AMERICAN JOURNAL OF PSYCHOTHERAPY最新文献

Psychiatry residency programs in the United States and Canada currently require trainees to demonstrate competency in psychodynamic therapy. Developed by Habib Davanloo, intensive short-term dynamic psychotherapy (ISTDP) is a brief psychodynamic therapy with emerging evidence to support its efficacy as an evidence-based, cost-effective treatment for various common psychiatric disorders and personality pathologies. Davanloo's metapsychology of the unconscious offers a way to understand the psychodynamic processes that maintain patients' psychiatric symptoms. Some key clinical processes unique to ISTDP facilitate conceptualization of patients' problems and allow for effective interventions. ISTDP skills can be especially helpful when working with populations with complex and treatment-resistant conditions that are commonly encountered in psychiatric secondary- and tertiary-care settings. This article aims to examine the value of ISTDP training for psychiatrists. First, the benefits of being able to offer formal treatment with ISTDP are examined. Second, the unique skills acquired through ISTDP training, which can be used in general psychiatric care, are reviewed. Finally, the personal and systemic benefits of ISTDP training, including clinician self-monitoring, management of burnout, and team leadership, are discussed.

Ruptures to the therapeutic alliance are an inevitable part of therapy. The ability to repair these ruptures is an essential therapist skill. Racial, ethnic, and cultural differences between therapists and patients can increase the likelihood of rupture to the therapeutic alliance, potentially leading to unilateral treatment termination by patients. Therapists therefore need skills to work effectively with patients who have diverse, intersectional identities. In this article, the authors give therapists tools to help protect against ruptures and to repair ruptures when they occur by integrating three complementary models: taking a stance of cultural humility to decrease assumptions, identifying and directly broaching cultural topics, and implementing a six-stage cultural repair model. A case example is used to illustrate these tools and techniques in practice. These skills can improve collaboration and decrease the inherent power imbalance in the therapeutic relationship.

More than half of all people with borderline personality disorder will develop alcohol use disorder in their lifetime. These disorders mutually reinforce each other, with a higher risk for treatment failure and poor outcomes, including suicide, yet no widely available treatments have been found to be effective for both diagnoses concurrently, leaving patients and clinicians alike stranded between two clinical domains that rarely overlap despite shared features. In the absence of alternatives, good psychiatric management (GPM) capitalizes on standard-of-care interventions using generic clinical tools that do not require specialization. In an effort to broaden and stabilize the social networks of connections for patients with interpersonal hypersensitivity, GPM relies on a multimodal approach that combines the indicated pharmacological and psychosocial interventions for the treatment of alcohol use disorder with a common-factors approach for borderline personality disorder. This multimodal approach emphasizes psychoeducation, social rehabilitation, management of suicidality, and active management of these frequently comorbid conditions. In this article, the authors describe GPM's strategy of stabilizing and broadening the patient's social network to target the core interpersonal and stress hypersensitivity. To do this, clinicians can use interventions for significant others combined with empirically supported and widely available mutual-help groups, such as Alcoholics Anonymous, that structure and regulate relational instabilities with community norms, standards, roles, and procedures. GPM also promotes family interventions for both conditions to reduce conflict and increase support within existing relationships, thereby strengthening patients' capacity to work on their sobriety and borderline personality disorder by mitigating aloneness and its effects.

Borderline personality disorder has been estimated to occur among about 4% of those with autism spectrum disorder. This co-occurrence can escalate the challenges of treating either condition separately, and patients often face severe challenges in psychosocial and occupational functioning. Clinicians need guidance to manage a high degree of complexity, using standards of care and a synthesis of what is known so far, to navigate the currently limited armamentarium of clinical tools. This article reviews the available scientific research and clinical experience with respect to diagnosis, psychoeducation, treatment framework, safety management, other co-occurring disorders, and multimodal treatments. It also discusses future directions for generating new knowledge to improve the care of patients with this important co-occurrence. Although the discussion explores the unique complexity and relative lack of clinical guidelines at present, good psychiatric management serves as a clinical framework that anchors treatment approaches as the evidence base develops.

Over the past 50 years, intensive short-term dynamic psychotherapy (ISTDP) has been developed, implemented, and evaluated with respect to the treatment of a broad spectrum of complex, chronic, and treatment-resistant conditions. This therapy was developed specifically to treat a range of patients, including those who are highly defensive, those who experience the repression of emotions, and those who have cognitive-perceptual disruptions along with primitive defenses. These three groups of patients are characterized by patterns of attachment trauma and deficits related to neglect. Among the many categories of mental illness with these features that ISTDP can treat, personality disorders, treatment-resistant depression, and somatic symptoms have been the most frequently studied. In this article, the authors provide an overview of the ISTDP treatment method with regard to complex, chronic, and treatment-resistant conditions and summarize evidence for its effectiveness for diverse patient populations. On the basis of the available evidence, ISTDP warrants consideration as a tool for the management of diverse populations who have chronic and complex conditions and have not responded to other treatments.

Objective: Pharmacotherapy outcomes may be influenced as much by psychosocial factors as by medication. Comprehensive discussion of such factors may contribute to better patient outcomes and may counter aspects of a curriculum that prioritizes efficiency and that has the potential to undermine clinician empathy. This pilot study aimed to explore the benefits of teaching psychosocial aspects of prescribing and student acceptance of such teaching.

Methods: First-year medical students (N=22) at Quinnipiac University were surveyed after completing an online module explaining psychosocial principles of pharmacology and participating in role-plays.

Results: Nineteen participants (86%) strongly agreed that how they prescribe was as important as what they prescribe, and 17 participants (77%) strongly agreed that they would benefit from additional education.

Conclusions: An interactive activity can enhance first-year medical students' interest in and knowledge of the impact of integrating psychosocial factors into medical education on treatment adherence.

Objective: Despite the efficacy of current therapies, a significant proportion of patients with schizophrenia, a complex mental disorder marked by both positive (present) and negative (absent) symptoms, are considered to have treatment-resistant schizophrenia. Avatar therapy (AT) allows patients to interact with a three-dimensional representation of their most distressing voices in a virtual reality setting. The therapy shows promise in reducing impairments and improving quality of life through the establishment of a therapeutic alliance and the exploration of dyadic interactions (verbal exchanges) between patients and their avatar. The purpose of this study was to investigate differences in dyadic interactions throughout the immersive sessions of AT and to clarify the relationship between these interactions and therapeutic success by analyzing dyads as predictive indicators of positive outcomes in AT.

Method: Mean frequencies for the 10 most prevalent dyads identified in previous AT research were reported for 35 patients. A logistic regression model was implemented, and these dyads were used to predict variances in Psychotic Symptom Rating Scales-auditory hallucination scores 1 month after the completion of AT.

Results: Variances in mean frequencies were reported for the dyads. A positive relation between the avatar (provocation)-patient (self-affirmation) dyad and the therapeutic outcome was found to be significant (OR=2.29, p=0.049).

Conclusion: This research is pioneering in its in-depth examination of therapeutic interactions in AT, with a particular focus on dyadic interactions. Future studies should prioritize the quality rather than quantity of these interactions to more accurately forecast their effects on potential indicators of positive outcomes in AT.

Spiritual and religious experiences in the context of borderline personality disorder are underexplored by both researchers and clinicians, are central in the lived experience of some patients, and are likely to interact in complex ways with core symptoms and challenges. Effective navigation of this domain by clinicians and patients may require increasing, decreasing, or stabilizing engagement with spiritual and religious beliefs, practices, or communities, depending on the person. No empirically derived guidelines exist for how clinicians can address this area to help patients maximize benefits while minimizing harms. The author summarizes what is known about spirituality and religiosity in borderline personality disorder and draws on evidence-based theory and techniques from good psychiatric management to develop a preliminary phenomenology of spiritual connectedness amid interpersonal hypersensitivity and tentative guidelines for effectively addressing this domain.