Clarifying values in psychotherapy.

This article addresses the complex issue of how to clarify conflicts involving value judgments. The author reviews his experiences as therapist, supervisor, and consultant in offering second opinions on in-progress therapies. He summarizes six major obstacles to effective value clarifications and interpretations. Therapists can help patients to explicitly verbalize otherwise only implicit values. Distress from guilt and shame can be reduced by helping a patient reprioritize values and gain self-reflective awareness skills for resolving moral dilemmas.

Prolonged grief disorder: Psychometric validation of criteria proposed for DSM-V and ICD-11.

BACKGROUND: Bereavement is a universal experience, and its association with excess morbidity and mortality is well established. Nevertheless, grief becomes a serious health concern for a relative few. For such individuals, intense grief persists, is distressing and disabling, and may meet criteria as a distinct mental disorder. At present, grief is not recognized as a mental disorder in the DSM-IV or ICD-10. The goal of this study was to determine the psychometric validity of criteria for prolonged grief disorder (PGD) to enhance the detection and potential treatment of bereaved individuals at heightened risk of persistent distress and dysfunction. METHODS AND FINDINGS: A total of 291 bereaved respondents were interviewed three times, grouped as 0-6, 6-12, and 12-24 mo post-loss. Item response theory (IRT) analyses derived the most informative, unbiased PGD symptoms. Combinatoric analyses identified the most sensitive and specific PGD algorithm that was then tested to evaluate its psychometric validity. Criteria require reactions to a significant loss that involve the experience of yearning (e.g., physical or emotional suffering as a result of the desired, but unfulfilled, reunion with the deceased) and at least five of the following nine symptoms experienced at least daily or to a disabling degree: feeling emotionally numb, stunned, or that life is meaningless; experiencing mistrust; bitterness over the loss; difficulty accepting the loss; identity confusion; avoidance of the reality of the loss; or difficulty moving on with life. Symptoms must be present at sufficiently high levels at least six mo from the death and be associated with functional impairment. CONCLUSIONS: The criteria set for PGD appear able to identify bereaved persons at heightened risk for enduring distress and dysfunction. The results support the psychometric validity of the criteria for PGD that we propose for inclusion in DSM-V and ICD-11. Please see later in the article for Editors' Summary.

Formulating transference in cognitive and dynamic psychotherapies using role relationship models.

Configurational analysis, a system that can be used to organize formulations of transference phenomena, may be helpful to cognitive behavioral as well as psychodynamic therapists. We interviewed 41 experienced psychotherapists, 24 of whom were psychodynamic therapists and 17 of whom were cognitive-behavioral therapists. The therapists first each rated one of their well-known patients on a list of 12 simple positive and negative transferences. Next, they described the patient's transference in their own words. After that, each therapist formulated the same patient's transference contents according to a more complex format, the Role Relationships Model Configuration (RRMC). Both groups reported relatively similar levels of both positive and negative transference reactions. Both groups found the RRMC format useful, with 38 (92.7%) of the 41 therapists indicating that they found the RRMC method "moderately" to "very" useful. Using the RRMC as a structured approach to identify and describe transference and relationship patterns appears to be helpful to psychotherapists with different theoretical orientations.

Value reprioritization in psychoanalysis.

As psychoanalysts, we sometimes seem to regard values as radioactive materials that must be handled with heavy lead gloves. But the gloves should not be so thick that they interfere with the goal of sorting out values. Reasons for our hesitation to deal with issues related to values may include real disagreements with the morals of a patient, a fear of evoking unproductive and negative emotional states, and our own unresolved conflicts about value dilemmas. Psychoanalytic technique should at times include clear verbal statements of values. By being explicit about what is often implicit, we can help our patients in their work of ameliorating harsh, primitive, and critical attitudes and to self-own rules, principles, and codes of conduct. A patient with reprioritized personal values may then function with heightened interpersonal compassion, kindness, and cooperation, gaining in return love, intimacy, respect, and self-esteem.

Addressing nicotine dependence in psychodynamic psychotherapy: perspectives from residency training.

OBJECTIVE: According to APA treatment recommendations, psychiatrists should assess and intervene in tobacco use with all of their patients who smoke. The ease with which this occurs may vary by treatment model. This study examined perspectives in residency training to identify a framework for addressing nicotine dependence within psychodynamic psychotherapy. METHOD: The authors collected data from a focus group of psychiatry residents and interviews with psychiatry residency faculty with expertise in psychodynamic psychotherapy. The transcribed interviews were analyzed for key themes and synthesized. RESULTS: Though the residents reported hesitancy to address patients' tobacco use, specifically in psychodynamic psychotherapy, the consensus from the expert faculty consultants was that tobacco interventions can and should be incorporated. The faculty provided suggestions, consistent with a psychodynamic formulation, for assessing patients' tobacco use and their interest in quitting, providing cessation treatment and/or referrals, and following up with patients to address relapse. CONCLUSIONS: The findings provide a useful framework, consistent with a psychodynamic model, for assessing and treating tobacco use with patients. Additional training and supervision likely are needed to increase residents' confidence and comfort with implementing these strategies.

Horowitz's Impact of Event Scale evaluation of 20 years of use.

OBJECTIVE: The main objective of this meta-analysis was to model the relations between a set of independent variables (age and gender of the trauma group, country where the study was performed, year of publication, type of event, time elapsed between event and measurement) and stress symptoms. METHODS: Data from 66 studies that used Horowitz's IES to examine the psychological impact of a major life event were subjected to meta-analysis. RESULTS: Results from hierarchical regression analysis indicated that type of event (episodes of illness and injury, natural and technological disaster, bereavement and loss, violence, sexual abuse, and war exposure) is a strong predictor of levels of intrusive and avoidant symptoms after a traumatic event. Intrusive and avoidant reactions reported by trauma victims tended to decrease linearly over time after the trauma. This finding was supported by the results reported by 20 different studies of stress reactions at two different time points after various events. Gender and cultural difference were relatively insignificant, whereas type of event induced different levels of stress reactions as measured with the IES. CONCLUSION: These data provide evidence for the value of the IES as a measure of stress reactions in a number of different populations. Data summarized here will be useful as a comparison resource in future studies of stress response syndromes.

Impact of Event Scale: psychometric properties.

BACKGROUND: For more than 20 years, the Impact of Event Scale (IES) has been widely used as a measure of stress reactions after traumatic events. AIMS: To review studies that evaluated the IES's psychometric properties. METHOD: Literature review. RESULTS: The results indicated that the IES's two-factor structure is stable over different types of events, that it can discriminate between stress reactions at different times after the event, and that it has convergent validity with observer-diagnosed post-traumatic stress disorder. The use of IES in many psychopharmacological trials and outcome studies is supportive of the measure's clinical relevance. CONCLUSIONS: The IES is a useful measure of stress reactions after a range of traumatic events, and it is valuable for detecting individuals who require treatment.

Diagnosis and treatment of stress response syndromes : General principles

Clinical assessment of persons exposed to external stress events requires careful inquiry into both kinds of deflection from a homeostatic (or homeokinetic) state: extreme warding-off of the stress event and its implications, resulting in ideational denial and emotional numbing; and intrusive repetitiousness of memories and associations to the stress event, with pangs of painful feeling. Across groups of persons, there is a general tendency to denial first and the intrusion, in a progression of phasic responses to stress. Individuals will vary in the order of entry into such phases, time spent in a phase, degree of ascillation between phases, and specific manifestations during any phase. Treatment, in addition to orientation according to individual personality, should be phase-specific (AU)