Economic Impact of the Statewide Implementation of an Evidence-Based Treatment: Multisystemic Therapy in New Mexico

Several states have made considerable investments into large-scale implementation of evidence-based treatments (EBTs), yet little is known about key success indicators for these implementation efforts such as cost and sustainability. To that end, the present study examined the economic impact of statewide implementation of multisystemic therapy (MST; Henggeler, Schoenwald, Borduin, Rowland, & Cuningham, 2009), a family- and community-based behavioral EBT for serious juvenile offenders in New Mexico. Participants were 1,869 youth who received MST across 23 teams during the study period. We conducted a cost-benefit analysis using metrics from state data sources that compared the cost of MST to its benefits (i.e., avoided expenses from pre- to posttreatment) in two domains: (a) behavioral health services (i.e., Medicaid claims) and (b) juvenile crime (i.e., taxpayer expenses, tangible and intangible expenses to crime victims). MST costs were based on Medicaid claims, which were reimbursed at an enhanced billing rate that was intended to cover expenses for both clinical and implementation (e.g., training, quality assurance) activities. Results suggest that implementation of MST in New Mexico over the 7-year study period may have produced net benefits, through 2 years posttreatment, of more than $4,643 per youth in avoided behavioral health claims and $15,019 per youth through reductions in juvenile crime. Stated differently, every dollar that New Mexico spent on MST appeared to have returned $3.34 for a total benefit of $64.2 million over the course of the study. We discuss implications of these findings for policymakers, administrators, and researchers who are interested in increasing the sustainability of complex EBTs in community settings.     

Narcissistic temptations to cross boundaries and how to manage them

The narcissism of analysts is considered here from the perspective of the narcissistic temptations of boundary crossing. The literature on boundary crossing in psychoanalysis has focused minimally on the more ordinary, nonsexual temptations analysts face with their patients. Narcissistic temptations with particularly impressive patients are explored. What analysts find impressive in their patients depends both on what patients bring and on what analysts need. This paper aims to heighten analysts' awareness of their narcissistic needs in treating patients who tempt them too much. The goal is for analysts to be able to catch and then examine their narcissistic excitement with such patients in order to avoid compromising the treatment. Danger signs and ways of managing the problems they point toward are presented.     

Clinical discussants as psychoanalytic readers

Psychoanalytic discussants of clinical papers face certain tasks, opportunities, and difficulties. To be willing to present and publish their analytic work for colleagues to study, analyst-authors and discussants need to expect that the other will respectfully complement his or her perspective. Discussants are encouraged to immerse themselves playfully in the affective force-field constituted between analysand and analyst within the process of the presentation. As discussants struggle to extricate themselves from this force-field, they contribute best by confining their understandings to the presentation process rather than trying to pin down the actual psychoanalytic situation. When this is done, discussants are under less pressure to inform presenters. This paper considers how discussants need to process their feeling responses to clinical papers so as to enhance rather than injure the analyst-author. This approach is illustrated with vignettes of the author's efforts as a clinical discussant to become a constructive psychoanalytic reader.     

I Dig Therefore We Are: Community Archaeology,Place‐based Social Identity,and Intergroup Relations Within Local Communities

Community involvement in archaeological digs aims to reconnect people with the history and heritage of where they live. This paper applies social psychological theories to understand how community archaeological projects create opportunities for place‐based social identity and positive intergroup relations. Focus groups were conducted across five areas of Greater Manchester (UK) with 24 participants who volunteered for Dig Greater Manchester, a community archaeology initiative. The focus groups aimed to understand how experiences of participating in digs and exploring local heritage modified, strengthened or initiated identification with place and community, thus moving from individual levels to social levels of identity. The findings offer insight as to the ways in which people make sense of their own—and others'—place‐based social identities as a result of participating in community archaeological digs . Copyright © 2017 John Wiley & Sons, Ltd.     

Neediness and narcissistic defensive action

Action-prone patients are difficult for most analysts to treat. The author describes patients who act in treatment by pressuring themselves and the analyst to get rid of what is wrong, to change the imperative, life-and-death qualities of need into something else. Viewing neediness in treatment as narcissistic defensive action helps the analyst address the patient's pressured flight away from focusing on the need of the analyst and toward action aimed at riddance. Ghent's (1992, 1993) views on neediness are discussed and seen to be complemented by a view of action as protection against narcissistic vulnerability. Analysts' intolerance, vulnerabilities, and needs with such patients are considered.     

Why we need to write openly about our clinical cases

To learn more about what is and is not effective in the psychoanalytic situation, analysts need to develop a library of detailed analytic case material. Open case writing, by not overconstraining readers, allows them enough access to the analytic couple's affective experience to persuade them of the authenticity and validity of the analyst-author's views. They are then free to rethink the material creatively on their own, to use it as they need to, and to learn from others, in order to enhance their analytic skills. Closed case writing hinders readers' creative freedom to understand and interpret, and hence to learn. To encourage analyst-authors to share their affective experiences in the analytic situation more openly, analysts need to establish a constructively collaborative attitude toward playing with clinical material. They need to take for granted that new readers, even authors themselves newly rereading their work, will discover something new. A dialectical process can then be established in which clinical authors and readers contribute to each other in an ongoing imaginative interchange.     

The wish to regress in patient and analyst

The analyst's wish to regress is used as a paradigm of the "forbidden" topic of what analysts want from their analysands. The aim is to expand the subjective domain of analysts' awareness so that they can analyze better by grasping more of their temptations with patients before enactment can occur. Clinical examples illustrate how the author temporarily joined patients in wish-fulfilling mutual regression. Analytic process is disrupted when the analyst wishes to relinquish the more differentiated role of the containing and interpreting analyst in favor of more childlike relatedness both with the patient and with the analyst's internal objects. The author, expecting a more typical counter-transference, had not anticipated that he might temporarily join these nonpsychotic patients in mutual regression. It is suggested that in the face of analytic impasse analysts should consider whether they might temporarily have joined the patient in mutually regressive wishes that have taken them away from more responsible analytic functioning.     

The sense of defect

The sense of defect, physical or psychological, is here regarded as a fantasy, a compromise formation, rather than an actual defect existing somewhere in the body, or in some psychological structure. It need not correlate with the reality to an external observer of physical or psychological disability. Psychoanalytic emphasis is directed to the motivations for the persistence of this sense of defect, rather than primarily to etiology (trauma) or genetic history. Accurate perception and evaluation, having been interdicted during childhood, is avoided with the magical hope that thereby one will be acceptable and what is wrong will disappear. The interaction between self and parents, real and fantasied, cannot be clearly known. The patient remains uncertain as to what is wrong, in whom it is located, and how it has come about. The sense of defect, physical or psychological, becomes the nidus around which much is crystallized. This is then offered up to a parent (and the superego) as an appeasement and seduction, aiming to help this parent feel better by agreeing that the child is indeed the cause of what is wrong. Dangerously destructive (and sexual) wishes are defended against and atoned for by emphasis on one's defectiveness.