Anorexia Nervosa: The Hospital's Role in Family Treatment

When an anorexia nervosa patient requires hospitalization for her ¹ 1 We will use the pronoun “her” to refer to anorexic patients since the overwhelming majority are female. Our discussion will focus mainly on younger adolescent girls who are still living with their families.
medical condition, the treatment team faces the problem of integrating the individual focus of inpatient care with the systems focus of family therapy. In this paper we propose a family-systems model of hospitalization, the aim of which is to facilitate such integration. The model draws on current theories of anorexia nervosa, as well as general concepts from psychodynamic, developmental, and family systems theories. The major hypothesis of the model is that all members of the anorexic family are developmentally arrested in the area of separation-individuation. On this assumption, we propose that the entire treatment team (including medical professionals and therapists) needs to function as “parents” to the anorexic family in much the same way that two cotherapists become parental figures in family therapy. Specifically, the team needs to provide those parenting responses that facilitate the family's individuation process.     

Simultaneous Group and Insulin Therapy

Abstract

The concept of focus can provide a meaningful bridge between theory and practice. The authors’ aim in this paper is to demonstrate that for theory to be clinically useful, it should provide a sense of focus and organization for clinical work. They illustrate how their particular use of a self–psychological/intersubjective model leads to an emphasis on what they refer to as “sustained empathic focus.” The authors’ choice of concepts leads them consistently to stress the patient’s subjective experience and emerging vulnerability.     

Posttraumatic play in young children exposed to terrorism: An empirical study

The phenomenon of “posttraumatic play” (PTP) has received much clinical recognition and little empirical support. The objective of this study was to examine various aspects of PTP in young children exposed to terror events and their relation to posttraumatic stress disorder (PTSD). Individual play sessions, conducted with 29 young Israeli children directly exposed to terrorism (M age = 5.47, SD = 1.34) and 25 matched unexposed children (M age = 5.62, SD = 0.87), were coded using the Children's Play Therapy Instrument–Adaptation for Terror Research (CPTI‐ATR; S.E. Chazan & E. Cohen, 2003). Analyses using these ratings showed (a) significant differences between the two groups, (b) significant associations with the caregiver's reports on child's exposure, and (c) significant associations with the caregiver's reports on the child's PTSD symptoms. Play activity ratings of predominant negative affects, frequent acting‐out/morbid themes, lowered developmental level, and reduced awareness of the child of him‐ or herself as a player significantly predicted more PTSD symptoms. PTP which included more coping strategies classified as “overwhelmed reexperiencing” and less “reenactment with soothing” was associated with a higher level of PTSD. Play analysis with the CPTI‐ATR may be helpful in identifying PTSD in children and also guide the selection of therapeutic techniques.     

Anxiety sensitivity and distress tolerance typologies and relations to posttraumatic stress disorder: A cluster analytic approach

A growing literature suggests a relationship between a high anxiety sensitivity (AS; the fear of anxiety and its related consequences)/low distress tolerance (DT; the capacity tolerate internal negative states) profile and posttraumatic stress disorder (PTSD) symptoms. However, specific profiles have not been identified or examined specifically in Veteran samples. Thus, the aims of the present study were to establish empirically derived profiles created from response patterns on the Anxiety Sensitivity Index and Distress Tolerance Scale and to examine associations with PTSD symptom clusters among a sample of combat-exposed Veterans (N = 250). A cluster analytic approach was used to identify AS/DT profiles, and a series of multivariate analyses of variance with post hoc analyses was conducted to examine the relationship between each AS/DT profile and each PTSD symptom cluster. Results indicated a 3-cluster solution including a high AS/low DT “at risk” profile, a low AS/high DT “resilient” profile, and an average AS/DT “intermediate” profile. The at-risk profile was associated with significantly greater symptoms in each PTSD cluster (i.e., hyperarousal, avoidance, re-experiencing) when compared to the other two profiles. The at-risk profile was also associated with greater depressive symptoms and lower self-reported resilience. These findings extend the previous literature by identifying a high AS/low DT “at risk” profile and its associations with PTSD symptoms, underscoring the potential utility in targeting these affect-regulation constructs for clinical intervention.     

Beyond stigma: Understanding the “inclined abstainers” in military behavioral health-care utilization

ABSTRACT

Low treatment utilization in Soldiers with combat-related Posttraumatic Stress Disorder (PTSD) is an ongoing issue. The critical concern is to better understand factors which prohibit a Soldier with PTSD who wants help from seeking treatment (an “inclined abstainer”). A total of 537 Active Duty Soldiers on a US Army post completed a brief survey comprising psychometrically validated measures of stigma, behavioral health treatment beliefs, resilience, PTSD symptoms, and treatment intentions. Health-care records were prospectively tracked for 12 months to determine the relation between survey answers and treatment utilization. Sixty-three percent of those who acknowledged having a mental health-related problem did not seek help within a one-year period. Greater severity of PTSD symptoms was associated with an increased likelihood of behavioral health engagement. Soldiers that were classified as “inclined abstainers” were also more likely to endorse negative beliefs about psychotherapy and report higher levels of resilience as compared to “inclined actors.” These results suggest that a treatment model of PTSD emphasizing self-efficacy and self-reliance, while addressing negative beliefs about psychotherapy, may help promote engagement of behavioral health services among Active Duty Soldiers.     

Settling on what we are: The central place of the sense‐of‐self in education,and the implication of the concepts of the teleon and telentropy for the development of the sense‐of‐self

The purpose of this article is to illustrate the centrality of the development of a person's sense‐of‐self in his or her personal growth, and so to justify why educators should deliberately focus the attention of learners on the development of their own senses‐of‐self.

We describe the sense‐of‐self as a person's working hypothesis of what he or she is, as a functioning being. (This is in contrast to the notion of self‐concept, which is composed of the beliefs and evaluations that one has about oneself as a person in a social context.)

To illustrate the centrality of the sense‐of‐self we introduce two associated concepts—the teleon and telentropy. Teleons are “purposeful action patterns,” which may be regarded as the defining characteristic of any living system, including human beings.

Telentropy is similar to entropy (encountered in physics and chemistry), but instead of dealing with the level of disorder in externally described systems, it represents the level of informational confusion existing within an organism regarding its own true nature.

We discuss the implications of the concepts “teleon” and “telentropy” for a person's educability, using examples from daily life and educational institutions.

We provide a number of suggestions for the revising of educational practice to foster the development of the sense‐of‐self in learners. This we demonstrate to have potentially beneficial effects of the general stress levels of society.     

McCandless's Response to “Soul Healing: A Model of Feminist Therapy”

The term soul healing captures the reader's imagination by intimating that therapy may do more than just focus on the healing of emotional pain. The author of “Soul Healing: A Model of Feminist Therapy,” Patricia M. Berliner, a psychologist, therapist, and sister of St. Joseph (Brentwood, New York) is to be applauded for recognizing the need for a model of therapy that consciously intends to address the concerns of women “who value the spiritual dimension in their lives” (p. 2).     

Intrusive re‐experiencing in post‐traumatic stress disorder: Phenomenology,theory, and therapy

The article describes features of trauma memories in post‐traumatic stress disorder (PTSD), including characteristics of unintentional re‐experiencing symptoms and intentional recall of trauma narratives. Re‐experiencing symptoms are usually sensory impressions and emotional responses from the trauma that appear to lack a time perspective and a context. The vast majority of intrusive memories can be interpreted as re‐experiencing of warning signals, i.e., stimuli that signalled the onset of the trauma or of moments when the meaning of the event changed for the worse. Triggers of re‐experiencing symptoms include stimuli that have perceptual similarity to cues accompanying the traumatic event. Intentional recall of the trauma in PTSD may be characterised by confusion about temporal order, and difficulty in accessing important details, both of which contribute to problematic appraisals. Recall tends to be disjointed. When patients with PTSD deliberately recall the worst moments of the trauma, they often do not access other relevant (usually subsequent) information that would correct impressions/predictions made at the time. A theoretical analysis of re‐experiencing symptoms and their triggers is offered, and implications for treatment are discussed. These include the need to actively incorporate updating information ( “I know now …”) into the worst moments of the trauma memory, and to train patients to discriminate between the stimuli that were present during the trauma ( “then”) and the innocuous triggers of re‐experiencing symptoms ( “now”).     

Rates of Subthreshold PTSD Among U.S. Military Veterans and Service Members: A Literature Review

The current study’s goal was to provide a comprehensive review of current subthreshold posttraumatic stress disorder (PTSD) rates among U.S. military veterans and service members. PubMed, PsycInfo, ProQuest, Web of Knowledge, Google Scholar, and any relevant articles’ reference lists identified studies of subthreshold PTSD in the U.S. military. Search terms included PTSD in combination with partial, subthreshold or sub-threshold, subsyndromal or sub-syndromal, subclinical or sub-clinical, and military or veteran. Sixteen articles met criteria for review. Current subthreshold PTSD rates ranged from 2.3% to 22.3%, with a weighted mean rate of 7.6%. Definitional variation within and across the “below threshold” terms produced some variability in rates reported. Few studies consistently reported on impairment and comorbidity in the subthreshold PTSD population. Variability of current subthreshold PTSD rates may be due to methodological issues such as sampling methods, sample sizes, and how below threshold PTSD was assessed and defined. Based on our findings, we provide a number of recommendations that can be used to inform future research of subthreshold PTSD among U.S. military veterans and service members. These recommendations include having a standardized term and definition, determining how to more properly assess subthreshold PTSD symptomatology, clarifying subthreshold PTSD diagnostic stability, and identifying appropriate sampling methods.     

Fraud and the American Dream: Toward an Understanding of Fraud Victimization

ABSTRACT

American culture and the practices of government focus an overwhelming majority of attention on violent “street” crime. As a result, very little is known about the victims of fraud. In order to contribute to this literature, a case study is provided that examines the victim population of a Ponzi scheme. Data are provided on the general characteristics of the victims, their investments, and the growth of the scheme. A theoretical model is formulated from Messner and Rosenfeld.'s work in Crime and the American Dream. This paper expands the concepts of this theory by providing evidence that it can be used to explain victim behavior.     

Using Stories in Dynamically Oriented Clinical Social Work

Abstract

This paper uses concepts from discourse analysis to understand the meaning making functions of narrative in clinical treatment and to describe the interactive processes through which these functions are achieved. “Negotiative” and “heuristic” narrative processes are described as they occur in ordinary conversation. The relevance of these concepts to clinical practice is then explored using case material.     

Psychiatry in the labyrinth: Deconstructing deviancy

Abstract

Deviancy is a key concept in psychiatry and other therapeutic disciplines, because it dramatizes the way in which they depend on the establishment of norms, in order to justify their theory and practice. The writings of Derrida as well as Goethe provide a different view: that “deviation” from a “norm” can be fundamentally important to the well‐being of the norm. Thus deviancy can be viewed not as something to be “corrected” but rather as a creative possibility to be encouraged and shaped in productive ways. As a case of “deviancy” we have selected the writings of John Perceval, whose Narrative provides a critique of the mental‐health establishment of his day, particularly the asylum, and offers an alternative to 19th‐century views of “lunacy.” We see his “schizophrenic” commentary on his “psychosis” and its treatment as analogous to the deconstructive, “schizophrenic” discourse of postmodernity which is similarly critical of the reigning, modernist psychiatric order.     

La psychothérapie assistée par la MDMA dans la prise en charge du syndrome de stress post-traumatique

Posttraumatic stress disorder (PTSD) is estimated to remain chronic and severe for 25–50% of patients despite psychotherapeutic treatment. Part of the reasons is that patients with PTSD can have difficulties in establishing a good therapeutical alliance with the therapist. Moreover, they often fail to re-think the content of the trauma without being overwhelmed by negative emotions and tend to rely on avoidance strategies and/or to abandon the therapy. MDMA (“ecstasy”) is a drug classified as an entactogen (en “within”, tactus “touch”, and gen “produce”), an amphetamine with psychedelic properties that possesses psychopharmacological properties to overcome these issues. Indeed, MDMA triggers the release of oxytocin, which favors the establishment of interpersonal relationship based on kindness and trust. Moreover, MDMA diminishes the activity of the amygdale, allowing patients to work on challenging memories with less fear and anxiety. Finally, MDMA may also provide access to meaningful spiritual experiences, release of tensions and a sense of healing on a non-verbal level that are not completely understood. But are viewed as important by patients. Today, there is no evidence that the use of MDMA in a clinical setting has bad neurologic, psychological or cognitive consequences. Results of phase II trials in the United States and Europe confirm that MDMA favors psychotherapy's outcome without severe adverse effects. Phase III trials are underway. The Multidisciplinary Association for Psychedelic Studies (MAPS) has published online a method proposal and trains therapists in MDMA-assisted psychotherapy.ConclusionFood and Drug Administration (FDA) and European Medicines Agency (EMA) could approve this therapeutic tool in the coming years.     

A New Multidimensional Measure of Spirituality‐Religiosity for Use in Diverse Substance Abuse Treatment Populations

Extant measures of spirituality‐religiosity, not developed specifically with substance abuse treatment populations in mind, may not be culturally appropriate in regard to either: (1) the 12‐step “culture” found in many treatment programs; or (2) racial‐ethnic minority populations overrepresented in publicly funded programs. A 40‐item four‐dimensional measure was developed, which differentiates “religiosity” (religious practices) from “spirituality” (an individual's relationships with God/higher power, others, and self). Instrument development involved: qualitative focus groups with individuals in seven diverse Texas treatment programs; quantitative exploratory and confirmatory (CFA) analyses to test the four‐factor model conducted using data from 237 diverse clients in treatment programs in Tennessee and Virginia. Confirmatory analyses indicate acceptable fit indices (>0.90) for the four‐factor model, and acceptable reliability estimates for all subdimensions (≥0.70) provide further support for the measures. Results support the potential usefulness of the measures.     

The Fallacy of the Private-Public Self-Focus Distinction

ABSTRACT Taking the distinction between Aristotelian and Galilean modes of thought (Lewin, 1931) as a background, the bifurcation of the self-focus concept into “private” and “public” types of self-focus is discussed critically A theoretical connection between the private-public distinction and other central concepts within the self-awareness literature is found to be lacking Further, it is found that (a) the relation between the theoretical definitions of “private” and “public” and their respective empirical definitions is not explicated, that (b) the public half of the dichotomy does not involve a focus of attention toward or away from the self, and perhaps most important, that (c) the conceptual work surrounding the private-public distinction illustrates how an Aristotelian approach to theorizing prevents the raising of pertinent questions     

Event centrality prospectively predicts PTSD symptoms

Background: Recent evidence suggests that event centrality has a prominent association with post-traumatic stress disorder (PTSD) symptoms. However, evidence for this notion thus far has been mostly correlational. We report two studies that prospectively examined the relationship between event centrality and PTSD symptoms. Study 1 Methods: Participants (N?=?1438) reported their most stressful event (“prior event”), along with event centrality, PTSD symptoms, and neuroticism. At Time 2 participants reported their most stressful event since Time 1 (“critical event”), along with measures of event centrality and PTSD symptoms. Study 1 Results: Event centrality for the critical event predicted PTSD symptoms, after controlling for event centrality and PTSD symptoms of the prior event and neuroticism. Study 2 Methods: In the second study (N?=?161) we examined changes in event centrality and PTSD symptoms over a month. Study 2 Results: Using a cross-lagged panel design, results revealed event centrality at Time 1 significantly predicted PTSD symptoms at Time 2, but the reverse was not significant. Conclusions: In two studies, a prospective association between event centrality and PTSD symptoms, but not the reverse, emerged. This evidence implicates event centrality in the pathogenesis and/or maintenance of PTSD symptoms.     

From Couple Therapy 1.0 to a Comprehensive Model: A Roadmap for Sequencing and Integrating Systemic,Psychodynamic, and Behavioral Approaches in Couple Therapy

Couple therapy is a complex undertaking that proceeds best by integrating various schools of thought. Grounded in an in‐depth review of the clinical and research literature, and drawing on the author's 40‐plus years of experience, this paper presents a comprehensive, flexible, and user‐friendly roadmap for conducting couple therapy. It begins by describing “Couple Therapy 1.0,” the basic conjoint couple therapy format in which partners talk to each other with the help of the therapist. After noting the limitations of this model, the paper introduces upgrades derived from systemic, psychodynamic, and behavioral/educational approaches, and shows how to combine and sequence them. The most important upgrade is the early focus on the couple's negative interaction cycle, which causes them pain and impedes their ability to address it. Using a clinical case example, the paper shows how all three approaches can improve couple process as a prerequisite for better problem solving. Additional modules and sequencing choice points are also discussed, including discernment counseling and encouraging positive couple experiences.     

Adaptation of CBT for Traumatized Egyptians: Examples from Culturally Adapted CBT (CA-CBT)

In this article we illustrate how CBT can be adapted to a traumatized Egyptian population with Islamic beliefs, giving examples from our adaptation of Culturally Adapted–CBT (CA-CBT) for this cultural group. We discuss a culturally sensitive assessment measure of local somatic complaints and cultural syndromes that was devised based on clinical experience with traumatized Egyptians. We also demonstrate how to normalize symptoms, create positive expectancy about the treatment, and educate about trauma. We give examples of how mindfulness can be adapted for an Egyptian Islamic population, and we describe local religious strategies, such as dhikr (religious chanting), salah (ritualistic prayer), and dua (supplication), that may be used to promote attentional shift from rumination topics and to teach attentional control. We describe how “loving kindness” can be adapted for this group. We outline how to modify culturally generated catastrophic cognitions and how to conduct interoceptive exposure and to create positive re-associations in a culturally sensitive manner. We describe how worry themes are explored and addressed based on a heuristic panic attack–PTSD model; how to teach anger management in a culturally sensitive way; and how to address sleep-related problems in this population. We suggest using cultural transitional “rituals” at the end of the treatment to give patients a sense of closure and a positive feeling of transformation. A case example is presented to illustrate cultural challenges associated with delivering CA-CBT to an Egyptian population. We introduce certain concepts such as cultural grounding and explanatory model bridging, both therapeutic techniques that increase adherence, positive expectancy, and cultural consonance.     

Emotional Processing Therapy for post traumatic stress disorder

While prolonged exposure is considered one of the “gold standard” and recommended treatments for post traumatic stress disorder (PTSD), it has been poorly utilised in clinical practice. Individuals with PTSD often find it too distressing to confront memories, and therapists may be uncomfortable using the therapy. A new Emotional Processing Therapy is described in which an emotional approach to prolonged exposure provides individuals with a new insight into how trauma is processed. A conceptual analysis of exposure suggests that it is exposure to distressing emotional experiences which is a key element. Viewing it as an emotion-based therapy, allows the creative addition of new emotional elements. Through exploring the individual’s emotional processing style, previously learned and unhelpful patterns can be addressed, and the addition of an “emotional preparation” phase helps them understand why it is important to face emotionally distressing memories before exposure sessions begin. Emotional Processing Therapy is intuitive and makes sense to those affected by PTSD. It is framed in an emotional context and is presented as part of a lifestyle change that may reduce the likelihood of psychological problems developing in the future.