A quality assurance programme for psychotherapy — The finnish experience

In many respects the status of psychotherapy in public health-care systems is similar to that of alternative medicine. The roots of training are outside universities. Legitimation and public funding have been non-existent or insufficient as compared with other fields of health care. Also a great deal of mysticism is attached to both. It is therefore relevant to study the role of psychotherapy from the frame of reference given by research into alternative health care.

Formal health care is characterised by (1) legalised status, (2) access to public funding and (3) integration in the formal medical curriculum. On the other hand there are several treatment philosophies which remain as outsiders from the point of view of formal health care. Informal health care approaches are characterised by (1) lack of legalised status, (2) no access to public funding and (3) no integration in the medical curriculum. Alternative medicine is a term usually attached to forms of informal health care like acupuncture, Spa-culture etc.

Psychotherapy in the public health sector lies somewhere between formal and informal health care. While it has no legalised status, anyone may call himself ‘psychotherapist’. Its definition remains obscure and its public accountability poor.

In this paper I have tried to show how one country — Finland — has tried to grapple with this problem as it attempted to set up psychotherapy services whose quality could be properly monitored — ‘Quality Assurance’ — allowing for public accountability. Now that psychotherapy is well established as a valuable treatment in the field of mental health it is possible to consider future expansion as a cost-effective way to improve the general mental health of the country.     

Our Cosmos,from Substance to Process

Philosophies of nature over the past three centuries have gone through three distinct phases, beginning with classical views and now evolving into a process view at the dawn of the 21st century. These phases derive from a complex weaving of two frameworks of physics since Newton's time [classical, modern] with two principal metaphysical frameworks[substance, event]. Problematic fin de siècle claims at the end of both the 19th and 20th centuries appear to have a common root in substance metaphysics and part/whole reductionism. Going beyond such simplistic forms of modernism requires a more integrated, ecological worldview, or process view of nature.     

The effects of action,normality, and decision carefulness on anticipated regret: Evidence for a broad mediating role of decision justifiability

Two distinct theoretical views explain the effects of action/inaction and social normality on anticipated regret. Norm theory (Kahneman & Miller, 1986) emphasises the role of decision mutability, the ease with which one can imagine having made a different choice. Decision justification theory (Connolly & Zeelenberg, 2002) highlights the role of decision justifiability, the perception that the choice was made on a defensible basis, supported by convincing arguments or using a thoughtful, comprehensive decision process. The present paper tests several contrasting predictions from the two theoretical approaches in a series of four studies. Study 1 replicated earlier findings showing greater anticipated regret when the chosen option was abnormal than when it was normal, and perceived justifiability mediated the effect. Study 2 showed that anticipated regret was higher for careless than for careful decisions. Study 3 replicated this finding for a sample holding a different social norm towards the focal decision. Finally, Study 4 found that, when decision carefulness, normality and action/inaction were all specified, only the former showed a significant effect on anticipated regret, and the effect was again mediated by perceived justifiability. Decision justification theory thus appears to provide a better account of anticipated regret intensity in this context than does norm theory.     

The Work Process as Spatial Situation: A Sketch

Interacting with the work of art entails a spatial situation, which is double. On a mental plane it is encapsulated reverie, on a physical plane it is production and consumption. These two are woven together as an orthogonal text or texture. The space of the work of art thus contains both the process of its making and its viewing. Seen as a dimensional space it is non linear. It is characterized by oscillations, discepancies, misalignements, multiplicity and recurrence. There is a correspondance between the studio and the exhibition area, as well as a dialogue between privileged and unprivileged spaces. The situation has something in common with oneiric space, where weightlessness and gravity oscillate.     

The Cognitive Processes Underlying Risky Choice

In this article, we tested two concepts of decision making: expected utility theory and heuristic choice. In Experiment 1, we applied think‐aloud protocols to investigate violations of expected utility theory. In Experiments 2 to 4, we introduced a new process‐tracing method—called predict‐aloud protocols—that has advantages over previously suggested research methods. Results show the following: (i) people examine information between rather than within gambles; (ii) the priority heuristic emerges as the most frequently used strategy when problems are difficult; and (iii) people check for similarity when problems are easy. Copyright © 2012 John Wiley & Sons, Ltd.     

THE SECOND SPHERE AND THE STORY OF NO STORY

The author discusses Roy Schafer's ideas of the second self and second reality, as well as his consistent theme of storyteller and story. The latter theme is also explored in the context of more recent psychoanalytic influences, such as Bionian thought, trauma theory, the French approach, and the interpersonal perspective. To illustrate the idea of the nonstory in today's clinical encounters, the author presents two clinical vignettes.     

‘And when you were a child?’: how therapists working with parents alongside individual child psychotherapy bring the past into their work

When a child is offered psychotherapy, it is common that regular meetings will be offered to the parents. However, there are debates in the literature about the degree to which such parent work should include a focus on the parents’ own childhood experiences. This study aimed to examine the way that those offering parent work as part of a study evaluating the treatment of adolescent depression dealt with this issue in their work with parents, both in the study and in routine clinical practice. Design: five therapists were interviewed on the subject of working with parents’ childhood experiences within parent work parallel to child psychotherapy. Data were analysed qualitatively, using Interpretative Phenomenological Analysis. Findings: participants described the need to consider the different parameters of this work to individual adult therapy; in addition, participants felt that it was necessary to negotiate permission to work on the parents’ childhood experiences. They also spoke of making use of insight into the repetition of the parents’ history, the analysis of parental projections and offering containment within the relationship; this varies from the ‘transference work’ of individual therapy and a different style of interpretation was described. Conclusions: there is a need to give more attention to the neglected field of working with parents alongside individual child psychotherapy, especially at a time when such work is under threat within many public services. There are particular technical issues related to work with parents’ own childhood histories that are different to how one might work in individual therapy with a parent.     

Killing the dead: evolution of melancholic identifications underlying suicide attempts in adolescence

Psychic processes underlying suicidal behaviours during adolescence and their evolution are explored. A longitudinal study was conducted of thirty adolescent patients hospitalised following a suicide attempt. Clinical interviews were used combined with the Rorschach Test and the Thematic Apperception Test (TAT) a few days after the suicide attempt and one year later. Results initially showed common forms of psychic adjustment: melancholic identifications were linked to an excessive dependence on objects. One year later, these forms of psychic adjustment changed: for many adolescents, the melancholic identifications shifted and self-image improved. The emergence of representations of murder fantasies immediately after the suicidal behaviour allowed a possible transformation of violence into symbolisation. A case study illustrates these psychic changes.