Looking at the latest epidemiological data, it could be argued that we are in the midst of a pandemic of mental illness, of dimensions never before seen in human history. The WHO estimates that over 350 million people around the world are presently suffering from depression, which constitutes almost 5-6 per cent of the population. At its extreme, depression may lead to suicide, by which it is estimated that around 1 million people die every year. And the numbers continue growing. Faced with this rising tide of illness, it is impossible to overestimate the importance of hard facts and data indicating the paths researchers and clinicians may follow in search of ways to help. Sometimes, as suggested by a meta-analysis of 50 years of studies on indicators that help predict suicide attempts, we are entirely helpless. In other cases, like with the recent meta-analysis of the neural correlates of the changes brought about by psychotherapy in depressed brains, study results do bring us hope.
The results of the first systematic review and meta-analysis of biological markers evaluated in randomized trials of psychological treatments for depression in Neuroscience and Biobehavioral Reviews are another attempt at understanding methods of treating this terrifying illness. The authors – Ioana A. Cristea, Eirini Karyotaki, Steven D. Hollon, Pim Cuijpers and Claudio Gentili – quite rightly point out that understanding how psychological interventions impact or are impacted by biological variables has important implications. For many people, their depression co-occurs with a bodily illness, such as cancer, diabetes, heart disease, and immune system and neurological disorders, and at times is a consequence of that illness. Although we still know little about the reciprocal cause-and-effect mechanisms between psychic and somatic symptoms, some studies have suggested that psychological interventions not only change mood, but also normalise the functioning of the autonomic nervous system, with a therapeutic effect on physical conditions, such as heart disease. But is this really true?
In the first study of its kind, researchers have asked people to describe in their own words what it’s like to live with Avoidant Personality Disorder (AVPD) – a diagnosis defined by psychiatrists as “a pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation”. Like all personality disorder diagnoses, AVPD is controversial, with some critics questioning whether it is anything other than an extreme form of social phobia.
To shed new light on the issue, lead author Kristine D. Sørensen, a psychologist, twice interviewed 15 people receiving outpatient treatment for AVPD: 9 women, 6 men, with an average age of 33, and none of them in work. Writing in the Journal of Clinical Psychology, Sørensen and her colleagues said the overarching theme to emerge from the in-depth interviews was the participants’ struggle to be a person. “They felt safe when alone yet lost in their aloneness,” the researchers said. They “longed to connect with others yet feared to get close.” In the researchers’ opinion, the participants’ profound difficulties with their “core self” and in their dealings with others do indeed correspond to “a personality disorder diagnosis”.
With the number of referrals to the UK’s only gender identity development service (GIDS, at the Tavistock and Portman NHS Trust) increasing sharply in recent years – a pattern seemingly mirrored in other European countries and the US (anecdotally, at least — many countries don’t keep comprehensive data the way the UK does) – debate has inevitably intensified over how best to help transgender and gender nonconforming (TGNC) youth. As some expert clinicians have pointed out, there has been a tendency for commentators, campaigners and the general public to adopt an oversimplified view in which therapists are seen as fitting one of two categories: those who don’t believe their clients when they say they are trans (and who are therefore condemned by trans advocacy groups for practicing conversion therapy), and others who simply accept their clients’ statements about their gender, and who are therefore affirming or affirmative.
The clinical reality is more complicated: these days, there is a welcome consensus against actual conversion therapy — forcing a young person to “go back” to being cisgender — but at the same time responsible clinicians do not simply nod along to what a young person with gender dysphoria says. There are complexities inherent to childhood and adolescent development, and many experts warn it’s important not to accidentally medicalise perfectly normal qualms about growing up, hitting puberty, and being exposed to powerful and often frustratingly restrictive gender roles. Young people present at gender clinics with a wide variety of issues ranging from comorbid mental-health issues to unexamined trauma, and the process of helping them determine the best path forward, particularly with regard to medical interventions like puberty blockers or cross-sex hormones, is a lot more complicated than making a rapid decision to deny or approve such interventions.
Indeed, in an open-access practice review published in the BMJ last year, clinicians at UCL, GIDS and Great Ormond Street Hospital explained that the thorough psychosexual assessment period for such clients “usually takes 6 months or more over a minimum of four to six sessions” and involves a range of psychometric measures and interviews, covering the client’s expectations and understanding of social and physical transition, their mood and emotional functioning. The review adds that, “With the adolescents, there is an in-depth consideration of their sexuality and fertility, and possible preservation approaches are discussed. The attitude of important people in the child’s life towards gender dysphoria needs to be explored and understood.”
Now a study published in Psychology & Sexuality by a pair of Norwegian researchers, Reidar Schei Jessen and Katrina Roen, has explored these complexities from clinical psychologists’ perspective, including what it means to help a young person work through the issues they are facing and to make important decisions about medical treatment.
In recent years, researchers have sought to look under the hood to understand the neural correlates of the changes brought about by psychotherapy. Not only can such understanding help us hone in on the precise processes that are being acted upon in therapy, thus helping us focus on these gains, they could also show where pharmacological interventions might be complementary, and where they could directly obstruct the therapeutic work. Now a systematic review and meta-analysis in Psychiatry Research: Neuroimaging has outlined all we know so far about how therapy changes the depressed brain, and it suggests key changes occur in emotional processing areas.
The structured nature of Cognitive Behavioural Therapy/CBT and its clearly defined principles (based on the links between thoughts, feelings and behaviours) make it relatively easy to train practitioners, to ensure standardised delivery and to measure outcomes. Consequently, CBT has revolutionised mental health care, allowing psychologists to alchemize therapy from an art into a science. For many mental health conditions, there is now considerable evidence that CBT is as, or more, effective than drug treatments. Yet, just like any form of psychotherapy, CBT is not without the risk of unwanted adverse effects.
A recent paper in Cognitive Therapy and Research outlines the nature and prevalence of these unwanted effects, based on structured interviews with 100 CBT-trained psychotherapists. “This is what therapists should know about when informing their patients about the upcoming merits and risks of treatment,” write Marie-Luise Schermuly-Haupt and her colleagues.
Psychotherapists are devoted to improving people’s psychological health, but sometimes their efforts fail. A new qualitative study in Psychotherapy Research delves into what therapists take away from these unsuccessful experiences.
Andrzej Werbart led the Stockholm University research team that focused on eight therapy cases where the clients – all women under the age of 26 – had experienced no improvement, or in three cases, had deteriorated. This was based on comparing their pre- and post-therapy symptom levels following one to two sessions per week of psychoanalytically-focused therapy for about two years, to deal with symptoms such as depressed mood, anxiety, or low self-esteem.
Abraham Maslow was one of the great psychological presences of the twentieth century, and his concept of self-actualisation has entered our vernacular and is addressed in most psychology textbooks. A core concept of humanistic psychology, self-actualisation theory has inspired a range of psychological therapies as well as approaches taken in social work. But a number of myths have crept into our understanding of the theory and the man himself. In a new paper in the Journal of Humanistic Psychology, William Compton of Middle Tennessee State University aims to put the record straight.
How do you choose the best possible therapist for someone who needs help? Does it make any difference if the therapist is about the same age, for instance, or the same gender, or from the same socio-economic background?
It seems intuitive that it might be easier to relate to someone from a similar background. However, while a positive relationship between client and therapist is known to be one of the most important factors for a good treatment outcome, there’s been surprisingly little work on how their respective personal attributes might interact to create a successful alliance.
Now work led by Alex Behn, affiliated to both the Pontifical Catholic University of Chile and the Millennium Institute for Research in Depression and Personality, in Santiago, published in the Journal of Clinical Psychology, attempts to help plug that gap.
Many training programmes for psychotherapists and counsellors include a mandatory personal therapy component – as well as learning about psychotherapeutic theories and techniques, and practising being a therapist, the trainee must also spend time in therapy themselves, in the role of a client. Indeed, the British Psychological Society’s own Division of Counselling Psychology stipulates that Counselling Psychology trainees must undertake 40 hours of personal therapy as part of obtaining their qualification.
What is it like for trainees to complete their own mandatory therapy? A new meta-synthesis in Counselling and Psychotherapy Research is the first to combine all previously published qualitative findings addressing this question. The trainees’ accounts suggest that the practice offers many benefits, but that it also has “hindering effects” that raise “serious ethical considerations”.
Although psychotherapy is effective for many people, it doesn’t help everyone. In fact, in some cases it can do more harm than good. And while clinical researchers publish many studies into the outcomes of different therapeutic approaches, such as CBT or psychoanalytic psychotherapy, we actually know relatively little about the specific therapist behaviours that clients find beneficial or unwelcome.
A new study in the Journal of Clinical Psychology, although it involves only a small sample, has broken new ground by asking clients to provide detailed feedback on a second-by-second basis of their experience of a recent therapy session, and to explain their perspective on what took place. Intriguingly, the very same therapist behaviours were sometimes identified as helpful and at other times as a hindrance, showing just what a challenge it is to be a therapist.
“It is important to recognise that all therapists are going to make mistakes,” write Joshua Swift at Idaho State University, and his colleagues. “Perhaps the success of the session does not depend on whether errors are made but on the frequency of mistakes and how quickly therapists are able to repair them.”