Psychoanalysis in modern mental health practice

Differential neural response to psychoanalytic intervention techniques during structural interviewing: A single-case analysis using EEG

Background

Previous studies detected changes in the electroencephalographic (EEG) signal as an effect of psychoanalytic interventions. However, no study has investigated neural correlates of specific psychoanalytic interventions in the EEG power spectrum yet. In the present case study, we contrasted three types of interventions (clarification, confrontation, and interpretation) and a neutral control condition during a structural psychoanalytic interview conducted while EEG was recorded.

Methods

A 27-year-old male patient diagnosed with major depressive disorder and borderline personality disorder with recurrent suicidal and self-injurious behavior underwent a structural interview while recording EEG. Two independent experts selected by consensus the characteristic episodes of the four conditions (clarification, confrontation, interpretation, and neutral control) within the interview, which were included in the EEG analyses. Fast Fourier transformation (FFT) was applied to subsegments of the intervention type to analyze the EEG power spectra. Alpha and beta power from central, frontal, and parietal sites were considered in linear mixed-effects models with segments as a random factor with maximum-likelihood estimates due to the lack of balance in the length of the interview segments.

Results

The interventions "interpretation" and "confrontation" showed a significantly lower alpha power compared with the control condition in the central electrodes. In the frontal and parietal sites of the alpha power and all beta power sites, the omnibus tests (full model/model without intervention) and comparisons relative to control conditions showed no significant overall result or failed significance after alpha error correction.

Conclusion

Incisive interventions, such as confrontation with discrepancies and interpretation of unconscious intrapsychic conflicts, may have provoked temporary emotional lability, leading to a change in psychic processing akin to interference from external stimuli. This conclusion is consistent with the finding that interpretations, which are potentially the most concise interventions, had the strongest effects on alpha power. Using EEG during therapeutic psychoanalytic intervention techniques might be a helpful tool to evaluate differential responses to the psychotherapeutic process on a neural level. However, this single-case result has to be replicated in a larger sample and does not allow generalizations.

Epistemic injustice and the psychiatrist

BACKGROUND

Psychiatrists depend on their patients for clinical information and are obligated to regard them as trustworthy, except in special circumstances. Nevertheless, some critics of psychiatry have argued that psychiatrists frequently perpetrate epistemic injustice against patients. Epistemic injustice is a moral wrong that involves unfairly discriminating against a person with respect to their ability to know things because of personal characteristics like gender or psychiatric diagnosis.

METHODS

We review the concept of epistemic injustice and several claims that psychiatric practice is epistemically unjust.

RESULTS

While acknowledging the risk of epistemic injustice in psychiatry and other medical fields, we argue that most concerns that psychiatric practice is epistemically unjust are unfounded.

CONCLUSIONS

The concept of epistemic injustice does not add significantly to existing standards of good clinical practice, and that it could produce changes in practice that would be deleterious. Psychiatrists should resist calls for changes to clinical practice based on this type of criticism.

EMOÇÕES VIVENCIADAS PELOS PSICOTERAPEUTAS-APRENDIZES NOS SERVIÇOS-ESCOLAS: UMA LEITURA PSICANALÍTICA

Os atendimentos clínicos realizados nos serviços-escolas são permeados por uma série de experiências emocionais vivenciadas pela díade psicoterapeuta-aprendiz/paciente. Diante das diversas nuances da clínica psicanalítica, o psicoterapeuta-aprendiz vivencia experiências que refletem em sua subjetividade. Este estudo teve como objetivo investigar as vivências emocionais dos estudantes de graduação em psicologia durante os estágios em clínica psicanalítica e analisar as emoções percebidas em si mesmos pelos psicoterapeutas-aprendizes nos atendimentos em psicoterapia psicanalítica. Trata-se de um estudo clínico-qualitativo, utilizando-se o referencial teórico psicanalítico. Participaram 27 estudantes de psicologia, que realizavam atendimentos nos serviços-escolas de quatro Instituições de Ensino Superior. A coleta de dados foi realizada através de entrevistas semidirigidas, as quais foram submetidas à análise de conteúdo. Nos resultados observou-se a presença das vivências de ansiedade, medo, insegurança e nervosismo, presentes no processo psicoterapêutico. A identificação com as vivências emocionais dos pacientes e as dúvidas referentes à percepção das próprias emoções, foram importantes aspectos encontrados neste estudo. Tais resultados podem contribuir para a reflexão sobre a vivência desta experiência para o psicoterapeuta-aprendiz, a fim de melhor prepará-lo para os desafios da prática clínica psicanalítica.

How Our Caregivers Shape Who We Are: The Seven Dimensions of Attachment at the Core of Personality

Psychology defines personality as the stable traits of an individual, and cognitive research suggests that a set of core beliefs is at the root of these traits. From this perspective, two major questions remain unanswered: (1) What are the core beliefs that make up personality? (2) How are they acquired? An interesting answer is provided by attachment theory, according to which attachment is at the basis of personality. The current theoretical formulation, however, does not sufficiently clarify the relationship between the two. Adopting a cognitive-clinical approach, we put forward a novel version of attachment theory, arguing that it can better account for the relationship between attachment and personality, thereby providing more convincing answers to questions (1) and (2). In particular, we propose that: (A) attachment information is acquired over seven dimensions; (B) the acquisition of each dimension is induced by a specific caregiving feature and (C) realized through a specific acquisition mechanism - imprinting. In a nutshell, we propose an Attachment-Personality Model (APM) according to which seven attachment dimensions constitute the knowledge core of personality. We finally discuss the significant implications of the model, especially its clinical application in terms of conception, assessment, and treatment of mental disorders. The model can be empirically tested, and we suggest three ways to do that.

The Interpersonal Neurobiology of Intersubjectivity

In 1975, Colwyn Trevarthen first presented his groundbreaking explorations into the early origins of human intersubjectivity. His influential model dictates that, during intimate and playful spontaneous face-to-face protoconversations, the emotions of both the 2-3-month-old infant and mother are nonverbally communicated, perceived, mutually regulated, and intersubjectively shared. This primordial basic interpersonal interaction is expressed in synchronized rhythmic-turn-taking transactions that promote the intercoordination and awareness of positive brain states in both. In this work, I offer an interpersonal neurobiological model of Trevarthen's intersubjective protoconversations as rapid, reciprocal, bidirectional visual-facial, auditory-prosodic, and tactile-gestural right brain-to-right brain implicit nonverbal communications between the psychobiologically attuned mother and the developing infant. These co-constructed positive emotional interactions facilitate the experience-dependent maturation of the infant's right brain, which is in an early critical period of growth. I then address the central role of interpersonal synchrony in intersubjectivity, expressed in a mutual alignment or coupling between the minds and bodies of the mother and infant in face-to-face protoconversations, as well as how these right brain-to-right brain emotional transmissions generate bioenergetic positively charged interbrain synchrony within the dyad. Following this, I offer recent brain laterality research on the essential functions of the right temporoparietal junction, a central node of the social brain, in face-to-face nonverbal communications. In the next section, I describe the ongoing development of the protoconversation over the 1st year and beyond, and the co-creation of a fundamental energy-dependent, growth-promoting social emotional matrix that facilitates the emergence of the highly adaptive human functions of mutual play and mutual love. In the final section, I discuss the clinical applications of this interpersonal neurobiological model of intersubjectivity, which has a long history in the psychotherapy literature. Toward that end, I offer very recent paradigm-shifting hyperscanning research that simultaneously measures both the patient and therapist during a psychotherapeutic interaction. Using the Trevarthen's two-person intersubjective model, this research demonstrates changes in both brains of the therapeutic dyad and the critical role of nonverbal communications in an emotionally-focused psychotherapy session. These studies specifically document interbrain synchronization between the right temporoparietal junction of the patient and the right temporoparietal junction of the clinician, a right brain-to-right brain nonverbal communication system in the co-constructed therapeutic alliance. Lastly, I discuss the relationship between the affect communicating functions of the intersubjective motivational system and the affect regulating functions of the attachment motivational system.

Improving the physician-patient relationship utilizing psychodynamic psychology: a primer for health professionals

Background

The quality of the physician-patient relationship is associated with improved healthcare outcomes and patients’ complaints due to dissatisfaction. Factors that influence the quality of the physician-patient relationship include verbal communication, nonverbal communication, and clinical empathy. These factors have been studied from diverse theoretical approaches hindering their integration into a theoretical framework applicable in clinical practice and accessible for lay clinicians.

Objective

The aim of this paper is to put forward a psychodynamic framework that includes the factors associated with a better quality of the physician-patient relationship and is applicable in clinical practice and accessible for lay clinicians.

Theoretical discussion

Basic concepts necessary to comprehend transference and countertransference phenomena were outlined. Then, based on the concepts of transference and countertransference, a psychodynamic framework to understand and manage the physician-patient relationship was put forward.

Conclusion

This is the first paper that presents a psychodynamic framework applicable in clinical practice and accessible to lay clinicians for understanding and managing the physician-patient relationship. Additionally, this work could serve as introductory material to Balint groups.

De la psychanalyse à la psychothérapie psychodynamique à Albert-Prévost

Objectifs Cet article décrit dans un premier temps les contributions du Dr Camille Laurin au développement des services psychiatriques à Albert-Prévost et plus spécifiquement le rôle qu’il a joué dans la promotion de la psychanalyse comme pensée ordonnatrice des soins thérapeutiques dans ce milieu. Dans un deuxième temps, la pratique de la psychothérapie psychodynamique est abordée à partir des enjeux contemporains liés à la médecine basée sur les données probantes, les neurosciences et le développement des technologies de la communication. Les modalités actuelles d’enseignement de l’approche psychodynamique à Albert-Prévost sont également introduites.

Méthode Dans la première partie, une recherche biographique a été effectuée. Dans la seconde, une revue de la littérature a été présentée.

Résultats Dr Camille Laurin a joué un rôle de premier plan dans le développement de la pensée psychanalytique à Albert-Prévost. Son héritage demeure bien vivant ainsi qu’en témoignent les divers stages et activités de formation offerts dans ce domaine au Centre de psychothérapie de cette institution. L’efficacité de la psychothérapie dynamique comme méthode de traitement est confirmée depuis maintenant plusieurs années. Les neurosciences et la psychanalyse bénéficient d’une ouverture à un dialogue interdisciplinaire. Le développement des technologies de la communication et de l’intelligence artificielle est appelé à modifier éventuellement la pratique de la psychothérapie.

Conclusion Les principes théoriques associés à la psychanalyse sont encore aujourd’hui enseignés à tous les résidents en psychiatrie de l’Université de Montréal. Dr Camille Laurin a joué un rôle essentiel dans le développement de cette approche à Albert-Prévost et plus généralement au Département de psychiatrie de l’Université de Montréal.

Young adults' transition to a plant-based diet as a psychosomatic process: A psychoanalytically informed perspective

This study examined transition to a plant-based diet by young adults and the challenges and conflicts this brings. Interviews were conducted with nine young adults in Sweden and the answers were analysed guided by a psychological method from descriptive phenomenology. The results indicate that the transition to a plant-based diet is a process comprising five dimensions: 1) Exploring new ways of living based on health anxieties, 2) regulating conflicting emotions through differentiation, 3) transforming traditional models into new alternatives, 4) confirming new skills and abilities and 5) integrating experiences and emotions into a whole. These five dimensions reflect how transition to a plant-based diet is experienced physically and emotionally. The results also indicate that plant-based meals and ingredients used in the new diet are loaded with symbols and conflicting emotions. Psychoanalytically informed theory, especially object relation theory, was used in discussing what can happen to the mind during the transition. In a wider perspective, this study provides insights into how a dietary transition can bring stability to the life of young adults and help them endure and master their situation. More research is needed to assess the role of mental health in transitioning to a plant-based diet and to draw more general conclusions, an area where psychodynamic theory can provide insights.

The French Integrative Psychosocial Rehabilitation Assessment for Complex Situations (FIPRACS): Modelization of an Adapted Assessment Method Toward Long-Term Psychiatric Inpatients With Disabling, Severe and Persistent Mental Illness

For the past forty years, the generalization of community-based approaches has prompted psychiatry into promoting a deinstitutionalization movement and a psychosocial rehabilitation approach (PSR) for individuals with schizophrenia and related difficulties. Unfortunately, this approach generally does not involve the most severe cognitive and psycho-affective clinical situations among this population despite an increasing number of publications advocating that all individuals should be included in PSR and deinstitutionalization programs. In this context, considering the absence of an assessment battery designed for French individuals with particularly disabling, severe, and persistent mental illness (IDSPMI), we constructed an integrative assessment model adapted to this specific population. To select the most suitable tools for this population, a literature review (inspired by the PRISMA protocol) and a systematic review were combined with a clinical assessment study. The literature review first identified the cognitive and psycho-affective functions which mainly influence the day-to-day life adaptation of individuals engaged in a PSR/deinstitutionalization program. The systematic review then gathered all of the useable French validated tools to assess the initially selected dimensions (n = 87). To finish, for each dimension, the selected 87 tools were included in a clinical assessment study performed within a French psychiatric hospital. The authors collected and verified the characteristics of each tool (validity, French norms, French version, the average speed of the test, ease of use, ability to assess other dimensions). Their suitability was also assessed when applied to IDSPMI. Based on this final clinical evaluation, the authors selected one tool per function to create the French Integrative Psychosocial Rehabilitation Assessment for Complex Situations (FIPRACS). This battery is an assessment tailored to the neurocognitive and psycho-affective potentials of IDSPMI. While further validation studies of this battery are ultimately required, the practical/clinical implications of this battery are presented and discussed.

Recovery for all in the community; position paper on principles and key elements of community-based mental health care

BACKGROUND

Service providers throughout Europe have identified the need to define how high-quality community-based mental health care looks to organize their own services and to inform governments, commissioners and funders. In 2016, representatives of mental health care service providers, networks, umbrella organizations and knowledge institutes in Europe came together to establish the European Community Mental Health Services Provider (EUCOMS) Network. This network developed a shared vision on the principles and key elements of community mental health care in different contexts. The result is a comprehensive consensus paper, of which this position paper is an outline. With this paper the network wants to contribute to the discussion on how to improve structures in mental healthcare, and to narrow the gap between evidence, policy and practice in Europe.

MAIN TEXT

The development of the consensus paper started with an expert workshop in April 2016. An assigned writing group representing the workshop participants built upon the outcomes of this meeting and developed the consensus paper with the input from 100 European counterparts through two additional work groups, and two structured feedback rounds via email. High quality community-based mental health care: 1) protects human rights; 2) has a public health focus; 3) supports service users in their recovery journey; 4) makes use of effective interventions based on evidence and client goals; 5) promotes a wide network of support in the community and; 6) makes use of peer expertise in service design and delivery. Each principle is illustrated with good practices from European service providers that are members of the EUCOMS Network.

CONCLUSIONS

Discussion among EUCOMS network members resulted in a blueprint for a regional model of integrated mental health care based upon six principles.

Latent trajectories of change for clients at a psychodynamic training clinic

OBJECTIVE

Employing practice-based research methods, we addressed the need to examine the effectiveness of psychodynamic treatment as a supplement to the efficacy evidence offered by randomized clinical trials.

METHOD

We used person-centered analyses to generate latent subgroups of clients (N = 118; M _age  = 40.92; 53.4% female; 81.4% Caucasian; 80.5% heterosexual) receiving contemporary relational psychotherapy (CRP) at a psychodynamic community mental health training clinic.

RESULTS

Subgroups of clients reported a change in depression, social conflict, and anxiety symptomatology, and overall life satisfaction, depicted by significant quadratic growth curves. Findings also offered exploratory support for a theoretical proposition from CRP that improved relational functioning would correspond to improved affect dysregulation and overall life satisfaction.

CONCLUSION

Clinical and training implications highlight the need to distinguish subgroups of "responders" and "nonresponders" to inform treatment.