Learning clinical skills: an ecological perspective.

The pedagogy underpinning clinical psychology training is often reliant upon the acquisition and transmission of knowledge and the practice of skills. The dominant paradigm in the training of clinical psychologists emphasises competence-based training drawing upon a scientist practitioner model of practice, often underpinned by knowledge of evidence-based interventions. Little has changed over the past 40 years. Training is predicated upon the assumption that effective therapy is attributed to the therapist's skills to implement specific therapeutic processes and her or his capacity to form an effective working alliance with the client or patient. We provide an argument for an alternative paradigm in which ecological principles are privileged with a view to enhancing clinical training of psychologists in health settings responsive to the trainee as well as the broader societal context in which they practice, by adopting a pedagogy which prioritizes the relationship between the person and the environment. The proposed approach brings an ecological set of assumptions to the learning experience in clinical contexts. Key principles, drawn from an ecological perspective includes: affordances, the emergence of self-organisation in clinical learning, constraints and rate limiters. The approach is supported by examples applied to clinical learning contexts. Implications for clinical training are discussed. The ways in which an ecological approach may contribute to more effective learning outcomes through the use of representative learning contexts may inform learning design, how learning is actioned in clinical psychology as well as future research on the pedagogy of clinical training.

Mechanisms of Change in Intensive Short-Term Dynamic Psychotherapy: Systematized Review.

OBJECTIVE: Despite increasing evidence for the effectiveness of intensive short-term dynamic psychotherapy (ISTDP), evidence supporting the purported mechanisms of change in ISTDP is lacking. This systematized review aimed to describe the major theorized mechanisms of change in ISTDP, critically evaluate the emerging literature pertaining to its purported mechanisms, and explore directions for future research. METHODS: A systematized search of the literature was conducted by using online databases (PsychInfo, PubMed, EMBASE, and CINAHL). RESULTS: Fourteen studies met inclusion criteria. The included studies explored at least one theorized ISTDP mechanism of change and attempted to operationalize or otherwise empirically examine the mechanism in relation to the therapeutic process. Examined mechanisms included "unlocking the unconscious" and specific therapist interventions. CONCLUSIONS: The current body of literature has several limitations, most notably the lack of a consensus definition for unlocking the unconscious. This difficulty in measuring mechanisms of change is common across therapeutic modalities and limits the validity and comparability of findings. Despite these limitations, the literature suggests a possible association between theorized mechanisms of change and positive therapy outcomes. Future research directions are discussed.

Postcoital Dysphoria: Prevalence and Correlates Among Males.

Consensual sexual activity is believed to be associated with a positive emotional experience, however, postcoital dysphoria (PCD) is a counterintuitive phenomenon characterized by inexplicable feelings of tearfulness, sadness, or irritability following otherwise satisfactory consensual sexual activity. Prevalence of PCD has been reported among females, but not among males. The present study utilized an anonymous online questionnaire to examine the prevalence and correlates of PCD among an international sample including 1,208 male participants. Forty-one percent reported experiencing PCD in their lifetime and 20.2% reported experiencing PCD in the previous four weeks. Between 3% and 4% of the sample reported experiencing PCD on a regular basis. PCD was found to be associated with current psychological distress, childhood sexual abuse, and several sexual dysfunctions. Results indicate that the male experience of the resolution phase may be far more varied, complex, and nuanced than previously thought and lays a foundation for future research investigating PCD among males. Findings have implications for therapeutic settings as well as the general discourse regarding the male sexual experience.

Recently resettled refugee women-at-risk in Australia evidence high levels of psychiatric symptoms: individual, trauma and post-migration factors predict outcomes.

BACKGROUND: Despite increasing numbers of refugee women-at-risk being resettled and their potential vulnerability, there exists no empirical research into the psychiatric health of this unique subgroup with which to guide policy and practice. This research aimed to investigate psychiatric symptom status of a sample of refugee women-at-risk recently resettled in Australia, as well as factors contributing to symptoms of trauma, anxiety, depression, and somatization. The level of psychiatric symptomatology is compared to reference groups of women from Sudan and Burma, who entered Australia under the Humanitarian Entry Programme, and who did not meet criteria as women-at-risk. METHODS: This is a cross-sectional survey of 104 refugee women-at-risk across several ethnic groups including a demographic questionnaire, the Harvard Trauma Questionnaire, Post-migration Living Difficulties Checklist, and Hopkins Symptom Checklist to assess individual factors, traumatic experiences, post-migration problems, and symptoms of trauma, anxiety, depression, and somatization. A series of multiple hierarchical regression analyses examined factors predicting psychiatric symptoms. RESULTS: Substantial proportions of participants reported psychiatric distress in symptomatic ranges, including for traumatization (41%), post-traumatic stress disorder (20%), anxiety (29%), and depression (41%), as well as significant symptoms of somatization (41%). These findings are significantly higher than those derived from reference groups of women from Sudan or Burma, resettled in the same area and utilizing a similar methodology. Higher numbers of trauma events and post-migration living difficulties predicted higher trauma, depression, and somatic (but not anxiety) symptoms. Having children predicted higher trauma, anxiety, and somatic symptoms. Greater English fluency predicted higher anxiety symptoms. Region of birth predicted anxiety and depression symptoms. Age predicted trauma and anxiety symptoms. CONCLUSIONS: Findings suggest that recently arrived refugee women-at-risk are at high risk of psychiatric disorders. The results indicate a need for comprehensive psychiatric assessment to identify women in need of treatment very early after resettlement, with implications for medical practice, service delivery, and policy programs.

Metacognitive Interpersonal Therapy for Personality Disorders Featuring Emotional Inhibition: A Multiple Baseline Case Series.

Metacognitive interpersonal therapy (MIT) is an integrative psychotherapeutic approach targeting personality disorders (PDs) featuring inhibition and avoidance. The current case series reports the outcome of a time-limited, 12-month MIT intervention for people with PDs featuring emotional inhibition. Seven participants were diagnosed with a PD on the basis of a structured clinical interview. The study followed a multiple baseline design, with baseline measures taken for 3 weeks before intervention. Participants underwent 12 months of weekly MIT sessions, with outcome measures taken every 3 months. Outcome variables were diagnostic recovery, symptom severity, and alexithymia. All participants improved over the course of the 12-month intervention across most measures. For six of the participants, the intervention was a likely driver of change. The current study contributes to a growing evidence base regarding the effectiveness of MIT for the treatment of PDs.

Therapist Reflective Functioning, Therapist Attachment Style and Therapist Effectiveness.

This study investigated the relationship between two therapist attributes (reflective functioning and attachment style) and client outcome. Twenty-five therapists treated a total of 1001 clients. Therapists were assessed for reflective functioning and attachment style using the Adult Attachment Interview and the Experiences in Close Relationships Scale. Clinical outcome was measured using the Outcome Questionnaire (OQ-45). Data were analysed using hierarchical linear modelling. Results indicated that therapist reflective functioning predicted therapist effectiveness, whereas attachment style did not. However, there was evidence of an interaction between therapist attachment style and therapist reflective functioning. Secure attachment compensated somewhat for low reflective functioning and high reflective functioning compensated for insecure attachment. Possible implications for the selection of therapy training candidates and therapist training are discussed.

Reawakening reflective capacity in the psychotherapy of schizophrenia: a case study.

Disturbed sense of self has long been identified as a common experience among people suffering with schizophrenia. More recently, metacognitive deficits have been found to be a stable and independent feature of schizophrenia that contributes to disturbed self-experience and impedes recovery. Individual psychotherapy designed to target poor metacognition has been shown to promote a more coherent sense of self and enhanced recovery in people with schizophrenia. We provide a report of a 2-year individual psychotherapy with a patient suffering with chronic schizophrenia. Progress was assessed over the course of treatment using the Metacognition Assessment Scale and the Brief Psychiatric Rating Scale. The patient experienced improved metacognitive capacity and reduced symptom severity over the course of therapy. Implications for clinical practice are discussed.

Sexual desire, erectile dysfunction and the biomedicalization of sex in older heterosexual men.

AIM: To examine sexual desire in older age and the use of pharmaceuticals for sexual enhancement in the context of erectile dysfunction. BACKGROUND: The ability of the older person to fulfil sexual desire has not been well supported in Western society. DESIGN: The paper draws on themes that emerged during a phenomenological study of sexual desire in older age. METHOD: Narratives were collected between 2008-2010 from in-depth interviews with six men and two women aged 65-84 years who were part of a larger Australian study of sexual desire in older age. FINDINGS: Emergent themes reveal that for some older people, the biomedicalization of sex can be a disappointing experience. CONCLUSION: The findings illuminate the need for nurses who are at the front line of health care, health policy makers and educators, to consider sexual desire experienced in older age in the context of sexual health and healthy ageing. This study will contribute to a growing body of knowledge about sexual desire in older age.

A Qualitative Study of Adolescents from Refugee Backgrounds Living in Australia: Identity and Resettlement.

Identity formation among young people from refugee backgrounds is complex, as it occurs while they are both integrating into a novel cultural landscape and navigating the intricacies of adolescence. The present study explored sense of identity and experiences among refugee youth in the context of resettlement. Nineteen young people (15-18 years) from refugee backgrounds, settled in Brisbane, Australia, took part in the study. An individual semi-structured interview, drawing upon the Tree of Life method, was used. The thematic analysis (TA) methodology was adopted, and several themes emerged: experiencing changes in family roles; experience of belonging; experience of bonds with lost loved ones; dealing with emotions in a new context; experience of self in the context of change. There was one emergent overarching theme of meaning-making in the context of change. These themes were explicated within the framework of social identity and sociocultural theories, which emphasises the dynamic co-construction of identity through the interplay of belonging and meaning-making within specific contextual settings. This study highlights the fundamental role of social context, particularly the fostering of school belonging, in the multifaceted process of identity construction. The findings identify the importance of integrating multiple identities and experiences to develop a comprehensive and resilient sense of personal cohesion and selfhood.

The Multidimensional Loss Scale: validating a cross-cultural instrument for measuring loss.

The Multidimensional Loss Scale (MLS) represents the first instrument designed specifically to index Experience of Loss Events and Loss Distress across multiple domains (cultural, social, material, and intrapersonal) relevant to refugee settlement. Recently settled Burmese adult refugees (N = 70) completed a questionnaire battery, including MLS items. Analyses explored MLS internal consistency, convergent and divergent validity, and factor structure. Cronbach alphas indicated satisfactory internal consistency for Experience of Loss Events (0.85) and Loss Distress (0.92), reflecting a unitary construct of multidimensional loss. Loss Distress did not correlate with depression or anxiety symptoms and correlated moderately with interpersonal grief and trauma symptoms, supporting divergent and convergent validity. Factor analysis provided preliminary support for a five-factor model: Loss of Symbolic Self, Loss of Interdependence, Loss of Home, Interpersonal Loss, and Loss of Intrapersonal Integrity. Received well by participants, the new scale shows promise for application in future research and practice.

The Importance of Local and Global Social Ties for the Mental Health and Well-Being of Recently Resettled Refugee-Background Women in Australia.

Social connections are foundational to the human condition and are inherently disrupted when people are forcibly displaced from their home countries. At a time of record high global forced migration, there is value in better understanding how refugee-background individuals engage theirsocial supports or ties in resettlement contexts. A mixed methods research design aimed to understand the complexities of how 104 refugee-background women experienced their social networks in the first few months of resettlement in Australia. One of the research activities involved participants completing a survey with both quantitative and qualitative components. The quantitative analyses identified the impact of post-migration living difficulties that represented social stressors (worry about family, loneliness and boredom, feeling isolated, and racial discrimination) on the women's mental health outcomes in the months following resettlement. The qualitative data highlighted the complexities of social relationships serving as both stressors and sources of support, and the importance of recognizing extended families and supports around the globe. The findings point to the need for nuanced accounts of the social contexts surrounding refugee resettlement as important influences able to promote trauma-informed and gender sensitive practices to support mental health and well-being in new settings.

Mental health of newly arrived Burmese refugees in Australia: contributions of pre-migration and post-migration experience.

OBJECTIVE: This study documents the mental health status of people from Burmese refugee backgrounds recently arrived in Australia, then examines the contributions of gender, pre-migration and post-migration factors in predicting mental health. METHOD: Structured interviews, including a demographic questionnaire, the Harvard Trauma Questionnaire, the Post-migration Living Difficulties Checklist and Hopkins Symptom Checklist assessed pre-migration trauma, post-migration living difficulties, depression, anxiety, somatization and traumatization symptoms in a sample of 70 adults across five Burmese ethnic groups. RESULTS: Substantial proportions of participants reported psychological distress in symptomatic ranges including: post-traumatic stress disorder (9%), anxiety (20%) and depression (36%), as well as significant symptoms of somatization (37%). Participants reported multiple and severe pre-migration traumas. Post-migration living difficulties of greatest concern included communication problems and worry about family not in Australia. Gender did not predict mental health. Level of exposure to traumatic events and post-migration living difficulties each made unique and relatively equal contributions to traumatization symptoms. Post-migration living difficulties made unique contributions to depression, anxiety and somatization symptoms. CONCLUSIONS: While exposure to traumatic events impacted on participants' mental well-being, post-migration living difficulties had greater salience in predicting mental health outcomes of people from Burmese refugee backgrounds. Reported rates of post-traumatic stress disorder symptoms were consistent with a large review of adults across seven western countries. High levels of somatization point to a nuanced expression of distress. Findings have implications for service provision in terms of implementing appropriate interventions to effectively meet the needs of this newly arrived group in Australia.

Children of substance-using mothers: child health engagement and child protection outcomes.

AIM: Maternal substance use has been associated with a range of child risk factors. The study investigated the relationship between engagement with child health services and child protection outcomes for children of substance-using mothers. METHODS: The sample comprised 119 children of mothers who disclosed opiate, amphetamine or methadone use during a maternity admission between 2000 and 2003. Statutory child protection agency and child health engagement information for the first 2 years of life was obtained. The relationship between type of maternal substance use, child health engagement and child protection outcomes was examined. RESULTS: Of study group infants, 72% were engaged with child health services during the first 2 years of life. Chi-squared analysis showed no significant relationship between child health engagement and child protection reports. Child health engagement was associated with decreased substantiated child protection notifications for children of methadone using mothers, but not for children of illicit substance users. CONCLUSIONS: Almost a quarter of identified children of substance-using mothers are not accessing standard child health services in their first 2 years of life. This study provides support for increased attention to the provision of child health services for children of methadone using mothers. Further research into effective intervention strategies for children of illicit substance-using mothers is indicated.

Schizophrenia and the progression of emotional expression in relation to others.

Gaining an improved understanding of people diagnosed with schizophrenia has the potential to influence priorities for therapy. Psychosis is commonly understood through the perspective of the medical model. However, the experience of social context surrounding psychosis is not well understood. In this research project we used a phenomenological methodology with a longitudinal design to interview 7 participants across a 12-month period to understand the social experiences surrounding psychosis. Eleven themes were explicated and divided into two phases of the illness experience: (a) transition into emotional shutdown included the experiences of not being acknowledged, relational confusion, not being expressive, detachment, reliving the past, and having no sense of direction; and (b) recovery from emotional shutdown included the experiences of being acknowledged, expression, resolution, independence, and a sense of direction. The experiential themes provide clinicians with new insights to better assess vulnerability, and have the potential to inform goals for therapy.

Narrative therapy for adults with major depressive disorder: improved symptom and interpersonal outcomes.

This study investigated depressive symptom and interpersonal relatedness outcomes from eight sessions of manualized narrative therapy for 47 adults with major depressive disorder. Post-therapy, depressive symptom improvement (d=1.36) and proportions of clients achieving reliable improvement (74%), movement to the functional population (61%), and clinically significant improvement (53%) were comparable to benchmark research outcomes. Post-therapy interpersonal relatedness improvement (d=.62) was less substantial than for symptoms. Three-month follow-up found maintenance of symptom, but not interpersonal gains. Benchmarking and clinical significance analyses mitigated repeated measure design limitations, providing empirical evidence to support narrative therapy for adults with major depressive disorder.

Development and Validation of the Postsex Experience (P-SES) Scale.

INTRODUCTION: There is little systematized research on the postsex phase of the sexual cycle, due in part to the absence of literature on the period immediately following sexual activity. AIM: The paper describes the development and validation of the Postsex Experience Scale (P-SES), an instrument designed to measure the psychological dimensions of the postsex period of the human sexual response cycle. METHODS: Scale development involved (a) item construction, selection, and subsequent validation through item analysis, and (b) a factor analysis of the item intercorrelations of the P-SES and the establishment of its factorial validity, based upon an online survey of 4,217 respondents. RESULTS: In the exploratory factor analysis of the psychometric structure of the scale, structures for males and females differed. 3 factors emerged, which captured the male postsex experience. These factors were labeled Sense of Sexual Alienation, Positive Connection with Self, and Feeling Connected with Partner. 4 factors best captured the female postsex experience and were labeled Self-Loathing, Positive Connection with Self, Sense of Being Emotionally Overwhelmed, and Feeling Connected with Partner. CLINICAL IMPLICATIONS: There is strong evidence for acknowledging a wide variation in postsex experience in both men and women across sexual orientations. STRENGTHS & LIMITATIONS: Strengths include a large heterogeneous sample leading to the provision of a metric to investigate novel aspects of human sexuality. Limitations include the potential underreporting of experiences due to the structure of the scale and its reference to "general experiences" and presentation bias. CONCLUSIONS: The P-SES provides a framework for assessing the postsex experience in women and men, providing opportunities to gain a better understanding of the variations in postsex experience. Schweitzer RD, du Plessis G, Maczkowiack J, et al. Development and Validation of the Post Sex Experience (P-SES) Scale. Sex Med 2021;9:100291.

Persistent psychological distress in resettled refugee women-at-risk at one-year follow-up: Contributions of trauma, post-migration problems, loss, and trust.

The mental health of women has been largely neglected in the refugee literature, notwithstanding the specific gender-related issues that confront women seeking asylum. Furthermore, a specific category of women, deemed to be women-at-risk, face particular challenges in their journey and resettlement process. This longitudinal study investigated psychological distress in refugee women-at-risk one year after resettlement in Australia. Follow-up survey of 83 women-at-risk (mean age = 33.41 years; SD = 11.93) assessed: trauma events and symptoms; loss events and loss distress; level of post-migration problems; anxiety, depression, and somatic symptoms; and absence of trust in community members. Participants demonstrated no symptom change since initial assessment (p > .05). Substantial proportions of women reported traumatization (39%), PTSD (20%), anxiety (32%), and depression (39%) above clinical cut-offs, and high levels of somatization and loss distress. Post-migration problems, trauma events, and region of birth were associated with all symptoms, with post-migration problems the strongest predictor. Absence of trust in community members was associated with trauma, depression, and somatic symptoms. Initial trauma and somatic symptoms were associated with follow-up traumatic and somatic symptoms. Loss and trauma events were associated with loss distress. Findings underline the role of post-migration problems on psychological distress and the need to consider women's psychological wellbeing in the context of their trauma and loss history, potential impacts of ethnicity, and complex socio-cultural dynamics underpinning issues of trust within communities. Effective service delivery requires that practitioners screen for and address psychological distress in women-at-risk at least up to 18 months after resettlement.

Anger and depression predict hospital use among chronic heart failure patients.

Costly hospital readmissions among chronic heart failure (CHF) patients are expected to increase dramatically with the ageing population. This study investigated the prognostic ability of depression, anger and anxiety, prospectively, and after adjusting for illness severity, on the number of readmissions to hospital and the total length of stay over one year. Participants comprised 175 inpatients with CHF. Depression, anger, anxiety, and illness severity were measured at baseline. One year later, the number of readmissions and length of stay for each patient were obtained from medical records. Depression and anger play a detrimental role in the health profile of CHF patients.

Psychometric Properties of the Multidimensional Loss Scale with Refugee Women-at-Risk Recently Arrived in Australia.

Refugee women-at-risk represent a distinct and vulnerable refugee population. We investigated the psychometric properties of the Multidimensional Loss Scale (MLS) with 104 women-at-risk, recently-arrived in Australia. Cross-sectional survey included: the MLS (indexing loss events and loss distress); Harvard Trauma Questionnaire (Indexing Trauma Events and Trauma Symptoms), and; Hopkins Symptom Checklist-37 (indexing anxiety, depression, and somatization symptoms). Exploratory factor analyses of MLS loss distress revealed a six-factor model (loss of symbolic self; loss of home; loss of interdependence; loss of past aspirations; interpersonal loss, and; loss of intrapersonal integrity). Cronbach alphas indicated satisfactory internal consistency for loss events (0.83) and distress (0.88). Correlations supported convergent validity of loss distress with trauma symptoms (r = 0.41) and divergent validity with anxiety (r = 0.09), Depression (r = 0.29), and somatic (r = 0.24) symptoms. Findings support MLS use in assessment of loss and associated distress with refugee women-at-risk.

The Human-Nature Experience: A Phenomenological-Psychoanalytic Perspective.

Drawing upon phenomenology and psychoanalytic concepts, we explore and explicate participants' lived experience of the natural world. The authors draw upon Husserl's description of consciousness as intentionality and his later work on the life-world, in exploring experiences which provide a basis for a psychochoanalytic understanding of the human-nature experience. Unstructured interviews were undertaken with nine participants, each of whom regarded nature as being significant for their sense of wellbeing. The lived experiences were explicated drawing upon the two processes: Giorgi's descriptive phenomenological psychological methodology and psychoanalytic researcher reflexivity. Data analysis and explication involved the following steps: (1) a thorough reading of each interview transcript, (2) breaking data into parts by demarcating meaning units, (3) organizing data by translating meaning units into units of psychological experience through coding, and (4) arriving at a summary of the data which involved organizing and reviewing units of psychological experience. The process of reflection led to the formulation of an essential psychological structure of participants' lived experience of the natural world. We argue that the human-nature relationship can be conceived in terms of psychoanalytic concepts, and in particular, constructs based upon an understanding of the primacy of attachment relationships. The natural world is elucidated as (a) nature being experienced as a primary attachment, (b) nature experienced as a secure base, (c) nature experienced as twinship, (d) nature experienced as containing, and (e) nature experienced as embodied. This paper extends previous empirical descriptions of the human-nature relationship by incorporating psychoanalytic processes and theory into a theoretically informed qualitative methodological stance. Beyond the traditional notion of nature as something 'out there' that we can interact with for cognitive or emotional restoration, participants in this study described the experience of nature as being integral to their sense of self. This study suggests that experiences that facilitate immersion in nature provide opportunities for the development of an integrated sense of self that has a profound impact on a participant's sense of wellbeing. The findings further demonstrate the convergence between phenomenology and psychoanalytic constructs which offers a richness to our understanding the subjectivity of participants and their relationship with nature, a perspective not often attainable through more traditional quantitative research methodologies.