APP conference summary

This is an account of the extended assessment of a 22-year-old man who was initially sent for a court report, having been accused of setting fires. He had a history both of delinquency and, importantly, of childhood asthma. Although he proved unable to engage in psychotherapy, some management was provided, such as Winnicott advocates in cases of delinquency. This paper explores the symbolic meanings and functions of the patient's delinquent acts, drawing upon theoretical concepts from Freud, Aichhorn, and Deutsch. Of particular importance is the link between this patient's delinquency, his asthma, and the unresolved mourning for his dead mother which he carried not simply for himself but for his whole family.     

Psychotherapy with an adolescent boy who refused medical treatment

In this paper we describe psychotherapeutic work carried out in a paediatric hospital to illustrate the important contribution of a psychoanalytically-oriented approach in a hospital context. The work concerns an adolescent boy who had undergone several surgical operations with the result that some of his natural orifices were obstructed and artificial ones had to be created. He was referred to us because he refused pharmacological and rehabilitative treatment necessary prior to further surgery and his eventual recovery. The boy's experience of loss of control of his life and the more primitive anxieties of not feeling safely contained in his physical and psychic skin emerged and were worked through in the psychotherapeutic relationship. The parallel work with medical staff reduced the risk of splitting and acting out by the patient and professionals. The approach adopted enabled this boy to resume his medical treatment and his developmental process.     

A Program Intervention for Pediatric Bipolar Disorder: Preliminary Results

The effectiveness of a behaviorally based day treatment program for young children diagnosed with Pediatric Bipolar Disorder (PBD) was evaluated using pretreatment and posttreatment mean scores from the Child Behavior Checklist (CBCL). Data were evaluated in aggregate and using the clinically significant change method for children diagnosed with PBD, Attention Deficit Hyperactivity Disorder (ADHD), Oppositional Defiant Disorder (ODD), Adjustment Disorder, and no diagnosis/clinical and subclinical groups. Significant effects were found for all groups except the no diagnosis/subclinical group on the Internalizing scale and for all groups on the Externalizing scale. Clinically significant change was supported for the PBD, ADHD, ODD, and Adjustment Disorder groups. Implications and limitations of the study are discussed.     

Treating PTSD in active duty service members using cognitive processing therapy or prolonged exposure therapy: Examining everyday practice at a military outpatient clinic

The Institute of Medicine has stressed the need for evaluations of evidence-based treatments (EBTs) for posttraumatic stress disorder (PTSD) among active duty service members (AD) using a variety of evaluation approaches (Institute of Medicine, 2012). The current study examined the clinical files of 134 service members who completed treatment for PTSD using either prolonged exposure (PE) or cognitive processing therapy at an outpatient clinic. At the completion of each session, therapists made a clinical rating as to whether or not the session was protocol adherent. The total number of treatment sessions and the proportion of sessions rated as being protocol adherent were calculated. Multi-level models estimated the change in patient PTSD and other psychological symptoms over time as a function of clinician-rated protocol adherence and total number of sessions. Approximately 65% of clinic encounters were rated by therapists as being protocol adherent. Significant reductions in PTSD and psychological symptoms were associated with protocol adherence, and this was particularly true for patients who began treatment above clinical thresholds for both PTSD and other psychological symptoms. However, as the number of sessions increased, the impact of protocol adherence was attenuated. Patient characteristics, including gender, ethnicity, and co-morbidity for other psychiatric disorders were not related to symptom change trajectories over time. These findings suggest that protocol adherence and efficiency in delivery of EBTs for the treatment of PTSD with AD is critical.     

Short‐term cognitive‐behavioral treatment in multicultural primary care of patients with longstanding backache

The efficacy of cognitive‐behavioral therapy in multi‐cultural primary care patients with longstanding backache is not evaluated. The purpose of this study was to investigate the outcome of a four weekly‐treatment given by primary care physicians regarding pain‐related worry, depression and severe pain and to determine which social, clinical or gender factors were associated with outcome.The study group consisted of 245 patients in consecutive order from 19 countries, 18 to 45 years, entering rehabilitation program because of longstanding backache. Prevalences of pain‐related worry and depression and severe pain was counted and compared before and after. Logistic regression was used to calculate the odds (OR; 95% CI) for persistent pain‐related worry and/or persistent depression and severe pain (VAS ≥ 50). The prevalences of pain‐related worry and depression were both significantly lower after treatment (pain‐related worry 83% before vs. 38% after; depression 43% before vs. 31% after). Also the number of patients scoring ≥ 50 VAS was a little, but significantly, fewer (68% vs. 61%). Use of interpreter doubled the risk of having persistent pain‐related worry (OR 2.1; 95% CI 1.1–4.1) but the risk was not significant regarding persistent depression (OR 1.8; 0.6‐5.4). The rating of VAS rating ≥ 50 after treatment was twice as high, OR 2.3 (95% CI 1.1–4.6) in the 38–45 year old age group. To conclude, a focus on pain ideas reduced pain‐related worry and depression in these patients with various sociocultural backgrounds and longstanding backache.     

Thoughts about the development of a potential space in the psychotherapeutic treatment of infantile psychosis

This paper describes the usefulness for the child psychotherapist of some Winnicottian concepts in psychoanalytic treatment of very young psychotic children. Particular attention is given to the concept of ‘potential space’ as Winnicott has formulated it in his writings. Three clinical cases are presented, one of these includes a complete mother-child session in order to show how the therapist can work to create a space where psychic events can become possible.     

To be in touch

This study examined the constellation of interaction structures – repetitive patterns of interactions between patient and therapist over the course of treatment – that emerged in the psychodynamic therapy (PDT) of a child diagnosed with borderline personality disorder and treated by two doctoral student therapists. Identification of these interaction structures can inform therapists of what might be expected from patients with particular symptom or behaviour patterns and how interactions change over time. This study also examined each session’s adherence to three session prototypes: PDT, cognitive-behavioural therapy (CBT) and reflective functioning (RF) process. The Child Psychotherapy Q-Set (CPQ) is a 100-item instrument that assesses the processes within a single psychotherapy session. Items reflect a wide range of therapist attitudes and behaviours, patient attitudes and behaviours and interactions between therapist and patient. Experts used the CPQ to define PDT, CBT and RF process session prototypes. The results suggested that four distinct interaction structures could be identified and that their constellations differed between the two therapists and also differed over time within each treatment. Therapists were more structured and accommodating early on in their treatments and more interpretive later. Prototypical PDT process was more prominent in the sessions than RF process, which in turn was more prominent than CBT process. Unique therapeutic processes are at work in every dyad, despite holding the patient and theoretical orientation constant. An effective treatment in one dyad might not work in another due to therapist-specific and dyad-specific effects.     

THE INTERPLAY BETWEEN RELIGIOUS LEADERS AND ORGAN DONATION AMONG MUSLIMS

Bioethics and health researchers often turn to Islamic jurisconsults (fuqahā’) and their verdicts (fatāwā) to understand how Islam and health intersect. Yet when using fatwā to promote health behavior change, researchers have often found less than ideal results. In this article we examine several health behavior change interventions that partnered with Muslim religious leaders aiming at promoting organ donation. As these efforts have generally met with limited success, we reanalyze these efforts through the lens of the theory of planned behavior, and in light of two distinct scholarly imperatives of Muslim religious leaders, the ?ilmī and the islāhī. We argue for a new approach to health behavior change interventions within the Muslim community that are grounded in theoretical frameworks from the science of behavior change, as well the religious leadership paradigms innate to the Islamic tradition. We conclude by exploring the implications of our proposed model for applied Islamic bioethics and health research.     

Women's views about intimate examinations and sexually inappropriate practices by their general practitioners

Abstract

The aim of this survey of 472 adult women was to assess women patients' feelings about intimate examinations and their perceptions and experiences of sexually inappropriate medical practice. Two-thirds of women preferred a women doctor for intimate examinations. Slightly more than two-thirds found intimate examinations embarrassing and stressful, and strongly expressed the need for information and on-task, health-related comments during these examinations. General personal comments or non-medical touching were not particularly welcomed, even for the purpose of comforting the patient. There was a range of views about patients' personal relationships with doctors, with the lines between acceptable and unacceptable behaviour somewhat ambiguous. A small but significant number of women perceived that they had been sexually harassed (5%) or abused (3%) by a doctor, with this experience more common for non-English speaking women. Results were discussed in terms of implications for improved doctor practice, particularly during intimate examinations and with vulnerable patients.     

A comparison of computer and questionnaire methods of history-taking in a genito-urinary clinic

Abstract

Information on the medical history and symptomatology of 69 patients presenting at a genito-urinary (GU) clinic was obtained either by a computerized interview or a paper questionnaire and the results compared. A comparison was also made between these methods and notes taken during a standard physician interview. Significantly more symptoms were elicited by the computer than the paper questionnaire. Both methods also elicited significantly more symptoms than were recorded by the physician. The patients reported having previously attended a GU clinic more often to the computer than to the physician whereas the questionnaire was no different from the physician. The results indicate that computers can be used satisfactorily to facilitate medical history- taking in GU clinics and may result in a more complete profile of symptoms than either written questionnaire or physician interview.