Clients’ experiences of dynamic interpersonal therapy (DIT): opportunities and challenges for brief,manualised psychodynamic therapy in the NHS

Dynamic interpersonal therapy (DIT) is a brief manualised psychodynamic intervention for depression. This is a first study exploring clients’ experiences of DIT specifically and brief, manualised psychodynamic psychotherapy (PP) in general. Interpretative phenomenological analysis was the methodology employed. Five participants completed a semi-structured interview, three weeks to ten months after completing DIT. The scores of pre- and post-therapy outcome measures of depression and anxiety were also available. Two emerging superordinate themes are presented here: (1) ‘The Distinct Features of DIT’, referring to how its therapeutic style and time limitations were experienced and (2) the ‘Impact of Therapy’, referring to perceived outcomes. While previous findings showed that therapist’s perceived limited activity in long-term PP was experienced as hindering/unhelpful, the perceived sense of direction in DIT appeared adequate to most participants. Secondly, the time limitations provoked complex responses. Reactions to the distinct elements of DIT are to be treated both as therapeutic opportunities and as challenges. Further, in line with psychoanalytic theory, most participants described relational changes that went beyond symptom relief and remained in progress after therapy ended. Intriguingly, there was no consistency between participants’ qualitative accounts of change and the scores of the outcome measures.     

The relationship between childhood adversity,psychiatric disorder and clinical severity: results from a multi-centre study

Although several studies have shown a clear association between childhood adversities and later development of a number of psychiatric disorders, a number of recent reports have cast doubts regarding the aetiological role played by abuse, neglect and loss, arguing that they are neither necessary nor sufficient to account for the development of subsequent psychopathology. In this study, we aimed to investigate the associations and predictive power of childhood adversities on later onset of Axis-I &-II psychiatric conditions and the impact on severity of psychiatric presentation in a large sample of patients. This cross-sectional multi-centre study evaluated patients (N = 1136) recruited in fourteen NHS psychotherapy departments in the UK. Patients were assessed using a number of rater-based questionnaires and self-rated measures. Multiple regression analyses showed that childhood experiences of loss and physical abuse were predictive of severe personality disorder and borderline personality disorder, but not of other less severe PD and Axis-I diagnoses. Sexual abuse predicted later onset of Post-traumatic Stress Disorder. In addition, we found that childhood abusive experiences were strongly associated with severity of psychiatric distress, interpersonal problems and global functioning. Having experienced two or more childhood adversities significantly increased severity of psychiatric distress, interpersonal malfunctioning and CORE scores.     

Don’t tell me I’m normal: inpatient psychotherapy of a severely abused patient at the Cassel Hospital

This paper is a case study of a patient with severe personality disorder undergoing treatment at the Cassel Hospital. It looks at a phase of her individual psychoanalytic psychotherapy and how that sits within an institutional model of treatment that can be understood as applied psychoanalysis, in which Tom Main’s concept of a ‘culture of enquiry’ aims to observe and bring together splitting and projective processes operating at all levels of the organisation. The patient, who had been sexually abused and then suffered a prolonged suicidal breakdown, exerted intense pressure on the institution through her experience of herself as both a victim of abuse and a participant in it. A working through is described, in which different parts of the patient that had been projected into different parts of the institution are brought together, and her primitive demand for a two-person world gives way to an acceptance of triangulation. Themes from her individual sessions are enacted in the milieu-based treatment, and conversely struggles in the patient community appear in her sessions. It is from drawing these parts of the patient together as a whole institution that the treatment derives its power and effectiveness.     

WALKER PERCY,LANGUAGE, AND HOMO SINGULARIS

The novelist Walker Percy argued that modern science has a tremendous blind spot in its view of human nature. Unlike purely physical phenomena, which can be explained by the interaction of dyadic relationships, human beings must also be understood in terms of triadic relationships brought into being by symbolic language. The self brought into being by symbolic language is nonmaterial but real, and operates by different “laws” than those that govern dyadic relations. In making this case, Percy drew a sharp line between human and nonhuman language, a line that more recent developments in science has challenged. However, Percy's central point, that the agent of symbolic language cannot be understood within a materialist framework, remains valid.     

Meta‐Analysis of Counseling Outcomes for the Treatment of Posttraumatic Stress Disorder

This meta‐analysis of 152 published posttraumatic stress disorder (PTSD) clinical trials from 1990 to 2012 concluded that counseling generally produced a small to large effect of treatment across all comparison conditions at termination (d+ = 0.30 to 0.89). These gains were maintained at longest follow‐up (d+ = 0.58 to 0.86) for the wait‐list, treatment‐as‐usual, and single‐group comparisons, but not for the follow‐up placebo comparison (d+ = 0.15), probably because of the low power (j = 3 placebo studies). Clinical trial findings were synthesized using a random‐effects model. No effects of publication bias or moderating variables were evident. No difference was found between trauma‐focused and non‐trauma‐focused approaches. Implications for counseling practice and future PTSD outcome research are addressed.     

Behaviorism and Society

A probable list of causes for the limited acceptance of behaviorism in our society is identified. This is followed by a summary review of the proposed solutions identified in other papers in this special issue of The Behavior Analyst, most of which relate to either better marketing of either the behavior analytic process or the results achieved as a consequence. One paper proposes a more broad conception of behavior analysis. This paper endorses the solutions identified in previous papers and then goes on to propose an even more broad conception of behavior analysis and makes the point that behavior analysis is unlikely to flourish unless behavior analysts understand a good deal more about the cultural and other contextual features of the environments in which they work.     

Changes over time in head and neck cancer patients’ and caregivers’ illness perceptions and relationships with quality of life

Objective: This study investigated changes in illness perceptions from diagnosis to six months later in patients with head and neck cancer (HNC) and their caregivers. The study also examined whether discrepancy in patient and caregiver perceptions at diagnosis predicted patient health-related quality of life (HRQL) at six months.

Design: Forty-two patient–caregiver dyads completed the Brief Illness Perception Questionnaire (Brief IPQ) at diagnosis and again six months later. Patients also completed a HRQL questionnaire at both time points. Analyses were performed using the Actor–Partner Interdependence Model.

Main Outcome Measure: Total patient HRQL assessed by the Functional Assessment of Cancer Therapy (FACT-H&N).

Results: Perceptions of emotional impact and illness concern reduced over time in patients and caregivers. Perceptions of treatment control and identity increased in caregivers only. After controlling for the effects of baseline HRQL, and the individual contribution of patient and caregiver illness perceptions, greater discrepancy in perceptions of timeline, personal control, and illness identity among dyads at diagnosis predicted lower patient HRQL at six-month follow-up.

Conclusion: Patients’ and their caregivers’ perceptions of HNC are dynamic over time. Greater discrepancy between patients’ and caregivers’ illness perceptions at diagnosis predict poorer subsequent patient HRQL.     

Executive and attentional contributions to Theory of Mind deficit in attention deficit/hyperactivity disorder (ADHD)

Attention deficit/hyperactivity disorder (ADHD) in children has been associated with attentional and executive problems, but also with socioemotional difficulties possibly associated with deficits in Theory of Mind (ToM). Socioemotional problems in ADHD are associated with more negative prognoses, notably interpersonal, educational problems, and an increased risk of developing other psychiatric disorders that emphasize the need to clarify the nature of their ToM deficits. In this study, we hypothesized that ToM dysfunction in children with ADHD is largely attributable to their attentional and/or executive deficits. Thirty-one children with ADHD (8–12 years, IQ > 85) and 31 typically developing (TD) children were assessed using executive functions (inhibition, planning, and flexibility) and attentional tasks, as well as two advanced ToM tasks (Reading the Mind in the Eyes and Faux Pas) involving different levels of executive control. Children with ADHD performed more poorly than TD children in attentional, executive function, and ToM tasks. Linear regression analyses conducted in the ADHD group indicated that inhibition scores predicted performance on the “Faux Pas” task the best, while attention scores were the best for predicting performance on the Reading the Mind in the Eyes task. When controlled for inhibition and attentional variables, ToM performance in children with ADHD was actually similar to TD children. Contrarily, controlling for ToM scores did not normalize performance for inhibition and attentional tasks in children with ADHD. This unidirectional relationship suggests that deficits in the EF and attentional domains are responsible for ToM deficits in ADHD, which therefore may contribute to their socioemotional difficulties.     

Current knowledge on motor disorders in children with autism spectrum disorder (ASD)

Motor symptomatology in autism is currently poorly understood, and still not included in the autism spectrum disorder (ASD) diagnostic criteria, although some studies suggest the presence of motor disturbances in this syndrome. We provide here a literature review on early motor symptoms in autism, focusing on studies on psychomotor issues (tone, postural control, manual dexterity, handedness, praxis). The approach adopted in research to study altered motor behaviors is generally global and there is no detailed semiology of the motor or neuromotor disorders observed in people with ASD. This global approach does not enable understanding of the neuro-developmental mechanisms involved in ASD. Identification of clinical neuro-psychomotor profiles in reference to a standard would help to better understand the origin and the nature of the disorders encountered in ASD, and would thus give new directions for treatment.     

Out of our skulls: How the extended mind thesis can extend psychiatry

The thesis that mental states extend beyond the skull, otherwise known as the extended mind thesis (ExM), has attracted considerable philosophical attention and support. It has also been accused of lacking practical import. At the same time, the field of psychiatry has remained largely unacquainted with ExM, tending to rely instead upon what ExM proponents would consider to be outdated models of the mind. ExM and psychiatry, therefore, have much to offer one another, but the connection between the two has remained largely unexplored. Here, I consider what implications ExM may have for psychiatry and, in so doing, reveal how psychiatry may lend practical import to ExM. First, I detail the possibility of the extension of one mental state relevant to psychiatry. I augment this example by surveying other possibilities for extension in the context of psychiatric diagnoses. I then consider ways in which such extensions might alter psychiatric diagnosis and treatment. Overall, I argue that recognition of the truth of ExM could alter the diagnostic status of certain individuals by correcting both false positives and false negatives, re-conceptualize certain aspects of treatment, help us re-envision psychiatric research, and potentially increase empathy towards those individuals considered to be mentally disordered or mentally different.