神経科学

こんな時代なので
精神療法という
まったく心理の領域の出来事を
神経科学でどこまで説明できそうかという問題については
興味がわく

還元主義的方法論からすれば
当然神経細胞の働きに還元されるべき事なのである

しかしながら
たとえば
ある人の名前を思い出すとして
どこにどのように記憶されてあるものか
どのように想起するものか
その程度のことさえまだ科学になっていない

記憶のかけらはどこにどのように収納されているのか
判断の原型はどこでどのように発動しているのか

科学になっていない

そのことを残念に思うが
科学になるだろう時の概略を想像してみることもできる
そのことの楽しみはある 

教育分析

教育分析で何が起こりどのような結末になるか
そのことも人間の心理を考える上でなかなかよい材料になると思う

人間とは徹底的にそのような存在なのである

The Neuroscience of Psychotherapy: Building and Rebuilding the Human Brain

For years, the brain has been viewed as a relatively static entity, determined by the interaction of genetic preprogramming and early childhood experience.

In contrast to this view, recent theoretical perspectives and technological advances in brain imaging have revealed that the brain is an organ continually built and re-built by one's experiences. We are now beginning to learn that many forms of psychotherapy, developed in the absence of any scientific understanding of the brain, are supported by neuroscientific findings.

Louis Cozolino's The Neuroscience of Psychotherapy illustrates in a clearly written and accessible way how the brain's architecture is related to the problems, passions, and aspirations of human beings. As Cozolino so eloquently argues, all forms of psychotherapy-from psychoanalysis to behavioral interventions-are successful to the extent to which they enhance change in relevant neural circuits.

Beginning with an overview of the intersecting fields of neuroscience and psychotherapy, this book delves into the brain's inner workings, from basic neuronal building blocks to complex systems of memory, language, and the organization of experience. It continues by explaining the development and organization of the healthy brain and the unhealthy brain. Common problems such as anxiety, trauma, and codependency are discussed from a scientific and clinical perspective. Cozolino concludes by introducing the emerging paradigm of the psychotherapist-as-neuroscientist and presents some practical applications of neuroscience to psychotherapy. Throughout the book, the science behind the brain's workings is applied to day-to-day experience and clinical practice.

Written for psychotherapists and others interested in the relationship between brain and behavior, this book encourages us to consider the brain when attempting to understand human development, mental illness, and psychological health.

About the Author

Louis Cozolino, PhD, is Professor of Psychology at Pepperdine University and a private practitioner. He is the author of The Healthy Aging Brain, The Neuroscience of Human Relationships, The Neuroscience of Psychotherapy, and The Making of a Therapist.

\\\\\

The Neuroscience of Human Relationships: Attachment And the Developing Social Brain (Norton Series on Interpersonal Neurobiology)

Louis Cozolino (Author)

The Neuroscience of Psychotherapy: Healing the Social Brain  

The Mindful Therapist: A Clinician's Guide to Mindsight and Neural Integration (Norton Series on Interpersonal Neurobiology) by Daniel J. Siegel 

On Learning from the Patient

On Learning from the Patient

Patrick Casement

Further Learning from the Patient: The Analytic Space and Process [Paperback]

Patrick Casement (Author) 

 

 Review

"An excellent book which conveys expressively what may happen in a 

vivid psychoanalytic encounter. It will presumably establish a firm 

place for itself in psychoanalytic training." - Ludwig Haesler, 

Bulletin of the European Federation of Psychoanalysts

 

Product Description

On Learning from the Patient is concerned with the potential for 

psychoanalytic thinking to become self-perpetuating. Patrick Casement 

explores afresh the dynamics of the helping relationship - learning to

 recognize how patients offer cues to the therapeutic experience that 

they are unconsciously in search of. Using many telling clinical 

examples, he illustrates how, through trial identification, he has 

learned to monitor the implications of his own contributions to a 

session from the viewpoint of the patient. He thus shows how, with the

 aid of this internal supervision, many initial failures to respond 

appropriately can be remedied and even used to the benefit of the 

therapeutic work. By learning to distinguish better what helps the 

therapeutic process from what hinders it, ways are discovered whereby 

the circularity of pre-conception can more effectively be avoided by 

those who aim to understand the unconscious of others. From this 

lively examination of key clinical issues, the author comes to see 

psychoanalytic therapy as a process of re-discovering theory - and 

developing a technique that is more specifically related to the 

individual patient.

 

The dynamics illustrated here, particularly the processes of 

interactive communication and containment, occur in any helping 

relationship and are applicable throughout the caring professions. 

Patrick Casement's unusually frank presentation of his own work, aided

 by his lucid and non-technical language, allows wide scope for 

readers to form their own ideas about the approach to technique he 

describes. This book, together with its sequel Further Learning from 

the Patient, will be invaluable to trainee and practising analysts or 

therapists, and those teaching in related professions.

私は妄想症であるという陳述

これは「私は嘘つきである」という自己言及陳述と同じではない

私は一部分は妄想症であると正確に判断できる自分が一部分いる
との意味であるかもしれないし

自己言及的に
「私は妄想症である」という妄想症に支配されているとの事態も考えられる

私は妄想症であると語り、全くパラドックスに陥らない場合もたくさんある

妄想は妄想、それを判断する部分は判断する部分
なぜ訂正しないかは謎だけれど、これが自分の妄想だと思っているので訂正しないのかもしれない 

Introducing Cognitive Analytic Therapy. Principles and Practice By Anthony Ryle & Ian B. Kerr

Introducing Cognitive Analytic Therapy. Principles and Practice

By Anthony Ryle & Ian B. Kerr

 

Isaac Marks, Emeritus Professor 　この名誉教授先生が書評を書いた

Leningradで ‘Pavlovian’ psychotherapyなんて余計なことを書いたものだから
Ryleさんも、いったいなんだってーの、何も関係ないでしょ、と食いついた

どういう評価であれCATということばをこれだけ反復して使いまくってくれているのは
書評を依頼された人としてある種、誠実なのかもしれない
たいてい、中身なんか読まない
CATという文字だけ頭に残る

 

Reading this book brought to mind a sobering experience from my youth.

 In 1966, I visited a psychotherapy institute in Leningrad (now St 

Petersburg). Its doctors said they used ‘Pavlovian’ psychotherapy. 

How did they do this? They admitted patients, took a detailed history 

of their upbringing and showed them how current maladaptive behaviours

 grew out of earlier forms of interaction with family and others which

 needed revision to become more appropriate to current circumstances. 

Western psychotherapists using a similar approach might have been 

surprised to hear that Pavlov was its progenitor. Now Ryle & Kerr see 

it as part of cognitive analytic therapy (CAT), which takes about 16 

sessions. Together with the patient, the therapist writes a 

reformulation letter that sets out aims in therapy. The patient 

self-monitors, with the help of a diary, to spot problems as they 

arise and try to revise them, and rates target problems. The patient 

and therapist exchange goodbye letters at the penultimate or last 

session to review what has been achieved or remains to be done, and 

follow-up is arranged.

パブロフを持ち出しても持ち出さなくても
過去に形成された行動思考パターンが繰り返される
意識化されないものは反復して行動化される
というだけの話で
まったく平明な話である

問題を探り出す部分では精神分析的な手法が役に立つし
それを訂正するなりする場合には認知療法の手法が役に立つ

これも全く平明な話 

 

治療目標を決めて
日記を書き
問題に焦点を当て
だんだん良くなって
最後にお手紙を書きましょうというのだそうだ

書くことが好きな人には向いていると思う 

 

Case examples show how CAT assessment is done and reformulation 

letters and diagrams are constructed. Its use of a goal-oriented 

approach, diary-keeping, self-ratings and collaboration with the 

patient overlaps with the practice of behavioural and cognitive 

therapists. However, a case history of CAT in a patient with 

obsessive?compulsive rituals (pp. 138-144) highlights how CAT differs 

from behaviour therapy by exposure and ritual prevention: the ‘ 

target problem’ procedures did not mention the rituals, the 

post-treatment rating of improvement did not say whether or not 

rituals reduced, and a mean of 16 sessions of ‘brief’ CAT exceeds 

the 9 sessions usual with face-to-face behavioural therapy, let alone 

the single hour of clinician contact needed with computer-aided 

behavioural therapy. The authors acknowledge the paucity of controlled

 trials of CAT. The aim of CAT in early dementia seemed unclear (p. 

156).

The authors say that CAT derives its ideas from evolutionary 

psychology, genetics, developmental neurobiology and psychology, and 

uses a ‘ Vygotskian perspective’ regarding ‘sign mediation’, ‘ 

Bakhtinian concepts of the dialogic self’ and ‘Kellyian personal 

construct therapy, cognitive therapy and psychoanalytic object 

relations theory’. These supposed roots remind one of the historian's

 warning of ‘idols of origin’.

A would-be practitioner might learn more from the book's case 

illustrations than its turgid theoretical digressions, replete with 

redundant argot. We need not have heard of Vygotsky to know about 

meaning, intention and signs, or of Bakhtin to know that we are social

 beings.

The case histories give an idea of what CAT is about, but the book 

testifies to the long journey ahead before psychotherapy can reach the

 authors' laudable goal of a lucid language, method and evidence-base 

shared by all practitioners.

ソフトを更新しなければならないとき

PCを使っていて
ソフトを更新しなければならないことがある

そのソフトを20年使ってきたのに更新しなければならないとすれば
たぶん環境と適合しなくなっているせいだと思う

新しいソフトならば間違いもあるが
代々使ってきたソフトにそんなに間違いはない

ただ道路は歩行者は右側通行とか赤は止まれとか
そのレベルのルールに変更があった場合は
やはりソフトの変更が必要になる

そのような意味でのソフトの変更をCBTは担当する

BSキーが効かないから
しばらくDelキーで何とかするとか
操作法の話だ
それもCBTの範囲内のことだ

全体として一番大きな要因はやはり環境が変化することである

たとえば虫などは環境変化にたいしてDNA変化で対応している
人間は脳に乗せているソフトの変更だけで乗り切ることができる

それが原則である
しかしそれができないこともある
そこでソフトの変更を一緒に考えることになる

ーーーーー
ハードとソフトを分別して述べているのだが
PCならばソフトはハードディスクに情報として収録されている

脳の場合はどこにどのような形でソフトの情報が収録されているのかと考えると
ハードとの区別はやや曖昧になる

いずれにしても環境に対する曖昧な部分があるから
日本語でも英語でも学習できるわけだ 

ハードとしては普遍文法が組み込まれていて
そこに各種言語が乗せられる
そのようなイメージ
そしてどこが壊れているのか調べることになる

 

 

 

 

思ったことは書けない

思ったことが書けないブログ
どうでもいいことしか書かないブログ

でも
わかっている人が読めば
あの事はこうだったのかと
分かるブログ

ややこしくてかなわん 

不幸のきっかけと本当の不幸

不幸のきっかけと本当の不幸とは別のものであることがある

捻挫したのがきっかけで
肥満となり
結果として認知症になったとか

雨に降られたのがきっかけで
風邪を引き
肺炎になったことにされて
そのまま死んだとか
ただ雨に降られただけなのに

汝自身を知れ-3

汝自身を知れという場合に
個人的に第一はやはり精神分析だと思う

精神分析がいかにして治療であるかは
かなり問題がある

治療の総体としては
CBTがやはり第一の大河となっていると思う

普通に考えたら
精神分析で原因、症状を知り
CBTで治療するのが合理的であると思う 

汝自身を知れ-2

汝自身を知れ
なんて言われるくらいの場面では
はっきり言うのも面倒くさいが
ちょっと点検してみたほうがいいよ
というくらいの意味になる

自分自身についての不都合な真実について認識したらどうかということで
まるで認知療法の変形である

認知療法の寛大なところは
あなたが思い込んでいるよりも現実は悪くないですよと
懇切丁寧に何度でも教えることだ
別の方法がありますよと
なんどでも教えてくれる

あなたが思い込んでいるより現実は悪いですよという話は告知とかそんなことになる
治療法とも言えない
賢い人はそんなことをしたら逆恨みされると知っているのでなるべく回避する

知らないほうが幸せなんだろうなと
思うこともしばしばである
結局、言わない

汝自身を知らなくて良い
どうせみんな死ぬんだし
正確な認識なんて保証もないわけだし
少しの間でも幸せならそれでいいのだろう
愚かさに応じて幸せでいれば良い

賢さのゆえに不幸せになるのも仕方がない

ーーー
しかし愚かであるがゆえに幸せということがあるものだろうか
また賢いがゆえに不幸せであるということがあるものだろうか



 

汝自身を知れ

自分自身を知ることは難しい

鏡を見れば分かりそうなものだけれど
たいていは「この鏡が歪んでいる」と思うものだ

ということは鏡によって歪められていない
本当の自分の姿を知っているということになるのだろうか

そして長い間見続けていると歪んだ顔が当たり前になり
美しくさえ思えてくる
恐ろしいことだ
そして自分に似た要素を持つ他人を好きになる

電車で見かける夫婦や恋人たちのどことなく似ている顔つき

ナルシスは池に映る自分に恋をする

もう自分の顔が歪んでいるとも鏡が歪んでいるとも
考えなくなっている
大抵の場合は両方が歪んでいるのだが
平凡な幸せのためには
何も知らないほうがいい

ところがそんななかで
白雪姫の継母の鏡は無慈悲に真実を告げる
誰も幸せにならない真実 

白雪姫の継母の鏡は「声」で真実を告げる
その声の主は誰か

声の主は社会である

人間は社会の中に生きることなく
ただ自分と向き合っているだけのとき
途方もなくナルシストである
二人でいる時も自己愛を備給しあうだけで基本的にナルシストである

三人になったとき
この人は自分ともう一人とどちらが好きなのだろうと
疑念がわく
この意味での嫉妬は基本的に重要である
ある人から見て、私はもう一人より上なのか下なのか

この人には自分ともう一人がどのように見えているのだろうかと想像を始める
その想像の総体が社会である

ここでいう社会とは自由平等で一人が一票の民主主義社会ではない
社会科で習う社会ではない

想像上の嫉妬と優越感の総体
その中に自分というものが位置づけられる
ある種の座標軸

動物行動学では順位性社会を説明して
それを社会の原型とする
それも強力な説明である

しかしそれを原型として
そこからどの程度妄想的に離れるかが人間のありようである

自意識というものを持たない場合は
動物行動学の原理が原理となるのかもしれない

しかし自意識はそれを修飾してさらには逸脱してゆく

逸脱した自意識が見事に同期して集団として機能している
そこが奇跡だと思う

法というものをなぜ認め合っているかといえば
ほぼ全ては恐怖のためだと思うが
極めて一部は、このようにして生成された個人内部の社会が、集団に共有されるとみなされる部分があり
それを法とみなしているものだろう

分析認知療法 Anaiytic-cognitive therapy ANCOT

精神的な困難の原因を探るとして二つの大きな柱は
精神病理学と精神分析学だと思う

器質性の疾患については精神病理学
心因性の疾患については精神分析学
がまずもっとも蓄積があり説得力もある

PCの不具合の時にハードの問題なのかソフトの問題なのかと
考えるのと似ているとたとえとして用いてもよいかも知れない

問題がソフトにあるならばパッチを当てたりバージョンアップすればいいことだ
それに相当するのが認知行動療法である

したがって
個人的な結論としては
1.まず問題がハードなのにあるのかソフトにあるのか見極める
2.ハードの問題ならば第一に薬剤が大切である
3.ソフトの問題ならば薬剤を開始すると共に、精神分析で原因を見極めて
認知行動療法でソフトを改善、バージョン・アップすれば
解決するだろうと思う

ーーー
イギリスのしょぼい流派が自分たちのことを
cognitive-analytic therapy と自称しているのだが
多くの弱小流派と同じで
認知行動療法と同じくらい効くと言い張っている
なぜかいずれも認知利用法と同じく16回で治ると言い張る

みんな同じからくりでみんな同じようにしょぼい
いい治療法部分はおおかた認知行動療法が取ってしまったので
仕方がないと思われる

しかしそのことを確認するためにも
認知分析療法の文献を集めて読む羽目になっている

読んでみると、ほかのインチキ流派よりは少しはまともで、まともである故に
穏当な意見しか言えず、従って埋没してゆくようである

ーーーー
誰がどう考えても
ソフトの不具合ならば
精神分析で原因を探り
認知療法でソフトの手直しをすればいいに決まっているので
個人的に「分析認知療法」と名前を付けて研究することにした。 
だつて分析してから認知療法するのだから、このネーミングが正しい

ーーー
この世界ではACTが既に二つもあり紛らわしいのだが
Anaiytic-cognitive therapy を素直に頭文字を取ると　これもACTになってしまう

そこで個人的にANCOTと名付けることにした
日本語では分析認知療法である。 

ーーーーー
世界ANCOT学会事務局を品川心療内科に置き
会長は私が務める

日本ANCOT支部は新橋心療内科に置き
日本支部会長はI先生にお願いする
ANCOT治療者としての経験と適性を見極めて
I先生が極めて恣意的に資格を認定する

世界ANCOT学会事務局の事務長は田中、事務局員として木幡、高野が当たる。
誰も英語は出来ないので全て日本語しか受け付けない。
といっても誰も全く用はないと思うので電話もない。

ただここで明らかに設立を宣言したので、そのつもりでよろしく。
約款その他は追々明らかにする。
その中で入会規約、入会費用、維持費用、ワークショップ参加費用、その他を発表する。
まず法人登記をしよう。

 

Elizabeth Wilde McCormick Change for the Better: Self Help Through Practical Psychotherapy

Change for the Better: Self-Help through Practical Psychotherapy 

Elizabeth Wilde McCormick

Product Description

'This is a guide for real people living and struggling in real life, ordinary circumstances… it is full of humane, creative compassion for those who would like to change' - Counselling Psychology Review

Change for the Better, Third Edition is a popular, practical guide for therapists and clients which describes in ordinary language how learned patterns of response contribute to psychological problems such as depression, anxiety, phobia, and relationship difficulty.

Presenting an easy-to-follow programme, leading psychotherapist, Elizabeth Wilde-McCormick shows readers how to identify their own different inner dialogues, and the traps, dilemmas, snags, and unstable states of mind that lead to things going wrong. Exercises feature throughout the book to enable self-reflection and help the reader achieve lasting change.

Based on Cognitive Analytic Therapy, a focussed short term therapy pioneered and developed at Guy's and St Thomas' Hospitals in London, Change for the Better, Third Edition can be used as a self-contained self-help programme or as preparation for clients entering therapy. It is also recommended to students on CAT courses and many therapists find the book helpful in their own development and as a source of material to use directly with clients.

In response to its continuing popularity this Third Edition has been published, including the most recent development in CAT practice. The new edition also places emphasis upon the transformation of unhelpful learned reciprocal role procedures that underlie our relationship with ourselves and other people. It also features new chapters on unstable states of mind seen in people given a borderline personality diagnosis, on dissociation, eating problems, and stress.

Elizabeth Wilde McCormick has been in practice as a psychotherapist for over twenty five years. She is also a teacher, trainer and writer. She is a founder member of The Association for Cognitive Analytic Therapy at Guy's Hospital, London, and the author of a number of best-selling self-help books.


ーーーーーーーーーーーーーーーーーーーーーーーーーーーーーーーーーーーーーーーー

Change for the Better: Self-Help through Practical Psychotherapy
チェンジ・フォー・ザ・ベター：実際的な心理療法でセルフ‐ヘルプ
（より良い明日を求めて/素敵な明日のために/素敵な明日を手に入れよう/明日に向かって/素敵に変身？？）

Elizabeth Wilde McCormick

Product Description
内容

'This is a guide for real people living and struggling in real life, ordinary circumstances… it is full of humane, 
creative compassion for those who would like to change' - Counselling Psychology Review
「この本は、ごく普通の生活の中で苦しんでいる人々に贈るガイドです。変わりたいと思っている人々に対して思いやりのある、
想像力のある同情心でいっぱいです」－カウンセリング・サイコロジー・レビュー



Change for the Better, Third Edition is a popular, practical guide for therapists and clients which describes in ordinary language how learned patterns of response contribute to psychological problems such as depression, anxiety, phobia, and relationship difficulty.
「チェンジ・フォー・ザ・ベター」第３版は広く読まれている実践的ガイドである。日常的な言葉で、抑うつ、不安、恐怖症、人間関係のもつれなどの心理的な問題に対して、身についた返答のパターンがどのように貢献しているのかを説明している。



Presenting an easy-to-follow programme, leading psychotherapist, Elizabeth Wilde-McCormick shows readers how to identify their own different inner dialogues, and the traps, dilemmas, snags, and unstable states of mind that lead to things going wrong. Exercises feature throughout the book to enable self-reflection and help the reader achieve lasting change.
簡単にできるプログラムを提示して、一流の心理療法家であるElizabeth Wilde-McCormickは、読者に事態を悪化させる内的対話、わな、ジレンマ、予期できない障害、不安定な心に気づく方法を示している。


Based on Cognitive Analytic Therapy, a focussed short term therapy pioneered and developed at Guy's and St Thomas' Hospitals in London, Change for the Better, Third Edition can be used as a self-contained self-help programme or as preparation for clients entering therapy. It is also recommended to students on CAT courses and many therapists find the book helpful in their own development and as a source of material to use directly with clients.
認知分析療法に基づいた、焦点を絞った短期療法がロンドンの Guy's ＆ St Thomas' 病院で開発され発展した。「チェンジ・フォー・ザ・ベター」第３版はセルフ‐ヘルププログラムとしても、クライエントが心理療法を受ける前の準備としても用いることができる。



In response to its continuing popularity this Third Edition has been published, including the most recent development in CAT practice. The new edition also places emphasis upon the transformation of unhelpful learned reciprocal role procedures that underlie our relationship with ourselves and other people. It also features new chapters on unstable states of mind seen in people given a borderline personality diagnosis, on dissociation, eating problems, and stress.
人気が続いていることに答えてこの第三版が出版されました。ＣＡＴ実践における、ごく最近の発展についても書かれている。新版では、自分と他人との関係の基礎に流れている、役に立たない習得された仕返しの役割過程を変換することに重きが置かれている。境界性人格障害、解離性障害、摂食障害、ストレスと診断された人々に見られる不安定な心について、新しい章が割かれている。　　



Elizabeth Wilde McCormick has been in practice as a psychotherapist for over twenty five years. She is also a teacher, trainer and writer. She is a founder member of The Association for Cognitive Analytic Therapy at Guy's Hospital, London, and the author of a number of best-selling self-help books.
Elizabeth Wilde McCormick は２５年以上心理療法家として実践を重ねてきた。彼女は先生であり、トレーナーで作家でもある。彼女は認知分析療法協会（ガイズ病院、ロンドン）の設立メンバーであり、ベストセラーになっているいくつものセルフ‐ヘルプ本の作者である。

The Story of Research into Cognitive Analytic Therapy: Tony Ryle

The Story of Research into Cognitive Analytic Therapy:  Tony Ryle

Research has always been integral to the CAT approach. Dr Anthony Ryle, the founder of CAT, comments that: “Working with patients to find the best descriptions of what it was we were trying to change as part of outcome research, demonstrated to me the power of collaboratively arriving at such descriptions.” In this sense, research methodology is within every CAT therapy as well as being a way of looking at overall outcomes for patients and refining the model and method.

Introduction

CAT was formally defined as a distinct model in 1985 but it emerged from my descriptive, epidemiological and repertory grid research and conceptual developments of the previous decades (Ryle, 1967, 1969, 1975 and 1982) and from the general recognition of the common factors underlying change in psychotherapy. I was interested in the whole person perspective of dynamic psychotherapy but was frustrated by the fact that neither its process nor outcome was researched. As I saw it, such research required working with patients to establish their individual aims in a form which, in contrast to behavioural and the emerging cognitive models, identified underlying psychological processes and not just symptoms, thoughts and behaviours. Working with patients on the early reformulation of their presenting problems in these terms in order to produce descriptions which would allow the measurement of change proved so therapeutically powerful that it transformed my practice and became a key feature of what became CAT.

A complete list of published CAT studies, books and journal articles is published on the website and in the bibliography and reference list.

Early research contributing to the development of CAT

As in any new development, observation and description of the process and effects of therapy preceded large scale formal studies. Clinical practice, conceptual development and more formal research have continued to be mutually influential. Early research into individuals and small groups was carried out, combining the use of standard questionnaires with the measurement of individually identified features. Repertory grids offered a means of measuring relevant changes in how patients construed themselves and others, through the prediction of desirable changes in selected measures identified in pre-therapy grids. This was combined with rating changes in the individual Target Problems and underlying Target Problem Procedures which were arrived at in the reformulation process (Ryle, 1980). This research led to the first elaboration of a general model, the Procedural Sequence Model, later developed into the Procedural Sequence Object Relations Model (Ryle, 1982, 1990).

Studies of outcome

Brockman et al. (1987) reported a small randomised controlled trial comparing the effectiveness of CAT and a brief psychodynamic model, using both standard (nomothetic) and individual (ideographic) measures. CAT was more effective as measured by the latter, repertory grid-based, measures. Ryle and Golynkina (2000) published a descriptive, evaluated study of a series of cases of clients given a diagnosis of borderline personality disorder (BPD) treated with CAT. The clinically and statistically significant effect of adding CAT to a well developed service for older adolescents with borderline features was reported by Chanen et al., 2008, 2009 a and b in a large, well-designed RCT.

Many other evaluated but not controlled trials of CAT in a number of patient groups have been completed. Early CAT research anticipated the current demand for evidence based practice; the subsequent failure to offer more RCT-based evidence has a number of explanations, notably the fact that CAT has developed rapidly and in a number of geographical locations but has lacked a central academic base. Moreover, the ethical and design problems of RCTs and their limited clinical usefulness in psychotherapy research have been widely discussed. Single case experimental design studies offer more clinically relevant findings; Kellett (2005, 2007) has demonstrated the use of this methodology to study CAT with personality-disordered patients and this approach has been applied to a series of cases of BPD (Kellett, Bennett and Ryle, in preparation).

Studies of process

A number of investigations of aspects of process have been published. Bennett and Parry (1998) demonstrated the accuracy of reformulation. They developed an empirically-based model of good practice using the method of Task Analysis on the basis of which an audiotape-based measure of therapist’s general psychotherapy and specific CAT skills (CCAT) has been developed (Bennett and Parry, 2004). A study of how threats to the therapeutic alliance in the CAT treatment of BPD were dealt with led to the description of an empirically-validated model of CAT practice (Bennett, Parry and Ryle, 2006) providing a well designed adherence measure . This was applied and validated in a later study (Daly, Llewelyn and McDougall (2010). Recently Sue Llewelyn has shown correlation between good therapy outcome and the therapist’s ability to work with and overcome threats to the therapeutic alliance (Rupture-Repair model) (Daly, Llewellyn and McDougall, 2010).

The development of the clinical model

CAT grew from an initial attempt to integrate psychoanalytic and cognitive models and the process of differentiating from these sources continued. CAT-based critiques of psychoanalysis include Ryle, (1996, 2003) and of cognitive models include Ryle (2001, 2010). The incorporation of ideas from Vygotsky and Bakhtin and of evidence from developmental studies is described in Ryle and Kerr (2002).

The Multiple Self State Model (MSSM) of Borderline Personality Disorder identifying structural dissociation as a key feature was proposed (Ryle, 1997 a and b) and a repertory grid study confirmed that patients could identify the characteristics of their dissociated self states (Golynkina and Ryle, 1999). During the last decade three books were published describing the use of CAT with adult abuse survivors (Pollock, 2001), with older patients (Hepple and Sutton, 2004) and with offenders (Pollock, Stowell-Smith and Gopfert, 2006). The use of the CAT model within staff groups has been described and evaluated (Kerr, Dent-Brown and Parry, 2007; Thompson, Donnison, et al, 2008). CAT has also been used with clients in small groups (Duignan and Mitzman 1994, Maple and Simpson 1995, Hepple 2010).

The development of research tools

A questionnaire indicating poor personality integration, the Personality Structure Questionnaire (PSQ) (Pollock, Broadbent, Clarke et al., 2001) provides an effective screening tool and its repeated use provides an indication of the timing and extent of change in the degree of structural dissociation in the course of therapy. The States Description Procedure (SDP) (Bennett, Pollock and Ryle, 2005) and the revised version (SDPr) (Ryle, 2007) provide a basis for patients' guided self-reflection through which the number and characteristics of individual borderline patients' dissociated self states can be identified.

The current situation

More CAT-related research is in process and as the model becomes consolidated it is to be hoped that more formal studies will be carried out. But the close links between clinical experience, conceptual developments and the process and outcome research developments which has characterised CAT are likely to continue to yield more clinically relevant but imperfect studies of process than more formal conventionally-blessed outcome studies. The Research website will maintain an up-to-date list of published work and will aim to report work in press or in process.

Follow this link for the list of key references.

Training in Cognitive Analytic Therapy

Training in Cognitive Analytic Therapy

The Association for Cognitive Analytic Therapy accredits and supports a variety of training offered by its members. They aim to be flexible and responsive to the needs of trainees and to the resources of training groups. There are four types of course at present, offering different levels of training in CAT theory and practice. All training is aimed at introducing CAT to people with qualifications in professions allied to mental health work and are provided in service but may offer places to individuals who work outside of the NHS in relevant non-statutory services such as Eating Disorder services or Addiction services. 

CAT is a versatile approach to psychological help and currently there are three main areas of the application of CAT in practice.

• As a broadly based psychological therapy focusing on a collaborative educational and therapeutic relationship
• As a consultative or team training tool working with the context and systems around the client in difficulty
• As a method of teaching relational thinking and relational skills to enhance general professional and psychological skills in working with people.

Training courses emphasise these elements to differing degrees.

Introductory Courses:

These comprise either short, introductory workshops usually of one or two days in length or longer, six month to one year introductions. While certificates of attendance for CPD may be given, the courses are not assessed and do not lead to a qualification. [Booking via the ACAT website].

CAT is a broadly based psychological therapy focusing on a collaborative educational and therapeutic relationship

CAT Skills Training:

This training is designed for those working in the health and caring professions to acquire a basic understanding of CAT and to apply it to their routine work, rather than to practice CAT as an individual therapy. The training may be delivered to whole teams or to groups of interested individuals and it can be offered in a range of formats, to suit the requirements of the group. It is usually completed within one year and leads to an ACAT Skills Training Certificate.

Practitioner Training:

Practitioner training enables core professionals with competence in their own field to enhance their understanding and skills in psychological therapy by learning the theory and methods of CAT. These courses usually last two years and are assessed, leading to accreditation as a CAT Practitioner and eligibility for full membership of ACAT. The courses are held at a number of venues across the country. Most Practitioner trainings are Postgraduate Diplomas leading to ACAT Accreditation and a Diploma in CAT awarded by Sheffield Hallam University. Further information and application process can be found within each course link.

MSc Cognitive Analytic Therapy

ACAT now offers an MSc in CAT in collaboration with Sheffield Hallam University. This award constitutes the completion of a research stage of the CAT practitioner training (PG Diploma).

Psychotherapy Training:

Psychotherapy training enables CAT Practitioners to become Cognitive Analytic psychotherapists via an additional two-year assessed course, which leads to eligibility for registration with the United Kingdom Council for Psychotherapy. There is currently one Psychotherapy Training within ACAT, which is a two-year residential training (two year course with three residential weeks per year), known as the Interregional Residential ACAT Psychotherapy Training (IRRAPT). Applicants to the Psychotherapy Training must have completed a two-year CAT Practitioner training.

Supervisor Training
There is no formal training as a CAT Supervisor but instead applicants are required to produce a proposal to meet the accreditation criteria. The training is based upon an apprenticeship model provided by ACAT for experienced CAT practitioners and psychotherapists to progress towards accreditation as a CAT supervisor.

Accreditation of Prior Learning (APL) and Accreditation of Prior Experiential Learning (APEL):

In exceptional circumstances individuals may wish to have past training and experience recognised by ACAT and Sheffield Hallam University as equivalent to its current standards and to count towards an award. Guidelines exist outlining procedures for this route. The Sheffield Hallam procedures are currently under development.

Please make any general enquiries on training to the ACAT Office, Susan Van Baars [e-mail].

Current Training Courses

CAT Introductory Events

20th October 2011 to 21st October 2011 ------ Two Day Introduction to CAT for People with LD 
10th November 2011 to 11th November 2011 ------ Two day introduction to Cognitive Analytic Therapy 
26th January 2012 to 27th January 2012 ------ Two Day introduction to Cognitive Analytic Therapy 
23rd March 2012 to 24th March 2012 ------ Two day introduction to Cognitive Analytic Therapy 
28th June 2012 to 29th June 2012 ------ Two day introduction to Cognitive Analytic Therapy 

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CAT Practitioner Trainings

14th September 2011 to 12th June 2013 ------ CAT Practitioner Training - Newcastle 
20th September 2011 to 25th June 2013 ------ CAT Practitioner Training - North London 
21st September 2011 to 30th June 2013 ------ CAT Practitioner Training - Cornwall 
1st October 2011 to 30th June 2013 ------ CAT Practitioner Training - Brighton 
5th October 2011 to 30th June 2013 ------ CAT Practitioner Training - Berkshire 
6th October 2011 to 30th June 2013 ------ CAT Practitioner Training - North - now FULL 
9th January 2012 to 31st December 2013 ------ West Midlands CAT Practitioner Training 

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CAT Psychotherapist Trainings

1st October 2012 ------ Inter Regional Residential ACAT Psychotherapy Training 

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CAT Skills Trainings

1st October 2011 ------ CAT Skills for Working with Complex Clients in Adult Mental Health or Forensic Settings 

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CAT Supervisor Trainings

1st February 2012 to 3rd February 2012 ------ Residential Supervisor Training: Relational Skills in CAT Supervision 

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CAT Training Events

 

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MSc Cognitive Analytic Therapies

 

What is ACAT?

What is ACAT?

 

ACAT is the Association for Cognitive Analytic Therapy. It is a registered charity, number 1141793.

ACAT is a national association of members for the development of Cognitive Analytic Therapy. It has a membership of nearly 800 individual members.

ACAT’s aims are as follows:

Educating health professionals and promoting proper standards and good practice in  cognitive analytic therapy

Increasing awareness and understanding of cognitive analytic therapy amongst health professionals, service providers and the public

Through its aims, ACAT contributes to the development, maintenance and auditing of all CAT training courses and accredits CAT trainees.

ACAT facilitates research and the continuing professional development of all its members

ACAT is the guardian of standards within CAT, embodied in its Codes of Ethics and Practice and Complaints Procedures.

ACAT is a member of the International Association for Cognitive Analytic Therapy (ICATA).

ACAT is a member of the Cognitive Psychotherapies College (CPC) and Humanistic and Integrative Section (HIPS) of the United Kingdom Council for Psychotherapy (UKCP).

 

ACAT welcomes members of the public, health professionals, ACAT accredited professionals, and anyone interested in finding out more about CAT. We hope the Association, through this website and membership opportunities, will inform and inspire and, for those new to Cognitive Analytic Therapy, encourage further interest and, perhaps, even study.

Cognitive Analytic Therapy is an active and collaborative method of therapy and in this same spirit every member of ACAT is welcomed and encouraged to become actively involved in any aspect of the organisation.

the Association for Cognitive Analytic Therapy (ACAT)

http://www.acat.me.uk/page/home

 How does CAT work?

CAT is a very active therapy, inviting you to be the observer of your own life and to take part in what needs change. The changes needed may be small, such as stopping being caught in a trap of avoiding things, or they may be larger, such as finding new ways of relating to other people. The first thing that happens with any human encounter is our reaction to the other person. If we feel warm and happy we are likely to feel accepted. Conversely, if we feel got at, criticised or humiliated we tend to feel hurt and misunderstood, we might respond by being angry and defensive or give up trying and get depressed and isolated. Many of our automatic responses to other people stem from patterns of relating in early life. 

 

For example, if you had learned in your childhood that you only received love and care by pleasing others you might have the belief: ‘Only if I always do what others want will I be liked’ which puts you in a trap of pleasing others, and can lead to you feeling used and abused. When you realise you have got used to being in this trap you can start to notice how often it catches you and can begin to change what you do and learn to find other more useful ways of standing up for yourself and relating to others. CAT shows you the way to change your learned attitudes and beliefs about yourself and others, and helps you focus on ways to make better choices.

 

The process of a CAT therapy is to help us look at patterns of relating, and the effect these patterns are having on our relationships, our work and the way we are with ourselves. Together with your therapist, in the safety of the therapeutic relationship you will gradually develop an understanding of the ways in which you have learned to cope with what has happened in your life. Often people who have been through abuse, neglect or trauma feel bad about themselves and this can affect self-confidence. The active part of CAT helps you to take part in the process of change in your own way. CAT is a very creative therapy and the process of understanding and self discovery may involve painting as well as writing, movement , self-reflection and learning to self-monitor through journal keeping.

 

ーーー

CAT shows you the way to change your learned attitudes and beliefs about yourself and others, and helps you focus on ways to make better choices.

 

 

 

米ヒューレット・パッカード パソコン事業の分離 あるいは他社への売却

　米ヒューレット・パッカードは2011年8月18日（米国時間）、同社のパソコン事業の分離を検討していることを明らかにした。子会社として分割するか、あるいは他社への売却に向けた可能性を探る。1年～1年半後をめどに手続きを進める。

　同社は企業ユーザーや官公庁のユーザーに対してより高い付加価値を提供することを目指し、事業再編を進めている。クラウド関連サービスなどの提供にリソースを集中させるため、プリンター、ソフトウエア、サービス、サーバー、ストレージ、ネットワーク事業に注力することを決めたとしている。

　米IDCの調査によると同社のパソコン世界市場シェアは18.5％で第1位。2位のデルの12.5％を上回っていた。一方で、2011年第3四半期（5-7月期）における同社パソコン事業の収益は前年同期比で3％減と成長に陰りが見えつつあった。そのうち、企業向けパソコンの収益は9％増だったが、個人向けパソコンは17％減だった。

　同時に、同社が展開していた携帯端末向けOS「webOS」については、スマートフォンやタブレットの開発を取りやめると発表した。webOSのソフトウエア資産としての価値を高める方向性は今後も模索していくという。同社は、2010年7月にwebOSを開発した米パームを買収し、スマートフォンやタブレットの市場で攻勢をかける方針を示していた。

総目次2008-5-2

「こころの薬箱」総目次2008-5-2

このとき作った目次の作り方を忘れていて
新しいのが作れない

高橋治著「風の盆恋歌」

http://d.hatena.ne.jp/smapg/20080416

今年もその季節である 

2011年甲子園について

2011年甲子園大会は大変面白かった 
しかし個人的に気になるところもあった

たとえば大阪のリトルリーグで活躍していた選手が
地方の私立学校に入学して甲子園を目指すというのは
何の意味があるのだろう
たとえば日ハム田中と巨人坂本は大阪で同級生だった
青森光星学院のベンチメンバー１８人中１０人が大阪育ち
一体どこが青森県勢なのだろうか
甲子園に出やすいというだけ

県別に代表を決めて甲子園に出られるのだから
出やすい地域から出たほうがいい、しかも特待生で勉強しなくていいし、学費もかからないという選手の側の都合と
学校の名前の宣伝になるという経営側の都合だと思うのだが
そんな背景があるならば
綺麗事を言ったとしても
甲子園大会はすでに綺麗事ではない

伝統校というものも納得できない
春夏何回出場とかNHKのアナウンサーが繰り返し言い続けるが
勉強しないで野球漬け、いい選手をかき集めて、ずるをしてきた伝統がありますというだけで
アホで恥ずかしいだろう

伝統校と言っても選手は毎年入れ替わるのだから何の意味があるのだろうか
後援会組織の資金力とか甲子園に行く時の応援団の強制的な動員力とかそんなものなのだろうか
本当は伝統校の強みというものは
部員がタバコを吸ったとか強姦をしたとか不祥事があったときにも
もみ消すだけの組織力があるというに過ぎなく
今年はあの学校には勝てそうにないなという場合に
不祥事をでっち上げて出場できなくするとかそのような伝統の力ということになる
選手に伝統の力なんてあるはずがない

ーーーーー
上の話は酒飲みの話だから嘘っぱちだけれど
選手とか監督のインタビューもおかしなものだ

優勝する力なんてないのに優勝目指しますとか言っている
普通ならば一戦一戦を全力プレーすることが目標です
とか
郷土の代表として恥ずかしくないプレーをしたいです
とかいうものだ
このあたりの教育はしないのだろうか

すごいのは「監督を胴上げしたい」というセリフだった
それが高校野球の目標なのか
完全に倒錯している
高校野球は教育だろう

そこそこいいところを見せて
大学とか実業団のスカウトに気に入ってもらい
進学とか就職を確実にしたいです
とでも言えば正直というものだろうが
それは言わないにしても
監督を胴上げして何になるんだ
監督に感謝はすればいいがそれが第一の目標ではないだろう

監督に従順な人間を作っているのが野球教育だとしたら
まあなんとも味の悪いものだ

練習してきたことを発揮できるように頑張りたいです
といえばいいし
このセリフは何も難しくないだろう

それとも過去の実例のようにユニフォームのFightersの読み方さえ知らないような選手ばかりなのだろうか

1年生や2年生が3年生を押しのけて試合に出ている
これは就職とか進学を考えればよくないことだ。就職率が悪くなる。
学校経営としてはとにかく勝って名前を売って生徒を集めたい気持ちのほうが優先のようだ

このあたりも教育ではなくて経営である

ーーーー
そして一番いいたいことだけれど
試合後のインタビューで相手を褒め称えることがないのはどうしてしまったのだろう
もうこの国は日本ではなくなったのだろうか

相手のピッチャーは最高でした。あのスライダーは打てませんでした。
守りも固かった
打撃も積極的で素晴らしくかろうじて抑えられた
鍛えあげられた素晴らしいチームと対戦できて本当にありがたい
選手たちには一生の財産になる
勝負は時の運です、たまたまうちが勝っただけです

くらいのことは
昔は言っていたような気がする

それが淳風美俗というものだろう

ーーーーー
青森の擁護をすると
青森には産業もなく経済力も非常に貧弱である
六ケ所村には放射性廃棄物最終処理施設
最終処理といっても半減期がプルトニウムは6500年である

「俺たちには関係ない」というだけのことだとすぐにわかる 

冬場の出稼ぎでしのいできたわけだが
昨今は公共事業も減少して收入がない
一年の半分は雪で一家の大黒柱は出稼ぎ
野球の練習ができるのは一部の恵まれた学校だけで
あとは雪の中をただ走るだけ

青森の年寄りはレインボーブリッジも俺達が作ったんだと胸をはっている

正直言って青森の光星学院と言っても
全然青森じゃなくて
大阪の光星学院なんだ

その昔、三沢高校の時代は
三沢ナインは5人が幼少から同じチームで野球を始め、駐留米軍の子弟相手に練習試合を行い力をつけていた
というわけで、ここでも米軍基地が影を落としている

Nassir Ghaemi The ethics of clinical innovation in psychopharmacology: Challenging traditional bioethics

 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2204021/?tool=pubmed

 

The ethics of clinical innovation in psychopharmacology: Challenging traditional bioethics

 

S Nassir Ghaemi1 and Frederick K Goodwin2

 

1Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA USA

2Department of Psychiatry, The George Washington University, Washington, DC USA

Corresponding author.

S Nassir Ghaemi: [e-mail]; Frederick K Goodwin: [e-mail]

Received August 13, 2007; Accepted November 8, 2007.

This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

 Other Sections▼

 

Abstract

Objective

To assess the scientific and ethical basis for clinical innovation in psychopharmacology.

 

Methods

We conducted a literature review, utilizing MEDLINE search and bibliographic cross-referencing, and historical evidence regarding the discovery and development of new medications in psychiatry. Clinical innovation was defined as use of treatments in a clinical setting which have not been well-proven in a research setting.

 

Results

Empirical data regarding the impact of clinical innovation in psychopharmacology are lacking. A conceptual and historical assessment of this topic highlights the ethical and scientific importance of clinical innovation. Ethically, it touches a borderline that, in our judgment, is not adequately framed in contemporary mainstream bioethics. Currently, research is viewed as not at all benefiting the patients who participate in it, while clinical care is viewed as being solely for the benefit of patients. Clinical innovation straddles these two worlds, uncomfortably at times. While many argue that clinical innovation should either be avoided or folded into research projects, we argue that clinical innovation is necessary for progress in psychopharmacology research, and that it can prosper best when guided by the following ethical principles: 1.) The treatment should be based on a viable hypothesis. 2.) Whenever possible, one's clinical observations should be reported so they can be evaluated by the scientific community. 3.) One should be willing to report unexpected observations of drug effects. 4.) A high standard of informed consent should be maintained. Again, this proposal goes against the standard view among bioethicists that research and clinical care are categorically opposed activities, as made clear by the either-or dichotomy of the Belmont Report on bioethics. This approach has so polarized our profession into clinicians versus researchers, that many clinicians will not apply new knowledge produced by clinical research until it eventually gets incorporated into formal treatment guidelines, while researchers have little to guide them as to what kind of new knowledge it is most important to provide.

 

Summary

Clinical innovation brings out the ambiguities in our current ethical conceptions of research versus clinical care. Yet, historically, clinical innovation has been an important contributor to progress in psychopharmacology. We argue that clinical innovation should not be discouraged, but rather it should occur under certain ethical conditions.

"Almost everyone can and should do research...because almost everyone has a unique observational opportunity at some time in his life which he has an obligation to record....If one considers the fundamental operations or methods of research, one immediately realizes that most people do research at some time or another, except that they do not call their activity by that name. There are seven operations....In simple language they are counting, sorting, measuring, comparing, nature-study, guess testing, and reappraisal....Guess testing is of course what most people think of when the word research is mentioned; except that it is bad manners to call a guess a guess. It should be called an hypothesis. Let us make one plea. Guessing becomes merely a game unless it is done in the context of a plan for action. It is a waste of time elaborating untestable hypotheses [1]."

John Cade

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Introduction

Most clinicians, researchers, and ethicists would agree that it is important to expand medical knowledge, and thus, at a very basic level, it is ethical to engage in research, given appropriate protections for research subjects. As a corollary, one might argue that it is unethical not to do research, and indeed advancing knowledge through research is recognized as one of the ethical principles of the American Psychiatric Association [2]. In other words, if no one engaged in research, and no one tried to expand the bounds of knowledge, that too would be an unethical state of affairs. We must, as a result, constantly be aware of the need to balance the risk of being ignorant versus the risks involved in obtaining new knowledge. Too often, this debate is one-sided, focused on the risks involved in obtaining new knowledge. But there are risks on both sides of the ledger, and not doing research poses real risks also. Hence the importance of assessing the merits of clinical innovation, which we believe is a legitimate component of the research process, as explained below.

We define clinical innovation as use of treatments in a clinical setting which have not been well-proven in a research setting.

Clinical innovation occurs, by definition, outside of formal research protocols. There is a risk that guidelines of any kind, however well-intentioned, will impede clinical innovation unnecessarily. On the other hand, there are limits to acceptable innovation, and in some cases, one can imagine cases of innovation that would appear to be unethical.

Part of the problem is that the bioethics community has sought to cleanly and completely separate clinical practice from research. In the Belmont Report of the National Commission for the Protection of Human Subjects,[3] for instance, an attempt was made to separate "practice", where "interventions are designed solely to enhance the wellbeing of an individual patient or client and that have a reasonable expectation of success", from "research", defined as "an activity designed to test an hypothesis, permit conclusions to be drawn, and thereby to develop or contribute to generalizable knowledge." In fact, the clinician/researcher engaging in clinical innovation is not acting with solely one set of interests in mind, but two. On the one hand, the clinician/researcher wants to help the individual patient; on the other hand, the clinician/researchers wants to gain some experience or knowledge from his observation. Some in the bioethics community set up this scenario as a necessary conflict. They seem to think that a choice must be made: either the clinician must choose to seek only to make the patient better, without learning anything in the process, or the clinician must seek to learn something, without any intention at all to improve the patient's lot. As with so much in life, there are in fact multiple interests here and there is no need to insist that those interests do not overlap at all. First and foremost in any clinical encounter is the clinician's responsibility to the individual welfare of the patient. Any innovative treatment, observation, or hypothesis cannot be allowed to lead to complete lack of regard for the patient's welfare. Unfortunately, the Belmont Report and much of the mainstream bioethics literature presumes complete and unavoidable conflict of these interests: "When a clinician departs in a significant way from standard or accepted practice, the innovation does not, in and of itself, constitute research. The fact that a procedure is "experimental", in the sense of new, untested, or different, does not automatically place it in the category of research.... [but] the general rule is that if there is any element of research in an activity, that activity should undergo review for the protection of human subjects." It may be worthwhile to point out the dominant role of the legal profession in bioethics and its orientation towards the adversary process (winner vs. loser, guilty vs. innocent) which is predicated on artificial dichotomies in which confluence of interest becomes conflict of interest. Indeed, many bioethicists lack personal experience either in clinical medicine or in clinical research. An analogy would be if lawyers ceded legal ethics to philosophers with no experience in the practice of the law.

This approach leads, in our opinion, to uncontrolled clinical innovation and overregulated formal research. We will return to the Belmont Report later, but now we will turn to what we think is the key to realizing the importance and legitimacy of clinical innovation outside of formal research protocols. We think the ultimate rationale for clinical innovation is evidence from the history of psychopharmacology that such innovation is essential to the discovery of new knowledge. Further, since such innovation, by definition, occurs outside of formal research protocols, if we grant it legitimacy, then we will need to think about how we can provide an ethical framework to support it.

While we focus here on psychopharmacology, the same issues apply to medicine in general (consider for example how new surgical techniques evolve), and the same problems exist in the understanding of research ethics in medicine. Since research with psychiatric medications in particular is often subject to criticism, we believe there is a special a need to clarify this matter in psychiatry.

The history of psychopharmacology

Every new class of agents in psychopharmacology has begun with clinical innovation or novel observations [4]. This has been the case with iproniazid, which was observed, in clinical settings, to have mood elevating properties in tuberculosis patients, and reserpine, which was observed to be associated with depression; these findings led to the development of monoamine oxidase inhibitors for the treatment of depression. Phenothiazines were used as anesthesia and a clinician observed that they had major tranquilizing effects, so they were subsequently tried as a treatment for psychosis and found to work [5]. When tricyclic antidepressants were being developed as potential treatments for schizophrenia (since they are chemical derivatives of phenothiazines), they were observed by an alert clinician to improve depressive symptoms in patients with schizophrenia [6]. Lithium was discovered by John Cade, who used it in a small group of selected manic patients (see below) [7]. And carbamazepine was initially extended to bipolar disorder based on innovative observation of evidence of benefit for mood in epilepsy [8]. In every case, when there has been a fundamental new departure in psychopharmacology, it always began with clinical innovation. It never began in a research protocol with well-thought out methodologies, hypotheses, outcome measures, and guidelines for ethical conduct.

This history is not unique to psychopharmacology. Antibiotics famously began in the serendipitous work of Alexander Fleming. Antihypertensives also were discovered based on unexpected observations. Clinical innovation is the fount of research discoveries for all of medicine, and psychiatry is no different.

Since advancing knowledge is recognized as an ethically justified and important activity, and clinical innovation precedes and is the source of major advances in formal clinical research (as noted above), then clinical innovation too is not only ethically justifiable, but is, indeed, ethically required.

If we accept that clinical innovation is ethically legitimate, then the question becomes, as with all research, what are the ethical guidelines within which clinical innovation can best be conducted, focusing on the proper assessment of the risk benefit ratio of research.

In other words, what is the ethical basis of clinical innovation? Perhaps two case scenarios will help clarify the subject.

Case scenarios

Dr. X primarily treats mood disorders and is interested in new drugs because many of his patients have failed treatment with "standard" medications. Many new medications become available to practitioners after being approved by the FDA for disorders other than depression (e.g., epilepsy). Dr. X begins to give these medications to some of his patients with mood disorders, and soon most of his patients are taking various combinations of them. Dr. X never publishes his experience, which is unfortunate because initially studies of those medications for mood disorders are sparse. Those studies which do appear are quite preliminary of necessity (uncontrolled, nonrandomized, small case series). When asked, Dr. X strongly asserts his beliefs regarding the benefits of certain medications he uses and the lack of utility of others.

Here is another scenario. Dr. Y also likes to use new drugs, similarly for mood disorders although the medications are FDA indicated only for other conditions. After using these agents in 5–10 patients, she usually publishes her experience. Sometimes, she then becomes involved in obtaining funding for more rigorous studies of those medications which appear potentially useful based on her publications. In some cases, her early experience is confirmed by randomized studies (and occasionally new FDA indications), and sometimes they are not confirmed.

Neither Dr. X nor Dr. Y prepare a protocol or obtain IRB approval or a research-based informed consent for their clinical use of any of these medications.

Are these doctors practicing ethically?

Before we can answer this question, let's consult the history of psychopharmacology in search of a model for effective innovation.

Innovation in psychopharmacology: lithium as a model

In the 1940s, John Cade hypothesized that mania and depression represented abnormalities of nitrogen metabolism [7]. He injected urine samples from psychiatric patients into guinea pigs, all of whom died. He concluded that the nitrogenous product, urea, was probably acting as a poison, and later tested uric acid solubilized as lithium urate, which led to marked calming of the pigs, without sedating them. Further tests identified lithium to be the calming agent, and Cade then proceeded, on the principle of primum non nocere, to try lithium himself before giving it to patients. His first patient improved markedly, but then experienced toxicity and died after a year. Despite improvement in other patients, Cade was quite concerned and abandoned using lithium further due to its toxicity, but reported his findings in detail. Other researchers, in the first randomized clinical trials in psychiatry, proved lithium safe and effective at nontoxic level.

Would we have lithium if Cade were working today? We think it is unlikely. If Cade worked in a hospital today, he likely would not have been able to obtain enough animal data to justify using lithium in humans. Hence, Cade's case highlights the opportunity costs of ethical restrictions on clinical innovation. The risks of not discovering drugs should not be ignored.

Cade's philosophy of research

As noted in the introductory quote to this paper, drawn from a presidential address given to the Australian and New Zealand College of Psychiatry near the end of his life, Cade identified "guess testing", comparable to what we are calling innovation in this paper, as essential to psychopharmacological research. And the most essential aspect of innovation, according to Cade, is that there should be hypothesis testing. In other words, innovative use of medications should not be random; it should be driven by legitimate hypotheses, and therefore provable or disprovable. This will turn out to be important, as discussed below. The role of serendipity, driven by hypothesis testing, has also been emphasized by many [4]. Indeed, Pasteur's famous maxim about chance favoring the prepared mind can be interpreted as involving the combination of serendipity and hypothesis testing. If one has hypotheses, and one is actively seeking to test them, then one is more likely to come across "chance" findings that others may either not observe or not experience. The presence of hypotheses is not indiscriminate however. Some kind of sound rationale, be it pharmacological or theoretical is needed, to support clinical innovation.

It is also important to emphasize, nonetheless, that chance findings can also be noticed by an alert physician even if no prior hypothesis exists. For instance, no hypothesis of antidepressant effect preceded the observation that use of reserpine led to depression, or that imipramine used in schizophrenia improved depressive symptoms. These two innovative observations, neither initially driven by hypotheses, set the ball in motion that ultimately led to a Nobel Prize given to Julius Axelrod and his colleagues for their working on unraveling the biochemical mechanisms of these agents. All this work started with clinical observation without hypothesis. Much clinical innovation begins with the use of a drug for an indication not used before, which then leads to novel observations that lead to a new hypothesis that can then be tested.

Thus, while one major path of clinical innovation is the path described by Cade, where one possesses an hypothesis, and one is experimentally interested in testing the hypothesis, and new findings occur as a result. In the other path of clinical innovation, alert clinicians watch for unexpected effects when using a drug for legitimate purposes. Without possessing an initial hypothesis, these clinicians find something they didn't expect. This truly serendipitous finding leads to hypotheses which can then lead to further clinical innovation and eventually more organized research.

Innovation and clinical trials

Most interested parties do not knowingly and overtly oppose innovation per se. Yet, if we assert that certain guidelines should encompass all innovation, we are in fact are taking a position against innovation, and not paying attention to the risks involved in not allowing sufficient innovation. If we insist that all clinical innovation should be regulated in some manner, then we are taking a purist position that focuses only on the risks of research, but not the risks of not doing research.

It is also striking that there is a double standard here: attempts to expand knowledge that are labeled "research" receive intense scrutiny, whereas clinical innovation receives no scrutiny at all. Yet the dividing line between "research" and clinical innovation is not clear-cut, and we believe that the best clinical work is also research in the sense of clinical innovation, and the best organized research grows out of clinical innovation [4].

It is vital to acknowledge that virtually everything that gets to clinical trials comes from early clinical innovation. Conceived in terms used by Evidence-based Medicine (EBM),[9] innovation in psychopharmacology more commonly proceeds bottom-up, rather than top-down (Table ​(Table1).1). Innovation proceeds usually from level V case reports, through levels III-IV naturalistic and nonrandomized studies, to levels I-II randomized studies.

Table 1

Innovation in psychopharmacology proceeds bottom-up more frequently than top-down in the levels of evidence

Frequently, clinical practice even outpaces or even corrects mistakes from randomized studies. For instance, in the classic case of SRI-induced sexual dysfunction, the early randomized clinical trials that led to FDA indications for those agents reported low rates of sexual dysfunction. However, clinical practice demonstrated much higher rates. In this case, the "less rigorous" evidence of clinical practice was more accurate than the "more rigorous" evidence of randomized clinical trials. This is often the case with side effects. For sexual dysfunction, a number of factors were involved: This side effect is the kind that needs to be actively assessed; passive patient self-report underestimates it. Since the clinical trials did not actively seek to identify sexual dysfunction, they did not detect it. Further, many side effects occur to a higher degree in patients with medical illnesses, or comorbid conditions like substance abuse, or in the young or the elderly, and these types of persons are generally excluded from clinical trials. Thus, the pure homogeneous clinical trial sample, which is highly selected to maximize drug efficacy, is not generalizable enough to the real world population in terms of side effects.

Hence clinical practice, and research conducted in the uncontrolled clinical setting, is highly generalizable and often produces more accurate data on certain issues, such as side effects, than do clinical trials.

What is ethical innovation in psychopharmacology?

Conventional wisdom holds that ethical research 1) is scientifically sound; 2) involves informed consent; and 3) is not characterized by unacceptable risk. These standards are supposed to met through the institutional review board (IRB) process.

In the setting of clinical innovation, where the IRB process is not invoked, it appears to us that these three imperatives of ethical research can be met in an alternative manner. To be scientifically sound, ideally, innovation must be hypothesis-driven, as strongly urged by Cade. Further, a greater degree of informed consent should be documented in clinical notes by the innovating clinician, as compared to the use of standard proven agents. Also, the issue of risk needs to be carefully weighed and documented by the practicing clinician. This last issue is no different than the same clinical judgment exercised on a daily basis by psychiatrists with proven but risky treatments (e.g., clozapine for schizophrenia). This is not a medico-legal issue primarily, but reflects the need for more clearly educating patients about the rationale for what is being proposed than is often the case with non-innovative treatments. Further, the patient needs to accept the rationale, as opposed to going along with the better known risks and benefits of already proven treatments. All of these options must be explicitly discussed with patients. What must be avoided at all costs is a doctor with a new idea who simply imposes it on his patients without the above safeguards.

In some cases, clinical innovation can be ethical in the absence of an hypothesis also. This is frequently the case with extremely refractory patients. In such cases, a new treatment may be tried with no hypothesis other than a test to see if it works. We assume that the usual clinical safeguards are in place, with attention paid to risks and patient consent as described above. Of course this rationale does not cover indiscriminate or even silly practice, such as the use of an antibiotic for treatment refractory depression. As mentioned previously, some kind of sound rationale, biological or conceptual, is required to support innovative practice as well as to avoid indiscriminate activities. In this setting, all clinicians have an obligation to report unexpected novel observations, which, when at their most novel, are not hypothesis-based.

The unique risk in innovative psychopharmacology is that risks and benefits are little understood; this differs form proven but risky treatments like clozapine. In this setting, one needs to have a mindset that is cautious though not closed-minded.

The cases

Let's illustrate these issues with our two scenarios. Dr X used all kinds of medications without attempting to organize, quantify, or publish his experience. Furthermore, he holds strong beliefs about the benefits and risks of medications based almost solely on his clinical experience. Dr. Y used the same medications, but reported her experience to the scientific community, and was involved in research protocols based on her pilot uncontrolled experience. What did Cade do? Cade used lithium with a research hypothesis in mind. He further tried it on animals before humans given the absence of any prior human use. He even tried it on himself before using it with other patients. He reported his experience immediately to the scientific community. One of his first patients in fact became toxic on lithium and died. Cade reported this death and curtailed his use of the medication. Other researchers were able to conduct rigorous research protocols based on Cade's early reports. Cade and Dr. Y have much in common, which we think helps us identify the ideal characteristics of ethical innovation.

Based on the above historical and conceptual considerations, ethical innovation, we submit, has the following ideal characteristics (Table ​(Table2).2). It involves the use of a new treatment based on a viable research hypothesis in an uncontrolled setting. The purpose of the innovator is not only to try to help his individual patient, but, at the very least, also to report his experience to the larger scientific community. Further, the innovator may himself be involved in advancing knowledge of that treatment beyond early uncontrolled clinical experience to more rigorous knowledge through research protocols (which then entail the usual protections of informed consent and IRB procedures).

Table 2

Proposed ethical guidelines for clinical innovation in psychopharmacology

Nonetheless, Dr. X is not necessarily unethical either. This is because the other pathway to innovation, though not ideal, is important. The second pathway involves pure chance observations in which unexpected findings occur without a priori hypotheses. Nor is it necessarily unethical to refrain from publishing one's experience; we simply mean to suggest that it is better to put one's experience in the public domain, preferably through publishing, so as to be open and transparent about one's activities, and also so as to spur others to re-examine and advance those observations.

The absence of an empirical literature

We were unable to locate any empirical literature on the above topics based on a literature review, utilizing MEDLINE search with key words "ethics", "research ethics", "innovation", and "psychopharmacology", supplemented by bibliographic cross-referencing. That search did identify a number of studies which address some of these questions conceptually, [10-23] but no studies in which the topic has been examined empirically. It seems that the world of psychopharmacology research has spent little time examining the sources of innovation, and there has been little overlap between researchers and the larger world of clinicians, where non-research based decisions are made on a day-to-day basis. Yet, as the example of Cade highlights, there is a need for more overlap between clinical work and research, that is, clinical researchers who are active clinicians engaging in innovative patient care as well as structured research studies. And yet the funding structure of research, and the regulatory structure of IRBs and governmental bodies, discourages such innovative clinical researchers.

The funding of innovative research

At the National Institute of Mental Health (NIMH), research funding has been divided between "intramural" and "extramural" types. Extramural research required extensive oversight into scientific utility. Intramural research did not require such oversight and was designed to encourage innovative ideas. In the terminology of Steve Brodie, an icon of Nobel-prize level psychiatric research, intramural research allowed investigators to "take a flier" on new ideas [24]. Unfortunately, now intramural research at the NIMH requires extramural-like levels of scientific oversight and justification. As a result, both inside the NIMH and outside, psychiatric research is more and more comprised of increasing pristine demonstrations of increasingly trivial points.

The NIMH has also tended to avoid funding of clinical psychopharmacology research on the grounds that a source of funds exists in private industry. Yet private industry targets its research to requirements of the Food and Drug Administration (FDA). There are only two purposes for an FDA indication. First, it makes a new medication available for prescribing physicians. And second, it gives a pharmaceutical company permission to market and advertise a medication for that indication. The FDA only reviews data submitted by pharmaceutical companies. Companies must have an economic incentive to go the FDA. Hence, at one level, FDA indications are purely the result of the economic decisions of pharmaceutical companies. Today, the tendency of third party payers to use FDA indications as a way to limit payment for treatments has incentivized drug companies to seek additional indications for their drugs, but in these cases too the presence or absence of an indication is primarily driven by economic, not scientific, motivations. Thus, there is minimal correlation between the amount of data supporting the use of a drug for a specific purpose and whether the drug is FDA approved for that use.

Also, the pharmaceutical industry does not generally fund long-term studies of medications, usually because of the limited length of expected marketing under patent and due to a lack of need for long-term data in terms of marketing benefit. Once a drug is on the market for an acute indication, clinicians tend to prescribe those agents for the very long-term. The prolonged use of antidepressants in unipolar depression is an example of this phenomenon. Studies of new agents such as SRIs do not exceed one year usually, and studies of tricyclic antidepressants have only been conducted for up to 5 years and even then in less than a hundred subjects. Yet on these meager grounds, it is perhaps not an exaggeration to say that millions of patients are taking these agents for decades or longer. This would appear to be ethically questionable, but those who promote more regulations on research are unintentionally contributing to inhibiting the kinds of studies that we need to conduct to remedy this situation. Unfortunately, the NIMH has rarely stepped in to fill this gap either, and the lack of solid long-term studies of major or minor psychiatric disorders is a serious problem in clinical psychopharmacology research.

Further, the Neuropharmacology division of the FDA has traditionally required rather conservative statistical paradigms, especially parallel rather than crossover designs, which do not provide information about the efficacy of new agents compared to each other. Pharmaceutical companies frequently will not pay for crossover studies, if the FDA will not allow their results to be included it the marketing of the drug. As the pharmaceutical industry is the most important source of funds for medical pharmacology research, it becomes more and more difficult to do research beyond the rigid criteria for registration, even with drugs that are already on the market.

Hence, clinicians do not have data based on FDA-oriented studies to guide many treatment decisions, and consequently clinicians are almost forced to innovate. Fortunately, the NIMH has recently expanded its use of services-based funding to obtain extensive clinical outcome data in psychiatric disorders (such as the Systematic Treatment Enhancement Program for Bipolar Disorder, STEP-BD). Further, private sources, such as the Stanley Foundation, are beginning to step forward to fill the gap with more flexible designs between the limited kinds and number of trials supported by the NIMH and the restrictive studies funded by the pharmaceutical industry.

Issues that merit empirical study

Given that there is an absence of empirical data on which to draw, we would like to suggest specific questions that can be assessed with empirical methods.

1. How frequently do clinicians practice outside of FDA indications in psychiatry? What specific conditions tend to be treated in that setting? What specific medications are used?

2. If we accept a definition of ethical innovation along the lines we suggest, how often do clinicians practice within those guidelines?

3. How frequently are new treatments in psychopharmacology introduced by uncontrolled clinical innovation? How frequently are they introduced by research trial protocols before clinical use?

4. How frequently do research protocols derive from or depend upon prior clinical innovation or serendipitous observations?

Relationship to formal clinical research

Some in the bioethics community seem to be unaware of the importance of clinical innovation. And thus, to them, perhaps, some of the arguments in this paper will not be convincing. We believe, in contrast, that much of the formal research enterprise depends on clinical innovation.

The argument of this paper is very simple: The only sensible reading of the historical record in psychopharmacology is that there is a factual link between clinical innovation and progress in the development of new treatments through formal clinical research. Clinical innovation is a legitimate activity, because it often serves a source of ideas and observations that later leads to classical research conducted in the formal manner of protocols, IRB reviews, and rigorous designs. Sometimes clinical practice can yield important knowledge beyond what can be gleaned from randomized clinical trial protocols. We have reviewed some historical examples, such as John Cade's discovery of lithium. Thus, clinical innovation is a legitimate and important activity. It seems to us that some critics of clinical innovation have little or no direct clinical experience, either in patient care or research, whereas those with significant experience in both activities tend to be more aware of the need for clinical innovation.

Does this approach conflict with federal standards, such as the Belmont Report, which has been identified by the National Institutes of Health Office of Human Subjects Research as the philosophical foundation for its ethical regulations [25]? As mentioned above, the Report leaves itself open to a strict interpretation when it asserts that "any element of research" requires formal review. However, the Report also establishes three fundamental ethical principles that are relevant to all research involving human subjects: Respect for Persons, Beneficence, and Justice. We do not see how the approach to clinical innovation outlined in this paper conflicts with these ethical principles. In fact, the absence of any ethical guidelines, as is currently the case, conflicts with these ethical principles. Thus, it may be that the status quo, which some professional medical ethicists seem to accept, is not in keeping with the principles underlying the Belmont Report. We seek to reinterpret such ethical principles in the setting of clinical innovation, whereas some in the bioethical community tend to focus on the formal mechanisms put in place to promote those principles. Even the NIH notes that the Report is "not a set of rules that can be applied rigidly to make determinations of whether a proposed research activity is ethically 'right' or 'wrong.' Rather, these regulations provide a framework in which investigators and others can ensure that serious efforts have been made to protect the rights and welfare of research subjects."

In sum, we suggest in this paper that research and clinical care should be viewed as a continuum, rather than as two categorically distinct activities. Research is primarily conducted to produce knowledge, and clinical care is primarily conducted to provide individualized care to a patient; but research also secondarily provides patient care, and clinical care secondarily produces knowledge. On that continuum, some kinds of research can actually provide a great deal of individual benefit to patients, and some kinds of clinical care can provide a great deal of new knowledge. We should give up the either-or dichotomy of the Belmont Report, which has so polarized our profession into clinicians versus researchers, and has produced clinicians who cannot apply the knowledge produced by our research, and researchers who do not know what kind of knowledge it is important to provide.

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Summary

The basic idea that underpins this paper, and which conflicts with those who promote formal regulations as the sole way to ethically conduct research, is that the best research is conducted by active clinicians, and that the best clinical work is conducted by active researchers. The strict wall separating pure research from pure clinical practice is at best a fiction, and at worst a dumbing down of both activities. Clinical innovation is the kind of activity that bridges this gap. Clinical innovation should be legitimized, accepted, and even encouraged within the framework of ethical guidelines, such as those we suggest, so as to avoid the alternative extremes of indiscriminate practice on the one hand and over-regulation of all research on the other.

Competing interests

Dr. Goodwin currently receives research support from GlaxoSmithKline. He currently serves on the speakers bureaus of GlaxoSmithKline, Pfizer and Lilly, and is a consultant for GlaxoSmithKline, Pfizer, Lilly, Wyeth and AstraZeneca.

Dr Ghaemi currently receives research grants from GlaxoSmithKline and Pfizer. He currently serves on the speakers' bureaus of GlaxoSmithKline, Astra Zeneca, Pfizer, Janssen and Abbott Laboratories, and has served on the advisory boards of GSK, Janssen, Pfizer, Shire, and Abbott Laboratories. Neither he nor his family hold equity positions in pharmaceutical corporations.

Authors' contributions

Both Drs. Ghaemi and Goodwin were responsible for the preparation and revision of this manuscript. Both authors read and approved the final manuscript.

Acknowledgements

This article was not funded.

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References

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Talking about cognitive analytic therapy

Talking about cognitive analytic therapy

1. J. Hepple

+Author Affiliations

1. Magnolia House, 56 Preston Road, Yeovil, Somerset BA20 2BN, UK

• EDITED BY STANLEY ZAMMIT

• Declaration of interest

• J.H. is a member of the Association for Cognitive Analytic Therapy and has published in the field.

 

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Isaac Marks' review ( Marks, 2003) encapsulates the reciprocal roles expressed in so much of the comparative debate in psychotherapy: dismissing: dismissed, contemptuous: contemptible. To contemptuously attack the review would simply be to continue the dance and to encourage further polarising responses. I have great respect for Isaac Marks' work and would invite him to join in a dialogue with cognitive analytic therapy. It was thought-provoking to consider the role of Pavlov in the developmental understanding of symptoms.

Cognitive analytic therapy has its devotees among therapists and clients. It is a tremendously human therapy where the strengths of cognitive theory and object relations theory have more recently begun to incorporate strikingly original ideas on human development, dialogue and the construction of interpersonal meaning from the Russian tradition. For many this represents an exciting evolution of thought concerning the nature of the psychotherapeutic relationship and the process of change in psychotherapy.

Cognitive analytic therapy has attempted to integrate the cognitive and the analytic as well as the dialogic Eastern approach to development with the reductionist Western scientific tradition. A more challenging task is to bring into dialogue the entrenched culs-de-sac of psychotherapy theory and their defenders. So, let's start to talk and engage in some positive role-play–valuing: valued, respecting: respected, giving: receiving.

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References

1. ↵
    

   Marks, I. (2003) Book review: Introducing Cognitive Analytic Therapy. Principles and Practice, by A.Ryle & I.B. Kerr. British Journal of Psychiatry,182, 179–180.

    

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A. Ryle Cognitive analytic therapy

Cognitive analytic therapy

A. Ryle

CPTS, Munro Centre,Guy’s Hospital, London SE1 9RT, UK

I. B. Kerr

+ Author Affiliations

Community Health Sheffield NHS Trust, Limbrick Centre, Sheffield, UK

EDITED BY STANLEY ZAMMIT

 

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The review by Marks ( 2003) of our book Introducing Cognitive Analytic Therapy: Principles and Practice ( Ryle & Kerr, 2002) is both rude and misleading. His reminiscences about a visit to Leningrad in 1966 have nothing to do with the book and we certainly do not see ‘Pavlovian therapy’ (with which we are entirely unfamiliar) as ‘part of cognitive analytic therapy (CAT)’. His objection to the fact that our explicitly integrative model draws on a wide range of sources tells us more about the limitations of his own conceptual framework than about CAT. These limitations are also evident in his inability to understand or unwillingness to mention the key features of CAT, which he seriously misrepresents. These include: (a) focus on ‘reciprocal role procedures’, which are formed though the internalisation of socially meaningful, intersubjective experience and subsequently determine both interpersonal behaviours and self-management; and (b) the practical emphasis on the joint creation of descriptions of these, which serve to enlarge patients’ capacity for self-reflection and change and therapists’ ability to provide reparative, non-collusive relationships.

The reviewer’s bias is epitomised in his discussion of one of the case histories in the book (pp. 138–144). While asserting that this ‘patient with obsessive–compulsive rituals’ would have been better served by nine sessions of behavioural therapy or by one session plus computer-aided therapy, he fails to record that the patient was presented precisely to illustrate the limitations of cognitive–behavioural approaches and does not mention that she had previously dropped out of an anxiety-management group and of cognitive–behavioural treatment. Of this she had noted that the more her symptoms were worked on, the ‘more grimly’ she hung onto them. This was not a report of the treatment of obsessive–compulsive rituals, it was a summary of the psychotherapy of a person, an unhappy woman with a history of many years of panic, phobias, obsessive–compulsive behaviours and irritable bowel syndrome. The case was chosen, in part, to demonstrate how focus on presenting symptoms can actually be counterproductive and paradoxically collude with the enactment of underlying reciprocal role procedures in a patient who had come to be regarded as ‘difficult’ and ‘resistant’. This patient’s list of ‘target problem procedures’, as worked out with her, included a pervasive need to control both her feelings and other people’s behaviours. As is usual in CAT, this formulation, and her therapy, focused on intra- and interpersonal attitudes, assumptions and behaviours (procedures) and paid little direct attention to her symptoms. Therapy included, importantly, work on reciprocal enactments with the therapist. Assessment at termination and follow-up showed major improvements in her life, and psychometric testing demonstrated reductions in symptoms at termination with further reductions at 6-month follow-up.

We think it unfortunate that so obviously partisan a reviewer was selected to discuss a book outside his area of expertise and sympathy and that it was considered appropriate to publish so tendentious a review of the work of colleagues.

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References

↵ Marks, I. (2003) Book Review: Introducing Cognitive Analytic Therapy (A. Ryle & I. B. Kerr). British Journal of Psychiatry, 182, 179–180. FREE Full Text

cognitive analytic therapy

Early intervention for adolescents with borderline personality disorder using cognitive analytic therapy: randomised controlled trial

 

Andrew M. Chanen, MBBS, MPM, FRANZCP

ORYGEN Research Centre, Department of Psychiatry, University of Melbourne, and ORYGEN Youth Health, Northwestern Mental Health, Melbourne

Henry J. Jackson, PhD, FAPS

School of Behavioural Science, University of Melbourne

Louise K. McCutcheon, Dpsych

ORYGEN Research Centre, Department of Psychiatry, University of Melbourne, and ORYGEN Youth Health, Northwestern Mental Health, Melbourne

Martina Jovev, PhD

ORYGEN Research Centre, Department of Psychiatry, University of Melbourne

Paul Dudgeon, PhD

School of Behavioural Science, University of Melbourne

Hok Pan Yuen, MSc

ORYGEN Research Centre, Department of Psychiatry, University of Melbourne

Dominic Germano, Mpsych and Helen Nistico, Mpsych

ORYGEN Youth Health, Northwestern Mental Health, Melbourne

Emma McDougall, BSc, Caroline Weinstein, BSc and Verity Clarkson, BSc

ORYGEN Research Centre, Department of Psychiatry, University of Melbourne

Patrick D. McGorry, MD, PhD, FRANZCP

+Author Affiliations

ORYGEN Research Centre, Department of Psychiatry, University of Melbourne, and ORYGEN Youth Health, Northwestern Mental Health, Melbourne, Australia

Dr Andrew Chanen, ORYGEN Research Centre, Locked Bag 10, Parkville, Victoria 3052, Australia. Email: [e-mail]

Declaration of interest

None. Funding detailed in Acknowledgements.

 

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Abstract

Background

No accepted intervention exists for borderline personality disorder presenting in adolescence.

Aims

To compare the effectiveness of up to 24 sessions of cognitive analytic therapy (CAT) or manualised good clinical care (GCC) in addition to a comprehensive service model of care.

Method

In a randomised controlled trial, CAT and GCC were compared in out-patients aged 15–18 years who fulfilled two to nine of the DSM–IV criteria for borderline personality disorder. We predicted that, compared with the GCC group, the CAT group would show greater reductions in psychopathology and parasuicidal behaviour and greater improvement in global functioning over 24 months.

Results

Eighty-six patients were randomised and 78 (CAT n=41; GCC n=37) provided follow-up data. There was no significant difference between the outcomes of the treatment groups at 24 months on the pre-chosen measures but there was some evidence that patients allocated to CAT improved more rapidly. No adverse effect was shown with either treatment.

Conclusions

Both CAT and GCC are effective in reducing externalising psychopathology in teenagers with sub-syndromal or full-syndrome bipolar personality disorder. Larger studies are required to determine the specific value of CAT in this population.

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Borderline personality disorder is a severe mental disorder that usually emerges during adolescence,1 and adolescents with this disorder commonly seek clinical help.2,3 We have previously reviewed the prospects for developing prevention and early intervention strategies for the disorder4 and concluded that current evidence supports indicated prevention,5 targeting groups with precursor signs and symptoms such as substance use disorders or borderline personality disorder traits,6 along with early intervention for first presentations of borderline personality disorder.

We report a hybrid efficacy/effectiveness7 randomised controlled trial of early intervention for adolescents with sub-syndromal or full-syndrome borderline personality disorder using a novel, time-limited psychotherapy, cognitive analytic therapy,8 compared with ‘manualised’, structured, team-based, non-specialised ‘ good clinical care’ specifically developed for this trial. Based upon our review,4 we predicted that, compared with good clinical care, cognitive analytic therapy would perform significantly better in decreasing borderline psychopathology, general psychopathology (internalising and externalising psychopathology) and parasuicidal behaviours (suicide attempts and non-suicidal self-injury)9 and in improving social and occupational functioning.

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Method

Participants

Participants were aged 15–18 years, were sufficiently fluent in English and fulfilled two to nine DSM–IV criteria for borderline personality disorder.1Participants were also required to have had one or more of the following in childhood: any personality disorder symptom, any disruptive behaviour disorder symptom, low socio-economic status, depressive symptoms and a history of abuse or neglect. These factors were selected because of their high odds ratios for the development of personality disorders in young adults10,11and because they were measurable in our sample.

Exclusion criteria were learning disability, psychiatric disorder due to a general medical condition, pervasive developmental disorder, severe primary Axis I disorder that should be the principal focus of treatment (e.g. medically unstable anorexia nervosa or severe obsessive–compulsive disorder) and receiving more than nine sessions of specialist mental health treatment in the previous 12 months. No potential participant was excluded on the basis of these criteria. Potential participants were not approached if they had sustained psychosis and met criteria for ORYGEN Youth Health’s Early Psychosis Prevention and Intervention Centre.12

Procedure

The study was approved by the North Western Health Care Network Behavioural and Psychiatric Research and Ethics Committees. It was conducted from October 2000 to October 2004 at the Helping Young People Early (HYPE) clinic, a specialised early intervention programme for borderline personality disorder at ORYGEN,12 the government-funded mental health service for young people aged 15–18 years in western metropolitan Melbourne, Australia. Referrals to ORYGEN are taken directly from the community (via emergency departments, primary care, family, school or self-referral) for acute, severe mental health problems. The referrals are not specifically for borderline personality disorder treatment.

After complete explanation of the study procedures, written informed consent was obtained from all participants and their parent or guardian where appropriate. Eligibility criteria were first assessed by a full clinical interview, supplemented by the Structured Clinical Interview for DSM–IV Axis I Disorders – Patient Version (SCID–I/P),13 the Schedule for Affective Disorders and Schizophrenia for School-Age Children – Present and Lifetime version (K–SADS–PL) disruptive behaviour disorders module,14 and the Structured Clinical Interview for DSM–IV Axis II Disorders (SCID–II) borderline personality disorder module.15 Final diagnosis was by a consensus group, comprising at least two senior investigators (A.C., H.J., L.M., P.M.), using a modified longitudinal, expert, all data (LEAD) standard.16 Participants were remunerated with AU$20 for the first three research assessments and AU$40 for the final follow-up to cover out-of-pocket expenses.

Participants were allocated to cognitive analytic therapy (CAT) or good clinical care (GCC) using a stratified block randomisation procedure with block size equal to four. This was designed and overseen by a statistician (H.P.Y.) who was masked to patient data. Stratification was according to the number of DSM–IV borderline personality disorder criteria (cut-off point 5). In order to accommodate the requirements of the clinical service, randomisation occurred following informed consent but prior to baseline assessment. The nature of the randomisation procedure was concealed from the therapists by using an on-site, password-protected computer program, operated by an independent ORYGEN administrative staff member who entered all participants’ data. The administrative staff member communicated the outcome of the randomisation to the therapist and the therapist discussed this with the patient.

Research assessments

Assessments were conducted independently by three graduate research assistants (V.C., C.W., E.M.) trained by the principal investigator (A.C.) and supervised by another senior investigator (H.J.) who was masked to patient names and treatment allocation. No ‘unmaskings’ were reported during the conduct of the trial. Research assistant masking was tested upon completion of their employment (without warning) by asking them to guess each participant’s treatment allocation using a checklist. Kappa values were 0.36, 0.07 and 0.06 respectively, indicating satisfactory masking.

Figure 1 shows the flow of participants through the trial. Participants were assessed at four fixed time points: baseline (n=78), 6 months (n=70), 12 months (n=70) and 24 months (n=68). Assessments were completed for at least three of the four time points in 92% of the sample.

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Fig. 1

Trial profile (CAT, cognitive analytic therapy; GCC, good clinical care).

Diagnostic interviews

Diagnoses were obtained using the SCID–I/P, the K–SADS–PL disruptive behaviour disorders module and the full SCID–II. In keeping with previous research, a personality disorder criterion was scored positive if it had been present for 2 years and did not occur exclusively during an Axis I disorder.17Also, antisocial personality disorder criterion A (age 18 years) was ignored and ‘personality disorder not otherwise specified’ was defined as either nine positive personality disorder criteria across any personality disorder domains or falling one criterion short of ‘caseness’ for a specific personality disorder diagnosis but having two additional criteria from any other personality disorder domain.2

Outcome measures

Primary outcome variables were defined a priori. We anticipated that the CAT group would show a greater reduction in psychopathology and parasuicidal behaviour (suicide attempts and non-suicidal self-injury)9 and greater improvement in global functioning.

Psychopathology

The SCID–II borderline personality disorder dimensional score was derived by summing the nine SCID–II items, scored 1 (absent), 2 (sub-threshold) or 3 (present). Scores range from 9 to 27. For follow-up assessments, each borderline personality disorder criterion was rated for the interval between assessments.

Internalising and externalising psychopathology scores were derived from the Youth Self-Report (YSR) questionnaire, a widely used instrument which assesses behavioural and emotional functioning in young people aged 11–18 years.18,19 It has 112 items, rated 0 (not true), 1 (somewhat or sometimes true) and 2 (very true or often true). The Young Adult Self-Report (YASR) is an analogue of the YSR for people aged 18–30 years, containing 116 items rated using the same YSR response format.20 As some of the items of the internalising and externalising sub-scales differ between the YSR and YASR, in keeping with previous research we calculated the mean item scores for each scale to ensure comparability.2 The resulting scores ranged between 0 and 2.

Parasuicidal behaviour

Parasuicidal behaviour was assessed by semi-structured interview (developed by the investigators and available upon request) that included enquiring into each form of parasuicide and the number of episodes. The number of episodes was then coded as none, monthly, weekly or daily.

Global functioning

Global functioning was assessed using the widely used Social and Occupational Functioning Assessment Scale (SOFAS).21

Treatment conditions and therapists

Both forms of treatment comprised up to 24 weekly sessions.

Therapists

The three therapists (two female, one male) were 6th-year degree clinical psychologists (standard for Australia), trained in cognitive–behavioural therapy, with at least 2 years post-training experience. In order to control for therapist effects such as gender, training and experience, they delivered both interventions and the accompanying case management.

Cognitive analytic therapy

Cognitive analytic therapy is a time-limited, integrative psychotherapy developed in the UK over the past 25 years by Ryle & Kerr.22 This therapy arose from a theoretical and practical integration of elements of psychoanalytic object relations theory and cognitive psychology, developing into an integrated model of development and psychopathology. It has increasingly been used with complex and relational disorders, especially borderline personality disorder.8,23 We selected this therapy because it had been developed for use in public health services and was suitable for early intervention. Drs Anthony Ryle and Ian Kerr conducted initial training over 9 months, comprising 100 h of face-to-face, large- and small-group seminars in Melbourne and London, and telephone-supervised practice. Study recruitment commenced when Dr Ryle judged that all three therapists were adherent to the therapy.

Each case in this arm of the study was supervised by an expert from the Association for Cognitive Analytic Therapy in the UK. Dr Ryle conducted a weekly telephone supervision group for some cases; all other cases were individually supervised, using weekly emailed process notes and monthly telephone calls. At the end of each session, the therapist summarised the session with the patient. The recording of this summary was converted to a secure mp3 file and emailed with the process notes. The summaries and notes were rated for treatment integrity and used for supervisor feedback.

Standardised good clinical care

Standardised good clinical care was a modular treatment package developed specifically for this study (further information available from the authors) and explicitly designed for the same purpose as Linehan’s ‘ treatment by experts’,24 namely to control for some factors commonly believed to be effective in psychotherapy (availability, accessibility and duration of therapy, institutional prestige and general factors associated with receiving therapy). This intervention was designed to deliver standardised, high-quality, team-based clinical care that might be achievable in mental health services in more economically developed countries. It used a simple problem-solving model for all participants,25 with additional modules determined by the co-occurring problems (e.g. depression, anxiety or anger management) identified by the patient and/or therapist. Some modules included basic cognitive– behavioural concepts such as identifying that thoughts and feelings are related and the use of monitoring and challenging unhelpful thoughts or beliefs. Supervision occurred weekly in a peer group led by a senior clinical psychologist external to the study.

Common elements of the treatment models

Both treatments used common elements of the HYPE service model of care and had equal access to assertive case management, psychiatrist appointments, activity groups, crisis team and in-patient care and pharmacotherapy (as indicated). As the principal investigator (A.C.) was also the study psychiatrist, all decisions to initiate pharmacotherapy were reviewed and approved by an experienced psychiatrist independent of the study.

Treatment integrity

In addition to the use of treatment manuals, expert training and supervision, all sessions were audio-recorded. All therapists and some supervisors audited randomly selected whole-session recordings to provide qualitative feedback to therapists contemporaneous with the trial. Cognitive analytic therapy was rated for adherence and competency by supervisor monitoring of the use of the specific ‘tools’ of the therapy (narrative formulation, diagrammatic formulation and ‘goodbye letter’) at the appropriate phase of therapy and by using the Therapist Intervention Checklist (Bennett, personal communication, 2006), short version rating of the session summary recording and detailed process notes. Four domains of this checklist were rated on a scale of 1–4 (1, well done; 2, partially done; 3, inadequately or not done; 4, hammering or ‘ overkill’):

noting key contents of the session

using contents to propose links and explore possible patterns

inviting patient’s reaction to the therapy/session

proposing/elaborating procedural descriptions of these reactions.

Total scores ranged from 4 to 16, where scores below 8 indicated satisfactory adherence. Cognitive analytic therapy supervisor ratings for 163 therapy sessions across 25 patient–therapist dyads had a mean score of 6.3 (s.d.=1.1).

Treatment adherence for good clinical care and differentiation of this treatment from cognitive analytic therapy used a 21-item scale devised by C.W. and L.M. (further information available from the authors). Items drawn from the respective treatment manuals were rated as either present or absent, and included 10 prescribed items corresponding to the GCC sub-scale (scoring range 0–10) and 11 proscribed items corresponding to the CAT sub-scale (scoring range 0–11).

Thirty-seven recordings were selected randomly from early, middle or late therapy (sessions 3, 12 or 20) and rated across 37 patient–therapist dyads (by C.W.). Mean score for the GCC subscale was 8.83 (s.d.=0.25), indicating excellent adherence. Mean score for the CAT sub-scale was 0.52 (s.d.=0.11), indicating negligible ‘contamination’ of good clinical care with elements of cognitive analytic therapy.

Treatment of missing data and statistical methods

Sample size was determined using the SCID–II borderline personality disorder dimensional score. A magnitude of three points difference (i.e. one borderline personality disorder feature) between the two treatment groups was considered clinically important. Past research data from our programme gave us a standard deviation of 3.6 for this score, producing an expected effect size of 0.8 (3/3.6). Therefore, we sought to detect a medium to large effect size (i.e. 0.6–0.8) and with alpha set at 0.05 and power at 0.8, a sample size of 26–45 in each group would be needed.26 We therefore aimed to have a sample of 40 in each group.

Data analysis was by intention to treat. Missing values for the CAT and GCC groups on outcome measures due to withdrawal or non-attendance subsequent to baseline were assumed to have occurred at random, conditional on the completely observed pre-treatment scores on all outcome measures (see, for example, Schafer & Graham,27 for a general review of missing data and their treatment). Ten multiply imputed data-sets were generated using the PAN package in the R statistical program,28,29 for which the imputation model was the same as the one used in the actual statistical modelling of the data.

Treatment differences and change over times were analysed by using thextmixed procedure in Stata version 9.2 for Windows for the continuous total borderline personality disorder, SOFAS, internalising and externalising outcome measures and by using the gllamm package for the ordinal categorical parasuicidal behaviour. The four time points were coded as – 1, –0.75, –0.5 and 0 in all models, thereby implying that regression coefficients involving time measured the linear rate of change from baseline to 24-month follow-up and that regression intercepts referenced group differences at the last follow-up point (no evidence of non-linear change in either the CAT or the GCC group was observed or found in preliminary models).

A linear random intercept model best fitted the SOFAS and internalising measures, whereas total borderline personality disorder and externalising outcomes were best represented by a linear random intercepts and slopes model. Parasuicidal behaviour was best fitted by a logistic proportional odds random intercepts model. Effects for all outcome measures were adjusted by additionally incorporating into all fitted models time-varying covariates for total SCID–II antisocial personality disorder score, presence of a mood disorder, and presence of a substance use disorder.

Only primary model parameters directly relevant to the study objectives are presented here. They are: first, group differences at 24 months (indicating whether cognitive analytic therapy was better or worse than good clinical care at the final follow-up); second, the linear rate of change from baseline to final follow-up for the GCC group (indicating the extent to which the reference group improved or deteriorated over the 24 months of the study); and third, differential rate of change for the CAT group (indicating whether the rate of improvement or deterioration in this group was substantially stronger than in the GCC group). All model parameters for continuous outcome measures are presented here as partial standardised effects, whereas those for the categorical measures of parasuicidal behaviour are presented as conditional odds ratios. Complete tables of all modelling results are available upon request from the authors.

The ten multiply imputed data-sets provided ten sets of model parameter estimates and their standard errors. These values were averaged over all ten imputed data-sets using Rubin’s rules for scalar estimands to obtain mean multiply imputed model parameter estimates.30 Finally, 95% confidence intervals were calculated for all parameter estimates using Rubin’s Student’s tapproximation.30

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Results

The characteristics of participants (n=41 CAT, n=37 GCC) are shown in online Table DS1.

Treatment received

The flow of patients through the study is shown in Fig. 1. The median number of therapy sessions received and the interquartile range (IQR) were 13.0 (IQR 8–23) for the CAT group and 11.0 (IQR 4.5–23) for the GCC group. The median numbers of individual non-therapy contacts (e.g. case management and psychiatrist appointments) were 33.0 (IQR 20.5–54.0) and 32.0 (IQR 18.5–52.5) respectively. There was no significant difference between the two groups on the number of therapy sessions or non-therapy contacts at any of the three follow-up time points (all P>0.05). The median interval from enrolment to discharge was 42.9 weeks (IQR 24.1–58.3) for the CAT group and 39.4 weeks (IQR 20.6–52.1) for the GCC group. The median number of contacts of any type per week was 1.4 (IQR 0.9–1.8) for the CAT group and 1.3 (IQR 0.8–1.6) for the GCC group.

Most patients who withdrew from the interventions continued to participate in research assessments (Fig. 1). Termination of therapy occurred with a formal final session (negotiated) or without a formal final session (drop-out). Negotiated termination was commonly because the patients believed that they had received enough treatment. There was no difference between the two study groups in the numbers of participants completing treatment, negotiating early termination or dropping out of treatment (χ2=1.57, P=0.46).

Observed means and standard deviations at all four time points for the two groups are presented in Table 1 for the four continuous outcomes measures, whereas Table 2 contains the observed proportions in each category of parasuicidal behaviour. Summary statistics of the ten multiply imputed data-sets are available from the authors.

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Table 1 Treatment group scores for continuous outcome measures at each time point

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Table 2 Group proportions for frequency of parasuicide at each time point

Longitudinal treatment effects

Both treatment groups demonstrated improvements over the 2-year period from baseline to final follow-up (based on the estimates displayed in the first row of Table 3). The GCC group evidenced a median improvement in absolute terms over all four continuous outcome measures of 0.88 standard deviation, whereas the median improvement for the CAT group was 1.02 standard deviations. Moreover, the two treatment groups showed a substantial reduction over time in the odds of a higher frequency of parasuicidal behaviour incidents (OR=0.32 for CAT and OR=0.08 for GCC).

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Table 3 Parameter estimates from longitudinal modelling of outcome measures for the two treatment groups

Differential rates of change

Of critical interest was whether or not differences existed between the CAT and GCC groups in their relative rates of improvement from baseline to final follow-up. The second row of Table 3 shows that the expected rate of improvement was faster for CAT compared with GCC in externalising (–0.50 s.d.) and internalising (–0.29 s.d.) pathologies, and moderately faster for GCC in general functioning (–0.26 s.d.); the upper boundary of the respective 95% confidence intervals (CIs), however, indicated these differential rates may at worst be slight. There was no meaningful or substantial difference between the two treatments in their respective rates of change over time for borderline personality disorder total scores and for frequency of parasuicidal behaviour.

Group comparisons at final follow-up

The third row of Table 3 reveals that the largest difference for cognitive analytic therapy over good clinical care at 24-month final follow-up was in externalising psychopathology (–0.32 s.d.), with the upper limit of the 95% CI again indicating that this difference could also at worst be slight. No other noticeable difference at 24 months could be reasonably inferred on the remaining outcome measures.

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Discussion

This is the first published randomised controlled trial of cognitive analytic therapy for any problem and it substantially enhances the evidence base for this psychotherapy. Two major findings emerge from this study. First, to our knowledge, this is the first study to show that early intervention for sub-syndromal or first-presentation borderline personality disorder is possible and that it results in significant positive effects upon a broad range of patient outcomes. Second, patients in both treatment groups demonstrated significant and clinically substantial improvement, with cognitive analytic therapy showing some evidence of more rapid onset of benefit. These findings demonstrate ‘proof of concept’ for early intervention in borderline personality disorder and should also help to allay fears of iatrogenic harm arising from early diagnosis and treatment specifically for borderline personality disorder.31,32 The patients in this study were, on average, 13–15 years younger than those in recent randomised controlled trials for borderline personality disorder.7,24,33,34 Moreover, their mean age was comparable to the mean age at first psychiatric contact reported in the randomised controlled trial by Clarkin et al (17 years)7,35 and was 5 years below that reported by Davidson et al (22 years).34 Only longer-term follow-up of this sample will demonstrate whether the gains made through early intervention are sustained and whether they divert patients from the poor outcomes associated with these traits and the course of disorder that leads to persistent problems and possibly to adult treatment settings.

Cognitive analytic therapy yielded the greatest median improvement on the four continuous outcome measures over the 2-year period. At 24 months, this therapy also showed a faster rate of improvement over time and lower levels of externalising psychopathology compared with good clinical care. However, the effect sizes for group differences in rate of change and at 24-month follow-up are less than those hypothesised in the power analysis used for designing the study and represent medium-sized differences using Cohen’s qualitative guidelines.36 Also, the effect of cognitive analytic therapy upon externalising psychopathology is interesting because the focus of this therapy is relational, not behavioural as in good clinical care. Further studies are required to examine possible mechanisms of action of this psychotherapy.

Both treatments were delivered exactly as they are intended to be delivered in clinical services and the HYPE clinic continues as a ‘real world’ service offering these interventions. The outcomes reported were achieved with a relatively small median ‘dose’ of therapy (13 CAT sessions and 11 GCC sessions) but delivered within a comprehensive service model. This included 2.5 case management sessions for every CAT session and 2.9 for every GCC session, highlighting that intervention involves more than just formal psychotherapy. This small dose of therapy does not necessarily imply that more would be better. The explicit time limit is an integral feature of cognitive analytic therapy, making it an exemplary intervention in terms of balancing the allocation of healthcare resources with the need for broad implementation of early intervention for borderline personality disorder. It also appears to be consistent with patient preferences and does not preclude future episodes of care.

The actual amounts of time spent with the CAT and GCC patients were almost identical, strengthening the claim that the findings favouring cognitive analytic therapy over good clinical care are actually due to CAT and that CAT adds value to the HYPE service model. The common elements of CAT and GCC (the HYPE service model) facilitate therapy delivery. They should not be viewed as incidental to treatment or as something to be controlled for in experimental designs, since they appear to be fundamental to the treatment models themselves.

Clinical experience suggests that ‘treatment as usual’ for borderline personality disorder ranges from untested specialised treatments through to mutually hostile clinical contact with likely iatrogenic harm (‘maltreatment as usual’),31 and it is notable that GCC was not ineffective. This finding is consistent with the comparison by Linehan et al of ‘treatment by experts’ with historical treatment as usual.24 In contrast to treatment by experts, this study’s good clinical care is a manualised, non-expert intervention that can be disseminated and replicated. It is possible that service reforms using existing resources and the HYPE model incorporating good clinical care might have important effects upon patient outcomes compared with the status quo of treatment as usual in most clinical services.

Borderline personality disorder in adolescence

Personality pathology is as important a form of psychopathology in adolescence as it is in adulthood,37 yet diagnosing adolescent personality pathology remains controversial.32 We have reviewed the growing body of evidence that indicates that a diagnosis of borderline personality disorder is no less reliable or valid in adolescence than it is in adulthood.4 It is widely acknowledged that personality disorders are best understood as dimensional constructs,38 and both sub-syndromal and full-syndrome borderline personality disorder in adolescence exist on a continuum of clinical severity and are prospectively associated with diverse functional and psychopathological poor outcomes, including a future diagnosis of borderline personality disorder, increased risk of Axis I disorders (especially substance use and mood disorders), interpersonal problems, distress and reduced quality of life.4 We do not claim that the patients in this study have the ‘late-stage’ borderline personality disorder syndrome described in DSM–IV and typically seen in adult mental health services. Like early intervention for first-episode psychosis,39 early intervention for borderline personality disorder usually involves including milder ‘cases’ or forms of disorder and targets the diverse outcomes associated with the presenting symptoms (e.g. borderline personality disorder, Axis I pathology, interpersonal problems) rather than narrowly focusing upon the ‘late-stage’ syndrome,4,39 especially as progression to symptomatically chronic borderline personality disorder is uncommon, even in adulthood.40

Strengths of the study

Good clinical care was an active, non-specialised intervention that was clearly characterised, with documented good adherence and equal access to the elements of care not included in formal psychotherapy. This provided a more rigorous control condition than the common comparison condition of treatment as usual, which is seldom characterised. Also, both cognitive analytic therapy and good clinical care were delivered in their intended ‘real world’ form and with equal access to a comprehensive service model of care, which was characterised and measured. Also, the study was conducted in a front-line clinical service, with clinical referrals from the community and with few exclusion criteria, enhancing its external validity.

Using the same therapists to deliver both treatment conditions allowed for rigorous control of some therapist effects (gender, experience, personality). However, it also allowed for possible treatment ‘contamination’ or sabotage. The GCC treatment integrity measure and random peer audits revealed excellent adherence to the model and negligible overt contamination. However, covert contamination was still possible, i.e. ‘thinking in CAT’. Additionally, although our group were not cognitive analytic therapy ‘ insiders’, arguably reducing therapist allegiance effects, the team reported developing a preference for this form of therapy during the trial. Also, the therapists were experienced in cognitive–behavioural therapy but new to cognitive analytic therapy. Treatment effects might have been more pronounced with greater experience in the latter therapy.

Limitations

The sample size, although comparable with other published randomised controlled trials for adult borderline personality disorder, is still relatively small in absolute terms and restricts the degree of precision for detecting the small to medium kinds of treatment effects found in our study. Also, participants were not randomised to therapists, allowing some potential biasing through matching of patient to therapist. It would also have been preferable to perform the randomisation procedure after baseline assessment. We cannot say whether the eight participants who withdrew prior to baseline assessment did so as a result of their assignment to a particular treatment group. Finally, as this is the first study of its kind, the findings reported are preliminary and need replication.

Implications of the study

This study should improve clinicians’ confidence that a diagnosis of sub-syndromal or full-syndrome adolescent borderline personality disorder can now be matched with an effective intervention. Cognitive analytic therapy might be preferred to good clinical care, but the latter was not ineffective and service reform using this model might be achieved more swiftly, with cognitive analytic therapy implementation as a second phase of development. Further studies are required to replicate these findings and to investigate the mechanisms of change, the sustainability of the improvements beyond 2 years and the effectiveness of cognitive analytic therapy in samples of older people with borderline personality disorder.

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Acknowledgments

The authors thank all participants in this study and the staff of ORYGEN Youth Health. Particular thanks go to Dr Anthony Ryle, Dr Ian Kerr, Ms Eva Burns-Lundgren, Dr Dawn Bennett, Dr Jackie Withers and the Association for Cognitive Analytic Therapy (UK) for training and supervision in cognitive analytic therapy. Thanks also go to Associate Professor John Gleeson for supervision of standardised good clinical care, Dr Andrew Court for independent psychiatric assessments, Dr Carol Hulbert, Ms Helen Mildred and Dr Denise Charman for advice on the implementation of the study and to Professor Anthony Jorm and Dr Sarah Hetrick for comments on an earlier version of this manuscript. This work was supported by grants 98-0198 from the Victorian Health Promotion Foundation, Melbourne, Australia and grant 990748 from the National Health and Medical Research Council Canberra, Australia. The ORYGEN Research Centre is supported by an unrestricted grant from the Colonial Foundation, Melbourne, Australia.

Received December 14, 2007.

Revision received July 15, 2008.

Accepted July 30, 2008.

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References

↵ American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (4th edn, Text Revision) (DSM–IV–TR). APA, 2000.

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誠実さには限りがない

誠実さには限りがない

無限に尽くすことを(自分または神に)要求されてしまう

現実にはお互い様の原理で収めるけれど

それがまた全くお互い様になっていない

それぞれの考える神は異なっているらしい

誠実であろうとする限り、自責と背中合わせである

xhvy

Adrian Wells Metacognitive Therapy for Anxiety and Depression

Metacognitive Therapy for Anxiety and Depression

 Adrian Wells

Over the last ten years I have gone through many of the different counselling programmes on offer through the NHS, including basic counselling, trauma counselling, CBT and Beat the Blues- not to mention the thousands spent on private treatments. Some of these treatments offered short term improvements, but none provided long lasting gains I could retain. 

The physical response of my anxiety was so great, at one point I had to have an operation to enable me to urinate properly. The heart palpitations perfectly mimicked what I imagine having a heart attack would be like and the constantly active mind (worry) sent me into bouts of spiralling depression with no escape in sight. 

My search for a cure to what started off as Obsessive Compulsive Disorder (OCD) and later developed into the broader Generalised Anxiety Disorder (GAD) led me to a book called `Cognitive Therapy of Anxiety Disorders' (same author), which in turn led to this current publication. 

The book is very well written and there is minimal technical jargon in it. It is aimed at practitioners, rather than to be used as a self-help guide, but, nonetheless after some time spent slowly digesting the relevant chapters, massive gains can be achieved. 

The concepts are logical and the content is fairly straight forward after the initial understanding. There are individual rating scales, treatment plans and process diagrams for GAD, OCD, PTSD and MDD, plus more general chapters which detail the common themes. 

There are examples of behaviour, which I could immediately relate to and begin to question my own behaviours. Hypothetical questions gave me something productive to think about, stimulated recovery and enabled me to see the bigger picture. There are experiments to challenge unhelpful beliefs and enable new, more helpful counter evidence to generate a `new plan' for processing information. 

The book clearly describes the technique of `Detached Mindfulness', which is a key component to the therapy. This allows thoughts to be treated as `events in the mind', rather that actively engaging with them in the first place. This means that the content of thoughts and worries is largely irrelevant and things can be treated in a more logical problem solving manner. 

I cannot rate this book highly enough. From a personal perspective it has turned my life around and the future (which wasn't looking too promising) is now looking bright. In my opinion, the NHS fails to successfully treat conditions like mine and advances such as this have the potential to save large amounts of money- I'm sure I have cost the tax-payer a small fortune unnecessarily, when treatments such as this could be available. 

Since I picked the book up eighteen months ago, I have unravelled my condition back to the route cause and come off all medication, that included a maximum dose of the beta blocker propranolol. I have travelled to Australia on my own, done a sky dive, a bungee jump and climbed Mount Kilimanjaro......,things that GAD suffers may believe will never be possible for them. 

My condition is more complex and I am under the care of a clinical psychologist to round off my own progress, but I believe a full recovery is only a matter of time. 

Thanks again to Professor Wells, at al, and I hope this review is useful to whoever reads it. Good luck and best wishes.

Anthony Ryle、 Ian B. Kerr Introducing Cognitive Analytic Therapy: Principles and Practice

Introducing Cognitive Analytic Therapy: Principles and Practice

Anthony Ryle、 Ian B. Kerr

Introducing Cognitive Analytic Therapy is a systematic, up-to-date and comprehensive introduction to the origin, development and practice of CAT. Since its initial presentation as a model of individual psychotherapy, CAT has grown to represent a general theory of psychological development and change, reflecting in particular the influence of Vygotsky.

Economical in cost and applicable to a wide spectrum of disorders, CAT is now widely used by a range of mental health service providers. The practice of CAT has been extended to different settings and patient groups, most notably in the area of Borderline Personality Disorder.

Introducing Cognitive Analytic Therapy includes a range of features to aid scholars and trainees:

• illustrative case histories and numerous case vignettes

   

• chapter summaries, further reading and a glossary of key terms

   

• resources for use in clinical settings