Introduction: babies in the consulting room: what happens when analyst, mother, and infant meet?

Analytic work with a pregnant woman may foster the psychological gestation of the self-as-mother. For the mother--as for the infant--the developmental process continues well beyond delivery. It should not surprise us, then, that many mothers continue to bring their babies to sessions after birth. Analytic work in this context can affect a patient's sense of herself, and perhaps her competence, as a mother. Yet the presence of babies in the consulting room is an underacknowledged feature of contemporary practice. For this section of JAPA, we have collected three papers that explore some of the unique challenges and opportunities that arise when a patient brings her baby to treatment. Earlier versions of each paper were first presented at a panel, "Babies in the Consulting Room," at the June 2011 meeting of the American Psychoanalytic Association in San Francisco.     

Toddlers benefit from labeling on an executive function search task

Although labeling improves executive function (EF) performance in children older than 3 years, the results from studies with younger children have been equivocal. In the current study, we assessed performance in a computerized multistep multilocation search task with older 2-year-olds. The correct search location was either (a) not marked by a familiar picture or given a distinct label, (b) marked by a familiar picture but not given a distinct label, (c) marked by a familiar picture and labeled by the experimenter, or (d) marked by a familiar picture and labeled by the participant. The results revealed that accuracy improved across conditions such that children made the fewest errors when they generated the label for the hiding location. These findings support the hierarchical competing systems model, which postulates that improved performance can be explained by more powerful representations that guide search behavior.     

Maximal care considerations when treating patients with end-stage heart failure: ethical and procedural quandaries in management of the very sick

Deciding who should receive maximal technological treatment options and who should not represents an ethical, moral, psychological and medico-legal challenge for health care providers. Especially in patients with chronic heart failure, the ethical and medico-legal issues associated with providing maximal possible care or withholding the same are coming to the forefront. Procedures, such as cardiac transplantation, have strict criteria for adequate candidacy. These criteria for subsequent listing are based on clinical outcome data but also reflect the reality of organ shortage. Lack of compliance and non-adherence to lifestyle changes represent relative contraindications to heart transplant candidacy. Mechanical circulatory support therapy using ventricular assist devices is becoming a more prominent therapeutic option for patients with end-stage heart failure who are not candidates for transplantation, which also requires strict criteria to enable beneficial outcome for the patient. Physicians need to critically reflect that in many cases, the patient’s best interest might not always mean pursuing maximal technological options available. This article reflects on the multitude of critical issues that health care providers have to face while caring for patients with end-stage heart failure.     

The Use of Propensity Scores in Mediation Analysis

Mediation analysis uses measures of hypothesized mediating variables to test theory for how a treatment achieves effects on outcomes and to improve subsequent treatments by identifying the most efficient treatment components. Most current mediation analysis methods rely on untested distributional and functional form assumptions for valid conclusions, especially regarding the relation between the mediator and outcome variables. Propensity score methods offer an alternative whereby the propensity score is used to compare individuals in the treatment and control groups who would have had the same value of the mediator had they been assigned to the same treatment condition. This article describes the use of propensity score weighting for mediation with a focus on explicating the underlying assumptions. Propensity scores have the potential to offer an alternative estimation procedure for mediation analysis with alternative assumptions from those of standard mediation analysis. The methods are illustrated investigating the mediational effects of an intervention to improve sense of mastery to reduce depression using data from the Job Search Intervention Study (JOBS II). We find significant treatment effects for those individuals who would have improved sense of mastery when in the treatment condition but no effects for those who would not have improved sense of mastery under treatment.     

Development of the Mental Clutter Scale

Mental fog is a core symptom of fibromyalgia. Its definition and measurement are central to an understanding of fibromyalgia-related cognitive disability. The Mental Clutter Scale was designed to measure mental fogginess. In an exploratory factor analysis of two different samples (n=128 and n=170), cognitive symptoms of fibromyalgia loaded on 2 dimensions: cognition and mental clarity. The mental clarity factor comprised 8 items with factor loadings greater than .60 and was named the Mental Clutter Scale. The factor stability of the new scale was good, internal consistency was .95, and test-retest reliability over a median of 5 days was .92. The 8-item scale is a quick measure of mental fog that provides clinicians with information about cognitive functioning in fibromyalgia.     

Childhood Social Withdrawal,Interpersonal Impairment,and Young Adult Depression: A Mediational Model

Building on interpersonal theories of depression, the current study sought to explore whether early childhood social withdrawal serves as a risk factor for depressive symptoms and diagnoses in young adulthood. The researchers hypothesized that social impairment at age 15 would mediate the association between social withdrawal at age 5 and depression by age 20. This mediational model was tested in a community sample of 702 Australian youth followed from mother’s pregnancy to youth age 20. Structural equation modeling analyses found support for a model in which childhood social withdrawal predicted adolescent social impairment, which, in turn, predicted depression in young adulthood. Additionally, gender was found to moderate the relationship between adolescent social impairment and depression in early adulthood, with females exhibiting a stronger association between social functioning and depression at the symptom and diagnostic level. This study illuminates one potential pathway from early developing social difficulties to later depressive symptoms and disorders.     

Associations between symptoms of maternal postpartum depression,gestational age and infant social withdrawal: A longitudinal study in a community cohort

Infant social withdrawal is a risk factor for non-optimal child development; thus, it is important to identify risk factors associated with withdrawal. In a large community sample (N = 19,017), we investigate whether symptoms of maternal and partner postpartum depression (PPD; measured with the Edinburgh Postnatal Depression Scale) and prematurity are predictors of infant social withdrawal (measured with the Alarm Distress Baby Scale). Withdrawal was assessed at 2–3, 4–7 and 8–12 months postpartum. Linear regressions showed that prematurity predicted higher infant social withdrawal at all time points, and maternal symptoms of PPD were positively associated with withdrawal at 2–3 months. Logistic regressions showed that odds for elevated social withdrawal were increased with elevated levels of maternal symptoms of PPD at 2–3 and 8–12 months. Partner's symptoms of PPD were not associated with withdrawal. Future studies should investigate how PPD symptoms and prematurity may impact the individual development of social withdrawal.     

Comparing Holographic Reprocessing and Prolonged Exposure for Women Veterans with Sexual Trauma: A Pilot Randomized Trial

This pilot study compares an emerging evidence-based treatment, holographic reprocessing (HR) to prolonged exposure (PE) versus a person-centered (PC) control group to treat symptoms of distress in female Veterans with sexual trauma. In contrast to PE, HR does not include exposure to a target event of trauma. Instead, HR focuses on healing the internal working model or type of attachment style that may form as a result of interpersonal trauma or maltreatment. The model reveals how people perceive themselves and others. These perceptions set in motion emotional, cognitive, and behavioral tendencies wherein people unconsciously replicate similar types of relationships that reinforce their worldview. Fifty-one female Veterans with sexual trauma were randomly assigned to one of three treatments and completed pre- and post-treatment measures of psychiatric symptoms (anxiety, depression, and PTSD) and post-traumatic cognitions. ANOVAs found significant decreases on all variables. Post-hoc comparisons revealed that HR and PE treatments demonstrated significantly greater decreases in symptoms compared to the PC control group. Chi square analyses revealed that HR produced a significantly lower dropout rate 1 (6 %) compared to PE 7 (41 %) and PC 6 (35 %). These initial results are promising and further investigation of HR is warranted.     

A Neuropsychological Model of Mentally Tough Behavior

Four studies were conducted with two primary objectives: (a) to conceptualize and measure mental toughness from a behavioral perspective and (b) to apply relevant personality theory to the examination of between‐person differences in mentally tough behavior. Studies 1 (N = 305 participants from a range of different sports) and 2 (N = 110 high‐level cricketers) focused on the development of an informant‐rated mental toughness questionnaire that assessed individual differences in ability to maintain or enhance performance under pressure from a wide range of stressors. Studies 3 (N = 214) and 4 (N = 196) examined the relationship between reinforcement sensitivities and mentally tough behavior in high‐level cricketers. The highest levels of mental toughness reported by coaches occurred when cricketers were sensitive to punishment and insensitive to reward. Study 4 suggested that such players are predisposed to identify threatening stimuli early, which gives them the best possible opportunity to prepare an effective response to the pressurized environments they encounter. The findings show that high‐level cricketers who are punishment sensitive, but not reward sensitive, detect threat early and can maintain goal‐directed behavior under pressure from a range of different stressors.