibromyalgia impact, fatigue, and pain for the treatment patients, suggesting that an integrated model of group psychotherapy may have beneficial psychological and functional effects for some patients with fibromyalgia.     

Out of the Ashes

SUMMARY

From the aftermath of a failed suicide attempt, a consumer describes her painful journey through a long course of psychosocial rehabilitation in a day treatment program, culminating in the cherished goal of emptoyment. As an individual with multiple disabilities, her past experience with occupational therapy in physical rehabilitation only addressed the presenting body part, not the whole person. Her feelings and need to learn emotional coping skills were not acknowledged until her desperate call for help through an overdose. In the process of becoming whole, she deals with the new stigma of an even more disabling label-mental illness.     

Beyond silence: working with Phoebe

This paper gives an account of a three-year period of silence that took place during the course of the intensive psychotherapy of a pre-adolescent girl with a diagnosis of ‘major depression’. The meaning and significance of silence in the therapeutic context is explored, as well as the importance of the ‘safety’ (Quinodoz, ‘The psychoanalytic setting as the instrument of the container function’, International Journal of Psycho-Analysis, 73: 627–35, 1992) and containing function of the setting that allows patients with a similar pathology a much needed regression, eventually enabling the birth and development of mature ‘verbal’ object relationships. Challenges and changes in the countertransference during a silent period in the course of psychotherapy are also discussed.     

Curious bedfellows: Psychoanalytic understanding and old age psychiatry

SUMMARY

The author outlines an approach to assessment, or as she prefers to call it, psychoanalytic consultation, in the Health Service. This involves giving the patient an experience of the analytic process, which they can then assess in a way, while the assessor gains information about a number of categories that can be thought of hierarchically, which inform the advice given the patient and the referrer about management and treatment. The safety of the patient is paramount, as psychoanalytic psychotherapy is a powerful and disruptive treatment. However it is argued that, on the whole, ‘suitability for psychotherapy’ should be on the basis of exclusion rather than involving the patient passing a sort of ‘suitability test’. The latter may enable public psychotherapy services to deny the incompleteness of what they are able to offer.     

Pertinence clinique en population dépressive d’un médiateur thérapeutique axé sur les ressources personnelles : évaluation par protocole individuel de type arrêt—reprise sur une patiente hospitalisée pour dépression

IntroductionThe low to moderate benefit of current care on optimal functioning in depressed patient encourages the development and evaluation of new interventions in this area.ObjectiveThis study aims at the clinical evaluation by single case of a serious game focused on personal resources in depressed population.MethodThe recommendations of the Single-Case Reporting Guideline In BEhavioural Interventions (SCRIBE) Statement were respected to design and report the results of this single-case research (Tate et al., 2016). A Withdrawal/Reversal ABA design has been applied to a young patient hospitalized for depression. Each phase contained 3 measurement opportunities spaced 7 to 10 days apart. In intervention phase B, a serious game was introduced in positive psychotherapy workshops without replacing the patient's usual care.ResultsIn the patient, serious game had a clinically significant benefit on depression, psychological well-being and affects. On the other hand, an increase in stress and anxiety levels, as well as a progressive decrease in the feeling of autonomy were also observed.ConclusionSerious game as a therapeutic mediator seems to have demonstrated its effectiveness for the patient. The reduction in depression coupled with the increase in stress and anxiety points out a favourable progression of the patient's problem. Elements specific to the patient's intra-individual problem were highlighted and could shed light on her clinical management.     

Network-level dynamics underlying a combined rTMS and psychotherapy treatment for major depressive disorder: An exploratory network analysis

BackgroundDespite the growing use of repetitive transcranial magnetic stimulation (rTMS) as a treatment for depression, there is a limited understanding of the mechanisms of action and how potential treatment-related brain changes help to characterize treatment response. To address this gap in understanding we investigated the effects of an approach combining rTMS with simultaneous psychotherapy on global functional connectivity.MethodWe compared task-related functional connectomes based on an idiographic goal priming task tied to emotional regulation acquired before and after simultaneous rTMS/psychotherapy treatment for patients with major depressive disorders and compared these changes to normative connectivity patterns from a set of healthy volunteers (HV) performing the same task.ResultsAt baseline, compared to HVs, patients demonstrated hyperconnectivity of the DMN, cerebellum and limbic system, and hypoconnectivity of the fronto-parietal dorsal-attention network and visual cortex. Simultaneous rTMS/psychotherapy helped to normalize these differences, which were reduced after treatment. This finding suggests that the rTMS/therapy treatment regularizes connectivity patterns in both hyperactive and hypoactive brain networks.ConclusionsThese results help to link treatment to a comprehensive model of the neurocircuitry underlying depression and pave the way for future studies using network-guided principles to significantly improve rTMS efficacy for depression.     

Gaze,dominance and humiliation in the Schreber case1

In this paper the author reviews Freud's study of Schreber's Memoirs and the Memoirs themselves from a perspective of nearly 100 years. He argues that Schreber's illness began as a melancholic depression but quickly developed paranoid features which subsequently escalated into a gross paranoia which nevertheless retained its depressive and hypochondriacal base. Finally the chaotic fragmentation became organized under the dominance of an omnipotent narcissistic organisation which led to a clinical improvement without any relinquishment of his delusional beliefs. As a subsidiary theme he examines the role of gaze in Schreber's object relations and argues that gaze was used to project into his objects, then to scrutinise the object to see if the projections had been received and tolerated, and finally as an expression of dominance. His urgent demand for relief provoked an omnipotence in his objects which he was then able triumphantly to frustrate and which ushered in a struggle over dominance in the course ofwhich Schreber was abused and humiliated. He was unable to find an object who could contain his distress and these factors contributed to the failure to tolerate guilt and to work through his depression.     

The effect of contingent reinforcement on target variables in outpatient psychotherapy for depression: a successful and unsuccessful case using functional analytic psychotherapy

The current study investigated a behavior-analytic treatment, functional analytic psychotherapy (FAP), for outpatient depression utilizing two single-subject A/A+B designs. The baseline condition was cognitive behavioral therapy. Results demonstrated treatment success in 1 client after the addition of FAP and treatment failure in the 2nd. This study highlights the challenges in measuring treatment progress and outcome idiographically in this population.