Safety-signal therapy in agoraphobics: a preliminary test

It has been argued that persistent avoidance behaviour is strongly influenced by safety signals, and that agoraphobic avoidance behaviour is a clinical example of this influence. It was proposed that agoraphobic avoidance can be reduced by the judicious use of safety signals, and specifically, by training patients to travel towards rather than away from safety. A safety-signal technique in which the patient travelled towards the therapist at the most fear-inducing situations was compared with conventional therapist-assisted exposure. In the second part of the treatment programme, both groups of agoraphobics were given homework assignments. The safety-signal technique resulted in slightly better clinical gains than those achieved by therapist assisted exposure, but after these relatively brief programmes, the improvements in both groups were weak. Global clinical outcome was influenced by age, chronicity and long-term benzodiazepine use.     

THE TRIADIC INTERSUBJECTIVE MATRIX IN SUPERVISION: THE USE OF DISCLOSURE TO WORK THROUGH PAINFUL AFFECTS3

The use of the psychoanalyst's subjective reactions as a tool to better understand his/her patient has been a central feature of clinical thinking in recent decades. While there has been much discussion and debate about the analyst's use of countertransference in individual psychoanalysis, including possible disclosure of his/her feelings to the patient, the literature on supervision has been slower to consider such matters. The attention to parallel processes in supervision has been helpful in appreciating the impact of affects arising in either the analyst/patient or the supervisor/analyst dyads upon the analytic treatment and its supervision. This contribution addresses the ways in which overlapping aspects of the personalities of the supervisor, analyst and patient may intersect and create resistances in the treatment. That three‐way intersection, described here as the triadic intersubjective matrix, is considered inevitable in all supervised treatments. A clinical example from the termination phase of a supervised analysis of an adolescent is offered to illustrate these points. Finally, the question of self‐disclosure as an aspect of the supervisory alliance is also discussed.     

The efficacy of teaching psychology students exposure and response prevention for obsessive-compulsive disorder

The aim of the study was to investigate whether inexperienced student therapists could successfully learn exposure and response prevention for obsessive-compulsive disorder. Twenty out of 21 outpatients completed treatment as delivered by ten psychology students. A total of 60 hours group supervision and approximately 30 hours with individual supervision was given to the students over the course of three semesters. Large effect sizes were observed for measures of symptoms and depression. Sixty-two percent ( N = 13) of the intent to treat group achieved clinical significant change and 81% no longer met the diagnosis criteria ( N = 17). The treatment effects observed at the 6 month follow-up period were promising. The results are encouraging for training students in evidence based treatment for specific disorders.     

La gestion de la souffrance par le psychologue clinicien. Étude des impacts et des stratégies de coping

We focus in this study on strategies used by clinical psychologists to cope with their own or patient psychological distress in the framework of help relationship. A self-administered form was sent to listings of professionals by e-mail. The sample is made of 187 French clinical psychologists. To cope with patients’ suffering, psychologists use mostly avoidance coping style. And the strategies they prefer are “supervision”, “personal therapy” and “speaking with colleagues” (problem focused coping strategies). To cope with their own distress, which has a lot of negative impacts on help relationship, psychologists have most frequently a problem focused coping style but their favourite strategy is to “lighten their schedules”. And almost a quarter of the sample presents a significant level of distress. In conclusion, results show that psychological distress management by psychologists is an important question with a lot of ethical questions.     

Psychoanalytic treatment of a woman with anxiety attacks and conversion

This case study describes the psychoanalytic treatment of a young woman presenting with symptoms of overwhelming anxiety, panic, and conversion. The emphasis is on technique with detailed reporting on the psychoanalytic process. Attention is paid to transference-countertransference paradigms at critical junctures in the treatment. The role of clinical supervision in the unfolding of the process is described also. This patient developed an identifiable transference neurosis during the course of the treatment, which became the focus of the analysis. Follow-up observations on this patient are also presented, as she returned for a brief course of treatment 4 years following initial termination.     

Batterer men in prison and in court-referred treatment programmes: what is the difference?

This paper describes the demographic, gender violence and psychopathological characteristics of 399 men in a specialized treatment programme for gender violence. Furthermore, a comparison of all the variables studied among the subjects referred by the court to the treatment programme (n = 276) and those who were imprisoned (n = 123) was conducted. The results showed the existence of numerous statistically significant differences between groups, primarily in psychopathological variables and in cognitive bias about women and violence use. In general, imprisoned batterers showed more irrational beliefs both about women and about violence as a strategy to cope with everyday difficulties. Moreover, batterers in prison had significantly higher scores on all psychopathological symptoms as assessed by SCL-90-R, as well as in most of STAXI-2 subscales. According to these results, batterers in prison showed a higher severity in variables studied than those who were referred by the court to the treatment programme. Implications of these results for further research and clinical practice are also commented on.     

Virtual Reality Exposure in the Treatment of Panic Disorder With Agoraphobia: A Case Study

In this work we present a case example of the use of virtual reality exposure for the treatment of panic disorder with agoraphobia. The assessment protocol and procedure (including a baseline period) and the cognitive-behavioral treatment program are described. The clinical measures were categorized into target behaviors, panic and agoraphobia measures, global functioning, and general psychopathology measures. The patient’s expectations and satisfaction with regard to the virtual treatment were also assessed. The results showed an important reduction in all clinical measures after treatment with virtual exposure and the patient reached the therapeutic goals established during the pretreatment assessment. The patient also reported a good acceptance of virtual exposure. The goals achieved in the virtual environment generalized to real agoraphobic situations and to other real situations not treated. Three-, 6-, and 12-month follow-up assessments were conducted and long-term therapeutic gains were maintained.     

Compliance with a behavioural weight-loss programme: Target setting and locus of control

The effects on weight loss of two ‘target-setting’ strategies were compared for a sample of obese females following a dietary/behavioural weight-loss programme. Predictions concerning the interaction between target-setting strategy and Locus-of-Control orientation were examined. The option of adopting a ‘variable’ food intake strategy, which allowed compensations or planning variations around an average target, was associated, for externals, with greater weight loss than a ‘consistent’ strategy, in which daily targets for food intake were always the same. Internals did not respond differentially to the two conditions. A measure of verbal intelligence was significantly correlated with control orientation but intelligence was not significantly correlated with weight loss. Some theoretical and clinical implications are discussed.     

Toward the science‐informed practice of clinical supervision: The Australian context

Although supervision of clinical practice is mandatory for trainee psychologists, surprisingly little is known about the key ingredients of effective supervision and the relationship between supervision and patient outcomes. The purpose of this paper was to review current regulations that shape supervision in Australia and explore the links between these regulations and the components of effective supervision. Although recent developments including supervisor training and other quality control programs are an indication of progress, there are several empirical and conceptual issues in the supervision literature that require resolution. The second part of this paper identifies the gaps in the supervision literature and suggests steps to advance the development of a mature science of clinical supervision. The main areas requiring attention include the identification of the mechanisms by which supervision produces change in supervisees and their patients, the refinement of measurement methods and instrumentation, and the need to pursue collaborative research that maximises the generalisability of research findings.     

The Acceptability of Computer-Aided Cognitive Behavioural Therapy: A Pragmatic Study

The clinical and cost-effectiveness of a computer-aided cognitive behavioural therapy (CCBT) programme, Beating the Blues, is indicated by a number of studies, but relatively little is known about its acceptability for patients with depression, anxiety, or both. This study investigated the acceptability of Beating the Blues offered on eight scheduled clinic visits with brief face-to-face support. Pre and posttreatment measures explored the relationship among programme acceptability, treatment continuation, and outcomes for people accessing the programme in routine care. Two hundred and nineteen patients with depression, anxiety, or both were offered Beating the Blues in 11 primary and secondary care practices. One hundred and ninety-one (87%) completed the pretreatment measures and 84 (38%) completed a treatment feedback questionnaire. Analysis of treatment acceptability for CCBT indicated a positive patient experience with the programme. Pretreatment expectancies predicted CCBT treatment completion but not outcomes. No differences were found between men and women on pretreatment measures. Posttreatment, women reported more favourable responses to the therapy, finding the programme more helpful and more satisfactory, than did men. No relationship between treatment acceptability and age was found. Study limitations, including research methods and attrition rates, and implications for future research are discussed. It is concluded that the Beating the Blues CCBT programme is an acceptable treatment for common mental health problems in routine care.     

Supervising professionals involved in the psychological care of people infected with HIV/AIDS

The provision of psychological care for people with HIV/AIDS in the last decade has led to a demand for professional supervision of counsellors and other professionals who work with this patient group. While there are many similarities in the supervisory process with professionals working with patients with other medical and psychological problems, there are also unique and specific issues which stem from working with people with HIV/AIDS. Some of these are discussed in this paper. The supervisory process described relates to a systemic conceptual framework. Tasks in clinical supervision and dijiculties in supervision are highlighted. Suggestions are offered for setting up and developing supervision sessions in clinical practice.     

慢性乙型肝炎治疗路线图的评价——应答指导的临床治疗策略

慢性乙型肝炎治疗路线图是根据患者对抗病毒药物应答的不同、用病毒及其抗原水平在治疗的整个过程中对患者进行科学管理、制定治疗策略、确定治疗时间的一种优化治疗方案。本文将从它的可行性和意义、重要性、治疗策略的确定及在临床上应用的局限性等方面进行论述。     

Strengthening doctoral supervision in a Doctor of Psychology (DPsych) Specialisation in Child and Adolescent Psychology

Supervision differs in PhD and DPsych contexts. PhD supervision focuses on students' pursuit of a career in academia, with the emphasis on research. In a DPsych framework, the focus of supervision is to assist students, who are experienced practitioners in a professional field, to complete a structured course and a research component. The aim of the article is to reflect on the application of supervision principles, models, metaphors and supervisory styles within a DPsych context. This article presents a case illustration of supervision in a DPsych programme (with specialisation in child and adolescence, or DPsych Child) presented at the University of the Free State in South Africa. Supervision focuses on developing the DPsych students' doctoral identity so that they, as scientist-practitioners, could contribute ultimately to the professional context of child psychology and apply theoretical knowledge to complex challenges. The article proposes that research on supervision processes and practices within a DPsych Child context could complement explorations into the value of the implementation of the scientist-practitioner model and thus augment quality assurance of the DPsych programme.     

Therapist Behavior During Exposure Tasks Predicts Habituation and Clinical Outcome in Three Randomized Controlled Trials for Pediatric OCD

This study measured therapist behaviors in relation to subsequent habituation within exposure tasks, and also tested their direct and indirect relationships (via habituation) with clinical outcomes of exposure therapy. We observed 459 videotaped exposure tasks with 111 participants in three clinical trials for pediatric obsessive-compulsive disorder (POTS trials). Within exposure tasks, therapist behaviors and patient fear were coded continuously. Outcomes were habituation and posttreatment change in symptom severity, global improvement, and treatment response. More therapist behaviors that encourage approach—and less use of accommodation, unrelated talk, and externalizing language—predicted greater subsequent habituation during individual exposure tasks (exposure-level), and also predicted improved patient clinical outcomes via higher “total dose” of habituation across treatment (patient-level indirect effect). For six of seven therapist behaviors analyzed, the relationship with subsequent habituation within exposure differed by patient fear (low, moderate, or high) at the time the behavior was used. Two therapist behaviors had direct effects in the opposite direction expected; more unrelated talk and less intensifying were associated with greater patient symptom reduction. Results shed light on the “black box” of in-session exposure activities and point to specific therapist behaviors that may be important for clinical outcomes. These behaviors might be best understood in the context of changing patient fear during exposure tasks. Future studies should test whether therapist behaviors can be experimentally manipulated to produce improvement in clinical outcomes.     

Kontextanalytische Supervision in der psychoanalytischen Ausbildung

Clinical practice with supervision is that area of psychoanalytic education, in which psychotherapeutic competence is learned, developed and imparted. From the results of the current research about education and supervision, the tasks and aims of supervision are derived. Based on that a context-analytical concept of supervision is evolved. In context-analytical supervision a researching attitude is adopted by which the interactional evaluation of the patient/supervisee is captured and understood for to follow this in psychotherapeutic/supervisory acting and intervening. Finally the potential of context-analysis as a method of qualitative research is pointed out.     

Psychoanalytic developmental psychology and the supervision of psychotherapy supervisor trainees

While literature on psychotherapy supervision abounds, literature on supervisor supervision (i.e., the actual supervision of a supervisor trainee who is in the process of learning to supervise) is far more scarce. How might the supervision of supervision process be best understood? What is the developmental experience of supervisor trainees? How can supervisors effectively intervene when working with supervisor trainees? Those questions have been addressed in only the most meagre fashion, and guidance on how to engage in the supervision of supervision is sorely lacking. In this paper, a psychoanalytic developmental framework is used to provide a means of conceptualising the supervisor trainee experience and to suggest a programme by which supervisors can best respond to their supervisor trainees' needs. Supervisor trainee ‘unfolding’ and ‘becoming’ are captured within a developmental progression that punctuates separation and individuation processes. The place of the supervisor – in holding and containing, loosening and liberating, buffering and bolstering, and refuelling and reloading – is considered in the facilitation of supervisor trainee development.     

The Importance of Program Evaluation: How Can it be Applied to Diverse Genetics Education Settings?

The role of a genetic counselor often entails providing education to patient, community and/or health professional groups. While counseling supervision assists genetic counselors to be reflective about their clinical work and to enhance clinical skills, evaluation is a rather analogous process in the provision of education. Program evaluation of education activities can be applied to provide information about the needs of the target group (needs assessment), the delivery of the program (process evaluation) as well as determining the extent to which the education activity has met its intended aims (summative evaluation). Evaluation assists the educator to assess the impact of their program and provides an evidence base about genetics education. Although program evaluation can be a complex activity, the tools are ones that can be used by individuals to evaluate single or simple education activities. The components of evaluation are discussed with reference to genetic counseling practice and three very different examples of actual evaluations are provided to illustrate the diversity of evaluation strategy and programs to which it can be applied.     

The effects of dropping in‐situation safety behaviors in the treatment of social phobia

Over the past years, important advances in the cognitive–behavioral treatment of social phobia have taken place. There is wide evidence that demonstrates exposure is an effective treatment for social phobia. However, some research has noticed that exposure has limitations in treating this disorder. In clinical practice we find patients who do not achieve marked reductions in anxiety using this technique. One of the mechanisms that can be involved is the use of in‐situation safety behaviors, which patients use to prevent the feared consequences in social situations. The aim of this study is to present a single case study where we compare the improvement achieved using exposure alone versus exposure dropping in‐situation safety behaviors. The social phobic patient improved significantly when exposure was combined with the drop of in‐situation safety behaviors. Copyright © 2003 John Wiley & Sons, Ltd.     

When do trauma experts choose exposure therapy for PTSD patients? A controlled study of therapist and patient factors

To investigate when and why therapists opt for or rule out imaginal exposure (IE) for patients with posttraumatic stress disorder (PTSD), 255 trauma experts were randomized to two conditions in which they were presented with four cases in which the patients' comorbidity and treatment preferences were manipulated. The results confirmed IE to be an underutilized approach, with the majority of professionals being undertrained in the technique. As predicted, the patient factors influenced the expert's choice of therapy: in case of a comorbid depression, IE was significantly less preferred than medication. Also, IE was significantly more likely to be offered when patients expressed a preference for trauma-focused treatment. The therapist factors were also found to be importantly related to treatment preferences, with high credibility in the technique being positively related to the therapists' preference for IE. Perceived barriers to IE, such as a fear of symptom exacerbation and dropout, were negatively related to the perceived suitability of the treatment when patients had suffered multiple traumas in childhood. The results are discussed in the light of clinical implications and the need of exposure training for trauma professionals.