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Am J Psychother [journal]
- Effectiveness and cost effectiveness of Davanloo's intensive short-term dynamic psychotherapy: does unlocking the unconscious make a difference? [Journal Article]
- Am J Psychother 2013; 67(1):89-108.
More than 20 years ago Habib Davanloo coined the term unlocking of the unconscious to describe how the psychodynamic concept of the human unconscious can become accessible using the technique of Intensive Short-Term Dynamic Psychotherapy (ISTDP). According to Davanloo, the possibility that unconscious material will be revealed is greatly increased when therapeutic efforts promote dominance of the unconscious therapeutic alliance over unconscious resistance. When these ingredients are present there is a psychic shift that allows unacceptable painful feelings to come to the surface. Toward adding further empirical support for the concept, in this article we compare outcomes between patients who experienced one or more major unlocking of the unconscious (N = 57) to those who did not experience major unlocking (N = 32) during ISTDP treatment. Significant and widespread differences were seen between these two groups, those with major unlocking had greater symptom reduction, interpersonal gains, and cost reduction for treatment. The relevance of this to clinical practice and healthcare utilization will be discussed.
- Controversies in psychotherapy research: epistemic differences in assumptions about human psychology. [Journal Article]
- Am J Psychother 2013; 67(1):73-87.
It is the thesis of this paper that differences in philosophical assumptions about the subject matter and treatment methods of psychotherapy have contributed to disagreements about the external validity of empirically supported therapies (ESTs). These differences are evident in the theories that are the basis for both the design and interpretation of recent psychotherapy efficacy studies. The natural science model, as applied to psychotherapy outcome research, transforms the constitutive features of the study subject in a reciprocal manner so that problems, treatments, and indicators of effectiveness are limited to what can be directly observed. Meaning-based approaches to therapy emphasize processes and changes that do not lend themselves to experimental study. Hermeneutic philosophy provides a supplemental model to establishing validity in those instances where outcome indicators do not lend themselves to direct observation and measurement and require "deep" interpretation. Hermeneutics allows for a broadening of psychological study that allows one to establish a form of validity that is applicable when constructs do not refer to things that literally "exist" in nature. From a hermeneutic perspective the changes that occur in meaning-based therapies must be understood and evaluated on the manner in which they are applied to new situations, the logical ordering and harmony of the parts with the theoretical whole, and the capability of convincing experts and patients that the interpretation can stand up against other ways of understanding. Adoption of this approach often is necessary to competently evaluate the effectiveness of meaning-based therapies.
- Prediction of attachment status from observation of a clinical intensive psychotherapy interview. [Journal Article]
- Am J Psychother 2013; 67(1):47-71.
The present study addresses whether it is possible to accurately determine a subject's Adult Attachment Interview (AAI) classification by observing a video-recorded clinical psychotherapy discussion that uses the principles of Intensive Short-Term Dynamic Psychotherapy (ISTDP).A random sample of eight of the author's (Robert J. Nebrosky) private practice patients participated in an AAI administered by an experienced interviewer. The authors were blind to the results of the AAI, which were scored and classified by Erik Hesse, PHD (consultant and expert in AAI coding and classification). The authors used the Adult Attachment Clinical Rating Scale (AA-CRS), which is an adapted version of the AAI "states-of-mind scales," in conjunction with the structured ISTDP interview to obtain main classifications and subclassifications. The authors determined the pathway of unconscious anxiety according to the procedures described by Davanloo (1995, 2001) and ten Have-de Labije (2006), beginning with the structured ISTDP interview, then categorized the patient's defenses and quality of the patient's observing and attentive ego, discussed the clinican's knowledge of the patient's attachment history, and from this data drew first the major gateway of attachment using the AA-CRS. Then the authors categorized the subclassifications using the AA-CRS.The authors predicted seven out of eight AAI main classifications correctly, and five out of eight AAI subclassifications correctly, indicating that there was a statistically significant relationship between predicted and expected values for main classifications and subclassifications.The authors conclude that the systematic ISTDP inquiry at the level of the stimulus (current, past, and therapeutic relationship) and response (defence, anxiety, and impulse/feeling) and combined with the clinician's knowledge of the patient's clinical history can effectively substitute for the AAI interview and therefore, yield an experiential reference from which to explore the patient's state of mind using the Adult Attachment Clinical Rating Scale (AA-CRS). The authors speculate that the differences in subclassification could be accounted for by variations and/or differences in biographical knowledge obtained by the the clinician versus that of the AAI coder (Hesse).
- Practice-based evidence: 45 years of psychotherapy's effectiveness in a private practice. [Journal Article]
- Am J Psychother 2013; 67(1):23-46.
Of 2,259 patients seen during 45 years of private practice, outcome data was produced for 1,599 cases. The mean (SD) number of sessions per case was 18.82 (29.89). The dropout rate was 18.76%. Of all treated cases with outcome data 4 (0.25%) were rated as Much Worse; 11 (0.69%), Worse; 497 (31.08%), No Change from Intake; 546 (34.15%), Improved; and 541 (33.83%), Much Improved. The mean (SD) pre-/post-treatment effect size (ES) was 1.90 (1.61), the median was 1.62, and the range was from -2.91 to +15.22. Patients and parents of minors rated outcomes more positively than the therapist did. Outcome varied significantly across diagnostic categories. There was a significant, positive relationship in length of treatment and outcome. The therapist's effectiveness did not improve across the years. Years with the largest patient caseloads or the greatest proportion of patients with managed-care insurance tended to show the poorest outcomes.
- Psychotherapy-lite: obesity and the role of the mental health practitioner. [Journal Article]
- Am J Psychother 2013; 67(1):3-22.
Obesity is a chronic medical disorder that is the result of a complex interaction of genetic, environmental, neuro-endocrinological, psychosocial, and behavioral factors. There are treatment algorithms, depending on the severity of obesity, and a multi-component approach, including attention to psychological issues, is recommended regardless of the level of obesity. Cognitive-behavioral therapy is beneficial in assisting with stimulus control, self-monitoring of lifestyle changes, goal-setting, and restructuring negative and self-defeating thoughts, and psychodynamic (insight-oriented) psychotherapy is useful in assisting with conflicts regarding excessive weight, body image, relationship to food and disordered patterns of eating, and dealing with the prejudice and overt discrimination obese patients may experience. Neither therapy is particularly effective alone and either and/or both may need to be continued indefinitely to avoid inevitable weight regain. Psychological intervention before and during the difficult process of dieting, as well as before and after bariatric surgery, is essential for some vulnerable patients. Since psychological factors are neither primarily etiological nor even necessarily predominant in obesity, the mental health professional plays an important, though adjunctive--"psychotherapy-lite" role--in treating obese patients.
- The role of edge-sensing in experiential psychotherapy. [Journal Article]
- Am J Psychother 2012; 66(4):391-406.
In experiential psychotherapy three modes of experiencing are managed in parallel--experiencing in the domain of explicit knowing, experiencing in implicit knowing, and experiencing in the zone of emergent formation where the other two meet. Gendlin (1996) argued that therapy is a "process that centrally involves experience before it becomes one of a set of defined 'packages' and again afterword when it dips back into the prepackaged zone at the edge of experiencing" (p. 4). In Gendlin's terms, the "edge" is where the prepackaged and packaged zones meet. Encounter at the edge, what we call edge sensing, is dwelling in the meeting point between what is known explicitly and what is known in an implicit bodied way. This encounter extends to dyadic encounter at the interpersonal edge in the therapeutic relationship. Edge sensing is an intrasubjective and intersubjective process crucial for the moving forward process of change.
- Three problems with the theory of cognitive therapy. [Journal Article]
- Am J Psychother 2012; 66(4):375-90.
Three problems with the theory of cognitive therapy are presented. Each is argued as a problem for the model of change in cognitive therapy, not for their impact (if any) on treatment. They are (a) the unpredictability of cure and relapse, (b) the epistemologically irreconcilable differences between the model of pathology and the model of change, and (c) the inability to conceive of ambivalence. Each problem is discussed, and some counterarguments are offered.
- Interpersonal psychotherapy for depressed adolescents adapted for self-injury (IPT-ASI): rationale, overview, and case summary. [Journal Article, Research Support, N.I.H., Extramural, Research Support, Non-U.S. Gov't]
- Am J Psychother 2012; 66(4):349-74.
Non-suicidal self-injury (NSSI), the intentional destruction of one's own body tissue without the conscious intent to die, is a significant health concern among adolescents, however, there are few psychosocial interventions designed to treat NSSI. The current paper describes an adaptation of Interpersonal Psychotherapy for Depressed Adolescents (IPT-A) to be used with adolescents who have symptoms of depression and are engaging in NSSI. Specifically, we describe the rationale for the adaptations made to IPT-A for self-injury (IPT-ASI), and a case vignette to illustrate the implementation of IPT-ASI. Non-suicidal self-injury is often triggered by interpersonal stressors, and IPT-ASI directly aims to help clients to improve their interpersonal relationships by increasing emotional awareness and understanding, and teaching communication and problem solving skills via supportive and didactic techniques. The case vignette demonstrates the successes and challenges of using IPT-ASI for an adolescent with moderate depression and NSSI behaviors who began treatment with much difficulty expressing her emotions.
- Imagining the other: the influence of imagined conversations on the treatment process. [Journal Article]
- Am J Psychother 2012; 66(4):331-48.
The Constructivist Grounded Theory Study reported in this paper is based on the narrative experiences of psychotherapists who used the intersession experience of having an imagined conversation with a client. The therapists reported that they use imagined conversations with clients between sessions when they have reached an impasse in the therapeutic process, and they noted the experience helps them solve the difficulty by helping to provide greater insight into their clients' perspectives. The participants' experiences suggest a theory that explains how imagination can help one understand another: motor memory may surface implicit relational knowing.
- Beyond attachment: psychotherapy with a sexually abused teenager. [Case Reports, Journal Article]
- Am J Psychother 2012; 66(4):313-30.
When children are abused they utilize strategies already in place to cope with stress. These strategies develop during early life within the family and may be part of the unconscious framework formed within attachments and relationships. The case presented illustrates a teen-aged girl who was the victim of sexual abuse and experienced depression, PTSD and substance abuse. This paper describes the psychodynamic psychotherapy used to examine the patient's coping skills, which predated the abuse, and how these coping mechanisms were used to ameliorate her symptoms.