The psychoanalytic treatment of psychosis

The authors provide a brief review of the role of psychoanalysis in current mental health practice, psychoanalytic perspectives on the aetiology of the psychoses and analytic approaches to nosology and diagnosis as a framework for a structural approach to the various manifestations of psychosis. The paper then moves on to the discussion of appropriate techniques for the treatment of psychoses which depart from the exploratory treatment used in neurotic patients. The final section of the paper examines the results of recent outcome studies of psychoanalysis and addresses some of the consequences for service planning and delivery.

Where did we go wrong? An examination of students treatment of experimental error in engineering mechanics laboratories

The ability of engineers and applied scientists to undertake experimental measurements is a fundamental requirement of the profession. However, it is not simply good enough to be able to perform experiments if we are not able to interpret the results. In this study, reports prepared by mechanical engineering students were examined to determine how students dealt with the disparity between experimental measurements and theoretical results in their Engineering Mechanics laboratories. Analysis of the reports, and discussions with students in their laboratory classes, revealed a superficial understanding or regard for experimental error. This superficial treatment of experimental error is, most likely, due to a number of factors that are discussed. Some possible strategies for addressing the issue are also examined.

Guideline-based programs in the treatment of complex PTSD

The term “post-traumatic stress disorder” (PTSD) is a relatively new diagnostic label, being formally recognized in 1980 in the Diagnostic Statistical Manual for Psychiatric Illness – Third Edition (DSM-III) of the American Psychiatric Association (APA, 1980). Complex Post-Traumatic Stress Disorder (CP) is a more recently discussed, and newly-classified, phenomenon, initially discussed in the early 1990s (Herman, 1992a). Thus, as research into effective treatments for CP is sparse, the treatment of CP is the topic of this study, in which a guideline-based treatment program developed by the researcher for the treatment of CP is implemented and evaluated. Ten individuals participated in this study, undertaking individualized, guideline-based treatment programs spanning a period of six months. In providing background information relevant to this study, an explanation is provided regarding the nature of CP, and the reasons for its consideration as a separate phenomenon to PTSD. The adequacy of the PTSD formulation in enabling effective assessment and treatment of CP is also explored, with endorsement of previous researchers’ conclusions that the CP construct is more useful than the PTSD construct for assessing and treating survivors of long-term and multiple forms of abuse. The PTSD classification is restrictive, and not necessarily appropriate for certain forms of trauma (such as prolonged trauma, or multiple forms of trauma), as such trauma experiences may lead to specific effects that lay outside those formerly associated with PTSD. Such effects include alterations in affect regulation, consciousness, self-perception, interpersonal relationships, and in systems of meaning. Following discussion regarding the PTSD/CP classification, an examination of treatment methods currently used in the treatment of PTSD, and a review of treatment outcome studies, takes place. The adequacy of primary treatment methods in treating CP symptoms is then examined, with the conclusion that a range of treatment methods could potentially be useful in the treatment of CP symptoms. Individuals with a diagnosis of CP may benefit from the adoption of an eclectic approach, drawing on different treatment options for different symptoms, and constantly evaluating client progress and re-evaluating interventions. This review of treatment approaches is followed by details of an initial study undertaken to obtain feedback from individuals who had suffered long-term/multiple trauma and who had received treatment. Participants in this initial study were asked open-ended questions regarding the treatment approach they had experienced, the most useful aspect of the treatment, the least useful aspect, and other strategies/treatment approaches that may have been useful – but which were not used. The feedback obtained from these individuals was used to inform the development of treatment guidelines for use in the main study, as were recommendations made by Chu (1998). The predominant focus of the treatment guidelines was “ego strengthening”, a term coined by Chu (1998) to describe the “initial (sometimes lengthy) period of developing fundamental skills in maintaining supportive relationships, developing self-care strategies, coping with symptomatology, improving functioning, and establishing a positive self identity” (p.75). Using a case study approach, data are then presented relating to each of the ten individuals involved in the treatment program: details of his/her trauma experience(s)and the impact of the trauma (as perceived by each individual); details of each individual’s treatment program (as planned, and as implemented); post-treatment evaluation of the positive and negative aspects of the treatment program (from the therapist’s perspective); and details of the symptoms reported by the individual post-treatment, via psychometric assessment and also during interview. Analysis and discussion of the data relating to the ten participants in the study are the focal point of this study. The evaluation of the effectiveness of each individual’s treatment has been based predominantly on qualitative data, obtained from an analysis of language (discourse analysis) used by participants to describe their symptoms pre- and post-treatment. Both blatant and subtle changes in the language used by participants to describe themselves, their behaviour, and their relationships pre- and post-treatment have provided an insight into the possible changes that occurred as a result of the treatment program. The language used by participants has been a rich source of data, one that has enabled the researcher to obtain information that could not be obtained using psychometric assessment methods. Most of the participants in this study portrayed notable changes in many of the CP symptoms, including being more stable and having improved capacity to explore their early abuse. Although no direct cause-effect relationship between the participants’ treatment program and the improvements described can be established from this study, the participants’ perception that the program assisted them with their symptoms, and reported many aspects of “ego strengthening”, is of major importance. Such self-perception of strength and empowerment is important if an individual is going to be able to deal with past trauma experiences. In fact, abreactive work may have a greater chance of succeeding if those who have experienced long-term or multiple trauma are feeling more empowered, and more stable, as were the participants in this study (post-intervention). In concluding this study, recommendations have been made in regard to the use of guideline-based treatment programs in the responsible treatment of CP. Strengths and limitations of this study have also been highlighted, and recommendations have been made regarding possibilities for future research related to CP treatment. On the whole, this study has supported strongly other research that highlights the importance of focusing on “ego strengthening” in assisting those who have suffered long-term/multiple trauma experiences. Thus, a guideline-based program focusing on assisting sufferers of long-term trauma with some, or all, of the symptoms of CP, is recommended as an important first stage of any treatment of individuals who have experienced long-term/multiple trauma, allowing them to develop the emotional and psychological strength required to deal with past traumatic events. Clinicians who are treating patients whose history depicts long-term or multiple trauma experiences (either from their childhood, or at some stage in their adult life) need, therefore, to be mindful of assessing individuals for symptoms of CP – so that they can treat these symptoms prior to engaging in any work associated directly with the past traumatic experiences.

Does Australia's treatment of non-citizens accord with its international human rights obligations? with specific reference to the treatment of on-shore refugees

The son of immigrants, I was motivated to write a paper addressing the issues of alienation and discrimination which confronts non-citizens upon arriving in Australia. Apart from descendants of Australia's indigenous population, the common bond shared by all citizens and permanent residents of Australia is that they are either themselves immigrants or are descended from immigrants. In this paper I will look at whether Australia's law and practice meets its international human rights treaty and convention obligations vis-a-vis non-citizens. To investigate this issue I trace the history of immigration to Australia and look at the political policies which influenced the treatment of non-citizens from 1788 to present times. In 1958 when my parents stepped upon Australian soil as displaced persons, Australia was a very different place from Australia in the 1990s. At that time Australia was still firmly under the influence of the 'White Australia Policy' which openly encouraged discrimination against non-anglo saxons. Since those times Australia has advanced to become one of the most culturally diverse nations in the world where multiculturalism is encouraged and a non-discriminatory immigration program is supported by both Australia's major political parties. However, notwithstanding the great social advances made in Australia in recent decades the traditional legal sources of law, namely, judicial pronouncements, statutes and the Commonwealth Constitution have not kept pace and it is my submission that Australia's body of law inadequately protects the rights of non-citizens when compared to Australia's international human rights convention and treaty obligations. This paper will consider these major sources of law and will investigate how they have been used in the context of the protection of the rights of non-citizens. It will be asserted that the weaknesses exposed in the Australian legal system can be improved by the adoption of a Bill of Rights1 which encompasses Australia's international human rights treaty and convention obligations. It is envisaged that a Bill of Rights would provide a framework applicable at the State, Territory and Federal levels within which issues pertaining to non-citizens could be resolved. The direction of this thesis owes much to the writings, advice and supervision of Dr. Imtiaz Omar who was always available to discuss the progress of this work. Dr. Omar is a passionate advocate of human rights and has been a tremendous inspiration to me throughout my writing. I owe a debt of thanks to the partners of Coulter Burke who with good nature ignored the sprawl of books and papers on the boardroom table, often for days at a time, thus enabling me to return to my writing from time to time as my inspirational juices ebbed and waned. Thanks also go to my typists Julie Pante, Vesna Dudas and Irene Padula who worked after hours and on weekends always without complaint, on the various versions of this thesis. My final acknowledgement goes to my wife Paula who during the years that I was working on this thesis encouraged me during my darker moments and listened to all my frustrations yet never doubted that I would one day complete the task successfully. I wish to thank her wholeheartedly for her motivation and belief in my abilities. The law relied upon in the thesis is as at the 30th June, 1998. Bill or Charter of Rights 'are taken to be enactments which systematically declare certain fundamental rights and freedoms and require that they be respected'. See Evans, G. 'Prospect and Problems for an Australian Bill of Rights' (1970) 3 Australian Year Book of International Law 1 at 16. Some such notable exception is the New Zealand Bill of Rights Act 1990, contained in an ordinary statute.

Clinical, ethical and legal considerations in the treatment of newborns with non-ketotic hyperglycinaemia

Non-ketotic hyperglycinaemia (NKH) is a devastating neurometabolic disorder leading, in its classical form, to early death or severe disability and poor quality of life in survivors. Affected neonates may need ventilatory support during a short period of respiratory depression. The transient dependence on ventilation dictates urgency in decision-making regarding withdrawal of therapy. The occurrence of patients with apparent transient forms of the disease, albeit rare, adds uncertainty to the prediction of clinical outcome and dictates that the current practice of withholding or withdrawing therapy in these neonates be reviewed. Both bioethics and law take the view that treatment decisions should be based on the best interests of the patient. The medical-ethics approach is based on the principles of non-maleficence, beneficence, autonomy and justice. The law relating to withholding or withdrawing life-sustaining treatment is complex and varies between jurisdictions. Physicians treating newborns with NKH need to provide families with accurate and complete information regarding the disease and the relative probability of possible outcomes of the neonatal presentation and to explore the extent to which family members are willing to take part in the decision making process. Cultural and religious attitudes, which may potentially clash with bioethical and juridical principles, need to be considered.

Is phase-specific, community-oriented treatment of early psychosis- an economically viable method of improving outcome?

Objective: The Early Psychosis Prevention and Intervention Centre (EPPIC) provides a comprehensive 'real-world' model of early intervention to young people experiencing an emerging psychotic disorder. A prospective study has already provided evidence of improved clinical outcome at 12 months after entry. The present study examined whether the service was also cost-effective.

Method: A cost-effectiveness analysis compared EPPIC with its immediate precursor service, from the perspective of the government funding agency. Only direct costs were included.

Results: EPPIC proved to be more cost-effective. The weighted average cost per patient for the first 12 months was cheaper (by äD 7110 per patient), while treatment outcomes were superior. The savings were due to the marked reduction in in-patient costs outweighing substantial increases in the costs of community care.

Conclusion: These results, while encouraging in terms of the further development of integrated, phase-specific intervention programmes for early psychosis, are not conclusive, and further research is required.

Motivational interviewing and cognitive behaviour therapy in the treatment of adolescent overweight and obesity : study design and methodology

Background

Despite the high prevalence and negative physical and psychosocial consequences of overweight and obesity in adolescents, very little research has evaluated treatment in this population. Consequently, clinicians working with overweight and obese adolescents have little empirical research on which to base their practise. Cognitive behavioural therapy has demonstrated efficacy in promoting behaviour change in many treatment resistant disorders. Motivational interviewing has been used to increase motivation for change and improve treatment outcomes. In this paper we describe the rationale and design of a randomised controlled trial testing the efficacy of motivational interviewing and cognitive behaviour therapy in the treatment of overweight and obese adolescents.
Methods

Participants took part in a motivational interview or a standard semi-structured assessment interview and were then randomly allocated to a cognitive behavioural intervention or a wait-list control condition. The cognitive behavioural intervention, the CHOOSE HEALTH Program, consisted of 13 individual treatment sessions (12 face-to-face, 1 phone call) followed by 9 maintenance sessions (7 phone calls, 2 face-to-face). Assessments were conducted prior to participation, after the treatment phase and after the maintenance phase of intervention. Improvement in body composition was the primary outcome; secondary outcomes included improved cardiovascular fitness, eating and physical activity habits, family and psychosocial functioning.
Conclusion

Despite the demonstrated effectiveness of motivational interviewing and cognitive behavioural therapy in the long-term management of many treatment resistant disorders, these approaches have been under-utilised in adolescent overweight and obesity treatment. This study provides baseline data and a thorough review of the study design and treatment approach to allow for the assessment of the efficacy of motivational interviewing and cognitive behavioural therapy in the treatment of adolescent overweight and obesity. Data obtained in this study will also provide much needed information about the behavioural and psychosocial factors associated with adolescent overweight and obesity.

Parent management training, comorbidity, and treatment of children with oppositional defiant disorder

This study found that Parent Management Training was a successful treatment for promary school aged children who were referred to a mental health clinic and diagnosed with Oppositional Defiant Disorder. The positive outcome was not affected by the child having comorbid disorders. These findings have relevance to the clinical field.

Mechanisms and treatment of psychoses

This study investigates the mechanisms and treatment of psychoses from a psychoanalytic viewpoint, based on a re-examination of the psychoanalytic literature. By integrating the research materials of this study the researcher has been led to propose three types of foreclosure to explain the mechanisms of psychoses.