Psychoanalytic perspectives on substance use and antisocial personality disorder

Psychoanalysis and related psychodynamic psychotherapies have historically had a limited engagement with substance use and antisocial personality disorders. This in part reflects an early preoccupation with ‘transference neuroses’ and in part reflects later de-emphasis of diagnosis and focus on therapeutic process. Nonetheless, psychoanalytic perspectives can usefully inform thinking about approaches to treatment of such disorders and there are psychoanalytic constructs that have specific relevance to their treatment. This paper reviews some prominent strands of psychoanalytic thinking as they pertain to the treatment of substance abuse and antisocial personality disorders. It is argued that, while Freudian formulations lead to a primarily pessimistic view of the prospect of treatment of such disorders, both the British object relations and the North American self psychology traditions suggest potentially productive approaches. Finally the limited empirical evidence from brief psychodynamically informed treatments of substance use disorders is reviewed. It is concluded that such treatments are not demonstrably effective but that, since no form of psychotherapy has established high efficacy with substance use disorders, brief psychdynamic therapies are not necessarily of lesser value than other treatments and may have specific value for particular individuals and in particular treatment contexts.

Work-related subjective experiences among community residents with schizophrenia or schizoaffective disorder

Objective: To develop a self-report scale of subjective experiences of illness perceived to impact on employment functioning, as an alternative to a diagnostic perspective, for anticipating the vocational assistance needs of people with schizophrenia or schizoaffective disorders. Method: A repeated measures pilot study (n1 = 26, n2 = 21) of community residents with schizophrenia identified a set of work-related subjective experiences perceived to impact on employment functioning. Items with the best psychometric properties were applied in a 12 month longitudinal survey of urban residents with schizophrenia or schizoaffective disorder (n1 = 104; n2 = 94; n3 = 94). Results: Construct validity, factor structure, responsiveness, internal consistency, stability, and criterion validity investigations produced favourable results. Work-related subjective experiences provide information about the intersection of the person, the disorder, and expectations of employment functioning, which suggest new opportunities for vocational professionals to explore and discuss individual assistance needs. Conclusion: Further psychometric investigations of test-retest reliability, discriminant and predictive validity, and research applications in supported employment and vocational rehabilitation, are recommended. Subject to adequate psychometric properties, the new measure promises to facilitate exploring: individuals' specific subjective experiences; how each is perceived to contribute to employment restrictions; and the corresponding implications for specialized treatment, vocational interventions and workplace accommodations.

An Investigation of Organic Factors in the Neuropsychological Functioning of Patients with Borderline Personality Disorder

The hypothesis to be tested in this study was that the cognitive deficits that have been documented in patients with Borderline Personality Disorder (BPD) are largely the consequence of organic insult, either developmental or acquired. Using a cross–sectional design, 80 subjects (males and females) who met the criteria for BPD participated in the study. They completed a battery of neuropsychological tests and a comprehensive interview assessing organic status as well as measures of the potentially confounding factors of current levels of depression and anxiety. It was expected that BPD-patients with a probable history of organic insult would perform significantly worse than would BPD patients without such a history. Analyses of the results provided partial support for the hypothesis. Subjects with both BPD and a history of organic insult were significantly more impaired on several measures including measures of attention than were BPD only subjects. The results suggested that the impaired cognitive performance of persons diagnosed with BPD may, in part, be attributed to organic factors.

Your voice counts : Listening to the voice of high school students with autism spectrum disorder

Supporting students with Autism Spectrum Disorders (ASD) in inclusive settings presents both opportunities and significant challenges to school communities. This study, which explored the lived-experience of nine students with ASD in an inclusive high school in Australia, is based on the belief that by listening to the voices of students, school communities will be in a better position to collaboratively create supportive learning and social environments. The findings of this small-scale study deepen our knowledge from the student perspective of the inclusive educational practices that facilitate and constrain the learning and participation of students with ASD. The students’ perspectives were examined in relation to the characteristics of successful inclusive schools identified by Kluth. Implications for inclusive educational practice that meets the needs of students with ASD are presented.

Mind games : applying White’s principles of narrative therapy to the creation of a cabaret about depression and bipolar disorder

This PhD represents my attempt to make sense of my personal experiences of depression through the form of cabaret. I first experienced depression in 2006. Previously, I had considered myself to be a happy and optimistic person. I found the experience of depression to be a shock: both in the experience itself, and also in the way it effected my own self image. These personal experiences, together with my professional history as a songwriter and cabaret performer, have been the motivating force behind the research project. This study has explored the question: What are the implications of applying principles of Michael White’s narrative therapy to the creation of a cabaret performance about depression and bipolar disorder? There is a 50 percent weighting on the creative work, the cabaret performance Mind Games, and a 50 percent weighting on the written exegesis. This research has focussed on the illustration of therapeutic principles in order to play games of truth within a cabaret performance. The research project investigates ways of telling my own story in relation to others’ stories through three re-authoring principles articulated in Michael White’s narrative therapy: externalisation, an autonomous ethic of living and rich descriptions. The personal stories presented in the cabaret were drawn from my own experiences and from interviews with individuals with depression or bipolar disorder. The cabaret focussed on the illustration of therapeutic principles, and was not focussed on therapeutic ends for myself or the interviewees. The research question has been approached through a methodology combining autoethnographic, practice-led and action research. Auto ethnographic research is characterised by close investigation of assumptions, attitudes, and beliefs. The combination of autoethnographic, practice-led, action research has allowed me to bring together personal experiences of mental illness, research into therapeutic techniques, social attitudes and public discourses about mental illness and forms of contemporary cabaret to facilitate the creation of a one-woman cabaret performance. The exegesis begins with a discussion of games of truth as informed by Michel Foucault and Michael White and self-stigma as informed by Michael White and Erving Goffman. These concepts form the basis for a discussion of my own personal experiences. White’s narrative therapy is focused on individuals re-authoring their stories, or telling their stories in different ways. White’s principles are influenced by Foucault’s notions of truth and power. Foucault’s term games of truth has been used to describe the effect of a ‘truth in flux’ that occurs through White’s re-authoring process. This study argues that cabaret is an appropriate form to represent this therapeutic process because it favours heightened performativity over realism, and showcases its ‘constructedness’ and artificiality. Thus cabaret is well suited to playing games of truth. A contextual review compares two major cabaret trends, personal cabaret and provocative cabaret, in reference to the performer’s relationship with the audience in terms of distance and intimacy. The study draws a parallel between principles of distance and intimacy in Michael White’s narrative therapy and relates these to performative terms of distance and intimacy. The creative component of this study, the cabaret Mind Games, used principles of narrative therapy to present the character ‘Jo’ playing games of truth through: externalising an aspect of her personality (externalisation); exploring different life values (an autonomous ethic of living); and enacting multiple versions of her identity (rich descriptions). This constant shifting between distance and intimacy within the cabaret created the effect of a truth in ‘constant flux’, to use one of White’s terms. There are three inter-related findings in the study. The first finding is that the application of principles of White’s narrative therapy was able to successfully combine provocative and empathetic elements within the cabaret. The second finding is that the personal agenda of addressing my own self-stigma within the project limited the effective portrayal of a ‘truth in flux’ within the cabaret. The third finding presents the view that the cabaret expressed ‘Jo’ playing games of truth in order to journey towards her own "preferred identity claim" (White 2004b) through an act of "self care" (Foucault 2005). The contribution to knowledge of this research project is the application of therapeutic principles to the creation of a cabaret performance. This process has focussed on creating a self-revelatory cabaret that questions notions of a ‘fixed truth’ through combining elements of existing cabaret forms in new ways. Two major forms in contemporary cabaret, the personal cabaret and the provocative cabaret use the performer-audience relationship in distinctive ways. Through combining elements of these two cabaret forms, I have explored ways to create a provocative cabaret focussed on the act of self-revelation.

The lived experience of post-traumatic stress disorder as described by motor vehicle accident victims in Jordan

Aim: To explore the lived experience of post-traumatic stress disorder (PTSD) as described by individuals who have been involved in a motor vehicle accident (MVA) in Jordan. Background: Motor vehicle accident (MVA) survivors who develop post-traumatic stress disorder (PTSD) have become an important health issue. The World Health Organisation (WHO) states that trauma resulting from MVAs is a phenomenon of increasing concern, with death from injuries projected to rise from 5.1 million in 1990 to 8.4 million in 2020 particularly in developing countries such as Jordan (WHO, 2002). The impact of trauma from MVAs inevitably compromises the victim’s quality of life (WHO, 2002; Blanchard & Hickling, 2007) resulting in psychological and emotional distress, occupational disability, family disintegration, and socio-economic difficulty (Jordan Ministry of Health, 2005). The development of PTSD as a result of an MVA is not limited to the individual, but also extends to the family, friends, and the health care team involved in the person's care and rehabilitation. Design: A descriptive phenomenological approach was used for this study. Method: This study was conducted in an orthopaedic unit in Amera Basma Hospital in Irbid Jordan. Fifteen (15) participants were voluntary recruited through the process of purposeful sampling. Data was collected by face-to-face in depth-interviews. Interviews were digitally recorded and transcribed verbatim. The process of analysis was undertaken using Colaizzi’s (1978) eight step approach with the addition of two extra steps. Findings: The process of analysis identified seven themes explicated from the participants’ transcripts of interview. The seven themes were: 1. Feeling frustrated at a diminishing health status 2. Struggling to maintain a sense of independence 3. Harbouring feelings of not being able to recover 4. Feeling discriminated against and marginalised by society 5. Feeling ignored and neglected by health care professionals 6. Feeling abandoned by family, and 7. Moving toward acceptance through having faith in Allah. Conclusion: The findings of this study have the potential to make a significant contribution to extant knowledge on the topic which can inform future nursing practice, education, policy development, and research initiatives in Jordan and internationally.

The relationship between chronic disease self-efficacy and nutritional status, functional ability and quality of life in older adults at risk of hospital readmission

Background and significance: Older adults with chronic diseases are at increasing risk of hospital admission and readmission. Approximately 75% of adults have at least one chronic condition, and the odds of developing a chronic condition increases with age. Chronic diseases consume about 70% of the total Australian health expenditure, and about 59% of hospital events for chronic conditions are potentially preventable. These figures have brought to light the importance of the management of chronic disease among the growing older population. Many studies have endeavoured to develop effective chronic disease management programs by applying social cognitive theory. However, limited studies have focused on chronic disease self-management in older adults at high risk of hospital readmission. Moreover, although the majority of studies have covered wide and valuable outcome measures, there is scant evidence on examining the fundamental health outcomes such as nutritional status, functional status and health-related quality of life. Aim: The aim of this research was to test social cognitive theory in relation to self-efficacy in managing chronic disease and three health outcomes, namely nutritional status, functional status, and health-related quality of life, in older adults at high risk of hospital readmission. Methods: A cross-sectional study design was employed for this research. Three studies were undertaken. Study One examined the nutritional status and validation of a nutritional screening tool; Study Two explored the relationships between participants. characteristics, self-efficacy beliefs, and health outcomes based on the study.s hypothesized model; Study Three tested a theoretical model based on social cognitive theory, which examines potential mechanisms of the mediation effects of social support and self-efficacy beliefs. One hundred and fifty-seven patients aged 65 years and older with a medical admission and at least one risk factor for readmission were recruited. Data were collected from medical records on demographics, medical history, and from self-report questionnaires. The nutrition data were collected by two registered nurses. For Study One, a contingency table and the kappa statistic was used to determine the validity of the Malnutrition Screening Tool. In Study Two, standard multiple regression, hierarchical multiple regression and logistic regression were undertaken to determine the significant influential predictors for the three health outcome measures. For Study Three, a structural equation modelling approach was taken to test the hypothesized self-efficacy model. Results: The findings of Study One suggested that a high prevalence of malnutrition continues to be a concern in older adults as the prevalence of malnutrition was 20.6% according to the Subjective Global Assessment. Additionally, the findings confirmed that the Malnutrition Screening Tool is a valid nutritional screening tool for hospitalized older adults at risk of readmission when compared to the Subjective Global Assessment with high sensitivity (94%), and specificity (89%) and substantial agreement between these two methods (k = .74, p < .001; 95% CI .62-.86). Analysis data for Study Two found that depressive symptoms and perceived social support were the two strongest influential factors for self-efficacy in managing chronic disease in a hierarchical multiple regression. Results of multivariable regression models suggested advancing age, depressive symptoms and less tangible support were three important predictors for malnutrition. In terms of functional status, a standard regression model found that social support was the strongest predictor for the Instrumental Activities of Daily Living, followed by self-efficacy in managing chronic disease. The results of standard multiple regression revealed that the number of hospital readmission risk factors adversely affected the physical component score, while depressive symptoms and self-efficacy beliefs were two significant predictors for the mental component score. In Study Three, the results of the structural equation modelling found that self-efficacy partially mediated the effect of health characteristics and depression on health-related quality of life. The health characteristics had strong direct effects on functional status and body mass index. The results also indicated that social support partially mediated the relationship between health characteristics and functional status. With regard to the joint effects of social support and self-efficacy, social support fully mediated the effect of health characteristics on self-efficacy, and self-efficacy partially mediated the effect of social support on functional status and health-related quality of life. The results also demonstrated that the models fitted the data well with relative high variance explained by the models, implying the hypothesized constructs under discussion were highly relevant, and hence the application for social cognitive theory in this context was supported. Conclusion: This thesis highlights the applicability of social cognitive theory on chronic disease self-management in older adults at risk of hospital readmission. Further studies are recommended to validate and continue to extend the development of social cognitive theory on chronic disease self-management in older adults to improve their nutritional and functional status, and health-related quality of life.