Working with the complexities of adolescent mental health problems: applying Time‐limited Adolescent Psychodynamic Psychotherapy (TAPP)

This article discusses the application in a CAMHS setting of a distinctive intervention for adolescent mental health difficulties, Time‐limited Adolescent Psychodynamic Psychotherapy (TAPP). TAPP has been developed specifically for working with adolescents and the characteristic developmental and psychosocial complexities they present to mental health services. It is widely recognised that supporting the developmental process in adolescence is central to therapeutic interventions and the therapeutic aim of TAPP is to enable recovery of the capacity to meet developmental challenges. The key factors of TAPP are described, including the formulation and working with a developmental focus, the therapeutic stance, working with transference and counter‐transference, working with time limits, and the emphasis on engagement of adolescents in therapy in TAPP. The experiences of introducing and developing TAPP in the CAMHS service are discussed with two brief and one extended case examples and this leads to a discussion of the kinds of outcomes achieved. It is concluded that TAPP is a key and relevant intervention for adolescents in complex and vulnerable situations; further work will be undertaken to continue its application in these settings and to formally assess outcomes.

Psychotherapy and its alternatives: Commentary on a critique

In this commentary, Michael Rustin reviews the articles in the symposium, outlining their main aims and arguments. He goes on to provide some critical reflections, asking questions about the key concept of the ‘therapeutic state’. He notes that little attention is given to psychoanalytic or other psychological theories of the mind, as distinct from the biological models which are the main object of criticism in the symposium. He argues that just as it is justifiable and useful to take account of theories of the mind in considering issues of mental health and therapy, so it is desirable also to take account of the structures of society which have responsibility for generating conditions of mental well- or ill-being, and to reflect on how these may be changed. The commentary argues that the counter-cultural and somewhat ‘post-modern’ critical approach which informs the symposium can only form part of a sufficient response to the problems which the symposium identifies.

Psychotherapy in a neoliberal world

The neoliberal regime has significant consequences for the psychotherapies. In particular, the idea that individuals is deserving of support from society and government when they need it – for example in managing the inevitable stresses of the life cycle – is being displaced by an ideology of total individual responsibility. Psychotherapies framed around relational conceptions of the self find themselves particularly out of key with this dominant way of thinking. Governmental approaches to developmental needs become more instrumental, measurement-oriented and ‘disciplinary’ in this situation. Market incentives and disciplinary sanctions are introduced to ensure that institutions and their personnel conform to governmental directives. There is pressure on psychotherapists to adapt to this instrumentalised environment to survive. However, ‘expressive individualisation’ was also stimulated by the cultural liberation of the 1960s, and survives alongside the ‘possessive individualism’ of neoliberalism. This alternative culture has not been entirely suppressed, and therapies continue to be sought which offer the possibility of self-understanding and growth, although the pressure is for such therapies to become luxury goods. What is at risk under neoliberalism is the idea that society should support the self-development and self-understanding of all its citizens, as an aspect of a modern kind of democratic citizenship.

Brief Psychotherapy with Children in a Specialist School: An Exploration of the Underlying Issues for Children and Mainstream Schools

This thesis explores brief psychotherapy with children on placement at a specialist school setting, as part of an on-site, child psychotherapy outreach provision. The study sought to explore two research questions concerning the themes that could emerge in brief work with children and how these themes could be discussed in relation to the understanding formed by their mainstream school teachers. A qualitative research design was used to investigate these questions. The methods used to collect data were case studies, concerning the brief psychotherapy with 4 boys, aged 7 years, and and semi-structured interviews were conducted with the teachers. Thematic analysis was used to explore the data. The themes that were derived from the analysis were described in detail. The research found that brief work has considerable benefit for children and mainstream schools. Through the brief work intervention, the children all made significant progress in all areas of their lives a school. Contributions that the research makes to related fields, the implications that it has for policy and practice and recommendations for future research were all discussed.

An Investigation into the Implementation of CYP-IAPT Routine Outcome Measures in their First Year of Integration into Child Psychotherapy Practice

This thesis examines the impact on child and adolescent psychotherapists within CAMHS of the introduction of routine outcome measures (ROMs) associated with the Children and Young People’s Improving access to Psychological Therapies programme (CYP-IAPT). All CAMHS therapists working within a particular NHS mental health Trust1 were required to trial CYP-IAPT ROMs as part of their everyday clinical practice from October 2013-September 2014. During this period considerable freedom was allowed as to which of the measures each therapist used and at what frequency. In order to assess the impact of CYP-IAPT ROMs on child psychotherapy, I conducted semi-structured interviews with eight psychotherapists within a particular CAMHS partnership within one NHS Trust. Each statement was coded and grouped according to whether it related to initial (generic) assessment, goal setting / monitoring, monitoring on-going progress, therapeutic alliance, or to issues concerning how data might be used or interpreted by managers and commissioners. Analysis of interviews revealed greatest concern about session-by session ROMs, as these are felt to impact most significantly on psychotherapy; therapists felt that session-by-session ROMs do not take account of negative transference relationships, they are overly repetitive and used to reward / punish the therapist. Measures used at assessment and review were viewed as most compatible with psychotherapy, although often experienced as excessively time consuming. The Goal Based Outcome Measure was generally experienced as compatible with psychotherapy so long as goals are formed collaboratively between therapist and young person. There was considerable anxiety about how data may be (mis)used and (mis)interpreted by managers and commissioners, for example to end treatment prematurely, trigger change of therapist in the face of negative ROMs data, or to damage psychotherapy. Use of ROMs for short term and generic work was experienced as less intrusive and contentious.

Grounded Theory methods in child psychotherapy research

This article considers the place of qualitative research in psychoanalysis and child psychotherapy. It discusses why research methodology for many years occupied so small a place in these fields, and examines the cultural and social developments since the 1960s which have changed this situation, giving formal methods of research much greater significance. It reflects on the different pressures to develop formal research methods which arise both from outside the psychoanalytic field, as a condition of its continued professional survival, and from within it, where its main aim is the development of fundamental psychoanalytic knowledge, It suggests that the conduct of mainly quantitative research into treatment outcomes is largely a response to these external pressures, whilst the main benefits to be gained from the development of qualitative research methods, such as Grounded Theory, are in facilitating the knowledge-generating capacities and achievements of child psychotherapists themselves. The paper describes Grounded Theory methods, and explains how they can be valuable in the recognition of hitherto unrecognised meanings and patterns as these are made visible in clinical practice. Finally, it briefly describes five different examples of completed doctoral studies, all of which have added significantly to the knowledge-base of child psychotherapy, and which demonstrate how much can be accomplished using this method of research.

What is the Role of Attachment in Contemporary Psychotherapy? A Grounded Theory Exploration of the Perspective of Experienced Psychologists

Since Bowlby devised his theory of attachment, originally for clinical purposes, refinements and extensions have developed its clinical utility. The research question asked how experienced contemporary clinicians now perceive the role of attachment in the formulation and treatment of distress by reference to their clinical work. Using grounded theory methodology, underpinned by a relativist, moderate social constructionist epistemology, initial sampling consisted of 16 in-depth interviews with experienced clinicians. The tentative theoretical categories that emerged were then developed in theoretical sampling in further interviews with 5 of the initial interviewees. The final theoretical categories to emerge concerned the prevalence of caregiver-related problems, the provision of safety together with the prioritisation of the relationship with self as attachment-related treatment strategies, and attachment theory’s provision of understanding in problem formulation. Whilst this suggests that attachment-related ideas are integrated in contemporary practice, it also suggests that the clinical utility now offered by attachment theory, as established in the literature, has not found broad appeal amongst clinicians despite the commonness of attachment-related presenting problems. The implications of this are manifold. To begin with, attachment theorists have largely failed to bring the potential now offered by attachment-related therapeutic interventions to the market. This situation makes it incumbent on the next generation of attachment researchers to more clearly articulate techniques with which clinicians, of whatever theoretical orientation, can better leverage attachment-related knowledge in their clinical work. In this enterprise, perhaps the knowledge and experience of expert clinicians could be harvested, as this research has done. Moreover, researchers must expand the evidence base that such interventions actually work. Beyond the implications for clinical utility and efficacy, the findings strengthen counselling psychology’s influence on society’s perception and treatment of attachment-related problems.

A Comparison of Audio Recordings and Therapist's Process Notes in Child and Adolescent Psychoanalytic Psychotherapy

Therapistsʼ process notes - written descriptions of a session produced shortly afterwards from memory - hold a significant role in child and adolescent psychoanalytic psychotherapy. They are central in training, in supervision, and in developing oneʼs understanding through selfsupervision and forms of psychotherapy research. This thesis examines such process notes through a comparison with audio recordings of the same sessions. In so doing, it aims to generate theory that might illuminate the causes of significantly patterned discrepancies between the notes and recordings, in order to understand more about the processes at work in psychoanalytic psychotherapy and to explore the nature of process notes, their values and limitations. The literature searches conducted revealed limited relevant studies. All identified studies that compare process notes with recordings of sessions seek to quantify the differences between the two forms of recording. Unlike these, this thesis explores the meaning of the differences between process notes and recordings through qualitative data analysis. Using psychoanalytically informed grounded theory, in total nine sets of process notes and recordings from three different psychoanalytic psychotherapists are analysed. The analysis identifies eight core categories of findings. Initial theories are developed from these categories, most significantly concerning the role and influence of a ʻcore transference dynamicʼ between therapist and patient. Further theory is developed on the nature and function of process notes as a means for the therapistʼs conscious and unconscious processing of the session, as well as on the nature of the influence of the relationships – both internal and external – within which they are written. In the light of the findings, a proposal is made for a new approach for learning about the patient and clinical work, ʻthe comparison methodʼ (supervision involving a comparison of process notes and recordings), and, in particular, for its inclusion within the training of psychoanalytic psychotherapists. Further recommendations for research are also made.

Investigating Links Between Intimacy and Violence in Intensive Psychotherapy

This research examines links between intimacy and violence within the transference relationship of a three year old boy during intensive psychotherapy. Psychoanalytic clinical findings are used to examine triggers to violence that initially appeared to link with moments of emotional warmth. The research uses a retrospective single case study design. The clinical data cover a period of transition in the child's life from being a 'looked after child' in foster care to being adopted. There was a history of early trauma from neglect and domestic abuse. Clinical process notes from supervised sessions were coded using an adapted grounded theory approach to reveal complex interlinking themes of intimacy, violence, Oedipal issues, control and difficulties regulating affect. Data in this study show how intimacy and violence are linked when there is evidence of a separation between the self and the object of intimacy. Explosive violence is triggered by the threat of loss of the object and the rage is, at times directed towards the object of intimacy. The findings of this study support concepts identified by earlier research in the field about the impact of a lack of maternal containment on innate violence, associated struggles with the Oedipal complex and the impact upon the capacity for symbol formation and thinking. However, the research findings challenge Glasser's (1979) theory of the 'core complex' that suggests that intimacy triggers violence. The results of this research indicate that it is the threat to the loss of intimacy as a result of separation from the object that is the trigger to violence. I believe this study may, in a modest way, further understanding about links between violence and intimacy in human relationships. This may help other child psychotherapists be alert to certain dangers when dealing with violence in the therapy room.

‘To me, it's like a little box of tricks’: Breaking the depressive interlock as a programme participant in mindfulness-based cognitive therapy

Objectives. Mindfulness meditation practices have become increasingly popular in clinical therapies, changing patterns of depressogenic thinking for individuals who experience consecutive episodes of depression. We were interested in finding out how Mindfulness Based Cognitive Therapy (MBCT) worked for programme participants by focussing on how meditative practices changed their relationships to their thoughts. Design. Data for the study came from six semi-structured research interviews carried out with individuals who had taken part in an 8 week MBCT programme Methods. We used Interpretative Phenomenological Analysis (IPA) to analyse the experiential accounts. Results. We report on two superordinate themes – Engaging the Neutral Mind (with subordinate themes ‘breaking the paralysis of worry’ and ‘choosing to think differently’) and Experiencing the Neutral Mind (with subordinate themes of ‘reflection on previous thinking styles’ and ‘becoming psychologically self-reliant’). Conclusions. Themes from the present study offer support to the assertion that mindfulness meditation helps facilitate a different mode of meta-cognitive processing with which to handle depression-related cognitions. Practitioner Points Participants reported that they experienced an enhanced capacity to differentiate between their thought processes, experiencing an ability to tolerate some more uncomfortable thoughts and experiencing a/more choice in how to respond to thoughts Participants recognised that ruminating over negative thoughts was related to depressive states and experienced a shift in meta-cognitive processes that actively challenged depressogenic cognitions Participants became more psychologically self-reliant and therapeutically independent following MBCT Integrating mindfulness based practices in therapy may be a mediating factor in sustaining psychological wellbeing and may help clients develop self-compassion Future research looks to examining exit cases to understand elements of MBCT which are experienced as less successful by clients

Destructive Groups: The Role of Projective Identification in Suicidal Groups of Young People

Group suicidal behaviour by young people has been attracting increasing worldwide attention, but the subject has rarely been studied from a clinical or psychodynamic perspective. Although etiological factors are not well understood, unconscious as well as conscious group processes likely contribute to self-destructive actions. In this article we discuss the role of projective identification in the development of suicidal behavior by individuals who are part of a destructive group. We consider how these factors may operate, illustrated through a case description of a young man involved with a group of high school students that included at least four who made serious suicide attempts. Recognition and understanding of these forms of communication have important implications for clinical practice and suicide prevention.

Autistic Functioning and Language Development

This thesis is a retrospective qualitative study based on psychotherapy sessions with children presenting autistic features who use language in atypical ways. The aim was to understand, through the transferential relationship, what psychological context in terms of anxieties and defences prevents the child from using language efficiently. Hypotheses concerning children‘s use of language in the context of their emotional oscillation and evolution during the course of treatment were noted and checked against subsequent developments. They were also triangulated with the outcome of a grounded theory analysis. The grounded theory analysis led to the emergence of higher-level themes that were compared within and across cases and allowed factors surrounding the children‘s use of language to be conceptualized. The grounded theory method was used in parallel with the usual process of evaluation of the dynamics of each session and patient used by psychoanalysts a posteriori and which is part of the researcher‘s background. This procedure was enhanced by the use of Bion‘s Grid, here in a version adapted to the aims of the research. This approach is discussed in detail in the Methodology chapter. The psychoanalytic theoretical background that supported the research was mainly based on the tradition of Object-Relations Theory, particularly the evolution of Kleinian thinking represented by Bion‘s works, and as far as autism is concerned, by Frances Tustin and Donald Meltzer‘s formulations. Concerning the subject of language development, Meltzer‘s explorations on the necessary conditions for its development and the philosopher Wittgenstein‘s investigations on the social function of language were the main influences of this work. The evolution of the children‘s use of language in parallel with their emotional development in the context of their psychotherapies was analyzed and some hypotheses about the oscillations in their emotional and mental functioning were made. The oscillation in the children‘s emotional state, language use and thinking processes was also studied in terms of a general fluctuation between different mental states that was considered to be present in different degrees and quality in mental life and more strongly when there are limitations in communication skills and social interaction. A few excerpts from notes on adolescent and adult cases with autistic features were included in the Discussion Chapters to briefly illustrate this aspect.

A Psychological Exploration of Long-Term LSD Users

All research involving the psychoactive compound lysergic acid diethylamide (LSD) was terminated globally following its prohibition more than 50 years ago, though illicit use remained fairly stable. A considerable resurgence of research interest in LSD has received considerable attention in various publications and professional fora. One of the main applications considered is LSD-assisted psychotherapy to address a number of difficulties like end-of-life anxiety, addiction/alcoholism, post-traumatic stress, and depression. However, due to the highly contradictory nature of early research findings and division in the literature, one is left uncertain as to whether psychology as a profession is currently equipped to critically evaluate these advances, let alone embrace them. The purpose of the present study was to contribute to current psychological knowledge on long-term LSD use. A group of long-term LSD users who claimed beneficial use were the focus here. A mixed methods design was employed. 110 users completed an online survey assessing for demographics, patterns of use, and specific personality traits through three psychometric measures, Big Five Inventory (BFI), General Self Efficacy scale (GSE) and Satisfaction With Life Scale (SWLS). Eight individual interviews were also conducted and analysed by Thematic Analysis (TA). Gaining different perspectives on reality and increasing self- awareness appeared to be essential elements of the belief system that these non-problematic long-term LSD users adopted in order to make sense of their LSD use. Qualitative findings also suggested the existence of a common set of life values, rules and the adoption of a hierarchical system between LSD users. Novices appeared to be tutored and guided by elders whose presence and input was valued and who were listened to and respected. A role for ‘wiser/elder’ users as those imparting valuable knowledge to novices was therefore also suggested. The underlying aim may possibly be an attempt to minimise risks and maximise potential benefits of LSD use. A prospective role for LSD as a deterrent of substance misuse, a ‘gateway drug to no drugs’ was also hinted and remains in need of iv further investigation. Claims regarding beneficial LSD use and ‘change’ through LSD use were confirmed by the participant sample. No noteworthy differences between psychometric scores of the LSD-using group and those of the general population (as suggested by normative data comparisons) were found, possibly due to methodological limitations, especially considering the highly subjective nature of the LSD experience and its effects. The determining role of extra-pharmacological variables or ‘set and setting’ in the outcome of LSD use suggested in earlier literature was re-validated. Knowledge on their specific components was enriched, and a potentially significant value for adopting a flexible, adaptable and solution-focused mind-set in order to better manage the effects of LSD was highlighted. Due to the highly selected nature of the participant sample, present findings should serve as suggestions for further research in order to clarify the aforementioned issues and to make explicit the mechanisms by which they operate. The complex nature of LSD, its use and its effects have been re-confirmed here. It is imperative that the current knowledge base on the substance is enriched before LSD is introduced in a clinical psychology professional context.

Othering, blame and shame when working with people living with HIV

Significant advances in HIV treatment has meant that for the majority of patients with HIV they are able to live a normal lifespan. However, HIV remains a highly stigmatizing disease with the potential to significantly impact on ones social identity and sense of self. This paper draws on data from a qualitative study of interviews with five gay men, to explore the experiences of shame in relation to living with HIV. The paper adopts a psychoanalytic lens to highlight the mechanisms of splitting that may be involved at both a social and individual level, and the experience of shame among the participants. The paper aims to use this research data to supplement our understanding of what may be occurring ‘on the couch’ with patients who are living with HIV.

Incongruence between clinicians’ assessment and self-reported functioning is related with psychopathology among patients diagnosed with gastrointestinal disorders

In a previous exploratory study we observed no relevant differences in psychopathology, personality, and functioning between inpatients diagnosed with gastrointestinal motor disorders (GMDs) or functional gastrointestinal disorders (FGDs) [1]. However, we observed higher levels of incongruence between clinician-assessed performance status and patients’ self-reported levels of functioning among patients diagnosed with FGDs. Likewise, research in other medical conditions has shown incongruences between self-reported and clinician-reported or objective measures [2]. Furthermore, in a study on chronic depression, the authors found that discrepancies between patients’ and physicians’ assessments of medical comorbidities were related to higher levels of depressive symptomatology [3]. In this line, the aim of this study was to explore whether the inconsistencies between clinician-assessed and patient self-reported levels of functioning could be related to psychopathology among patients admitted for evaluation of gastrointestinal motility.