Education Innovations in the Department of Psychiatry at Washington University.

The Department of Psychiatry at Washington University has been innovating psychiatric education during the second millennium at all levels of training - undergraduate medical, general residency, and child and adolescent psychiatry (CAP) fellowship training. Undergraduate medical education now occurs in three phases. The 18-month pre-clerkship phase is divided into seven multidisciplinary modules that span basic, social, and clinical sciences. Psychiatry is part of the seven-week long Brain and Behavior module. The yearlong second phase includes a six-week traditional psychiatry clerkship-like experience bracketed by an introductory foundational week and a one-week consolidation period. The third phase is 18 months in length and provides in-depth exploration of both clinical and non-clinical areas. The residency training program has enlarged the number of residents undergoing training and simultaneously greatly expanded the clinical exposure to include rotations in eating disorders and perinatal psychiatry. In addition, our residents can choose to enhance their training in either our research or leadership focused options, both of which are also available to trainees in our child and adolescent program. Additionally, our CAP trainees are exposed to several unique areas including eating disorders and substance use disorders. We believe that these innovations across the educational spectrum allow us to prepare our learners for the practice of psychiatry in the 21st century.

The Generative Presence of Relatedness.

In this guest editorial, the authors introduce a special issue of the American Journal of Clinical Hypnosis that focuses on relational factors of hypnosis in psychotherapy. The authors have invited a number of esteemed colleagues to comment on aspects of the therapeutic relationship, and how it informs and influences the processes, techniques, and outcomes of hypnosis and therapy. In addition to summarizing each of these articles, this article analyzes the major relational themes that present across the articles.

Dancing in the In-Between: Hypnosis, Transitional Space, and Therapeutic Action.

This article develops the idea that hypnosis is an interactive phenomenon occurring in a relational matrix. A tripartite model for explicating this relational matrix is presented, which includes a discussion of transference, contemporary relationship factors, and the interaction of these to produce a sense of therapeutic alliance. These relationship factors are central to the therapeutic action of hypnosis as a vehicle to potentiate change and growth. The unique and specific contribution of each of these factors to the process of hypnotherapy and to therapeutic action is examined. Phenomenologically, this relational interaction is conceptualized as occurring in transitional space, shaped by processes of regression and attunement. From this perspective, the hypnotherapist is viewed as a kind of transitional object whose empathic presence contains and facilitates those interactive phenomena which evoke and balance the transferential and contemporary aspects of the relationship and which allow for uniquely evocative developmentally focused interventions in trance work. Several examples are presented from an ongoing case that demonstrate how these relational variables shape the hypnotherapeutic process and how they can be used for uncovering and self-examination, for structural maturation, for affect regulation, and for emerging ego mastery. The therapeutic action demonstrated relies on hypnotic interventions rooted in the various components of the relational matrix made possible by the clinician's awareness of and attunement to these and by hisor her informed and sensitive management of them and of his or her own intersubjectivity. Specific strategies are presented via these examples to effectively utilize this experience in the service of treatment goals.

Hypnosis and The Therapeutic Relationship: Relational Factors of Hypnosis in Psychotherapy.

Over the years, the field of hypnosis has often given more attention to the state and procedural factors of hypnosis than the relational ones. In an attempt to address this imbalance, the 60th annual meeting of the American Society of Clinical Hypnosis (ASCH) had as its theme "Hypnosis and the Treatment Relationship." A centerpiece of this meeting was a collegial discussion among a panel of psychologists with expertise in relational hypnotherapy. The panel addressed several pertinent questions: (1) What are the healing qualities of relationship in psychotherapy? (2) What makes hypnosis relational in nature? (3) How do relational factors of hypnosis resemble healthy attachment processes and recapitulate stalled developmental maturation? (4) How does relationally informed hypnotherapy influence and strengthen the relationship, process, and outcome of psychotherapy? This article summarizes the factors that led to the creation of this panel; provides an edited transcript of this panel discussion, along with additional commentary on several key points raised; and concludes with a summary of the main themes and recommendations for further clinical practice and study.

Attachment-Focused Psychotherapy and the Wounded Self.

The concept of the "wounded self" (Wolfe, 2005) offers an integrative theoretical framework for self-wounds and their developmental origins. Alladin (2013, 2014, 2016) integrated hypnotherapy into this model to comprehensively address the unconscious protective mechanisms and maladaptive conscious cognitive strategies of the wounded self. The purpose of this article is to propose how an attachment-focused psychotherapy could be utilized in working with the wounded self. With its emphasis on developmental maturation through the frame of the attachment relationship, attachment theory is well-positioned to offer conceptual and treatment insights in treating the wounded self. E. B. Spiegel's (2016) attunement, representation, and mentalization approach to attachment-focused psychotherapy described how hypnosis can be utilized across attachment processes of attunement, representation, and mentalization toward structural maturation and developmental repair of patients with histories of complex relational trauma. In this article, the attunement, representation, and mentalization attachment approach and associated interventions are further explicated in the treatment of self-wounds in the borderline and narcissistic spectrums of personality organization. These principles of conceptualization and treatment interventions are then applied in a case example.

Attachment-Focused Hypnosis in Psychotherapy for Complex Trauma: Attunement, Representation, and Mentalization.

The relational and psychological functions of attunement, representation, and mentalization are essential components of a secure attachment experience. Psychotherapeutic approaches informed by attachment theory have gained significant empirical and clinical support, particularly in the area of complex trauma. Despite these advances, attachment-informed trauma treatment could benefit greatly from the experiential wealth that clinical hypnosis has to offer. In its utilization of shared attention, tone of voice, pacing, representational imagery, and hypnotic language, clinical hypnosis as a state, relationship, and technique offers psychotherapists a way of introducing a healthy attachment experience and renewing appropriate developmental functioning in patients who are survivors of complex trauma. In this article, attunement, representation, and mentalization are reviewed from a hypnotherapeutic perspective.

Clients' and therapists' real relationship and session quality in brief therapy: an actor partner interdependence analysis.

This study used the Actor Partner Interdependence Model (APIM; Kenny & Cook, 1999) to examine the associations of client- and therapist-rated real relationship (RR) and session quality over time. Eighty-seven clients and their therapists (n = 25) completed RR and session quality measures after every session of brief therapy. Therapists' current session quality ratings were significantly related to all of the following: session number (b = .04), their session quality rating of the previous session (b = .24), their RR in the previous session (b = 1.091), their client's RR in the previous session (b = .17), and interactions between their own and their clients' RR and session number (b = -.16 and ß = -.04, respectively). Clients' ratings of current session quality were significantly related to only their own RR in the previous session (b = .47). Implications for future research and practice are discussed.

The unfolding of the real relationship and the outcome of brief psychotherapy.

This study sought to assess the association of client- and therapist-rated real relationship with each other and with the outcome of brief psychotherapy. It also aimed to determine whether changes over time in perceptions of the real relationship and increasing convergence between clients' and therapists' ratings of the real relationship were associated with outcome. Forty-two clients and their therapists (n = 19) at 2 university counseling centers completed measures assessing the strength of their real relationship after every session of brief psychotherapy. They also completed an outcome measure at the end of treatment. Clients' ratings of the real relationship after the first session, first quarter of treatment, and after all sessions combined related to outcomes. Therapists' ratings of the real relationship at these time points did not relate to outcome. However, increases over time in therapists' ratings of real relationship strength, as well as increasing convergence with clients' ratings of the real relationship, did relate to outcome. Implications for future research and practice are discussed.

Neuropsychological performance following a history of multiple self-reported concussions: a meta-analysis.

Debate continues about the long-term neuropsychological impact of multiple mild traumatic brain injuries (MTBI). A meta-analysis of the relevant literature was conducted to determine the impact of having a history of more than one self-reported MTBI (versus just one MTBI) across seven cognitive domains, as well as symptom complaints. The analysis was based on 8 studies, all conducted with athletes, involving 614 cases of multiple MTBI and 926 control cases of a single MTBI. The overall effect of multiple MTBI on neuropsychological functioning was minimal and not significant (d = 0.06). However, follow-up analyses revealed that multiple self-reported MTBI was associated with poorer performance on measures of delayed memory and executive functioning. The implications and limitations of these findings are discussed.