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’.     

Elevated disgust sensitivity in blood phobia

In order to demonstrate elevated disgust sensitivity and facilitated disgust learning in patients suffering from blood injection injury phobia, 23 phobics and 20 controls underwent an evaluative conditioning experiment. They were presented with picture pairs consisting of affectively neutral pictures (CS), which were followed by either disgust-inducing, fear-inducing, pleasant, or neutral scenes (US). During the presentation we recorded the electromyogram (EMG) of the musculus levator labii as a specific disgust indicator. Affective ratings for the pictures were determined before and after conditioning. Also, CS-US contingency verbalisation (CV) was assessed. Phobics reported a greater overall disgust sensitivity, experienced stronger feelings of disgust, and showed greater EMG responses while viewing disgust-eliciting scenes than control subjects. Evaluative conditioning occurred equally in both groups and depended on CV.     

How automatic is “automatic vigilance”? The role of working memory in attentional interference of negative information

Whereas attentional interference of negative information has previously been assumed to be automatic, the present research hypothesised that this effect depends on the availability of working-memory resources. In two experiments, participants judged the gender of angry versus happy faces. Working-memory load was manipulated by the presence or absence of a math task (Study 1) or mental rehearsal of a one- versus 8-digit number (Study 2). The results showed that angry faces interfered more with gender naming than happy faces, but only when working-memory load was low. As such, attentional interference of negative stimulus features can be modulated by top-down attentional control processes.     

Cancer fear and the interpretation of ambiguous information related to cancer

We tested the hypothesis that people with a high fear of cancer would be more likely to interpret ambiguous information about cancer in a negative manner compared with people low on cancer fear. Adults (n=47) aged 50–70, who scored either high (n=16) or low (n=31) on cancer fear, took part in a laboratory-based ambiguous sentences task. Participants were presented with ambiguous cancer and social threat scenarios mixed with unambiguous neutral scenarios. Interpretations were assessed in a recognition task, by asking participants to rate disambiguated sentences in terms of how similar in meaning they were to the originals. People high on cancer fear were more likely to endorse negative interpretations of the original ambiguous cancer scenarios than were people low on cancer fear. This negative interpretation bias was specific to cancer scenarios and was not observed for the social threat scenarios.     

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.     

Overgeneral autobiographical memory predicts changes in depression in a community sample

This study investigated whether overgeneral autobiographical memory (OGM) predicts the course of symptoms of depression and anxiety in a community sample, after 5, 6, 12 and 18 months. Participants (N = 156) completed the Autobiographical Memory Test and the Depression Anxiety Stress Scales-21 (DASS-21) at baseline and were subsequently reassessed using the DASS-21 at four time points over a period of 18 months. Using latent growth curve modelling, we found that OGM was associated with a linear increase in depression. We were unable to detect changes over time in anxiety. OGM may be an important marker to identify people at risk for depression in the future, but more research is needed with anxiety.     

The appraisal basis of anger occurrence and intensity revisited

In a diary study we examined the relation between anger appraisals on the one hand, and the occurrence and intensity of anger experiences in frustrating situations on the other hand. The appraisals of frustration, other presence, other-accountability, and hostile intention are shown to be jointly sufficient for the occurrence of anger experience. Absence of one or more of these appraisals further results in a smaller proportion of anger occurrences, in lower anger intensities, and in both within- and between-person differences in anger occurrence. These results are interpreted in terms of anger experience as a categorical phenomenon for which the jointly sufficient set of appraisals acts as a cognitive point of reference. Willingness to go for anger categorisations in appraisal patterns that deviate from this cognitive point of reference is, at least in part, subject to dispositional individual differences.     

Embodiment effects in memory for facial identity and facial expression

Research suggests that states of the body, such as postures, facial expressions, and arm movements, play central roles in social information processing. This study investigated the effects of approach/avoidance movements on memory for facial information. Faces displaying a happy or a sad expression were presented and participants were induced to perform either an approach (arm flexion) or an avoidance (arm extension) movement. States of awareness associated with memory for facial identity and memory for facial expression were then assessed with the Remember/Know/Guess paradigm. The results showed that performing avoidance movements increased Know responses for the identity, and Know/Guess responses for the expression, of valence-compatible stimuli (i.e., sad faces as compared to happy faces), whereas this was not the case for approach movements. Based on these findings, it is suggested that approach/avoidance motor actions influence memory encoding by increasing the ease of processing for valence-compatible information.     

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.     

Outcome interdependence shapes the effects of prevention focus on team processes and performance

Although the effects of regulatory focus on individual-level performance have often been studied, relatively little is yet known about team-level effects. Filling this void, we integrate the notion that promotion-focused individuals are concerned with progress and achievement, whereas prevention-focused individuals are concerned with security and vigilance, with the insight that team processes and performance depend on outcome interdependence (individual versus team rewards). The hypothesis that prevention-focused teams react more strongly than promotion-focused teams to differences in outcome interdependence was tested among 50 teams performing an interactive command-and-control simulation. Regulatory focus and outcome interdependence were both manipulated. The results showed that prevention-focused teams working for team rather than individual rewards reported higher work engagement and less error intolerance, coordinated more effectively, and performed better. Promotion-focused teams were not influenced by outcome interdependence. We discuss the implications of our results for theory and effective team management.