Transference neurosis is a term that Sigmund Freud introduced in 1914 to describe a new form of the analysand’s infantile neurosis that develops during the psychoanalytic process.
Based on Dora’s case history, Freud suggested that during therapy the creation of new symptoms stops, but new versions of the patient’s fantasies and impulses are generated. He called these newer versions “transferences” and characterised them as the substitution of the analyst for a person from the patient’s past. According to Freud’s description: “a whole series of psychological experiences are revived not as belonging to the past, but as applying to the person of the analyst at the present moment”. When transference neurosis develops, the relationship with the therapist becomes the most important one for the patient, who directs strong infantile feelings and conflicts towards the therapist, e.g. the patient may react as if the analyst is his/her father.
Transference neurosis can be distinguished from other kinds of transference because:
It is very vivid and it rekindles the infantile neurosis.
It is generated by the feelings of frustration that the analysand inevitably experiences during sessions, since the analyst does not fulfil the analysand’s longings.
In transference neurosis the symptoms are not stable, but they are transformed.
Regression and repetition play a key role in the creation of transference neurosis.
Transference neurosis reveals the particular meanings that the analysand has given to current infantile relationships and events, which generate internal conflicts between wishes and particular defences formed to strive against them. These meanings are united and create several transference patterns.
Resolution
Once transference neurosis has developed, it leads to a form of resistance, called “transference resistance”. At this point, the analysis of the transference becomes difficult since new obstacles arise in therapy, e.g. the analysand may insist on fulfilling the infantile wishes that emerged in transference, or may refuse to acknowledge that the current experience is, in fact, a reproduction of a past experience. However, the successful resolution of transference neurosis through interpretation will lead to the lifting of repression and will enable the Ego to solve the infantile conflicts in new ways. Furthermore, it will allow the analysand to recognize that the current relationship with the analyst is based on repetition of childhood experiences, leading to the detachment of the patient from the analyst.
The replacement of the infantile neurosis by transference neurosis and its resolution through interpretation remains the main focus of the classical psychoanalytic therapy. In other types of therapy, either the transference neurosis does not develop at all, or it does not play a central role in the therapy process. Although it is more likely for transference neurosis to develop in psychoanalysis, where the sessions are more frequent, it may also appear during psychotherapy.
Intensive short-term dynamic psychotherapy (ISTDP) is a form of short-term psychotherapy developed through empirical, video-recorded research by Habib Davanloo.
The therapy’s primary goal is to help the patient overcome internal resistance to experiencing true feelings about the present and past which have been warded off because they are either too frightening or too painful. The technique is intensive in that it aims to help the patient experience these warded-off feelings to the maximum degree possible; it is short-term in that it tries to achieve this experience as quickly as possible; it is dynamic because it involves working with unconscious forces and transference feelings.
Patients come to therapy because of either symptoms or interpersonal difficulties. Symptoms include traditional psychological problems like anxiety and depression, but they also include physical symptoms without medically identifiable cause, such as headache, shortness of breath, diarrhoea, or sudden weakness. The ISTDP model attributes these to the occurrence of distressing situations where painful or forbidden emotions are triggered outside of awareness. Within psychiatry, these phenomena are classified as “Somatoform Disorders” in DSM-IV-TR.
The therapy itself was developed during the 1960s to 1990s by Habib Davanloo, a psychiatrist and psychoanalyst from Montreal. He video recorded patient sessions and watched the recordings in minute detail to determine as precisely as possible what sorts of interventions were most effective in overcoming resistance, which he believed was acting to keep painful or frightening feelings out of awareness and prevent interpersonal closeness.
ISTDP is taught by Habib Davanloo at McGill University, as well as in other University and post-graduate settings around the world. The ISTDP Institute offers on-line ISTDP training materials, including introductory videos and skill-building exercises.
Origins and Theoretical Foundation
In 1895, Josef Breuer and Sigmund Freud published their Studies on Hysteria, which looked at a series of case studies where patients presented with dramatic neurological symptoms, such as “Anna O” who suffered headaches, partial paralysis, loss of sensation, and visual disturbances. These symptoms did not conform to known patterns of neurological disease, and neurologists were thus unable to account for symptoms in purely anatomical or physiological terms. Breuer’s breakthrough was the discovery that symptomatic relief could be brought about by encouraging patients to speak freely about emotionally difficult aspects of their lives. Experiencing these emotions which had been previously outside of awareness seemed to be the curative factor. This cure became known as catharsis, and the experiencing of the previously forbidden or painful emotion was abreaction.
Freud tried various techniques to deal with the fact that patients generally seemed resistant to experiencing painful feelings. He moved from hypnosis to free association, interpretation of resistance, and dream interpretation. With each step, therapy became longer. Freud himself was quite open about the possibility that there were many patients for whom analysis could bring little or no relief, and he discusses the factors in his 1937 paper “Analysis Terminable and Interminable.”
From the 1930s through the 1950s, a number of analysts were researching methods of shortening the course of therapy without sacrificing therapeutic effectiveness. These included Sándor Ferenczi, Franz Alexander, Peter Sifneos, David Malan, and Habib Davanloo. One of the first discoveries was that the patients who appeared to benefit most from therapy were those who could rapidly engage, could describe a specific therapeutic focus, and could quickly move to experience their previously warded-off feelings. These also happened to represent those patients who were the healthiest to begin with and therefore had the least need for the therapy being offered. Clinical research revealed that these “rapid responders” were able to recover quickly with therapy because they were the least traumatised and therefore had the smallest burden of repressed emotion, and so were least resistant to experiencing the emotions related to trauma. However, these patients represented only a small minority of those arriving at psychiatric clinics; the vast majority remained unreachable with the newly developing techniques.
A number of psychiatrists began directing their psychotherapeutic research into methods of overcoming resistance. Dr. David Malan popularised a model of resistance, known as the Triangle of Conflict, which had first been proposed by Henry Ezriel. At the bottom of the triangle are the patient’s true, impulse-laden feelings, outside of conscious awareness. When those emotions rise to a certain degree and threaten to break into conscious awareness, they trigger anxiety. The patient manages this anxiety by deploying defences, which lessen anxiety by pushing emotions back into the unconscious.
The emotions at the bottom of Malan’s Triangle of Conflict originate in the patient’s past, and Malan’s second triangle, the Triangle of Persons, originally proposed by Menninger, explains that old emotions generated from the past are triggered in current relationships and also get triggered in the relationship with the therapist. The question of how maladaptive patterns of interpersonal behaviour could arise from early childhood experiences in the family of origin was postulated within psychoanalytic theory. Independent empirical support came from Bowlby’s newly arising field of Attachment Theory.
Bowlby and Attachment Trauma
John Bowlby, a British psychiatrist and psychoanalyst, was very interested in the impact on a child of adverse experiences in relation to its primary attachment figures (usually the mother, but often the father and others) in early life. He concluded, in opposition to received psychoanalytic dogma of the day, that childhood experience was far more important than unconscious fantasy. He also elucidated the nature of attachment, a system of behaviours exhibited by human and other mammalian infants which are innate and have the goal of physical proximity to the mother. For instance, a child taken out of its mother’s arms cries loudly in protest, and it is only quieted by being restored to its mother’s arms. Bowlby observed that the innate attachment system would be activated by loss of proximity to the mother, and that long-lasting trauma to the child could result from attachment interruption. Long term consequences included increased propensity to psychiatric disorders, poor relationship function, and decreased life satisfaction.
Bowlby conducted numerous studies and noted strong correlations between adverse early-life circumstances – primarily the lack of a consistent and nurturing relationship with the mother – as the source of numerous difficulties, including persistent depression, anxiety, or delinquency in adulthood. Childhood traumatisation to the attachment bond, usually through separation from or loss of the primary mother or mother-substitute, led to adult difficulties. Since Bowlby, the effects of trauma over development have consistently been shown to have a significant detrimental impact on adult psychological functioning.
Davanloo’s Discovery of the Unconscious Consequences of Attachment Trauma
In the 1960s, while Bowlby was observing children directly, Davanloo was beginning his work with symptomatic and character-disturbed adults. As he began his video-recording work and became progressively successful against higher levels of resistance, he noted that particular themes reappeared with striking consistency in patient after patient.
First, the therapist’s efforts to get to know the patient’s true feelings often aroused a simultaneous mixed feeling in the patient, composed of deep appreciation for the therapist’s relentless efforts to get to know the patient deeply, combined with equally deep irritation at the therapist for challenging the patient to abandon long-held resistances which could thwart the therapeutic effort.
Davanloo noted, in concert with Malan’s Triangle of Conflict, that patients would unconsciously resist the therapist’s efforts to get to the root of their difficulties. He also observed, from his videotaped sessions, that patients would simultaneously send off signals of their unconscious anxiety. Davanloo carefully monitored these signals of anxiety and saw that they represented the rise of complex mixed feelings with the therapist. The mix represented that part of the patient seeking relief from painful symptoms but also an active desire to avoid painful, repressed feelings.
As Davanloo became more skilled at unlocking the patient’s true unconscious feelings, he noted an often very predictable sequence of feelings. The sequence was by no means invariable, but it occurred frequently enough to allow the therapist to hypothesise its existence in a majority of cases.
First, after a high rise of mixed feeling with the therapist, manifested as signals of intense anxiety (tension in skeletal muscle, often manifested as wringing of the hands, accompanied with deep, sighing respirations), there would often be a breakthrough of rage, accompanied by an immediate drop in anxiety. This rage, Davanloo discovered, is intensely felt. It often has a violent impulse associated with it, sometimes even a murderous impulse. Once patients feel this rage, they are able to describe vividly detailed fantasies of what the rage would do if it were to take on a life of its own.
The rage is a product of thwarted efforts to attach from the past. Those thwarted efforts to love and be loved yield pain, in the form of what Bowlby described as protest. The pain yields a reactive rage at the loved person who thwarted attachment efforts.
Complete experiencing of the rageful impulse is typically accompanied by a tremendous relief at finally getting something out which has yearned for release. However, the relief is typically short lived.
Next, Davanloo almost invariably noted that patients then experience a tremendous wave of guilt about the rage. The guilt is a product of the fact that the old rageful feelings were with a person who was also loved. It is this guilt, Davanloo discovered, which is the key ingredient in symptom formation and character difficulties. Symptoms and interpersonal difficulties (usually unconscious efforts to ward off intimacy and closeness) are the product of guilt, which turns the rage back on the self. For instance, the rage of a two-year-old toward a mother who dies may be experienced in the present as suicidal feelings (self-directed murderous rage).
Beneath the guilty feelings from the past, Davanloo almost invariably noted painful feelings about thwarted efforts at emotional closeness to parents and others in childhood. Finally, at the deepest layer of feelings are the still powerful yearnings for closeness, attachment, and love.
The goal of the ISTDP therapist is, as rapidly as possible, to help the patient overcome resistance, and then experience all the waves of mixed, genuine feeling, previously unconscious, triggered by the intense therapeutic process. Those feelings are traced back to their origins in the past, and then both therapist and patient come to understand how the patient came to be the “consciously confused, unconsciously driven” person in the present. Old pockets of emotion are drained, the patient has a clearer self-narrative, and self-destructive symptoms and defences are renounced. The understanding gained is not just cognitive, but goes to the fundamental, emotional core. The influence of Freud’s early trauma theory is evident.
Specific Therapeutic Interventions
Davanloo discovered the layers of the dynamic unconscious through a process of developing specific interventions which allow the therapist to reach those layers. Those interventions, applied in a specific fashion at specific times in the therapeutic process, are all calculated to overcome the patient’s resistance as quickly and completely as possible, to allow the earliest and fullest experience of true feelings about the present and past as quickly as possible. Those interventions are known as pressure, challenge, and head-on collision.
I. Pressure: Therapeutic Encouragement and Reaching through to the Patient
Pressure is the principal ingredient of ISTDP, and it takes many forms. Initially, pressure takes the form of encouraging the patient to describe symptoms and interpersonal difficulties as specifically as possible, so both patient and therapist get the clearest picture possible of the precise difficulties. It starts from the moment the patient walks into the room, in the form of the question, “Are there some difficulties you are experiencing which you would like us to have a look at?”
The primary form of pressure is pressure toward feeling. Again, this is exerted mainly in the form of questions, such as, “How did you feel toward your boss for humiliating you in front of your staff? We see that you got anxious and depressed, but how did you feel?”
Pressure can be toward the patient’s will: “Can we look to your feelings? Do you want us to look to your feelings?”
Pressure is also exerted toward the therapeutic task: “Our goal here, if you want, is to get to the root, the engine, driving your difficulties. So, can we look at a specific time when you experienced anxiety? This will give us a clear picture of the problem which we can use to get to the engine.”
In its essence, pressure is encouragement from the therapist to the patient. It is encouragement to renounce defences, tolerate anxiety, and walk, with the therapist, into those places which have previously been off-limits. It is a way of saying, “There’s nothing in there we cannot face together, and we do so in your service, to relieve you of painful difficulties.”
Patients with low resistance are often quite responsive to pressure alone. However, as explained above, those are the patients who are healthiest to begin with. For patients with higher levels of resistance, usually the product of a more traumatised early phase of life, pressure quickly leads to the patient erecting barriers with the therapist. Those barriers are the patient’s habitual defences against avoided feelings. The combination of intentional (conscious) and unintentional (unconscious) defences is called the resistance. The therapist is constantly monitoring for both the rise in anxiety and the appearance of resistance. When resistance does make its appearance, new interventions, in addition to pressure, are called for.
II. Challenge: Pointing Out and Interrupting Defences in Concert with the Patient
Challenge is a two-stage process. The first stage is clarification, which is the therapist’s effort to confirm that resistance is operating, and also to acquaint the patient with the specific defence being deployed. Patients are often quite unaware of their own defences. Clarification takes the form of a question, meant to clarify the defence to both patient and therapist: “Do you notice that when you speak of being angry with your boss that you smile and giggle? Is a smile something you sometimes do to cover up a deeper feeling?”
When a defence is properly clarified, both patient and therapist can work together against it, because it represents an obstacle to the therapeutic task of getting to the patient’s true feelings. A defence which has not been clarified is still invisible to the patient. It is also important to note that in childhood, defences can be a useful tool in emotionally overwhelming or traumatic situations. According to Los Angeles-based psychiatrist Katherine Watkins, M.D.:
“defenses such as dissociation and repression can shield us from intense feelings that we are developmentally unprepared to experience and process. However as we grow up, this shielding cuts us off from our full range of feelings, even when we are now emotionally able to handle the feelings.”
Challenge to the defences represents an exhortation to the patient to abandon the defence: “Again you smile when I ask you about feelings in relation to being humiliated by your husband. If you don’t smile, how were you truly feeling?” This particular intervention is a very powerful one in the therapist’s arsenal. As with all powerful interventions, if it is misapplied, the consequences can be severe: rapid misalliance with the therapist, worsening of symptoms, and treatment dropout. This is because the patient perceives a premature challenge, applied when a defence has not been clarified, as a criticism or a personal attack.
A common misunderstanding of ISTDP is that the therapist’s role is to badger the patient through the use of Challenge. However, the proper use of challenge is as an aid or enhancement to the therapeutic alliance by removing an obstacle to the rise in complex feelings with the therapist. If challenge originates as a product of frustration in the therapist or as a misunderstanding of the unconscious, then stalemate is virtually assured.
The main purpose of challenge is to remove any obstacles in the way of the mutually agreed upon task of getting to the engine of the patient’s present difficulties: warded-off, complex feelings in relation to traumatising experiences with important attachment figures in the past.
The majority of patients are able to experience their true mixed feelings with a combination of Pressure and properly clarified Challenge. However, a sizable minority of patients erect a massive wall of resistance with the therapist. This wall is erected automatically and is an over-learned, habitual response, used to avoid emotional intimacy, both with the therapist and with other important figures in the patient’s personal orbit. When the therapist observes that the patient’s resistance has fully crystallised, it is time to deploy the ultimate intervention.
III. Head-On Collision: Pointing Out the Reality of the Defences and Encouragement to Overcome Them
The Head-on Collision is an intervention aimed not at any single defence but rather aimed at the entire defensive structure being deployed by the patient. It is an urgent appeal to the patient to exert maximal effort to overcome the resistance, and it takes the form of a summary statement to the patient which explains the consequences of continuing to resist:
Let’s take a look at what’s happening here. You have come on your own free will, because you are experiencing a problem which causes you pain. We have set out to get to the root of your difficulties, but every time we attempt to move toward it, you put up this massive wall. The wall keeps me out, and it keeps you from knowing your own true feelings. If you keep me out, you keep me useless. Is that what you want? Because, as you see, you are certainly capable of keeping me useless to you. My first question is, why would you want me to be useless? You see, the consequences of this would be that I would be unable to help you. I’d like to, but the nature of this work is that I can’t help everyone. Sometimes I fail. However, can you afford to fail? How much longer do you want to carry this burden?
This complex intervention is simultaneously aimed at the patient’s will, is a reminder of the task, and is a wake-up call to the therapeutic alliance to exert maximal effort against the resistance. It is a reminder, in stark terms, that the therapeutic task is in jeopardy and may well fail. Finally, it is a reminder to the patient of the consequences of failure, as well as an implied reminder that success is also possible.
The interventions of Pressure, Challenge, and Head-on Collision, all aimed at helping the patient experience true feelings in relation to the present and past, allowed Davanloo to expand the scope of patients who can be helped by short-term psychodynamic psychotherapy. A model which initially worked only with highly motivated patients able to describe a clearly problematic area can now be applied to patients whose difficulties are diffuse and whose motivation is also initially quite diffuse. The results are deep, lasting changes in areas of both symptomatic and interpersonal disturbances.
It is also worth stressing that ISTDP, unlike traditional psychodynamic therapies, assiduously avoids interpretation until such time as the unconscious is open. The use of trial interpretations is explicitly avoided. The phase of interpretation only commences once it is clear to both therapist and patient that there has been a passage of previously unconscious emotion. Quite often, it is then the patient who takes the lead in interpreting:
“The incredible rage I felt toward you when you refused to let me off the hook regarding my feelings is exactly the same rage that I felt toward my father when I was five years old and found out he had been killed in the war and wasn’t coming home. I buried the rage that day because I felt so guilty about it. That’s the day I became depressed.”
Evidence Base
Davanloo’s initial research was published in the form of a qualitative case series of approximately 200 patients. He maintains a large video library of treated cases which he uses for teaching conferences, though this has not yet been made available for other psychotherapy researchers to independently verify and quantify Davanloo’s claims. Recent studies however, support the efficacy of the ISTDP technique, as described below. He claims efficacy with psychological symptoms, medically unexplained symptoms (so-called functional or somatoform disorders), and characterological disturbances (referred to as Personality Disorders in DSM).
Empirical research into the efficacy of ISTDP, and other brief psychodynamic psychotherapies is active. There are now over 60 published outcome studies in ISTDP including 40 randomised controlled trials for depression, anxiety, personality, somatic symptom and substance use disorders. There are also over 20 studies showing the cost effectiveness of the method through reducing doctor visits, medication costs, hospital costs and disability costs. Summary of cost effectiveness studies to 2018
ISTDP has been investigated for:
Personality Disorders.
Depression and Treatment Resistant Depression.
Anxiety Disorders.
Functional Neurological Disorders.
Somatic Symptom Disorders: at least 20 studies as of October 2019.
Summary of ISTDP Somatic Condition Studies:
Cost effectiveness studies: at least 22 studies as of October 2019.
As an Adjunct to Care in Severe Mental Disorders.
Substance Use Disorders.
A Cochrane systematic review examined the efficacy of short-term psychodynamic psychotherapies for common mental disorders such as depression, anxiety and personality disorders. Without distinguishing between different forms of STDP from Davanloo’s ISTDP, modest to large short-term gains were reported for a broad range of people experiencing common mental disorders. Further research is required to determine the effectiveness and long term benefits of psychodynamic psychotherapies for common mental disorders. Neuroscientist and Nobel Prize winner, Eric Kandel refers to Davanloo’s technique and its effectiveness in providing relief from emotional disturbances.
Relationship to Cognitive Therapy
Cognitive therapy (CT), developed by Aaron T. Beck, focuses on illogical thoughts as the main driver of emotional difficulties. These beliefs, such as, “Everything I attempt inevitably fails,” are postulated to cause emotional states like depression or hopelessness. The therapist collaborates with the patient to determine which faulty cognitions are currently accepted by the patient as true. Together, the patient and therapist discover these cognitions and collaboratively explore the evidence for and against them. Relief of symptoms comes from replacing unfounded cognitions with more reality-based thoughts. CBT has been shown effective in numerous trials[citation needed], particularly for depression and anxiety disorders.
While ISTDP accepts the presence of faulty cognitions, the causality is thought to be reversed. The ISTDP therapist would posit that unconscious emotions lead to unconscious anxiety, which is managed by unconscious defences. These defences can certainly include hopeless, helpless, or self-deprecating cognitions. Rather than examining evidence for and against a thought like, “I am unable to know my own true feelings,” an ISTDP therapist might say, “If you adopt that position, which is essentially a position of helplessness, we will not get to the engine driving your difficulties. If you renounce this helpless position, how are you truly feeling right now?”
Both the CT and ISTDP therapist call the thought into question, with the goal of ultimately liberating the patient. The difference is that the ISTDP therapist sees the faulty cognition as preventing access to the true, buried feelings, while the CT therapist sees the faulty cognition as the cause of the painful emotions leading to the painful psychological state. It may well be the case that causality flows in both directions, dependent on the individual, the emotions, and the cognitions involved. As of this writing, though both CT and ISTDP show good evidence of clinical efficacy, the theoretical question of whether feelings drive thoughts or thoughts drive feelings remains unresolved; it could well be the case that thought and feeling are inextricably bound, and that we have not yet developed adequate psychological or neuroscientific concepts and tools to frame these sorts of questions properly.
Transference (German: Übertragung) is a phenomenon within psychotherapy in which the feelings a person had about their parents, as one example, are unconsciously redirected or transferred to the present situation.
It usually concerns feelings from a primary relationship during childhood. At times, this transference can be considered inappropriate. Transference was first described by Sigmund Freud, the founder of psychoanalysis, who considered it an important part of psychoanalytic treatment.
Occurrence
It is common for people to transfer feelings about their parents to their partners or children (that is, cross-generational entanglements). Another example of transference would be a person mistrusting somebody who resembles an ex-spouse in manners, voice, or external appearance, or being overly compliant to someone who resembles a childhood friend.
In The Psychology of the Transference, Carl Jung states that within the transference dyad both participants typically experience a variety of opposites, that in love and in psychological growth, the key to success is the ability to endure the tension of the opposites without abandoning the process, and that this tension allows one to grow and to transform.
Only in a personally or socially harmful context can transference be described as a pathological issue. A modern, social-cognitive perspective on transference explains how it can occur in everyday life. When people meet a new person who reminds them of someone else, they unconsciously infer that the new person has traits similar to the person previously known. This perspective has generated a wealth of research that illuminated how people tend to repeat relationship patterns from the past in the present.
High-profile serial killers often transfer unresolved rage toward previous love or hate-objects onto “surrogates”, or individuals resembling or otherwise calling to mind the original object of that hate. It is believed in the instance of Ted Bundy, he repeatedly killed brunette women who reminded him of a previous girlfriend with whom he had become infatuated, but who had ended the relationship, leaving Bundy rejected and pathologically rageful (Bundy, however, denied this as a motivating factor in his crimes). This notwithstanding, Bundy’s behaviour could be considered pathological insofar as he may have had narcissistic or antisocial personality disorder. If so, normal transference mechanisms cannot be held causative of his homicidal behaviour.
Sigmund Freud held that transference plays a large role in male homosexuality. In The Ego and the Id, he claimed that eroticism between males can be an outcome of a “[psychically] non-economic” hostility, which is unconsciously subverted into love and sexual attraction.
Transference and Counter-Transference during Psychotherapy
In a therapy context, transference refers to redirection of a patient’s feelings for a significant person to the therapist. Transference is often manifested as an erotic attraction towards a therapist, but can be seen in many other forms such as rage, hatred, mistrust, parentification, extreme dependence, or even placing the therapist in a god-like or guru status. When Freud initially encountered transference in his therapy with patients, he thought he was encountering patient resistance, as he recognised the phenomenon when a patient refused to participate in a session of free association. But what he learned was that the analysis of the transference was actually the work that needed to be done: “the transference, which, whether affectionate or hostile, seemed in every case to constitute the greatest threat to the treatment, becomes its best tool”. The focus in psychodynamic psychotherapy is, in large part, the therapist and patient recognising the transference relationship and exploring the relationship’s meaning. Since the transference between patient and therapist happens on an unconscious level, psychodynamic therapists who are largely concerned with a patient’s unconscious material use the transference to reveal unresolved conflicts patients have with childhood figures.
Countertransference is defined as redirection of a therapist’s feelings toward a patient, or more generally, as a therapist’s emotional entanglement with a patient. A therapist’s attunement to their own countertransference is nearly as critical as understanding the transference. Not only does this help therapists regulate their emotions in the therapeutic relationship, but it also gives therapists valuable insight into what patients are attempting to elicit in them. For example, a therapist who is sexually attracted to a patient must understand the countertransference aspect (if any) of the attraction, and look at how the patient might be eliciting this attraction. Once any countertransference aspect has been identified, the therapist can ask the patient what his or her feelings are toward the therapist, and can explore how those feelings relate to unconscious motivations, desires, or fears.
Another contrasting perspective on transference and countertransference is offered in classical Adlerian psychotherapy. Rather than using the patient’s transference strategically in therapy, the positive or negative transference is diplomatically pointed out and explained as an obstacle to cooperation and improvement. For the therapist, any signs of countertransference would suggest that his or her own personal training analysis needs to be continued to overcome these tendencies. Andrea Celenza noted in 2010 that “the use of the analyst’s countertransference remains a point of controversy”.
Improving Access to Psychological Therapies (IAPT) is a National Health Service (England) initiative to provide more psychotherapy to the general population.
It was developed and introduced by the Labour Party as a result of economic evaluations by Professor Lord Richard Layard, based on new therapy guidelines from the National Institute for Health and Care Excellence as promoted by clinical psychologist David M. Clark.
Brief History
Richard Layard, a labour economist at the London School of Economics, had become influential in New Labour party politics and was appointed to the House of Lords in 2000. He had a particular interest in the happiness of populations and mental health; his father, John Layard, was an anthropologist who had survived suicidal depression and retrained as a Jungian psychologist after undergoing psychoanalysis by Carl Jung. In 2003 Richard Layard met the clinical psychologist David M. Clark, a leading figure in Cognitive Behavioural Therapy who was running the Centre for Anxiety Disorders and Trauma (with Anke Ehlers and Paul Salkovskis) at the Institute of Psychiatry and Maudsley Hospital. Clark professed to high rates of improvement from CBT but low availability of the therapy despite NICE guidelines now recommending it for several mental disorders.
Layard, with Clark’s help, set about campaigning for a new national service for NICE-recommended treatments, particularly CBT. One key argument was that it would be cost-effective and indeed eventually pay for itself by increasing productivity and reducing state benefits such as Disability Living Allowance and Incapacity Benefit (which had seen rising claims since their introduction by John Major’s Conservative Party in 1992 and 1995 respectively). The plan was accepted in principle by the newly re-elected Labour government in 2005 and gradually put into practice directed by Clark. Layard names several others as having helped gain the initial political traction for the initiative – MP Ed Miliband, psychiatrist Louis Appleby (then National Director for Mental Health), David Halpern (psychologist), psychiatrist David Nutt, MP Alan Milburn (married to a psychiatrist) and eventually the Prime Minister Gordon Brown.
In 2006 the Mental Health Policy Group at the LSE published ‘The Depression Report’, commonly referred to as the Layard Report, advocating for the expansion of psychotherapy on the NHS. This facilitated the development of IAPT initiatives, including two demonstration sites (pilot studies) and then training schemes for new types of psychological practitioner. The programme was officially announced in 2007 on World Mental Health Day. Some mental health professionals cast doubt on the claims early on. In the official publication of the British Psychological Society in 2009, experienced clinical psychologists John Marzillier and Professor John Hall strongly criticised IAPT’s promoters for glossing over both the data gaps acknowledged in the NICE reports and the complexity of the multiple issues typically affecting people with mental health problems and their ability to sustain employment; they were met with much agreement as well as angry criticism. One researcher cited the UK initiative as the most impressive plan to disseminate stepped-care cognitive behaviour therapy. But the plan appears not to have worked, Davis (2020) in the Journal of Evidence Based Mental Health, noted that 73% of IAPT clients receive low intensity therapy first (guided self help, computer assisted CBT or group psychoeducation) but only 4 % are transferred to high intensity therapy and the first transition appointment is the least well attended.
Aims
The aim of the project is to increase the provision of evidence-based treatments for common mental health conditions such as anxiety and depression by primary care organisations. This includes workforce planning to adequately train the mental health professionals required. This would be based on a ‘stepped care’ or triage model where ‘low intensity’ interventions or self-help would be provided to most people in the first instance and ‘high intensity’ interventions for more serious or complex conditions. Outcomes would be assessed by standardised questionnaires, where sufficiently high initial scores (a ‘case’) and sufficiently low scores immediately after treatment (below ‘caseness’), would be classed as ‘moving to recovery’. The NICE (National Institute for Health and Clinical Excellence) therapy guidelines presume reliable diagnosis. IAPT therapists do not make formal diagnoses. This calls into question IAPT’s claimed fidelity to the NICE guidelines, particularly as it does not monitor therapists treatment adherence.
Evaluation
Initial demonstration sites reported outcomes in line with predictions in terms of the number of people treated (especially with ‘low intensity’ interventions such as ‘guided self-help’) and the percentages classified as recovered and as in more employment (a small minority) to ten months later. It was noted that the literature indicates a substantial proportion of patients would recover anyway with the passage of time or with a placebo – in fact the majority of those whose condition had lasted for less than six months, but only a small minority of those whose condition had been longer-lasting.
There has been some debate over whether IAPT’s roll-out may result initially in low quality therapy being offered by poorly trained practitioners.
Beacon UK benchmarked IAPT performance across England for 2011-2012 and reported that 533,550 people accessed (were referred to) IAPT services – 8.7% of people suffering from anxiety and depression disorders – with around 60% entering treatment sessions. Most local IAPT services did not reach the target of a 50% ‘recovery’ rate.
In 2012-2013, 761,848 people were referred to IAPT services. 49% went into treatment (the rest either assessed as unsuitable for IAPT or declined), although around half of those dropped out before completing at least two sessions. Of the remainder, 127,060 people had pre-treatment and post-treatment mental health questionnaires submitted indicating ‘recovery’ – a headline rate of 43%. A report by the University of Chester indicated that sessions were costing three times more to fund than the original Department of Health estimates.
For 2014-2015 there were nearly 1.3 million referrals to IAPT, of which 815,665 entered treatment. Of those, 37% completed sufficient sessions, with 180,300 showing a ‘reliable recovery’ (on anxiety and depression questionnaires completed before and immediately after treatment) – which was just over one in five of those who entered treatment, just under half of those who completed enough sessions. Opinion on IAPT remained divided. The number of trained IAPT therapists did not appear to have met the government’s target of 6000, resulting in high caseloads. Some complained of seeing more ‘revolving door’ patients and excess complexity of cases, while the NHS has acknowledged problems with waiting times and recovery rates. However Norman Lamb, who championed IAPT within the coalition government 2010-2015, disagreed with picking faults with such an extensive and world-leading advance in evidence-based treatment. Others lauded the success in rising numbers of referrals, but warned of the failure to improve recovery rates. It was noted that both antidepressant prescribing and psychiatric disability claims have continued to rise.
In 2017 fewer than half of the Clinical Commissioning Groups met the target (15.8%) for the number of people who should be accessing talking therapies. There has been no publicly funded independent audit of IAPT . A study of 90 IAPT cases assessed with a ‘gold standard’ diagnostic interview revealed that only the tip of the iceberg recovered, in the sense of losing their diagnostic status. The results were identical whether or not the person was treated before or after personal injury litigation.
In July 2021 55,703 appointments out of the total 434,000 which went ahead involved one or more practitioners who did not have an accredited IAPT qualification. There are about 2000 psychological wellbeing practitioners in the service, with another 1,200 trainees. They are supported by high intensity therapists and counsellors of which there are about 4,000 with 700 trainees.
Updates
In December 2010, Paul Burstow, Minister for Care Services, announced an extension to the IAPT project to include Children and Young Peoples services. The government pledged £118m annually from 2015 to 2019 to increase access to psychological therapies services to children and young people.
When the programme officially started in 2008 it was only for working age adults, but in 2010 it was opened to all ages.
In 2015 Clark and fellow clinical psychologist Peter Fonagy, writing in response to wide-ranging criticism from child and adolescent psychiatrist Sami Timimi, stated that IAPT now has increasing support for the non-CBT modalities recommended by NICE for depression: counselling, couples therapy, interpersonal psychotherapy and brief psychodynamic therapy; and for Children and Young People (CYP-IAPT) more systemic family therapy, interpersonal therapy and parenting therapy is on the way. Timimi described the changes as still “light” on relational/collaborative therapy compared to the ‘technical model’ derived from ’eminence-based’ NICE guidelines via inadequate diagnostic categories.
A Payment by Results system is being developed for IAPT, whereby each local Clinical Commissioning Group can reward each local provider according to various targets met for the service and for each client – particularly for how much change in scores on the self-report questionnaires. The March 2021 issue of the British Journal of Clinical Psychology has highlighted the considerable controversy over IAPT’s claims of success, Scott( 2021) and Kellett et al., (2021) have responded with their own commentary ‘The costs and benefits of practice-based evidence: Correcting some misunderstandings about the 10-year meta-analysis of IAPT studies’.
The emphasis of the treatment of bipolar disorder is on effective management of the long-term course of the illness, which can involve treatment of emergent symptoms.
Treatment methods include pharmacological and psychological techniques.
Principles
The primary treatment for bipolar disorder consists of medications called mood stabilisers, which are used to prevent or control episodes of mania or depression. Medications from several classes have mood stabilising activity. Many individuals may require a combination of medication to achieve full remission of symptoms. As it is impossible to predict which medication will work best for a particular individual, it may take some trial and error to find the best medication or combination for a specific patient. Psychotherapy also has a role in the treatment of bipolar disorder. The goal of treatment is not to cure the disorder but rather to control the symptoms and the course of the disorder. Generally speaking, maintenance treatment of bipolar disorder continues long after symptom control has been achieved.
Following diagnostic evaluation, the treating clinician must determine the optimal treatment setting in order to ensure the patient’s safety. Assessment of suicide risk is key, as the rate of suicide completion among those with bipolar disorder may be as high as 10-15%. Hospitalisation should be considered in patients whose judgement is significantly impaired by their illness, and those who have not responded to outpatient treatment; this may need to be done on an involuntary basis. Treatment setting should regularly be re-evaluated to ensure that it is optimal for the patient’s needs.
Mood Stabilisers
Lithium Salts
Lithium salts have been used for centuries as a first-line treatment for bipolar disorder. In ancient times, doctors would send their mentally ill patients to drink from “alkali springs” as a treatment. Although they were not aware of it, they were actually prescribing lithium, which was present in high concentration within the waters. The therapeutic effect of lithium salts appears to be entirely due to the lithium ion, Li+.
Its exact mechanism of action is uncertain, although there are several possibilities such as inhibition of inositol monophosphatase, modulation of G proteins or regulation of gene expression for growth factors and neuronal plasticity. There is strong evidence for its effectiveness in acute treatment and prevention of recurrence of mania. It can also be effective in bipolar depression, although the evidence is not as strong. It is also effective in reducing the risk of suicide in patients with mood disorders.
Potential side effects from lithium include gastrointestinal upset, tremor, sedation, excessive thirst, frequent urination, cognitive problems, impaired motor coordination, hair loss, and acne. Excessive levels of lithium can be harmful to the kidneys, and increase the risk of side effects in general. As a result, kidney function and blood levels of lithium are monitored in patients being treated with lithium. Therapeutic plasma levels of lithium range from 0.5 to 1.5 mEq/L, with levels of 0.8 or higher being desirable in acute mania.
Lithium levels should be above 0.6 mEq/L to reduce both manic and depressive episodes in patients. A recent review concludes that the standard lithium serum level should be 0.60-0.80 mmol/L with optional reduction to 0.40-0.60 mmol/L in case of good response but poor tolerance or an increase to 0.80-1.00 mmol/L in case of insufficient response and good tolerance.
Monitoring is generally more frequent when lithium is being initiated, and the frequency can be decreased once a patient is stabilised on a given dose. Thyroid hormones should also be monitored periodically, as lithium can increase the risk of hypothyroidism.
Anticonvulsants
A number of anti-convulsant drugs are used as mood stabilisers, and the suspected mechanism is related to the theory that mania can “kindle” further mania, similar to the kindling model of seizures. Valproic acid, or valproate, was one of the first anti-convulsants tested for use in bipolar disorder. It has proven to be effective for treating acute mania. The mania prevention and antidepressant effects of valproic acid have not been well demonstrated. Valproic acid is less effective than lithium at preventing and treating depressive episodes.
Carbamazepine was the first anti-convulsant shown to be effective for treating bipolar mania. It has not been extensively studied in bipolar depression. It is generally considered a second-line agent due to its side effect profile. Lamotrigine is considered a first-line agent for the treatment of bipolar depression. It is effective in preventing the recurrence of both mania and depression, but it has not proved useful in treating acute mania.
Zonisamide (trade name Zonegran), another anti-convulsant, also may show promise in treating bipolar depression. Various other anti-convulsants have been tested in bipolar disorder, but there is little evidence of their effectiveness. Other anti-convulsants effective in some cases and being studied closer include phenytoin, levetiracetam, pregabalin and valnoctamide.
Each anti-convulsant agent has a unique side-effect profile. Valproic acid can frequently cause sedation or gastrointestinal upset, which can be minimised by giving the related drug divalproex, which is available in an enteric-coated tablet. These side effects tend to disappear over time. According to studies conducted in Finland in patients with epilepsy, valproate may increase testosterone levels in teenage girls and produce polycystic ovary syndrome in women who began taking the medication before age 20. Increased testosterone can lead to polycystic ovary syndrome with irregular or absent menses, obesity, and abnormal growth of hair. Therefore, young female patients taking valproate should be monitored carefully by a physician. Excessive levels of valproate can lead to impaired liver function, and liver enzymes and serum valproate level, with a target of 50–125 µg/L, should be monitored periodically.
Side effects of carbamazepine include blurred vision, double vision, ataxia, weight gain, nausea, and fatigue, as well as some rare but serious side effects such as blood dyscrasias, pancreatitis, exfoliative dermatitis, and hepatic failure. Monitoring of liver enzymes, platelets, and blood cell counts are recommended.
Lamotrigine generally has minimal side effects, but the dose must be increased slowly to avoid rashes, including exfoliative dermatitis.
Atypical Antipsychotic Drugs
Antipsychotics work best in the manic phase of bipolar disorder. Second-generation or atypical antipsychotics (including aripiprazole, olanzapine, quetiapine, paliperidone, risperidone, and ziprasidone) have emerged as effective mood stabilisers. The evidence for this is fairly recent, as in 2003 the American Psychiatric Press noted that atypical anti-psychotics should be used as adjuncts to other anti-manic drugs because their mood stabilising properties had not been well established. The mechanism is not well known, but may be related to effects on glutamate activity. Several studies have shown atypical antipsychotics to be effective both as single-agent and adjunctive treatments. Antidepressant effectiveness varies, which may be related to different serotonergic and dopaminergic receptor binding profiles. Quetiapine and the combination of olanzapine and fluoxetine have both demonstrated effectiveness in bipolar depression.
In light of recent evidence, olanzapine (Zyprexa) has been US Food and Drug Administration (FDA) approved as an effective monotherapy for the maintenance of bipolar disorder. A head-to-head randomised control trial (RCT) in 2005 has also shown olanzapine monotherapy to be just as effective and safe as lithium in prophylaxis.
The atypical antipsychotics differ somewhat in side effect profiles, but most have some risk of sedation, weight gain, and extrapyramidal symptoms (including tremor, stiffness, and restlessness). They may also increase the risk of metabolic syndrome, so metabolic monitoring should be performed regularly, including checks of serum cholesterol, triglycerides, and glucose, weight, blood pressure, and waist circumference. Taking antipsychotics for long periods or at high doses can also cause tardive dyskinesia – a sometimes incurable neurological disorder resulting in involuntary, repetitive body movements. The risk of tardive dyskinesia appears to be lower in second-generation antipsychotics than in first-generation antipsychotics but as with first-generation drugs, increases with time spent on medications and in older patients.
New Treatments
A variety of other agents have been tried in bipolar disorder, including benzodiazepines, calcium channel blockers, L-methylfolate, and thyroid hormone. Modafinil (Provigil) and Pramipexole (Mirapex) have been suggested for treating cognitive dysfunction associated with bipolar depression, but evidence supporting their use is quite limited. In addition riluzole, a glutamatergic drug used in ALS has been studied as an adjunct or monotherapy treatment in bipolar depression, with mixed and inconsistent results. The selective oestrogen receptor modulator medication tamoxifen has shown rapid and robust efficacy treating acute mania in bipolar patients. This action is likely due not to tamoxifen’s oestrogen-modulating properties, but due to its secondary action as an inhibitor of protein Kinase C.
Cognitive Effects of Mood Stabilisers
Bipolar patients taking antipsychotics have lower scores on tests of memory and full-scale IQ than patients taking other mood stabilisers. Use of both typical and atypical antipsychotics is associated with risk of cognitive impairment, but the risk is higher for antipsychotics with more sedating effects.
Among bipolar patients taking anticonvulsants, those on lamotrigine have a better cognitive profile than those on carbamazepine, valproate, topiramate, and zonisamide.
Although decreased verbal memory and slowed psychomotor speed are common side effects of lithium use these side effects usually disappear after discontinuation of lithium. Lithium may be protective of cognitive function in the long term since it promotes neurogenesis in the hippocampus and increases grey matter volume in the prefrontal cortex.
Antidepressants
Antidepressants should only be used with caution in bipolar disorder, as they may not be effective and may even induce mania. They should not be used alone, but may be considered as an adjunct to lithium.
A recent large-scale study found that severe depression in patients with bipolar disorder responds no better to a combination of antidepressant medications and mood stabilisers than it does to mood stabilisers alone and that antidepressant use does not hasten the emergence of manic symptoms in patients with bipolar disorder.
The concurrent use of an antidepressant and a mood stabiliser, instead of mood stabiliser monotherapy, may lower the risk of further bipolar depressive episodes in patients whose most recent depressive episode has been resolved. However, some studies have also found that antidepressants pose a risk of inducing hypomania or mania, sometimes in individuals with no prior history of mania. Saint John’s Wort, although a naturally occurring compound, is thought to function in a fashion similar to man-made antidepressants, and so unsurprisingly, there are reports that suggest that it can also induce mania. For these reasons, some psychiatrists are hesitant to prescribe antidepressants for the treatment of bipolar disorder unless mood stabilisers have failed to have an effect, however, others feel that antidepressants still have an important role to play in treatment of bipolar disorder.
Side effects vary greatly among different classes of antidepressants.
Antidepressants are helpful in preventing suicides in people suffering from bipolar disorder when they go in for the depressive phase.
NMDA-Receptor Antagonists
In a double-blind, placebo-controlled, proof-of-concept study, researchers administered an N-methyl-d-aspartate-receptor antagonist (ketamine) to 18 patients already on treatment with lithium (10 patients) or valproate (8 patients) for bipolar depression. From 40 minutes following intravenous injection of ketamine hydrochloride (0.5 mg/kg), the researchers observed significant improvements in depressive symptoms, as measured by standard tools, that were maintained for up to 3 days, an effect not observed in subjects who received the placebo. Five subjects dropped out of the ketamine study; of these, four were taking valproate and one was being treated with lithium. One patient showed signs of hypomania following ketamine administration and two experienced low mood. This study demonstrates a rapid-onset antidepressant effect of ketamine in a small group of patients with bipolar depression. The authors acknowledged the study’s limitations, including the dissociative disturbances in patients receiving ketamine that could have compromised the study blinding, and they emphasised the need for further research.
A more recent double-blind, placebo-controlled study by the same group found that ketamine treatment resulted in a similarly rapid alleviation of suicidal ideation in 15 patients with bipolar depression.
Ketamine is used as a dissociative anaesthetic, and is a Class C substance in the United Kingdom; as such, it should only be used under the direction of a health professional.
Dopamine Agonists
In a single controlled study of twenty one patients, the dopamine D3 receptor agonist pramipexole was found to be highly effective in the treatment of bipolar depression. Treatment was initiated at 0.125 mg t.i.d. and increased at a rate of 0.125 mg t.i.d. to a limit of 4.5 mg qd until the patients’ condition satisfactorily responded to the medication or they could not abide the side effects. The final average dosage was 1.7 mg ± .90 mg qd. The incidence of hypomania in the treatment group was no greater than in the control group.
Psychotherapy
Certain types of psychotherapy, used in combination with medication, may provide some benefit in the treatment of bipolar disorders. Psychoeducation has been shown to be effective in improving patients’ compliance with their lithium treatment. Evidence of the efficacy of family therapy is not adequate to support unrestricted recommendation of its use. There is “fair support” for the utility of cognitive therapy. Evidence for the efficacy of other psychotherapies is absent or weak, often not being performed under randomised and controlled conditions. Well-designed studies have found interpersonal and social rhythm therapy to be effective.
Although medication and psychotherapy cannot cure the illness, therapy can often be valuable in helping to address the effects of disruptive manic or depressive episodes that have hurt a patient’s career, relationships or self-esteem. Therapy is available not only from psychiatrists but from social workers, psychologists and other licensed counsellors.
Jungian Therapy
Jungian authors have likened the mania and depression of bipolar disorder to the Jungian archetypes ‘puer’ and ‘senex’. The puer archetype is defined by the behaviours of spontaneity, impulsiveness, enthusiasm or mania and is symbolised by characters such as Peter Pan or the Greek god Hermes. The senex archetype is defined by behaviours of order, systematic thought, caution, and depression and is symbolised by characters such as the Roman god Saturn or the Greek god Kronos. Jungians conceptualise the puer and senex as a coexistent bipolarity appearing in human behaviour and imagination, but in neurotic manifestations appears as extreme oscillations and as unipolar manifestations. In the case of the split puer-senex bipolarity the therapeutic task is to bring the puer and senex back into correlation by working with the patient’s mental imagery.”
Lifestyle Changes
Sufficient Sleep
If sleeping is disturbed, the symptoms can occur. Sleep disruption may actually exacerbate the mental illness state. Those who do not get enough sleep at night, sleep late and wake up late, or go to sleep with some disturbance (e.g. music or charging devices) have a greater chance of having the symptoms and, in addition, depression. It is highly advised to not sleep too late and to get enough high quality sleep.
Self-Management and Self-Awareness
Understanding the symptoms, when they occur and ways to control them using appropriate medications and psychotherapy has given many people diagnosed with bipolar disorder a chance at a better life. Prodrome symptom detection has been shown to be used effectively to anticipate onset of manic episodes and requires high degree of understanding of one’s illness. Because the offset of the symptoms is often gradual, recognising even subtle mood changes and activity levels is important in avoiding a relapse. Maintaining a mood chart is a specific method used by patients and doctors to identify mood, environmental and activity triggers.
Stress Reduction
Forms of stress may include having too much to do, too much complexity and conflicting demands among others. There are also stresses that come from the absence of elements such as human contact, a sense of achievement, constructive creative outlets, and occasions or circumstances that will naturally elicit positive emotions. Stress reduction will involve reducing things that cause anxiety and increasing those that generate happiness. It is not enough to just reduce the anxiety.
Co-Morbid Substance Use Disorder
Co-occurring substance misuse disorders, which are extremely common in bipolar patients can cause a significant worsening of bipolar symptomatology and can cause the emergence of affective symptoms. The treatment options and recommendations for substance use disorders is wide but may include certain pharmacological and nonpharmacological treatment options.
Other Treatments
Omega-3 Fatty Acids
Omega-3 fatty acids may also be used as a treatment for bipolar disorder, particularly as a supplement to medication. An initial clinical trial by Stoll et al. (1999) produced positive results. However, since 1999 attempts to confirm this finding of beneficial effects of omega-3 fatty acids in several larger double-blind clinical trials have produced inconclusive results. It was hypothesized that the therapeutic ingredient in omega-3 fatty acid preparations is eicosapentaenoic acid (EPA) and that supplements should be high in this compound to be beneficial. A 2008 Cochrane systematic review found limited evidence to support the use of Omega-3 fatty acids to improve depression but not mania as an adjunct treatment for bipolar disorder.
Omega-3 fatty acids may be found in fish, fish oils, algae, and to a lesser degree in other foods such as flaxseed, flaxseed oil and walnuts. Although the benefits of Omega-3 fatty acids remain debated, they are readily available at drugstores and supermarkets, relatively inexpensive, and have few known side effects (All of these oils, however, have the capacity to exacerbate GERD (gastroesophageal reflux disease) – food sources may be a good alternative in such cases).
Exercise
Exercise has also been shown to have antidepressant effects.
Electroconvulsive Therapy
Electroconvulsive therapy (ECT) may have some effectiveness in mixed mania states, and good effectiveness in bipolar depression, particularly in the presence of psychosis. It may also be useful in the treatment of severe mania that is non-responsive to medications.
The most frequent side effects of ECT include memory impairment, headaches, and muscle aches. In some instances, ECT can produce significant and long-lasting cognitive impairment, including anterograde amnesia, and retrograde amnesia.
Ketogenic Diet
Because many of the medications that are effective in treating epilepsy are also effective as mood stabilizers, it has been suggested that the ketogenic diet – used for treating paediatric epilepsy – could have mood stabilising effects. Ketogenic diets are diets that are high in fat and low in carbohydrates, and force the body to use fat for energy instead of sugars from carbohydrates. This causes a metabolic response similar to that seen in the body during fasting. This idea has not been tested by clinical research, and until recently, was entirely hypothetical. Recently, however, two case studies have been described where ketogenic diets were used to treat bipolar II. In each case, the patients found that the ketogenic diet was more effective for treating their disorder than medication and were able to discontinue the use of medication. The key to efficacy appears to be ketosis (a metabolic state characterised by elevated levels of ketone bodies in the blood or urine), which can be achieved either with a classic high-fat ketogenic diet, or with a low-carbohydrate diet similar to the induction phase of the Atkins Diet. The mechanism of action is not well understood. It is unclear whether the benefits of the diet produce a lasting improvement in symptoms (as is sometimes the case in treatment for epilepsy) or whether the diet would need to be continued indefinitely to maintain symptom remission.
The Role of Cannabinoids
Acute cannabis intoxication transiently produces perceptual distortions, psychotic symptoms and reduction in cognitive abilities in healthy persons and in severe mental disorder, and may impair the ability to safely operate a motor vehicle.
Cannabis use is common in bipolar disorder, and is a risk factor for a more severe course of the disease by increasing frequency and duration of episodes. It is also reported to reduce age at onset.
Alternative Medicine
Several studies have suggested that omega-3 fatty acids may have beneficial effects on depressive symptoms, but not manic symptoms. However, only a few small studies of variable quality have been published and there is not enough evidence to draw any firm conclusions.
True self (also known as real self, authentic self, original self and vulnerable self) and false self (also known as fake self, idealised self, superficial self and pseudo self) are psychological concepts, originally introduced into psychoanalysis in 1960 by Donald Winnicott.
Winnicott used true self to describe a sense of self based on spontaneous authentic experience and a feeling of being alive, having a real self. The false self, by contrast, Winnicott saw as a defensive façade, which in extreme cases could leave its holders lacking spontaneity and feeling dead and empty, behind a mere appearance of being real.
The concepts are often used in connection with narcissism.
Characteristics
Winnicott saw the true self as rooted from early infancy in the experience of being alive, including blood pumping and lungs breathing – what Winnicott called simply being. Out of this, the baby creates the experience of a sense of reality, a sense that life is worth living. The baby’s spontaneous, nonverbal gestures derive from that instinctual sense, and if responded to by the parents, become the basis for the continuing development of the true self.
However, when what Winnicott was careful to describe as good enough parenting – i.e., not necessarily perfect – was not in place, the infant’s spontaneity was in danger of being encroached on by the need for compliance with the parents’ wishes/expectations. The result for Winnicott could be the creation of what he called the false self, where “Other people’s expectations can become of overriding importance, overlaying or contradicting the original sense of self, the one connected to the very roots of one’s being”. The danger he saw was that “through this false self, the infant builds up a false set of relationships, and by means of introjections even attains a show of being real”, while, in fact, merely concealing a barren emptiness behind an independent-seeming façade.
The danger was particularly acute where the baby had to provide attunement for the mother/parents, rather than vice versa, building up a sort of dissociated recognition of the object on an impersonal, not personal and spontaneous basis. But while such a pathological false self stifled the spontaneous gestures of the true self in favour of a lifeless imitation, Winnicott nevertheless considered it of vital importance in preventing something worse: the annihilating experience of the exploitation of the hidden true self itself.
Precursors
There was much in psychoanalytic theory on which Winnicott could draw for his concept of the false self. Helene Deutsch had described the “as if” personalities, with their pseudo relationships substituting for real ones. Winnicott’s analyst, Joan Riviere, had explored the concept of the narcissist’s masquerade – superficial assent concealing a subtle hidden struggle for control. Freud’s own late theory of the ego as the product of identifications came close to viewing it only as a false self; while Winnicott’s true/false distinction has also been compared to Michael Balint’s “basic fault” and to Ronald Fairbairn’s notion of the “compromised ego”.
Erich Fromm, in his book The Fear of Freedom distinguished between original self and pseudo self – the inauthenticality of the latter being a way to escape the loneliness of freedom; while much earlier the existentialist like Kierkegaard had claimed that “to will to be that self which one truly is, is indeed the opposite of despair” – the despair of choosing “to be another than himself”.
Karen Horney, in her 1950 book, Neurosis and Human Growth, based her idea of “true self” and “false self” through the view of self-improvement, interpreting it as real self and ideal self, with the real self being what one currently is and the ideal self being what one could become.
Later Developments
The second half of the twentieth century has seen Winnicott’s ideas extended and applied in a variety of contexts, both in psychoanalysis and beyond.
Kohut
Heinz Kohut extended Winnicott’s work in his investigation of narcissism, seeing narcissists as evolving a defensive armour around their damaged inner selves. He considered it less pathological to identify with the damaged remnants of the self, than to achieve coherence through identification with an external personality at the cost of one’s own autonomous creativity.
Lowen
Alexander Lowen identified narcissists as having a true and a false, or superficial, self. The false self rests on the surface, as the self presented to the world. It stands in contrast to the true self, which resides behind the façade or image. This true self is the feeling self, but for the narcissist the feeling self must be hidden and denied. Since the superficial self represents submission and conformity, the inner or true self is rebellious and angry. This underlying rebellion and anger can never be fully suppressed since it is an expression of the life force in that person. But because of the denial, it cannot be expressed directly. Instead it shows up in the narcissist’s acting out. And it can become a perverse force.
Masterson
James F. Masterson argued that all the personality disorders crucially involve the conflict between a person’s two selves: the false self, which the very young child constructs to please the mother, and the true self. The psychotherapy of personality disorders is an attempt to put people back in touch with their real selves.
Symington
Neville Symington developed Winnicott’s contrast between true and false self to cover the sources of personal action, contrasting an autonomous and a discordant source of action – the latter drawn from the internalisation of external influences and pressures. Thus for example parental dreams of self-glorification by way of their child’s achievements can be internalised as an alien discordant source of action. Symington stressed however the intentional element in the individual’s abandoning the autonomous self in favour of a false self or narcissistic mask – something he considered Winnicott to have overlooked.
Vaknin
As part of what has been described as a personal mission to raise the profile of the condition, psychology professor (and self-confessed narcissist) Sam Vaknin has highlighted the role of the false self in narcissism. The false self replaces the narcissist’s true self and is intended to shield him from hurt and narcissistic injury by self-imputing omnipotence. The narcissist pretends that his false self is real and demands that others affirm this confabulation, meanwhile keeping his real imperfect true self under wraps.
For Vaknin, the false self is by far more important to the narcissist than his dilapidated, dysfunctional true self; and he does not subscribe to the view that the true self can be resuscitated through therapy.
Miller
Alice Miller cautiously warns that a child/patient may not have any formed true self, waiting behind the false self façade; and that as a result freeing the true self is not as simple as the Winnicottian image of the butterfly emerging from its cocoon. If a true self can be developed, however, she considered that the empty grandiosity of the false self could give way to a new sense of autonomous vitality.
Orbach (False Bodies)
Susie Orbach saw the false self as an overdevelopment (under parental pressure) of certain aspects of the self at the expense of other aspects – of the full potential of the self – producing thereby an abiding distrust of what emerges spontaneously from the individual himself or herself. Orbach went on to extend Winnicott’s account of how environmental failure can lead to an inner splitting of mind and body, so as to cover the idea of the false body – falsified sense of one’s own body. Orbach saw the female false body in particular as built upon identifications with others, at the cost of an inner sense of authenticity and reliability. Breaking up a monolithic but false body-sense in the process of therapy could allow for the emergence of a range of authentic (even if often painful) body feelings in the patient.
Jungian Persona
Jungians have explored the overlap between Carl Jung’s concept of the persona and Winnicott’s false self; but, while noting similarities, consider that only the most rigidly defensive persona approximates to the pathological status of the false self.
Stern’s Tripartite Self
Daniel Stern considered Winnicott’s sense of “going on being” as constitutive of the core, pre-verbal self. He also explored how language could be used to reinforce a false sense of self, leaving the true self linguistically opaque and disavowed. He ended, however, by proposing a three-fold division of social, private, and of disavowed self.
Criticisms
Neville Symington criticised Winnicott for failing to integrate his false self insight with the theory of ego and id. Similarly, continental analysts like Jean-Bertrand Pontalis have made use of true/false self as a clinical distinction, while having reservations about its theoretical status.
The philosopher Michel Foucault took issue more broadly with the concept of a true self on the anti-essentialist grounds that the self was a construct – something one had to evolve through a process of subjectification, an aesthetics of self-formation, not something simply waiting to be uncovered: “we have to create ourselves as a work of art”.
Literary Examples
Wuthering Heights has been interpreted in terms of the true self’s struggle to break through the conventional overlay.
In the novel, I Never Promised You a Rose Garden, the heroine saw her outward personality as a mere ghost of a Semblance, behind which her true self hid ever more completely.
Sylvia Plath’s poetry has been interpreted in terms of the conflict of the true and false selves.
Dialectical behaviour therapy (DBT) is an evidence-based psychotherapy that began with efforts to treat personality disorders, ADHD, and interpersonal conflicts.
There is evidence that DBT can be useful in treating mood disorders, suicidal ideation, and for change in behavioural patterns such as self-harm and substance use. DBT evolved into a process in which the therapist and client work with acceptance and change-oriented strategies, and ultimately balance and synthesize them, in a manner comparable to the philosophical dialectical process of hypothesis and antithesis, followed by synthesis.
This approach was developed by Marsha M. Linehan, a psychology researcher at the University of Washington, to help people increase their emotional and cognitive regulation by learning about the triggers that lead to reactive states and helping to assess which coping skills to apply in the sequence of events, thoughts, feelings, and behaviours to help avoid undesired reactions.
Linehan developed DBT as a modified form of cognitive behavioural therapy (CBT) in the late 1980s to treat people with borderline personality disorder (BPD) and chronically suicidal individuals. Research on its effectiveness in treating other conditions has been fruitful; DBT has been used by practitioners to treat people with depression, drug and alcohol problems, post-traumatic stress disorder (PTSD), traumatic brain injuries (TBI), binge-eating disorder, and mood disorders. Research indicates DBT might help patients with symptoms and behaviours associated with spectrum mood disorders, including self-injury. Work also suggests its effectiveness with sexual-abuse survivors and chemical dependency.
DBT combines standard cognitive-behavioural techniques for emotion regulation and reality-testing with concepts of distress tolerance, acceptance, and mindful awareness largely derived from contemplative meditative practice. DBT is based upon the biosocial theory of mental illness and is the first therapy that has been experimentally demonstrated to be generally effective in treating BPD. The first randomised clinical trial of DBT showed reduced rates of suicidal gestures, psychiatric hospitalisations, and treatment drop-outs when compared to treatment as usual. A meta-analysis found that DBT reached moderate effects in individuals with borderline personality disorder.
Overview
DBT is considered part of the “third wave” of cognitive-behavioural therapy, and DBT adapts CBT to assist patients to deal with stress.
This approach was developed by Marsha M. Linehan, a psychology researcher at the University of Washington, to help people increase their emotional and cognitive regulation by learning about the triggers that lead to reactive states and helping to assess which coping skills to apply in the sequence of events, thoughts, feelings, and behaviours to help avoid undesired reactions.
Linehan developed DBT as a modified form of cognitive behavioural therapy (CBT) in the late 1980s to treat people with borderline personality disorder (BPD) and chronically suicidal individuals. Research on its effectiveness in treating other conditions has been fruitful; DBT has been used by practitioners to treat people with depression, drug and alcohol problems, post-traumatic stress disorder (PTSD), traumatic brain injuries (TBI), binge-eating disorder, and mood disorders. Research indicates DBT might help patients with symptoms and behaviours associated with spectrum mood disorders, including self-injury. Recent work also suggests its effectiveness with sexual-abuse survivors and chemical dependency.
DBT strives to have the patient view the therapist as an ally rather than an adversary in the treatment of psychological issues. Accordingly, the therapist aims to accept and validate the client’s feelings at any given time, while, nonetheless, informing the client that some feelings and behaviours are maladaptive, and showing them better alternatives. DBT focuses on the client acquiring new skills and changing their behaviours, with the ultimate goal of achieving a “life worth living”, as defined by the patient.
In DBT’s biosocial theory of BPD, clients have a biological predisposition for emotional dysregulation, and their social environment validates maladaptive behaviour.
DBT skills training alone is being used to address treatment goals in some clinical settings, and the broader goal of emotion regulation that is seen in DBT has allowed it to be used in new settings, for example, supporting parenting.
Four Modules
Mindfulness
Mindfulness is one of the core ideas behind all elements of DBT. It is considered a foundation for the other skills taught in DBT, because it helps individuals accept and tolerate the powerful emotions they may feel when challenging their habits or exposing themselves to upsetting situations.
The concept of mindfulness and the meditative exercises used to teach it are derived from traditional contemplative religious practice, though the version taught in DBT does not involve any religious or metaphysical concepts. Within DBT it is the capacity to pay attention, nonjudgmentally, to the present moment; about living in the moment, experiencing one’s emotions and senses fully, yet with perspective. The practice of mindfulness can also be intended to make people more aware of their environments through their five senses: touch, smell, sight, taste, and sound. Mindfulness relies heavily on the principle of acceptance, sometimes referred to as “radical acceptance”. Acceptance skills rely on the patient’s ability to view situations with no judgment, and to accept situations and their accompanying emotions. This causes less distress overall, which can result in reduced discomfort and symptomology.
Acceptance and Change
The first few sessions of DBT introduce the dialectic of acceptance and change. The patient must first become comfortable with the idea of therapy; once the patient and therapist have established a trusting relationship, DBT techniques can flourish. An essential part of learning acceptance is to first grasp the idea of radical acceptance: radical acceptance embraces the idea that one should face situations, both positive and negative, without judgment. Acceptance also incorporates mindfulness and emotional regulation skills, which depend on the idea of radical acceptance. These skills, specifically, are what set DBT apart from other therapies.
Often, after a patient becomes familiar with the idea of acceptance, they will accompany it with change. DBT has five specific states of change which the therapist will review with the patient:
Precontemplation is the first stage, in which the patient is completely unaware of their problem.
In the second stage, contemplation, the patient realises the reality of their illness: this is not an action, but a realisation.
It is not until the third stage, preparation, that the patient is likely to take action, and prepares to move forward. This could be as simple as researching or contacting therapists.
Finally, in stage 4, the patient takes action and receives treatment.
In the final stage, maintenance, the patient must strengthen their change in order to prevent relapse.
After grasping acceptance and change, a patient can fully advance to mindfulness techniques.
There are six mindfulness skills used in DBT to bring the client closer to achieving a “wise mind”, the synthesis of the rational mind and emotion mind: three “what” skills (observe, describe, participate) and three “how” skills (nonjudgementally, one-mindfully, effectively).
Distress Tolerance
Many current approaches to mental health treatment focus on changing distressing events and circumstances such as dealing with the death of a loved one, loss of a job, serious illness, terrorist attacks and other traumatic events. They have paid little attention to accepting, finding meaning for, and tolerating distress. This task has generally been tackled by person-centred, psychodynamic, psychoanalytic, gestalt, or narrative therapies, along with religious and spiritual communities and leaders. Dialectical behaviour therapy emphasizes learning to bear pain skilfully. This module outlines healthy coping behaviours intended to replace harmful ones, such as distractions, improving the moment, self-soothing, and practicing acceptance of what is.
Distress tolerance skills constitute a natural development from DBT mindfulness skills. They have to do with the ability to accept, in a non-evaluative and non-judgemental fashion, both oneself and the current situation. Since this is a non-judgmental stance, this means that it is not one of approval or resignation. The goal is to become capable of calmly recognizing negative situations and their impact, rather than becoming overwhelmed or hiding from them. This allows individuals to make wise decisions about whether and how to take action, rather than falling into the intense, desperate, and often destructive emotional reactions that are part of borderline personality disorder.
Emotion Regulation
Individuals with borderline personality disorder and suicidal individuals are frequently emotionally intense and labile. They can be angry, intensely frustrated, depressed, or anxious. This suggests that these clients might benefit from help in learning to regulate their emotions. DBT skills for emotion regulation include:
Identify and label emotions.
Identify obstacles to changing emotions.
Reduce vulnerability to emotion mind.
Increase positive emotional events.
Increase mindfulness to current emotions.
Take opposite action.
Apply distress tolerance techniques.
Emotional regulation skills are based on the theory that intense emotions are a conditioned response to troublesome experiences, the conditioned stimulus, and therefore, are required to alter the patient’s conditioned response. These skills can be categorised into four modules: understanding and naming emotions, changing unwanted emotions, reducing vulnerability, and managing extreme conditions:
Learning how to understand and name emotions:
The patient focuses on recognising their feelings.
This segment relates directly to mindfulness, which also exposes a patient to their emotions.
Changing unwanted emotions:
The therapist emphasizes the use of opposite-reactions, fact-checking, and problem solving to regulate emotions.
While using opposite-reactions, the patient targets distressing feelings by responding with the opposite emotion.
Reducing vulnerability:
The patient learns to accumulate positive emotions and to plan coping mechanisms in advance, in order to better handle difficult experiences in the future.
Managing extreme conditions:
The patient focuses on incorporating their use of mindfulness skills to their current emotions, to remain stable and alert in a crisis.
Interpersonal Effectiveness
The three interpersonal skills focused on in DBT include self-respect, treating others “with care, interest, validation, and respect”, and assertiveness. The dialectic involved in healthy relationships involves balancing the needs of others with the needs of the self, while maintaining one’s self-respect
Tools
Specially formatted diary cards can be used to track relevant emotions and behaviours. Diary cards are most useful when they are filled out daily. The diary card is used to find the treatment priorities that guide the agenda of each therapy session. Both the client and therapist can use the diary card to see what has improved, gotten worse, or stayed the same.
Chain Analysis
Chain analysis is a form of functional analysis of behaviour but with increased focus on sequential events that form the behaviour chain. It has strong roots in behavioural psychology in particular applied behaviour analysis concept of chaining. A growing body of research supports the use of behaviour chain analysis with multiple populations.
Efficacy
Borderline Personality Disorder
DBT is the therapy that has been studied the most for treatment of borderline personality disorder, and there have been enough studies done to conclude that DBT is helpful in treating borderline personality disorder. A 2009 Canadian study compared the treatment of borderline personality disorder with dialectical behaviour therapy against general psychiatric management. A total of 180 adults, 90 in each group, were admitted to the study and treated for an average of 41 weeks. Statistically significant decreases in suicidal events and non-suicidal self-injurious events were seen overall (48% reduction, p=0.03; and 77% reduction, p=0.01; respectively). No statistically-significant difference between groups were seen for these episodes (p=.64). Emergency department visits decreased by 67% (p<0.0001) and emergency department visits for suicidal behaviour by 65% (p<0.0001), but there was also no statistically significant difference between groups.
Depression
A Duke University pilot study compared treatment of depression by antidepressant medication to treatment by antidepressants and dialectical behaviour therapy. A total of 34 chronically depressed individuals over age 60 were treated for 28 weeks. Six months after treatment, statistically-significant differences were noted in remission rates between groups, with a greater percentage of patients treated with antidepressants and dialectical behaviour therapy in remission.
Complex Post-Traumatic Stress Disorder (CPTSD)
Exposure to complex trauma, or the experience of traumatic events, can lead to the development of complex post-traumatic stress disorder (CPTSD) in an individual. CPTSD is a concept which divides the psychological community. The American Psychological Association (APA) does not recognise it in the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, the manual used by providers to diagnose, treat and discuss mental illness), though some practitioners argue that CPTSD is separate from post-traumatic stress disorder (PTSD).
CPTSD is similar to PTSD in that its symptomatology is pervasive and includes cognitive, emotional, and biological domains, among others. CPTSD differs from PTSD in that it is believed to originate in childhood interpersonal trauma, or chronic childhood stress, and that the most common precedents are sexual traumas. Currently, the prevalence rate for CPTSD is an estimated 0.5%, while PTSD’s is 1.5%. Numerous definitions for CPTSD exist. Different versions are contributed by the World Health Organisation (WHO), The International Society for Traumatic Stress Studies (ISTSS), and individual clinicians and researchers.
Most definitions revolve around criteria for PTSD with the addition of several other domains. While The APA may not recognise CPTSD, the WHO has recognized this syndrome in its 11th edition of the International Classification of Diseases (ICD-11). The WHO defines CPTSD as a disorder following a single or multiple events which cause the individual to feel stressed or trapped, characterised by low self-esteem, interpersonal deficits, and deficits in affect regulation. These deficits in affect regulation, among other symptoms are a reason why CPTSD is sometimes compared with borderline personality disorder (BPD).
Similarities between CPTSD and Borderline Personality Disorder
In addition to affect dysregulation, case studies reveal that patients with CPTSD can also exhibit splitting, mood swings, and fears of abandonment. Like patients with borderline personality disorder, patients with CPTSD were traumatised frequently and/or early in their development and never learned proper coping mechanisms. These individuals may use avoidance, substances, dissociation, and other maladaptive behaviours to cope. Thus, treatment for CPTSD involves stabilising and teaching successful coping behaviours, affect regulation, and creating and maintaining interpersonal connections. In addition to sharing symptom presentations, CPTSD and BPD can share neurophysiological similarities, for example, abnormal volume of the amygdala (emotional memory), hippocampus (memory), anterior cingulate cortex (emotion), and orbital prefrontal cortex (personality). Another shared characteristic between CPTSD and BPD is the possibility for dissociation. Further research is needed to determine the reliability of dissociation as a hallmark of CPTSD, however it is a possible symptom. Because of the two disorders’ shared symptomatology and physiological correlates, psychologists began hypothesising that a treatment which was effective for one disorder may be effective for the other as well.
DBT as a Treatment for CPTSD
DBT’s use of acceptance and goal orientation as an approach to behaviour change can help to instil empowerment and engage individuals in the therapeutic process. The focus on the future and change can help to prevent the individual from becoming overwhelmed by their history of trauma. This is a risk especially with CPTSD, as multiple traumas are common within this diagnosis. Generally, care providers address a client’s suicidality before moving on to other aspects of treatment. Because PTSD can make an individual more likely to experience suicidal ideation, DBT can be an option to stabilize suicidality and aid in other treatment modalities.
Some critics argue that while DBT can be used to treat CPTSD, it is not significantly more effective than standard PTSD treatments. Further, this argument posits that DBT decreases self-injurious behaviours (such as cutting or burning) and increases interpersonal functioning but neglects core CPTSD symptoms such as impulsivity, cognitive schemas (repetitive, negative thoughts), and emotions such as guilt and shame. The ISTSS reports that CPTSD requires treatment which differs from typical PTSD treatment, using a multiphase model of recovery, rather than focusing on traumatic memories. The recommended multiphase model consists of establishing safety, distress tolerance, and social relations.
Because DBT has four modules which generally align with these guidelines (Mindfulness, Distress Tolerance, Affect Regulation, Interpersonal Skills) it is a treatment option. Other critiques of DBT discuss the time required for the therapy to be effective. Individuals seeking DBT may not be able to commit to the individual and group sessions required, or their insurance may not cover every session.
A study co-authored by Linehan found that among women receiving outpatient care for BPD and who had attempted suicide in the previous year, 56% additionally met criteria for PTSD. Because of the correlation between borderline personality disorder traits and trauma, some settings began using DBT as a treatment for traumatic symptoms. Some providers opt to combine DBT with other PTSD interventions, such as prolonged exposure therapy (PE) (repeated, detailed description of the trauma in a psychotherapy session) or cognitive processing therapy (CPT) (psychotherapy which addresses cognitive schemas related to traumatic memories).
For example, a regimen which combined PE and DBT would include teaching mindfulness skills and distress tolerance skills, then implementing PE. The individual with the disorder would then be taught acceptance of a trauma’s occurrence and how it may continue to affect them throughout their lives. Participants in clinical trials such as these exhibited a decrease in symptoms, and throughout the 12-week trial, no self-injurious or suicidal behaviours were reported.
Another argument which supports the use of DBT as a treatment for trauma hinges upon PTSD symptoms such as emotion regulation and distress. Some PTSD treatments such as exposure therapy may not be suitable for individuals whose distress tolerance and/or emotion regulation is low. Biosocial theory posits that emotion dysregulation is caused by an individual’s heightened emotional sensitivity combined with environmental factors (such as invalidation of emotions, continued abuse/trauma), and tendency to ruminate (repeatedly think about a negative event and how the outcome could have been changed).
An individual who has these features is likely to use maladaptive coping behaviours. DBT can be appropriate in these cases because it teaches appropriate coping skills and allows the individuals to develop some degree of self-sufficiency. The first three modules of DBT increase distress tolerance and emotion regulation skills in the individual, paving the way for work on symptoms such as intrusions, self-esteem deficiency, and interpersonal relations.
Noteworthy is that DBT has often been modified based on the population being treated. For example, in veteran populations DBT is modified to include exposure exercises and accommodate the presence of traumatic brain injury (TBI), and insurance coverage (i.e. shortening treatment). Populations with comorbid BPD may need to spend longer in the “Establishing Safety” phase. In adolescent populations, the skills training aspect of DBT has elicited significant improvement in emotion regulation and ability to express emotion appropriately. In populations with comorbid substance use, adaptations may be made on a case-by-case basis.
For example, a provider may wish to incorporate elements of motivational interviewing (psychotherapy which uses empowerment to inspire behaviour change). The degree of substance use should also be considered. For some individuals, substance use is the only coping behaviour they know, and as such the provider may seek to implement skills training before target substance reduction. Inversely, a client’s substance use may be interfering with attendance or other treatment compliance and the provider may choose to address the substance use before implementing DBT for the trauma.
Metacognitive therapy (MCT) is a psychotherapy focused on modifying metacognitive beliefs that perpetuate states of worry, rumination and attention fixation.
It was created by Adrian Wells based on an information processing model by Wells and Gerald Matthews. It is supported by scientific evidence from a large number of studies.
The goals of MCT are first to discover what patients believe about their own thoughts and about how their mind works (called metacognitive beliefs), then to show the patient how these beliefs lead to unhelpful responses to thoughts that serve to unintentionally prolong or worsen symptoms, and finally to provide alternative ways of responding to thoughts in order to allow a reduction of symptoms. In clinical practice, MCT is most commonly used for treating anxiety disorders such as social anxiety disorder, generalised anxiety disorder (GAD), health anxiety, obsessive compulsive disorder (OCD) and post-traumatic stress disorder (PTSD) as well as depression – though the model was designed to be transdiagnostic (meaning it focuses on common psychological factors thought to maintain all psychological disorders).
Metacognition, Greek for “after” (meta) “thought” (cognition), refers to the human capacity to be aware of and control one’s own thoughts and internal mental processes. Metacognition has been studied for several decades by researchers, originally as part of developmental psychology and neuropsychology. Examples of metacognition include a person knowing what thoughts are currently in their mind and knowing where the focus of their attention is, and a person’s beliefs about their own thoughts (which may or may not be accurate). The first metacognitive interventions were devised for children with attentional disorders in the 1980s.
Model of Mental Disorders
Self-Regulatory Executive Function Model
In the metacognitive model, symptoms are caused by a set of psychological processes called the cognitive attentional syndrome (CAS). The CAS includes three main processes, each of which constitutes extended thinking in response to negative thoughts. These three processes are:
Worry/rumination.
Threat monitoring.
Coping behaviours that backfire.
All three are driven by patients’ metacognitive beliefs, such as the belief that these processes will help to solve problems, although the processes all ultimately have the unintentional consequence of prolonging distress. Of particular importance in the model are negative metacognitive beliefs, especially those concerning the uncontrollability and dangerousness of some thoughts. Executive functions are also believed to play a part in how the person can focus and refocus on certain thoughts and mental modes. These mental modes can be categorised as object mode and metacognitive mode, which refers to the different types of relationships people can have towards thoughts. All of the CAS, the metacognitive beliefs, the mental modes and the executive function together constitute the self-regulatory executive function model (S-REF). This is also known as the metacognitive model. In more recent work, Wells has described in greater detail a metacognitive control system of the S-REF aimed at advancing research and treatment using metacognitive therapy.
Therapeutic Intervention
MCT is a time-limited therapy which usually takes place between 8-12 sessions. The therapist uses discussions with the patient to discover their metacognitive beliefs, experiences and strategies. The therapist then shares the model with the patient, pointing out how their particular symptoms are caused and maintained.
Therapy then proceeds with the introduction of techniques tailored to the patient’s difficulties aimed at changing how the patient relates to thoughts and that bring extended thinking under control. Experiments are used to challenge metacognitive beliefs (e.g. “You believe that if you worry too much you will go ‘mad’ – let’s try worrying as much as possible for the next five minutes and see if there is any effect”) and strategies such as attentional training technique and detached mindfulness (this is a distinct strategy from various other mindfulness techniques).
Research
Clinical trials (including randomised controlled trials) have found MCT to produce large clinically significant improvements across a range of mental health disorders, although as of 2014 the total number of subjects studied is small and a meta-analysis concluded that further study is needed before strong conclusions can be drawn regarding effectiveness. A 2015 special issue of the journal Cognitive Therapy and Research was devoted to MCT research findings.
A 2018 meta-analysis confirmed the effectiveness of MCT in the treatment of a variety of psychological complaints with depression and anxiety showing high effect sizes. It concluded (Morina & Normann, 2018):
“Our findings indicate that MCT is an effective treatment for a range of psychological complaints. To date, strongest evidence exists for anxiety and depression. Current results suggest that MCT may be superior to other psychotherapies, including cognitive behavioral interventions. However, more trials with larger number of participants are needed in order to draw firm conclusions.”
In 2020, a study showed superior effectiveness in MCT over CBT in the treatment of depression. It summarised (Callesen et al., 2020):
“MCT appears promising and might offer a necessary advance in depression treatment, but there is insufficient evidence at present from adequately powered trials to assess the relative efficacy of MCT compared with CBT in depression.”
In 2018-2020, a research topic in the journal Frontiers in Psychology highlighted the growing experimental, clinical, and neuropsychological evidence base for MCT.
References
Morina, N. & Normann, N. (2018) The Efficacy of Metacognitive Therapy: A Systematic Review and Meta-Analysis. Frontiers in Psychology. 9:2211. doi:10.3389/fpsyg.2018.02211.
Callesen, P., Reeves, D., Heal, C. & Wells, A. (2020) Metacognitive Therapy versus Cognitive Behaviour Therapy in Adults with Major Depression: A Parallel Single-Blind Randomised Trial. Scientific Reports. 10(1):7878.
1936 – Jürg Schubiger, Swiss psychotherapist and author (d. 2014).
Jurg Schubiger
Jürg Schubiger (14 October 1936 to 15 September 2014) was a Swiss psychotherapist and writer of children’s books. He won the Deutscher Jugendliteraturpreis (German Youth Literature Award) in 1996 for Als die Welt noch jung war.
For his “lasting contribution” as a children’s writer Schubiger received the biennial Hans Christian Andersen Medal in 2008. The award conferred by the International Board on Books for Young People is the highest recognition available to a writer or illustrator of children’s books.
1915 – Jerome Bruner, American psychologist and author (d. 2016).
1940 – Phyllis Chesler, American feminist psychologist, who wrote Women and Madness (1972).
Jerome Bruner
Jerome Seymour Bruner (01 October 1915 to 05 June 2016) was an American psychologist who made significant contributions to human cognitive psychology and cognitive learning theory in educational psychology.
Bruner was a senior research fellow at the New York University School of Law. He received a B.A. in 1937 from Duke University and a Ph.D. from Harvard University in 1941. He taught and did research at Harvard University, the University of Oxford, and New York University. A Review of General Psychology survey, published in 2002, ranked Bruner as the 28th most cited psychologist of the 20th century.
Phyllis Chesler
Phyllis Chesler (born 01 October 1940) is an American writer, psychotherapist, and professor emerita of psychology and women’s studies at the College of Staten Island (CUNY).
She is known as a feminist psychologist, and is the author of 18 books, including the best-seller Women and Madness (1972), With Child: A Story of Motherhood (1979) and An American Bride in Kabul: A Memoir (2013). Chesler has written on topics such as gender, mental illness, divorce and child custody, surrogacy, second-wave feminism, pornography, prostitution, incest, and violence against women.
In more recent years, Chesler has written several works on such subjects as anti-Semitism, Islam, and honour killings. Chesler argues that many western intellectuals, including leftists and feminists, have abandoned Western values in the name of multicultural relativism, and that this has led to an alliance with Islamists, an increase in anti-Semitism, and to the abandonment of Muslim women and religious minorities in Muslim-majority countries.
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