Cases to cases: A study of psychotherapy

The background to the study was a research project on psychotherapy (279 subjects) in the context of the Finnish Student Health Service. Patients were divided into three groups by duration of treatment. For each group, a hypothetical case was constructed. The hypothetical case in relation to short-term treatment (less than six months) is someone whose temporarily disturbed mental balance is supported by the therapist. The hypothetical case in relation to medium-term treatment (one to two years) exhibits recovery through release from self-objects. The hypothetical case in relation to long-term treatment (two to five years) was marked by the partial working through of object relationships.     

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’.     

Attentional interference by threat and post-traumatic stress disorder: The role of thought control strategies

Attentional interference by threat is associated with PTSD, but the mechanisms of this relationship remain unclear. Attentional interference might be related to increased use of maladaptive thought control strategies, such as suppressing unwanted thoughts (thought suppression) or replacing threatening thoughts with everyday concerns (worry), which increase PTSD risk. Conversely, attentional interference might be associated with reduced use of adaptive strategies, such as talking about threatening thoughts (social control), which decrease PTSD risk. This study tested if thought control strategies mediate the relationship between attentional interference and PTSD. Sixty-one male Vietnam-era veterans completed measures of PTSD symptoms and thought control strategies. Participants also completed a Visual Search Task measuring attentional interference, which required participants to identify a target letter string among a group of threat or neutral words. Attentional interference by threat was related to PTSD symptoms, and mediation analyses revealed significant indirect effects of attentional interference through thought suppression and worry. Attentional interference was related to re-experiencing and avoidance, but not hyperarousal, symptom clusters. Thought suppression was a unique mediator for re-experiencing, whereas thought suppression and worry both mediated the relationship with avoidance. These results offer evidence for maladaptive thought control strategies as a mechanism linking attentional biases for threat to PTSD.     

Happy,sad, scary and peaceful musical excerpts for research on emotions

Three experiments were conducted in order to validate 56 musical excerpts that conveyed four intended emotions (happiness, sadness, threat and peacefulness). In Experiment 1, the musical clips were rated in terms of how clearly the intended emotion was portrayed, and for valence and arousal. In Experiment 2, a gating paradigm was used to evaluate the course for emotion recognition. In Experiment 3, a dissimilarity judgement task and multidimensional scaling analysis were used to probe emotional content with no emotional labels. The results showed that emotions are easily recognised and discriminated on the basis of valence and arousal and with relative immediacy. Happy and sad excerpts were identified after the presentation of fewer than three musical events. With no labelling, emotion discrimination remained highly accurate and could be mapped on energetic and tense dimensions. The present study provides suitable musical material for research on emotions.Keywords.     

Emotional awareness,gender, and peculiar body-related beliefs

Research has broadly established that emotional disturbances are associated with body image disturbances. This is the first study to examine links between facets of emotional awareness and peculiar body-related beliefs (PBB), or beliefs about an imagined or slight defect in one's appearance or bodily functioning. In a sample of college students (n=216), we found that low emotional clarity (the extent to which the type and source of emotions are understood) was associated with higher PBB in both women and men, and the relation between emotional clarity and PBB was further moderated by attention to emotions (the extent to which emotions are attended to) and gender. Men with low attention to emotions and women with high attention to emotions both experienced higher levels of PBB if they also reported low levels of emotional clarity. This interactive effect was not attributable to shared variance with body mass index, neuroticism or affect intensity.     

Neuroscience,mind and meaning: an attempt at synthesis in a Relational Affective Hypothesis

This paper sets out a falsifiable Relational Affective Hypothesis, describing a neurological and relational pathway, through which affect and sensations arising from the interior of the body are translated, in a relational context, into language and a capacity for symbolisation. It describes the role of psychodynamic defences in narcissistic disorder, which can result in collapse in the function of this pathway. The hypothesis arose from clinical psychodynamic work with patients with severe and complex narcissistic disorders. They are characterised as severe, because they are at high risk of completed suicide and so are commonly treated in locked units, and complex because of their anorexic and bulimic eating patterns, tendency towards somatisation and the co-occurrence of autistic difficulties. A more or less profound failure of symbolisation is a feature common to these presentations. This interdisciplinary thinking offers a perspective on brain and psychological development, taking into account the complex interplay between genetic, environmental, relational and dynamic influences. It can be tested empirically and has implications for psychoanalytic thinking, psychiatry and neuroscience.     

Surviving as a personality disorder service

Personality disorder services working along psychotherapeutic lines gained appeal with Health Care Commissioners following the publication of the National Institute for Health and Clinical Excellence (NICE) guidelines for Borderline & Antisocial Personality Disorders and the emerging successful application of psychoanalytically derived approaches. In parallel to this creative development, the economic downturn has faced the National Health Service (NHS) with considerable challenges in its ongoing survival. The potential for creative pursuit often then sits in competition, juxtaposed with the need to survive. We examine the impact of this dynamic upon the therapeutic efforts of a newly established personality disorder service. We suggest that both conscious and unconscious aspects stirred up within such encounters are demanding of the need for development of a capacity within each to bear contact with unfamiliar experiences. Through attention to that development, both patient and clinician may further enliven and enrich individual and collective identities, such that the potential to survive creatively is actualized.     

Attentional bias to violent images in survivors of dating violence

This study investigated the time-course characteristics of attentional bias, such as vigilance and maintenance, towards violent stimuli in dating violence (DV) survivors. DV survivors with PTSD symptoms (DV-PTSD group; n=14), DV survivors without PTSD symptoms (Trauma Control group; n=14), and individuals who were never exposed to dating violence (NDV group; n=15) viewed slides that presented four categories of images (violent, dysphoric, positive, and neutral) per slide, for ten seconds. Our results revealed that the DV-PTSD group spent more time on violent stimuli than did the Trauma Control or NDV groups. The DV survivors, both with and without PTSD symptoms, spent more time on dysphoric stimuli and less time on happy stimuli than did the NDV group. In addition to the effects of PTSD, researchers should also be considering the effects of simple traumatic exposure.     

Sport-Based Group Therapy Program for Boys with ADHD or with Other Behavioral Disorders

A group of children with Attention Deficit Hyperactivity Disorder (ADHD) was compared to children with other behavior and emotional problems. All the participants participated together in 20 weekly sessions for 1 academic year. The participants were assessed with three questionnaires on three different occasions: before the beginning of the group, at the completion of the group, and 1 year after the completion of the group. The results showed that the children indicated improvement in two behavior domains while their parents indicated improvement in the children's behavior in five domains. The most striking improvement was reduction of anxiety.     

A Child With Autism Spectrum Disorder Teaches Siblings to Skateboard: Effects on Sibling Skills and Family Social Behavior

Abstract

Children with autism spectrum disorder (ASD) may have few common activities with their siblings who do not have ASD, and this can limit their opportunities for social play. In this study, we used a multiple-baseline across skills design to assess the effects of a boy with ASD following an activity schedule to teach his favorite activity of skateboarding to his two siblings who do not have ASD. Family social behavior was also measured before and after sibling training. After training by the boy with ASD, both of the siblings’ skateboarding skills improved, and measures of family social behavior also increased. Results suggest that sibling relationships may benefit when a child with ASD teaches siblings to play.