Elena Faccio

What Works with Individuals in a Clinical Setting

Castelnuovos review of research on psychotherapeutical effectiveness (Castelnuovo, 2010), gathers together and summarizes a large body of literature. It explains the background of methods used in psychotherapeutic outcome research, while examining the premises behind the empirically supported treatment (EST) movement, clearly demonstrating the truth of Wittgensteins sentence: “Tell me how you do research and I will say what you research” (Wittgenstein, 1921, p. 13). It is not the object of research that determines the methodology chosen; on the contrary, it is the implicit investigation criteria that define (and selectively construct) the object of research. The assessment of effectiveness goes to the heart of the problem of how the research plan influences the result of any comparison between different approaches: the closer the treatment gets to the chosen methodology, the more probability it has to obtain positive results. The method chosen contributes to establishing the nature of the problem to which it is applied, and when the method is based on the classic empirical tradition, the psychological problems which it investigates logically appear to occur naturally, in the end (Castelnuovo et al., 2004, 2005). Westen et al. (2004) remind us that the way in which we ultimately decide upon the experimental method involves another series of assumptions; i.e., that the experimental method represents the Gold Standard for identifying truly efficacious treatment plans; that psychotherapy lends itself to a high degree of manipulation; that a large number of patients presenting the same problem can be treated at the same time (which in turn presumes that psychotherapy can effectively treat everyone). Therefore, only certain theoretical and clinical approaches are well represented by outcome-focused research: those approaches aiming to make the symptom disappear, being inspired, as they are, by the “medical model” (Elkins, 2009). According to estimates (Truscott, 2010), there are around 250 different theories and approaches. In order to be considered epistemologically valid, any approach must define its effectiveness coherently with its assumptions. An approach must be proven on the same level on which it declaredly operates: a behavioral level for behavioral therapy, a language level for a narrative approach, etc. The increasing focus on treatment goals often neglects the need for more effective differentiation within psychotherapeutic approaches, in light of the persisting equivalence paradox (Strauss, 2010). Any attempt to provide a single, overall conceptualization of effectiveness in psychotherapy is destined to suffer from partiality and reductivism: any definition is necessarily linked to the epistemological background which has generated it (“we must measure the correlation between what an approach promises and its final outcome, independently of the approach chosen” Castelnuovo, 2010, p. 8). If we consider the history of EST movement, we see that researchers initially tended to welcome the methodology used for random and controlled trials, mainly because of its inherent potential. Later, however, many researchers have moved on from unconditional trust in the experimental method to cautious skepticism: paradoxically, the more rigorous and provable research is according to criteria linked to “classic scientific method,” the less it becomes valid, significant and classifiable from the point of view of day-to-day practice. For this reason, representing psychotherapeutical processes and applying research findings and recommendations to the therapeutic field continue to prove difficult. As Castelnuovo points out, research into psychotherapy should enhance the experience of both therapist and client. For this to occur, quantitative and qualitative data, or objective and subjective experiences, “should collude rather than collide” (Campbell, 2008, p. 47). We must couple the effort to find statistically significant measurements with the equally important effort to discover clinical significance. Both the quantitative and the qualitative methodology, though differing greatly, are indispensable in overcoming any difficulty deriving from an overestimation of the subjective or objective level (Campbell, 2008). To conclude, asHagemoser (2009, p. 601) lucidly observes, although the proponents of empirically supported therapies (ESTs) argue that “because manualized ESTs have demonstrated efficacy in treating a range of psychological disorders, they should be the treatments of choice,” their success does not derive from their assumptions, which are full of gaps and logically weak; but instead, from economical and political variables which may be contributing to the expansion of ESTs, and to a resulting restriction of the practitioners autonomy.

Auditory hallucinations as a personal experience: analysis of non-psychiatric voice hearers’ narrations

This exploratory research investigates the phenomenon of non-psychiatric auditory hallucinations from the perspective of the voice hearer, evaluating the possibility that this experience can contribute the maintenance and adaptation of the hearers personal identity system. A semi-structured interview was administered to 10 Italian voice hearers, six men and four women, aged 18-65 years, who had never been in contact with any mental health services because of the voices, even though some of them had been hearing voices for decades. Participants were not distressed or worried about the voices; on the contrary they developed their own understanding, personal coping resources and beliefs in relation to the positive functions of the voices. These results indicate that voices cannot be considered merely as symptoms, but may be seen also as adaptation systems. Consequently, we should avoid trying to helping voice hearers to eliminate or deny voices, and rather we should help them to feel allowed to preserve them.

“Measuring up to Measure” Dysmorphophobia as a Language Game

We look into the transformation of meanings in psychotherapy and suggest a clinical application for Wittgenstein’s intuitions concerning the role of linguistic practices in generating significance. In post-modern theory, therapy does not necessarily change reality as much as it does our way of experiencing it by intervening in the linguistic-representational rules responsible for constructing the text which expresses the problem. Since “states of mind assume the truths and forms of the language devices that we use to represent them” (Foucault, 1963, p. 57), therapy may be intended as a narrative path toward a new naming of one’s reified experiences. The clinical problem we consider here, the pervasive feeling of inadequacy due to one’s excessive height (dysmorphophobia), is an excellent example of “language game” by which a “perspicuous representation” (the “therapy” proposed by Wittgenstein in the 1953) may bring out alternatives to linguistically-built “traps”, putting the blocked semiotic mechanism back into motion.

The Semantics of Power Among People With Eating Disorders

The study aimed to empirically test the hypothesis, developed within the systemic-constructionist theory of family semantic polarities, that the semantics of power are particularly meaningful for people with eating disorders. The repertory grid technique was used to elicit constructs from 30 young patients (10 anorexic, 10 bulimic, and 10 obese) and from a matched control group; the two sets of constructs were compared in terms of their semantic content. Overall the results confirmed the hypothesis, although further investigation into the semantic peculiarities of individual eating disorders is required. Methodological limitations and possible clinical applications are discussed.

The power semantics in self and other repertory grid representations: a comparison between obese and normal-weight adult women

According to systemic-constructivist theory, all psycho-pathological organizations are linked to specific meanings which are developed by the individual within problematic situations in the context of learning, particularly within the family. The aim of this empirical study is to support the theory that eating disorders are linked to the “power semantics,” concept developed by Ugazio. The hypothesis that the bipolar construct “winner/loser” and the associated meanings are predominant for obese people, has been verified by interviewing 44 women (22 obese/overweight; 22 controls) using the Repertory Grid Test developed by Kelly. The participants’ elicited constructs were classified according to their semantic content and the data compared using statistical techniques. The power semantics were more prevalent and important in the Obese Group than in the Control Group. These results are critically discussed, highlighting possible clinical developments.

Change in Psychotherapy: A Dialogical Analysis Single-Case Study of a Patient with Bulimia Nervosa

Starting from the critical review of various motivational frameworks of change that have been applied to the study of eating disorders, the present paper provides an alternative conceptualization of the change in psychotherapy presenting a single-case study. We analyzed six psychotherapeutic conversations with a bulimic patient and found out narratives “for” and “against” change. We read them in terms of tension between dominance and exchange in I-positions, as described by Hermans. These results indicate that the dialogical analysis of clinical discourse may be a useful method to investigate change from the beginning to the end of therapy.

Time experience during the assisted reproductive journey: a phenomenological analysis of Italian couples’ narratives

Objective: This study explores the time experience of Italian couples undergoing medically assisted reproductive procedures. Background: Research has mainly focused on the motivation for childbearing and the impact of infertility on women, with little attention given to the couple’s experience during assisted reproduction procedures. Methods: We conducted semi-structured interviews with nine women and seven men undergoing a medically assisted reproductive programme at a fertility clinic in Italy. An interpretative phenomenological analysis was used to analyse the transcripts. Results: Four main themes were identified: present moment, waiting, hope, and death. Each theme describes the experiences of the study participants and was linked to their personal identities and body perceptions. Conclusion: Time is a significant dimension in understanding participants’ experience because it represents the contradictory emotions and expectations that characterise a medically assisted reproductive journey. Health professionals might take into account the indications derived from these results to forge their approach to patients’ needs, and policymakers might adjust the organisation of the medically assisted reproductive system to patients’ time experience.

Transsexual parenthood and new role assumptions

This study explores the parental role of transsexuals and compares this to common assumptions about transsexuality and parentage. We conducted semi-structured interviews with 14 male-to-female transsexuals and 14 men, half parents and half non-parents, in order to explore four thematic areas: self-representation of the parental role, the description of the transsexual as a parent, the common representations of transsexuals as a parent, and male and female parental stereotypes. We conducted thematic and lexical analyses of the interviews using Taltac2 software. The results indicate that social representations of transsexuality and parenthood have a strong influence on processes of self-representation. Transsexual parents accurately understood conventional male and female parental prototypes and saw themselves as competent, responsible parents. They constructed their role based on affection toward the child rather than on the complementary role of their wives. In contrast, mens descriptions of transsexual parental roles were simpler and the descriptions of their parental role coincided with their personal experiences. These results suggest that the transsexual journey toward parenthood involves a high degree of re-adjustment, because their parental role does not coincide with a conventional one.

Extracting information from Repertory Griddata: new perspectives on clinical and assessmentpractice

The repertory grid technique devised by Kelly (1955/1991) can be useful in clinical practice and research, because it provides significant information in terms of the respondents’ mental structure. However, it is a complex technique calling for a substantial investment of time and effort by both clinician and respondent if the information obtained is to be relevant and useful. Its main advantage is that it allows the patient’s personally relevant data to be subjected to the rigor of the mathematical-statistical elaboration of underlying structures in the data provided by computer analysis. The present article shows how this can be undertaken using a grid completed by a woman with an eating disorder. Additionally, the paper provides a historical context for grid analyses carried out with a freeware computer program available in English and Italian that incorporates recently developed methods of grid analysis.

New drugs and polydrug use: implications for clinical psychology

The abuse of legal and illegal drugs is a complex and constantly evolving phenomenon. In recent years the polydrug use, term that refers to the use of two or more psychoactive drugs in combination to achieve a particular effect, has been on the rise. In many cases, one drug (amphetamine, cocaine, or heroin) is used as a base, with additional drugs being added to compensate for the side effects of the primary drug and to make the experience more enjoyable. The traditional traffic of drugs, always cheaper and more often available on the Internet, is expanding to include medical prescription drugs that can be ordered without prescription, “smart” drugs (substances legally sold for other uses, such as fertilizers, bath salts, dietary supplements), and synthetic drugs (Cinosi et al., 2014). In Italy, in 2013, the Department of Drug Control Policy (DPA) has identified, made illegal, and seized more than 250 new substances, including synthetic cannabinoids, cathinones, phenethylamines, piperazines, and metossietamine (Dipartimento Politiche Antidroga Relazione annuale al Parlamento, 2013). With the change in substances, the methods of recruitment and their use have also changed. The assumption is that combination of drugs increases the health risk much more compared to a single drug, e.g., alcohol and cocaine increase cardiovascular toxicity (Snenghi et al., 2015); alcohol or depressant drugs, when taken with opioids, lead to an increased risk of overdose; opioids or cocaine taken with ecstasy or amphetamines also result in additional acute toxicity. Benzodiazepines are notorious for causing death when mixed with other depressant substances, such as opioids, alcohol, or barbiturates (Kelly et al., 2015). The unpredictability of the effect, due to the use of several substances randomly mixed, makes the substance use more attractive. Instead of looking for a specific effect, as was the case with the use of a single drug, polyusers seek the maximum alteration of consciousness and loosening of inhibitions (the so-called garbage head syndrome), which makes it much easier to achieve the euphoria. The new phenomenology of the “culture” of the buzz calls for a re-thinking by the therapists and experts in the field in order to promote various forms of integration between professionals and to calibrate new methods of intervention.