The cultural change narrative as a core component of therapeutic change.

Introduction: Research indicates a similar effect of Mentalization-based treatment (MBT) and Dialectical behavior therapy (DBT) for borderline personality disorder (BPD). However, there is a paucity in studies investigating the change narrative received from and developed in these treatments. The aim of the present study is to investigate similarities and differences in the change narratives provided by MBT and DBT, and how these narratives reflect the rationale, explanations, and procedures of the provided treatment. Methods: The study is a qualitative analysis of seven interviews conducted by the authors. Three of the participants had received MBT, and four of the participants had received DBT. This study presents an Interpretative Phenomenological Analysis (IPA) of the change narratives received in two specialized treatments for BPD. Results: The main findings from the IPA were that the change narratives described by the participants reflected the treatment they received. The DBT participants highlighted explicit learning of tools and techniques, with predictable and safe therapists. In contrast, the MBT participants emphasized a long-lasting process of exploring to create procedural learning with therapists who followed their lead. Discussion: The participants' stories of change shed light on how a change narrative was developed, and therefore how the rationale, explanations and procedures were conveyed differently by MBT and DBT.

Causality in psychotherapy research: Towards evidential pluralism.

Identifying causal relationships is at the heart of all scientific inquiry, and a means to evidence base practices and to guide policymaking. However, being aware of the complexities of interactions and relationships, scientists and academics are cautious about claiming causality. Researchers applying methods that deviate from the experimental design generally abstain from causal claims, reserving them for designs that adhere to the evidential ideals of empiricism (e.g., RCTs), motivated by the Humean conceptions of causality. Accordingly, results from other designs are ascribed lower explanatory power and scientific status. We discuss the relevance of also other perspectives of causality, such as dispositionalism and the power perspectives of various realist approaches, which emphasize intrinsic properties and contextual variations, as well as an inferentialist/epistemic approach that advocates causal explanations in terms of inferences and linguistic interaction. The discussion will be illustrated by the current situation within psychotherapy research and the APA Policy Statement on Evidence-Based Practice. The distinction between difference-making and causal production will be proposed as a possible means to evaluate the relevance of designs. We conclude that clarifying causal relationships is an ongoing process that requires the use of various designs and methods and advocate a stance of evidential pluralism.

Pedagogical stance in mentalization-based treatment.

BACKGROUND: A common aspect of evidence-based treatments for people with borderline personality disorder (BPD) is pedagogical interventions and formats. In mentalization-based treatment (MBT) the introductory course has a clear pedagogical format, but a pedagogical stance is not otherwise defined. METHODS: Treatment integrity was quantitatively assessed in a sample of 346 individual MBT sessions. Nine group sessions and 24 individual MBT sessions were qualitatively subjected to interpretative phenomenological analysis (IPA). RESULTS: The dominating intervention type was MBT Item 16-therapist checking own understanding (31% of the interventions). IPA unveiled the following: (1) a pervasive, but hidden/implicit psychopedagogical agenda, (2) psychopedagogical content seemed precious for the patients, and (3) four tentative strategies for pedagogical interventions in MBT (a) independent reasoning; (b) epistemic trust; (c) mental flexibility; and (d) application of verified insights, knowledge, or strategies. CONCLUSION: Development and clarification of the pedagogical stance in MBT could further improve the quality of therapists' interventions.

Negotiating Gender in Everyday Life: Toward a Conceptual Model of Gender Dysphoria in Adolescents.

A growing number of adolescents are seeking medical care to alleviate gender dysphoria (GD). This qualitative study explored the subjective experiences of GD among help-seeking transgender and gender nonconforming (TGNC) youth in order to develop a more nuanced conceptualization of the phenomenon. Fifteen life-mode interviews were conducted with newly referred youth between the ages of 13 and 19. All participants were assigned female at birth. The data were analyzed using thematic analysis. The participants targeted five major themes that characterize GD: (1) Bodily sensations were constant reminders of GD throughout the day, (2) emotional memories from the past of being different and outside triggered GD, (3) the process of coming out was a transformative experience that changed how the participants understood themselves, (4) GD both increased and decreased in relation to others, (5) everyday life required careful negotiation to feel whole without developing new forms of GD. Based on the results, we suggest a more conceptually nuanced model of GD, one which accounts for how bodily sensations and emotional memories from the past were sources that elicited GD. The sources were mediated through the process of coming out and relating to others, and this resulted in the negotiation of GD today. The conceptual model suggested in the present study could ideally shed light on preexisting knowledge on TGNC youth struggling with GD. In addition, an improved understanding of GD could ideally help clinicians when addressing individual treatment needs.

Navigating in the dark: Meta-synthesis of subjective experiences of gender dysphoria amongst transgender and gender non-conforming youth.

OBJECTIVE: We conducted a meta-synthesis of qualitative research on subjective experiences of gender dysphoria (GD) amongst transgender and gender non-conforming (TGNC) youth in order to improve clinical encounters, complement existing knowledge and potentially influence future research. METHODS: We systematically searched for qualitative studies on GD in English, German, Spanish and Scandinavian languages in seven databases. Starting with 2000 articles, we finally included 12 papers in the meta-synthesis, following Noblit and Hare's (1988) seven steps for qualitative meta-synthesis research. RESULTS: Through the consistent comparison of key concepts, we were able to cluster the findings from the 12 included studies into four meta-themes: (1) the emerging understanding and awareness of GD was described as navigation in the dark, (2) the importance of relationships and societal norms, (3) the role of the body and the exploration of one's own body and (4) sexuality and sexual impulses. The young person's relation with his or her own body and sexuality influences subjective experiences of GD. The experiences are always mediated in relation with other people and societal norms, and they are both long-lasting and changing. CONCLUSION: The phenomenological analysis indicated that GD is a complex phenomenon involving manifold factors that changes across time and place for each individual. GD is not a static phenomenon but an expression of continuous negotiation amongst the body, its impulses, sexual desire and the relationships in which each person participates. Therefore, clinicians who treat TGNC youth should help them to reflect on this developmental process over time as a complement to medical approaches.

Antecedents of fathers' perception of child behavior at child age 12 months.

This study investigates whether fathers' adverse childhood experiences (ACE) and attachment style reported during pregnancy predict fathers' perception of child behavior assessed 12 months postpartum, expressed by the Parenting Stress Index (PSI), Child Domain. Prospective fathers (N = 835) were recruited to "The Little in Norway (LiN) study" (Moe & Smith) at nine well-baby clinics in Norway, with data collection composed of five time points during pregnancy and two time points postpartum (6 and 12 months). The main analyses included linear regression, path-analysis modeling, and intraclass correlation based on mixed effects modeling. First, linear regression analyses showed that neither fathers' ACE nor attachment style significantly predicted perceived child behavior postpartum directly. Furthermore, path analyses showed that ACE and less secure attachment style (especially avoidant attachment) measured early in pregnancy strongly predicted negatively perceived child behavior, mediated by fathers' mental health symptoms during pregnancy and partner disharmony postpartum. Second, intraclass correlation analyses showed that fathers' perceived child behavior showed substantial stability between 6 and 12 months postpartum. Family interventions beginning in pregnancy may be most beneficial given that fathers' early experiences and perceptions of attachment in pregnancy were associated with later partner disharmony and stress.

Este estudio investiga si las experiencias adversas de los papás en su niñez y el estilo de afectividad reportado durante el embarazo predicen las percepciones de los papás sobre el comportamiento del niño según evaluación a los 12 meses después del parto, expresada por el Índice de Estrés de Crianza (PSI), Ámbito del Niño. Los papás con la posibilidad de participar (N = 835) fueron reclutados para el "estudio El Pequeño en Noruega (LiN)" (Moe y Smith, 2010) en nueve clínicas de revisión pediátrica en Noruega, con un proceso de recoger información compuesto de cinco momentos temporales durante el embarazo y dos momentos después del parto (6 y 12 meses). Los análisis principales incluyeron regresión lineal, diseños de análisis de trayectoria y correlación intraclase basados en diseños de efectos mixtos. Primero, los análisis de regresión lineal mostraron que ni las experiencias adversas de los papás en su niñez ni el estilo de afectividad predijeron significativamente la percepción del comportamiento del niño posterior al parto directamente. Es más, los análisis de trayectoria mostraron que las experiencias adversas en la niñez y un menos seguro estilo de afectividad (especialmente la afectividad esquiva) tal como fueron medidos a principios del embarazo predijeron fuertemente la percepción negativa del comportamiento del niño, todo lo cual fue mediado por los síntomas de salud mental de los papás durante el embarazo y la desarmonía de la pareja después del parto. Segundo, los análisis de correlación intraclase mostraron que la percepción que tenían los papás acerca del comportamiento del niño mostraba una estabilidad sustancial entre los 6 y 12 meses después del parto. Las intervenciones familiares que comienzan durante el embarazo pudieran ser más beneficiosas dado que las tempranas experiencias de los papás y sus percepciones de la afectividad durante el embarazo se asociaron con la posterior desarmonía y estrés de la pareja.

Cette étude s'est interrogée si les expériences adverses de l'enfance des pères et le style d'attachement rapporté durant la grossesse prédisait la perception des pères du comportement de l'enfant évalué 12 mois après la naissance, exprimé par l'Index de Stress de Parentage (en anglais PSI), le Domaine de l'Enfant. Des pères potentiels (N = 835) ont été recruté pour l'étude norvégienne "The Little in Norway (LiN) study" (Moe & Smith, 2010) dans neuf cliniques de bien-être du bébé en Norvège, avec un recueil de données comprenant cinq points de recueil durant la grossesse et deux après la grossesse (6 et 12 mois). Les analyses principales ont inclus une régression linéaire, une modélisation de l'analyse des trajectoires et une corrélation intraclasse basée sur une modélisation des effets mixtes. Tout d'abord, les analyses de régression linéaires ont montré que ni les expériences adverses vécues par les pères durant leur enfance ni le style d'attachement ne prédisait directement de façon importante le comportement de l'enfant perçu après la naissance. De plus les analyses de parcours ont montré que les expériences adverses vécues pendant l'enfance et le style d'attachement moins sécure (particulièrement l'attachement évitant) mesurés tôt dans la grossesse prédisaient fortement le comportement de l'enfant perçu négativement, médié par les symptômes de santé mentale des pères durant la grossesse et la discorde entre partenaires après la naissance. Deuxièmement les analyses de corrélation intraclasse ont montré que le comportement de l'enfant perçu des pères faisait preuve de stabilité substantielle entre 6 et 12 mois après la naissance. Des interventions sur la famille commençant durant la grossesse peuvent être plus bénéfiques au vu des expériences vécues des pères et les perceptions de l'attachement durant la grossesse étaient liées à la discorde ultérieure entre les partenaires et au stress.

The Epistemological Stance of Psychoanalysis: Revisiting the Kantian Legacy.

Psychoanalysis, as conceived by Freud, originates from an epistemological position that is often at odds with related disciplines such as psychology and psychiatry. We argue that psychoanalysis is wedded to a Kantian epistemology that is rigorously committed to modesty. The aim of the article is to illustrate how Freud's thinking was embedded within a Kantian epistemology. Even if he was not explicit, a prevailing Kantian philosophical discussion influenced Freud. Hence, the article shall not argue for Freud as working with Kant as a philosopher, but more narrowly address his epistemological stance as influenced by Kant. Drawing on recent philosophical work, we clarify the difference between a Kantian transcendental idealism and the more modern critical realism, and show why the former is best suited for the psychoanalytic enterprise. This leads to a discussion of how we may understand transcendental idealism as a crucial if tacit premise in modern object-relations theory. We touch upon the implicit epistemological position in Klein and Winnicott, and the more explicit one advanced by Bion. Finally, we explore the psychoanalytic attitude towards the possibility of knowledge.

A listening perspective in psychotherapy with suicidal patients: Establishing convergence in therapists and patients private theories on suicidality and cure.

OBJECTIVE: To explore ways that psychotherapists and suicidal patients handle suicidality as a topic, and how it impacts the bond between them. METHOD: Nineteen suicidal patients and their therapists participated in a naturalistic study. Patients were interviewed before they started in therapy, and both patients and therapists were interviewed after three sessions and after one year. RESULTS: Whether suicidality was frequently or seldomly addressed during the sessions did not bear any direct influence on the establishment of a working alliance. Rather, the sense of being engaged in a process of change followed from the therapist's capacity to establish a wide listening perspective, with sensitivity towards their own uncertainties, as well as to implicit and explicit messages about the patient's state of mind. The "private theories" of suicidality and cure that were held by the two parties tended to converge as a result of their work together. If convergence was not established early on, what mattered was their capacity to detect and work on their divergences. Unaddressed divergences led to vicissitudes and eventually resignation. CONCLUSIONS: Listening and exploring divergences in private theories of cure mattered for the creation of a viable working alliance directed at the patient's efforts to live their life.

Analytic change: Assessing ways of being in a psychoanalytic follow-up interview.

The article argues that the concepts of relational scenario, structuralized affect and actualized affect are proposed candidates for observation of changes in relational ways of being as it is expressed in transference. A psychoanalytic follow-up interview of a former analytic patient is presented in order to illustrate how change in relational ways of being may be registered and studied. By triangulating the patient's verbal report of change with nonverbal information and transference-countertransference dynamics, one may grasp qualitative changes in relational ways of being. The case presented illustrates a former patient's on-going process of working towards representing aggression in a more direct manner and how this process is made observable with the aid of the proposed concepts in the interview situation. The proposed concepts of relational scenario, structuralized and actualized affect discussed are compared to the concept of transference used in studies of core conflictual relationship theme (CCRT).

"Yes, of course it hurts when buds are breaking": therapist reactions to an adolescent client's sexual material in psychodynamic psychotherapy.

This article focuses on the therapist's emotional reactions to a young female client's revelations about her fear of being raped that came up in the course of an open-ended psychodynamic psychotherapy. The client suffered from depression and emotional disturbance related to the overwhelming developmental tasks of adolescence, including individuation and psychosexual development. The patient's fears and nightmares not only raised ethical dilemmas in the therapist regarding how to handle the implications of these revelations but also reactivated the therapist's own issues from her adolescent period. The fact that the material of the patient found a "hook" (Gabbard, 1995) in the therapist enabled a deeper understanding of the patient that helped resolve her inner conflicts and move on in her development.