A research team from UCLA under the leadership of doctor Faustner performed brain scans of 14 adults diagnosed with BDD and 16 healthy controls in order to map the brain's connections to examine how the white-matter networks are organised.

People with BDD had a pattern of abnormally high network "clustering" across the entire brain. This suggests that these individuals may have imbalances in how they process "local" or detailed information. The researchers also discovered specific abnormal connections between areas involved in processing visual input and those involved in recognizing emotions.

Find the link here.

V. S. Rachmanadran argues that studying patients with anosognosia (Anton-Babynski syndrome) - that is patients who, following a stroke in the right hemisphere develop paralysis in the right side of the body, but deny that this is the case - will offer an experimental bridge to understanding Freudian defensive systems such as denial, repression and reaction formation. His suggestion is that the left hemisphere is invested in maintaining a coherent belief system and will typically deny small anomalies that do not fit within the belief system. The right parietal lobe has a role in noticing inconsistencies when they become significant enough and raising this into awareness. If this part of the brain is offline there is nothing to inhibit the left hemisphere's propensity to construct reality in a way that strictly fits with its previous beliefs. 

This lecture was delivered at the The 5th Neuro-Psychoanalysis Congress, Rome 2004 on "Splitting, Denial and Narcissism: Neuropsychoanalytic Perspectives on the Right Hemisphere."

Session 1

Perception, Concepts and the Self: Perspectives from Western Science and Philosophy
Presenters: Richard J. Davidson and Jay Garfield

Jay Garfield: Why should we care about concepts of perception and self? 

We tend to take for granted our perceptions and do not distinguish between our perceptions and reality. We also confuse a designated self from the real self. We assume that our concepts reflect reality as it is. 

Here are my notes from this workshop. 

Between 20%and 50% of mental health practitioners will lose a client to suicide during our professional life, depending on the context in which we work. 

What characterises the suicidal mind is: they always want to live and they always want to die. We can get caught up in the thinking that because a client called out the ambulance after ingesting medication she didn’t really want to die. It’s important to keep this in mind: both wanting to live and wanting to die.

The way we approach suicidality has to be thought out. We can’t throw everything we have at someone. It can be confusing and overwhelming. We do it because we want to be covered.

 

Perceived burdensomness+thwarted belongingness combined with developed fearlessness and ability leads to serious attempt or death by suicide

 

Development of fearlessness – the suicide person has gone through a journey that has allowed them to override the natural instinct for self-preservation and to overcome fear.

Fearlessness of physical injury is developed by habituation – getting used to threat of bodily harm to the point that it no longer provokes fear but may induce states that are pleasurable. One has to suppress or depress the fear response. 

 

Reduction of the fear response through repeated exposure to violence/injury/physical pain/provocation/abuse. Emergence of an opponent process which is the exact opposite reaction to the same stimulus. Eventually overtime the idea of self-harm does no longer evoke the fear response, it evokes feelings of pleasure or calm.

 

Anorexia nervosa is a good example of how habituation works

There is a high rate of suicide in AN (a study looked at 240 women. 9 died of suicide. This is very high). This is because they have already been through a process of habituation and are likely to use incredibly lethal means because they are habituated thr

 

Different channels for habituation: Numbing of the body sensations in young children who are neglected. Physical abuse early in life leaves people with a high level of tolerance for physical pain but little tolerance for psychological pain.

 

It is important to decouple biological death and lethal self injury from the suicidal risk. A ‘slow graceful swan dive into nothingness’ is NOT the same as jumping off a cliff. Suicidal people are not thinking about the actuality of what they are doing. A realistic description awakens the fear response.

 

Societal and cultural expectations and in some countries (US) legal statues which almost state that a counsellor must  stop a suicidal person from killing themselves as if we have that innate capacity.  It works its way up into the legislative and complaint process. In fact, we don’t have that capacity to stop people from killing themselves. We should stop being anxious about that and stop buying into this fantasy. 7% of all suicides occur in psychiatric hospitals under increased surveillance.

 

“Perhaps what makes all of this so complicated is the fact that unlike medicine, surgery or dentistry the mental health clinician is the instrument of care – there is no equipment failure, no pathogen, no virus to otherwise blame. We are the instrument of care; it does not get any more personal than that” (Jobes, 2011)

This impacts on how we feel towards the patient and the therapeutic relationship, which is the most precious thing we have.

 

Israel Orbach – “Therapeutic empathy with the suicidal wish”.

Two elements are always required when we work with the suicidal person. It is important both to empathise with the suicidal wish and at the same time to confront the self-destructiveness and state that biological death is not a solution to life’s problem.

 

 

Outdated model of working with suicidal people was reductionistic. Suicide was seen as symptom of depression involved but this is an insufficient explanation.. The clinician was seen as the ‘expert’ and in a one-up position. Inpatient hospitalization, treating the psychiatric disorder and using of ‘no-suicide’ contracts.

 

There is no evidence that inpatient stays are in and of themselves effective treatment for suicidality. In fact they become risk factors. In fact people are more suicidal when they come out of hospital. The group in society most likely to die by suicide are those who have just left psychiatric hospital. 3 out of 100 will kill themselves. The general population is 15 out of 100.000

There is a belief going around that we can stop people from killing

 

Using the CAMS (Collaborative Assessment and Management of Suicidality) model authored by prof. David Jobes

This is an overall process of clinical assessment, treatment planning and management of suicidal risk with suicidal outpatients.

 

Key component

-       clinical assessment of risk

-       treatment planning around what is most relevant to a person with suicidality.

-       management of suicidal risk

-       advocates a collaborative stance: sitting side by side and putting suicide on the table

-       suicide status form: pain, stress, agitation, hopelessness, self hate

-       identifying reasons for living vs reasons for dying.

-       intensive outpatient care that is suicide specific

-       developing other means of coping and problem solving

-       systematically eliminating the need for suicidal coping

 

Risk assessment:

-       Individual rating their own risk of suicide. We are really bad at guessing where the individual think they are

-       Crisis response plan

-       Separate risk assessment from predition. Risk assessment is NOT prediction.  We are terrible at predicting suicide. It’s such a rare behaviour that it’s very hard to predict even with people who are in a high risk category

-       How invested are they in the plan? What is the intent? Have they got access to means?

-       A risk assessment is simply a best guess – current and static risk factors

-       Clinician’s ‘gut’ intuition needs to be contextualised

-       Risk assessment will dictate the type of treatment and the frequency of contact

-       Most designated high risk are unlikely to kill themselves! (3 out of 100 of those who just come out of psychiatric hosp will kill themselves, but WHICH 3? That is impossible to predict) Many who kill themselves are designated low risk. It’s extremely difficult behaviour to predict.

-       We can’t make people divulge what is going on internally!

-       We shouldn’t be too hard on ourselves if we get it wrong.

When should hospitalisation be considered

   - extremely high risk of suicide

-       is the person at clear and imminent danger of risk

-       person is unwilling to work collaboratively and work at resolving problems and putting suicide behaviour ‘off the table’

When are we negligent?

-       If there is clear and imminent danger by death and we do nothing to try and avert this, that is negligent

****This article was published in Psychotherapy in Private Practice, 13 (1), 69-95****The Psychotherapy in Private Practice Journal is available online at: http://www.informaworld.com.

Read the full article here 

Psychologists have paid very little attention to the effect their profession has on themselves and have consistently avoided examining its effects on their families. This paper explores the question: Are psychotherapists' families disadvantaged, or are they fortunate to have a therapist-parent who is an authority in the emotional, cognitive, and behavioral domains? Related areas that are explored are the uniqueness of psychotherapists' personalities and the effect of their practice on their personal lives. The paper focuses on the ramifications of the psychotherapists' practice on their own lives and their families', and proposes possibilities for enhancing the positive and preventing the negative effects of their careers on themselves and their intimate connections.

Psychologists have studied the effects of a variety of professions on the professions' practitioners. Physicians, career military personnel, corporate executives, political leaders, and artists are among the many who have been analyzed by psychologists. However, psychologists have failed to systematically study the effect practicing psychotherapy has on their own lives. Similarly, psychologists study the effects of every conceivable kind of family dynamic on children. They have studied the children of alcoholics and schizophrenics, disabled infants, and the children of divorce. They have compiled volumes on baby rats, infant gorillas, puppies, and bunnies. Yet they have consistently neglected to inquire into the dynamics of their own families. They have consistently avoided hypothesizing on the impact of being or living with a person who is an expert in the emotional, cognitive, and behavioral domains.

While limited attention has been given to the effect of psychotherapy on the practitioner, even less has been given to its effect on the practitioner's family. Short of a half a dozen anecdotal articles on families of psychotherapists, even fewer clinical reports on family or group therapy, a single empirical study (Goldney, Czechowicz, Bibden, Govan, Miller, & Tottman, 1979), a page or two on analysts' children in books by leading psychologists, such as Kohut (1977), Miller (1981), and Bettelheim (1976), and a thorough and thoughtful, but extremely anti-therapist biased book by Thomas Maeder (1989) titled Children of Psychiatrists and Other Psychotherapists, the field is suspiciously empty.

The resistance to attending to the complexity of psychotherapists' lives is not only reflected in the lack of comprehensive analysis, but also by the American Psychological Association's governing board and membership's reticence to set up a nationally coordinated program to identify and treat distressed psychologists and prevent burnout. Psychologists, psychiatrists, and counselors have been instrumental in the development of employee assistance programs tailored to serve the needs of other distressed or impaired professional employees. In contrast to psychotherapists, the American Medical Association (AMA) and the American Bar Association (ABA) as well as national organizations of dentists, attorneys, nurses, and pharmacists long ago established avenues for distressed professionals who are seeking help (Kilburg, Nathan, & Thoreson, 1986; Laliotis & Grayson, 1985).

The reasons for this lack of attention to the hazards of the profession are open to speculation. Many therapists claim that their professional lives have no bearing on their personal lives. Therapists may possess a prejudicial sense of grandiosity and invulnerability; they may assume they are capable of helping other professionals, but be incapable of recognizing that they themselves need help. Kottler (1987) attributes their resistance to the illusion that psychotherapy is the pure application of "scientifically tested principles and reliable therapeutic interventions" (p. 26). Other psychologists admit their reasons for not studying themselves stem from defensiveness and the professional practice of focusing all investigations on the patients (Farber, 1983).

This paper maps the complexity of the interaction between the practice of psychotherapy and the personal and familial life of the practitioner. It is based on the author's work in individual, couple, and family psychotherapy with psychotherapists and their families, and on a series of workshops conducted with such families regarding the impact of their clinical practice on their own and their families' lives. Participants were representative of all therapeutic disciplines: psychiatrists, clinical psychologists, clinical social workers, and master level trained counselors.

The clinical data gleaned from these subjects is combined with an extensive review of the literature. Together these provide a map to guide in the exploration of this rarely visited wilderland of therapists' family dynamics. This paper identifies the areas of inquiry, separates myths from realities, and critically examines the existing theories and research. In addition, to specify the strengths and weaknesses the profession brings to psychotherapists' families, the paper suggests ways of enhancing the positive and minimizing the negative effects.

The basic question posed by the paper is: Are psychotherapists' families disadvantaged, or are they fortunate to have a therapist-parent who is an authority in the emotional, cognitive, and behavioral domains?

In order to answer this, three further questions must be thoroughly investigated:

Presentation delivered at the Psychologists Protection Society 40th  anniversary Symposium on the 27th of June 2014 by Ian Gilman-Smith

 

The speaker is a psychotherapist and social worker with experience as an expert witness. He is involved in the process of making a decision in the case of someone who lacks legal capacity

Summary: 

-       There is no neat script that can be handed out to assist us in dealing with professional issues around confidentiality

-       There are different issues to a degree depending of context: private practice, organisational work

-       There is a lot of conflicting information about policies

-       The therapeutic relationship is not only with our clients. We don’t work in a vacuum, isolated from the rest of the world.

-       Clients come to therapy because they want to, are referred by GP, family members, have been sent by court order,

-       Working with multi- or inter-disciplinary teams. Liaising with other members of the client’s professional team

-       The backdrop of social-media. The information is shared potentially with the rest of the world.

-       Care program approach was developed to support professionals in communicating with each-other (Baby P. was seen by 51 professionals, sex abuse scandals involving celebrities

 

-       A mantra that professionals refer to is “sessions are confidential

-       Do we know what we mean when we use the word ‘confidential’? Sometimes we don’t.

-       Clients agree to proceed as if statements about confidentiality are the small print on a mortgage contract

-       Our intentions are to form a trusting relationship in which they can disclose and find relief from the issues that bring them to therapy

-       Are we merely using the term to reassure ourselves and our clients

 

From a legal perspective confidentiality is highly complex. Legal documents include

-       Freedom of Information Act

-       Human Rights Act

-       Mental Capacity Act

-       Access to Medical Reports Act

-       Terrorism Act

 

In our adversarial legal system barristers are not necessarily on the therapist's side. They are highly skilled at understanding the nuances of these different documents.

 

There is a common law duty to confidentiality

-       patient information should only be disclosed with the patient’s consent.

 

What is it to be reasonable in how we practice

-       they judge professionals by the standards of other professionals

-       are your actions accepted as common practice?

-       Would your peers do the same? On what grounds do you make that judgement?

 

-       the omission to do something which a prudent and reasonable man would do

-       clear reporting of risk and risk management

 

-       English law does not recognise privilege just because a document is considered confidential by a party of another

-       Information that could incriminate a third party, diplomatic papers – nothing else is

-       Documents cannot be made privileged by simply attaching a label

-       One of the roles of the therapist is to hold and make sense of complex information

-       Taking the pre-emptive view that we need to be informed about confidentiality and not to do so would be negligent.

-       Looking at worse-case scenarios because they help us bring into sharp focus the issues around confidentiality.

-        

Are we exempt from meddling  if we work in private practice

-       court order to give written evidence as to the course of therapy in county courts, criminal courts, coroner’s courts

-       such requests are legally enforceable and they can be enforced by being fined or sent to prison in contempt of court

 

Thresholds to confidentiality

-       risk-assessment: risk is so easily overlooked.

-       Consider a number of domains of risk: not just risk to self or others in broader terms: intentional self harm, unintentional self-harm, risk from others, risk of exploitation from others or society, risk to others, ability to survive (resources and living skills), psychological risk (thinking feeling and behaviour), social risk (problems with activities or in relationship with other people).

-       Can public good be achieved by disclosing the risks identified. If there a risk to life of limb – that decision is easier to make

-       Client disclosing something of concern such as ‘I can’t go on anymore’

 

   -  if you identify risk but decide not to contact next of   kin, GP, emergency services then reason:  What did I think of that information? What allowed you to make an informed decision? What was your thinking? Was this the action that would have been taken on the reasonable therapist?

-  struck by the sweeping generalisations that therapists make about their clients i.e.: he drinks “far too much”

- clear documented process helps account for our actions in a courtroom setting

- written records do not need to be voluminous but need to be thorough

- fact finding: the judge wants to know the facts of the case: client presentation, level of risk, historical account, your professional views

- professionals becoming incompetent or highly hostile in court, contradicting themselves

- the private practitioner is far more vulnerable:

- responsibility for: managing the issues of confidentiality pre, during and post therapy

- responsibility for being professional CPD, supervision DBS check, indemnity, CPD, registration with the ICO.

 

Any risk identified needs to be made explicit in the therapy session

-       supporting the client in  managing risk themselves

-       contacting another agency

-       using the resource of the therapy encounter

-       what if the client does not support you in contacting the GP

-        implications of breaking confidentiality: risk not to uphold the right human rights, risk damaging the therapeutic therapy, right to privacy

-       implications of not breaking confidentiality may have severe consequences: fail to protect the rights and freedom of others, minimising harm to vulnerable adults and children

-       it is clinician’s responsibility to report abuse of vulnerable adults or children. What is “vulnerable person” (is or may be in need of community services, unable to take care or protect himself against significant harm or exploitation, mental disorder, age)

 

-       Clinicians with widely different views: ‘destroy notes’, or ‘keep no notes’, ‘record everything’, ‘write report as if I was going to be cross-examined’

-       Whatever confidentiality goes beyond one’s mind can be requested

-       It’s your judgement call how you record and account

-       Notes should be accurate, secure, processed in line with client’s rights, kept no longer than necessary

-       Complaints can be made within 5 years since the alleged incident. Claims of negligence can be made within 6 years since the alleged incident

-       Registering with ICO. Information governance if we keep reports on our computers.

James Rye 

People want a professional service that is easy to access and packaged for them. 

Mistakes I’ve made and learned from. 

- Profit equals income minus expenditure.

- I was a naïve amateur with dysfunctional beliefs about private practice

 

Dysfunctional beliefs

- money is dirty: no, money is important

- there is difficulty in charging for help but solicitors and doctors charge for help

- it’s OK to charge for help

- some people believe aspects of private practice is beneath them (advertising, charging, doing the accounts)

 

Marketing sharks

-       supermarket cards

-       voucher schemes

-       hospital/surgery cards

-       advertorial in the police service, local fire-station, hospital magazine (don’t pay as policemen can get therapy for free)

 

Make it easy for people to work with you

-       We need to advertise : directories, web-page

-       Multiple contact methods: webform in googledocs.

-       Handling calls professionally – virtual assistant: diverting the phone

-       Payment: buying a £50 card reader

-       Paypal link if working online

-       Avoiding the numbers: not logging all expenditure (e.g. mileage)

 

Unrealistic charging:

-       balancing what we’re worth, what it cost us to train, what local people charge, what is moral

-       If we are keeping people out of the welfare system, out of secondary care we are saving people a lot of money so charge.

-       Don’t subsidise people by paying for their therapy

 

-       too many counsellors/psychologists delivering the same thing

-       why are you different/unique

-       what are you going to offer and are you the person to deliver it

-       what do clients want?

-       only 30% of his clients come from self-referral, agency referrals or EAP’s (55%)

-       Other sources of income: internet/phone, supervision, couple counselling, CBT, training, consultancy

-       How can you specialise: either in the content or the method of delivery. Be different in some way!

-       It is a mistake to not see the landscape.

-       There is a whole industry training people to see clients for a long time which is costly and people have limited resources

 

Seeing the landscape: reaching people through technology

-       What seems unusual now fifty years from now will be the norm

-       Accepting that online/telephone counselling is different

-       Delivery method: technology is happening whether we like it or not. Be weary of conservatism and judgements against new methods of delivery. Having to learn about new methods although. We can reach clients who we couldn’t reach otherwise (disabled, living abroad, suffering from agoraphobia)

 

Risk Naivety

-       house insurance companies will see more risk if you're working from home

-       personal safety (buddy system, not leaving key, emergency services on speed-dial, panic button)

-       people cross boundaries: higher proportions of complaints come from private practice and most of them are about boundary crossing.

-       Business boundaries: life/work balance is difficult to keep if working from home. Most people want to come in the evening, after 5pm. The danger is to take anyone at any time of day or night.

 

Link resources

"Psychology is evolving faster than ever. For decades now, many areas in psychology have relied on what academics call “questionable research practices” – a comfortable euphemism for types of malpractice that distort science but which fall short of the blackest of frauds, fabricating data.

But now a new generation of psychologists is fed up with this game. Questionable research practices aren’t just being seen as questionable – they are being increasingly recognised for what they are: soft fraud." 

(Extract from Chris Chambers' blog post "Physics envy: Do hard sciences hold the solution to replication crisis in Psychology?"

Steve Cole, Phd one of the pioneer researchers in the new field of psycho-immunology, delivers the Meng Wu Lecture at CCARE Stamford University. Watch it here.

How we interact, how we connect has a tremendous influence on how our genes are expressed.  Traditionally we saw ethics, morality and the world of tangible, molecular biology of cells as very different worlds/domains. We are starting to see the shadow of each domain playing out in the other.

 

The genome isn’t expressing all its 20.000 genes at the same time. There is a lot of decision about which genes get expressed. The change of the activity of genes within our white blood cell is linked to

protracted, extended situations:

From a study by Irwin and Comle, Nature Reviews, Immunology, 2011

One of the major ways in which these experiences play on the genome is through the fight-flight stress response activated by the sympathetic nervous system, with the release of adrenaline (epinephrine) and noradrenaline (norepinephrine). Noradrenaline is released in the vicinity of a cell. Through its nteraction with receptors (ADRB2) on the surface of the cell the result is a pumped-up activity of genes involved in the expression of pro-inflamatory immune response genes and a stomping down of the activity of other genes (antiviral immune response genes).  

Through exposure to really overwhelming stress a second response kicks in – a defeat/withdrawal response, where your system shuts down, you are overwhelmed and your body hunkers down and just tries to survive. That response is mediated by a second hormonal pathway - the HPA (Hypothalamus - Pituitary - Adrenal). The hypothalamus tells your adrenal glands to produce more cortisol, which has a different impact on gene expression – it lowers the expression of antiviral immune response genes and lowers the expression of pro-inflammatory immune response genes.

 

Different experiences of the same event – either as a challenge that can be overcome or as something profoundly overwhelming is going to have different effects on my genome, it will evoke different kinds of biological response.

Studies by Cole et al. Proc Nat Acad of Sci USA, 2011 and Powell et al. Proc Nat Acad of Sci, USA, 2013

Our bodies are extremely dynamic at a cellular or molecular level. The average protein in the human body has a half-life of eighty days so that every single day we have to replace 1 – 2% of the proteins in our body and that process is open to ‘advice’ from the world outside the body, including the world that psychology creates in my mind. 

Gene expression can also catalyse the production of new cells (monocytes and dendritic cells which don’t live very long). This process is also orchestrated by changes in gene expression that are susceptible to regulation by the nervous system. In people who are confronting uncertain environments, the brain interprets those environments as threatening and activates these fight-and-fight responses. 

Norepinephrine signalling is delivered into the bone marrow in a form of a ‘piece of advice’ to the stem cell which says 'produce more myeloid cells: monocytes, granulocytes, dendritic cells'. As a consequence of that we have more of these cells going out into the body and circulating. For most of our development that made good sense but if there is nothing for those cells to respond to - because there is no physical injury and hence no bacterial infections. These cells are programmed to find trouble and do something about it. Some of the trouble they find might be the early stages of proliferation of cancer or damage to the wall of our blood vessels or minor damage in brain cells, all of which attracts these charged, primed immune cells. As these cells attempt to repair tissue damage but can inadvertently contribute to the sort of disease that nowadays are the true architects of our longevity . We no longer die of infectious disease, we now die of heart disease, cancer and neuro-degenerative diseases.

(Sloan et al. 2010 Cancer Research – done on a mouse injected with cancer cells and then confined to a small space – a stress inducing situation)

When animals have too many of these charged up monocytes in their body during the early stages of tumour-development they get many more cancer cells escaping from the initial tumour site and spreading out (metastasising). This is mediated by those immune cells, which having gone into the tumour to kill the microbes and repair damaged tissue. They liquify tissue so that the cancer cells can grow out, they help grow blood vessels into the tumour thus feeding it and suppress the rest of the immune system’s response to the growing cancer.

 

We used to think of the brain and the immune system as separate it turns out that what is going on in the world has some association with what goes on in our body at a microbial level. Over millions of years our immune system has learned to listen to the chatter from the brain and if it hears indications that you are feeling substantially threatened it gets ready to deal wit tissue damage, whether tissue damage is happening or not and inadvertently it fertilisers diseases and becomes the architect of a host of problems.

-       Central nervous system: inflammation and neuro-degenerative disease

-       Vasculature: artherosclerosis

-       Lungs: URI, asthma

-       Lymphoid tissue: neoinnervation, HIV/SIV

-       Solid tumor in the breast, ovaries: metastasis

 

That is why so many different types of adversity (isolation, low SES, social threat, bereavement) seem to draw out disease. There are many different ways that humans have learned to feel threatened and stressed.

There are two different ways to run our bodies which correspond to two social genomic programs in immune cells. One operates in a world in which we are attached and safe, connected. In this the big threats that we confront are the diseases that travel from one to another (viruses). A separate modus operandi takes place in the context in which we are separated from our community or feel threatened within our community, which up-regulates these inflammatory genes which produce monocytes, geared to fight bacteria (in anticipation of tissue damage). It doesn’t help us as well because it fertilises chronic diseases.  

 

What is the secret to making people feel genuinely safe? (Frederickson et al., PNAS, 2013) How should we live? What is the best way to thrive in human life? What is the nature of true happiness. Hedonic happiness: consuming happy experiences (Epicur). Eudaimonic happiness: satisfaction that derives from a deeper sense of making a contribution to a purpose or a group outside ourselves, a community, a cause, creation, discovery. It turns out that either eudaimonic or hedonic pursuits are correlated to low levels of depression, but when researchers asked the genome, eudaimonic happiness is correlated with healthy immune profiles whereas hedonic happiness is not.