Managing Transference and Countertransference in Cognitive Behavioral Supervision: Theoretical Framework and Clinical Application.

Dysfunctional patterns, beliefs, and assumptions that affect a patient's perception of other people often affect their perceptions and behaviours towards the therapist. This tendency has been traditionally called transference for its psychoanalytical roots and presents an important factor to monitor and process. In supervision, it is important to put the patient's transference in the context of the conceptualization of the case. Countertransference occurs when the therapist responds complementary to the patient's transference based on their own dysfunctional beliefs or assumptions. Transference and countertransference provide useful insights into the inner world of the patient, therapist, and supervisor. Guided discovery is one of the most common approaches used by a supervisor and a supervisee to map all types and directions of transference and countertransference. Other options to map transference and countertransference are imagery and role-playing techniques.

Schema Therapy for Patients with Bipolar Disorder: Theoretical Framework and Application.

Bipolar disorder (BD) is a severe mood disorder characterized by episodes of depression and hypomania or mania. Despite its primarily biological roots, the onset and course of the disorder have also been related to psychosocial factors such as early adverse experiences and related maladaptive schemas. Several researchers proposed a schema therapeutic model to treat patients with BD. In this paper, we further develop the theoretical model and elaborate on seven elements that were found effective in the psychosocial interventions with individuals with BD: monitoring mood and early symptoms of relapse, recognizing and management of stressful situations and interpersonal conflicts, creating a relapse prevention plan, stabilizing the sleep/wake cycle and daily routine, encouraging the use of medication, and reducing self-stigma and substance use. Apart from that, we describe the elements of the schema work with patients who suffer from BD. Illustrative clinical cases accompany the theoretical framework. The research of the schema therapy with patients with severe mental illnesses has only recently started developing. The presented paper also aims to encourage further research in this area and highlight potentially beneficial research goals.

Self-Stigma and Treatment Effectiveness in Patients with SSRI Non-Responsive Obsessive-Compulsive Disorder.

PURPOSE: Obsessive compulsive disorder (OCD) is a debilitating mental disorder that often takes a chronic course. One of the factors influencing the treatment effectiveness in anxiety and depressive disorders is the self-stigma. This study focused on the relationship between the self-stigma, symptomatology, and therapeutic outcomes in patients with OCD. PATIENTS AND METHODS: Ninety-four inpatients with OCD, who did not sufficiently respond to at least one selective serotonin reuptake inhibitor trial, participated in the study. They attended a six-week therapeutic program consisting of exposure and response prevention, transdiagnostic group cognitive behavioral therapy, individual sessions, mental imagery, relaxation, sport, and ergotherapy. The participants completed several scales: the Internalized Stigma of Mental Illness Scale (ISMI), the self-report Yale-Brown Obsessive Compulsive Scale (Y-BOCS-SR), Beck Anxiety Scale (BAI), Beck Depression Scale-II (BDI-II), and Dissociative Experiences Scale (DES). A senior psychiatrist filled in the Clinical Global Impression (CGI-S). RESULTS: The average scales' scores considerably declined in all measurements except for DES. The self-stigma positively correlated with all psychopathology scales. It was also higher in patients with a comorbid personality disorder (PD). The higher self-stigma predicted a lower change in compulsion, anxiety, and depressive symptoms but not the change of obsessions or the overall psychopathology. CONCLUSION: The self-stigma presents an important factor connected to higher severity of OCD. It is also a minor predictor of a lower change in symptomatology after combined treatment.

Imagery in cognitive behavioral supervision.

OBJECTIVE: This article describes the role of imagery in supervision which is a part of the work of both the supervisee and the supervisor. Imagination bears outstanding importance in psychotherapy and supervision. METHOD: The relevant texts for this narrative review were identified through the Web of Science and PubMed databases, within the period 1990-2019. The search terms included: Supervision, Cognitive behavioural therapy, Imagination, Imagery, Imagery rescripting, Therapeutic relationship, Supervisory relationship. The report also includes information from the books referred to by the articles. The supervisory experiences of the authors were also incorporated. The theoretical part is supplemented with case vignettes of strategies using imagination in CBT supervision. RESULTS: Working with imagery can be used in transformative experiential learning. It can help to better map the situation with the patient, including its emotional components and basic psychological needs, to realise how the therapeutic relationship is set up, as well as to rework own therapist attitudes, schemas and emotional - behavioural responses, and plan future steps in the therapy. Many therapy steps could be learned during imagery exercises. Imagery also helps to understand and regulate the supervisory relationship. CONCLUSION: It is useful to integrate imagery to the supervision. Using imagery can help to understand the patient, the therapeutic relationship better, and to plan optimal therapeutic strategies, as well as reflect/self-reflect and train difficult skills which promote professional and personal growth.

Pulmonary rehabilitation and oropharyngeal exercises as an adjunct therapy in obstructive sleep apnea: a randomized controlled trial.

OBJECTIVE: It is well recognized that the most effective treatment for obstructive sleep apnea (OSA) is continuous positive airway pressure (CPAP). Different treatment possibilities comprise surgery, mandibular advancement, pulmonary rehabilitation, and oropharyngeal and facial exercises (PR program). However, these treatments showed inconsistent results. The purpose of the study was to compare the short-term effects of CPAP and the combination of PR program with CPAP on OSA severity, ventilatory functions, and changes in body characteristics in a newly diagnosed patient. METHODS: This study was a single-center, two-arm, parallel, randomized, controlled, open-label trial. Forty patients with OSA (20 men, 20 women, aged 54.2 ± 6.8 years) with moderate to severe obstructive sleep apnea were randomized to CPAP and CPAP + PR. The PR group underwent six weeks of 60-min twice-weekly individual PR programs. The primary outcome measure was apnea/hypopnea index, oxygen desaturation index, and Epworth Sleepiness Scale. The secondary outcome measures were a percentage of total sleep time with oxygen saturation below 90%, body mass index (BMI), vital capacity and forced expiratory volume in 1 s (% of predicted), neck, waist, and hip circumferences. RESULTS: Five patients with OSA did not complete the program. The comparison between baseline and final assessment was made in 15 patients in the CPAP + PR group and 20 patients in the control group with CPAP only. Although OSA severity was controlled with CPAP treatment in both groups, a significant reduction of neck, waist, and hip circumferences, BMI, and improvement of pulmonary function were confirmed only in the CPAP + PR group after treatment. CONCLUSION: Treatment with CPAP combined with the PR program improved OSA patients to a greater extent than only CPAP.

Prediction of treatment response and the effect of independent component neurofeedback in obsessive-compulsive disorder: a randomized, sham-controlled, double-blind study.

AIMS: The goal of this study was to assess the effect of independent component neurofeedback (NFB) on EEG and clinical symptoms in patients with obsessive-compulsive disorder (OCD). Subsequently, we explored predictors of treatment response and EEG correlates of clinical symptoms. METHODS: In a randomized, double-blind, parallel design, 20 inpatients with OCD underwent 25 sessions of NFB or sham feedback (SFB). NFB aimed at reducing EEG activity in an independent component previously reported abnormal in this diagnosis. Resting-state EEG recorded before and after the treatment was analyzed to assess its posttreatment changes, relationships with clinical symptoms and treatment response. RESULTS: Overall, clinical improvement in OCD patients was not accompanied by EEG change as assessed by standardized low-resolution electromagnetic tomography and normative independent component analysis. Pre- to posttreatment comparison of the trained component and frequency did not yield significant results; however, in the NFB group, the nominal values at the downtrained frequency were lower after treatment. The NFB group showed significantly higher percentage reduction of compulsions compared to the SFB group (p = 0.015). Pretreatment higher amount of delta (1-6 Hz) and low alpha oscillations as well as a lower amount of high beta activity predicted a worse treatment outcome. Source localization of these delta and high beta oscillations corresponded with previous EEG resting-state findings in OCD patients compared to healthy controls. CONCLUSION: Independent component NFB in OCD proved useful in percentage improvement of compulsions. Based on our correlation analyses, we hypothesize that we targeted a network related to treatment resistance.

Psychological aspects and psychotherapy of inflammatory bowel diseases and irritable bowel syndrome in children.

BACKGROUND: Despite holistic approach to psychosomatic medicine, gastroenterological disorders (GI) tend to be categorized broadly into "functional" and "organic". Major GI illnesses are Inflammatory bowel diseases (IBD) include ulcerative colitis and Crohn's disease. Both are chronic, with remissions and relapses over the years while irritable bowel syndrome (IBS) is a common, often disabling functional gastrointestinal disorder. METHODS: A literature review was performed using the National Library of Medicine PubMed database, including all resources within the period 1991-2008, additional references were found through bibliography reviews of relevant articles. RESULTS: Psychological problems: Higher scores of neuroticism, depression, inhibition, and emotional instability, are typical for many patients with chronic diseases and nonspecific for chronic gastroenterological disorders. Patients with chronic gastrointestinal disorders have impaired health-related quality. Psychological treatments: There have been few adequate psychological treatment trials in IBD. These achieved lower demands for health care rather than a reduction of anxiety or depression. Psychotherapy with chronic gastrointestinal disorders could lead to improve the course of the disease, changing psychological factors such as depression and dysfunctional coping and improving the patient's quality of life. CONCLUSIONS: There seem to be "risk patients" in whom psychosocial components have a bigger influence on the course of disease than in other patients; and those would probably benefit from psychotherapeutic treatment. Psychological treatments help patients manage the psychological distress which worsens bowel symptoms and quality of life.

Augmentation of antidepressants with bright light therapy in patients with comorbid depression and borderline personality disorder.

BACKGROUND: Borderline personality disorder (BPD) is typically characterized by instability and impaired behaviour, affectivity, interpersonal relations and lifestyle. The most common condition comorbid with BPD is a depressive episode. Depression is associated with severe disturbance of the circadian rhythms. This is apparent in depressive patients with BPD. Both sleep and diurnal rhythms are disturbed and the symptoms fluctuate. Bright light may be an effective in treatment of seasonal affective disorder, circadian sleep disorder and jet lag. It also improves sleep-wake patterns and behavioural disorders in hospitalized patients with Alzheimer's disease. Several studies have suggested antidepressant effects of phototherapy in non-seasonal depressive episodes. The treatment of comorbid depressive disorder and borderline personality disorder (BPD) is usually reported to be less successful than the treatment of patients without personality disorder. Studies describing the use of bright light in depressed patients with comorbid BPD have not been published so far. METHOD: The aim of this open study was to assess the effectiveness of a 6-week combined therapy with the application of bright light (10,000 lux, 6:30 to 7:30 a.m. for 6 weeks) added to SSRIs in drug-resistant depressed patients with comorbid BPD who did not respond with improvement to 6-week administration of antidepressants. The study comprised 13 female patients who met the ICD-10 diagnostic criteria for research and the DSM-IV-TR diagnostic criteria for major depression. The participants were regularly evaluated using the CGI, HAMD and MADRS scales and the BDI and BDI self-report inventories. RESULTS: According to all the assessment instruments, the application of bright white light leads to a significant improvement. However, the results must be interpreted with caution due to the open nature of the study.

Bright light therapy.

Bright light is a treatment of choice for seasonal affective disorder. Other indications for bright light therapy have also been tested. These include non-seasonal depression, bipolar depression, chronic depressive disorder, ante- and postpartum depression, late luteal phase dysphoric disorder, circadian phase sleep disorders, jet lag, shift work problems, and behavioral disturbance and insomnia in organic dementia. Future studies should focus on exploring the use of light therapy in combination with sleep deprivation, other classes of antidepressants, and with psychotherapy and their possible combined effect on subtypes of depression or other mentioned diagnoses, light treatment duration, and the applicability and efficacy of adjunct light treatment for in-patients.

The effect of repetitive transcranial magnetic stimulation (rTMS) on symptoms in obsessive compulsive disorder. A randomized, double blind, sham controlled study.

BACKGROUND: The goal of our study is to assess whether transcranial magnetic stimulation (rTMS) would facilitate the effect of antidepressant in OCD patients. METHOD: The aim of the randomized, double-blind, sham controlled study was to compare the 2 and 4 week efficacy of the 10 sessions rTMS with sham rTMS in serotonin reuptake inhibitor resistant OCD patient. Thirty three right-handed patients were randomly assigned to either active rTMS or to sham rTMS. Active rTMS with the frequency of 1 Hz at 110% of motor threshold (MT) was administered over the left dorso-lateral prefrontal cortex. The same time schedule was used for sham administration. Thirty patients finished the study, three patients' dropped out at the beginning. Psychopathology was assessed by CGI, HAMA, Y-BOCS and BAI before the treatment, immediately after the experimental treatment, and 2 weeks after the experimental treatment by an independent reviewer. RESULTS: Both groups improved during the study period but the treatment effect did not differ between them in any of the instruments. CONCLUSION: Low frequency rTMS administered over the left dorso-lateral prefrontal cortex during 10 daily sessions did not differ from sham rTMS in facilitating the effect of serotonin reuptake inhibitors in OCD patients.

Bright light therapy and/or imipramine for inpatients with recurrent non-seasonal depression.

INTRODUCTION: The aim of a double-blind study was to assess the efficacy of bright light therapy and/or imipramine in the treatment of inpatients suffering with recurrent non-seasonal major depressive disorder. METHOD: 34 in-patients with DSM-III-R diagnosis of major depressive disorder, recurrent type, were randomly allocated into 3 treatment groups. After 4-day washout period with baseline assessment they underwent 3 weeks of different types of treatment: a) Group A: bright light therapy (5000 lux from 6-8 a.m.) and imipramine 150 mg/day. b) Group B: bright light therapy (5000 lux from 6-8 a.m.) and imipramine-like placebo. c) Group C: dim red light (500 lux from 6-8 a.m.) and imipramine 150 mg/day. Outcome measures included weekly Hamilton Psychiatric Rating Scale for Depression, Clinical Global Impression Scale, Montgomery and Asberg Psychiatric Rating Scale for Depression and Beck Depression Inventory. RESULTS: Patients of all three groups improved significantly. The improvement of the patients of group B treated with bright light therapy plus placebo was superior to the other two groups, but not significantly. CONCLUSION: Bright light therapy can be effective in the treatment of non-seasonal major depressive disorder.