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Developing a Mentalization-Based Treatment (MBT) for Therapeutic Intervention with Couples (MBT-CT)
No full textThis paper outlines the organisation of a new project that aims to develop a model for adapting mentalization-based treatment (MBT) for therapeutic work with couples (MBT-CT), where one or both partners present with personality problems which may be contributing to their relationship difficulties. Describing how the Tavistock Centre for Couple Relationships (TCCR) has developed this project and how a therapeutic model is beginning to emerge from the work, the paper focuses on the rationale and specifics of getting the project off the ground and some of the emerging clinical issues. It does not include clinical illustrations
UK and Irish surveillance study of gender identity disorder (GID) in children and adolescents
No full textPurpose:
The incidence of childhood/adolescent Gender Identity
Disorder (GID) is unknown. GID is an important condition where
gender identity differs from biological sex. It is associated with
significant distress, particularly with puberty, with much controversy
internationally over the optimal timing of hormonal treatment. We
examine the incidence and clinical presentation in UK and Irish
children and adolescents.
Methods:
STUDY POPULATION: Children and adolescents aged
4-15.9 years in the UK and Republic of Ireland. DESIGN: Joint British
Paediatric Surveillance Unit (BPSU) and Child and Adolescent Psychiatry Surveillance System (CAPSS) study. New cases of GID reported by clinicians over a 19-month reporting period (01-Nov-2011
to 01-June-2013) are validated against the authoritative DSM-IV-TR
(2000). Exclusions include disorders of sexual differentiation and
major psychosis. PRIMARY OUTCOME: Incidence of childhood/
adolescent GID, calculated by dividing the number of validated cases
by the base population of children and adolescents aged 4-15.9 years.
Sources of denominator data: UK Office of National Statistics and the
Central Statistics Office in Ireland. STATISTICAL ANALYSIS:
Descriptive statistics and comparisons using two-sample t-tests or Mann-
Whitney U tests for continuous data and Chi-squared or Fisher’sexact tests
for categorical data.
Results:
Preliminary descriptive data from the first 15 months’sur-veillance (n¼
138 cases, 69 males) indicate that similar numbers of
males and females are affected by this condition. Early estimates
suggest UK and Irish incidences of 1:80,000 and <
1:200,000 respectively. There is a lag of several years between median [inter-
quartile range] onset of symptoms (7y [4-12y]) and presentation to
Paediatricians or Psychiatrists (14.5y [11.9-15.2y]), with most cases
presenting at 14 or 15 years. Only a quarter of all cases (n¼35) were
less than 12 years old at reporting, but 50% of cases reported by
Paediatricians. There are high levels of psychiatric co-morbidity at pre-
sentation, with at least one other mental health diagnosis in 45%, and
two or more other diagnoses in adolescents aged 12 years and over.
Conclusions: We present the first ever population-level data on
the incidence, clinical features and presentation of childhood/
adolescent GID. These data will inform clinical management,
including the highly controversial debate around early pubertal
suppression in this group
The negotiation of blame in family therapy with families affected by psychosis
No full textDespite wide agreement in the systemic field that therapists should take a non-blaming stance, historically there has been little exploration of how this stance is achieved in practice. The difficulty in knowing how to put ‘non-blaming’ into practice is further heightened by competing models of intervention with families affected by psychosis. This study contributes to a body of literature that is concerned with how complex issues of morality are achieved dialogically by considering how family therapists manage the tension of intervening to promote change whilst maintaining a multi-partial, non-blaming stance.
Two therapies carried out with families affected by psychosis are analysed using the methods of Conversation Analysis (CA) and Membership Categorization Analysis (MCA). In both therapies the sequences examined are drawn from the second session of therapy where explicit blaming events occur. By examining blaming events chronologically through the course of a session the study shows how the rules about the way blame is talked about are achieved interactionally.
The analysis demonstrates that systemic theory’s emphasis on the importance of being non-blaming is grounded in a sophisticated understanding of the threat blame poses to co-operation and agreement. In both therapies, the delicacy and ambiguity with which blame is treated serves to enable the conversation to continue without withdrawal. However the cost of ambiguity is a possible misunderstanding of the intent of the speaker. The resulting misalignment, where it continues over several turns and sequences, leads to explicit blame becoming relevant as a solution to a redundant pattern of interaction.
The findings indicate that the management of blame requires both the exploration of blame and its interruption when emotions and conflict run high. The former enables understanding and movement towards therapeutic goals while the latter is necessary to promote therapeutic and family alliances. An unintended consequence of the injunction to be non- blaming might be the premature closing down of topics, militating against problem resolution.
The study concludes that CA and MCA offer a wealth of knowledge about mundane conversational practices that can be applied fruitfully to systemic therapy process research, teaching and supervision
Behind closed doors: A grounded theory of the social processes that describe how parents talk to their children about parental mental health difficulties
No full textSince the government commissioned the Crossing Bridges programme in 1998 (Falcov, 1998) and through legislation and a number of government policies and initiatives since, there has been emphasis on addressing the needs of families where there are parental mental health problems. Furthermore, there is a fast-growing body of research pointing to the needs of these families. However, service structures, development and provision have lagged behind. Most often parents with mental health difficulties have access to services addressing their individual mental health needs while their needs as parents and the needs of their children remain largely invisible. One such need that has been highlighted repeatedly in the literature is the need for children to have information about and make sense of their parent’s mental health difficulties. Given the lack of services to respond to this need, it is most often left to the parent to make decisions about and respond to their child’s search for understanding.
This study is a qualitative study that explores parents’ experiences of decision-making and responding to this need, and the social processes and dominant discourses that impact on these experiences. Fifteen parents with mental health difficulties were interviewed, using semi-structured individual interviews, which were transcribed, and interpretive Grounded Theory was employed to analyse and interpret the data.
The grounded theory that was constructed suggest two main social processes that impact on parents’ talking with their children about parental mental health issues. Firstly, within a relational context, parents were Negotiating mutuality between themselves and their children. Secondly, within an identity context, parents had to navigate Holding on to self, holding on to life. These social processes indicate that both parents’ relationships with their children and also their own sense of themselves within the context of their mental distress powerfully shape telling, talking and keeping silent. Implications of these findings both in relation to clinical interventions and future research are considered. In particular, the importance of positioning the parent as active role-player in the healing of their child, and positioning the child as active role-payer in their own meaning-making, are highlighted. Furthermore, developing ‘double-stories’ beyond the mental health story and beyond ‘information’ is emphasised and the importance of a sense of continuity of self and identity over time for parent and child is accentuated. Finally, the importance of allowing for complex and ever-evolving understandings of mental distress is indicated, and the role of both talking and remaining silent in this process is stressed
Family therapists’ experiences of working with adolescents who self-harm and their families: A grounded theory study
No full textThis study is a qualitative enquiry into family therapists’ experiences of working with young people who self-harm and their families. To date, in spite of self-harm being a serious public health concern, there is relatively little exploration of the subject in family therapy literature. The study attempts to describe, understand and illuminate family therapists’ experiences: the therapeutic issues encountered, the stances adopted in response to the issues encountered, and the emotional impact on the therapist of working with this client group.
A total of nine experienced family therapists participated in semi-structured interviews. The study employed a grounded theory method for data analysis. The analysis yielded a theory of therapists’ experiences that included a Core Category and three Main Categories.
The Core Category that emerged was:
•Cultivating the Practice of Hope – Withstanding the Pull to Hopelessness.
The three Main Categories were:
•Making the Situation Safe
•Conversing Therapeutically – The Practice of Hope
•Team and Organisational Processes: Supporting Therapists.
The Core Category is the central feature of this theory. It proposes that the central concern for the therapist is how to stay engaged with the family and the young person in the context of serious risk of self-harm and in situations where change is difficult to achieve and hopelessness can pervade. The therapist has to try to understand and make sense of family members’ distress, and be touched by and open to their feelings of despair and hopelessness without becoming overwhelmed and despairing themselves. The therapist response to this dilemma is the stance of hopefulness. It is both a therapeutic stance and orientation, and is enacted in practice through finding ways to cultivate hope in the therapeutic encounter.
While the Core Category is the central ‘story’ the three Main Categories are linked to the Core Category.
The Main Category, Making the Situation Safe describes the initial stage of the work, with its focus on ensuring the safety of the young person.
The Main Category, Conversing Therapeutically – the Practice of Hope describes how the therapists enacted the ‘practice of hope’.
The Main Category, Team and Organisational Processes: Supporting Therapists describes how the context in which the therapists work, the nature of relationships, the team and organisational structures, play a critical role in supporting therapist hope, so that they can withstand the pull to hopelessness.
This study aims to make a contribution towards articulating a framework for family therapy with adolescents who self-harm and introduces a new vocabulary – the language of hope and hopelessness
Paraphilias and paraphilic disorders: Diagnosis, assessment and management
No full textWe outline the difficulties in classifying paraphilias as mental disorder and summarise the changes to this diagnostic category in DSM-5. We review the research on the epidemiology and aetiology of paraphilias, and provide guidance on assessment and referral options for general psychiatrists when they encounter patients who may meet diagnostic criteria for a paraphilic disorder. Empirical evidence for effective treatments for paraphilias is limited, and specific treatment services are scarce, particularly for individuals presenting with legal paraphilias or those who are committing paraphilic sexual offences but who have not been convicted
Meeting the challenge, making a difference: Working effectively to support people with personality disorder in the community
No full textThe purpose of this guide is:
To know more and to understand more about personality disorder, and how this impacts on individuals who may attract this diagnosis, and the staff, teams and organisations which may work with them.
To invite people to think about their own attitudes to working with people with personality disorder.
To provide some information about services that might be available, how to access help for people with personality disorders, and what can be expected from services.
To offer guidance on helpful and unhelpful ways of responding to people with personality disorders
