Working with psychosis: Part 3 – ‘Struggling to contain madness – losing and recovering a capacity to think’

This is the penultimate paper in a series about working with a patient suffering from a psychotic disorder. The paper describes the third year of the work in which ‘John’ had four breakdowns in a period of six months. Much of the time I was unable to think. I was sitting on the edge of my chair either worrying that John was breaking down again or trying to help him recover from a breakdown. My small office became a cramped prison cell in which I felt myself a witness to a disturbing dance into and out of madness. A turning point seemed to happen as I developed a way of thinking about John's breakdowns. I seemed then to become a less persecutory figure in John's mind and more someone to whom John could turn for help. We found a way of thinking and talking about an infant in John. John responded by finding a way of being in my office as though he was reclining in a hammock. His breakdowns ceased. He was able to share in common humanity's concerns following September 11. Finally, I discuss thoughts about containment particularly about the paternal role in containment, drawing on Robert Caper's elaboration of Bion's ideas about containing psychotic aspects of experience.     

Response to “Turning Words and Twisting Truths”

SUMMARY

Too often, in discussions of psychotherapy, the techniques are given undue emphasis. Research suggests that the same techniques are differentially effective when used by equally trained and supervised therapists. Not only are some therapists more effective, irrespective of the type of therapy they practice, but some, because of their personal qualities, may actually harm those with whom they work. This research reflects the vast importance of the ubiquitous element in therapy, that of the “person” of the therapist. The question, then, follows, how may personhood be developed? This question is explored as it relates to both breadth and depth of life experience.     

Relationship of Long Term Effects of Childhood Sexual Abuse to Identity of the Offender

Sexual abuse is defined as the involvement of children and adolescents in sexual activities they do not fully comprehend and to which they do not freely consent. The long term effects of these violations of children have been described clinically. This study was initiated to demonstrate differences in emotional distress experienced by childhood victims of sexual abuse and their non-abused counterparts. Clinical records of 311 women were reviewed following termination from psychotherapy. Fifteen (15%) percent of the women indicated that they had been abused by a father, brother, grandfather, stepfather, friend, or stranger.     

Psychoanalysis in Psychiatric Institutions - Theoretical and Clinical Approaches

The paper presents historical remarks about psychoanalysis in institutions with a special focus on the contributions of nurses working in psychoanalytic settings. A case report of the forensic psychotherapy ward in Reichenau Mental Hospital, which is organised as a therapeutic community, shows how individual psychotherapy, group psychotherapy and special nursing care contribute to significant progress in the treatment of a severely narcissistic arsonist.     

Walking in the lost child's tracks: revisiting the therapeutic nature of reclaiming

This paper outlines the research methodology used as part of a professional doctorate in psychoanalytic psychotherapy. The project researched the maternal state of mind following the loss of an infant or small child and the birth of the next baby. Three mothers were seen for psychoanalytic psychotherapy on a weekly basis as part of this research. They were encouraged to bring their new baby to sessions. The author describes how an interest in this area of research developed as a result of working as a child psychotherapist with 'replacement children' (Cain and Cain, 1964). An argument is made to show that the psychoanalytic method is unique and that the psychoanalytic setting may be considered an 'ideal laboratory' (Fonagy and Moran, 1993) for psychoanalytic psychotherapeutic research. Clinical material is used from one case study to show how material can be analysed and demonstrates the research methodology used within the project. The material explores the developing therapeutic relationship and focuses on the way one mother in the research group experienced the loss of a small child prior to the birth of her next baby. Cet article décrit brièvement la méthodologie de recherche employée dans le cadre d'un doctorat professionnel en psychothérapie psychanalytique. Le projet de recherche porte sur l'état psychique maternel à la suite de la perte d'un nourrisson ou d'un enfant en bas âge lorsque un nouveau bébé vient à naître. Dans le cadre de cette recherche, trois mères ont bénéficié d'une psychothérapie psychanalytique à raison d'une séance hebdomadaire. Il leur était proposé d'amener leur bébé aux séances. L'auteur décrit comment son intérêt pour ce champ de recherche s'est développé à partir de son travail de psychothérapeute d'enfants auprès d'"enfants de remplacement" [A. Cain & B. Cain 1964]. Elle affirme que la méthode psychanalytique à sa propre valeur et que le cadre psychanalytique peut être considéré comme un "laboratoire idéal" [P. Fonagy & G. Moran 1993] pour la recherche en psychothérapie psychanalytique. Le matériel clinique d'une étude de cas montre comment l'analyser et illustre la méthodologie de la recherche employée dans ce projet. Ce matériel explore l'évolution de la relation thérapeutique et traite en détail de la façon dont une des mères de l'échantillon a vécu la perte d'un enfant en bas âge avant la naissance de son bébé actuel. Questo articolo mette in rilievo la metodologia di ricerca utilizzata come parte di un dottorato professionale in psicoterapia psicoanalitica. Il progetto di ricerca studiava lo stato mentale materno conseguente la perdita di un neonato o bambino piccolo e la nascita del bambino successivo. Come parte della ricerca tre madri furono seguite una volta alla settimana in psicoterapia psicoanalitica, ed incoraggiate a portare alle sedute i loro nuovi bebe'. L'autore descrive come il suo interesse in questa area si e' sviluppato conseguentemente al suo lavoro come psicoterapeuta infantile con 'bambini sostituti' (Cain e Cain, 1964. Si cerca di mostrare l'unicita' del metodo psicoanalitico e come esso possa essere considerato un 'laboratorio ideale' (Fonagy e Moran, 1993) per la ricerca in psicoterapia psicoanalitica. Viene usato il materiale clinico di un caso per mostrare come esso possa essere analizzato e illustrare il metodo di ricerca usato nel progetto. Il materiale esplora la relazione terapeutica nel suo evolversi e si concentra sul modo in cui una madre nel gruppo di ricerca visse la perdita di un bambino piccolo precedente la nascita dell'altro bebe'. Dieser Artikel umreisst die Forschungsmethodik, die als Teil einer Doktorarbeit in psychoanalytischer Psychotherapie verwendet wurde. Das Projekt erforschte den müterlichen Gemütszustand nach dem Verlust eines Babys oder kleinen Kindes und der Geburt des nächsten Babys. Als Teil dieser Forschung wurden drei Mütter einmal wöchentlich in Psychotherapie gesehen. Sie wurden ermuntert, ihr Neugeborenes zu den Stunden mitzubringen. Die Autorin beschreibt, wie das Interesse in diesem Forschungsbereich sich als Folge ihrer Arbeit als Kinderpsychotherapeutin mit 'Ersatzkindern' entwickelt hatte. (Cain und Cain 1964). Es wird argumentiert, dass die psychoanalytische Methode einzigartig ist und das psychoanalytische Setting als ein 'ideales Labor' (Fonagy und Moran,1993) für psychoanalytische psychotherapeutische Forschung angesehen werden kann. Es wird klinisches Material einer Fallstudie benutzt, um zu zeigen, wie das Material analysiert werden kann und es demonstriert die Forschungsmethodik, die im Projekt benutzt wird. Das Material erforscht die sich entwickelnde therapeutische Beziehung und legt den Schwerpunkt auf die Art und Weise, wie eine Mutter in der Forschungsgruppe den Verlust eines kleinen Kindes vor der Geburt ihres nächsten Babys erlebte.     

A slow unfolding – at double speed: reflections on ways of working with parents and their young children within the Tavistock clinic's under fives service

This paper describes clinical work carried out as part of the Tavistock Clinic Under Fives Service, which offers brief focused psychoanalytically based interventions to families with young children, as well as longer-term work. It elaborates psychoanalyst Annette Watillon's idea that it is the dramatic way in which children enact their (and their family's) predicament in the consulting room which speeds up the process of change. The author clusters clinical cases into three categories, each cluster representing a different kind of ‘dramatic’ enactment and leading to a different kind of intervention relating to the therapist's role, the structure of the interventions and the ‘ports of entry’ for the work. The categories are defined as: ‘child-led drama’ with the therapist in the role of ‘therapeutic observer’; ‘internal parental drama’ with the therapist in the role of ‘therapeutic consultant’; and ‘external parental drama’ with the therapist in the role of ‘therapeutic modulator’. The author defines these categories, illustrating each category with clinical examples.     

Culturally educated questioning: Toward a skills-based approach in multicultural counselor training

Increased resources are being committed to the multicultural training of counselors. Despite these gains, training continues to focus almost exclusively on the acquisition of cultural awareness and culture-specific knowledge. Valuable though they are, awareness and knowledge, the authors argue, do not necessarily result in effective multicultural counseling skill. Therefore, it is recommended that current training models be modified to include techniques through which cultural knowledge can be synthesized into effective counseling interventions. Specifically, it is suggested that programs stress the need to conduct cultural assessments of clients using what the authors term “culturally educated questioning”: empirically rooted inquiry designed to elicit from clients clinically relevant cultural data. The benefits of culturally educated questioning, including its safeguards against cultural stereotyping, are discussed.     

How eye movements affect unpleasant memories: support for a working-memory account

Eye movement desensitization and reprocessing can reduce ratings of the vividness and emotionality of unpleasant memories-hence it is commonly used to treat posttraumatic stress disorder. The present experiments compared three accounts of how eye movements produce these benefits. Participants rated unpleasant autobiographical memories before and after eye movements or an eyes stationary control condition. In Experiment 1, eye movements produced benefits only when memories were held in mind during the movements, and eye movements increased arousal, contrary to an investigatory-reflex account. In Experiment 2, horizontal and vertical eye movements produced equivalent benefits, contrary to an interhemispheric-communication account. In Experiment 3, two other distractor tasks (auditory shadowing, drawing) produced benefits that were negatively correlated with working-memory capacity. These findings support a working-memory account of the eye movement benefits in which the central executive is taxed when a person performs a distractor task while attempting to hold a memory in mind.     

Emotion-regulation skills as a treatment target in psychotherapy

Background

Deficits in emotion-regulation skills have been shown to be integral to the development and maintenance of a wide range of mental disorders.

Aim

To evaluate the importance of these skills as a treatment target in psychotherapeutic interventions.

Method

Nine specific emotion-regulation skills were assessed in a sample of 289 inpatients before and after cognitive-behavioural treatment. Self-reports of success in pretreatment skills application were first compared to those of 246 non-clinical controls. Pretreatment skills application and change in skills application during therapy were then related to a variety of outcome measures. Finally, the effects of integrating a brief training of general emotion-regulation skills into the CBT-based treatment were evaluated in a controlled trial.

Results

Uni- and multivariate analyses identified the skills of acceptance, tolerance, and active modification of negative emotions as particularly important for current mental health and treatment outcome. Replacing parts of the standard CBT treatment with the emotion-regulation training enhanced the effects of the CBT treatment on skills application and on other measures of mental health.

Conclusion

Incorporating interventions that directly target general emotion-regulation skills may improve the effectiveness of psychotherapeutic interventions.