What happens when therapists dream about their clients?

We often dream about what we've been doing and who we've been with, so it should come as little surprise to discover many psychotherapists dream about their clients. In fact a new study reports that nearly 70 per cent of thirteen participating therapists said that they'd had such dreams.

Psychologist Clara Hill and her colleagues asked the 13 student psychotherapists to keep dream journals for the duration of the time they worked at a community clinic - either one or two years. The number of dreams recorded in the journals ranged from 6 to 150 per year, and the proportion that were about clients ranged from 0 to 0.19 (average 0.06). Also, at the end of a period of therapy with a client they'd dreamed about, the therapists took part in an interview with the researchers about their dream experiences and what they'd gained from them.

The student therapists described their dreams about clients as disturbing and directly related to the therapy, often depicting the struggles involved. "Dreams appeared to function as a means for therapists to process difficulties they were experiencing in the therapy with these clients," the researchers said.

Although unpleasant, the dreams about clients appeared to be beneficial. Therapists described how the dreams of clients led to useful insights. To paraphrase one example, a female therapist dreamt of being in a circus and her client appearing on the back of an elephant, and remaining in the middle of the ring even as the other riders and their elephants left. The therapist said her client looked liked a mannequin and just sat their not interacting with the audience. The dream led the therapist to think about her client's depression and the possibility she might have been forcing happiness and optimism on her. It also made the therapist realise that she cared for her client, that her client was willing to try new things, but that she (the therapist) needed to adjust her pacing and tone.

"In this rich qualitative examination of these therapists' dreams, then, we learn that such dreams, though clearly distressing … nevertheless yielded helpful lessons that therapists then effectively applied to their continued clinical work," said Hill and her colleagues.

There was little evidence that therapists discussed their dreams of clients with their supervisors. Given the apparent insights derived from client dreams, the researchers suggested that therapy training programmes incorporate more focus on working with dreams in supervision. They also suggested expanding this line of research to see whether therapists using other approaches (e.g. CBT, psychoanalysis) also dream of their clients, and whether they too find it beneficial.

The researchers acknowledged some limitations of their study including the small sample size and the fact that keeping dream journals may have encouraged a greater than usual focus on dreams among the participating therapists. However, the researchers didn't show any scepticism towards the therapists' claims that their dreams had been beneficial for therapy. Readers of a more scientific persuasion will no doubt demand more rigorous evidence before believing this is really true.

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Hill CE, Knox S, Crook-Lyon RE, Hess SA, Miles J, Spangler PT, and Pudasaini S (2014). Dreaming of you: Client and therapist dreams about each other during psychodynamic psychotherapy. Psychotherapy research : journal of the Society for Psychotherapy Research PMID: 24387006

--further reading--
When therapists have the hots for their clients

Post written by Christian Jarrett (@psych_writer) for the BPS Research Digest.

Very old and very cool - recognising a distinct mental strength of the elderly

A pair of researchers in Switzerland say there is an attitude common among the very old that is best described as "senior coolness". Based on detailed analysis of in-depth interviews in German with 15 people aged 77 to 101 (average age 86; 12 women), and also reflected in interviews with a further 60 older people, Harm-Peer Zimmermann and Heinrich Grebe describe a commonly held attitude of "comprehensive composure, indeed nonchalance and indifference, towards old age".

They argue that this runs counter to the narrative of very old age frequently depicted in the media, which tends to focus either on deterioration, dementia and burden, or on sprightly older people who defy their age. Those in the latter group "are assured of the media's approving attention, all the others more or less come under suspicion of having failed - for which they themselves are held responsible," write Zimmermann and Grebe.

In contrast to this dominant narrative, the researchers describe old people who live with health problems and other challenges with a kind of cool detachment. They are not defying their age, but rather they are able to rise above it with emotional nonchalance. This senior coolness was observed across the sample regardless of age, wealth, education or gender.

The researchers cite many examples from the interviews to make their case. Here is a sample:

Mrs B (aged 87), a former nursing assistant, is no longer able to keep up with her housework. "Whenever I think: 'Oh, you ought to tidy things up again!', I don't do it every time, it doesn't bother me." 

Mrs M (aged 88), a retired school teacher who uses a walking frame, reflects on how she will never be able to travel abroad again. "I'll never get there [to the ocean] again - never mind. That's just the thing, you make the most of the things you've had […] Of course, it's a shame I've never been to Greece. But: so what? As a child I saw half the world." [words in italics were uttered in English.]

Mrs H (aged 86), a former laundry shop worker, speaking about her incontinence: "I can think of more pleasant things." 

Mrs L (aged 84), a former unskilled assistant at trade auctions, suffers from chronic pain. "… [Y]ou take what comes. What else can you do? I can still take pleasure in this and that."

Former German Chancellor Helmut
Schmidt was voted the "coolest guy"
in Germany in 2008 when aged
89, he's now 95. 

The researchers stressed that their elderly interviewees did not speak with complete indifference. They recognised the difficulties of old age, but they did so in a manner of detachment and with balance, also focusing on the positive aspects of their lives. To do this, they drew on their memories and on humour and irony. This allows them to deal with personal and external challenges in a "calm and composed manner" the researchers said. They reject old-age stereotypes and do not allow their difficulties to spoil their lives.

This "senior coolness" is a "particular mental strength of very old people," the researchers concluded. "For us, 'senior coolness', refers to a personal constitution and composure that gives ageing people a sense of inner security and poise. It is about facing the indignities of ageing with reserve and distance. It is about giving a dignified form to life and the process of ageing."

_________________________________

Harm-Peer Zimmermann and Heinrich Grebe (2014). “Senior coolness”: Living well as an attitude in later life. Journal of Aging Studies DOI: 10.1016/j.jaging.2013.11.002

Post written by Christian Jarrett (@psych_writer) for the BPS Research Digest.

Elderly twins reflect on a lifetime of striving to be an individual

Twin sisters posing at the annual double take parade in 2007, in Twinsburg, Ohio - the largest annual gathering of twins in the world. (Photo by Rick Gershon/Getty Images).

Twins fascinate. Early in life they're often dressed alike, given complementary names, and bought shared gifts. Identical twins in particular intrigue us, and tales abound of their linked fates and close bonds. But a new study of 20 older twins in Sweden offers a different perspective. Interviewed individually about their lives, these twins reflected on a life spent trying to carve out a unique identity. "We were expected to always be together," remembered a male non-identical twin. "It was fun for a time, but later on it became boring to be seen as one instead of two individuals."

Sirpa Pietilä and her team interviewed most of the participants in their homes, although a few opted to meet in a public place. The participants were aged 78 to 90, including seven intact pairs of twins (where both were still alive) - four identical pairs and three non-identical or "fraternal". There were also six twins who'd lost their twin sibling - two of these participants were identical, four fraternal.

In terms of companionship, the participants made the kind of comments that we're used to hearing about twins. Losing a twin was devastating. "I'm only half now, there's only half of me left," said Norah (identical), aged 90. In childhood it felt entirely normal to be a twin, and the twins described how they expected other children to also come in twos.

Yet, the surprising message to come from the interviews was the way these twins had clearly strived through life to forge a strong sense of self (presumably unlike those attending Twinsburg - see pic above). The participants drew attention to the differences in their birth order (one twin is always slightly older than the other by a few minutes), with the elder usually seen as more dominant. They emphasised their deliberate pursuit of different hobbies and careers. Indeed, none of the participants had worked in the same company as their twin. The interviewees also tended to describe a closer affiliation with a different parent than their twin. They also described resenting being referred to as "the twins" - as a single social unit rather than as two different people. As soon as they were old enough, the participants said they'd chosen to wear different clothes from their twin.

"It is symptomatic of the lifelong lack of confirmed individuality that these older twins of around 80 years of age still seemed to feel the need for emphasising that they were individuals," the researchers said.

Even the frustration of receiving identical presents persisted into old age. "… like recently it was our 78th birthday we both received vases … and my sister got exactly the same vase," said one female twin with disappointment. "And then from another grandchild we both received a large teacup each, my sister got one too, the same, but I didn't want to say anything. I can't understand how they don't think?"

Sirpa Pietilä and her colleagues acknowledged the limitations of their qualitative methodology - "objective truths cannot be obtained," they said, and there are obvious problems with relying on reminiscences. Nonetheless, they said their research broke new ground because most research of this kind has been focused on twins who are young. "It seems like there is an ongoing lifelong identity work of claiming oneself as an individual," the researchers concluded. This revelation can hopefully "lead to a greater sensibility towards the two individuals who make up a set of twins."

_________________________________

Pietilä S, Björklund A, and Bülow P (2013). 'We are not as alike, as you think' sense of individuality within the co-twin relationship along the life course. Journal of aging studies, 27 (4), 339-46 PMID: 24300054

--further reading--
why psychologists study twins
Unborn fetuses demonstrate their sociability after just 14 weeks gestation

Post written by Christian Jarrett (@psych_writer) for the BPS Research Digest.

What's it like to hear voices that aren't there?

Traditionally, when a person says they can hear voices that don't exist in external reality (not to be confused with inner speaking), psychiatry has treated this as a sign of mental illness. However, it's become clear in recent years that many people hear hallucinated voices without it causing them distress. To improve our understanding of how voice-hearing becomes problematic it's clear we need to understand more about the different ways that people experience hearing voices.

Now Lucy Holt and Anna Tickle have published a "meta-ethnographic synthesis" of what we know so far about the varieties of people's voice-hearing experiences. The researchers trawled the peer-reviewed literature using key-word searches to find studies of adequate quality that involved asking adults to describe their voice-hearing experiences first-hand. This process uncovered seven papers, published between 2003 and 2011, involving the first-hand accounts of 139 people aged 19 to 84 (52 per cent were women).

Holt and Tickle analysed the papers looking for recurring themes in people's descriptions of their voice-hearing. The results are fascinating and some insights potentially useful for clinicians. The first theme is that most people gave the voices they heard an identity - often they named them, or they attributed a gender to them. Some people heard voices that belonged to real people encountered in the past, other voices were seen as belonging to God or a spiritual force.

Another important theme was the amount of power that people perceived their heard voices as having, and, related to that, how much power they felt they had over them. There was a continuum such that some people felt completely powerless over their heard voices, while others felt they could take them over. Intriguingly this appeared to be related to the explanations people gave for their heard voices. Those who subscribed to a biomedical account, believing that their voices were caused by a chemical imbalance in the brain, tended to feel less in control of their voices. The perceived power of voices was also linked to the voices' identity, particularly if they were attributed to an authoritarian figure.

People also spoke of the strategies that their voices used to maintain power, such as criticising the person and exploiting his or her weaknesses. Other participants described strategies they used to regain control of their voices, such as using distraction or, opposite to that, deliberately engaging with the voices.

The way that heard voices affected people's relationships was another theme. People described how hearing voices made it difficult to lead an ordinary life. Heard voices could interfere with social relationships, for example by making critical comments about friends or family. But voices could also play a beneficial role by reducing loneliness. "I have not got many friends … so the only thing I can stay very close to are the voices and I do stay very close to them," said one person.

Yet another theme related to whether people saw a distinction between their own thoughts and the voices they heard. Most people recognised a clear difference between the two, perceiving heard voices as "coming from outside the self but manifested inside the body". One exception to this was a study conducted in a psychiatric setting. Here most of the participants endorsed a biomedical explanation for their voices, and they saw their heard voices and own thoughts as one.

Holt and Tickle said their review contained useful insights for therapists, most of all by showing that "'voice hearing' is clearly not a homogenous experience." The findings also suggest ways that therapists might help their clients who hear voices, for example by boosting their feelings of self-worth. Therapists could also benefit by realising that heard voices sometimes have an adaptive function.

Unfortunately, the quality of the studies identified in this review was disappointing. Many failed to provide quotes from participants; others failed to acknowledge the influence of the researcher's own interpretative stance on the results. "It is evident that the quality of research investigating the first person perspective of hearing voices warrants improvements," Holt and Tickle said.
_________________________________

  Holt L and Tickle A (2013). Exploring the experience of hearing voices from a first person perspective: A meta-ethnographic synthesis. Psychology and psychotherapy PMID: 24227763

--further reading--
The same voices, heard differently?
A new approach to help those who hear voices
Hearing music that isn't there
The science of how we talk to ourselves in our heads
A Community of One: Social Cognition and Auditory Verbal Hallucinations

Post written by Christian Jarrett (@psych_writer) for the BPS Research Digest.

How young boys build imaginary worlds together

I remember, aged five or so, a friend and I were the cool police motorcyclists from the TV show CHiPs. Our props were limited to the usual paraphernalia of a suburban home and yet somehow both of us knew when the other person was on foot or on his Kawasaki motorbike, which routes through the house were motorways, where the baddies were located, and most important, we both understood the plot of our game.

For a new study, a team of psychologists in Australia has taken an interest in the conversation that allows this kind of coordinated imaginary game-play between childhood friends. Frances Hoyte and her colleagues video recorded three boys aged five to six - Alan, Bradley, and Max - as they played with each other in pairs for half an hour. Alan and Bradley had previously identified each other as being "very best friends", as had Bradley and Max. Alan and Max were "just a little bit friends."

Each pairing from this trio was asked to play together with various props available to help them on their way, including brightly coloured building blocks, wooden discs, bottle tops and pebbles. The toys were chosen deliberately to be open-ended, "so that the materials did not prescribe a specific agenda for play."

Hoyte's team identified three conversational themes in the boys' playtime interactions. The first, found in the conversations in all three pairs, the researchers called "making together". "The goal of the first talk type," the researchers said, "was to co-construct a representation of some real or imaginary object."

The second kind of talk - "sharing personal information" - was only found between the pairs of boys who were best friends. The final talk type - "storytelling" - was also found only between best friends and involved the boys bringing a fictional scenario to life. In one, Alan and Bradley blasted off into space together in a rocket. Sometimes events are described in the third person, other times the children assume the character roles themselves:

Bradley: They breathe out fire out their um shoes
Alan: There we go (noise effects)
Bradley: And then off they go
Bradley: They keep on burning their feet
Alan: Yeah
Bradley: And they don't say "ow"

Another story these boys concocted together appeared to involve shooting their entire family. The researchers chose not to dwell on the disturbing content of this particular game and focused instead on the common features of joint imaginary play, including: negotiation, sharing of power and control, and frequent use of declaratives and imperatives, and mental process verbs such as "think," "know" and "say". The researchers observed that: "The children also share a sense of what would be exciting, or appealing to imagine. Possibly, this shared outlook or view of the world underpins their narrative construction and allows them to successfully create the story together."

Hoyte and her colleagues admitted they really need to study more children and to follow patterns of changing play conversation over time. This way they'll be able to discover how friendship levels and play influence each other, and also whether joint imaginary play has consequences for language development.

_________________________________

Frances Hoyte, Jane Torr, and Sheila Degotardi (2013). The language of friendship: Genre in the conversations of preschool children Journal of Early Childhood Research DOI: 10.1177/1476718X13492941

--Further reading--
Kids with invisible friends have superior narrative skills
Fantasy-prone children struggle to apply lessons from fantasy stories
Background TV disrupts children's play

Post written by Christian Jarrett (@psych_writer) for the BPS Research Digest.

They need to "Man up!" - what students who drink think of those who don't

There's a scene in the 2013 comedy film The World's End in which a group of middle-aged old school friends are on a nostalgic pub crawl, yet one of them, Andy Knightly, insists on abstaining from alcohol. "I haven't had a drink for sixteen years Gary," he tells the ring-leader and lush Gary King. "You must be thirsty then," Gary retorts.

This social dynamic - the reluctant non-drinker coerced to join in with the drinking majority - will be familiar to many readers. And given the health risks of excess alcohol consumption, it's also a scenario that's caught the attention of health psychologists. How are non-drinkers perceived? Does gender identity play a part in the pressure to drink?

For a new study Dominic Conroy and Richard de Visser interviewed 12 middle-class undergrads aged 20 to 29. There were seven men and five women and all were regular drinkers. The semi-structured interviews, loosely guided towards discussion about non-drinkers, were conducted by a man in his early 30s.

Three main themes emerged from the interviews - first, non-drinking was seen as something strange that required explanation. "It seems a bit alien, doesn't it?" said Tina. "It'll be like 'why are you not joining in? …. Why do you want to alienate?" said Andy. There were also signs of ambivalence. "… in a way respect but … in a way you're probably more likely to distance yourself from someone like that as well," said Penny.

The second theme was that non-drinkers were seen as anti-social, but also more sociable at the same time. "It can be kind of awkward," said Sarah. "Maybe [they're] actually more sociable actually because you don't need the alcohol to umm … [be] social with people," said Andy. "… y'know they're the lucky ones they don't need a stimulant already to have fun … it's all in there already it's in their heads."

The final theme related to the difference between the way non-drinking was perceived in men and women. Mike said that to stop drinking with his life-long male friends would be a rejection of them - it's something they'd always done together. In contrast, there seemed more tolerance of non-drinking by women, and even facilitating strategies - if one woman was abstaining, one interviewee described how another female member of the group might join them so that they didn't feel left out. There was also a sense of respect for a woman who chose not to drink: "Oh, good for her, y'know, she's looking after herself," said Tina. But for a man, Tina added, "it's like 'Oh why are you not having a drink?' kind of 'Man up!'."

This idea of non-drinking by men as somehow unmanly was most strongly encapsulated in the descriptions given by the interviewee Mike, who said there are issues of (heterosexual) masculinity in drinking stamina. "Why he's not drinking with us? [said of a non-drinking friend] … he's gonna be … he's being gay tonight [we might say]… I think we're playing on the stereotype that a masculine heterosexual man can drink more."

Conroy and de Visser acknowledged that their study has limitations - including the narrow middle class student sample and the likely influence of the interviewer. But nonetheless they said there were useful clues here towards helping reduce excess drinking, especially among students. " … [O]ne route upon which health promotion campaigns might capitalise to promote a more positive view of non-drinking among men [is] emphasising that diverse modes of masculinity and social behaviour exist beyond those embedded in dominant hegemonic assumptions."

_________________________________

Conroy D, and de Visser R (2013). 'Man up!': Discursive constructions of non-drinkers among UK undergraduates. Journal of health psychology, 18 (11), 1432-44 PMID: 23188922

Post written by Christian Jarrett (@psych_writer) for the BPS Research Digest.

A study of suicide notes left by children and young teens

In 2010 more people died by suicide than were killed in war, by murder, or in natural disasters. In Norway, the location of a heart-rending new study of suicide notes left by children and young teens, suicide is the second leading cause of death for this age group. We need urgently to do more to understand why so many young people are taking their own lives.

The researchers Anne Freuchen and Berit Grøholt predicted that, given their immaturity, the young authors of suicide notes would show signs of confusion. Also, because diagnoses of mental illness are lower in children and young teens, the researchers predicted that the notes would show fewer signs of inner pain compared with notes left by older teens and adults.

In all, Freuchen and Grøholt had access to 23 suicide notes left by 18 youths (average age 14; 5 girls) who took their own lives between 1993 and 2004. They also interviewed the children's parents and referred to police reports. For comparison, the researchers also interviewed the parents of 24 youths who died by suicide during the same period but did not leave a note.

Analysing the notes revealed ten themes, each of which was present in three or more of the notes: they were addressed to someone (most often parents); the author gave reasons for the suicide; they declared their love; expressed a settlement with themselves (e.g. "it's better for me to be dead"); expressed a settlement with someone else (e.g. "I do this for you, dad"); asked for forgiveness; expressed good wishes (e.g. "good luck in the future"); expressed aggression (e.g. "you bastards"); over half included instructions (e.g. "give Peter Playstation 2"); and just under half expressed inner pain.

Contrary to their predictions, Freuchen and Grøholt said that "the notes are coherent and do not reveal confusion or overwhelming emotions. The children and young adolescents emphasise their consciousness of what they are about to do and they take full responsibility."

According to the parental interviews, the children and teens who left the notes had not sought help with the issues that led to their suicide. At the same time, they had communicated their thoughts about suicide more often than those who didn't leave notes. One has to wonder why this did not trigger more effective preventive action. Similarly, three of the notes took the form of school essays, and yet none of them were acted upon by school authorities.

The fact that many of the notes conveyed declarations of love and gave explanations suggests, the researchers said, that the authors were well aware of the implications of their actions. "These children and adolescents somehow retain their dignity," the researchers said. "They act like decent people do, they bear their pain alone, and even manage to take care of others by leaving detailed instructions with respect to giving away their assets."

The researchers do not extract many practical lessons from their findings, other than calling for more research into parent-child/teen relationships in the hope of developing preventative strategies. Moreover, they cautioned that it is not possible to generalise or draw conclusions from this small sample. Another methodological limitation is that the suicide notes are from an era that pre-dates the rise of social media (which can be a source of threat, a support, and an outlet), so it's not clear how relevant insights from this study are for young people today.

_________________________________

Anne Freuchen, and Berit Grøholt (2013). Characteristics of suicide notes of children and young adolescents: An examination of the notes from suicide victims 15 years and younger. Clinical Child Psychology and Psychiatry DOI: 10.1177/1359104513504312

--Further reading--
The mental health charity Young Minds has a helpline for parents.

Mindfull is a new website for 11 - 17 year-olds who are feeling down or depressed.

Occupational hazard - links between professions and suicide risk have changed over time.

What's different about those who attempt suicide rather than just thinking about it?

Post written by Christian Jarrett (@psych_writer) for the BPS Research Digest.

"It's about accepting that you're mortal" - Extreme sports enthusiasts on overcoming fear

In a safety-obsessed culture, why do some people throw caution to the wind and pursue sports where a wrong move often means instant death? Clues come from a series of interviews conducted with a group of 15 extreme sport participants (aged 30 to 70; 10 men) about their relationship with fear, including BASE jumpers (who launch themselves off high buildings), big wave surfers and waterfall kayakers.

Eric Brymer and Robert Schweitzer transcribed the interviews and looked for emerging themes. Contrary to traditional accounts of extreme sports enthusiasts as thrill seekers with a death wish, the interviewees described fear as an aversive, bodily sensation that the rest of us can recognise. A "gut-wrenching, terrible experience" was how one BASE jumper put it. "If you want a true slogan for these sports," he added, "it is Oh please don't let me die!". However, the interviewees also described how they face their fears and "push past" them.

Also contrary to some of the "devil may care" stereotypes that have dominated scientific and media portrayals of this group, the interviewees spoke of the importance of fear as a "healthy emotion" that "keeps you alive". Indeed, another of the themes related to "managing fear", with several participants describing their "fascination" with controlling their fear so as to avoid panic. "Fear is both a primal emotion and an experience to be savoured, confronted or broken through" the researchers said, "rather than as a stimulus for retreat."

The last theme on "self-transformation" was the most intriguing. The participants described how experiencing, controlling and pushing past intense fear left them positively changed and better equipped to deal with the tribulations of everyday life. A mountain climber described dealing with fear as "empowering" and "feeling very at peace" afterwards. A BASE jumper described the pursuit as "the ultimate metaphor for jumping into life rather than standing on the edge quivering". She also captured poetically the sense many of the interviewees had of becoming one with nature at the moment of most intense danger, as if "just a leaf in the wind: you're totally vulnerable and totally part of the environment at the same time. It's about accepting that you're mortal ... very vulnerable ... like a piece of dust ... in the wind." Another participant talked about a transformational "aura" that stayed with him "for as long as you care to remember."

According to Brymer and Schweitzer, these accounts "provide a critique of fear" as it is usually understood in conventional psychology, as always associated with dread. For the extreme sports enthusiast, fear is a useful emotion that aids survival but which ultimately can be transcended leading to personal growth and change. "By facing our greatest 'true' fears," said Brymer and Schweitzer "whether they be death, uncertainty or something else and taking action despite these fears, we transcend our own limitations and invite new possibilities into our lives."

_________________________________

Brymer, E., and Schweitzer, R. (2013). Extreme sports are good for your health: A phenomenological understanding of fear and anxiety in extreme sport. Journal of Health Psychology, 18 (4), 477-487 DOI: 10.1177/1359105312446770

Post written by Christian Jarrett (@psych_writer) for the BPS Research Digest.

What is cognitive behavioural therapy like for a teenager?

Most research into CBT (cognitive behavioural therapy) for teenagers has focused on whether it works or not, with largely positive results. Surprisingly little attention has been paid to finding out what it is actually like for a teenager to undertake CBT.

Deanna Donnellan and her colleagues have made an initial effort to plug this gap, conducting in-depth interviews with three teenage girls who'd completed a course of individual CBT, asking them about their perception of the therapy and what it meant to them.

The pseudonymous interviewees were Mary, who had problems with sickness and anxiety; Katherine, who had anxieties around her appearance and restricted her eating; and Samantha, who experienced low mood and practised self-harm. The teenagers were aged 15 years on average.

One the main themes to emerge related to progress and change. Mary saw the therapy in terms of helping to remove her problems; Samantha saw it as more than that, as a chance to move forward in her life; and Katherine felt she had developed new perspectives on life and the future. All three experienced increases to their self-efficacy (their confidence in their own abilities). Donnellan and her colleagues pointed out a related practical insight here - they found the teenagers clearly had "ultimate goals" for therapy (such as a growth in character or a return to "normality"), which could be hidden beneath the immediate aims of the CBT.

Another key theme to emerge related to engagement with therapy. The teens were mostly disengaged and passive at the start, but they gradually began to participate more. Mary achieved this engagement by taking some control - she agreed to take on some of her homework tasks around eating, but refused others. Samantha didn't say much at the start, but came to realise that she could benefit from exploring her emotional issues. Katherine felt desperate and unable to make decisions at the start, but the graded nature of the therapy helped her feel more stable.

The researchers said issues of control were very important in teen therapy given that most teenagers' therapy will have been instigated by their parents. "Power and its ability to impact negatively upon therapeutic potential might ... be mitigated by a process of collaboration and encouraging the client to negotiate their position in the therapeutic relationship," they said.

What about rapport with the therapist? Although she benefited from therapy, Mary was not on the same page as her therapist:

"for an example she might use someone being scared of dogs and how the thoughts of the dog biting them would make them cross the road (...) it was like relates nowhere near to like feeling sick and how feeling sick affects ya it was nothing near that".

Mary blamed part of this on her therapist seeming "really old". "I think for most teenagers," Mary said, "... you'd feel easier to talk to someone who, not obviously dead young, but d'ya know not someone in their 50s or something or like old." In contrast, Samantha was pleasantly surprised at her therapist's ability to relate to her situation:

"It was a bit disconcerting cos she like, not knew about it, but knew how to like deal with all this stuff, which I wasn't entirely expecting but it was helpful."

The final theme related to the structure of the way therapy was delivered. Mary felt like some of the progress was too slow and there was frequent repetition. For Samantha, the structure and predictability of CBT was an advantage, and the boundaries laid down by her therapist helped her feel safe. Katherine also liked the graded pace of therapy, with the gentle start helping her to feel more comfortable.

Donnellan's team said their interviews were a "tentative" first step towards finding out what CBT is like for young people. The findings demonstrate "the importance of the process of therapy, just as much as the content," they said. Based on this, some practical recommendations include: recognising the importance of the first stages of therapy for engaging with a teenage client; addressing the teen client's preconceptions about therapy; and finding out the pace and style they'd like the therapy to progress at.

"The service delivering CBT needs to promote the young person as being in control from the outset," the researchers said, "regardless of who is making the decision to access therapy. This may set the scene for them to develop control over their problems and establish stability in their life."

_________________________________

Donnellan, D., Murray, C., and Harrison, J. (2012). An investigation into adolescents' experience of cognitive behavioural therapy within a child and adolescent mental health service. Clinical Child Psychology and Psychiatry, 18 (2), 199-213 DOI: 10.1177/1359104512447032

Post written by Christian Jarrett (@psych_writer) for the BPS Research Digest.

What's it like to have OCD?

Research with people who have obsessive-compulsive disorder (OCD) is often impersonal. Participants' thoughts, feelings and behaviours are reduced to ticked boxes on a questionnaire. There's a risk the real story of what it's like to have OCD doesn't get told. Helen Murphy and Ramesh Perera-Delcourt have taken a different approach. They interviewed 9 people (one woman) with OCD, face-to-face, for about an hour each, to hear how these people felt about their condition and about any treatment they'd received.

The researchers transcribed the interviews and highlighted key themes. Regarding the experience of OCD, the main themes were "wanting to be normal and fit in", "failing at life", and "loving and hating OCD."

Participants found comfort in meeting other OCD support-group members. They also spoke of caring too much about what other people are thinking of them. OCD can interfere with education, relationships and careers and frequently, participants compared their own stalled life trajectories against what they perceived as the societal norm. "I feel like I've got to make up for lost time in a way," one man said. There were in-depth descriptions of the painful situations created by OCD - one man who house-shared had to scrub the entire bathroom with powerful cleaning product for an hour every day before he could use it. But at the same time, there was a fear of losing the crutch that the condition provides. "I wish I could do that [stop checking], I wish I could stop," another man said, adding: "Well, not totally."

In relation to therapy, the main themes were "wanting therapy", "finding the roots", and "a better self". Participants spoke of the relief that came from having their problems recognised and listened to. The importance of rapport between participants and their therapists was mentioned repeatedly, consistent with what's known about the importance of the therapeutic relationship. Although aspects of CBT were found useful by many ("it helped me focus on what is important to me in life," said one), others commented on the lack of interest in the roots of the condition. "There's been a 'stuff the past' sort of thing but it's like cutting a plant above the soil - the roots are still there," said another participant. CBT helped participants with self-esteem issues. "... reanalysing things ... has made me realise that I wasn't to blame for all kinds of things," one person said.

Murphy and Perera-Delcourt concluded that examining people's narratives can help to "understand the lived experience and lessen public and self stigma". Given the way their participants emphasised the value of rapport in therapy, the researchers questioned claims that computerised CBT is a valid substitute. They also highlighted the apparent importance to people with OCD of understanding its origins. "Developmental issues in the maintenance of the disorder have been generally neglected and our findings suggest that understanding and talking through the origins of OCD may lessen treatment resistance," they said.

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Murphy, H. and Perera-Delcourt, R. (2012). ‘Learning to live with OCD is a little mantra I often repeat’: Understanding the lived experience of obsessive-compulsive disorder (OCD) in the contemporary therapeutic context. Psychology and Psychotherapy: Theory, Research and Practice DOI: 10.1111/j.2044-8341.2012.02076.x

Post written by Christian Jarrett (@psych_writer) for the BPS Research Digest.

What clients think CBT will be like and how it really is

Some people expect cognitive behavioural therapy (CBT) to be more prescriptive than it is, and therapists to be more controlling than they really are. That's according to a series of interviews with 18 clients who undertook 8 sessions (14 hours) of CBT to help with their diagnosis of generalised anxiety disorder.

Henny Westra and colleagues selected for interview nine clients whose therapy had ended positively and nine whose therapy had ended poorly. Four of the clients were male. There were four CBT therapists - two men and two women. One was PhD qualified, two were senior clinical psychology grad students, one was junior.

The vast majority of client comments (84 per cent) relating to expectations were that the CBT was not what they'd anticipated. Clients whose outcome was good tended to say they'd been pleasantly surprised - the therapist was collaborative and non-judgmental, and they'd had the opportunity to direct the therapy and choose what to talk about. Of the therapeutic process, the positive outcome clients felt, to their surprise, that they could trust the process, felt comfortable, and that they learned more than they expected. Both good and poor outcome clients worked harder in therapy than they anticipated.

Unsurprisingly, the poor outcome clients tended to say they'd been disappointed by the therapeutic process. In the majority of cases, they took pains not to blame their therapist, instead attributing their lack of progress to time constraints, poor health, their own unrealistic expectations, or their failure to remember the techniques. Direct criticism of the therapist was rare (even though interviewees were reassured their comments were confidential). One person said it would have been better not to have waited until session seven to discuss a key subject from their past.

Sixteen per cent of expectation-related comments conveyed that therapy was just as had been expected. One good outcome client in this category said they thought the therapist would get to the root of their problems, and he did. Poor outcome clients, by contrast, tended to make superficial remarks: 'it was fairly similar to what I expected, I guess'.

The broader context for this research is that client expectations are one of several factors that are known to be associated with therapeutic success (with positive expectations tending to precede good outcomes). However, very little research until now has looked at expectancy violations - that is, when therapy isn't what was expected, for good or bad.

'The findings ... suggest that expectancy disconfirmation in CBT, particularly negative expectations for the therapist and the therapy process, is a common and potentially powerful phenomenon in the experiences of CBT clients with good outcomes,' the researchers said.

A major shortcoming of this research is that the interviews weren't conducted until after the final therapy session, so it's possible that clients recalled their earlier expectations in light of their positive or negative experiences in therapy.
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Westra, H., Aviram, A., Barnes, M., & Angus, L. (2010). Therapy was not what I expected: A preliminary qualitative analysis of concordance between client expectations and experience of cognitive-behavioural therapy. Psychotherapy Research, 20 (4), 436-446 DOI: 10.1080/10503301003657395

Post written by Christian Jarrett (@psych_writer) for the BPS Research Digest.

"I wanted a new challenge" - Cross-cultural differences in workers' thoughts about their career changes

It's not many generations ago that workers expected to have a job for life, most probably one that followed in the footsteps of their father, and his father before that. In many of today's richer societies, it's all different. Longer education and greater individual choice mixed with mergers, take-overs and bankruptcies mean that people's careers are typically punctuated by a series of distinct transitions or chapters. But how do people perceive these transitions and do such perceptions vary between cultures? To find out, Katharina Chudzikowski and her colleagues interviewed a mix of over a hundred nurses and blue- and white-collar workers from five countries - Austria, Serbia, Spain, USA and China.

Their stand-out finding? Workers in the United States didn't ever attribute a career transition to an external cause, such as conflict with a boss. Not once. Instead they tended to mention internal factors, such as their desire for a fresh challenge. By contrast, workers in China almost exclusively stressed the role played by external factors. Meanwhile, workers in the the European nations were more of a mix, attributing their career transitions to both internal and external factors.

The researchers said a lot of the transitions reported by the participants, especially in the USA and Europe, were positive. Generally-speaking, people are known to be biased towards attributing positive events to themselves, and so it's perhaps little wonder that many workers attributed all these positive career transitions to internal causes. "In addition," the researchers said, "in many cultures 'being in charge' of one's life is positively valued. Conversely, reconstructing crucial career transitions as purely triggered by external circumstances does not convey a great amount of competence."

Where workers showed a greater tendency to attribute their career transitions to external causes, this seemed to be related to the influence of a collectivist culture and an economy in flux. "Countries with more dynamic economic change show a stronger emphasis on organisational and macro factors," the researchers said.

Apart from the value of its findings, the study also provides a useful demonstration of the difficulties involved in conducting cross-cultural research. For example, whilst interviews were conducted in the participants' native languages, the transcripts were translated into English for qualitative analysis, which raised some interesting problems. For example, some German-speaking interviewees cited "Wirtschaft" as an influencing factor - a word that can mean economy, industry, commerce or business world, but which also has mythical-religious undertones. There's no real direct equivalent in English.
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Chudzikowski, K., Demel, B., Mayrhofer, W., Briscoe, J., Unite, J., Bogićević Milikić, B., Hall, D., Las Heras, M., Shen, Y., & Zikic, J. (2009). Career transitions and their causes: A country-comparative perspective Journal of Occupational and Organizational Psychology, 82 (4), 825-849 DOI: 10.1348/096317909X474786

Post written by Christian Jarrett (@psych_writer) for the BPS Research Digest.

Olympic athletes reveal their mental strategies

It's reassuring to learn that even the most elite athletes can suffer from mental frailties. Maurizio Bertollo and colleagues interviewed 13 members of Italy's 2004 pentathlon squad and a common theme to emerge was the curse of so-called "ironic effects". As one athlete explained: "In some circumstances my intention is not to do the best but to avoid making a bad shot. That is when I make a bad shot. When I think about avoiding the error, I make the error."

The modern pentathlon involves pistol shooting, épée fencing, 200m freestyle swimming, show jumping, and a 3km cross-country run, all conducted on the same day. Bertollo's research team transcribed the interviews they conducted with the pentathletes, generating 220 pages of text. They trawled this text, looking for common themes to emerge and then organised these according to different stages preceding, during and following a competitive event.

For example, several of the athletes said that during the days before an event they attempted to recreate the emotional stress of a real competition. They also said they prioritised relaxation time, set themselves goals and mentally rehearsed success.

During a competition, the athletes performed an opposite mental exercise to that conducted prior to the event, attempting to recreate the feelings, such as of muscle relaxation, that they achieved during training. They also revealed that they tried to avoid dwelling on mistakes; that they reassured themselves that dysfunctional emotions usually stop once a contest gets started; and that they strive to focus their attention in useful ways, such as on the sight and target during shooting.

As well as difficulties with "ironic effects", the athletes also spoke of the curse of bodily symptoms such as trembling and fatigue, and the feeling of a loss of control or choking. "There are times when I say, ‘I don’t see when this will end. Oh God, let me finish this contest! I want it to end!’ And I am in acute crisis," one athlete said.

The athletes also reported devoting considerable time to post-contest evaluation, especially so as to learn from their mistakes.
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M BERTOLLO, B SALTARELLI, C ROBAZZA (2009). Mental preparation strategies of elite modern pentathletes Psychology of Sport and Exercise, 10 (2), 244-254 DOI: 10.1016/j.psychsport.2008.09.003

Image is from Wikipedia and shows the conclusion of the Men's pentathlon event at the 2004 Summer Olympics.

Post written by Christian Jarrett (@psych_writer) for the BPS Research Digest.

What it's like for pregnant women to be rushed to hopsital with high blood pressure

For a pregnant woman to be rushed suddenly to hospital with high blood pressure can be terrifying - both she and her unborn child could be at serious risk. To help hospitals plan procedures for making the experience as comforting and supportive as possible, health psychologist Julie Barlow and her colleagues interviewed twelve pregnant women about their experience of being hospitalised with high blood pressure. The interviews were held within three days of the women's hospital admission.

Qualitative analysis of the women's comments uncovered four key themes. The women were searching for meaning in what had happened to them. For example, several of them reported feeling like frauds because they hadn't experienced any symptoms (their condition had been identified by routine tests). "It's to do with preeclampsia" one woman said, "but I didn't understand what that is cos I'm fine in myself and the baby's fine... and you're thinking 'why can't I go home?'"

The women tended to search for the possible causes of their condition, especially in relation to stressful events. One woman said it would be beneficial to learn relaxation techniques.

There were several comments pointing to the problem of inconsistent information from clinical staff. "I'm fed up with it," one woman said. "They tell you different things...when I got brought in, they says, you'll be in for a fortnight and you'll probably have the baby. And next breath...you'll probably have the baby in two to three days."

Evidence also emerged for what the researchers labelled social factors - the perceived benefit of support, especially from husbands, and the tendency for the woman to compare themselves to others at the hospital who were either better off than they were (so-called "upward social comparison") or less well off ("downward social comparison"). For example, one woman felt reassured by the sight of another patient having a normal delivery and appearing fine.

The researchers cautioned that this research is only preliminary; nevertheless, some practical implications were already apparent. For example, the researchers said hospital staff should be aware that "fear, anxiety and being in strange surroundings could interfere with women's ability to absorb information." Relationship support from partners and parents also seemed important, they said, and the introduction of relaxation techniques to the ward could be beneficial.
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Julie Helen Barlow, Jenny Hainsworth, Stephen Thornton (2008). Women's experiences of hospitalisation with hypertension during pregnancy: feeling a fraud Journal of Reproductive and Infant Psychology, 26 (3), 157-167 DOI: 10.1080/02646830701691384

Post written by Christian Jarrett (@psych_writer) for the BPS Research Digest.