Parallel process is a phenomenon noted between therapist and supervisor, whereby the therapist recreates, or parallels, the client’s problems by way of relating to the supervisor.
The individual’s transference and the therapist’s countertransference thus re-appear in the mirror of the therapist/supervisor relationship.
Attention to parallel process first emerged in the nineteen-fifties (1950s). The process was termed reflection by Harold Searles in 1955, and two years later T. Hora (1957) first used the actual term parallel process – emphasising that it was rooted in an unconscious identification with the client/patient which could extend to tone of voice and behaviour. The supervisee thus enacts the central problem of the therapy in the supervision, potentially opening up a process of containment and solution, first by the supervisor and then by the therapist.
Alternatively, the supervisor’s own countertransference may be activated in the parallel process, to be reflected in turn between supervisor and consultant, or back into the original patient/helper dyad. Even then, however, careful examination of the material may still illuminate the original therapeutic difficulty, as reflected in the parallel situation.
According to Michael First of the Diagnostic and Statistical Manual of Mental Disorders Version 5 (DSM-5) working committee the focus of a relational disorder, in contrast to other DSM-IV disorders, “is on the relationship rather than on any one individual in the relationship”.
Relational disorders involve two or more individuals and a disordered “juncture”, whereas typical Axis I psychopathology describes a disorder at the individual level. An additional criterion for a relational disorder is that the disorder cannot be due solely to a problem in one member of the relationship, but requires pathological interaction from each of the individuals involved in the relationship.
For example, if a parent is withdrawn from one child but not another, the dysfunction could be attributed to a relational disorder. In contrast, if a parent is withdrawn from both children, the dysfunction may be more appropriately attributable to a disorder at the individual level.
First states that “relational disorders share many elements in common with other disorders: there are distinctive features for classification; they can cause clinically significant impairment; there are recognizable clinical courses and patterns of comorbidity; they respond to specific treatments; and they can be prevented with early interventions. Specific tasks in a proposed research agenda: develop assessment modules; determine the clinical utility of relational disorders; determine the role of relational disorders in the aetiology and maintenance of individual disorders; and consider aspects of relational disorders that might be modulated by individual disorders.”
The proposed new diagnosis defines a relational disorder as “persistent and painful patterns of feelings, behaviors, and perceptions” among two or more people in an important personal relationship, such a husband and wife, or a parent and children.
According to psychiatrist Darrel Regier, MD, some psychiatrists and other therapists involved in couples and marital counselling have recommended that the new diagnosis be considered for possible incorporation into the DSM IV.
The idea of a psychology of relational disorders is far from new. According to Adam Blatner, MD, some of the early psychoanalysts alluded to it more or less directly, and the history of marital couple therapy began with a few pioneers in 1930s. J.L. Moreno, the inventor of psychodrama and a major pioneer of group psychotherapy and social psychology, noted the idea that relationships could be “sick” even if the people involved were otherwise “healthy,” and even vice versa: Otherwise “sick” people could find themselves in a mutually supportive and “healthy” relationship.
Moreno’s ideas may have influenced some of the pioneers of family therapy, but also there were developments in general science, namely, cybernetic theory, developed in the mid-1940s, and noting the nature of circularity and feedback in complex systems. By the 1950s, the idea that relationships themselves could be problematic became quite apparent. So, diagnostically, in the sense not of naming a disease or disorder, but just helping people think through what was really going on, the idea of relational disorder was nothing new.
The majority of research on relational disorders concerns three relationship systems:
Adult children and their parents;
Minor children and their parents; and
The marital relationship.
There is also an increasing body of research on problems in dyadic gay relationships and on problematic sibling relationships.
Marital disorders are divided into “Marital Conflict Disorder Without Violence” and “Marital Abuse Disorder (Marital Conflict Disorder With Violence).” Couples with marital disorders sometimes come to clinical attention because the couple recognise long-standing dissatisfaction with their marriage and come to the clinician on their own initiative or are referred by a health care professional. Secondly, there is serious violence in the marriage which is “usually the husband battering the wife”. In these cases the emergency room or a legal authority often is the first to notify the clinician.
Most importantly, marital violence “is a major risk factor for serious injury and even death and women in violent marriages are at much greater risk of being seriously injured or killed” (National Advisory Council on Violence Against Women 2000). The authors of this study add that “There is current considerable controversy over whether male-to-female marital violence is best regarded as a reflection of male psychopathology and control or whether there is an empirical base and clinical utility for conceptualizing these patterns as relational.”
Recommendations for clinicians making a diagnosis of “Marital Relational Disorder” should include the assessment of actual or “potential” male violence as regularly as they assess the potential for suicide in depressed patients. Further, “clinicians should not relax their vigilance after a battered wife leaves her husband, because some data suggest that the period immediately following a marital separation is the period of greatest risk for the women.
Many men will stalk and batter their wives in an effort to get them to return or punish them for leaving. Initial assessments of the potential for violence in a marriage can be supplemented by standardised interviews and questionnaires, which have been reliable and valid aids in exploring marital violence more systematically.
The authors conclude with what they call “very recent information” on the course of violent marriages which suggests that “over time a husband’s battering may abate somewhat, but perhaps because he has successfully intimidated his wife.”
The risk of violence remains strong in a marriage in which it has been a feature in the past. Thus, treatment is essential here; the clinician cannot just wait and watch. The most urgent clinical priority is the protection of the wife because she is the one most frequently at risk, and clinicians must be aware that supporting assertiveness by a battered wife may lead to more beatings or even death.
In some cases, men are abuse victims of their wives; there is not exclusively male-on-female physical violence, although this is more common than female-on-male violence.
Research on parent-child abuse bears similarities to that on marital violence, with the defining characteristic of the disorder being physical aggression by a parent toward a child. The disorder is frequently concealed by parent and child, but may come to the attention of the clinician in several ways, from emergency room medical staff to reports from child protection services.
Some features of abusive parent–child relationships that serve as a starting point for classification include:
The parent is physically aggressive with a child, often producing physical injury;
Parent-child interaction is coercive, and parents are quick to react to provocations with aggressive responses, and children often reciprocate aggression;
Parents do not respond effectively to positive or prosocial behaviour in the child;
Parents do not engage in discussion about emotions;
Parent engages in deficient play behaviour, ignores the child, rarely initiates play, and does little teaching;
Children are insecurely attached and, where mothers have a history of physical abuse, show distinctive patterns of disorganised attachment; and
Defining the relational aspects of these disorders can have important consequences. For example, in the case of early appearing feeding disorders, attention to relational problems may help delineate different types of clinical problems within an otherwise broad category. In the case of conduct disorder, the relational problems may be so central to the maintenance, if not the aetiology, of the disorder that effective treatment may be impossible without recognising and delineating it.
Relational psychoanalysis is a school of psychoanalysis in the United States that emphasizes the role of real and imagined relationships with others in mental disorder and psychotherapy. ‘Relational psychoanalysis is a relatively new and evolving school of psychoanalytic thought considered by its founders to represent a “paradigm shift” in psychoanalysis’.
Relational psychoanalysis began in the 1980s as an attempt to integrate interpersonal psychoanalysis’s emphasis on the detailed exploration of interpersonal interactions with British object relations theory’s ideas about the psychological importance of internalised relationships with other people. Relationalists argue that personality emerges from the matrix of early formative relationships with parents and other figures. Philosophically, relational psychoanalysis is closely allied with social constructionism.
Drives versus Relationships
An important difference between relational theory and traditional psychoanalytic thought is in its theory of motivation, which would ‘assign primary importance to real interpersonal relations, rather than to instinctual drives’. Freudian theory, with a few exceptions, proposes that human beings are motivated by sexual and aggressive drives. These drives are biologically rooted and innate. They are ultimately not shaped by experience.
Relationalists, on the other hand, argue that the primary motivation of the psyche is to be in relationships with others. As a consequence early relationships, usually with primary caregivers, shape one’s expectations about the way in which one’s needs are met. Therefore, desires and urges cannot be separated from the relational contexts in which they arise; motivation is then seen as being determined by the systemic interaction of a person and his or her relational world. Individuals attempt to re-create these early learned relationships in ongoing relationships that may have little or nothing to do with those early relationships. This re-creation of relational patterns serves to satisfy the individuals’ needs in a way that conforms with what they learned as infants. This re-creation is called an enactment.
When treating patients, relational psychoanalysts stress a mixture of waiting and authentic spontaneity. Some relationally oriented psychoanalysts eschew the traditional Freudian emphasis on interpretation and free association, instead emphasising the importance of creating a lively, genuine relationship with the patient. However, many others place a great deal of importance on the Winnicottian concept of “holding” and are far more restrained in their approach, generally giving weight to well formulated interpretations made at what seems to be the proper time. Overall, relational analysts feel that psychotherapy works best when the therapist focuses on establishing a healing relationship with the patient, in addition to focusing on facilitating insight. They believe that in doing so, therapists break patients out of the repetitive patterns of relating to others that they believe maintain psychopathology. Noteworthy too is ‘the emphasis relational psychoanalysis places on the mutual construction of meaning in the analytic relationship’.
Stephen A. Mitchell has been described as the “most influential relational psychoanalyst”. His 1983 book, co-written with Jay Greenberg and called Object Relations in Psychoanalytic Theory is considered to be the first major work of relational psychoanalysis. Prior work especially by Sabina Spielrein in the 1910s to 1930s is often cited, particularly by Adrienne Harris and others who connect feminism with the field, but as part of the prior Freud/Jung/Spielrein tradition.
Other important relational authors include Neil Altman, Lewis Aron, Hugo Bleichmar, Philip Bromberg, Nancy Chodorow, Susan Coates, Jody Davies, Emmanuel Ghent, Adrienne Harris, Irwin Hirsch, Irwin Z. Hoffman, Karen Maroda, Stuart Pizer, Owen Renik, Ramón Riera, Daniel Schechter, Joyce Slochower, Martha Stark, Ruth Stein, Donnel Stern, Robert Stolorow, Jeremy D. Safran and Jessica Benjamin – the latter pursuing the ‘goal of creating a genuinely feminist and philosophically informed relational psychoanalysis’. A significant historian and philosophical contributor is Philip Cushman.
Psychoanalyst and philosopher Jon Mills has offered a number of substantial criticisms of the relational movement. Mills evidently thinks this “paradigm shift” to relational psychoanalysis is not exclusively due to theoretical differences with classical psychoanalysis but also arises from a certain group mentality and set of interests: “Relational psychoanalysis is an American phenomenon, with a politically powerful and advantageous group of members advocating for conceptual and technical reform” from a professional psychologist group perspective: “most identified relational analysts are psychologists, as are the founding professionals associated with initiating the relational movement”.
From a theoretical perspective, Mills appears to doubt that relational psychoanalysis is as radically new as it is touted to be. In its emphasis on the developmental importance of other people, according to Mills, “relational theory is merely stating the obvious” – picking up on “a point that Freud made explicit throughout his theoretical corpus, which becomes further emphasized more significantly by early object relations therapists through to contemporary self psychologists.” Mills also criticizes the diminishing or even the loss of the significance of the unconscious in relational psychoanalysis, a point he brings up in various parts of his book Conundrums.
Psychoanalyst and historian Henry Zvi Lothane has also criticised some of the central ideas of relational psychoanalysis, from both historical and psychoanalytic perspectives. Historically, Lothane believes relational theorists overstate the non-relational aspects of Freud as ignore its relational aspects. Lothane maintains that, though Freud’s theory of disorder is “monadic,” i.e. focused more or less exclusively on the individual, Freud’s psychoanalytic method and theory of clinical practice is consistently dyadic or relational. From a theoretical perspective, Lothane has criticised the term “relational” in favour of Harry Stack Sullivan’s term “interpersonal”. Lothane developed his concepts of “reciprocal free association” as well as “dramatology” as ways of understanding the interpersonal or relational dimension of psychoanalysis.
Psychoanalyst and philosopher Aner Govrin examines the heavy price psychoanalysis paid for adopting postmodernism as their preferred epistemology. He posits that only analysts who thought they “know the truth,” created classical, interpersonal, self-psychology, ego psychology, Kleinian, Bionian, Fairbairnian, Winiccottian and other schools of thought. While the relational tradition had made extraordinary and positive contributions to psychoanalysis, and its postmodern epistemology is indeed moderate, as a political movement the American relational tradition had unwanted psychological and sociological effects on psychoanalysis. This led to a severe decline in the positive image of knowledge that is crucial for the building of new theories. Led by the relational movement, but influenced by a much broader movement in western philosophy and culture, this impact has greatly influenced international psychoanalysis. It has led not only to the disparagement of the school era but also to the devaluation of any attempt to know the truth.
Adopting a more sympathetic line of criticism, Robin S. Brown suggests that while relational thinking has done much to challenge psychoanalytic dogmatism, excessively emphasizing the formative role of social relations can culminate in its own form of authoritarianism. Brown contends that the relational shift has insufficiently addressed the role of first principles, and that this tendency might be challenged by engaging analytical psychology.
Therapy with a Map: A Cognitive Analytic Approach to Helping Relationships.
Author(s): Steve Potter.
Edition: First (1st).
Type(s): Paperback and Kindle.
A therapeutic relationship is a web of interactions, tasks and processes in space and time. It is not easy to stay aware of the relationship in the thick of talking and trying to help someone; but doing so boosts flexibility and enables deeper formulation. A therapist who can attend not only to a specific therapeutic model, but also to relational factors underlying all therapy, has a far greater chance of enabling change.
Therapy with a Map sets out a therapeutic process of talking accompanied by visual conversation maps set down in real time on paper. Like all maps, these help us to find our way, notice when we are lost, track our route and survey the wider landscape. The book uses mapping to introduce the tools and concepts of Cognitive Analytic Therapy (CAT), along with other relational, conversational and narrative approaches. By mapping patterns of thinking and relating, therapists can help clients to develop self-understanding, solve problems, and take away a freer, more self-aware relationship with themselves in the world.
Stephen Karpman used triangles to map conflicted or drama-intense relationship transactions. The Karpman Drama Triangle models the connection between personal responsibility and power in conflicts, and the destructive and shifting roles people play. He defined three roles in the conflict; Persecutor, Rescuer (the one up positions) and Victim (one down position). Karpman placed these three roles on an inverted triangle and referred to them as being the three aspects, or faces of drama.
The Victim in this model is not intended to represent an actual victim, but rather someone feeling or acting like one.
The Victim’s stance is “Poor me!”
The Victim feels victimised, oppressed, helpless, hopeless, powerless, ashamed, and seems unable to make decisions, solve problems, take pleasure in life, or achieve insight.
The Victim, if not being persecuted, will seek out a Persecutor and also a Rescuer who will save the day but also perpetuate the Victim’s negative feelings.
The rescuer’s line is “Let me help you.”
A classic enabler, the Rescuer feels guilty if they do not go to the rescue.
Yet their rescuing has negative effects: It keeps the Victim dependent and does not allow the Victim permission to fail and experience the consequences of their choices.
The rewards derived from this rescue role are that the focus is taken off of the rescuer.
When they focus their energy on someone else, it enables them to ignore their own anxiety and issues.
This rescue role is also pivotal because their actual primary interest is really an avoidance of their own problems disguised as concern for the victim’s needs.
The Persecutor insists, “It’s all your fault.”
The Persecutor is controlling, blaming, critical, oppressive, angry, authoritarian, rigid, and superior.
Initially, a drama triangle arises when a person takes on the role of a victim or persecutor. This person then feels the need to enlist other players into the conflict. As often happens, a rescuer is encouraged to enter the situation. These enlisted players take on roles of their own that are not static, and therefore various scenarios can occur. The victim might turn on the rescuer, for example, while the rescuer then switches to persecution.
The reason that the situation persist is that each participant has their (frequently unconscious) psychological wishes/needs met without having to acknowledge the broader dysfunction or harm done in the situation as a whole. Each participant is acting upon their own selfish needs, rather than acting in a genuinely responsible or altruistic manner. Any character might “ordinarily come on like a plaintive victim; it is now clear that the one can switch into the role of Persecutor providing it is ‘accidental’ and the one apologises for it”.
The motivations of the rescuer are the least obvious. In the terms of the triangle, the rescuer has a mixed or covert motive and benefits egoically in some way from being “the one who rescues”. The rescuer has a surface motive of resolving the problem and appears to make great efforts to solve it, but also has a hidden motive to not succeed, or to succeed in a way in which they benefit. They may get a self-esteem boost, for example, or receive respected rescue status, or derive enjoyment by having someone depend on them and trust them and act in a way that ostensibly seems to be trying to help, but at a deeper level plays upon the victim in order to continue getting a payoff.
The relationship between the victim and the rescuer may be one of co-dependency. The rescuer keeps the victim dependent by encouraging their victimhood. The victim gets their needs met by having the rescuer take care of them.
Participants generally tend to have a primary or habitual role (victim, rescuer, persecutor) when they enter into drama triangles. Participants first learn their habitual role in their family of origin. Even though participants each have a role with which they most identify, once on the triangle, participants rotate through all the three positions.
Each triangle has a “payoff” for those playing it. The “antithesis” of a drama triangle lies in discovering how to deprive the actors of their payoff.
Through popular usage and the work of Karpman and others, Karpman’s triangle has been adapted for use in structural analysis and transactional analysis.
Family Therapy Movement
After World War II, therapists observed that while many battle-torn veteran patients readjusted well after returning to their families, some patients did not; some even regressed when they returned to their home environment. Researchers felt that they needed an explanation for this and began to explore the dynamics of family life – and thus began the family therapy movement. Prior to this time, psychiatrists and psychoanalysts focused on the patient’s already-developed psyche and downplayed outside detractors. Intrinsic factors were addressed and extrinsic reactions were considered as emanating from forces within the person.
In the 1950s, Eric Berne developed transactional analysis, a method for studying interactions between individuals. This approach was profoundly different than that of Freud. While Freud relied on asking patients about themselves, Berne felt that a therapist could learn by observing what was communicated (words, body language, facial expressions) in a transaction. So instead of directly asking the patient questions, Berne would frequently observe the patient in a group setting, noting all of the transactions that occurred between the patient and other individuals.
The theory of triangulation was originally published in 1966 by Murray Bowen as one of eight parts of Bowen’s family systems theory. Murray Bowen, a pioneer in family systems theory, began his early work with schizophrenics at the Menninger Clinic, from 1946 to 1954. Triangulation is the “process whereby a two-party relationship that is experiencing tension will naturally involve third parties to reduce tension”. Simply put, when people find themselves in conflict with another person, they will reach out to a third person. The resulting triangle is more comfortable as it can hold much more tension because the tension is being shifted around three people instead of two.
Bowen studied the dyad of the mother and her schizophrenic child while he had them both living in a research unit at the Menninger clinic. Bowen then moved to the National Institute of Mental Health (NIMH), where he resided from 1954 to 1959. At the NIMH Bowen extended his hypothesis to include the father-mother-child triad. Bowen considered differentiation and triangles the crux of his theory, Bowen Family Systems Theory. Bowen intentionally used the word triangle rather than triad. In Bowen Family Systems Theory, the triangle is an essential part of the relationship.
Couples left to their own resources oscillate between closeness and distance. Two people having this imbalance often have difficulty resolving it by themselves. To stabilise the relationship, the couple often seek the aid of a third party to help re-establish closeness. A triangle is the smallest possible relationship system that can restore balance in a time of stress. The third person assumes an outside position. In periods of stress, the outside position is the most comfortable and desired position. The inside position is plagued by anxiety, along with its emotional closeness. The outsider serves to preserve the inside couple’s relationship. Bowen noted that not all triangles are constructive – some are destructive.
In 1968, Nathan Ackerman conceptualised a destructive triangle. Ackerman stated “we observe certain constellations of family interactions which we have epitomised as the pattern of family interdependence, roles those of destroyer or persecutor, the victim of the scapegoating attack, and the family healer or the family doctor. Ackerman also recognise the pattern of attack, defence, and counterattack, as shifting roles.
Karpman Triangle and Eric Berne
In 1968, Stephen Karpman, who had an interest in acting and was a member of the Screen Actors Guild, chose “drama triangle” rather than “conflict triangle” as, here, the Victim in his model is not intended to represent an actual victim, but rather someone feeling or acting like one. He first published his theory in an article entitled “Fairy Tales and Script Drama Analysis”. His article, in part, examined the fairy tale “Little Red Riding Hood” to illustrate its points. Karpman was, at the time, a recent graduate of Duke University School of Medicine and was doing post post-graduate studies under Berne. Berne, who founded the field transactional analysis, encouraged Karpman to publish what Berne referred to as “Karpman’s triangle”. Karpman’s article was published in 1968. In 1972, Karpman received the Eric Berne Memorial Scientific Award for the work.
Eric Berne, a Canadian-born psychiatrist, created the theory of transactional analysis, in the middle of the 20th century, as a way of explaining human behaviour. Berne’s theory of transactional analysis was based on the ideas of Freud but was distinctly different. Freudian psychotherapists focused on talk therapy as a way of gaining insight to their patients’ personalities. Berne believed that insight could be better discovered by analysing patients’ social transactions.
Games in transactional analysis refers to a series of transactions that is complementary (reciprocal), ulterior, and proceeds towards a predictable outcome. In this context, the Karpman Drama Triangle is a “game”.
Games are often characterised by a switch in roles of players towards the end. The number of players may vary. Games in this sense are devices used (often unconsciously) by people to create a circumstance where they can justifiably feel certain resulting feelings (such as anger or superiority) or justifiably take or avoid taking certain actions where their own inner wishes differ from societal expectations. They are always a substitute for a more genuine and full adult emotion and response which would be more appropriate. Three quantitative variables are often useful to consider for games:
“The ability of the players to change the currency of the game (that is, the tools they use to play it).
“Some games…can be played properly with only one kind of currency, while others, such as exhibitionistic games, are more flexible”, so that players may shift from words, to money, to parts of the body.
“Some people give up their games easily, others are more persistent”, referring to the way people stick to their games and their resistance to breaking with them.
“Some people play their games in a relaxed way, others are more tense and aggressive.
Games so played are known as easy and hard games, respectively”, the latter being played in a tense and aggressive way.
The consequences of games may vary from small paybacks to paybacks built up over a long period to a major level. Based on the degree of acceptability and potential harm, games are classified into three categories, representing first degree games, second degree games, and third degree games:
Undesirable but not irreversibly damaging.
May result in drastic harm.
The Karpman triangle was an adaptation of a model that was originally conceived to analyse the play-action pass and the draw play in American football and later adapted as a way to analyse movie scripts. Karpman is reported to have doodled thirty or more diagram types before settling on the triangle. Karpman credits the movie Valley of the Dolls as being a testbed for refining the model into what Berne coined as the Karpman Drama Triangle.
Karpman now has many variables of the Karpman triangle in his fully developed theory, besides role switches. These include space switches (private-public, open-closed, near-far) which precede, cause, or follow role switches, and script velocity (number of role switches in a given unit of time). These include the Question Mark triangle, False Perception triangle, Double Bind triangle, The Indecision triangle, the Vicious Cycle triangle, Trapping triangle, Escape triangle, Triangles of Oppression, and Triangles of Liberation, Switching in the triangle, and the Alcoholic Family triangle.
While transactional analysis is the method for studying interactions between individuals, one researcher postulates that drama-based leaders can instil an organisational culture of drama. Persecutors are more likely to be in leadership positions and a persecutor culture goes hand in hand with cutthroat competition, fear, blaming, manipulation, high turnover and an increased risk of lawsuits. There are also victim cultures which can lead to low morale and low engagement as well as an avoidance of conflict, and rescuer cultures which can be characterised as having a high dependence on the leader, low initiative and low innovation.
The Winner’s Triangle was published by Acey Choy in 1990 as a therapeutic model for showing patients how to alter social transactions when entering a triangle at any of the three entry points. Choy recommends that anyone feeling like a victim think more in terms of being vulnerable and caring, that anyone cast as a persecutor adopt an assertive posture, and anyone recruited to be a rescuer should react by being “caring”.
Vulnerable: A victim should be encouraged to accept their vulnerability, problem solve, and be more self-aware.
Assertive: A persecutor should be encouraged to ask for what they want, be assertive, but not be punishing.
Caring: A rescuer should be encouraged to show concern and be caring, but not over-reach and problem solve for others.
The Power of TED, first published in 2009, recommends that the “victim” adopt the alternative role of creator, view the persecutor as a challenger, and enlist a coach instead of a rescuer.
Victims are encouraged to be outcome-oriented as opposed to problem-oriented and take responsibility for choosing their response to life challenges.
They should focus on resolving “dynamic tension” (the difference between current reality and the envisioned goal or outcome) by taking incremental steps toward the outcomes he or she is trying to achieve.
A victim is encouraged to see a persecutor as a person (or situation) that forces the creator to clarify his or her needs, and focus on their learning and growth.
A rescuer should be encouraged to ask questions that are intended to help the individual to make informed choices.
The key difference between a rescuer and a coach is that the coach sees the creator as capable of making choices and of solving his or her own problems.
A coach asks questions that enable the creator to see the possibilities for positive action, and to focus on what he or she does want instead of what he or she does not want.
Do you know the difference between anxiety and stress? What can you do when you have a panic attack? How do you know when it is time to get help?
Anxiety is a mental health crisis that has gripped over three crore Indians. In Anxiety: Overcome It and Live without Fear, clinical psychologist Sonali Gupta delves into the condition, using case studies to identify how anxiety can be triggered at work, in relationships, and by social media. Gupta shares a unique glimpse into this mental health condition in India, especially among Gen Z and millennials.
Recommending strategies and techniques for anxiety-prone readers, this book will help you confront your fears and take control of your life.
Author(s): Freddy Jackson Brown and Duncan Gillard.
Edition: First (1st).
Do you want to change your relationship with painful thoughts and feelings that are holding you back from making changes to improve your life?
In this book, you will discover how to identify negative and unhealthy modes of thinking and apply Acceptance and Commitment Therapy (ACT) principles throughout your day-to-day life, creating a healthier, richer and more meaningful existence with yourself and others.
Psychological interventions for antisocial personality disorder.
Antisocial personality disorder (AsPD) is associated with poor mental health, criminality, substance use and relationship difficulties. This review updates Gibbon 2010 (previous version of the review).
Therefore the purpose of this review was to evaluate the potential benefits and adverse effects of psychological interventions for adults with AsPD.
The researchers searched CENTRAL, MEDLINE, Embase, 13 other databases and two trials registers up to 5 September 2019. They also searched reference lists and contacted study authors to identify studies.
Selection criteria concisted of randomised controlled trials of adults, where participants with an AsPD or dissocial personality disorder diagnosis comprised at least 75% of the sample randomly allocated to receive a psychological intervention, treatment-as-usual (TAU), waiting list or no treatment. The primary outcomes were aggression, reconviction, global state/functioning, social functioning and adverse events.
Data collection and analysis consisted of standard methodological procedures expected by Cochrane.
This review includes 19 studies (eight new to this update), comparing a psychological intervention against TAU (also called ‘standard Maintenance'(SM) in some studies).
Eight of the 18 psychological interventions reported data on our primary outcomes. Four studies focussed exclusively on participants with AsPD, and 15 on subgroups of participants with AsPD. Data were available from only 10 studies involving 605 participants.
Eight studies were conducted in the UK and North America, and one each in Iran, Denmark and the Netherlands. Study duration ranged from 4 to 156 weeks (median = 26 weeks).
Most participants (75%) were male; the mean age was 35.5 years. Eleven studies (58%) were funded by research councils. Risk of bias was high for 13% of criteria, unclear for 54% and low for 33%. Cognitive behaviour therapy (CBT) + TAU versus TAU One study (52 participants) found no evidence of a difference between CBT + TAU and TAU for physical aggression (odds ratio (OR) 0.92, 95% CI 0.28 to 3.07; low-certainty evidence) for outpatients at 12 months post-intervention.
One study (39 participants) found no evidence of a difference between CBT + TAU and TAU for social functioning (mean difference (MD) -1.60 points, 95% CI -5.21 to 2.01; very low-certainty evidence), measured by the Social Functioning Questionnaire (SFQ; range = 0-24), for outpatients at 12 months post-intervention. Impulsive lifestyle counselling (ILC) + TAU versus TAU One study (118 participants) found no evidence of a difference between ILC + TAU and TAU for trait aggression (assessed with Buss-Perry Aggression Questionnaire-Short Form) for outpatients at nine months (MD 0.07, CI -0.35 to 0.49; very low-certainty evidence).
One study (142 participants) found no evidence of a difference between ILC + TAU and TAU alone for the adverse event of death (OR 0.40, 95% CI 0.04 to 4.54; very low-certainty evidence) or incarceration (OR 0.70, 95% CI 0.27 to 1.86; very low-certainty evidence) for outpatients between three and nine months follow-up. Contingency management (CM) + SM versus SM One study (83 participants) found evidence that, compared to SM alone, CM + SM may improve social functioning measured by family/social scores on the Addiction Severity Index (ASI; range = 0 (no problems) to 1 (severe problems); MD -0.08, 95% CI -0.14 to -0.02; low-certainty evidence) for outpatients at six months. ‘Driving whilst intoxicated’ programme (DWI) + incarceration versus incarceration One study (52 participants) found no evidence of a difference between DWI + incarceration and incarceration alone on reconviction rates (hazard ratio 0.56, CI -0.19 to 1.31; very low-certainty evidence) for prisoner participants at 24 months.
Schema therapy (ST) versus TAU One study (30 participants in a secure psychiatric hospital, 87% had AsPD diagnosis) found no evidence of a difference between ST and TAU for the number of participants who were reconvicted (OR 2.81, 95% CI 0.11 to 74.56, P = 0.54) at three years. The same study found that ST may be more likely to improve social functioning (assessed by the mean number of days until patients gain unsupervised leave (MD -137.33, 95% CI -271.31 to -3.35) compared to TAU, and no evidence of a difference between the groups for overall adverse events, classified as the number of people experiencing a global negative outcome over a three-year period (OR 0.42, 95% CI 0.08 to 2.19).
The certainty of the evidence for all outcomes was very low. Social problem-solving (SPS) + psychoeducation (PE) versus TAU One study (17 participants) found no evidence of a difference between SPS + PE and TAU for participants’ level of social functioning (MD -1.60 points, 95% CI -5.43 to 2.23; very low-certainty evidence) assessed with the SFQ at six months post-intervention. Dialectical behaviour therapy versus TAU One study (skewed data, 14 participants) provided very low-certainty, narrative evidence that DBT may reduce the number of self-harm days for outpatients at two months post-intervention compared to TAU.
Psychosocial risk management (PSRM; ‘Resettle’) versus TAU One study (skewed data, 35 participants) found no evidence of a difference between PSRM and TAU for a number of officially recorded offences at one year after release from prison. It also found no evidence of difference between the PSRM and TAU for the adverse event of death during the study period (OR 0.89, 95% CI 0.05 to 14.83, P = 0.94, 72 participants (90% had AsPD), 1 study, very low-certainty evidence).
There is very limited evidence available on psychological interventions for adults with AsPD. Few interventions addressed the primary outcomes of this review and, of the eight that did, only three (CM + SM, ST and DBT) showed evidence that the intervention may be more effective than the control condition. No intervention reported compelling evidence of change in antisocial behaviour.
Overall, the certainty of the evidence was low or very low, meaning that we have little confidence in the effect estimates reported. The conclusions of this update have not changed from those of the original review, despite the addition of eight new studies. This highlights the ongoing need for further methodologically rigorous studies to yield further data to guide the development and application of psychological interventions for AsPD and may suggest that a new approach is required.
Gibbon, S., Khalifa, N.R., Cheung, N.H-Y., Vollm, B.A. & McCarthy, L. (2020) Psychological interventions for antisocial personality disorder. The Cochrane Database of Systematic Reviews. doi: 10.1002/14651858.CD007668.pub3.
Ferment – A Memoir of Mental Illness, Redemption, and Winemaking in the Mosel.
Author(s): Patrick Dobson.
Edition: First (1st).
Publisher: Skyhorse Publishing.
Type(s): Hardcover and Kindle.
A deeply moving account of one man’s return to the German town where he first pursued a career in winemaking, and his attempt to reckon with the mental illness, alcoholism, and enduring relationships that defined the most formative chapter of his life.
After an attempted suicide by hanging – with his son in the next room – author Patrick Dobson checks into a mental hospital, clueless, reeling from bone-crushing depression and tortuous, racing thoughts. A long overdue diagnosis of manic depression offers relief but brings his confused and eventful past into question.
To make sense of his suicide attempt and deal with his past, he returns to Germany where, three decades earlier, he arrived as twenty-two-year-old – lost, drunk, and in the throes of untreated mental illness – in search of a new life and with dreams of becoming a winemaker. The sublime Mosel vineyards and the ancient city of Trier changed his life forever.
Ferment charts his days in Trier’s vineyards and cellars, and the enduring friendships that would define his life. A winemaker and his wife become like parents to him. In their son, he finds a brother, whose death years later sends Dobson into a suicidal tailspin. His friends, once apprentices like himself, become leaders in their fields: an art historian and church-restoration expert, an art- and architectural-glass craftsman, a painter and photographer, and a theologian/journalist. The relationships he builds with them become hallmarks of a life well-lived.
In Ferment, Dobson reconnects with the people who stood by him through his dissolution and eventual recovery. In these relationships, he seeks who he was and how his time in Germany changed him. He peers into his memory to understand how manic depression and alcoholism affected who he was then and how his time in Germany made him who he’s become.
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