Timothy A. Carey

Psychological change from the inside looking out: A qualitative investigation

Abstract Regardless of the type of psychotherapy considered, change is the predominant goal. Psychotherapies differ in their explanations of how change occurs and what it is that needs to change, but pursuing change of something in some way is common. Psychotherapeutic methods, therefore, should be enhanced as knowledge of the change process improves. Furthermore, improving our knowledge about general principles of change may be of greater benefit to psychotherapy than increased knowledge about any particular change technique. This study addresses the questions ‘What is psychological change?’ and ‘How does it occur?’ from patients’ viewpoints. Answers to these questions were sought using qualitative methodology. At the end of treatment, 27 people were interviewed about their experience of change. Interviews were taped and transcripts analysed using the Framework approach. Change occurred across three domains: feelings, thoughts and actions. Participants described change as both a gradual process and an id...

What is Socratic questioning

To better understand Socratic questioning, the authors reviewed the literature regarding the Socratic method. Despite being regarded as a fundamentally important psychotherapeutic procedure, a great deal of discrepancy exists concerning various aspects of the method, and these incongruities are desc

An interview study investigating experiences of psychological change without psychotherapy

OBJECTIVES Given that most people who experience psychological distress resolve this distress without the assistance of psychotherapy, the study sought to increase our understanding of naturally occurring change including the facilitators of this change. DESIGN The study sought to replicate and extend earlier work in this area. The design involved recruiting participants who had experienced some form of psychological distress and had resolved this distress without accessing psychotherapy services. METHODS Qualitative methods were used for this study because the lived experience of the participants was of interest. Semi-structured interviews were used following a pro forma developed in earlier work. Interpretive Phenomenological Analysis was the analytical method adopted for this study to identify themes and patterns in the transcripts of the interviews of the participants. RESULTS Data analysis identified the themes of identity, connection, threshold, desire to change, change as a sudden and gradual process, and thinking process. An unexpected finding was the subjectivity associated with deciding whether or not a problem had actually resolved. CONCLUSIONS The results are discussed in terms of their implications for clinical practice including the apparent importance of people reaching an emotional threshold prior to change. A sense of identity also appears to be important in change experiences.

A biopsychosocial model based on negative feedback and control

Although the biopsychosocial model has been a popular topic of discussion for over four decades it has not had the traction in fields of research that might be expected of such an intuitively appealing idea. One reason for this might be the absence of an identified mechanism or a functional architecture that is authentically biopsychosocial. What is needed is a robust mechanism that is equally important to biochemical processes as it is to psychological and social processes. Negative feedback may be the mechanism that is required. Negative feedback has been implicated in the regulation of neurotransmitters as well as important psychological and social processes such as emotional regulation and the relationship between a psychotherapist and a client. Moreover, negative feedback is purported to also govern the activity of all other organisms as well as humans. Perceptual Control Theory (PCT) describes the way in which negative feedback establishes control at increasing levels of perceptual complexity. Thus, PCT may be the first biopsychosocial model to be articulated in functional terms. In this paper we outline the working model of PCT and explain how PCT provides an embodied hierarchical neural architecture that utilizes negative feedback to control physiological, psychological, and social variables. PCT has major implications for both research and practice and, importantly, provides a guide by which fields of research that are currently separated may be integrated to bring about substantial progress in understanding the way in which the brain alters, and is altered by, its behavioral and environmental context.

Patients taking the lead. A naturalistic investigation of a patient led approach to treatment in primary care

In an earlier paper (Carey, T. A. (2005). Can patients specify treatment parameters? A preliminary investigation. Clinical Psychology and Psychotherapy, 12, 326–335) an approach to treatment delivery was examined in which the duration and frequency of the appointments was scheduled by patients. Results of this approach were encouraging but the generalizability of the results was constrained because only one clinician trialed the approach and no standardized assessment measures were used. In the present study there are two clinicians involved and the Depression Anxiety Stress Scale (DASS) was used. The approach was introduced at one GP practice and monitored over a six-month period. Results suggest that this approach might be an effective way of promoting patient access to, and involvement in, service delivery as well as reducing waiting times.

Spare the rod and spoil the child. Is this a sensible justification for the use of punishment in child rearing

This paper examines the validity of the well-used proverb Spare the rod and spoil the child. To do this, the original form of the proverb from the Bible is compared with the modern form, and some significant differences are highlighted. The definition of punishment is considered, and the differences between punishment and corporal punishment are examined. Punishment is explored in some detail with attention given to the criteria that need to be satisfied in order for punishment to be effective. Discrepancies in the literature concerning these criteria are pointed out, making punishment a complex issue. The negative effects of punishment are significant with links to social problems such as teenage delinquency and violence. Reference is made to cultures where corporal punishment has been banned and the effects of this action. Given the problems associated with punishment programs, especially those being used in families, alternatives to punishment are discussed. Finally, an alternative form of the proverb to the current adaptation is offered.

A qualitative study of a social and emotional well-being service for a remote Indigenous Australian community: implications for access, effectiveness, and sustainability

BackgroundPeople living in rural and remote Australia experience increased mental health problems compared with metropolitan Australians. Moreover, Indigenous Australians are twice as likely as non Indigenous Australians to report high or very high levels of mental health problems. It is imperative, therefore, that effective and sustainable social and emotional wellbeing services (Indigenous Australians prefer the term “social and emotional wellbeing” to “mental health”) are developed for Indigenous Australians living in remote communities. In response to significant and serious events such as suicides and relationship violence in a remote Indigenous community, a social and emotional wellbeing service (SEWBS) was developed. After the service had been running for over three years, an independent evaluation was initiated by the local health board. The aim of the evaluation was to explore the impact of SEWBS, including issues of effectiveness and sustainability, from the experiences of people involved in the development and delivery of the service.MethodsPurposive sampling was used to recruit 21 people with different involvement in the service such as service providers, service participants, and referrers. These people were interviewed and their interviews were transcribed. Interpretative Phenomenological Analysis (IPA) was used to analyse the interview transcripts to identify superordinate themes and subthemes in the data.ResultsTwo superordinate themes and nine subthemes were developed from the interview transcripts. The first superordinate theme was called “The Big Picture” and it had the sub themes: getting started; organizational factors; funding; the future, and; operational problems. The second superordinate theme was called “On the Ground” and it had the subthemes: personal struggles; program activities; measuring outcomes, and; results.ConclusionsWhile the evaluation indicated that the service had been experienced as an effective local response to serious problems, recommendations and directions for future research and development emerged that were more broadly applicable. Issues such as appropriate staffing, localising decision making, identifying priorities and how they will be evaluated, and developing flexibility in terms of job descriptions and qualifications are highlighted.

What's therapeutic about the therapeutic relationship? A hypothesis for practice informed by Perceptual Control Theory

Evidence clearly suggests that the therapeutic relationship is important to successful outcomes in psychotherapy. It is less clear as to why this might be the case. Throughout the literature, various factors such as warmth, empathy, compassion, unconditional positive regard, and openness are identified as key. The way in which factors such as warmth and empathy bring about an amelioration of psychological distress, however, is not entirely obvious. We suggest that one possible mechanism through which these factors become important is by helping to create an environment where clients can examine their problems freely. Furthermore, we propose that when the therapeutic relationship is therapeutic, clients feel comfortable to consider whatever comes into their mind; with any filtering or evaluating happening after the ideas have been expressed, and not before. Psychological processes identified as maintaining psychological distress (e.g. thought suppression, avoidance, rumination) block this capacity. Our suggestion is that as internal experiences are being examined, the client has an opportunity to become aware of facets of the problem that were previously unattended to; and to continue this process outside therapy. Through this awareness-raising process the client?s problem can be reorganised via intrinsic learning processes to achieve a more contented state of mind.

Some Problems with Randomized Controlled Trials and Some Viable Alternatives

UNLABELLED Randomized controlled trials (RCTs) are currently the dominant methodology for evaluating psychological treatments. They are widely regarded as the gold standard, and in the current climate, it is unlikely that any particular psychotherapy would be considered evidence-based unless it had been subjected to at least one, and usually more, RCTs. Despite the esteem within which they are held, RCTs have serious shortcomings. They are the methodology of choice for answering some questions but are not well suited for answering others. In particular, they seem poorly suited for answering questions related to why therapies work in some situations and not in others and how therapies work in general. Ironically, the questions that RCTs cannot answer are the questions that are of most interest to clinicians and of most benefit to patients. In this paper, we review some of the shortcomings of RCTs and suggest a number of other approaches. With a more nuanced understanding of the strengths and weaknesses of RCTs and a greater awareness of other research strategies, we might begin to develop a more realistic and precise understanding of which treatment options would be most effective for particular clients with different problems and in different circumstances. Copyright

What primary health care services should residents of rural and remote Australia be able to access? A systematic review of “core” primary health care services

BackgroundThere are significant health status inequalities in Australia between those people living in rural and remote locations and people living in metropolitan centres. Since almost ninety percent of the population use some form of primary health care service annually, a logical initial step in reducing the disparity in health status is to improve access to health care by specifying those primary health care services that should be considered as “core” and therefore readily available to all Australians regardless of where they live. A systematic review was undertaken to define these “core” services.Using the question “What primary health care services should residents of rural and remote Australia be able to access?”, the objective of this paper is to delineate those primary health care core services that should be readily available to all regardless of geography.MethodA systematic review of peer-reviewed literature from established databases was undertaken. Relevant websites were also searched for grey literature. Key informants were accessed to identify other relevant reference material. All papers were assessed by at least two assessors according to agreed inclusion criteria.ResultsData were extracted from 19 papers (7 papers from the peer-reviewed database search and 12 from other grey sources) which met the inclusion criteria. The 19 papers demonstrated substantial variability in both the number and nature of core services. Given this variation, the specification or synthesis of a universal set of core services proved to be a complex and arguably contentious task. Nonetheless, the different primary health care dimensions that should be met through the provision of core services were developed. In addition, the process of identifying core services provided important insights about the need to deliver these services in ways that are “fit-for–purpose” in widely differing geographic contexts.ConclusionsDefining a suite of core primary health care services is a difficult process. Such a suite should be fit-for-purpose, relevant to the context, and its development should be methodologically clear, appropriate, and evidence-based. The value of identifying core PHC services to both consumers and providers for service planning and monitoring and consequent health outcomes is paramount.