Welcome to my blog, a place to explore and learn about the experience of running a psychiatric practice. I post about things that I find useful to know or think about. So, enjoy, and let me know what you think.

Tuesday, January 21, 2014

The Rest of the Meeting

As much as I enjoy the annual APSaA meeting at the Waldorf, I find it exhausting. So I only have three more groups to write about, because that's all I could manage to get myself to.

D. W. Winnicott
1. A Winnicottian Approach to the Treatment of Children and Adults with Asperger’s Syndrome: The Psychic Impact of Neurological Difference

This was another case-based group, so I'll have to stick to theory. A member of the British "middle school" (that's halfway between the Kleinians and the Freudians), Winnicott was a quintessentially British pediatrician. He had a drawing game he would play, particularly with children, where he would begin a drawing, and the child would add something, and they'd take turns, until he got a sense of what was happening emotionally for the child. His intuition with patients was astonishing. In The Piggle, he writes about his treatment of a young girl who went by the nickname, "Piggle". Her family lived far from him, so there were long stretches when they weren't meeting regularly. After one of those periods, she came to his office, and as soon as he opened the door and looked at her, he knew, without being told, that she needed to be called by her real name from then on.
Winnicott's writing is a little strange. His style is clear, but his concepts are often paradoxical. He was the originator of the term and concept, "transitional object", which he describes as an object that exists somewhere between fantasy and reality:

...the third part of the life of a human being, a part that we cannot ignore, is an 
intermediate area of experiencing, to which inner reality and external life both contribute.

If you've never read the paper, link to it, above. It's worth the time and effort.

He also originated the concepts of the "good enough mother", and the "holding environment". It's this last that is relevant for the treatment of Aspergers, or Autism Spectrum ( a term I seriously dislike, for reasons I can't get into).

Basically, the mother (or whoever is in that role) creates a safe, controlled environment for the baby, using her affection, often physical, and empathy for containment. "Spectrum" babies have great difficulty tolerating that kind of interaction, which they experience as intrusive. So from the get-go, things are different for those babies.

The presentation was about coming at the treatment from this perspective, and a lot of the focus was on helping the patient deal with the anxiety that goes with interacting with the world, for those with Aspergers, including pharmacological.

Nuff said.

2. Facing the Facts: Self-Disclosure and the Analytic Relationship

This group dovetailed nicely with the one about  the Analyst's Experience of Loss and Death, but it had a very different feel to it. There was something going on with the group, or the presentation maybe, that created a different environment in the room, so that people were not particularly forthcoming with their own experiences surrounding self disclosure.
There's always the tension between how much one tells ones patients about oneself, and how much one withholds. And either side can constitute a technical error. One thing that's difficult for people to talk about is the degree of sadism that exists in withholding information from patients. It's hard to remain cognizant of that, and at the same time, remember that there are good technical reasons not to tell the patient much about oneself. And I think that discomfort played out in the group discussion.

3. Research in Psychoanalysis: Concepts and Methodology of Single Case Research: the On-Line Archive

I was really excited about this group, and unlike the psychotherapy training group, I was not disappointed.

I've been thinking about this for a while. The typical analytic paper involves an initial section about the general topic, say, perversion,  with some relevant literature referenced, followed by a case presentation, including process, and finally a discussion. So what you're talking about here is an "n of 1".
The thing is, there are a boatload of "n's of 1" out there, so why not combine them into something analogous to a meta-analysis.

Well, this is happening. And it's called a "Meta-Synthesis"(qualitative, rather than quantitative). A group from the University of Ghent, in Belgium, is doing this work. They've compiled a whole bunch of single cases, and are starting to mine the data these cases generate.

They have a website, in English, called the Single Case Archive, where you can sign up for free, and search for different parameters within papers that have already been published. It's still pretty primitive, but it's expanding.

At the meeting, the Ghent people started out talking about why they decided to do this work. They were concerned about the overestimation of the quality of measures. In particular, with convergent validity. They modeled this, and it turned out that, if there are three different outcome measures used for the same data, the convergent validity is extremely poor (correlation coefficient 0.0-0.45).

They also modeled the impact of the measurement error, and it turns out to be abysmal.
Say you have a perfect measure, and you use it to measure 2 variables, x and y, and it turns out that x and y have a 0.60 correlation. If you then re-measure using a measure with a 0.45 correlation with the first, perfect measure, you will find that there is only a 0.12 correlation between x and y. So the true correlation between x and y is 0.60, but with a crappy measure, it looks like it's 0.12.
They figured this out with something called "Spearman's Disattenuation Formula".

One of the speakers showed a graph of a treatment, where interpersonal factors were being measured. There was an unequivocal improvement in the patient's ratings over the course of the treatment. However, this happened to be the speaker's patient, and he knew that the treatment was a disaster, and that the reason her interpersonal measures improved was that she was completely isolating herself.

So context is key, and you don't get that kind of data from a checklist. You get it from a detailed description. I can't wait to see where this research goes.

Well, that's my take on this year's meeting. Signing off.