Psychotherapy and shame

He looked right through me…..I was so ashamed!

We need to feel seen, to be recognised. Even the self-sufficient person may carry a fear of not being acknowledged; self-sufficiency can be a way to avoid the pain of being ignored. The narcissist is often reacting to a terrible fear of being rejected.

The pain of not being seen varies according to who is looking right through us. Being ignored by a stranger is different to being cold-shouldered by our partner. However, no matter what the level of intensity, most of us fear being ignored.

What are our reactions when we feel ignored? We feel awkward, we feel embarrassed and blush. To be ignored is a source of shame. Another person’s rudeness may diminish them in our eyes, but for us the main person who is cut down in size is ourselves. Even the possibility of shame can stop us from reaching out to others and can lead to acute social anxiety. Read more Psychotherapy and shame

The effectiveness of psychodynamic psychotherapy

A team from the Justus-Liebig University Giessen in Germany has conducted a systematic search for evidence for the effectiveness of psychodynamic psychotherapy. They concluded that this form of therapy was effective for a range of common mental disorders including major depressive disorder, social anxiety disorder, some personality disorders, somatoform pain disorder and anorexia nervosa. They also found some evidence for effectiveness in treating dysthymia, complicated grief, panic disorder, generalized anxiety disorder and substance abuse/dependence. Read more The effectiveness of psychodynamic psychotherapy

Talking therapy changes the brain

Researchers from Massachusetts General Hospital (MGH) have identified changes in the metabolic activity of a key brain region in patients successfully treated for depression with psychodynamic psychotherapy – talking therapy.

The study involved 16 patients with major depression who were offered weekly psychodynamic psychotherapy sessions. Each of the participants had unsuccessfully tried treatment for their depression with medication. Nine of the patients completed the course of psychotherapy and ‘almost all’ reported a greater than 50% reduction in their depression. Read more Talking therapy changes the brain

‘Stanford Prison’ and our capacity for cruelty

Maybe we’re not so bad after all.

Interesting piece from the BPS Research Digest about the Stanford Prison Experiment. That was the 1971 experiment in which a group of students was divided into jailers and inmates. The ‘jailers’ eventually became so brutal in their treatment of their ‘inmate’ peers that the experiment had to be abandoned. The lead investigator, Philip Zimbardo, used this result to argue that even good people will turn bad in certain situations.

I’d always accepted the results of this experiment at face value and it’s been used to explain, amongst other things, the atrocities at Abu Ghraib. What I hadn’t realised was the range of criticisms leveled at the experiment’s methodology and conclusions. These culminated in the 2002 BBC Prison Study, in which a similar experiment led to a far more nuanced and interesting outcome. Read more ‘Stanford Prison’ and our capacity for cruelty

Brain activity shows babies rehearsing speech months before first words

Geoff Ferguson – July 19th 2014

Brain activity in babies as young as seven months show that they are preparing to begin to speak.

Researchers from the University of Washington found that areas of the brain responsible for planning the motor movements associated with speech were activated when 7- and 11-month old babies heard speech sounds.

“Most babies babble by 7 months, but don’t utter their first words until after their first birthdays,” said lead author Patricia Kuhl, who is the co-director of the UW’s Institute for Learning and Brain Sciences. “Finding activation in motor areas of the brain when infants are simply listening is significant, because it means the baby brain is engaged in trying to talk back right from the start and suggests that 7-month-olds’ brains are already trying to figure out how to make the right movements that will produce words.”

Read more Brain activity shows babies rehearsing speech months before first words

Hearing violent voices in America and in India

Interesting piece in the New York Times about a study that compares voices heard by schizophrenics in the US and in India. The researchers wanted to see if people who heard voices in India heard the same exhortations to violence as those in the US. How influenced by culture were these voices?

‘The two groups of patients have much in common. Neither particularly likes hearing voices. Both report hearing mean and sometimes violent commands. But in our sample of 20 comparable cases from each country, the voices heard by patients in Chennai are considerably less violent than those heard by patients in San Mateo, Calif.’

Read more Hearing violent voices in America and in India

Depressed parents and their children

Medscape has recently carried two reports on studies that looked at the effects of parental depression.

One report looked at a study published in Pediatrics, which looked at links between depression in fathers and their parenting behaviour. The study was particularly interested in parenting behaviour that could negatively affect the child’s development, including the physical punishment of young children or the absence of shared activities, such as reading to the child.

The study looked at 1,746 fathers drawn form the Fragile Families and Child Wellbeing Study (FFCWS), an ongoing study that looks at a representative cohort of children born in the United States between 1998 and 2000. Families were recruited at the child’s birth and the fathers were interviewed when the child was one year old. Seven percent of the fathers reported a major depressive episode in the previous 12 months; many of these men were unemployed or also reported substance misuse.

Fathers identified as experiencing depression were:

  • More likely to have hit their child (41% of depressed fathers had spanked their child in the previous month, compared to 13% of non-depressed fathers),
  • Less likely to have read to their child (41% of depressed fathers had read to their child at least three times in the previous week, compared to 58% of non-depressed fathers).

Some points made by the study include:

  • That while some may argue for the use of corporal punishment in older children, its use in children under one year is very problematic.
  • That the increased likelihood of spanking by these fathers may be linked to some of the symptoms of depression, such as irritability and anger.
  • That around half of all fathers interviewed in the FFCWS thought that discipline was one of their key roles, even with younger children.
  • That over three quarters of all fathers had spoken to a pediatrician about their child in the previous year, presenting opportunities for screening for depression and for a discussion about parenting behaviour.

The study authors pointed to several limitations of their study, including the possibility that children with a difficult temperament might result in both negative parental behaviour and parental depression.

The second report in Medscape describes a study of 80 mothers and their children who participated in the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trial. The study looked at mothers who were experiencing major depression and whose children also experienced psychiatric symptoms and problem behaviours.

The study showed improvements in the children of mothers whose depression improved in treatment. This was not the case for the children of mothers whose depression did not improve, in fact there was an increase in the problematic behaviour of children whose mothers did not get better.

(Questions have been raised about the overall STAR*D programme, which was intended to test the effectiveness of anti-depressants. There are claims that the methodology used in the trial and the way that the trail was reported both overestimated the evidence for the effectiveness of drug treatments for depression. For example, see this article in Psychology Today.)

These two reports remind us of the crucial need to provide support for parents to avoid later problems for the children. Both mothers and fathers can experience depression following the birth of a child and those early months are so important for the baby’s emotional and intellectual development. Often today that support is not available from an extended family and other help needs to be available.

via Medscape (free registration required)

Record of an online analysis

Interesting description by Carole Rosen of an analysis that she conducted online using Skype. The analysis was conducted in Chinese with a patient in China, while Rosen was, I assume, located in New York and is not a native speaker of Chinese.

Rosen’s description of the clinical material is engaging and moving, but I was particularly interested in two aspects of her paper.

The first was the careful way in which she thought about the cultural framework of her Chinese patient. She describes both some general aspects of Chinese culture and also some specific issues faced by the generation that grew up during the Cultural Revolution. This understanding of her patient’s cultural and historical context was important in making sense of her patient’s inner world and in giving him the experience of being held in mind. It was also interesting to see how familiar themes, such as Oedipal relationships, were expressed within this cultural framework.

The second aspect of the paper that interested me was its description of communication across languages and across continents. Rosen was wary both of conducting the analysis in Chinese and of carrying it out over Skype. In both cases she seems to have established a good way of working with her patient, checking with him the meaning of unclear words and his preferred way of working at distance. She’s alert to the ways in which these issues are present within the transference and in themselves can provide useful avenues through which her patient’s phantasies can be explored.

Although I work solely in English, I’ve worked with many people who have English as a second language or who come from a very different culture to mine. In this work it’s been important to check our shared understanding of words. Even when working with someone whose first language is English, we can’t assume that we both mean the same thing by the same word. Being aware of and exploring different meanings is part of developing a shared understanding of each other and of building our relationship.

I’ve also worked via Skype and I agree that a therapeutic relationship can be developed in that way. It’s not the same as being in the room together, but a relationship can be built and change helped along.

via the website International Psychoanalysis

Psychoanalysis and research

An editorial piece for the December 2010 edition of the journal Psychoanalytic Psychotherapy makes for challenging reading. The authors strenuously criticise the indifference and resistance towards research that they see amongst many psychoanalysts.

Given the time, cost, and intensity of the demands placed on patients and therapists who enter into psychoanalysis, the fact that the field has neglected to perform appropriate assessments of whether or not the treatments we routinely recommend and deliver actually work is shocking.

The authors are not anti-psychoanalysis, both are staff members of the Columbia University Center for Psychoanalytic Training and Research. Part of their concern is for the diminishing prevalence and influence of psychoanalytic treatment, which they relate to the absence of sound evidence for its effectiveness. They dismiss those forms of evidence that are most often used by psychoanalysts and psychodynamic psychotherapists.

…clinical lore, collegial interaction, and direct observations by sole practitioners can appear superficially rational as a basis for determining the effectiveness of a treatment….
Psychoanalysts pride themselves on their awareness of the impact of fantasy and wishful thinking during their treatments, but minimize the impact of such factors on their subjective assessment of their own clinical outcomes.

In place of such subjectivity, the effectiveness of these treatments should be evaluated using randomised controlled trials based upon treatment manuals, so that the practitioner’s adherence to the treatment protocol can be assessed. Although some effectiveness studies have been published, it is claimed that many are flawed.

As I say, a challenging article, and one that leaves me with contradictory thoughts.

On the one hand I do feel the lack of a widely-accepted evidence base for the effectiveness of psychoanalytic psychotherapy. I do think that such a body of evidence is growing and I appreciate those studies that I see that add to this evidence.

However, I’m uneasy about the the insistence that randomised controlled trials provide the only trustworthy evidence of effectiveness. The work of John Ioannidis, for example, brings the reliability of such trials into question. In a study of 49 of the most highly regarded and frequently cited medical papers published in the last 13 years, his team found that 11 had not received independent verification, while of those that were retested, 14 or 41% ‘had been convincingly shown to be wrong or significantly exaggerated’. Two fifths of these key papers, when retested, were shown to be misleading, papers that were widely cited and referred to by physicians for guidance. (see my earlier post)

I’m also sceptical about the prospect of manualised treatment. For me psychotherapy is about an encounter between two people, with an attempt by the therapist to leave behind preconceptions and to see what use of him or her the patient or client wishes to make. Can a manual allow me to enter into that encounter without memory or desire? Although, I have to admit my ignorance of such manuals and how they are utilised.

And so I’m left with dilemmas that for now I cannot resolve. I want, for myself and for our profession, proof that this practice is effective, both for ethical reasons and to secure our place amongst recommended treatments. But I’m also not sure that the concept of treatment is the best way to describe this journey that I take with my patients. Certainly they come to me in distress and hoping for change. And, given the investment noted above, they deserve to find that our encounter is worthwhile and helps to bring about change. But I have doubts that this is best described in terms of a DSM diagnosis or the relief of a symptom.

Mother-infant psychoanalysis

A Swedish study, involving mothers with troubled infants, showed improvements in mother’s depression and her relationship with her baby following a two-month course of two or three times a week psychoanalytic treatment for both mother and infant.

I recently came across a link to this interesting study, reported in Science Daily last year. The study followed 80 mothers who had sought help at Child Health Centres, nursing centres or  parenting internet sites. All of the mother-infant pairs received support from the centres, but half were also assigned to joint psychoanalytic treatment at the Mother-Infant Psychoanalytic Project of Stockholm. The treatment lasted about two months, with two to three sessions a week.

The treatment provided a safe environment in which the mother and her baby could  express how they felt. With the help of the analyst the mother could come to understand her baby’s ‘difficult’ behaviour as a form of communication, rather than as an attack upon her or a result of her failure. In this safe place the mother and baby could finally find each other.

In follow-ups six months later, mothers who had received the psychoanalytic treatment showed improvements in their depression, better relationships with their babies and a greater sensitivity to their baby’s signals, as compared to mothers who had only received the support of the Child Health Centres.