Noter til pensum – Klinisk forelæsninger KA 1 – Introduktion til klinisk psykologi som praksisdisciplin • Elsass & Lauritsen (2006): Humanistisk sundhedsforskning, Videnskabsteori

I kapitels første halvdele diskuteres der humanistiske forsknings videnskabelighed, og hvor vidt det bør udføres efter naturvidenskabelige standarder eller udvikle egne standarder.

• En historiske gennemgang af forskellige videnskabsteoretiske retninger

I kapitels anden del rettes fokus mod 2 aktuelle perspektiver som stiller forskellige krav til god forskning.

• Naturalistisk forskningsperspektiv- forskeren kan løsrive sig fra situationen • Refleksivistisk forskningsperspektiv- forskeren kan ikke betragtes som adskilt

fra feltet som er undersøgt, han er en aktiv deltager. Undersøgelsesfelt konstrueres i forskningsprocessen.

• Fokus er lagt på teknologiens rolle inden for sundhedsområdet

• Hougaard (2004): Psykoterapi: Teori og Forskning, Terapeutiske Skoledannelser

En god overblik over de forskellige terapeutiske skoledannelser:

1) Psykoanalytisk/psykodynamisk – • Freud skelnede mellem 3 psykiske instanser: det’et, jeget, og overjeget • Personlighedens udvikling grundlægges i barndommen, hvor barnet

gennemlever en række psykoseksuelle faser og relationelle stadier i forhold til de primære omsorgspersoner.

• Forsvarsmekanismer er ubevidste strategier for at undgå at komme i kontakt med angstfremkaldende stimuli, især tanker og følelser.

• Psykopatologi i voksenalderen antages at have rod i ubevidste konflikter der kan spores tilbage til traumatiske barndomsoplevelser.

• Det centrale terapeutiske mål i den klassiske psykoanalyse er bevidstgørelsen af ubevidste driftstilskyndelser, forsvarsmekanismer, og barndomserindringer og en større opnået selverkendelse.

2) Oplevelsesorienteret/humanistisk • Emotionsfokuserede terapiformer med rod i humanistisk-eksistentialistisk

teoridannelse. • Inkluderer Rogers’ klient-centerede terapi, gestaltterapien, også katarsis-

eller emotionsterapier og forskellige former for kropsterapi.

• Kendetegne for disse terapier er: et optimistisk menneskebillede, terapeutens holdning af kongruens/ægthed, ubetinget accept og empatisk forståelse.

3) Adfærdsterapi • Stimulus-respons, exposure therapy, nu inddrager kognitive perspektiver.

4) Kognitivterapi • Emotioner og adfærd er en følge af personens fortolkning af særlige

begivenheder • Der arbejdes med forskellige niveauer 1) kognitiv struktur (organisering af

info i hukommelsen) 2) kognitiv indhold (det indhold der er lagret). De to niveauer til sammen udgør skemaer. 3) kognitive operationer (de processer hvormed personen indkoder, lagrer og genkalder info) og 4) kognitive produkter (de bevidste forestillinger, tanker, eller følelser der er resultatet)

• Centrale negative skemata antages at været dannet i barndommen. • Målet er kognitiv omstrukturering, ændringen af negative kognitioner.

5) System-/kommunikations-orienteret terapi • Systemterapi opfatter familien som et selvregulerende kybernetisk system

som gennem negativ feedback søger at bevare status quo i form af stabile og i tilfælde af psykopatologi uhensigtsmæssige relationer.

• (i en konstruktivistisk forståelsesramme) Terapeuten skal hverken diagnosticere eller intervenere i systemets interaktion, men derimod bidrage til at der skabes ny, mere hensigtsmæssig mening i en åben dialogisk proces, som ikke er præget af terapeutens bedreviden.

• Mirdal (2001) Om oplevelsen af andres lidelser ”Diagnoser er arbejdshypoteser, og ikke egenskaber hos patienten” Østergaard 1992 En beskrivelse af transkulturel klinisk psykologi og synet på sygdomsbegrebet mht. andre kulturer. Diskussionen om ’de tyrkiske kvinder’ og sociosomatiske sygdomme. • Mayou et al (2005) Somatoform disorders: time for a new approach in DSM-V Der fremlægges et forslag om at fjerne kategorien ‘somatoform disorders’ fra DSM og en forklaring om de nuværende problemer med DSM-III. Kritik af diagnoser: 1) Der er ofte ikke tale om distinkte sygdomme

• Systems of classification make unjustified categorical distinctions between disorders, and between normal and abnormal.

2) Konteksten tages ikke i betragtning • Symptom-based diagnostic criteria fail to adequately take into account the

context in which a person is living, and whether there is real internal disorder or a simple response to an ongoing situation.

3) I bund og grund er alle diagnostiske systemer dualistiske

• Alle teorier og klassifikationer har forståelse for at krop og psyke hænger sammen og påvirker hinanden, men alle diagnostiske klassifikationer splitter krop og sjæl ad.

4) Diagnostiske systemer afspejler moralske og politiske holdninger • Mange diagnoser afspejler politiske og moralske holdninger frem for

videnskabeligt veldefineret begreber. (fx gender identity disorder, culture bound syndromes)

Alle i Denmark skal kende til DSM selv det danske kliniske psykologi ikke har taget det til sig. WHO’s ICD-10 er den officielle i Danmark, men DSM har stadig store indflydelse. (alle engelsksprogede lærebøger, mange forsknings måleinstrumenter, tidsskrifter, og den har præget synet på psykopatologi i den vestlige verden.) Shortcomings of Somatoform Category

1. The terminology is unacceptable to patients. 2. The category is inherently dualistic 3. Somatoform disorders do not form a coherent category. 4. Somatoform disorders are incompatible with other cultures 5. There is ambiguity in the stated exclusion criteria 6. The subcategories are unreliable 7. Somatoform disorders lack clearly defined thresholds. 8. They cause confusion in disputes over medical-legal and insurance entitlements.

2 – Børns psykiske vanskeligheder i et udviklingspsykopatologisk perspektiv • Slade (2005) Parental reflective functioning: An Introduction A discussion of ‘reflective functioning’ – the capacity to understand behavior in light of underlying mental states and intentions – is presented. (Fonagy) The use of this understanding or function Fonagy called mentalisation. This function allows us to engage in productive, intimate and sustaining relationships and feel connected to others, but also to feel autonomous and separate of minds. Using the AAI (Adult Attachment Interview) Fonagy was able to show a link between RF ratings and attachment states of both the adults and their children. Fonagy also documented that RF mediated the relation between early trauma and later psychopathology. The importance of ‘parental reflective functioning’ is discussed referring to the parent’s capacity to hold the child’s mental states in mind. Through the mother’s capacity to hold in her mind a representation of her child as having feelings, desires, and intentions, the child begins to discover his own internal experience via his mother’s representation of it. This in brought about through parental affect mirroring (‘marked’).

When this mirroring is chronically misattuned, the infant is forced to internalize the representation of the object’s (parent’s) state of mind as a core part of himself. This is required for the infant to survive emotionally – to keep the relationship he so desperately needs going. When the parents mind is too terrifying to take on or if mirroring is altogether absent, the child experience his inner life as fragmented and empty, and fails to be able to develop sustainable nurturing relationships with others. In order to find a way to measure reflective processes within the context of the parent-child relationship, Slade et al used the PDI (Parental Development Interview) and an adaptation of the relective function scale (Fonagy) to score RF. • Beebe et al (2005) An expanded view of forms of intersubjectivity in infancy and

their application to psychoanalysis

• Fokus på både barnets og moderens bidrag i interaktionen: En bi-direktionel udviklingsforståelse, der fokuserer på den rytmiske koordination i non-verbal præ-refleksiv kommunikation, dvs affektiv afstemning foregår ikke kun som markeret spejling, men som koordination også af fx kropslige tidsmæssige rytmer.

• Et dyadisk system = Interaktiv co- regulation, dvs selv- og anden regulation er gensidigt afhængige

• Intersubjektivitet = En fælles og delt oplevelse af to subjekter, en psykologisk

intimitet.

• Foregår ofte på et implicit og præ-refleksivt non-verbalt oplevelsesniveau, der baserer sig på blandt andet kropslig adfærd i form af ansigtsudtryk, gestus og position, tone og styrke i stemmen og konteksten for adfærden (jvnf også fundet af mirror-neurons)

• Som Beebe et al bygger sine undersøgelser og teori på Tronicks MRM model ser

de intersubjektivitet som en dyadisk bevidstheds-tilstand, der opstår i og med en gensidig co-regulation: ”Mutual Regulation Model” (MRM).

• Barnet antages medfødt at være aktivt og motiveret til at kommunikere og til at etablere intersubjektive tilstande. Disse er dog ikke tilstande, der udelukkende er synkrone interaktionsmønstre.

• Tværtimod er det afgørende, at de består af både ”disruption” og ”repair”, og at den fælles oplevelse således er en ”forhandlet vi-mening” (ca 1/3 af tiden)

• Undersøgt ved Face-to-face-still-face paradigmet

• Et middel niveau af bi-direktionel koordination er relateret til sikker tilknytning, mens for høj eller for lav grad af koordination er forbundet med usikker tilknytning.

• Disruption and repair: De forhandlede vi-meninger giver barnet en oplevelse af egen handlekraft (agency).

It explores the theories about intersubjectivity in infancy and how they can be used in treatment of adults within psychoanalysis They begin by outlining two key ideas important for psychoanalysis that the three infancy theorists Meltzoff, Trevarthen, and Stern share: 1) the dialogic origin of mind – that the mind begins as a shared mind. The organization of experience beginning as dyadic and dialogic, has large impacts for psychoanalysis, which has often conceptualized the origin of mind within a one-person isolated model. This dyadic origin of mind has much in common with Balint’s primary love object or Bowlby’s attachment model, as well as Bakhtin who argued that nonverbal communication can be dialogical. 2) the power of correspondences– correspondences, matching, and similarities are a powerful and fundamental aspect of preverbal communication. The understanding of correspondence and matching provides psychoanalysis with detailed ways of conceptualizing how each person senses the state and moment-by-moment process of the other, in the nonverbal and implicit realm. As far as I have understood, correspondences is matching communicative expressions through time, form and intensity, as Stern would call attunement and ‘changing with.’ Trevarthen One of the most important contributions of the infant theorists of intersubjectivity is the description of prelinguistic origins of communicative competence. Trevarthen: “Linguistic forms of intersubjectivity have their foundation in prelinguistic forms; that intersubjectivity is initially preverbal and dialogical. Trevarthen proposes that coupling of rhythms is the key mechanism explaining how matching of communicative expression works. Coupling of rhythms is now used as an important organizing principle in psychoanalytic communication. Stern He expanded the concept of matching which he called ‘changing with’ into a ‘process’ model. He critiques the model of matching as imitation; it is a two-way communicative process. He describes ‘changing with’ as “Dynamic micro-momentary shifts in intensity over time that are perceived as patterned changes within ourselves and others” that allow us automatically and without awareness, to ‘change with’ the other, to ‘feel-what-has-been-perceived-in-the-other’. Stern’s concept of affect attunement is often misunderstood in psychoanalytic discussions and used synonymously with empathy. Beebe et al develop a fourth position on the meanings of forms of intersubjectivity in infancy, including differences as well as similarities in the interactions. They emphasize the complexity of these early interactions, and say that matching or correspondence can

be both optimal and nonoptimal for the exchange. There are both usual and disjunctive forms of difference, and the usual differences are a healthy part of the ongoing exchange. Contigency- Beebe et al expand on the concept of interpersonal contingencies: each partner is contigent on the other and ‘influences’ the other moment-by-moment. They show that matching doesn’t qualify as an analysis of interactive process without explicit documentation of contingencies. Matching doesn’t imply contingency, and contingency can occur without matching. • Rutter & Sroufe (2000) Developmental psychopathology: Concepts and

challenges It starts with an intro to the developmental view on psychopathology, the history and emergence of this thinking. The defining features of developmental psychopathology concepts include

1) attention to the understanding of causal processes • One of the most important messages of genetic research has been that

genetic influences are probabilistic and not deterministic, and that environmental factors are broadly speaking of roughly equal importance.

• An understanding of causal processes requires knowledge about how risk and protective mechanisms operate.

• Nature and nurture are not neatly separable, it can be difficult to pinpoint a cause or to partition the population variance based on individual differences. Often disorders occur in phases and the factors that influence each phase can be different. (direct and indirect effects)

2) appreciation of the role of developmental mechanisms • Sroufe & Rutter argue that it is possible to understand complex links

between early adaptation and later disorder only through detailed appreciation of the developmental process itself.

• There are well-documented age-dependent differences in vulnerability to particular kinds of experiences. So the developmental process plays a role.

3) consideration of continuities and discontinuities between normality and psychopathology

It then explains the accomplishments of developmental psychopathology in the areas of attachment disorder, antisocial behavior (incl. ADHD), autism, depressive disorder, schizophrenia, and intellectual development. Finally the challenges remaining for developmental psychopathology include:

• Measurement issues – poor agreement between parents, teachers, and children • Comorbidity – it is crucial to determine the meanings of comorbidity, because its

can distort the meaning of findings. (e.g. One could actually be a risk factor for the development of another.)

• Gender difference – why certain conditions are more prevalent among boys/girls.

• Cognitive processing – in some disorders such as autism the underlying problems seems to be cognitive deficits, while in other disorders seem to be characterized by unusual styles of cognitive processing rather than deficits (e.g. affective disorders). In cases such as ADHD, it remains uncertain.

• Nature-nurture interplay • Heterotypic continuity – showing that one behaviour follows another in

development is not enough to prove heterotypic continuity, more has to be done • Continuitites and discontinuities between normal variations and disorder • Developmental programming • Therapeutic mechanisms in treatment

• Sameroff (2000) Developmental systems and psychopathology The developmental view of psychopathology is causing changes in our view on pathology, individual development and social context.

• The blurring of the division between mental illness and mental health • The need to attend to patterns of adaptation rather than personality traits • The powerful influences of the social world on individual development

Progress in the study of developmental psychopathology has resulted from a set of irresolvable dialectical contradictions

• Labels/diagnoses/categories and the dynamic reality • Mental disorders and mental health (aspects of health in illness and illness

in health) • In the term ‘developmental psychopathology’ – by using a developmental

approach we may find that the ‘disease’ disappears when understood as one of many adaptational processes between an individual and life experience.

Developmental views place deviancy in the dynamic relation between individuals and their social contexts. Operational definitions and categorizing different disorders cause problems in that they reduce behavior to trait-like characteristics. However, seeing deviancy as a pattern of adaptation makes the process more complicated to understand, as when the situation and context changes, the individual changes. In the Rochester Longitudinal Study (RLS) it was shown that social circumstances were a more powerful risk factor than any of the parental mental illness measures. It also seemed that it may be quantity rather than quality of risk factors this is most predictive, as no single influence is enough to produce disorder.

It is also important to remember that the majority of children in every social class are not failures, pointing out the importance of protective factors, or promotive (befordrende) factors. An attempt is made to conceptualize the environment, in a model showing how environtype, genotype, and phenotype change and affect each other over time. The principles of development that apply to achievement of healthy growth can be seen as the same ones that apply to achievement of illness. Most illnesses are achievements of the active striving of an individual to reach an adaptive relation to its environment. The discussion of developmental psychopathology can be summarized in 3 aspects:

• An adaptational process • A linkage between constitution and experience • A linkage across time (contains the basis for continuities and discontinuities)

• Sroufe (1997) Psychopathology as an outcome of development The problems of the classical medical model are presented and a developmental model proposed. Childhood behavioral and emotional problems are often viewed as an endogenous disease; however within the developmental perspective maladaptation is viewed as a complex result of risk and protective factors operating over time. From a developmental point of view behaviour is not simply the interaction of genes and environment, but genes, environment, and the history of adaptation to that point. Bowlby’s developmental pathways concept is presented (the tree). 5 major implications of this model:

1) Disorder as deviation over time 2) Multiple pathways to similar manifest outcomes 3) Different outcomes of the same pathway 4) Change is possible at many points 5) Change is constrained by prior adaptation

Resilience is often seen as an internal trait within the child, however from a developmental viewpoint, resilience develops over time within the context of developmental influences. Comorbidity – gives the impression that the child has two disorders if the child’s problems cut across two categories, instead of questioning the entire system based on the medical model. Good sections on ADHD from a developmental perspective.

The importance of the developmental approach’s view of problems as adaptations is emphasized, and the view that the laws that govern normal development also governs the pathological.

3 – Voksnes psykiske vanskeligheder i et udviklingspsykopatologisk perspektiv Mange forskellige sygdomsmodeller,fx: • Degenerationsmodellen – en fejl i hjernen, kronisk, kan ikke kureres • Stress-sårbarhedsmodellen – genetisk sårbarhed, hvis stresset bliver patologi,

men indrager ikke beskyttelsesfaktorer, ser sårbarhed (kun genetisk) som ’cause’. • Neuroudviklingsmodellen – ikke kun genetisk, men kigger kun på fostrets

fysiologiske og neurologiske udvikling – skader og sygdomme. • Kognitive model – paradigmeskift fra diagnose til enkelte symptomer, de vinder

noget ved at få mere specificitet men mangler en integrativ teori • Psykodynamisk model – ser kun de psykiske ikke det biologiske, meget fokus på

interpersonelle og indre aspekter af personen. • Tilknytningsmodel – ikke enkelt symptomer, men samlet organisation:

tilknytningssystemet, det integrerer det kognitive, selvbilledet, interrelationelle • En narrativ model

• Bentall et al (2007) Prospects for a cognitive-developmental account of psychotic

experiences (kognitiv tilgang) The purpose of the article is to highlight the advantages of considering psychosis within the framework of mainstream developmental psychology. It shows limitations of the neurodevelopmental framework, which attributes the development of psychosis to neurological abnormalities in development. The neurodevelopmental framework argues that children destined to suffer from psychotic illness show developmental delays, clumsiness and abnormal affect even in infancy. They mean that the onset of psychosis in adolescence may be the consequence of an abnormal maturing process or ‘neurological time bomb’. Limitations of neurodevelopmental model:

1. The age of onset of psychosis – normal age is mid 20s after peak risk period 2. Problems with the static lesion model – most neurodevelopmental models are

insensitive to psychological change over the lifespan. They often see a single static lesion as the cause, but it is implausible that neurological damage can be insulated from developmental processes elsewhere in the system.

3. The non-specificity of neurodevelopmental impairments – these impairments may increase the risk that an individual may develop any kind of severe mental illness, as they are more general but they do not play a specific role in delusions and hallucinations. Emotion-related psychological processes are however more connected to positive symptoms.

The article suggests a psychological approach to positive symptoms, which has made progress in identifying specific cognitive and sociocognitive abnormalities which might lead to these symptoms. They emphasize the role of the social environment in psychosis, and explain how most neurodevelopmental models fail to acknowledge that role, although the evidence for environmental influences is at least as strong as for neurodevelopmental impairment. Two findings suggest that psychosis may require a combination of adverse circumstances and biological vulnerability. However there are often torturous biological arguments given to explain the environmental or familial aspects, totally overlooking more obvious psychological interpretation. They promote a developmental psychology framework, which attempts to understand the development of psychotic symptoms within the wider context of theories of normal psychological development. • Developmental origins of paranoid attributional style – children often model

attributional styles of their parents. • Theory-of-mind deficits have been found to be connected to some psychotic

symptoms. The development of ToM skills is influenced by the quality of the parent-child relationship and maternal mind-mindedness. This could suggest that the intergenerational transmission of psychosis could partially be due to differences in parental mind-mindedness, instead of being entirely genetic.

• Findings show correlations that suggest that differences in children’s vulnerability to hallucination-like experiences may reflect subtle source monitoring deficits, which again could be related with ToM deficits.

• 3 hypotheses are raised in order to explain the connection between hallucinations and trauma. These are also closely tied to source monitoring deficits which can be intensified through trauma.

This focus on the role of the social environment does not mean one should take no account of biological factors. This perspective may lead to a better understanding of the role of biological abnormalities is psychosis.

• Neurocognitive deficits have shown to be poorly associated with positive symptoms, but predict poor social functioning. These deficits could confer vulnerability because the individual is ill-equipped to cope with social stress. This would also explain the onset of symptoms in adolescence, where there are large developmental challenges primarily of a social nature.

• A developmental perspective may also cast light on the connection between genes and psychosis. By including the interaction between genes and the environment, missing links could be discovered.

• Lenzenweger & Cicchetti (2005) Towards a developmental psychopathology

approach to borderline personality disorder Borderline: kerneområder for vanskeligheder

• Emotionel dysregulering • Interpersonel dysfunktion • Mentaliseringsevne nedsat • Identitetsforstyrrelser • Impulsivitet • Selvskadende adfærd • Udtalt aggressivitet og angst • Sociale og arbejdsmæssige vanskeligheder • Belaster omgivelser: familie, venner, kolleger.

Outlines how a developmental perspective is necessary to make progress in the understanding of BPD. It is important to look developmentally at precursors to BPD in the environment, attachment organization, trauma, genetics etc., as well as maintaining factors. Given the bidirectional interplay between biology and experience, researchers must move away from the thinking that the neuro-biological process is a singular cause of BPD. (There is a good paragraph about the interaction between gene expression and social experiences, supporting my BA- thesis). • Read & Gumley (2008) Can attachment theory help explain the relationship

between childhood adversity and psychosis? (tilknytnings-tilgang) Really good text about how attachment theory and recent experiments can explain a link between abuse, neglect, loss or a disorganized attachment pattern in childhood and the development of psychosis including schizophrenia. For decades the ‘medical model’ had dominated our efforts to understand human distress, using a simplistic reductionistic paradigm to condemn schizophrenia patients to the belief that they are suffering from an irreversible brain disease. However, most of the public has never accepted this illness model. Fears of ‘parental blaming’ have inhibited the exploration of the developmental and interpersonal roots of psychosis. Schizophrenia has long been regarded as a non-affective psychosis, reinforced by the neurodevelopmental models isolated from developmental models of interpersonal

functioning and affect regulation. Newer findings have begun to show that schizophrenia and other psychoses are fundamentally characterized by affect dysregulation. This account can be sustained in the framework of attachment theory. The psychosocial causes of schizophrenia (and most other mental health problems)

• Poverty, urban living, and ethnicity • Child abuse and neglect • Parental loss • Unwanted pregnancies • The attachment context of early development

Using the PBI (Parental Bonding Instrument) relationships between psychosis and specific parental-child bonding patterns have been revealed. Critiques of the findings of poor parenting being a causal factor, have suggested that psychosis negatively biases memory or that the harsher parenting styles were a reaction to ‘pre-morbid’ abnormalities. However, newer findings disprove these critiques. The 3 main patterns of attachment are secure, avoidant, and ambivalent/resistant. However a minority don’t fall into these categories, and are said to be disorganized, which is statistically linked to unresolved traumas, loss or hostile parental attitudes. There is increasing research linking insecure attachment to psychosis and schizophrenia Attachment theory has the potential to provide a useful theoretical framework for conceptualizing the influence of the 3 broad areas: social cognition (and mentalisation), affect dysregulation, and damaged interpersonal relationships on development and course of psychosis. Lots of good references to research, turns many long-believed theories on their heads. 4 – Den kliniske psykologiske udredning for børn og voksne Voksne -forelæsningsslides Mål for indsamling af information • Tentativ diagnostisk vurdering • Vurdering af personlighed:

• Personlighedsforstyrrelse? • Affektregulering – tilknytningsstil • Extraversion – introversion • Eksternalisering – internalisering

• Motivation / modstand • Psykologisk mindedness / mentalisering • Vurdering af sværhedsgrad:

• Symptomniveau

• Funktionsniveau • Caseformulering – inkl. forudsigelse af forløbet • Anbefaling af behandlingsform

• Beutler et al (2004) Use of Psychological Tests/Instruments for Treatment

Planning The purpose of this text is to provide an overview of the growing body of research that suggest that test performance may predict both treatment outcome and a differential response to available treatments. Beutler and Clarkin tried to bring some order to the many different models of treatment assignment by grouping the patient characteristics presented by different theories into 7 (8) different categories, which appear to be promising for use in treatment planning

1. Functional Impairment – in this case shown through reduced levels of functioning in self-care, social responsibility, relationships, etc. Evidence shows a neg. relation between functional impairment and treatment outcome. Medication is often recommended in severe cases.

2. Subjective Distress – often keeps patients engaged in treatment and often correlates positively with treatment success, but there are mixed results in somatic cases.

3. Problem Complexity – such as comorbidity and personality disorders, high problem complexity should favor psychosocial over pharmacological interventions and systemic/dynamic treatments over symptom-focused ones.

4. Readiness for Change – patients in the action stage fit best to CBT or symptom/action-oriented therapies, while contemplative patients benefit more from consciousness-raising or motivation-enhancement techniques.

5. Reactant/Resistance Tendencies – Highly resistant patients improved more with nondirective therapy, and mildly or low resistant patients responded better to directive treatment.

6. Social support – patients who have high subjective or objective social support tend not to respond well to long-term or intensive treatment, while patients who do not feel supported do.

7. Coping Style – externalizing patients respond better to cognitive-behavioral therapy and internalizing patients respond better to interpersonal insight-oriented therapy

8. Attachment style – secure attachment leads to more stable alliances in treatment, fearful-avoidant tend to have problems in the alliance, preoccupied – poor in middle and stronger later in alliance, and dismissive – deterioration of alliance toward the end. However dismissive patients may show greatest improvement.

They promote the STS – Systematic Treatment Selection as a good instrument (combining 6 of the 8 mentioned dimensions) to assist in treatment planning and patient assessment. Børn – forelæsningsslides Indhold af udredning Henvisning Anamnese Undersøgelser Observationer Interview Konklusioner Anbefalinger

Alt det her samles i en case formulering, som viser en helhedsforståelse at barnets styrker og svagheder i det miljø det lever i. Komponenter i en undersøgelse Adfærdsrelateret og følelsesmæssig

Herunder adfærd i testsituationen, vurdering af personlighedstræk Kognitiv og udviklingsrelateret

Både generelt og specifikke funktioner Omverdens relateret

Kontakt til undersøger og andre, kulturelle, sociale forhold. Medicinsk

Ved behov – f.eks. check hørelse før fonologiske vanskeligheder?! Undervisningsrelateret

Ved behov

• Sillesen (1999) Klinisk undersøgelse af børn Den kliniske undersøgelse består af anamnese-optagelse og klinisk observation. Henvisning

• det er ofte sundhedsplejersken, børnehaven eller skolen der oplever et problem og forældrene kan vægrer sig mod at barnet bliver henvist. Det er vigtigt ikke at presse undersøgelsen igennem. Forældres motivation er afgørende for the senere behandlingsforløb.

Indkaldelse • På de fleste afdelinger er der et tværfagligt team, som sammen gennemgår

henvisninger og planlægger hvordan undersøgelsen skal forløbe. Hvis mange, skal der være rollefordeling. Nogle gange kan det være godt hvis forældrene og evt. barnet også er med til planlægning.

• Mht. barnets og forældres situation kan man overvejer om man vil holde det første samtale på afdeling, hjemmebesøg, osv.

Anamneseoptagelse

• Første formål er at etablere kontakt, informere dem om hvad en undersøgelse vil bestå i, og sikre deres accept til at deltage.

• Man kan evt. gøre dem opmærksom på hvad man fik oplyst i henvisning, og spørge ind til hvilken forhåndsorientering de har fået og hvad de oplever som det største problem

• Vær ikke for styrende i starten og give forældrene mulighed for at tale om det der presser mest, så får man også et indtryk af deres tankegang.

• Som interviewteknik er en systematisk anamneseoptagelse tit det som giver flest og mest nuancerede oplysninger. For det fleste passer det bedst med en semistruktureret form hvor man følger en disposition med mulighed for uddybning.

• Ikke kun en samling af data – hvad er vigtigt for familien, hvordan reagere de til forskellige spørgsmål, er der modstand?

• Anamneseskema 1. Henvisningsårsag – er forældrenes opfattelse det samme? 2. Familiær disposition – sygdom i familien (kan være godt at vente med

denne indtil senere, kan være angstprovokerende). 3. Familieforhold – far og mors opvækstforhold, familiens vilkår,

indbyrdes forhold 4. Svangerskab, fødsel og neonatalperiode – 5. Barnets psykiske udvikling – motoriske, sproglige, kognitive, sociale,

og emotionelle undvikling i forskellige udviklingsperioder 6. Barnets somatiske udvikling – sygdomme, hospitalsindlæggelser 7. Institutioner – dagpleje, vuggestue, børnehave skoler 8. Fritid – interesser, forhold til jævnaldrende 9. Nuværende problemer – sympotomer og adfærdsforstyrrelser,

varighed, udløsende faktorer, forudgående undersøgelser og behandling. Forhold til forældre og søskende.

• Vigtigt også at beskrive hvilke områder barnet fungerer godt på – ressourcer Klinisk observation

• Kun igennem direkte observation kan man få indsigt ind til barnets egen oplevelse • Gennem samtale eller leg • Det drejer sig primært om at dæmpe barnets ængstelse, vinde dets tillid, og

etablere en kontakt. • Såvel store som små børn har behov for at vide hvad der skal ske. • Husk barnet har ikke ønsket at blive undersøgt. • Observationsskema

1. Udseende – påklædning, mimik, kropsholdning 2. Motorik – koordination, aktivitetsniveau, fin/grovmotorik 3. Sprog – sprogforståelse, talesprog, ordforråd, udtalevanskeligheder 4. Kognition – intelligens, opmærksomhed, koncentration, realitetssans,

opgaveløsning, indlevelsesevne 5. Fantasi – kreativitet, leg, forestillingsevner 6. Emotionelle forhold – temperament, stemningsleje, angst affektudbrud 7. Kontakt – blikkontakt, prøves grænser af, normal initial

forbeholdenhed

8. Indsigt i egen situation – selvvurdering, håb, ønsker om fremtiden 9. Forsvarsmekanismer – alderssvarende eller umodne 10. Resume af barnets stærke og svage sider

• Ud over observation af barnet er det nyttigt at observere familien, kontakten, kommunikationen, dynamikken

• Vær opmærksom på ens egen tilstedeværelse og hvordan det påvirker vedkommende.

Diagnostisk hypotese • Diagnostisk afklaring er forudsætning for at kunne lægge en behandlingsplan • Barnets tilstand skal ses ift. dets udviklingsforløb, personlighed og intelligens. • Vurdere om årsagerne er primært biologiske eller psykosociale, hvilke egenskaber

i barnet og omgivelserne medvirker, og hvilke ressourcer de har. • Aarkrog (1999) Klinisk undersøgelse af unge God kontakt – ikke alle har motivation, kontakt vigtigere end systemisk anamnese Forskellige interview former (måske ikke så relavant) • Thomsen (1999) Rating Scales og diagnostiske instrumenter Typer af diagnostiske instrumenter

- Diagnostiske interview o Det strukturerede interview o Det semistrukturerede interview

- Rating scales og checklister o Selvrapporteringsskemaer (man undgår ’intervieweffekten’ hvor barnet

ønsker at tilfredsstille intervieweren, men også usikker, man ved ikke om de har forstået spørgsmålet eller gætter bare. Med yngre børn sværere at bruge – vigtigt at samle ind fra andre kilder (lærer, forældre)

Interviews og rating scales kan dele op i generelle screenings-instrumenter og diagnosespecifikke instrumenter.

• Fleischer (1999) Neuropsykologisk undersøgelse Neuropsykologiske undersøgelser bruges for at undersøge de kognitive funktioner af børn med kendt eller formodet hjerneskade. Med børn er det vigtigt at neuropsykologiske undersøgelser omfatter både testning of informationshentning/observation af barnets adfærd i naturlige sammenhæng. Testning er ikke tilstrækkelig for at undersøge sociale færdigheder, osv. Man vil ofte starte med en generel afdækning af barnets kognitive udvikling med et bredt test batteri. (Wechslers fx)

Efter vil må gå videre med mere specifikke tests, der giver mulighed for en nærmere analyse af afgrænsende funktioner. Neuropsykologiske undersøgelser er forskellige fra traditionel intelligenstestning ved at de lægger lige meget vægt på proces og produkt. Man interesserer sig for barnets arbejdsmåde og strategi, og psykologen går ind aktiv som samarbejdspartner og ændrer instruktion efter barnets behov. Et kognitivt hierarki (de kognitive hovedområderne kan stilles op hierarkisk, således at der er en vis logik i rækkefølgen af undersøgelsen)

o Motorik o Vågenhed o Opmærksomhed o Sprog o Hukommelse o Visuomotorisk konstruktion o Højere kognitive funktioner o Social kognition

• Mortensen (1999) Personlighedsprøver og projektive test

- Personlighedsprøver, hvor af mange kaldes projektive tests, har til formål at belyse barnets personlighed

- Fordelene ift. samtaler el. observation er at de går under overfladen og kan give en dybere forståelse. Standardisering af prøverne giver den fordel at man har et sammenligningsgrundlag.

- Projektive tests er næsten alle baseret på psykoanalytisk teori - Man kan få indsigt i både tanke- og fantasiindholdet hos barnet og også

personlighedsstrukturen og udviklingsniveauet - De enkelte resultater kan kun forstås i lyset af helheden, og der er ingen

rigtige/forkerte svar - Forskellige typer

o Rorschachtesten o Tegning o Tematiske billedtest o Prøver med legemateriale (minatureverden)

Undervisningsgang 5 • Chethik (2000) General characteristics of the child patient It outlines five major issues that make working with a child patient different than an adult, using the example of Mark.

1. The fluctuating state of the child’s ego –

o Children’s egos are more fluid than adults’; constantly shifting and regressing. Their expression of the unconscious is less logical and more primal; acting out dominates in most cases, and their pleasures and anxieties are lived out through action and play.

o Children are seldom motivated to attend therapy, can often be scared of the therapist and situation. They do not have self-observation capacities and tend to externalize problems, as a way of escaping anxiety and pain.

2. The child’s need for action: the function of play o Unlike adult therapy which is mainly based on verbalization, children are

still developing their thinking functions and capacity for symbol formation, therefore children naturally develop their affective world and express it through active and partly verbal play.

3. The child’s state of dependency: the role of parents o the need of love and approval from their parents is key to a child’s

development; therefore work with the parents is a central aspect of child therapy and can often determine the success or failure of the work.

4. The child’s developmental process: the need for growth o Rather than only working on the conflicts which have brought the child to

therapy, the therapist must also be aware and deal with the stresses of normal development as the child grows and passes through developmental stages.

5. The counterreactions to the child patient: the therapist’s internal reactions o Working with children often brings up strong internal reactions within the

therapist. The child’s acting out can provoke anger and bewilderment in the therapist, which can later lead to guilt for these feelings.

o The fact that the child is so dependent of his parents and family can bring up feelings of helplessness. These can bring on ‘rescue fantasies’ where the therapist wants to parent and protect the child from the ‘bad’ parents

o It can be helpful for the therapist to distinguish between these feelings and countertransference, and understand that these feelings, which can undermine treatment processes, are common and natural feelings when working with children.

• Fonagy (2000) Mentalisation and changing aims of child psychoanalysis It discusses which types of children are more suitable for psychoanalytic therapy It discusses how mentalisation is key to a child’s mental health, and that the security of attachment is the critical mediator. Suggestions are made as to how the therapist can help children with mentalising problems through play. They recommend a shift in analytic techniques for particularly disturbed or traumatized children from a conflict- and insight-oriented approach to a focused mentalisation-oriented approach.

• Lanyado (1999) Holding and letting go: some thoughts about the process of

ending therapy It parallels the processes of holding and letting go in a parent-child relationship and a therapist-child patient relationship, and describes some of the difficulties in ending a therapeutic relationship. • Bateman & Fonagy (2006) Using the mentalization model to understand severe

personality disorder An attachment theory perspective on borderline personality disorder. It explains how disorganised attachment due to lack of marked contingent mirroring leads to a reduced mentalisation functioning. Instead of creating a representation of his own experience the child internalizes the image of his caregiver as part of his self-representation (the alien self). Mentalisation difficulties, externalizing behaviour (in order to reduce the experience of incoherence) and self harm (in order to get rid of the alien self) are characteristic of BPD. BPD can be understood using the mentalisation model. • Gabbard (2005) Major modalities: Psychoanalytic/psychodynamic A good overview of the differences between and developments within psychoanalysis and psychodynamic therapy. Good definitions of transference, resistance, countertransference, the unconscious. It outlines of Freud’s theory, Klein’s object relations theory, Kohut’s self psychology, Bowlby and Ainsworth’s attachement theory, and postmodern schools. It explains different treatment principles within psychodynamic treatment and explores research findings showing its effectiveness. Undervisningsgang 6 • Grave & Blissett (2004) Is cognitive behaviour therapy developmentally

appropriate for young children? The paper questions whether CBT is appropriate for young children and whether developmental considerations have been incorporated into the theory and practice of CBT.

From a Piagetian viewpoint children from 2-7 are in the preoperational or prelogical stage, where thinking is dominated by perception. From 7-12 they can use logical thinking about concrete concepts, and after 12 they can use abstract hypothetical thinking. Experiments have shown that preschool children can demonstrate logical thinking under specific circumstances, but otherwise have difficulties. Harter shows that children from 4-12 chose action over thought strategies to deal with negative emotions, and would therefore prefer therapeutic endeavors that are active and concrete rather than abstract and introspective. CBT does not have as clear developmental roots as psychoanalytic and nondirective therapies. One area of developmental theory that has influenced CBT is the role of language in mediating and controlling behaviour. SSM (self-statement modification) and SIT (self-instructional training) are included in a CBT package to help children with difficulties in self-regulation and control. Evidence is not clear about the efficacy of CBT with younger children. Children over 11 definitely benefit more, however younger children can still benefit especially if one uses creative means of applying the model in a developmentally sensitive way. The narrative paradigm developed from the shift to a more constructivist approach to understanding human experience, seems to be a good way to use CBT in a way that is accessible to children. (although untested yet) • Stallard (2002) Cognitive Behaviour Therapy with Children and Young People In order to explore the appropriateness of CBT with children it is important to look at some key issues including the developmental variations in children through different stages and the influences of their primary caretakers on their cognitive processes. It is important that developmentally appropriate theoretical models are created that highlight the onset and maintenance of maladaptive cognitive processes in children. The lack of such a framework has led to diverse interventions under the umbrella of CBT, with a more behavioural rather than cognitive focus. More research is needed to understand the cognitive processing in children, and which aspects of the current therapies are useful, in order to properly assess whether CBT is the treatment of choice for children, and for which problems. • Elsass & Lauritsen (in press) Klinisk psykologi og positive psykologi Positiv psykologi (PP) har til hensigt at udvide det fokus på lidelse og patologi, som findes i den kliniske psykologi (KP), med emner som velvære og sundhed.

KP vil forsvare sig mod at PP er en ny disciplin ved at påstå at KP også har beskæftiget sig med patienterne positive ressourcer. Selv om det ikke udgør en afgørende kvalitativ forskel, udgør PP stadig et perspektivskift for KP i form af interessen for spiritualitet og mindfulness. PPs opfattelse af sundhed er bedst beskrevet af det relative sundhedsbegreb (afhængig af individuelle og kulturelle forskelle), i modsætning til det essentialistiske- (klar grænse mellem normal og sygeligt) eller fundamentalistiske sundhedsbegreb (baseret på en værdisætning af sundhedsidealet). Mindfulness er en meget benyttet interventionsmetode og kobles ofte sammen med både spiritualitet og positiv psykologi. Der er mange eksempler på at positive emotioner kan være helbredende, men der er ikke så mange empiriske undersøgelser lavet der lever op til evidenskriterier især indenfor det kliniske population. Mindfulness og meditationspraksis kan deles op i koncentrationsmeditation og indsigtsmeditation som kan sammenlignes med støttende og indsigtsgivende psykodynamisk-terapi. Der diskuteres begreberne ’Ideal egoet’ (abstrakte ideer egoet har om sig selv som værende perfekt og komplet) og ’ego idealet’ (individets aspirationer afledt af det grrænseløse oplevelse af narcisistisk omnipotens) En balance mellem ego idealet og ideal egoet er vigtigt for en persons modning. En ubalance mellem de 2 meditationsformer kan også fremme psykopatologi. • Germer (2005) Mindfulness: what is it? What does it matter? It is a great overview about mindfulness. It attempts to define mindfulness in a concise operational manner in order make it possible for mindfulness to be used by clinicians and researchers alike. They choose to work with the short definition 1) awareness 2) of present experience 3) with acceptance. There is a brief history of mindfulness, and explanation of its Buddhist roots, an explanation of formal and informal mindfulness, and the two types of meditation: concentration meditation (laser light) and mindfulness meditation (searchlight). He explains how mindfulness-oriented psychotherapy can be used at different levels: 1) by the therapist himself to help him in being present in the therapy 2) Mindfulness-informed psychotherapy- based on a theoretical frame of reference based on mindfulness without directly teaching the patient how to practice it 3) Mindfulness-based psychotherapy- involve teaching the patient specific mindfulness skills and exercises.

It is suggested that mindfulness may emerge as a new model of psychotherapy. It is outlined how mindfulness has already made its mark on many different fields from CBT to psychodynamic therapy, brain science, etc. The worldview or paradigm in western psychology that creates a metatheoretical frame of reference for mindfulness is contextualism. This worldview assumes that all reality is constructed by each individual within a particular context, and that causality is multidetermined. From this point of view, complaints, problems, or symptoms are not objective things that are to be diagnosed and then excised. Narrative therapy is a familiar example of modern constructivist psychotherapy.