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’.     

The indirect effect of attention bias on memory via interpretation bias: Evidence for the combined cognitive bias hypothesis in subclinical depression

Little research has investigated functional relations among attention, interpretation, and memory biases in depressed samples. The present study tested the indirect effect of attention bias on memory through interpretation bias as an intervening variable in a mixed sample of non-depressed and subclinically depressed individuals. Subclinically depressed and non-depressed individuals completed a spatial cueing task (to measure attention bias), followed by a scrambled sentences test (to measure interpretation bias), and an incidental free recall task (to measure memory bias). Bias-corrected bootstrapping yielded evidence for the hypothesised indirect effect model, in that an emotional bias in attention is related to a congruent bias in interpretative choices which are in turn reflected in memory. These findings extend previous research and provide further support for the combined cognitive bias hypothesis in depression. Theoretical and clinical implications of our findings are discussed.     

Dimensions of “uniquely” and “non‐uniquely” human emotions

Emotion scientists often distinguish those emotions that are encountered universally, even among animals ( “primary emotions”), from those experienced by human beings ( “secondary emotions”). No attempt, however, has ever been made to capture the lay conception about this distinction and to find the criteria on which the distinction is based. The first study presented in this paper was conducted in three countries involving four languages, so as to allow for cross‐cultural comparisons. Results showed a remarkable convergence. People from all samples not only differentiated between “uniquely human” and “non‐uniquely human” emotions on a continuum, but they did so on the same basis as the one used by emotion scientists to distinguish between “primary” and “secondary” emotions. Study 2 focused on the implicit use of such a distinction. When confronted with a human (animal) context, participants reacted faster to secondary (vs primary) emotions. The implications of the human uniqueness of some emotions within the social and interpersonal contexts are discussed.     

Counselor Education and Supervision: The Development of the CACREP Doctoral Standards

The purpose of this article is to illuminate the unique features of the Council for Accreditation of Counseling and Related Educational Programs guidelines and accreditation standards that shaped doctoral preparation in counselor education. Current issues that affect advanced training in counselor education and implications for future doctoral standards revisions are also presented.     

Editorial

Abstract

This paper will examine the current crisis in psychoanalysis in terms of the profession's decline, the apparent lack of patients, the ongoing debate over what constitutes psychoanalysis versus other therapies, and the lack of clinical focus in those debates. The concept of analytic contact will be introduced, and clinical material is used to showcase this concept as a bridge from the circular political debates to a more meaningful examination of what is psychoanalytic. In addition, case material will explore how patients tend to fight off the establishment of analytic contact in favor of safer, less threatening modes of relating. The author suggests that most patients fight off analytic contact and try to shift the treatment into something less analytic. It is up to the analyst to detect this, interpret it, and notice any countertransference collusion that may occur. Although the state of psychoanalysis as a profession is less than stellar in the eyes of the public, and the profession is apt to sabotage itself with endless debates about what constitutes true analytic work, the end is not necessary near. This paper proposes analytic contact to be the more useful focus of research and productive area of clinical exploration. If the decline of our field is to turn around, it will be on the clinical battlefront, not in terms of the theorizing among disagreeing groups of territorial analysts afraid of losing their political high-ground. The concept of analytic contact assumes that a deep exploration of intrapsychic phenomena, conflicts, and defenses, all within the realm of the transference, is the best clinical method of helping the mentally troubled individual. This genuine chance of change is best administered by a trained psychoanalyst. This simple idea is something the profession has contaminated with its often pointless arguments over frequency, analyzability, couch, and so forth. The clinical material will show that what happens in the room between analyst and patient is what best defines the true psychoanalytic treatment.     

Facilitating Accuracy in Showup Identification Procedures: The Effects of the Presence of Stolen Property

Law enforcement personnel regularly present suspects to eyewitnesses using showups. In this study, we examined the impact of the presence of stolen property on live showup identification performance. Two hundred seventy university students were exposed to a simulated theft. During the subsequent showup, we manipulated the presence of the target and stolen property. Binary logistic regression analyses indicated that both factors independently predicted the accuracy of identification decisions. Participants were more accurate when the target was in the showup and when the stolen property was present during the identification. Consistent with the item, context, and ensemble theory of recognition, the presence of stolen property led to an increase in sensitivity, suggesting ensemble formation. Future research on showups should continue to examine contextual variables that may lead to changes in sensitivity or criterion shift. Copyright © 2012 John Wiley & Sons, Ltd.     

I Feel Your Pain: Embodied Knowledges and Situated Neurons

The widely touted discovery of mirror neurons has generated intense scientific interest in the neurobiology of intersubjectivity. Social neuroscientists have claimed that mirror neurons, located in brain regions associated with motor action, facial recognition, and somatosensory processing, allow us to automatically grasp other people's intentions and emotions. Despite controversies, mirror neuron research is animating materialist, affective, and embodied accounts of intersubjectivity. My view is that mirror neurons raise issues that are directly relevant to feminism and cultural studies, but interventions are needed for the work to be compatible with nonreductionist critical thought. In this article I critique the dominant neuroscientific account of mirror neurons, called embodied simulation theory. I draw from feminist epistemologies as well as alternative interpretations of mirror neurons in cognitive science and philosophy of mind to consider mirroring as situated, embodied perception.     

Knowing That P without Believing That P

Most epistemologists hold that knowledge entails belief. However, proponents of this claim rarely offer a positive argument in support of it. Rather, they tend to treat the view as obvious and assert that there are no convincing counterexamples. We find this strategy to be problematic. We do not find the standard view obvious, and moreover, we think there are cases in which it is intuitively plausible that a subject knows some proposition P without—or at least without determinately—believing that P. Accordingly, we present five plausible examples of knowledge without (determinate) belief, and we present empirical evidence suggesting that our intuitions about these scenarios are not atypical.     

Size does matter: Women mentally rotate large objects faster than men

Performance in a computerized “mental rotation” task was measured in groups of males and females while they rotated Shepard‐Metzler‐like cube assemblies on either a standard laptop screen (size = 36 cm) or on a large display wall (584 cm) where the stimuli appeared at considerably larger sizes and within a much wider field of view than that typically used in most spatial tasks. Males and females did not differ significantly in performance in the standard size condition with regards to response time but females performed faster than males in the large display condition. Males were also found to be significantly more accurate than females, regardless of display. We found no sign of trading accuracy for speed for either of the sexes or screen size conditions. We surmise that such an effect may be due to differences in task‐solving strategies between the sexes, where a holistic strategy – which may be preferred by males is negatively affected by large object sizes, whereas a piecemeal approach, that may be preferred by females, is virtually unaffected by display size.     

Prospective and concurrent correlates of emotion perception in psychotic disorders: A naturalistic,longitudinal study of neurocognition,affective blunting and avolition

This naturalistic study investigated longitudinal and cross‐sectional symptomatic and neurocognitive correlates of social cognition indexed by emotion perception. Participants were 31 persons admitted to a psychiatric emergency ward due to acute psychosis. Positive and negative (i.e., affective blunting and avolition) symptoms were assessed at baseline and 12‐month follow‐up using the Positive and Negative Syndrome Scale. Participants completed neuropsychological assessments with alternative versions of the Repeatable Battery for the Assessment of Neuropsychological Status at baseline and at 12‐month follow‐up. Emotion perception was measured using the Face/Voice Emotion Test at 12‐month follow‐up. Correlational analyses (Spearman's rho) revealed strong and statistically significant associations between neurocognition and emotion perception (baseline r = 0.58, follow‐up r = 0.43). Associations between positive symptoms and emotion perception were weak or non‐existent (baseline r = 0.13, follow‐up r  =  –0.01). Emotion perception was moderately, but not significantly, associated with affective blunting at follow‐up (r = 0.33), but not at baseline (r = 0.21). The association with avolition was non‐existent (baseline r  =  –0.05, follow‐up r = 0.01). This study supports the notion that emotion perception has neurocognitive correlates. The cross‐sectional trend level association with affective blunting suggests that the ability to perceive emotions might be related to, but dissociable from the ability to express emotions.