“「自分は正しい」「これこそ本物」「これは良い事」 実はこう思った瞬間こそが人間が最も攻撃的になる時なのです。”

“「自分は正しい」「これこそ本物」「これは良い事」

実はこう思った瞬間こそが人間が最も攻撃的になる時なのです。”

Mild Cognitive Impairment MCI

Mild Cognitive Impairment

Ronald C. Petersen, M.D., Ph.D.

N Engl J Med 2011; 364:2227-2234June 9, 2011

 Comments open through June 15, 2011

Article

References

Comments (4)

This Journal feature begins with a case vignette highlighting a common clinical problem. Evidence supporting various strategies is then presented, followed by a review of formal guidelines, when they exist. The article ends with the author's clinical recommendations.

A 70-year-old woman has been noticing increasing forgetfulness over the past 6 to 12 months. Although she has always had some difficulty recalling the names of acquaintances, she is now finding it difficult to keep track of appointments and recent telephone calls, but the process has been insidious. She lives independently in the community; she drives a car, pays her bills, and is normal in appearance. A mental status examination revealed slight difficulty on delayed recall of four words, but the results were otherwise normal. Does the patient have mild cognitive impairment? How should her case be managed?

THE CLINICAL PROBLEM

Mild cognitive impairment represents an intermediate state of cognitive function between the changes seen in aging and those fulfilling the criteria for dementia and often Alzheimer's disease.1Most people undergo a gradual cognitive decline, typically with regard to memory, over their life span; the decline is usually minor, and although it may be a nuisance, it does not compromise the ability to function. A minority of people, perhaps 1 in 100, go through life with virtually no cognitive decline and are regarded as aging successfully. However, another trajectory of aging is characterized by a decline in cognitive function beyond that associated with typical aging; the decline is often recognized by those experiencing it and occasionally by those around them. Known as “mild cognitive impairment,” this entity has been receiving considerable attention in clinical practice and research settings.2

Mild cognitive impairment is classified into two subtypes: amnestic and nonamnestic.3 Amnestic mild cognitive impairment is clinically significant memory impairment that does not meet the criteria for dementia. Typically, patients and their families are aware of the increasing forgetfulness. However, other cognitive capacities, such as executive function, use of language, and visuospatial skills, are relatively preserved, and functional activities are intact, except perhaps for some mild inefficiencies. Nonamnestic mild cognitive impairment is characterized by a subtle decline in functions not related to memory, affecting attention, use of language, or visuospatial skills (Figure 1FIGURE 1Diagnostic Algorithm for Amnestic and Nonamnestic Mild Cognitive Impairment.). The nonamnestic type of mild cognitive impairment is probably less common than the amnestic type and may be the forerunner of dementias that are not related to Alzheimer's disease, such as frontotemporal lobar degeneration or dementia with Lewy bodies.4 In clinical trials involving patients with amnestic mild cognitive impairment, more than 90% of those with progression to dementia had clinical signs of Alzheimer's disease.5

The estimated prevalence of mild cognitive impairment in population-based studies ranges from 10 to 20% in persons older than 65 years of age.6-10 In the Mayo Clinic Study of Aging, a prospective, population-based study of persons without dementia who were between 70 and 89 years of age at enrollment, the prevalence of amnestic mild cognitive impairment was 11.1% and that of nonamnestic mild cognitive impairment was 4.9%. 11

Several longitudinal studies have shown that most persons with mild cognitive impairment are at increased risk for the development of dementia.6,8-10 As compared with the incidence of dementia in the general U.S. population, which is 1 to 2% per year, the incidence among patients with mild cognitive impairment is significantly higher, with an annual rate of 5 to 10% in community-based populations12 and 10 to 15% among those in specialty clinics (the latter rates reflecting the fact that cognitive impairment is typically more advanced by the time a person seeks medical attention).12,13Although some data suggest that the rate of reversion to normal cognition may be as high as 25 to 30%, recent prospective studies have shown lower rates.9 Moreover, reversion to normal cognition at the time of short-term follow-up does not preclude later progression. Longer periods of follow-up in community-based studies are needed to determine whether reported rates of progression are consistent over a prolonged period.

STRATEGIES AND EVIDENCE

Evaluation

For the clinician, making the distinction between mild cognitive impairment and normal aging can be a challenge. Subtle forgetfulness, such as misplacing objects and having difficulty recalling words, can plague persons as they age and probably represents normal aging. The memory loss that occurs in persons with amnestic mild cognitive impairment is more prominent. Typically, they start to forget important information that they previously would have remembered easily, such as appointments, telephone conversations, or recent events that would normally interest them (e.g., for a sports fan, outcomes of sporting events). However, virtually all other aspects of function are preserved. The forgetfulness is generally apparent to those close to the person but not to the casual observer.

The patient's history typically raises the suspicion of a decline in cognition, usually memory, and neuropsychological testing may be necessary to corroborate the decline, especially for cases in which the deficits are particularly subtle. Neuropsychological testing may be helpful to distinguish particularly mild cases from normal aging, but testing is not routinely needed to make the clinical diagnosis. A brief mental status examination in the physician's office, such as the Mini–Mental State Examination, is often insensitive to early impairment; more useful measures include the Short Test of Mental Status and the Montreal Cognitive Assessment14,15 (both provided in theSupplementary Appendix, available with the full text of this article at NEJM.org). At times, the so-called worried well can provide a convincing history of memory loss, but neuropsychological testing reveals normal performance. A reversible form of mild cognitive impairment may result from other conditions, such as depression, or from the side effects of medication; these possibilities should be assessed in the process of obtaining the patient history.

Differentiating mild cognitive impairment from dementia is generally not difficult. Typically, in patients with dementia, cognitive deficits are affecting daily functioning to the extent that there is loss of independence in the community; this information may be provided by the patient or by a family member. A diagnosis of dementia can be supported with the use of instruments such as the Functional Activities Questionnaire, which can be administered in a primary care setting and characterizes impairment in function that is within the range of dementia16 (this questionnaire is available in the Supplementary Appendix). However, a careful history taking is often sufficient to make this determination.

Prediction and Risk Factors

A question commonly raised by patients with mild cognitive impairment and their family members concerns the likelihood and time course of progression to dementia. Although the general rate of progression among those with a diagnosis of mild cognitive impairment is estimated at 10% per year, certain factors predict a more rapid progression. The degree of cognitive impairment at presentation is a clinical predictor of progression, which is likely to be more rapid in patients with greater impairment at baseline,17,18 probably because these patients are closer to the threshold for the diagnosis of dementia. Longitudinal data have shown that progression to dementia is more rapid among carriers of the apolipoprotein (APOE) ε4 allele than among noncarriers,5 although testing for the presence of the allele is not currently recommended in routine practice.

Various findings on imaging and tests for biomarkers may identify persons at risk for more rapid progression to dementia. 19 Although these measures are promising, they should not yet be used in routine clinical care, given the current lack of standardization among the techniques and the uncertainty regarding the optimal cutoff points for identifying high-risk groups.

The most extensively studied means of predicting progression of mild cognitive impairment to dementia is structural magnetic resonance imaging (MRI)19,20 (Figure 2FIGURE 2Coronal MRI Scans from Patients with Normal Cognition, Mild Cognitive Impairment, and Alzheimer's Disease.). A recent community-based study showed that among persons with amnestic mild cognitive impairment, those with volumetric measurements of the hippocampus that fell at or below the 25th percentile for age and sex had a risk of progression to dementia over a 2-year period that was two to three times as high as the risk among persons whose hippocampal measurements were at or above the 75th percentile.21 Other quantitative measures, such as larger ventricular volumes, have also been reported to predict progression.22However, at this time there are no accepted criteria for hippocampal atrophy or other proposed markers of progression on MRI. More data are needed to define these measures and to develop guidelines for their appropriate clinical use.23

Functional imaging techniques, such as ¹⁸F-fluorodeoxyglucose positron-emission tomography (¹⁸FDG-PET), which provide an index of synaptic integrity, have also been evaluated as predictors of progression to dementia. Studies indicate that patients with a pattern of hypometabolism in the temporal and parietal regions of the brain on ¹⁸FDG-PET, which is suggestive of Alzheimer's disease, may be at increased risk for rapid progression from mild cognitive impairment to Alzheimer's disease as compared with patients without this pattern.24-26 The Alzheimer's Disease Neuroimaging Initiative (ADNI; ClinicalTrials.gov number, NCT01231971), a multicenter longitudinal study, showed that for subjects with mild cognitive impairment who had this pattern of hypometabolism on ¹⁸FDG-PET, the risk of progression to Alzheimer's disease during the next 2 years was 11 times the risk among subjects who did not have this pattern.24

Analysis of markers in the cerebrospinal fluid has also been proposed as a means of assessing the risk of progression to Alzheimer's disease.27 A Swedish study showed that subjects with mild cognitive impairment who had low levels of β-amyloid peptide 42 (Aβ42) and elevated levels of tau protein in cerebrospinal fluid were significantly more likely to undergo progression to Alzheimer's disease than subjects without this profile (hazard ratio, 17.7; 95% confidence interval, 5.3 to 58.9); a similar relative risk of progression was associated with a low ratio of Aβ42 to tau in the cerebrospinal fluid.28 An international multicenter study of 750 subjects with mild cognitive impairment corroborated these general findings29,30 but used different cutoff points for abnormal findings. The reliability of these markers is highly variable across laboratories; standardization will be needed before they are considered for incorporation into routine care.

The use of molecular imaging, particularly of amyloid plaques in the brain (Figure 3FIGURE 3Axial Scans of the Brain Obtained with Positron-Emission Tomography and the Use of Amyloid-Binding Carbon 11–Labeled Pittsburgh Compound B.), has also been studied as a possible approach to risk stratification.31-33 In several studies, subjects with mild cognitive impairment in whom amyloid was detected on positron-emission tomography (PET) with the use of the amyloid-binding carbon 11–labeled Pittsburgh compound B had more rapid progression to Alzheimer's disease than did subjects in whom amyloid was not detected.34The rationale for using this technique to predict disease progression is that the presence of amyloid in a patient with mild cognitive impairment is likely to indicate that the patient has early Alzheimer's disease; however, amyloid has been detected on autopsy in clinically normal persons, indicating that the predictive value of this measure requires further study.35

Management

From a clinical perspective, patients with mild cognitive impairment should not be labeled as having early Alzheimer's disease, prodromal Alzheimer's disease, or mild cognitive impairment of the Alzheimer's disease type, since the patient and family are likely to hear only “Alzheimer's disease” and not appreciate the uncertainty of the association with Alzheimer's disease.36 Clinicians should make it clear that mild cognitive impairment is an abnormal condition but that the precise outcome is not certain.

At present, no medication intended for the treatment of mild cognitive impairment has been approved by the Food and Drug Administration (FDA). In several placebo-controlled clinical trials, there was no significant reduction in rates of progression to dementia among patients with mild cognitive impairment who were treated with agents used to treat Alzheimer's disease (donepezil, galantamine, and rivastigmine, administered at standard doses for Alzheimer's disease for 2 to 4 years). 5,37-40 In one trial evaluating the effects of high-dose vitamin E (2000 IU daily) or donepezil in persons with mild cognitive impairment, donepezil significantly reduced the risk of progression to Alzheimer's disease for the first 12 months of the study (and for up to 24 months in the subgroup of subjects who were carriers of APOE ε4) but had no significant effect on the risk of Alzheimer's disease at 36 months, which was the primary study outcome; vitamin E did not significantly reduce the risk of progression at any time point assessed.5

One potential explanation for the apparent lack of efficacy in the clinical trials of interventions in persons with mild cognitive impairment — other than a true absence of drug efficacy — concerns the heterogeneity of the subjects. As the diagnostic threshold moves to an earlier point in the clinical spectrum of cognitive impairment, the subtle changes in cognition could be due to a variety of causes other than a degenerative brain disease, making it difficult to determine whether an intervention has had a significant effect.

There is some evidence of a potential benefit from cognitive rehabilitation, including the use of mnemonics, association strategies, and computer-assisted training programs. 41,42 A recent systematic review of the literature on cognitive rehabilitation programs for persons with mild cognitive impairment, including some data from randomized clinical trials, showed significant improvement in cognitive function at the end of training.42

Observational data have shown associations between the presence of cardiovascular risk factors in patients with mild cognitive impairment and an increased risk of progression to dementia.7 Such risk factors should be addressed, although there is no definitive evidence that modification of risk factors slows disease progression. In a randomized trial that used the Cognitive Subscale of the Alzheimer's Disease Assessment Scale to compare the effect of a physical exercise program (brisk walking for 150 minutes per week) with that of usual care and education in persons with subjective memory loss, the exercise group had better cognitive function at 6 months (the primary study outcome), with some residual benefit noted at 18 months.43

AREAS OF UNCERTAINTY

More data are needed regarding the usefulness of various potential predictors of progression to dementia and their role in clinical practice. Further data on these concerns are awaited from the Alzheimer's Disease Neuroimaging Initiative, under way in the United States and Canada,27,44 and from similar ongoing studies in Japan, Europe, and Australia. Some of the goals of these studies are to better understand the role of MRI findings (e.g., hippocampal atrophy),22,45 findings on ¹⁸FDG-PET (patterns of hypometabolism in the brain), cerebrospinal fluid markers (levels of Aβ42 and tau), and findings on molecular imaging (amyloid plaques in the brain) in identifying the subgroup of persons with amnestic mild cognitive impairment who are likely to undergo progression to clinical Alzheimer's disease.27,46,47 Major challenges are to determine optimal cutoff points for these tests and to compare their relative reliability (alone and in combination). Randomized trials are needed to assess the potential benefits of pharmacologic and lifestyle interventions in persons with mild cognitive impairment who are predicted to be at high risk for rapid progression to Alzheimer's disease according to the results of imaging and of tests for biomarkers. The costs of such predictive testing (not only in financial terms but also in terms of potential adverse psychological effects or compromised ability to obtain long-term care insurance) must be balanced against the potential benefits, especially given the absence of therapies with proven effectiveness for mild cognitive impairment.

GUIDELINES FROM PROFESSIONAL SOCIETIES

In an evidence-based review published in 2001, the American Academy of Neurology recommended that clinicians monitor and follow patients with mild cognitive impairment, since they are at increased risk for dementia, particularly Alzheimer's disease.48 These guidelines are currently being updated in view of the considerable literature published since that time. Mild cognitive impairment is not included in the current edition of the Diagnostic and Statistical Manual of Mental Disorders, but the manual is being revised, and an entry for a condition similar to mild cognitive impairment, which precedes dementia, will be included.49

The National Institute on Aging and the Alzheimer's Association recently published new diagnostic guidelines for assessing the likelihood that mild cognitive impairment is caused by the underlying pathophysiology of Alzheimer's disease. The degrees of certainty are established according to the results of imaging and other tests for biomarkers50 (Table 1TABLE 1Suggested Criteria for the Likelihood That Mild Cognitive Impairment Is Due to Alzheimer's Disease.). As stated above, research is needed to determine the criteria for abnormal results. Consequently, these new guidelines are largely intended to inform research rather than clinical assessment, but the expectation is that they may ultimately guide clinical care.

SUMMARY AND RECOMMENDATIONS

The description of the 70-year-old woman in the vignette, who is forgetful but otherwise appears to be functioning normally, suggests there is reason to suspect amnestic mild cognitive impairment. A neurologic examination, including an assessment of mental status, is indicated to objectively document her cognitive function. Depression should be ruled out. Referral for neuropsychological testing may be appropriate, particularly if the concern is the degree of impairment relative to the cognitive changes of aging. Documentation of memory impairment that is not in proportion to that expected, given her age and education, with minimal involvement of other cognitive domains, such as attention, executive function, language skills, and visuospatial skills, and preservation of functional independence would confirm the diagnosis of amnestic mild cognitive impairment. An MRI scan is suggested to rule out other conditions that might explain her memory loss (e.g., vascular disease, tumor, or hydrocephalus); the results might also show changes (e.g., hippocampal atrophy) suggesting that she is at increased risk for rapid progression to Alzheimer's disease, although more data would be needed to justify the use of MRI for this purpose.

I would recommend a clinical reevaluation in 6 months to determine whether the forgetfulness is worsening. At this time, I would not routinely recommend tests to predict the risk of progression (e.g., ¹⁸FDG-PET or measurement of biomarkers in cerebrospinal fluid) but would encourage the patient to consider participation in research evaluating these tools. I would explain that at present there are no FDA-approved medications for this condition; I would also review the negative results of medication trials thus far and explain the costs and potential side effects of pharmacotherapy. I would recommend engagement in aerobic exercise, involvement in intellectually stimulating activities and participation in social activities, given that these might be beneficial and pose little risk, although more data are needed to inform their efficacy in reducing the risk of progression to the dementia stage of Alzheimer's disease.

Dr. Petersen reports receiving consulting fees from Elan Pharmaceuticals and GE Healthcare, receiving royalties from Oxford University Press, and serving as chair of data monitoring committees for Pfizer and Janssen Alzheimer Immunotherapy. No other potential conflict of interest relevant to this article was reported.

Disclosure forms provided by the author are available with the full text of this article at NEJM.org.

An audio version of this article is available at NEJM.org.

I thank Cheryl Baertlein, Dana Swenson-Dravis, and David Cahill for their contributions and Clifford R. Jack, Jr., M.D., and Val Lowe, M.D., for their advice on the development of earlier versions of this manuscript.

SOURCE INFORMATION

From the Department of Neurology, Mayo Clinic College of Medicine, and the Mayo Clinic Alzheimer's Disease Research Center — both in Rochester, MN.

Address reprint requests to Dr. Petersen at the Mayo Clinic, Department of Neurology, Gonda 8 South, 200 First St. SW, Rochester, MN 55905, or at [e-mail].

タルティーニ 6つのバイオリンソナタ集 演奏 Amoyal

タルティーニ　6つのバイオリンソナタ集　演奏　Amoyal 

有名なのは悪魔のトリルだけれど
それ以外のものも心になじむ

“ジャガイモを茹で、茹で上がったらサッと氷水に入れます。5〜10秒氷水に入れたあとに手で皮を剥くと、簡単にジャガイモの皮が剥けます。”

“ジャガイモを茹で、茹で上がったらサッと氷水に入れます。5〜10秒氷水に入れたあとに手で皮を剥くと、簡単にジャガイモの皮が剥けます。”

余計なことではありますが 私は中国の猫が心配です 日本でもたとえば水俣病の時に 猫達はかわいそうな運命をたどりました 中には人間の症状が出る前に 症状が出て苦しんだ猫もいたのです

余計なことではありますが
私は中国の猫が心配です

日本でもたとえば水俣病の時に
猫達はかわいそうな運命をたどりました

中には人間の症状が出る前に
症状が出て苦しんだ猫もいたのです

“5秒でおもいついたことを10年かかって完成させる。それが人生”

“5秒でおもいついたことを10年かかって完成させる。それが人生”

３科学誌は商業主義…ノーベル受賞者が「絶縁」

　【ワシントン＝中島達雄】今年のノーベル生理学・医学賞を受賞した米カリフォルニア大バークレー校のランディ・シェックマン教授（６４）が、世界的に有名な３大科学誌は商業主義的な体質で科学研究の現場をゆがめているとして、今後、３誌に論文を投稿しないとの考えを明らかにした。

　教授は９日、英ガーディアン紙に寄稿し、英ネイチャー、米サイエンス、米セルの３誌を批判した。研究者の多くは、評価が高まるとして、３誌への掲載を競うが、教授は「３誌は科学研究を奨励するよりも、ブランド力を高めて販売部数を増やすことに必死だ」と指摘した。

　その上で「人目を引いたり、物議を醸したりする論文を載せる傾向がある」との見方を示し、３誌が注目されやすい流行の研究分野を作り出すことで「その他の重要な分野がおろそかになる」と問題を提起した。

最近の映像を見ると これは本当の体験の代替物ではなくて、 これ自体が本物の体験であると思えてしまった 高解像度で鮮明、光線の当て方なども完璧で、 場合によっては画像ソフトで修正を加えている 加えすぎてもつまらないが。 静止画では一瞬を切り取っているがゆえに完璧が実現している。 人間が現実を体験するときには そこまで精細ではないし、一瞬をじっと見つめるわけでもないので これは新しい体験なのだと思う 見過ごしている息を呑むような一瞬を発見させられる 動画の領域ではまだそれほどの高精細のものは多くないと

昔、子供用三輪車というものがありました
子供はなぜだか乗り物が好きで
イマジナリーに自我を拡張していくもののようです

ーーー
最近の映像を見ると
これは本当の体験の代替物ではなくて、
これ自体が本物の体験であると思えてしまった

高解像度で鮮明、光線の当て方なども完璧で、
場合によっては画像ソフトで修正を加えている
加えすぎてもつまらないが。
静止画では一瞬を切り取っているがゆえに完璧が実現している。

人間が現実を体験するときには
そこまで精細ではないし、一瞬をじっと見つめるわけでもないので
これは新しい体験なのだと思う

見過ごしている息を呑むような一瞬を発見させられる

動画の領域ではまだそれほどの高精細のものは多くないと思うが
音響技術も進歩しているし
こちらも素晴らしい体験が出来ると思う

クラシックのライブ映像などを流したりしているが
ライブよりも、スタジオで作りこんだ完璧な演奏、その中に込められた演奏家の思想
そういうものを体験することが出来ると思う

“ 目下、某所で絶賛炎上中でありますが、パナソニックで大変なことが起きております。 パナソニック、ヘルスケア事業の全株を1650億円でＫＫＲに売却 http://jp.reuters.com/article/topNews/idJPTYE98Q06O20130927 ネタ自体は今年9月に発表された代物ではありますが、このパナソニックのヘルスケア事業、もともとは三洋電機のバイオメディカ事業部でありまして、そこの事業部の中に小規模医療法人や診療所などを中心に550万人ほどの日本人の医療情報を取り扱う電子

“

目下、某所で絶賛炎上中でありますが、パナソニックで大変なことが起きております。

パナソニック、ヘルスケア事業の全株を1650億円でＫＫＲに売却

http://jp.reuters.com/article/topNews/idJPTYE98Q06O20130927

　ネタ自体は今年9月に発表された代物ではありますが、このパナソニックのヘルスケア事業、もともとは三洋電機のバイオメディカ事業部でありまして、そこの事業部の中に小規模医療法人や診療所などを中心に550万人ほどの日本人の医療情報を取り扱う電子カルテ関連事業を運用しています。

　この電子カルテが最終的にKKRの手に渡りますと、20％の株式を引き続きパナソニックが握るとはいえ第三国資本の企業への譲渡や包括的な業務提携をされ次第、日本人の医療情報が海外に漏れなく流出するという騒ぎに直結するということで、さすがにそれはまずいだろうということであれこれ動きが出てきたという状況です。

　さすがに日本医師会も重い腰を挙げ、先日パナソニックの経営陣を呼んで話をしたようですが、当然のように木で鼻を括ったような対応になっていて好感が持てます。やっぱり私の知っているパナソニックはそうでないと門真じゃないっすよね。

　冗談を言っている場合ではないのが、情報の一部に調剤薬局のデータも含まれている可能性が指摘されていることで、医師会としては「本来、患者データが外部に漏れるはずはない。なぜならば患者の情報は医師が漏らさないからだ、はっはっは」と言っていたのが、まさかの電子カルテ業者に委託していた先が海外資本になるぜって話は想定していなかったようです。

”

what_are_the_benefits_of_mindfulness

what_are_the_benefits_of_mindfulness_a_practice_review_of_psychotherapy

Psychotherapy

2011. Vol. 48. No. 2,198-208
@ 2011 American Psvcholoeical Association

PRACTICE REVIEW

What Are the Benefits of Mindfulness? A Practice Review of
Psychotherapy-Related Research

Daphne M. Davis and Jeffrey A. Hayes
Pennsylvania State University

Research suggests that mindfulness practices offer psychotherapists a way to positively affect aspects of
therapy that accountfor successfultreatment.This paper provides psychotherapists with a synthesis of
the empirically supported advantages of mindfulness. DCfinitions of 血@ndfulness and evidence-based
interpersonal, affective, and intrapersonal benefits of mindfulness are presented. Research on therapists
who meditate and client outcomes oftherapists who meditate are reviewed.Implications for practice,
research, and training are discussed.

Keywords: mindfulness, psychotherapy, meditation,literature review

   Mindfulness has enjoyed a tremendous surge in popularity in the
past decade, both in the popular press and in the psychotherapy
literature (Didonna, 2009a; Shapiro & Carlson, 2009). Owing
largely to the success of mindfulness-based stress reduction
(MBSR) programs and the centralrole of mindfulness in dialecti-
cal behaviortherapy, as well as acceptance and commitment
therapy, mindfulness has moved from a largely obscure Buddhist
conceptto a mainstream psychotherapy construct. Advocates of
mindfulness would have us believe that virtually every client, and
theirtherapists, would benefitfrom being mindful.In fact, mind-
fulness has been proposed as a common factorin psychotherapy
(Martin,1997). Among its theorized benefits are self-control
(Bishop et al., 2004; Masicampo & Baumeister, 2007), objectivity
(Adele & Feldman, 2004; Brown, Ryan, & Creswell, 2007; Leary
& Tate, 2007; Shapiro, Carlson, Astin, & Freedman, 2006), affect
tolerance (Fulton, 2005), enhanced flexibility (Adele & Feldman,
2004), equanimity (Morgan & Morgan, 2005),improved concen-
tration and mental clarity (Young,1997), emotionalintelligence
(Walsh & Shapiro, 2006), and the ability to relate to others and
one's self with kindness, acceptance, and compassion (Fulton,
2005; Wallace, 2001).Is mindfulness as good as advertised, how-
ever? What does the research literature have to say aboutthe
benefits of mindfulness? The purpose ofthis paperis to provide
psychotherapists with information aboutthe empirically supported
advantages of mindfulness, contextualized by effect sizes ofthese
advantages.In addition, we review research on practices that have
been found to promote mindfulness, as well as the effects on
therapists and trainees exposed to mindfulness meditation. The
paper concludes with implications for practice,reseiirch, and train-
ing. We begin by exploringthe meaning ofthe term "mindful-ness."

Definitions: Ancient and Modern

   The term "mindfulness" has been used to referto a psycholog-
ical state of awareness, a practice that promotes this awareness, a
mode of processing information, and a characterologicaltrait
(Brown et al., 2007; Germer, Siege], & Fulton, 2005; Kostanski &
Hassed, 2008; Siegel, 2007b). The word mindfulness originally
comes from the Pali word sati, which means having awareness,
attention, and remembering (Bodhi, 2000). Mindfulness can sim-
ply be defined as "moment-by-moment awareness" (Germer et al.,
2005. p. 6) or as "a state of psychologicalfreedom that occurs
when attention remains quiet and limber, without attachmentto
any particular point of view" (Martin,1997. p. 291.italics included
in originaltext). Forthe purposes ofthe present paper, and forthe
sake of consistency with most ofthe research thatis reviewed
subsequently, mindfulness is defined as a moment-to-moment
awareness of one's experience withoutjudgment.In this sense,
mindfulness is viewed as a state and not a trait, and while it might
be promoted by certain practices or activities (e.g., meditation),it
is not equivalentto or synonymous with them. When slightly
different definitions of mindfulness are used in the literature thatis
reviewed,these shall be noted.
   Mindfulness has similarities to other psychotherapy-related con-
structs. For example, mindfulness is similarto mentalization
(Bateman & Fonagy, 2004. 2006; Fonagy & Bateman, 2008),the
developmental process of understanding one's own and others'
behaviorin terms ofindividuals'thoughts,feelings, and desires.
Both constructs emphasize the temporary, subjective, and fluid
nature of mental states and both are thoughtto enhance affect
regulation and cognitive flexibility (Wallin, 2007). Mindfulness
differs from mentalizing in that mindfulness is both being aware of
the "reflective self engaged in mentalizing, and the practice of
fully experiencing the rising and falling of mental states with
acceptance and without attachment and judgment. Wallin proposes
that the receptivity that mindfulness fosters enables the process of
mentalization to occur.
   A second construct,intersubjectivity (Benjamin,1990), has
been theorized to relate to Buddhist psychology (Epstein, 2007;
Surrey, 2005; Thompson, 2001; Wallace, 2001) and to being in the
present momentin psychotherapy (Stem, 2004). Mテndfulness and
intersubjectivity are similarin thatthey both enable a sense of
connection with others (Thompson, 2001), or what Thich Nhat
Hanh (1987) calls interbeing.Interbeing is a Buddhist notion that
by living in the present moment,the interdependent nature of all
phenomena and people is experienced (Hanh,1987). To date,there
is no research relating 山王ndfulness with either mentalization or
intersubjectivity.
   Finally,insight,the conscious process of making novel connec-
tions (Hill & Castonguay, 2007), can be construed as a beneficial
outcome of mindfulness practice. Siegel(2007b, 2009) has pro-
posed a neurological basis forthe connection between 皿テndfulness
and insight, and research discussed laterin this article has begun to
supportthis proposition.

How Can Mindfulness Be Enhanced?

   Although there are several disciplines and practices that can
cultivate mindfulness (e.g., yoga,tai chi, qigong; Siegel, 2007b),
the majority oftheoretical writing and empiricalresearch on the
subject has focused on mindfulness developed by mindfulness
meditation. Meditation refers to:

A family of self-regulation practices thatfocus on training attention
and awareness in orderto bring mental processes under greater
voluntary control and thereby foster general mental well-being and
development and/or specific capacities such as calm, clarity, and
concentration (Walsh & Shapiro, 2006. p. 228).

   While a myriad of meditation practices including Tibetan and
Zen Buddhist meditation styles also cultivate mindfulness,the
term mindfulness meditation is typically used synonymously with
Vipassana, a form of meditation that derives from Theravada
Buddhism (Gunaratana, 2002; Young,1997). Vipassana is a Pali
word forinsight or clear awareness and is a practice designed to
gradually develop mindfulness or awareness (Gunaratana, 2002).
 Mindfulness is systematically cultivated in Vipassana practice by
 applying one's attention to one's bodily sensations, emotions,
 thoughts, and surrounding environment(Bodhi, 2000; Germer,
 2005; Germer et al., 2005; Gunaratana, 2002; Wallace, 2001;
 Young,1997).
   While it may be assumed that all meditation practices equally
benefitthe practitioner,research ratherintriguingly suggests that
different styles of meditation practice elicit different brain activity
patterns (Cahn & Polich, 2006; Lutz, Dunne, & Davidson, 2007;
Valentine & Sweet,1999). For example, 仰山ndfulness meditation
more than concentrative forms of meditation (e.g.,focusing on a
mantra) has been shown to stimulate the middle prefrontal brain
associated with both self-observation and metacognition (Cahn &
Polich, 2006; Siegel, 2007b) and foster specific attentional mech-
anisms (Valentine & Sweet,1999). With the advancement of
neurologicaltechnology, mindfulness researchers are examining
distinct components of mindfulness meditation such as focused
attention, open monitoring (nonjudgmental moment-to-moment
observation of one's experience), and loving-kindness compassion
practice and their specific physiological outcomes (Lutz, Slagter,
Dunne & Davidson, 2008; Lutz et al., 2009).

     Empirically Supported Benefits of Mindfulness

   As research evidence begins to accumulate concerning the pos-
itive outcomes of mindfulness,itis possible to categorize tliese
benefits along several dimensions. Three dimensions that are par-
ticularly relevantto psychotherapy pertain to the affective,inter-
personal, and otherintrapersonal benefits of mindfulness. Another
empirically supported benefit of 山山ndfulness, empathy, will be
discussed laterin the paper when research is reviewed on thera-
pists who practice mindfulness meditation. Practical examples of
mindfulness-based interventions that could be used with clients are
provided in Table 1.

Table 1
Examples of Mindfulness-Based Interventions for Clients
Benefits
Practical mindfulness-based interventions to use with clients
Emotion regulation
Decreased reactivity &
   increased response
   flexibility
Interpersonal benefits
Intrapersona] benefits


"Can you stay with whatis happening right
   now? ... Can you breathe with whatis
   happening right now?"'
Slowly scan your entire body starting at your
   toes. Notice any sensations in your body
   withouttrying to change them.3
For couples: Face each other,look into each
   other's eyes and notice whatreactions,
   feelings, and thoughts arise.5
Therapist and client can practice mindfulness
   meditation together during the therapy
   session."

"What can you tell me about your experience right now? Notice
  any changes in yourfeeling, however subtle."'2
Can you allow and acceptthis feeling and stay in touch with it
   withoutreacting to it? If not, whatis happening in your
  experience that's reacting to this feeling? 4
For couples: Face each other,look into each other's eyes, and
  practice sending loving-kindness to one another.5
Informal daily practice can include: walking and eating meditations,
  such as mentally saying "lifting .... stepping forward.. heel
  touching..toe touching ..lifting ..." when walking.7

1 (Morgan, 2005. p.135). 2 (Morgan, 2005. p.138). 3 (Body Scan, Kabat-Zinn,1990).
4 (Adapted from Didonna, 2009b). 5 (MBRE, Carson et al2006). 
6 h (Lysack, 2005). 7 (Germer, 2005. p.14).


Affective Benefits
  Emotion regulation.   There is evidence that mindfulness
helps develop effective emotion regulation in the brain (Corcoran,
Farb, Anderson, & Segal, 2010; Farb et al., 2010; Siegel, 2007b).
  In terms of proposed mechanisms of change, Corcoran et al.
 theorize that mindfulness meditation promotes metacognitive
 awareness, decreases rumination via disengagementfrom perse-
 verative cognitive activities, and enhances attentional capacities
 through gains in working memory;these cognitive gains,in turn,
 contribute to effective emotion regulation strategies.
    In support of Corcoran et al-'s model,research indicates that
 mindfulness meditation is negatively associated with rumination
 and is directly related to effective emotion regulation (Chambers,
 Lo, & Alien, 2008; McKim, 2008; Ramel, Goldin, Carmona, &
 McQuaid, 2004).In particular, 20 nonclinical novice meditators
 who participated in a lo-day intensive mindfulness meditation
 retreat were compared to a waitlisted control group on 山エndful-
 ness,rumination, affect, and performance tasks for attention
 switching, sustained attention and working memory (Chambers et
 al., 2008). Following the meditation retreat,the meditation group
 had significantly higher self-reported mindfulness, decreased neg-
 ative affect,fewer depressive symptoms, and less rumination com-
 pared to the control group.In addition,the meditation group had
 significantly better working memory capacity and greater ability to
 sustain attention during a performance task compared to the con-
 trol group. Differences were not detected between the groups on
 self-reported anxiety or positive affect.
   Chambers et al.'s (2008)finding that mindfulness training de-
 creased rumination is consistent with research with participants
 having chronic mood disorders. Ramel et al.(2004)found that
 participants in an 8-week MBSR training had significantly less
 reflective rumination compared to: a) participants'initialrumina-
 tion scores, and b) a control group matched on age, gender, and
 initial depressive symptoms.In addition, decreases in rumination
 scores were significantly predicted by participants' amount of
 meditation practice.In another study, prepost scores after an
 8-week MBSR intervention were compared among a community
 sample that experienced ongoing anxiety, depression, and/or
 chronic pain (McKim, 2008). Following MBSR, participants had
 significantly higher scores on self-reported mindfulness and sig-
 nificantly lower scores on self-reported rumination, psychological
 distress, depression, anxiety, and physicalillness. Mindfulness
 scores significantly predicted anxiety,rumination, medical symp-
toms, and psychological distress. Furthermore,the relationship
between mindfulness and depression was significantly mediated
by decreased rumination.
   A recent meta-analysis of 39 studies supports the efficacy of
mindfulness-based therapy forreducing anxiety and depression symp-
toms (Hoffman, Sawyer, Witt, & Oh, 2010). MBSR and Ⅲ士ndfulness-
based cognitive therapy constituted the majority of mindfulness-based
therapies in tliese 39 studies. For clinical populations,the average
prepost effect size was large, and a moderate effect size was found
among nonclinical populations. For19 studies that assessed depres-
sive and anxiety symptoms in long-teⅠ巾 follow-ups, moderate effect
sizes supporting the effectiveness of mindfulness interventions were
detected. Hoffman et al. concluded that mindfulness-based therapy
has utility for potentially altering affective and cognitive processes
that underlie multiple clinicalissues.
   Hoffman et al.(2010)'s findings are consistent with evidence
that mindfulness meditation leads to increased positive affect and
decreased anxiety and negative affect(Davidson et al., 2003;
Erisman & Roemer, 2010; Farb et al., 2010; Jha, Stanley, Kiyo-
naga, Wong, & Gelfand, 2010; Way, Creswell, Eisenberger, &
 Lieberman, 2010).In one study, participants randomly assigned to
 an 8-week MBSR training group were compared to waitlisted
 controls on self-report measures of depression, anxiety, and psy-
 chopathology and on neuralreactivity as measured by functional
 magnetic resonance imaging (fMRI) after watching sad films (Farb
 et al., 2010). Participants exposed to MBSR displayed significantly
 less anxiety, depression, and somatic distress relative to the control
 group (Farb et al., 2010). Stillfurther,fMRI data indicated thatthe
 MBSR group had less neuralreactivity while exposed to the films
 than the control group, and they displayed distinctively different
 neuralresponses while watching the films than they did priorto the
 MBSR training. These findings suggestthat mindfulness medita-
 tion shifts individuals' ability to employ emotion regulation strat-
 egies that enable them to experience emotion selectively, and that
 the emotions they experience may be processed differently in the
 brain (Farb et al., 2010; Williams, 2010).
   In a study oftrait mindfulness. Way et al.(2010)investigated
 the relationships among mindfulness, depressive symptoms, and
 neural activity in a nonclinical sample of adults. Trait mindfulness
 was found to be inversely related to amygdala activity when
 participants were in a resting state; amygdala activity was further
 associated with depressive symptoms. This study provides support
 thattrait mindfulness may alter baseline amygdala activity so that
 serves a preventive or buffering role in depressive mood.
   Erisman and Roemer(2010) conducted a study in which partici-
 pants in an experimental group were exposed to a brief mindlulness
 intervention and then watched film clips that contained either positive
 affect or mixed affect. Compared to a control group, participants in
 the experimental group reported more positive emotions after watch-
 ing the film clips containing positive affect and reported less negative
 emotions after watching affectively mixed film clips.
   Jha et al.(2010) examined working memory capacity and emo-
 tional experience among a military group who participated in an
 8-week mindfulness training, a nonmeditating military group, and
 civilians; both military groups were in a highly stressful predeploy-
 ment period. The nonmeditating military group displayed decreased
 working memory capacity overtime whereas working memory ca-
pacity among nonmeditating civilians was stable across time. Within
the meditation military group, working memory capacity increased in
proportion to actual amount of meditation practice.In addition, med-
itation practice was directly related to self-reported positive affect and
inversely related to self-reported negative affect. Working memory
capacity mediated the relationship between meditation practice time
and negative affect. These findings suggestthat adequate mindfulness
meditation practice may enhance working memory capacity, similar
to results obtained by Chambers et al.(2008),thereby promoting
effective emotion regulation during periods of stress when working
memory may otherwise diminish.
   Thus,research indicates that meditation may elicit positive
emotions, minimize negative affect and rumination, and enable
effective emotion regulation. Even eight weeks of mindfulness
meditation practice may alterthe ways in which emotions are
regulated and processed in the brain (Williams, 2010). Emotion
regulation has such strong empirical support as a benefit of mind-
fulness meditation thatrecently the term "mindful emotion regu-
lation" was coined to referto "the capacity to remain mindfully
aware at alltimes,irrespective ofthe apparent valence or magni-
tude of any emotion thatis experienced" (Chambers, Gullone, &
Alien, 2009. p. 569).
  Decreased reactivity and increased response flexibility.
Research has demonstrated that Ⅲ士ndfulness meditation enables
people to become less reactive (Cahn & Polich, 2009; Goldin &
Gross, 2010; Ortner, K士ner, & Zeiazo, 2007; Siegel, 2007a, 2007b)
and have greater cognitive flexibility (Moore & Malinowski, 2009;
Siegel, 2007a, 2007b). Evidence indicates that 皿士ndfulness med-
itators develop the skill of self-observation that neurologically
disengages automatic pathways created from priorlearning and
enables present momentinputto be integrated in a new way
(Siegel, 2007a). Meditation activates regions ofthe brain associ-
ated with more adaptive responding to stressful or negative situ-
ations (Cahn & Polich, 2006; Davidson et al., 2003). Activation of
this region ofthe brain corresponds W士th fasterrecovery to base-
line after being negatively provoked (Davidson, 2000; Davidson,
Jackson, & Kalin, 2000).
   Moore and Malinowski(2009) compared a group of experi-
enced mindfulness meditators with a control group who had no
meditation experience on measures assessing their ability to
focus attention and suppress distracting information. The med-
itation group had significantly better performance on all mea-
sures of attention and had higher self-reported Ⅲテndfulness.
Mindfulness meditation practice and self-reported mindfulness
were correlated directly with cognitive flexibility and atten-
tionalfunctioning.
   In another study,individuals with one month to 29 years of
mindfulness meditation practice experience viewed pleasant,
unpleasant, and neutral pictures and then had theirreaction
times measured to categorizing tones as either short orlong
(Ortner et al., 2007). Reaction time was thoughtto represent
emotionalinterference with the categorization task. Meditation
experience was inversely related to emotionalinterference
when viewing unpleasant pictures. Ortner et al. suggestthat
mindfulness meditation practice may help individuals disen-
gage from emotionally upsetting stimuli, enabling attention to
be focused on the cognitive task at hand.In a follow-up study,
participants were assigned to either a 7-week training in mind-
fulness meditation,relaxation meditation, or a waiting list con-
trol group. The mindfulness meditation group exhibited less
emotionalinterference in response to the unpleasant pictures
than the other groups. Ortner et al.'s findings supportthe notion
that mindfulness meditation decreases emotionalreactivity.
   In addition, Cahn and Polich (2009) assessed the reactions of
very experienced mindfulness meditators to distracting stimuli.
Findings revealed that while in a meditative state, practitioners
displayed minimal emotional and cognitive reactivity to distracting
stimuli. These findings supportthe notion that mindfulness med-
itation contributes to decreased reactivity.
   A recent study investigated the effects of MBSR training on
emotionalreactivity and regulation of negative self-beliefs among
adults with social anxiety disorder(Goldin & Gross, 2010). Par-
 ticipants completed two attention tasks before and after participat-
ing in an 8-week MBSR training.In preposttests, participants
 displayed lowerlevels of negative emotion, decreased amygdala
 activity, and increased levels of activity in areas ofthe brain
 associated with attentional deployment.

Interpersonal Benefits

  The question of how mindfulness affects interpersonal behavior
has been pursued recently by scholars who have addressed con-
cepts such as mindfulrelating (Wachs & Cordova, 2007), mindful
responding in couples (Block-Lemer, Adair, Plumb, Rhatigan, &
Orsillo, 2007), and mindfulness-based relationship enhancement
(MBRE)(Carson, Carson, Gil, & Baucom, 2006). Evidence indi-
cates thattrait mindfulness predicts relationship satisfaction, abil-
ity to respond constructively to relationship stress, skillin identi-
fying and communicating emotions to one's partner, amount of
relationship conflict, negativity, and empathy (Bames, Brown,
Krusemark, Campbell, & Rogge, 2007; Wachs & Cordova, 2007).
Bames et al.found that people with highertrait mindfulness
reported less emotional stress in response to relationship conflict
and entered conflict discussion with less anger and anxiety. Evi-
dence shows that mindfulness is inversely correlated with distress
contagion and directly correlated with the ability to act with
awareness in social situations (Dekeyser, Raes, Leijssen, Leyson,
& Dewulf, 2008). Thus, empirical evidence suggests that mind-
fulness protects againstthe emotionally stressful effects ofrela-
tionship conflict(Bames et al., 2007),is positively associated with
the ability to express oneselfin various social situations (Dekeyser
el al., 2008), and predicts relationship satisfaction (Bames et al.,
2007; Wachs & Cordova, 2007). Given thatthe therapeutic rela-
tionship is emotionally intimate, potentially conflictual, and inher-
ently interpersonal,therapists'trait mindfulness may aid their
ability to cultivate and sustain successfulrelationships with clients.

OtherIntrapersonal Benefits

  In addition to the affective and interpersonal benefits identified
above, mindfulness has been shown to enhance functions associ-
ated with the middle prefrontallobe area ofthe brain, such as
self-insight, morality,intuition, and fear modulation (Siegel,
2007b, 2009). There is also evidence that mindfulness meditation
has numerous health benefits including increased immune func-
tioning (Davidson et al., 2003; see Grossman, Niemann, Schmidt,
& Walach, 2004 for a review of physical health benefits). Mind-
fulness meditation has been shown to improve well-being (Car-
mody & Baer, 2008) and reduce psychological distress (Coffey &
Hartman, 2008; OStafin et al., 2006).
  Neuroplasticity - the rewiring that occurs in the brain as a
result of experience - now explains how regular mindfulness
meditation practice alters the brain's physical structure and
functioning (Davidson et al., 2003; Lazar et al., 2005; Siegel,
2007a; Vestergaard-Poulsen et al., 2009). Changes in the structure
ofthe brain include thicker brain regions associated with attention,
sensory processing and sensitivity to internal stimuli(Lazar et al.,
2005), distinct gray matter concentrations (Holzel et al., 2008), and
thicker brain stems, which may accountfor positive cognitive,
emotional and immunoreactive benefits (Vestergaard-Poulsen et
al., 2009). Research suggests that states experienced during mind-
fulness meditation eventually can become effortless traits over
time (Farb et al., 2007; Siegel, 2007a). T卜us,the longertherapists
practice mindfulness meditation,the more they may benefitfrom
its effects.
   Other benefits of mindfulness meditation practice include in-
creased information processing speed (Moore & Malinowski,
2009), decreased task effort(Lutz et al., 2009), and having fewer
thoughts that are unrelated to the task at hand (Lutz et al., 2009).
In particular, Lutz et al.'s research implies that due to increased
attentional skills and increased ability to manage distractions,
therapists who practice mindfulness meditation may have an in-
creased ability to be presentto their clients.

Effects of Meditation on Therapists and
           Therapist Trainees

  Whereas the literature on the benefits of applying mindfulness
approaches to psychotherapy clients is vast(see Didonna, 2009
and Baer, 2006 forreviews),research on the effects of mindfulness
on psychotherapists is gradually emerging. This body ofliterature
will be reviewed and synthesized below. Practical examples of
mindfulness-based interventions fortherapists and therapisttrain-
ees in practice are shown in Table 2.

Table 2
Examples of Mindfulness-Based Interventions for Trainees and Therapists
Benefits
Empathy
Compassion
Counseling skills
Practical mindfulness-based interventions fortrainees' and therapists' mindfulness
In trainee dyads in "therapist" & "client" roles:
   Have therapists track theirinternalresponses to
   client, and what makes them feel more and less
  empathetic towards client.7
Visualize an image, color, or memory that elicits
  feeling friendly towards yourself. Visualize
   sending this feeling towards an image of yourself,
  or a challenging client.9
In dyads, sitin silence with eyes open. Pay attention
   to yourinternal experience in the presence of
  another person, practicing to bring your attention
  back to their breath when it wanders.10
In dyads, pause after each person speaks and consciously relax
  While pausing, with acceptance and curiosity ask yourself:
  Whatis happening now? What am Ifeeling now? What
  mightthis person be experiencing?3
Practice sending loving-kindness towards oneself,towards a
  loved one,towards a 'neutral' client,towards a challenging
  client, and towards all beings.9
Decreased stress
  & anxietv
Other benefits for
   therapists
Bring your attention to your experience of breathing.
   Imagine seeing a client. Pay attention to any
   feelings of anxiety and fear. Notice how they shift
   from momentto moment, allowing whatis to be
   there.''
Therapists can practice formal sitting mindfulness
   meditation individually orin groups.
In trainee dyads in "therapist" & "client" roles: Have therapists
   let go ofjudgments and the desire to say 'something' and
  practice fully listening to clients. Have therapists track when
  their attention wanders off and practice returning attention to
  back to present moment.
Jn dyads, have each person track their own internalfeelings,
  thoughts, & sensations as they stand at varying distances @
  from each other. Practice with an accepting attitude towards
  internalreactions with eyes open, with eyes closed,facing
  each other, & with their backs facing each other.'0
In between sessions,take one minute each to:1) Ask 'whatis
  my experience right now?' 2) Notice the sensation of each in
  and out breath 3) Expand your awareness to your whole
  body with an attitude of acceptance.'2

7 (Adapted from Shapiro & Izett, 2008). 8 (Adapted from Deep Listening & Authentically Speaking, Surrey, 2005). 9 (Adapted from Morgan & Morgan,
2005). 10 (From author's (Davis) mindfulness training at Naropa University). 11 (Adapted from Brach. 2003).  12 (Adapted from 3-minute Breathing
Space from MBCT, Segal, Williams, & Teasdale, 2002).


Empathy

  Mindfulness meditation consistently has been theorized to pro-
mote empathy (Anderson, 2005; Fulton, 2005; Martin,1997; Mor-
gan & Morgan, 2005; Shapiro & Izett, 2008; Walsh & Shapiro,
2006), and research utilizing a variety of methods is now accumu-
lating in support ofthis premise.In a within-subjects study on
meditation and empathy, counselors in training demonstrated in-
creased empathy after participating in a 4-week Zen meditation
training (Lesh,1970).In a between-groups experiment, premedical
and medical students who participated in an 8-week MBSR train-
ing had significantly higher self-reported empathy than a control
group (Shapiro, Schwartz, & Bonner,1998). A qualitative study
(Aiken, 2006) oftherapists who were experienced meditators
found thatthey believed that mindfulness meditation helped de-
velop empathy toward clients.In particular,interviews were con-
ducted with six psychotherapists who each had more than lo years
of experience practicing both therapy and mindfulness meditation.
Consistentthemes from the data indicated that 山山ndfulness helps
therapists: develop their ability to experience and communicate a
felt sense of clients'inner experiences; be more presentto clients'
suffering; and help clients express their body sensations and feel-
ings. Finally, along similarlines, Wang (2007) used a passive
design and found thattherapists who were experienced mindful-
ness meditators scored higher on measures of self-reported empa-
thy than therapists who did not meditate.

Compassion

  In addition to empathy, a second therapist characteristic that
seems to derive from meditation is compassion. For example,
MBSR training has been found to enhance self-compassion in
health care professionals (Shapiro, Astin, Bishop, & Cordova,
2005) and therapisttrainees (Shapiro, Brown, & Biegel, 2007).
Kingsbury (2009)investigated the role of self-compassion in re-
lation to Ⅲ士ndfulness. Two components of mindfulness, nonjudg-
ing and nonreacting, were strongly correlated with self-
compassion, and two dimensions of empathy,taking on others
perspectives (i.e., perspective taking) and reacting to others' af-
fective experiences with discomfort. Self-compassion fully medi-
ated the relationship between perspective taking and 皿士ndfulness.

Counseling Skills

   Empiricalliterature now demonstrates thatincluding mindful-
ness interventions in psychotherapy training may contribute to the
development of skills thatimpacttrainees' effectiveness as thera-
pists.In a 4-year qualitative study, counseling students reported
considerable positive effects on their counseling skills and thera-
peutic relationships,including being more attentive to the therapy
process, more comfortable with silence, and more attuned with
oneself and clients, aftertaking a 15-week course thatincluded
mindfulness meditation (Newsome, Christopher, Dahlen, & Chris-
topher, 2006; Schure, Christopher, & Christopher, 2008). Coun-
selors in training who have participated in similar mindfulness-
based interventions have reported significantincreases in self-
awareness,insights abouttheir professionalidentity (Bimbaum,
2008), and overall wellness (Rybak & Russell-Chapin,1998).

Decreased Stress and Anxiety

   Research has found that premedical and medical students report
 less anxiety and depression symptoms after an 8-week MBSR
 training compared to a waiting list control group (Shapiro et al.,
 1998). The control group evidenced similar gains after exposure to
 MBSR training. Similarly,following MBSR training,therapist
 trainees have reported decreased stress,rumination, and negative
 affect(Shapiro et al., 2007).In addition, when compared with a
control group, MBSR has been shown to decrease total mood
disturbance,including stress, anxiety and fatigue in medical stu-
dents (Rosenzweig, Reibel, Greeson, Brainard, & Hojat, 2003).
Using qualitative and quantitative measures, nursing students re-
ported better quality oflife and a significant decrease in negative
psychological symptoms following exposure to MBSR (Bruce,
Young. Turner, Vander Wal, & Linden, 2002). Recent evidence
from a study of counselortrainees exposed to interpersonal mind-
fulness training suggests that such interventions can foster emo-
tionalintelligence and social connectedness, and reduce stress and
anxiety (Cohen & Miller, 2009). Similarly,in a study of Chinese
college students,those students who were randomly assigned to
participate in a mindfulness meditation intervention had lower depres-
sion and anxiety, as well as less fatigue, anger, and stress-related
cortisol compared to a control group (Tang et al., 2007). T廿ese same
students evidenced greater attention, self-regulation, and immunore-
activity. Waelde et al.(2008) assessed changes in symptoms of
depression, anxiety, and posttraumatic stress disorder among New
Orleans mental health workers following an 8-week meditation inter-
vention that began lo weeks after Hurricane Katrina. Although
changes in depression symptoms were notfound, PTSD and anxiety
symptoms significantly decreased afterthe 8-week intervention. Find-
ings suggestthat meditation may serve a buffering role for mental
health workers in the wake of a disaster.

Other Benefits of Mindfulness for Therapists

   To date, one study has investigated the relationship between
mindfulness and counseling self-efficacy. Greason and Cashwell
(2009)found that counseling self-efficacy was significantly pre-
dicted by self-reported mindfulness among masters-levelinterns
and doctoral counseling students.In that study, attention mediated
the relationship between mindfulness and self-efficacy, suggesting
that mindfulness may contribute to the development of beneficial
attentional processes that aid psychotherapists in training (Greason
& Cashwell, 2009). Dreifuss (1990)interviewed six therapists who
practiced one ofthree mindfulness meditation styles (Vipassana,
Zen, and Vajrayana)for more than five years to examine the
influence oftheir meditation practice on their work as therapists.
Findings suggested thatlong-term mindfulness meditation practice
can positively impacttherapists' ability to distinguish their own
experience from their clients' experience, can enrich therapists'
clarity in their work with clients, and may help develop therapists'
self-insight. Other potential benefits of mindfulness include in-
creased patience,intentionality, gratitude, and body awareness
(Rothaupt & Morgan, 2007).

Client Outcomes of Therapists Who Meditate

   While the research reviewed above points rather clearly to the
 conclusion that 山主ndfulness meditation offers numerous benefits to
 therapists and trainees, do these benefits translate to psychotherapy
 treatment outcomes? To date, only one study provides evidence.In a
 study conducted in Germany,randomly assigned counselortrainees
 who practiced ZCn meditation for nine weeks reported higher self-
 awareness compared to nonmeditating counselortrainees (Grepmair
 et al., 2007). Whatis more importantis that after 9 weeks oftreat-
 ment, clients oftrainees who 皿Cditated displayed greaterreductions
 in overall symptoms,fasterrates of change, scored higher on mea-
 sures of well-being, and perceived theirtreatmentto be more effective
 than clients of nonmeditating trainees.
   Despite these promising results,three other studies suggestthat
 the relationship between counselortrainees' mindfulness and cli-
 ent outcomes is not so encouraging. Stanley et al.(2006) studied
the relationship between trait 皿士ndfulness among 23 doctoral-level
 clinical psychology trainees in relation to treatment outcomes of
 144 adult clients in a university community clinic that used manu-
alized, empirically supported treatments. Contrary to expectation,
therapist 皿士ndfulness was inversely correlated with client out-
come. This is consistent with otherfindings that suggest an inverse
relationship exists between therapists' mindfulness and client out-
comes (Bruce, 2006; Vinca & Hayes, 2007). Still otherresearch
suggests that no relationship exists between therapist mindfulness
and therapy outcome (Stratton, 2006).
   One ofthe difficulties with this small body ofresearch pertains
to the accuracy oftherapist self-reported mindfulness.It could be
that more mindful people are likely to score lower on a self-report
measure of mindfulness because they are aware ofthe degree to
which they are mindless. Conversely, people who are less mindful
may notrealize it and therefore may be inclined to rate themselves
higher on such measures. Also,itis noteworthy thatin the one
study with positive findings regarding outcome (Grepmair et al.,
2007), participants engaged in the practice of meditation rather
than simply reporting their mindfulness.In the studies with neg-
ative or nullfindings,there was no indication if participants had
ever engaged in actual meditation. Thus,it may be that meditation
is a better predictor of outcome tlian self-reported mindfulness (see
Grossman, 2008 for a comprehensive summary oflimitations to
mindfulness research).

FurtherImplications

Empirically Supported Relationships

   Many scholars have proposed thatthe development of skills and
qualities in therapists who practice mindfulness meditation will

strengthen the therapeutic relationship (Germer et al., 2005; Hick
& Bien, 2008; Shapiro & Carlson, 2009). Future research could
profitably address how therapists' mindfulness contributes to crit-
icalrelationship factors such as the formation and sustenance of
the working alliance, counter-transference management, and the
provision of unconditionalregard with difficult clients (Norcross,
2002). For example, one study (Wexler, 2006)found that both
client and therapist perceptions ofthe working alliance were
positively related to therapist self-reported mindfulness.In another
study, however,the relationship between mindfulness and working
alliance was not significant(Bruce, 2006). Again,it could be that
meditation practice is a better predictor ofthe working alliance
than self-reported mindfulness, although this awaits further study.
  With regard to countertransference management,itis plausible
thatthe nonreactivity and cognitive flexibility fostered by mind-
fulness should help therapists respond more freely and less defen-
sively to their clients (Gelso & Hayes, 2007). To date, one study
has investigated mindfulness and countertransference. Kholooci
(2008) examined the relationship between self-reported mindful-
ness and therapists' awareness of countertransference. Kholooci
found a significantinverse relationship between mindfulness and
countertransference awareness such thatthe more mindfulthera-
pists perceived themselves to be,the less aware they were oftheir
countertransference.
  In conclusion, while the psychological and physical health ben-
efits of mindfulness meditation are strongly supported by research,
the ways in which therapists' mindfulness meditation practice and
therapists' mindfulness translate to measureable outcomes in psy-
chotherapy remain unclear. Future research is needed to examine
the relations between therapists' mindfulness,therapists'regular
mindfulness meditation practice, and common factors known to
contribute to successfultreatment outcome. Doing so willfoster
understanding of how mindfulness meditation may enhance com-
munication and relationship building skills within the context of
psychotherapy.

Practice and Clinical Supervision

   Germer et al.(2005) proposed that mindfulness can be inte-
grated into psychotherapy through three means:therapist mindful-
ness (therapists' own practice of meditation to be more "mindful"
and present with clients), mindfulness-informed psychotherapy
(i.e., applying Buddhist psychology and mindfulness theory to
clinical work), and mindfulness-based psychotherapy (teaching
clients skills through the application of mindfulness practices).
Davis (2010) has proposed that mindfulness meditation also would
benefit clinical supervision by enhancing supervisors' presence to
their supervisees and enabling them to be less reactive to super-
visees' anxiety. Table 3 expands on Germer et al.(2005) and Davis
(2010) and provides practical examples and means ofintegrating
mindfulness into psychotherapy.
  The old adage that people can guide another on a path only as
far as they themselves have ventured also applies to therapists
integrating mindfulness into psychotherapy and into clinical su-
pervision (Davis, 2010).Introducing mindfulness approaches into
psychotherapy necessitates engaging in a mindful practice our-
selves as psychotherapists (Hick, 2008).It has been recently pro-
posed thattherapists who introduce mindfulness interventions with
clients may find it helpfulto explain mindfulness in terms of
attention, avoiding jargon that may have unintended negative
effects on clients (Carmody, 2009).

Training Implications

  Mindfulness as a metacognitive skill has been proposed as a
necessary component of psychotherapy training (Bruce, Manber,
Shapiro, & Constantino, 2010; Fauth, Gates, Vinca, Boles, &
Hayes, 2007; Vinca, 2009). As research on therapists' mindfulness
continues to emerge, should therapists' mindfulness demonstrate a
meaningfulrelationship with measurable outcomes in the thera-
peutic relationship and treatment outcomes, psychotherapy train-
ing could include mindfulness training. Given the push toward
outcome-based education,training and credentialing as measured
by training benchmarks and the acquisition of competencies
(Kaslow et al., 2002), perhaps mindfulness could be measured in
training programs as a necessary specific competency. Research
supportis needed to influence policy changes and changes in
psychotherapy training program requirements. Given that mind-
fulness meditation is a means to develop mindfulness, both coun-
selor education and continuing education programs could benefi-
cially offer mindfulness meditation training.

Table 3
Examples of Ways to Integrate Mindfulness in the Field of Psychotherapy
Ways mindfulness can be integrated
        into psychotherapy
Professional avenues forintegration
Therapist mindfulness
@ Therapists' personal meditation practice
@ Therapists' clinical work
@ Training programs
@ Clinical supervision
@ Continuing education
Mindfulness-informed psychotherapy
Mindfulness-based psychotherapy
Therapists' clinical work
Training programs
Clinical supervision
Continuing education
Therapists' clinical work
Training Programs
Clinical supervision
Continuing education
Mindfulness-based group therapy

Practical examples
"While others are speaking, practice letting go
  of your own thoughts,judgments, and
  analyzing, and return to listening
  receptively. Let yourlistening be
  wholehearted and attentive .... speak
  slowly enough to stay connected to your
  body and heart."'3
Apply me Buddhist principal of equanimity to
  a clientissue, such as: "What happens
  when you letthat need be there?"'4
Guide clients to: Close your eyes and with
  curiosity and non-judgment, allow whatever
  emerges in your awareness to be there,
   letting it come and go. Mentally label your
  experience, such as feeling, smelling,
   thinking, etc. as you sitforfew minutes.'5

13 (Deep Listening & Authentically Speaking, Surrey, 2005. p.110)
14 (Adapted from Welwood, 2002. p.190).15 (Adapted from Mindfulness, Morgan& Morgan, 2005).


Important Next Steps in Research

  Future research holds tremendous potentialfor uncovering more
aboutthe neurophysiological processes of meditation and the
benefits oflong-teⅠ血 practice on the brain. Research on neuro-
plasticity may help explain the relationship among length and
quality of meditation practice, developmental stages of meditators,
and psychotherapy outcomes. More research is needed to better
understand how the benefits of meditation practice accumulate
overtime.
  In addition, other means ofincreasing 皿づndfulness,in addition
to meditation, need to be explored. G士ven that currentresearch
does notindicate thattherapists' self-reported 皿エndfulness en-
hances client outcomes, better measures of 皿士ndfulness may need
to be developed or differentresearch designs that do notrely on
self-report measures need to be used. Garland and Gaylord (2009)
have proposed thatthe next generation of mindfulness research
encompass four domains:1) performance-based measures of
mindfulness as opposed to self-reports of 皿エndfulness, 2) scientific
evaluation of notions espoused by Buddhisttraditions, 3) neuro-
imaging technology to verify self-report data, and 4) changes in
gene expression as a result of mindfulness. Research along any one
or a combination ofthese lines is likely to enhance our under-
standing of mindfulness and its potential benefits to psychother-
apy.
  Given tlie empirical supportforthe benefits of mindfulness
reviewed in this paper,research is needed on effective and prac-
tical means ofteaching therapists 皿士ndfulness practices. While
formaltraining is required to teach MBSR,theoreticalliterature
focused on using a mindfulness-based curriculum and teaching
mindfulness practices is beginning to emerge (e.g., McCown,
Reibel, & Micozzi, 2010). Future research could include investi-
gating realistic ways mindfulness practices and/orformal mindful-
ness meditation could be integrated into trainees' practicum and
clinical supervision. Given that MBSR is a structured formatthat
has been successfully used with therapisttrainees (e.g., Shapiro et
al., 2007), MBSR may be a simple way fortherapists,regardless of
theoretical orientation,to integrate mindfulness practices into
trainees' practicum class or group supervision. Future research
questions could include: Does therapists" practice of mindfulness
meditation in clinical supervision with their supervisees affectthe
supervisory alliance, orrelational skills of supervisees? Does prac-
ticing formal mindfulness meditation as a group in practicum or
internship aid in group cohesion, self-care,relational skills, or
measurable common factors that contribute to successful psycho-
therapy? Given the limited research thus far on empathy, compas-
sion, decreased stress and reactivity, more research is needed on
how mindfulness meditation practice affects these constructs and
measurable counseling skills in both trainees and therapists. For
example, how does mindfulness meditation practice effect empa-
thy and compassion for midcareer orlate-careertherapists who are
already seasoned veterans?
   Shapiro and Carlson (2009) have suggested that mindfulness
meditation can also serve as a means of self-care to help combat
burnoutrates. Future research on not only how therapists' practice
of mindfulness meditation helps facilitate trainee development and
affects psychotherapy is needed, butthe ways in which therapists'
own practice of mindfulness meditation can help with burnout
rates and other detrimental outcomes of work-related stress.
   In addition, despite abundanttheoretical work on ways to con-
ceptually merge Buddhist and Western psychology to psychother-
apy (e.g., Epstein, 2007,1995),there is a lack ofliterature on what
itlooks like in session when a therapist employs Buddhist-oriented
approaches (i.e., mindfulness-informed psychotherapy as termed
by Germer, 2005)to specific clinicalissues and diagnoses. Given
the numerous and rich clinical applications of mindfulness-based
approaches to specific clinicalissues, more literature is needed on
the ways mindfulness-informed psychotherapy differs from
mindfulness-based psychotherapy in session with clients.
   In conclusion,the momentum within research on mindfulness
holds promise for a potentialtransformation in ways to facilitate
trainee and therapists' development, and means to affect change
mechanisms known to contribute to successful psychotherapy. The
field of psychotherapy could benefitfrom future research exam-
ining cause and effectrelationships and/or mediational models to
better understand the seemingly fruitful benefits of mindfulness
and mindfulness meditation practice.

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      Received April19. 2010
Revision received June 7. 2010
        Accepted June 8. 2010 









 

映画館で遠慮もなしに私語をする人がいて 一体どうなっているんだ、ここはあんたのリビングじゃない! という意見 ーー 映画館だけではない。 会議をすれば、私語が絶えない。発言者にも気持ちというものがある。 講演会でも私語。おまけに携帯。

映画館で遠慮もなしに私語をする人がいて
一体どうなっているんだ、ここはあんたのリビングじゃない!
という意見

ーー
映画館だけではない。
会議をすれば、私語が絶えない。発言者にも気持ちというものがある。

講演会でも私語。おまけに携帯。

進化論的精神病理学

フロイト以来の精神分析では、個体発生の歴史をさかのぼることが役立つ
同様に
系統発生をさかのぼることも有力な方法であるはずである

集合的無意識とかはそんな系統発生的な話だろう

Psychotherapy : evolutionary thinking

Psychotherapy

 1. Introductory remarks

Psychotherapy can be defined as the attempt to change cognitions, emotions, and behaviours in

humans who suffer from maladaptive consequences of their behaviour or have caused suffering in others, by means of scientifically evaluated psychological techniques and interventions.

Central to all kinds of psychotherapy is the assumption that alternative strategies to cope

with interpersonal stress or other adverse stimuli can be accomplished throughout the

human lifespan through learning and experience, albeit with different likelihood of

success depending on age at onset, duration, and severity of the underlying disorder.

It is widely acknowledged among psychotherapists that logic in therapeutic discourse alone

does not suffice to enable a patient to give up maladaptive strategies;rather,it is essential

that the patient feels a difference; perhaps first imaginatively, and later on, as therapy

progresses, as part of his or her 'real life' experience. Even though it becomes increasingly

clear that psychotherapy has the potential to induce long-lasting changes in brain

activation, particularly in the most recently evolved cortical midline structures involved

in the representation of self and others, and in phylogenetically older brain centres

involved in emotion regulation,the fact that any kind of psychotherapy is deeply rooted in the

evolved psychology of our species is more implicitly, rather than explicitly, approved by therapists.

Mental representation of self and others is, however, at the core of interpersonal and intrapersonal conflict, as well as of conflict resolution.

The ability to infer mental states and anticipate future actions of other individuals may

not only have been a major driving force in human brain evolution, but also a major

source of cognitive distortion causing psychological distress (for further details,

see Chapters 2 and 5).

2. Historical developments in psychotherapy

The origins of psychotherapeutic treatment date back to the late 19th century when

Sigmund Freud and Josef Breuer developed what later became known as psychoanalysis

and psychoanalytic psychotherapy. The value of many of Freud's discoveries cannot be

overestimated, although several of his ideas appear scientifically flawed today. Above all,

the fact that most of our mental life is unconscious and only small fragments of mental 

processes surface conscious reflection or are accessible to the reflexive self has greatly changed our view of human mentality in pervasive ways. It was also Freud who emphasized the important role of phylogenetic ancient drives and motives for human psychology, and that disintegration of drives and motives with an individual's conscious desires, expectations and self-appraisal has the potential to cause psychological malfunctioning and subjective 

distress. Even though Freud recognized evolution as an important scientific concept to 

explain human psychology, his conceptualization was strongly influenced by the assumption 

of Lamarckian inheritance (inheritance of acquired characters), recapitulation

theory (the repetition of phylogeny in ontogeny), and group selection (as opposed to

individual and kin selection). For reasons that may have lain in his personal history (he

was brought up by a nanny, while his mother remained unattainable for him), Freud

came to overemphasize infantile sexuality and the Oedipal model as central to intrapsychic  conflict( although it has been argued that the Oedipal situation may have evolved

as an unconscious 'seductive' strategy of the infant to increase parental investment).

Moreover, he did not recognize that incest avoidance was deeply rooted in biology and

clearly a selected mechanism to avoid accumulation of deleterious mutations,rather

than being part of a universal neurosis that manifested through repression of incestuous

impulses. Today, Freud's drive theory appears simplistic and overly mechanistic, and his

overemphasis of aggressive instincts as driving forces behind human behaviour is no

longer shared by most therapists (although still prevalent in many textbooks).

  Freud's colleagues Carl Gustav Jung and Alfred Adler developed their ideas 

independent of Freud and took many of the basic psychoanalytic hypotheses further. Both acknowledged the importance of non-conscious information processing and the role of defence mechanisms in coping with intrapersonal conflict. Similar to Freud,they were convinced that much of an individual's non conscious mental life was brought to surface in dreams and by 'free association'. Jung elaborated upon the phylogenetic aspects of human mental life shared by all individuals (called 'collective unconscious')represented in 'archetypes', which Jung conceived of as being much richer and diverse compared to Freud's drive theory. 

By contrast, Adler focused on compensation of inherited 'inferiority feelings' as a basic psychological mechanism shaping an individual's life-style. In contrast to Freud, Adler recognized the importance of sociality ('community feeling')for human development and the impact of early rearing conditions and birth order on individual psychological development. Both Jung and

Adler believed that therapeutic success was linked to the quality of the therapeutic

relationship and that a warm, accepting and empathetic alliance with the patient was

vital to psychotherapy, which to some extent differed fundamentally to Freud's more

distant-analytic perspective.

  In the 1950, John Bowlby and his pupils began to develop attachment theory by combining insights from psychoanalysis with ethology, and developmental and cognitive psychology. Bowlby came to realize that the quality of an infant's emotional relationship with his or her primary caregiver, including the development of feelings of security and protection, had the potential to bias cognitive processes in terms of expectations and predictions 

of future interpersonal relationships in adult life. In other words, personality development 

entails the emergence of mental templates or models of self and others representations, which,in part, determine the way an individual unconsciously creates his or her

interpersonal and social environment, based on so-called inner working models. This

focus on early actual relationships was at odds with classic analytic views that a child's

primary motivation to bond with its mother is motivated by the infant's polymorphic

sexual drives. Instead, Bowlby and his co-workers saw human behaviour guided by

innate tendencies to secure survival through establishing close proximity to an 

attachment figure, usually the mother. Accordingly,the attachment system is automatically

activated when an infant perceives threat or danger (compare Chapter 3).

If the caregiver is unavailable, unresponsive to the infant's needs or even abusive, hyperactivation or deactivation of the attachment system are secondary strategies to either retain proximity or to distance oneself from others by denying threat to the individual's sense of security. Unlike classic psychoanalysis, attachment theory sees actual interpersonal conflict and internalized models of interpersonal relationships at the core of psychological problems,rather than conflict between 

divergent drives, motives, and fantasies.

  Behaviourism and cognitive social learning theories were originally formulated in diametrical  opposition to psychoanalytic theory.

In particular,these theories utterly denied the existence of innate behavioural predispositions. On the contrary, early behaviourists assumed that humans were born as 'blank sheets', and that behaviour was simply the result of learned or conditioned responses, which, in the case of maladaptive behaviour, could simply be unlearned (through extinction). 

This perspective greatly neglected the role of biological motives,individual development and defence mechanisms in favour of situational influences on cognition and behaviour. 

Conditioning surely contributes to the acquisition of fear and anxiety or pathological habits such as substance dependence and compulsive behaviour.

It needs to be emphasized, however,that learning has a biological basis itself that cannot be separated from an individual's genetic endowment and early environmental contingencies, perhaps even those in one's foetal life. 

On the contrary, imprinting-like learning during an individual's foetal and early postnatal period may perhaps be most impervious to therapeutic modification later in life. The role of early

experience is now widely recognized among behaviour therapists, and with regards to the

anxiety disorders, evolutionary ideas have been incorporated into the psychoeducational

part of behaviour therapy. Moreover,the proposition of 'cognitive schemas' by cognitive

behaviour therapy is in many respects akin to the assumption of evolved information

processing biases that are modified through individual experience.

  As the sharp distinction between analytic and behavioural concepts of personality

development and psychological problems has increasingly proven impracticable and

scientifically untenable, it is now time to integrate the complex interactions between

early and present experience, genetics, and the evolutionary history of our species. This

complex interplay sets the stage for human interaction,including the patient or

client-therapist relationship. Hence, any form of psychotherapy, whatever 'school' it may

belong to, ought to consider an integrative perspective including the basic needs for 

security, protection,respect and empathetic containment, which all humans share as

members of the same species.

3. Patient-therapist or client-therapist relationship

There has been considerable debate over the question what actually helps a patient in

psychotherapy. Although still not entirely clear,there is consensus that the role of the

patient-therapist or client-therapist relationship cannot be overestimated, whereas the

particular therapeutic method is perhaps less important compared to patient and 

therapist variables (some professionals favour the term  'client' over 'patient', because the former does not exclusively invoke pathology as source of help seeking; here,the terms are more or less used interchangeably). The differential contributions of relationship and method to therapeutic success vary, however, according to the nature

and complexity of the disorder. In the treatment of complex personality disorders

relationship-associated variables may be more important, whereas in the treatment of

simple phobias the use of a manual-driven approach may prevail over therapist variables.

  Among the most important determinants of a successful basis for psychotherapy on the

side of the therapist is the ability to be genuinely empathetic and accepting, and

to create a therapeutic atmosphere that is as egalitarian and reciprocal as possible

to foster trust,feelings of safeness, and protection from further traumatization in the patient.

In some respect,the therapeutic alliance should emulate the safety and stability of a kinship

bond, diminish the dominance hierarchy between patient and therapist, and thus help to avoid distant professionalism. Such a therapeutic stance acknowledges the role of evolved psychological mechanisms involved in the formation of trustful interpersonal

alliances. At the same time, however,the therapist should be able to set clear boundaries

and be straightforward about the prerequisites for a trustful therapeutic alliance.

For example,it should be made clear to the patient that successful therapy requires

abstinence from drug and alcohol consumption, because intoxication leads to distorted

reality perception and may cause inappropriate behaviour. Moreover, some clients may

strive for a deeper relationship than is professionally acceptable or warranted, and 

limitations of the therapist's availability ought to be pointed out. To avoid disappointment or

confusion on either side,it may be useful --depending on the nature of the disorder--to

explicitly reach consensus overrules of conduct before formally commencing therapy,

perhaps using a leaflet or information sheet, or even a written contract about rules

of conduct. It can be assumed that all patients benefit from an unambiguous therapeutic

attitude.

  Beyond attitude and role models, a therapist's authenticity critically depends on his or her non-

verbal behaviour. Many patients are hypervigilant to deception and may therefore quickly sense if the therapist is not sincerely interested in the patient's needs and emotional distress, or unconsciously signals ambivalent feelings toward the patient. In addition, subtle signs of hierarchizing such as an elevated sitting position or perhaps simply a desk put between the client's and the therapist's chairs, as well as, signs of unconscious rejection like folding one's arms or turning away from the patient ought to be avoided. 

Therapists should be able to carefully self-monitor their nonverbal behaviour. 

On the other hand,therapists should forestall clients' perception of the therapist as being subordinate, emotionally weak or inconsistent, because such inequality may be equally deleterious to therapeutic progress.

  On the patient or client's side, it is important that a patient has the genuine wish for a

change,though some patients initially expect that others change attitudes and behaviour,

rather than they themselves. A useful categorization of a client's willingness to actively

engage in therapy has been put forth by the school of Brief Therapy, according to which a

'visitor' does not see the therapist on a voluntary basis, has no complaints and no 

expectations regarding a change of the current situation. In such a case,therapy is impossible.

A 'complainant' is subjectively distressed but expects others to change. Complainants

should be encouraged to consider alternatives to their current(maladaptive) behaviour.

A 'customer' is genuinely motivated to change the situation, and may respond best to

therapeutic interventions that aim at enabling the patient to give up dysfunctional

behaviour and to pursue biosocial goals more effectively. Active support and encouraging

the patient to take a chance for a change may be warranted in patients with pronounced

tendencies of regression.

  In addition to determining a client's (unconscious) motivation for therapy,it may be

helpful to explore the client's representation or state of mind of attachment. In adults,

 the way past relationships with important attachment figures are  represented and verbalized corresponds with the individual's acquired attachment style in infancy. Incoherent verbalization suggests  insecure attachment during infancy and childhood.

  Insecurely attached individuals may either have difficulties in remembering their childhood or over-idealize parents. They have a dismissing state of mind; as children,they most likely developed an avoidant attachment style. 

Others are quickly overwhelmed by adverse memories when asked about their

relationship to parents and have preoccupied states of mind. They may switch from

idealization to anger and rage when recalling aspects of the primary attachment figure.

As children,they usually displayed an ambivalent attachment style. Individuals who as

children experienced abuse or neglect or were otherwise traumatized due to the 

unavailability of a primary attachment figure and lack of protection and security often report

childhood memories in a pronounced disorganized way (compare Chapter 3).

  The importance of a careful evaluation of attachment representations in adult clients

lies in the fact that past experiences with primary caregivers shape an individual's ability

to represent self and others' mental states. Moreover,it has a profound impact on how

current relationships are formed,including the therapeutic relationship. Hence,the

exploration of the client's current problems along with his or her way to arrange close

relationships may help the therapist to get an impression how the therapeutic alliance

may develop, and how the individual therapeutic process should ideally be tailored

according to the patient's needs.

   The apparent paradox here is --contrary to widely held views that parents' emotional

responsiveness and availability bears the risk of 'spoiling' the infant --that securely

attached individuals whose primary caregivers respond to infants' needs, are emotionally

available and provided a safe haven for infants from which they can explore the 

environment, and are better able to move to a mature autonomous state. Securely attached 

individuals are also better at reflecting upon their own and others' mental states, compared to

 individuals whose primary attachment figures are emotionally unavailable or even

 abusive. It is the latter who have more difficulties in maintaining trusting interpersonal

 relationships, and who chronically over-activate or deactivate their attachment systems.

4. The social brain and psychotherapy

Sociality and proximity to significant others are central to human nature throughout the human

lifespan (and not needs that have to be outgrown).

These basic needs are ultimately linked with human immaturity at birth,long dependence on parental care and other aspects of human life history such as the formation of long-term pair-bonds and investment in offspring of both sexes (compare Chapter 3). 

Human psychology is designed by nature to guide the individual in accomplishing biosocial goals, which include care-giving, care-eliciting,forming social bonds and alliances, attaining social status, and mating. 

Successful accomplishment of these goals may increase the likelihood of translation into reproductive success, but humans are by no means fitness maximizers in that they are able to (consciously) calculate how to increase their inclusive fitness (compare Chapter1).

Due to the complexity of ancestral human communities with the need to delicately

balance selfish and altruistic behaviour, humans have evolved a set of psychological

mechanisms to evaluate reciprocality and cooperation by means of detecting cheaters,

collectively punishing cheaters, but also to subtly deceive others. These social manoeuvres

have induced a cognitive 'arms race', which has led to sophisticated ways to predict the behaviour of others by inferring their mental states. Competition between selfish motives and altruism may be an important source of intrapersonal conflict. 

The emotions of shame and guilt may have specifically

evolved through group-selection and to maintain reciprocal relationships. The induction

of guilt and shame serve manipulative purposes to reinforce the cooperative behaviour of

individuals who under specific circumstances are tempted to behave selfishly. However,

the possibility to act in selfish ways is enhanced by the cognitive ability to conceal one's

real motives before the self,referred to as 'self-deception'. Self-deception may in the first

place have evolved to enhance the ability to deceive others, because if an individual is

unaware of his or her selfish motives,it is easier to send more convincing signals to others

so as to disguise the individual's real intention. This assumption is intriguing because it suggests that natural selection has not favoured cognitive capacities to produce accurate images of the world, but to systematically distort conscious awareness and to block inadvertent access to non-conscious information processing. These mechanisms are active in distinct ways in healthy as well as disordered mental life, and play an important role in psychological problems and disorders requiring psychotherapy.

  The primary target of any therapeutic intervention including psychotherapy is the

reduction of mental pain and subjective distress. Mental pain can be seen as an adaptive

signal to alert the individual of impending or actual threats or losses. Psychopathology

often arises if individuals are precluded from achieving biosocial goals and forced to use inappropriate defences as secondary strategies to achieve biosocial goals. 

Excessive mental pain and suffering may result from continuing obstruction of biosocial goals, and chronic activation of the physiological stress axis  may lead to a vicious circle by producing anger, despair, and more distress. 

The difference  between adaptive mental pain and pathological mental pain causing suffering and

 enduring subjective distress is, however, a matter of degree,rather than category.

   Thwarting of biosocial goals may be caused by actual recent adverse or traumatic 

experiences, such as loss of job, divorce, or loss of important attachment figures. However,

 current problems always meet an individual's personal history and endowment to cope

 with stressful life-events. Here, genetic variation, early experiences and relationships with

 significant others, as well as gene-environment interaction affect an individual's actual

vulnerability, but also resilience against pathological stress responses.

Both healthy and disordered individuals possess several built-in means to reduce mental pain,to

  suppress painful memories, and to conceal unacceptable feelings or desires before the self by

   keeping them unconscious. The overarching mechanism through which this is achieved is

 commonly referred to as 'repression', a process akin to self-deception. 

Generally speaking,repression serves the function to actively distort

cognitive processes to decrease anxiety and keep dysfunctional pain out of conscious

awareness. It may also serve the purpose to inflate one's self-esteem so as to see one's role

in social competition more optimistically. Repression is also ubiquitously involved in

regulating important biosocial goals including sexuality and interpersonal 

communication, which underscores that it increases an individual's biological fitness, unless it

become inflexible and pervasive. This can, however, happen in situations in which an

unresolved conflict remains active, and resurfaces unintentionally and repetitively in

experience and behaviour.

  In its broader meaning,the term 'repression' embraces a set of self-deceptive defence

 mechanisms that combine denial of intolerable or unmanageable feelings with different modes of representations of self and others, where the maturity of denial and representation are inversely correlated. Mature defences involve more sophisticated forms of denial, but less difficulties in self-other distinction, whereas immature defences are characterized by the inability to differentiate between own and others' mental states and hence,loosening of ego-boundaries. Accordingly, mature defence  mechanisms comprise intellectualization (excessive

use of abstract thinking to conceal unacceptable motives),rationalization (rational 

justification of emotionally motivated action), and sublimation (partial satisfaction of

unconscious motives by means of culturally accepted activities), whereas introjection

(internalizing values or characteristics of another person), projection (attribution of

one's own desires to another person, where paranoid ideation is the psychotic extreme of

projection), and projective identification (projection of one's own negative attributes to a 

significant other with the tendency to introject the originally projected attributes) are

considered to be more ontogenetically 'primitive' and immature defence mechanisms.

Other,relatively mature defence mechanisms are displacement,isolation, and reaction

formation, with identification with the aggressor, dissociation and fragmentation lying at

the immature end of possible defences.

  Since early social relationships with primary caregivers have lasting effects on an 

individual's attitudes towards present and future patterns of social interaction, and the way

mentalities of others are appreciated, it is intuitively plausible that patients with early

traumatic experiences have greater difficulties in mental state attribution and hence use

'primitive' defence mechanisms more often than individuals who as children developed secure

attachment and an autonomous state of mind.

However,the activation of mature versus immature defence mechanisms critically depends on the level of psychological distress. In situations associated with extreme real threats or dangers (such as warfare, being taken as hostage, victimization through sexual coercion etc.), perhaps everyone would tend to activate his or her attachment system, use more primitive defence mechanisms, and shut down one's mentalizing system.

In other words,the activation of the attachment

system inhibits mentalization in both normal and abnormal personality development.

For example, healthy individuals who fall in love tend to ignore the less desirable

features of the loved one. In a similar vein, people who have experienced recurrent

trauma during early childhood chronically activate their attachment systems, and

hence shut down their mentalizing systems. Consequently,traumatized individuals

are particularly vulnerable to making use of immature defence mechanisms. Due to

their impaired ability to accurately represent own and other's mental states,they

may have more difficulties in distinguishing inner and outer reality, be more intolerant

of alternative perspectives or tend to construct mental images of the world that no

longer resemble reality. For example, a person with a history of childhood abuse may

as adult tend to identify with an abuser, disavow the abuser's malicious intents,

or even direct negative affect towards the self in the way that he or she 'deserves'

maltreatment.

  These examples may illustrate that mentalizing is at the core of evolved human

psychology and individual development. As the costly side of the coin,the mentalizing system may be particularly vulnerable to dysfunction (compare Chapters 3 and 4). However,this does by no means imply therapeutic nihilism. Rather, because the development of mentalizing abilities critically depends on environmental input,this cognitive capacity is one of the most 'open programmes', and therefore flexible enough to be retrained and modulated later in life. Mentalizing is essentially involved in regulating social interaction between individuals and should accordingly be actively encouraged and maintained in  psychotherapeutic discourse. 

The therapist has the difficult task, however,to find the

appropriate balance between inspiration of mentalizing in the patient and activation of

the patient's attachment system. Treating patients with severe personality disorders

may therefore require a careful examination of the patient's ability to mentalize. Poor

mentalizers tend to focus on external social factors,the physical environment, and

are often preoccupied with social rules and norms. At the same time,they may have

difficulties in expressing anger Wトen norms are violated by others. Poor mentalizers also

tend to generalize and express rigidity or inappropriate certainty about the thoughts

and feelings of others. A possible explanation could be that emotionally unresponsive

or unavailable primary caregivers, who themselves have difficulties in appreciating

their child's mental states, may tend to overly induce shame and guilt in the child to

 sanction the child's selfish behaviour. Individuals who were reared in emotionally

unresponsive conditions may then tend to obey to those rules that are acceptable for

the parent, but unconsciously act upon repressed selfish motives, and appreciate

own and others' mental states only in an inflexible one-sided way. As adult patients or

clients,these individuals may perhaps express over-confidence in their mental state

attributions to others and deny objective realities that are not consistent with their

self-interests and preferences.

  Mentalizing in psychotherapy entails a process of joint attention focussing on the

patient's mental states. This often requires the therapist to be active in questioning and constructing images of the patient's mental states. The main goal is to help the patient access                            and explore his or her mental life and to encourage him or her to think about alternative perspectives on interpersonal processes. However, as mentalizing and attachment are inversely related, mentalizing may be discouraged when the patient is overwhelmed with emotions in favour of empathy and support. A patient's ability to accept mentalizing interventions depends on his or her experience of the therapeutic relationship as a 'secure base'. 

From such a base, patients may be able to adopt alternative, more trustful models of interpersonal relationships,to give up dysfunctional modes of repression, and to improve emotion regulation.

  Focussing on the therapeutic relationship and mentalizing processes emphasizes the

view that psychotherapy in general may benefit from insights of human cognitive and

emotional evolution, and that one of the most recently evolved human capacities may be

actively used to reduce subjective distress and suffering. Most 'schools' of psychotherapy,

not only psychodynamic approaches, acknowledge that the quality of the therapeutic

relationship influences outcome and prognosis of the therapeutic process. Likewise,

working with patients' and therapists' mental states is part of many forms of 

psychotherapeutic interventions. Encouraging patients to apprehend their own mental states and

those of significant others is certainly a useful tool across psychotherapeutic modalities,

but should be carefully monitored,regardless whether psychodynamic or cognitive-

behavioural intervention techniques are preferred.

5. Sex differences in response to psychotherapy

Differences in the psychology of men and women may influence psychotherapy in many ways. For example, differences between the sexes exist regarding vulnerability to psychosocial stressors. Adverse life events, such as disruption of an emotionally

intense relationship, physical or sexual abuse, usually have greater impact on females.

Conversely, males may be particularly susceptible to develop psychological distress due to

actual or impending loss of social status. These differences may not only account for greater

prevalence rates of depression, anxiety disorders or post-traumatic stress disorder in women,

but also for differences in seeking therapeutic help, and response to treatment. Differences

between men and women are deeply anchored in divergent adaptations of men and women

to problems relating to the need to cooperate,to form close relationships with kin,to

compete for mates, and to successfully reproduce (for details, see Chapter1). Typically, men

are selected to compete intra-sexually for access to women. Women, by contrast, are selected

to invest more heavily in potential offspring, and therefore,to carefully select suitable mates.

Human females are highly cooperative breeders, a mechanism through which humans were

able to shorten inter-birth intervals considerably. Men, in contrast to women, face the 

problem of uncertain paternity, which has led to greater sexual jealousy in men (whereas

emotional jealousy can also be intense in women; for details, see Chapters 1 and 16).

  In psychotherapy,these divergent behavioural tendencies in men and women may manifest in differences in verbalization of emotional problems, response to emotional and social support, use of submissive behaviours, dysfunctional coping strategies such as drug or alcohol abuse, challenging the value of therapy, and feelings of being stigmatized by therapy. Men,for example, are more likely to conceal emotions,feelings of inferiority or vulnerability, whereas women may 'attach' to the therapist more easily compared to men. So it could be that women, even though they more often suffer severe trauma, including those that transgress important personal boundaries such as physical or sexual abuse,respond better to psychotherapy, because of women's greater openness and superior ability to verbalize and re-integrate negative emotions. In contrast, men may experience psychotherapeutic aid as a threat to social status and independence, which could explain men's greater reluctance to seek therapy.

  Taking these differences between the sexes seriously suggests that, depending on the

nature of the disorder or psychological problem, women may be better therapists

for women, and men may be better therapists for men. Acknowledging sex differences in

behaviour may also be useful in special therapeutic settings such as couples therapy and

other systemic approaches.

Afterthought: Are there side-effects of psychotherapy?

The question whether or not psychotherapeutic interventions can have adverse effects

has received little attention. The matter is indeed hard to address empirically, because,

 unlike studies into psychopharmacology, double-blind placebo controlled approaches

 are impracticable. Anecdotal reports suggest, however, that transgression of therapeutic

 rules and norms by the therapist can occur,if counter-transference is poorly controlled

 and the therapist fails to maintain therapeutic abstinence. In extreme cases this may

 include a sexual relationship between therapist and client. Psychotherapists acting that

way disregard the special vulnerability of patients seeking attachment and a secure base,

 or even mistake a client's dysfunctional sexual advances for mature behaviour. Although

 no data exist, such violations of rules of conduct in psychotherapy on the side of

the therapist are probably rare. In the strict sense, norm violations in therapy cannot

be considered side-effects, because, by definition, side-effects occur despite proper

application of treatment.

   From an evolutionary point of view, which emphasizes the role of nonverbal 

communication between client and therapist,the classic settings of psychoanalysis may produce

harmful effects in patients whose disorders require visual contact and exchange of supportive

nonverbal signals or patients whose condition may deteriorate if regressive tendencies

induce overwhelming feelings of helplessness. Thus,in the treatment of patients with

severe depression or personality disorders,for example,techniques such as 'free association'

while the therapist is out of sight of the patient may have deleterious side-effects. Moreover,

patients who are traumatized or have otherwise developed insecure attachment styles

probably do not benefit from therapeutic neutrality. Instead, many patients require active

encouragement, positive motivation,reassurance and empathy (see above).

  A disturbing finding is that patients with severe personality disorder may experience a

substantial reduction of symptoms or even remission without therapy, and that 

spontaneous recovery rates may even be higher than in patients who have received treatment. One speculative explanation that has been suggested is that patients with severe personality

disorders who have deficits in mentalizing have difficulties in integrating interventions in

insight-oriented psychotherapies,i.e.interpretations of the patient's mental states offered

by the therapist. In other words, dissonance between the patient's inner experience and the

therapist's interpretation thereof may cause emotional turmoil and instability. Thus,

premature explanations of unconscious material should be avoided in such patients.

  Conversely, helping patients to understand own and others' mental states may be

harmful if these patients misuse the ability to mentalize for deceptive and exploitative

(selfish) purposes. Individuals with psychopathy usually have highly developed 

mentalizing skills, however,they fail to empathize with others. Improving mentalizing in

psychopaths may therefore have a profoundly negative impact on interpersonal 

relationships in many ways. For example, skillful psychopathic mentalizers may better be able to

anticipate and predict the behaviour of potential victims. Moreover, violent psychopaths

in forensic custody with good mentalizing qualities may have the potential to convince

therapists of their apparent progress in therapy.

  Many more scenarios of possible side-effects of psychotherapy are conceivable. Future

studies may be able to clarify some of the issues raised above. In any event, all 

psychotherapeutic tools should be critically evaluated in terms of differential indication and possible contraindications.

笠原先生の小精神療法

笠原先生の小精神療法

  

うつ病の小精神療法に関する「笠原の 7 カ条」

1)うつ病は病気であり、単に怠けではないことを認識してもらう

2)できる限り休養をとることが必要

3)抗うつ薬を十分量、十分な期間投与し、欠かさず服用するよう指導する

4)治療にはおよそ 3 ヶ月かかることを告げる

5)一進一退があることを納得してもらう

6)自殺しないように誓約してもらう

7)治療が終了するまで重大な決定は延期する

Psychotherapy: evolutionary

Psychotherapy can be defined as the attempt to change cognitions, emotions, and behaviours in humans who suffer from maladaptive consequences of their behaviour or have caused suffering in others, by means of scientifically evaluated psychological techniques and interventions.

Central to all kinds of psychotherapy is the assumption that alternative strategies to cope with interpersonal stress or other adverse stimuli can be accomplished throughout the human lifespan through learning and experience, albeit with different likelihood of success depending on age at onset, duration, and severity of the underlying disorder. 

It is widely acknowledged among psychotherapists that logic in therapeutic discours alone does not suffice to enable a patient to give up maladaptive strategies; rather, it is essential that the patient feels a difference; perhaps first imaginatively, and later on, as therapy progresses, as part of his or her 'reallife' experience. 

Even though it becomes increasingly clear that psychotherapy has the potential to induce long-lasting changes in brain 

activation, particularly in the most recently evolved cortical midline structures involved in the representation of self and others, and in phylogenetically older brain centres involved in emotion regulation, the fact that any kind of psychotherapy is deeply rooted in the evolved psychology of our species is more implicitly, rather than explicitly, approved by therapists.

Mental representation of self and others is, however, at the core of interpersonal and intrapersonal conflict, as well as of conflict resolution.

The ability to infer mental states and anticipate future actions of other individuals may not only have been a major driving force in human brain evolution, but also a major source of cognitive distortion causing psychological distress.

“マスロー（A.H.Maslow,1908-1970）は有名な心理学者で、人間が持つ内面的欲求を五段階に体系化した人です（ゆえにマスローの欲求五段階説とも言われます）。 つまり、人間の持つ欲求は、生理的欲求－安全への欲求－社会的欲求－自我欲求－自己実現欲求といった形で低次元の欲求から高次元の欲求へと５つの階層をなしており、低次元の欲求が満たされてはじめて高次元の欲求へと移行するというものです。”

“マスロー（A.H.Maslow,1908-1970）は有名な心理学者で、人間が持つ内面的欲求を五段階に体系化した人です（ゆえにマスローの欲求五段階説とも言われます）。

つまり、人間の持つ欲求は、生理的欲求－安全への欲求－社会的欲求－自我欲求－自己実現欲求といった形で低次元の欲求から高次元の欲求へと５つの階層をなしており、低次元の欲求が満たされてはじめて高次元の欲求へと移行するというものです。”

“大抵のことに効くおまじないをここで一つ この世の一割の人は、あなたが大好きで この世の一割の人は、あなたが大嫌い 残りの八割は、そもそも興味がない この数字は、覆せない 自分の行動が公明正大に間違ってないと言えるなら、「ああ、あれは一割か」と思うべし”

“大抵のことに効くおまじないをここで一つ 

この世の一割の人は、あなたが大好きで 

この世の一割の人は、あなたが大嫌い 

残りの八割は、そもそも興味がない 

この数字は、覆せない 

自分の行動が公明正大に間違ってないと言えるなら、「ああ、あれは一割か」と思うべし”

“ちょっとしたコツを紹介しましょう。相手が「あなた」に対して腹を立てているとしても、あなたではない「ほかの誰か」に対して腹を立てていると想像してください。そして、そういう場合と同じように対応するのです。おそらくあなたは、まず話を聞いて、相手がどんなに頭にきているか分かっているということを相手に伝えようとするでしょう。 それで、自分の意図を説明する機会がやってこなかったら？ 実際に試してみてわかったのは、自分でも驚いたのですが、「結果」について理解していることを伝えると、自分の意図を正当化する必要性もなくな

“ちょっとしたコツを紹介しましょう。相手が「あなた」に対して腹を立てているとしても、あなたではない「ほかの誰か」に対して腹を立てていると想像してください。そして、そういう場合と同じように対応するのです。おそらくあなたは、まず話を聞いて、相手がどんなに頭にきているか分かっているということを相手に伝えようとするでしょう。

それで、自分の意図を説明する機会がやってこなかったら？　実際に試してみてわかったのは、自分でも驚いたのですが、「結果」について理解していることを伝えると、自分の意図を正当化する必要性もなくなることでした。

なぜなら、どういうつもりだったかを説明するのは、そもそもが関係を修復するためだからです。けれども、相手のいやな思いに共感を示したことで、すでにこの目的は達成されています。たいていの場合、この時点でお互いにその話題から離れられるようになっているはずです。

それでも、まだ自分の意図を説明する必要があると感じたら？　「ちゃんと話も聞いてもらえたし、理解もしてもらった」と相手が感じたら、機会はまだあります。

こういうことがすべてうまくいくと、お互いの関係が変化するだけでなく、ほかにも改善される点がしばしば見られます。それは、お互いの振る舞い方です。”

PSYCHOANALYSIS

ここで紹介するLuborskyという人はthe Core Conflictual Relationship Theme (CCRT) method
で有名な人。と言っても、世間的に言えば、たいして重要な考えではなく、従来の考え方を別の言い方で分かり易く表現したようなものだが。
この教科書の中の精神分析の項目はうまく書かれていて、よいと思った。
しかし2013年版が新しく出て、精神分析の項目は新しい筆者になっているので、LuborskyさんのCCRTの話も
たぶんもうこれで余りお目にかかれないものになるのではないかと思う。
以下は全文ではなく冒頭部分のみの紹介。
こうしてみるとやはり精神分析は知的だしインスピレーションがあるし理論としても魅力的だ。
しかし実際に治療に役立つのは認知行動療法である。特に薬剤と行動療法を併用した場合の治癒率が高いので
やはり時代はどんどん進んでいると感じる。

ーーー
PSYCHOANALYSIS

Ellen B. Luborsky, Maureen O’Reilly—Landy, and Jacob A. Arlow

“It doesn’t add up.”

How could a seemingly nice person abuse a child? Why would someone not show up at her own wedding, one she'd planned for a year? How could a child from a great neighborhood with fine schools and an intact family never develop any ambition?

The next time you wonder, give credit Where credit is due. Over one hundred years ago, Sigmund Freud pronounced that the surface, or manifest, level of life is but the topsoil of mental activity. Much of it happens at an unconscious level. Symptoms and problem behavior begin to make sense when the deeper levels are understood.

Psychoanalysis, a system of treatment as well as a way to understand human behavior, has given rise to discoveries and controversies that are actively with us today. It has seeped into the language (“Was that a Freudian slip?”) and made an impact on our thinking.

Consider your reaction to the questions raised at the beginning of the chapter. Did you wonder Whether the abuser had himself been abused? (Repetition of an early experience not consciously remembered.) Did you suspect that the woman who never showed up at her wedding had mixed feelings she couldn't face? (Inner conflict, with warded off emotional experience.) Did you think that the student without ambition had more issues than meet the eye? (The surface story Functioning as a cover for, or defense against, inner emotional experience.)

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Psychoanalytic thinking has evolved over the last century, so that classical and modern psychoanalytic approaches now coexist. It has spawned different forms of psychotherapy, with psychodynamic psychotherapy being its most direct descendant. According to Rangell (1963), most of the widely practiced forms of psychotherapy are based on some element of psychoanalytic theory or technique.

Psychoanalysis has affected fields that range from child development to philosophy to feminist theory. It has inspired thinkers and therapists who disagree With Freud’s premises to come up with methods of their　own. Whether because it is rejected, adapted, or accepted, Freud’s legacy is still with us.

The purpose of this chapter is to better understand psychoanalysis, particularly those concepts that have had staying power. Freud’s own concepts evolved over the course of his lifetime, and they continue to do so. Controversy and change have accompanied psychoanalysis since it began. The tests of time and of research have highlighted some ideas and discredited others. Both the clinical and the empirical evidence For the usefulness of psychoanalytic thinking will be explored.

 

The goals of this chapter are 

To present the central psychoanalytic concepts

To examine the ways in which those concepts have evolved

To demystify the language and principles of psychoanalysis

To look at the treatment methods that have emerged from a psychoanalytic perspective 

To consider different applications of psychodynamic ideas 

To examine research evidence for psychoanalytically oriented treatment 

To give examples of how psychodynamic ideas can be used in psychotherapy

Basic Concepts

You have been trained to find an anatomical basis for the functions of the organism and their disorders, to explain them chemically and view them biologically. But no portion of your interest has been directed to the psychical life, in which, after all, the achievement of this marvelously complex organism reaches its peak. (Freud, 1916, p. 20)

Psychoanalysis seeks to understand human behavior through an investigation of inner experience, and to treat psychological problems through a clinical application of that understanding. Consequently, the central tenets include both theoretical concepts and clinical methods.

Basic Theoretical Concepts

The Unconscious

The division of the psychical into what is conscious and what is unconscious is the fundamental premise of psychoanalysis. (Freud, 1923, p. 15)

The unconscious consists of states of mind that are outside awareness. They include both emotional and cognitive processes, along with forms of memory that affect the patient’s reactions and behavior. Although the concept of the unconscious mind predates psychoanalysis, Freud’s unique contribution was to discover how the concept could be used to understand and inform the treatment of psychological problems.

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The scientific status of the unconscious has been in question since the concept was proposed. Recent discoveries of neuroscience offer some support for the influence of mental processes that are outside conscious awareness.

Psychodynamics

Our purpose is not merely to describe and classify the phenomena, but to conceive of them as brought about by the play of forces in the mind. . . . We are endeavoring to attain a dynamic concept of mental phenomena. (Freud, 1917, p. 60)

Psychodynamics is the “play [that is, the interplay] of forces of the mind.” The concept of inner conflict is a prime example of psychodynamics at work. The term inner or intrapsychic conflict refers to conflict between parts of the self that hold opposing perceptions or emotions, one or more of which is out of awareness. This may result either in problematic behavior or in symptoms. For example, a patient may express the conviction that he loves his wife and would never do anything to hurt her, while having affairs outside of the marriage. He may be acting out feelings that conflict with his consciously held beliefs. Or a patient may get a headache whenever Monday comes. The symptom may express a conflict between the part of her that knows she must go back to work and the part that dreads doing so.

Symptoms in psychodynamic theory are often seen as an expression of inner conflict. Whereas in the medical or diagnostic model a symptom is a sign of a disorder, here a symptom is a clue, expressed through the language of behavior, to the patient’s core conflicts. Decoding its meaning in the course of treatment allows the feelings once expressed through the symptom to be expressed in less harmful ways. The symptom-context method is a clinical-research method that aids in that process.

 

Psychodynamic Psychotherapy.

Psychotherapies that follow in a psychoanalytic tradition are referred to as psychodynamic treatments. They retain the central dynamic principles of psychoanalysis but do not make use of the metapsychology, or formal theories of the structure of the mind. Even Freud came to the conclusion that metapsychological hypotheses are “not the bottom, but the top of the whole structure [of science] and they can be replaced and discarded without damaging it” (Freud, 1915b. p. 77).

Dynamic psychotherapy evolved from psychoanalysis to fill the need for a form of treatment that was not so lengthy and involved. Whereas psychoanalysis is typically conducted three to five times a week, with the patient lying down, dynamic psychotherapy usually takes place once or twice a week, with the patient sitting up. Supportive-expressive (SE) psychotherapy is a current form of dynamic treatment that incorporates clinical-research methods.

 

Defenses

The term defense”. . . is the earliest representative of the dynamic standpoint in psychoanalytic theory. (Freud, A., 1966, p. 42)

Defense mechanims are automatic forms of response to situations that arouse unconscious fears or the anticipation of “psychic danger." Examples of common defenses include avoidance and denial. These both function as “ways around” situations that bring up thoughts or emotions that the patient cannot tolerate. Effective defenses are essential for healthy functioning because they render painful and potentially overwhelming feelings manageable. However, they often cause problems in real life, because they tend to obscure or distort reality. For example, a student who spends all of her time online instead of studying for exams may be using the defense

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of avoidance to counteract the intense anxiety she would feel if she opened up the semester’s untouched work. Other defenses will be discussed in the next sections of this chapter.

 

Transference.

Transference, Freud’s cornerstone concept, refers to the transfer of feelings originally experienced in an early relationship to other important people in a person’s present environment. They form a pattern that affects the patient’s attitudes toward new people and situations, shaping the present through a “template” from the past.

Each individual, through the combined operation of his innate disposition and the influences brought to bear on him during his early years, has acquired a specific method of his own in the conduct of his erotic life. This produces a stereotype plate [or template], or several such, which is constantly repeated . . . in the course of a person’s life. (Freud, 1912, pp. 99-100)

In psychoanalysis, the analysis of the transference is fundamental to the treatment. The patient’s transference to the analyst enables them both to see its operating force and to work on separating reality from memories and expectations. The transference contains patterns from the past that may he remembered through actions or through repetition of the past, rather than through recollection; . . . the patient does not say that he remembers that he used to he defiant and critical toward his parents’ authority; instead he behaves that way to the doctor” (Freud, 1914, p. 150). ,

Transference has been investigated through clinical research on the Core Conflictual Relationship Theme (CCRT) method. This research, which both clarifies and validates the concept, will be explored later in this chapter.

Countertransference refers to the therapists reactions to the patient. As the counterpart to the transference, it refers to the therapists reactions to a patient that may be linked to personal issues the therapist needs to resolve. Countertransference has been used recently to evaluate whether the therapist’s reactions may be responses to the patients emotions or to nonverbal communications from the patient.

 

Basic Clinical Concepts

 

Free Association.

 

“Say what comes to mind” is a typical beginning to any psychoanalytic treatment. Unlike other forms of treatment, psychoanalysis invites all thoughts, dreams, daydreams, and fantasies into the treatment. Psychoanalysts believe that the expression of unedited thoughts will bring richer material about the inner workings of the mind. The less edited the material, the more likely that it will contain clues to parts of the self that may previously have been expressed through symptoms. Free association also gives the patient a chance to hear himself.

 

Therapeutic Listening.

Freud recommended maintaining a state of “evenly hovering attention” to what the patient says. That means that the analyst does not seize on one topic or another but, rather, listens to all the levels of the communication at once. That includes what the patient is literally saying, What kinds of emotions she conveys, and the analyst’s reactions while listening. This form of listening is at the foundation of the analytic method, since it allows a full heating of the patient. A second kind of therapeutic listening occurs when the analyst develops a sense of the patients patterns——those that may form the transference as well as those that link symptoms with their meanings.

Therapeutic Responding. Interpretation is the fundamental form of responding in traditional psychoanalysis. It involves sharing an understanding of a central theme of the patient, often a facet of the transference. Interpretations are intended to help a patient

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come to terms with conflicts that may have been driving his behavior or symptoms, offered when the analyst senses that the patient is ready to grapple with them.

The interpretation of dreams has a special place in psychoanalytic treatment. “The interpretation of dreams is the royal road to a knowledge of the unconscious activities of the mind” (Freud, 1932, p. 608). Freud believed that the manifest content, or surface story, of dreams could be decoded to reach the deeper, latent content. Ways to understand the language of the dream will be explored in the next section.

 

Empathy as a form of therapeutic responding has received increasing attention since the second half of the twentieth century. Empathic responding means attuning to the patient’s feeling states and conveying a sense of emotional understanding. Research now links the therapist's empathy with the outcome of treatment. 

The Therapeutic Alliance.

 

The therapeutic or working alliance is the partnership between the patient and therapist forged around Working together in the treatment. Greenson (1967) clarified the difference between the working alliance and the transference and emphasized the importance of the alliance to the treatment. Current research confirms that a positive helping alliance is one of the Factors that is consistently associated with a good outcome in psychotherapy.

Other Systems

 

Psychoanalysis serves as both the grandfather and the current relative to many forms of psychotherapeutic practice. Some other systems and theorists (notably Jung and Adler) branched off from psychoanalysis during Freud’s lifetime. Others began as later adaptations and either remained under the “analytic umbrella,” as did dynamic psychotherapy, or highlighted an essential difference, as did Carl Rogers.

A number of distinct, but still essentially psychoanalytic, theories have emerged since Freud’s time. These include classical psychoanalysis, ego psychology, interpersonal psychoanalysis, object relations and other relational perspectives, and self-psychology. Although psychoanalysis as a system of thought comprises many theories, three basic ideas are common to all and provide a framework for comparison with other systems of psychology: the role of the unconscious, the phenomenon of transference, and the relevance of past experiences to present personality and symptoms.

The Unconscious Mind

 

The first central concept that distinguishes psychoanalysis from many other systems of psychology is a belief in the importance of the unconscious in understanding the human psyche. Other systems of psychology that acknowledge the significance of the human unconscious are, understandably, those developed by theorists who studied directly with Freud. Most notable among these is Carl Jung. Jung retained Freud’s belief in the unconscious but saw it as consisting of two important aspects. In addition to the type of personal unconscious that Freud described, Jungian analysts believe in a collective The collective unconscious is made up of archetypal images, or symbolic representations of universal themes of human existence that are present in all cultures, as opposed to the more personal Freudian unconscious. Similar to psychoanalysis, neurosis in Jungian analysis results when one is excessively cut off from the contents of the unconscious and the meaning of the archetypes, which can be understood through various methods, including dream analysis. Jung brought in aspects of mysticism and spirituality that were rejected or ignored by earlier psychoanalysts but which are now beginning to receive attention from modern psychoanalysts, particularly those with an interest in meditation and Eastern religions.

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Adler, another of Freud’s students, departed from the belief in the unconscious as part of an intrapsychic system based on repression of drives, but he continued to believe that people know more about themselves than they actually understand.

The Existentialists are also concerned with the unconscious. Like psychoanalysts, they believe that people experience internal unconscious conflicts and that these are excluded from conscious awareness but still exert an influence on behavior, thoughts, and feelings. For them, it is anxiety about basic existential fears such as death, isolation, and meaninglessness that is being defended against.

Gestalt therapy was also an outgrowth of psychoanalysis but departed from it in radical ways, not only in eschewing much of its basic theory, but also by developing very structured and active therapeutic techniques. Despite these substantial differences, Fritz Perls held on to a belief in the therapeutic value of bringing what is unconscious into consciousness. Similarly, Moreno’s Psychodrama, by enacting problematic interpersonal situations, helps a patient get in touch with and express feelings she may not have realized she had. Alvin Mahrer’s experiential psychotherapy also differs from psychoanalysis in a Wide variety of Ways. Mahrer regards unconscious material as unique to each individual and believes it represents one of many aspects of a deeper potential for experiencing life. Finally, certain schools of family therapy deal with the ways in which members unconsciously play out particular roles in relation to each other.

The “depth psychologies,” those that acknowledge that deeper underlying processes and experiences have significant effects on human behavior, contrast sharply with behavioral and cognitive approaches. Such therapies, which include behavior therapy, ration ai emotive behavior therapy (REBT), cognitive and cognitive-behavior therapy (CBT), and multimodal therapy, are all rooted in learning theory. In these systems, the undesired symptom, behavior, or thought is understood as having been learned and reinforced by environmental events. These models do not look for meaning beyond observed behavior or conscious experience, and behavioral observation and self-report are their primary methods of assessment.

Some therapies derived from these models have demonstrated effectiveness in treating problems such as phobias and other well-defined anxiety disorders, as Well as certain symptoms of major depression. Thus, they have made a valuable contribution to the alleviation of psychological suffering. However, many difficulties for which adults seek psychotherapy are not so readily delineated and categorized. A woman may seek psychological treatment, for example, because she is unable to maintain a close and satisfying relationship, or because she experiences a sense of malaise for which she has no explanation. Further, even with well-defined symptoms, when “treatment-resistant” cases occur, these systems offer no conceptual tools for looking beyond the observable to understand What might have gone Wrong.

The Transference

 

A second idea common to psychoanalytic therapies is the transference. Freud was the first to recognize the therapeutic value of transference phenomena, in which the patient comes to experience others, the analyst in particular, in ways that are colored by his early experiences with important people in his life. Countertransference, or the response of the analyst to the patient and his transference, is also utilized in various ways in psychoanalysis. Most contemporary psychoanalysts regard countertransference as useful clinical information about the patient, including the types of Feelings he might evoke in others. Attention to transference and countertransference reflects interest both in the unconscious and in the importance of childhood experiences and early relationships. Jungian analysts and contemporary psychoanalysts work actively with the transference

-------------------------------------------6

and countertransference, reflecting a move within both orientations toward recognizing the mutual influence between patient and therapist.

Gestalt, Adlerian, and Client-centered (Rogerian) therapists have less confidence in the therapeutic value of transference. They place greater value on actively cultivating a positive relationship with the client by maintaining a stance that is visibly empathic, supportive and non-judgmental and attempting to bypass any negative transference phenomena. Being empathic and non-judgmental are also highly valued by psychoanalysts, but they remain open to the expression of both positive and negative feelings about the therapist and attempt to understand and interpret either. They believe that understand» ing these feelings is important if deep and lasting therapeutic change is to occur.

In REBT, the therapist attempts to eradicate transference phenomena at the outset by demonstrating that the client’s Feelings are based on irrational, maladaptive wishes. Behaviorally and cognitively oriented therapists attempt to enhance the working alliance, but transference is not part of their theories. Their more active stance, in which homework assignments are routinely given and explicit instructions are provided about how to change thoughts and behavior, establishes the therapist as an authority figure, a role that is utilized to encourage compliance.

 

The Role of Childhood Experiences

 

A third characteristic shared by psychoanalytically oriented clinicians is a belief that childhood experiences influence personality development, current relationships, and emotional vulnerabilities. Many contemporary psychoanalysts incorporate research findings demonstrating the long-term impact of the quality of a child’s early attachment, childhood trauma, early experiences of loss, and other related areas into their thinking about personality development. Any system for which transference is an important concept is necessarily one that recognizes this past-present relationship. Jungian analysts work actively with transference material and are similar to psychoanalysts in their view that aspects of early formative relationships affect the analytic relationship, affording the patient an opportunity to Work through these feelings and move beyond their negative impact.

Although Ellis does not use the term transference, he acknowledges that transferential thoughts and feelings toward the therapist might arise but regards them as little more than irrational beliefs. Rather than examine and attempt to understand them, he points out their unrealistic nature and applies his very systematic REBT procedure with the intention of eradicating them.

In psychodrama, early past experiences are thought to have an impact on one’s current situation, and these are explicitly role-played in an effort to rework and replace the psychologically harmful experiences with more positive ones. Rogerians and existentialists are concerned with the therapeutic relationship, but past experiences do not figure prominently in their thinking.

For systems greatly influenced by learning theory, such as cognitive, behavioral, and cognitive-behavioral therapies, as well as multimodal therapy, the past is significant only in terms of the direct antecedents to the dysfunctional behavior. This major difference from the analytic perspectives may limit the types of psychological problems that the systems that rely on learning theory are able to address.

 

Common Factors

 

Various approaches to psychotherapy differ in what they see as fundamental to the process. Dynamic psychotherapies differ from behavioral forms of treatment in their understanding of the origins of psychological problems, as well as in aspects of technique.

-------------------------------------------7

Although the differences among forms of therapy are frequently highlighted in writings about treatment, they also share important fundamentals. Establishing a working alliance is important in all forms of treatment, whether it is made explicit, as in psychodynamic theory, or not. So is the frame, or structure, of the treatment and the establishment of treatment goals. The role of common factors will be further explored in the Evidence section of this chapter.

 

Precursors

 

Psychoanalysis, as originated by Sigmund Freud (1856-1939), represented an integration of the major European intellectual movements of his time. This was a period of unprecedented advance in the physical and biological sciences. The crucial issue of the day was Darwin’s theory of evolution. Originally, Freud had intended to pursue a career as a biological research scientist, and in keeping with this goal, he became affiliated with the Physiological Institute in Vienna, headed by Ernst Bruecke. Bruecke was a follower of Helmholtz and was part of the group of biologists who attempted to explain biological phenomena solely in terms of physics and chemistry. It is not surprising, therefore, that models borrowed from physics and chemistry, as well as the theory of evolution, recur regularly throughout Freud’s Writings, particularly in his early psychological works.

Freud came to psychoanalysis by Way of neurology. During his formative years, great strides were being made in neurophysiology and neuropathology. This was also the time when psychology separated from philosophy and began to emerge as an independent science. Freud was interested in both fields. He knew the works of the “association” school of psychologists (Herhart, von Humboldt, and Wundt), and he had been impressed by the Way Gustav Fechner applied concepts of physics to problems of psychological research.

In the mid-nineteenth century, there was great interest in states of split consciousness. The French neuropsychiatrists had taken the lead in studying conditions such as somnambulism, multiple personalities, fugue states, and hysteria. Hypnotism was one of the principal methods used in studying these conditions. The use of the couch, with the patient lying down, began with the practice of hypnosis. The leading Figures in this field of investigation were Jean Martin Charcot, Pierre Janet, Hippolyte Bernheim, and Ambrose August Liebault. Freud Worked with several of them and was particularly influenced by Charcot.

 

Beginnings

 

Freud made frequent revisions in his theories and practice as new and challenging findings came to his attention. In the section that follows, special emphasis will be placed on the links between Freud’s clinical findings and the consequent reformulations of his theories. These Writings serve as nodal points in the history of the evolution of his theories: Studies on Hysteria, The Intrpretation of Dreams, Three Essays on Sexuality, On Narcissism, the metapsychology papers, Beyond the Pleasure (the Dual Instinct Theory), and The Ego and the M (the Structural Theory).

Studies on Hysteria (1395)

The early history of psychoanalysis begins with hypnotism. Josef Breuer, a prominent Viennese physician, told Freud of his experience using hypnosis. When he placed the patient in a hypnotic trance and encouraged her to relate what was oppressing her mind

-------------------------------------------8

at the moment, she would frequently tell of some highly emotional event in her life. awake, the patient was completely unaware of the “traumatic” event or of its connection with her disability, but after relating it under hypnosis, the patient was cured of her disability. The report made a deep impression on Freud, and it was partly in pursuit of the therapeutic potential of hypnosis that he undertook studies first with Charcot in Paris and later with Bernheirn and Liehault at'Nancy, France.

When Freud returned to Vienna, he used Breuer’s procedures on other patients and was able to confirm the validity of Breuefs findings. The two then established a Working relationship that culminated in Sturlzes on Freud and Breuer noted that recalling the traumatic event alone was not sufficient to effect a cure. The discharge of the appropriate amount of emotion was also necessary. Anna O., a patient whom Breuer cured in this way, referred to the treatment as “the talking cure.”

The task of treatment, they concluded, was to achieve catharsis of the undisch arged affect connected with the painful traumatic experience. The concept of a repressed trauma was fundamental in Freud’s conceptualization of hysteria, which led him, in an aphoristic Way, to say that hysterics suffer mainly from reminiscences.

Breuer and Freud differed on how the painful memories in hysteria had been rendered unconscious. Breuer’s explanation was a “physiological” one, in keeping with theories of psychoneuroses current at that time. In contrast, Freud favored a psychological theory. The traumatic events were "Forgotten or excluded from consciousness precisely because the individual sought to defend herself from the painful emotions that accompany recollection of repressed memories. That the mind tends to pursue pleasure and avoid pain became one of the basic principles of Freud’s subsequent psychological theory.

Breuer refused to continue this line of research, but Freud continued to Work independently. Meanwhile, Freud learned from his clinical experience that not all patients Could he hypnotized and that many others did not seem to go into a trance deep enough to produce significant results. He began using suggestion, by placing his hand on the patients’ foreheads and insisting that they attempt to recall the repressed traumatic event. This method was linked to an experiment he had witnessed while working with Bernheim. In his Autobiographical Study (1925, p. 8), Freud described the incident:

 

When the subject awoke from the state of somnambulism, he seemed to have lost all memory of what had happened While he was in that state, but Bernheim maintained that the memory was present all the same; and if he insisted upon the subject remembering, if he asseverated that the subject knew it all and had only to say it, and if at the same time he laid his hand on the subject’s forehead, then the forgotten memories began to return, hesitatingly at first, but eventually in a flood and with complete clarity.

 

Accordingly, Freud abandoned hypnosis in favor of a new technique of forced associations. However, Elisabeth von R, the first patient whom Freud treated by “Waking suggestion,” apparently rebuked Freud for interrupting her flow of thoughts. Freud took her response seriously, and the method of “free association” began to emerge.

 

Clinical Experience and Evolving Technique.

The responses of Freud’s patients to his procedures made for modification in his technique as Well as in his thinking. Not only did he attend to Elizabeth van R’s response to his “forced” questions, but he also began to notice that she actively refused certain questions. This observation prompted his thinking about resistance, or a force of “not wanting to know” in the patient. That furthered his emerging use of free association, where the task was to bring the resistances to the fore, rather than trying to circumvent them.

This technical innovation coincided with another interest that pervaded Freud’s thought at the time. He had found that two elements were characteristic of the forgotten

-------------------------------------------9

traumatic events to which he had been able to trace the hysterical symptoms. In the first place, the incidents invariably proved to be sexual in nature. Second, in searching for the pathogenic situations in which the repression of sexuality had set in, Freud was carried further and further back into the patient’s life, reaching ultimately into the earliest years of childhood. Freud first concluded that the patients he observed had all been seduced by an older person. In his further investigation, Freud realized that this was not always true, and he began to develop his theory of childhood sexuality, eventually coming to believe in the importance of childhood fantasies about sexuality.

Following the same principle of learning from patients, dynamic therapists who work with the survivors of childhood sexual abuse have reopened the topic of abuse and its aftermath in patients’ lives (Davies 6: Frawley, 1994). Thus, in the century that has followed Freud, attention has returned to actual abuse, along with the possibilities of complex, interwoven symbolic material.

 

The Interpretation of Dreams (1900)

The second phase of Freud’s discoveries concerned a solution to the riddle of the dream, Dreams and symptoms, Freud came to realize, had a similar structure. He saw both as products of a compromise between two sets of conflicting forces in the mind between unconscious wishes and the repressive activity of the rest of the mind. In effecting this compromise, an inner censor disguised and distorted the representation of the unconscious wishes. This process makes dreams and symptoms seem unintelligible, but Freud’s descriptions of the mechanisms of representation in the dream gave way to the understanding of dreams and their symbols.

The Interpretation of Dreams was the book where Freud first described the Oedipus complex, an unconscious sexual desire in a child, especially a male child, for the parent of the opposite sex, usually accompanied by hostility to the parent of the same sex, as Well as guilt over this wish to vanquish that parent. The development of that theory coincided with Freud’s own self analysis. Although the Oedipus complex continues to have an important place in classical psychoanalytic theory, more recent approaches that emphasize early attachment rather than childhood sexuality do not give it the same credence.

 

The Structure of Mind. In the concluding chapter of The Interpretation of Dreams, Freud attempted to elaborate a theory of the human mind that would encompass dreaming, psychopathology, and normal functioning. The central principle of this theory is that mental life represents a fundamental conflict between the conscious and unconscious parts of the mind. The unconscious parts of the mind contain the biological, instinctual sexual drives, impulsively pressing for discharge. Opposed to these elements are forces that are either conscious or readily available to consciousness, functioning at a logical, realistic, and adaptive level.

 

Because the fundamental principle of this conceptualization of mental functioning concerned the depth or “layer.” of an idea in relation to consciousness, this theory was called the topographic theory. According to this theory, the mind could be divided into three systems: consciousness, resulting from perception of outer stimuli as well as inner mental functioning; the preconscious, consisting of those mental contents accessible to awareness once attention is directed toward them; and finally the unconscious, comprising the primitive, instinctual wishes.

The concepts developed in The Interpretation of Dream unconscious conflict, infantile sexuality, and the Oedipus cornplex—enabled Freud to attain new insights into the psychology of religion, art, character formation, mythology, and literature. These ideas were published in The Psychopathology of Everyday Life (1901), and Their

-------------------------------------------10

Libido Theory. Freud conceived of mental activity as representative of two sets of drives: Libidinal drives seek gratification and are ultimately related to preservation of the species; these are opposed by the ego drive, which seeks to preserve the existence of the individual by curbing the biological drives, when necessary. The term refers to sexual energies, although they have different meanings and manifestations at different ages.

Freud proposed a developmental sequence of the libidinal drives. The oral phase extends from birth to about the middle of the second year. One of the earliest analysts, Karl Abraham (1924), observed that people whose oral needs were excessively frustrated turned out to be pessimists, whereas those whose oral desires had been gratified tended to be more optimistic. The oral phase is followed by the anal phase. A child may react to frustrations during that phase by becoming stubborn or contrary. Through formation the child may overcome the impulse to soil by becoming meticulously clean, excessively punctual, and quite parsimonious in handling possessions.

Somewhat later (ages 3 1/2 to 6), the child enters the phallic phase. In this stage, children become curious about sexual differences and the origin of life, and they may fashion their own answers to these important questions. They enjoy a sense of power and can idealize others. By this time, complex fantasies, including Oedipal fantasies, have begun to form in the n1ind of the child.

Today’s child may still come home from nursery school saying he wants to marry his teacher. Freud’s theories have allowed the culture to be relaxed about such statements, and the vast differences in the meaning of such feelings to a child and to an adult are better understood.

These early psychosexual phases are followed by a period of latency, from the age of 6 to the onset of puberty. Then, under the influence of the biological changes of puberty, a period of turbulence and readjustment sets in, and when development is healthy, this period culminates in the achievement of adequate mastery over drives, leading to adaptation, sexual and moral identity, and attachment to significant others.

 

On Narcissism (1914)

The next phase in the development of Freud’s concepts focused on his investigation into the psychology of the psychoses, group formation, and love—-for one’s self, one’s children, and significant others. He found that some individuals led lives dominated by the pursuit of self-esteem and grandiosity. These same factors seemed to operate in the relationship of an individual to the person with whom he or she was in love. The beloved was aggrandized and endowed with superlative qualities, and separation from the beloved was seen as a catastrophic blow to self-esteem. These observations on narcissism remain relevant to more recent attention to the narcissistic personality disorder.

 

The Ego and the Id (1923)

Having recognized that in the course of psychic conflict, conscience may operate at conscious and/or unconscious levels, and that even the methods by which the mind protects itself from anxiety may be unconscious, Freud reformulated his theory in terms of a structural organization of the mind. Mental functions were grouped according to the role they played in conflict. Freud named the three major subdivisions the ego, the id, and the superego.

ラックがGoogleグループによる意図しない情報公開に注意喚起、具体的な対策手順を例示

情報セキュリティベンダーのラックは2013年7月10日、米グーグルが提供している無償版のニュース投稿・共有サービス「Googleグループ」で、意図しない情報公開が行われている現状が企業にとってセキュリティリスクになるとして注意喚起を行った。

　「Googleグループ」は、サービスの利用登録をした初期状態では、すべての情報がインターネットに公開される設定となっている。グループ内のメンバーだけで外部に公開したくない情報の共有に利用するには、閲覧範囲を正しく設定する必要がある。

　ラックが調査したところ、同サービスを使用している組織で、情報が意図せず「公開」に至っているケースが多数確認されたという。この事象が深刻なリスクにつながっていると判断し注意を喚起するとともに、「Googleグループ」の画面を例示するなどして具体的な対策方法を提示している（写真）。

　同問題は7月10日に一部新聞が、環境省など中央官庁の内部情報などが、「Googleグループ」で誰でも閲覧できる状態になっていると報道し、顕在化していた。

http://www.lac.co.jp/security/alert/2013/07/10_alert_01.html

症例報告の意義

採録

「対照との有意差を出すために、やむを得ず大規模にせざるを得なかった。それが大規模試験の本質です」

　これは2002年、金沢で開催されたEBMワークショップでの名郷直樹先生（現・武蔵国分寺公園クリニック院長）の言葉です。初めてお目にかかった名郷先生のこの言葉は、私が持っていた大規模試験信奉を吹き飛ばしてくれました。そして翌年、私が「日本の臨床研究の底上げをする人材育成のため」と大見得を切って、臨床現場を離れて厚生労働省（後にPMDA：医薬品医療機器総合機構）に転じた後も、新薬審査業務の書類の山の中で、名郷先生の名言の行間に隠されたメッセージを学び取ることになったのです。

症例報告こそが原点

　本格的な臨床研究というと、多くの人は大規模試験を思い浮かべます。しかし、厚労省・PMDAでの新薬審査は、何千例ものランダム化比較試験とて、一つ一つの症例の積み重ねに過ぎないことを教えてくれました。

　大規模試験が個々の症例の積み重ねであるならば、臨床研究の原点は目の前の患者の研究、つまり症例報告に他なりません。そう言っているのは何も私だけではありません。多くの先達が症例報告の大切さを説いています1)。New England Journal of Medicine（NEJM）の一番の売り物が、Case Records of the Massachusetts General Hospitalであることは、本ブログの読者の誰しもが認めるところでしょう。しかし、国内ばかりでなく、海外でも非常に多くの医師が、「今時、症例報告を受け取ってくれる雑誌などない」と、素朴な勘違いをしているようです。

大規模試験偏重から症例報告誌の増加へ

　かつて、ページ数もインターネットのサーバー容量も制約が厳しかった時代、NEJMやLancetのような商業誌（！）を筆頭に、多くの雑誌が市場性を考え、広範な読者層に強い訴求力を持つ（と出版社が信じていた）大規模試験の論文を優先して掲載し、症例報告を受け付けなくなったことは事実です。

　ですが時代は変わり、今や紙媒体のみの医学雑誌などありません。サーバーの容量も実質上制約がなくなりました。インターネット上で、かつサーバーの容量が問題にならないならば、広い読者層への訴求力よりも、学問的な価値が重視される可能性が高くなります。

　さらには図書館の書庫に行かなければお目にかかれないような古い文献を除けば、オンラインでの論文検索も十分満足できる水準になりました。このような論文検索エンジンは、大規模試験論文も症例報告も同じ一つの論文として扱い、差別しません。そして今や熱心な臨床医ならば、大規模試験論文では到底カバーできない問題点を解決すべく、症例報告も検索しているのではないでしょうか。

　こうして、もともと臨床研究の原点だった症例報告は、IT技術の発展に伴い、新しい価値を得るようになったのです。症例報告の需要や価値は今後拡大することはあっても、縮小することは決してありません。

　それに伴い、医学系の出版事業も変わり、症例報告誌が雨後の竹の子のように登場しています(表)。新規参入のオンラインジャーナルの多くは、既存の雑誌との差別化のため、数百ドルから千数百ドル程度の投稿料を著者から取る一方、誰もが無料でPDFをダウンロードできるオープンジャーナルにして、引用数を増やし、インパクトファクターを稼いで良質な論文を呼び込むというビジネスモデルを取っているようです。

表　症例報告専門誌の例

Internal Medicine　 （http://www.jstage.jst.go.jp/browse/internalmedicine） 

General Medicine　 （http://www.jstage.jst.go.jp/browse/general/-char/ja） 

BMJ Case Reports　 （http://casereports.bmj.com/） 

Journal of Medical Case Reports （http://www.jmedicalcasereports.com/） 

Journal of Medical Cases （http://www.journalmc.org/index.php/JMC） 

Journal of Radiology Case Reports（http://www.radiologycases.com/index.php/radiologycases） 

International Journal of Case Reports and Images（http://www.ijcasereportsandimages.com/）

　そのような背景で雑誌を創刊する際、大規模試験論文も症例報告も掲載コストは大差ありませんから、多くの医師にとって敷居の低い症例報告に特化した方が有利だと考えても不思議はありません。

症例報告にこだわる意義

　もちろん、いくらインパクトファクターが稼げるといっても、症例報告は教授の椅子や大型研究費を手に入れるには余りにも非効率的な手段です。私もポストや科研費のために症例報告を書いてきたのではありません。

　私が若い頃からこつこつ書いてきた症例報告には、どれにも患者さんと私の両者の思いがこもっています。中でも、私が最も誇りとしているのは、周囲の人々に「臨床を離れた」と言われていた厚労省時代に、単名で執筆してLancetに掲載された筋萎縮性側索硬化症の患者さんについての症例報告です2)。また、つい最近も単名で症例報告を書きました。仙台の筋弛緩剤「事件」における誤診を明らかにしたこの論文3)の目的が、学部長や病院長の椅子ではないのは誰の目にも明らかでしょう。

　臨床を大切にする医師は、症例報告の大切さを身に染みて感じています。幸い、いつでも誰でもどこでも効率よく文献が検索できる時代になりました。あなたの貴重な経験を待っている人が地球上のどこかに必ずいるのです。あなたには、患者さんが教えてくれたことを、国境を越えて共有財産にする使命があるのです。

<参考文献>

1) Vandenbroucke JP. In Defense of case reports and case series. Ann Intern Med 2001;134:330-334

2) Ikeda M. Family bias by proxy. Lancet 2005;365:187

3) Ikeda M. Fulminant form of mitochondrial myopathy, encephalopathy, lactic acidosis, and stroke-like episodes: A diagnostic challenge. J Med Cases 2011;2:87-90.

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
なるほど
こうして説明されると症例報告の新しい意義が明確になる

涙を流した分だけ幸せになりなさい

涙を流した分だけ幸せになりなさい
と
ドラマで言っていた

私としてはもうすでに人生から充分なだけいただいたと思う

幸運の女神は、準備された心にのみ宿る

幸運の女神は、準備された心にのみ宿る
パスツール 

“ 多くの人は、予定や目標は立てるが、その中に、スランプ、やめたくなる衝動などを予定しない。 それらも組み込むのが賢者である。 ”

“

多くの人は、予定や目標は立てるが、その中に、スランプ、やめたくなる衝動などを予定しない。

それらも組み込むのが賢者である。

”

“ 山奥に引きこもり、たった一人で朽ち果てようとも、そこに死は起こりません。まさに死ぬとき、死ぬ本人は何が起きているのか、決して知ることはできません。そして、誰にも知られることのない者の死は、ただの「行方不明」でしょう。 我々の死、すなわち「私であること」の終わりは、まさに誕生同様、他者との縁の中で遂げられることなのです。 ”

“

山奥に引きこもり、たった一人で朽ち果てようとも、そこに死は起こりません。まさに死ぬとき、死ぬ本人は何が起きているのか、決して知ることはできません。そして、誰にも知られることのない者の死は、ただの「行方不明」でしょう。

　我々の死、すなわち「私であること」の終わりは、まさに誕生同様、他者との縁の中で遂げられることなのです。

”

“強運になるには、強運に見えることが大事、と著者の前田さんは教えてくれている。 そのための秘訣はシンプルだ。 「運が悪かったことは人に話さないで、運が良かったことは三倍にして話すこと」 それだけである。 だれでも運の悪い人のそばには行きたくない。 逆に運がいいことばかり話している人のところには人が集まってくる。 人が集まれば情報が集まってくる。 そして情報が集まれば運も集まってくるのだ。 そうして自分を強運環境におくことが重要なのだ。”

“強運になるには、強運に見えることが大事、と著者の前田さんは教えてくれている。

そのための秘訣はシンプルだ。

「運が悪かったことは人に話さないで、運が良かったことは三倍にして話すこと」

それだけである。

だれでも運の悪い人のそばには行きたくない。

逆に運がいいことばかり話している人のところには人が集まってくる。

人が集まれば情報が集まってくる。

そして情報が集まれば運も集まってくるのだ。

そうして自分を強運環境におくことが重要なのだ。”

人の思いは所詮、記憶の奴隷（「ハムレット」）

人の思いは所詮、記憶の奴隷（「ハムレット」）

双極性障害とADHDは密接に関連

双極性障害は合併症を有する割合が高いことが報告されている。なかでもADHDでみられる多弁、注意欠陥、多動性などの症状が、双極性障害の症状と高率にオーバーラップしていることから、双極性障害とADHDの関連に注目が集まっている。トルコ・チャナッカレ・オンセキズ・マルト大学のElif Karaahmet氏らは、双極性障害における注意欠陥・多動性障害（ADHD）の合併頻度、ならびにADHD合併の有無による双極性障害の臨床的特徴の相違について検討した。その結果、双極性障害患者の約23％にADHDの合併が認められたこと、ADHD合併例では双極性障害の発症年齢が低く、躁病エピソードの回数が多くみられたことを報告した。Comprehensive Psychiatry誌オンライン版2013年1月7日号の掲載報告。

　本研究では、双極性障害におけるADHDの合併頻度、ならびにADHD合併患者の臨床的特徴を明らかにすることを目的に検討を行った。2008年8月1日から2009年6月30日までにゾングルダク・カラエルマス大学Research and Application病院の双極性障害ユニットを訪れ、DSM-IV 分類により双極性障害と診断された患者は142例であった。同意書にサインした118例のうち、試験を完了した90例を評価対象とした。試験に参加した全患者に、社会人口統計学評価票である「ウェンダー・ユタ評価尺度（Wender Utah Rating Scale；WURS）」、「成人ADD/ADHD Diagnostic and Evaluation Inventory」および「DSM-IV 第 I 軸障害構造化面接（Structural Clinical Interview for DSM-IV Axis I Disorders, Clinical Version；SCID-I）」を施行し、評価した。

　主な結果は以下のとおり。

・双極性障害患者の23.3％に成人ADHDが認められた。

・成人ADHD合併の有無で、双極性障害患者の社会人口統計学的特性に相違はみられなかった。

・成人ADHD合併患者は、成人ADHD非合併患者に比べて最低1年間留年している者が多く、その差は統計学的に有意であった。

・成人ADHD合併群は、成人ADHD非合併群と比べて双極性障害発症年齢が有意に低く（p=0.044）、躁病エピソードの回数がより多かった（p=0.026）。

・成人ADHD合併群ではパニック障害（p=0.019）が、小児ADHD合併群では強迫性障害（p=0.001）が最も高頻度にみられた。

・双極性障害において成人ADHDは頻度の高い合併症であり、双極性障害の早期発症、多い躁病エピソード、Axis Iに分類されることなどと関連していた。

“養命酒。その原酒は、もち米100%の「みりん」です。”

“養命酒。その原酒は、もち米100%の「みりん」です。”

ーーー
みりんに漢方を混ぜて、宣伝効果で症状を軽減するというのは実に理想的ではないか。
副作用なんて出るはずがないし
思い込みに対して新しい思い込みを作って対処しようという戦略である

“サラリーマンを楽しむコツはいつ首になってもいいと思うこと。恋愛を楽しむコツはなるにようにしかならないことを自覚すること。そして自分でコントロールできるほんのわずかなことを真摯にがんばるのが長い人生を楽しむコツだと思う。”

“サラリーマンを楽しむコツはいつ首になってもいいと思うこと。恋愛を楽しむコツはなるにようにしかならないことを自覚すること。そして自分でコントロールできるほんのわずかなことを真摯にがんばるのが長い人生を楽しむコツだと思う。”