What is a difficult mental health case? An empirical study of relationships among domain variables

A difficult case in psychotherapy can be defined in many ways. This study proposes a model for that definition, in which three domains (patient characteristics, case characteristics, and therapist characteristics) are considered to impact on that definition. A total of 264 professionals received a questionnaire to assess the relative importance of a series of variables within and across these domains. Wilcoxon Matched-Pairs Signed-Ranks tests indicated that patient characteristics were considered more important than therapist or case characteristics in defining a difficult case. Case characteristics were considered more important than therapist characteristics. Pearson correlations, however, suggested that the three domains in the model are related. Correlations (for years of experience) and Kruskal-Wallis one-way ANOVA for ranks (for professions) also indicated that participants were able to identify variables within domains as important in that definition regardless of years of experience or professions. Across domains, the most important variables included the motivation of the client (a patient characteristic), dropout/attrition and multiple diagnoses (case characteristics), and the degree of therapist-client racial similarity (a therapist characteristic).     

A Review of: “Greenwald,R. (2009). Treating Problem Behaviors: A Trauma-Informed Approach.”

This single-case-design experiment examined an intervention to decrease bed-sharing in children, ages 2 through 6. Three sessions were conducted with each parent. At the first session, parents described bed-sharing history and began collecting baseline data. At the second session, parents were instructed to employ the intervention. At the third session, parents were interviewed and offered continued support, if needed. Participants included three children who slept with their parents 4 or more nights per week. The intervention resulted in a substantial decrease in bed-sharing behavior for all participants, and parents reported being satisfied with the intervention.     

Psychotherapy and close-process technique

The applicability and advantages of Paul Gray's concept of close-process in the practice of psychotherapy are discussed. Gray seems to have underestimated the potential and versatility of his technical approach to derivative psychotherapy procedures. Clinical vignettes are provided, describing some nodal points for intervention, and exploration of transferential, extratransferential and genetic aspects of the workable surface. Gray's methodology of intraclinical attention permits a more verifiable examination of sequences, an issue of special relevance in our age of empirical standards for the evaluation of dynamic therapies.     

THE ATTRACTION OF TOPOGRAPHICAL TECHNIQUE

The author argues that although the topographical model is useful for understanding certain psychological phenomena, its technical applications pose certain problems. The model's inherent tendency to bypass the analysand's ego capacities and mix his or her associations with the analyst's own make it less than adequate. There has never been a rapid evolution of psychoanalytic technique, and topographical and structural concepts have been applied in an unclear way. It is inaccurate to think that making the unconscious conscious is mostly characteristic of topographical technique, for the structural approach is a more comprehensive method for attaining this goal. The difficulties in transcending topographical technique seem to be related to certain historical inertias and irrational factors that make it especially attractive. Among these are the appeal of its simplicity, the gratification of epistemophilic and narcissistic tendencies, and the propitious ground for the analyst's projections that is provided by interpretations. The role of suggestion in topographical technique, its therapeutic effectiveness and its syntonicity are discussed and two brief clinical vignettes are presented. The author concludes that it is mainly because of its magnetic regressive features that this technique has not been superseded by the structural approach.     

The multiple baseline design across exemplars

Three variations of the multiple baseline design (MBD) have been identified in the behavioral literature: MBD across behaviors, subjects and situations. This analysis proposes an important variant of the MBD across behaviors, namely the MBD across exemplars. In this variant, two or more components (exemplars) of the behavior class form the baselines of the design. Thus, intervention is applied separately and sequentially to each target exemplar. The implicit rule of the MBD across exemplars can be seen in several published papers in the behavioral literature. The value of recognizing this variant of the MBD across behaviors is its usefulness as an alternative experimental intervention in clinical settings where the possibility of a convincing research design might not otherwise be seen.