Three
articles I came across this month have implications for treatment. Two relate to the care of adolescents and one
to the possibility for positive change to take place with adults during
incarceration that may be a relevant target for reinforcement post
incarceration.
Mattos, Henderson, Schmidt, & Hogue (2017)
Looked into the role that the therapeutic alliance plays in the engagement and
treatment outcome of conduct disturbed adolescents that present with
callous-unemotional (CU) traits; disregard of the feelings of others, blunted
affect and little concern for the effect their actions have on others. Literature cited indicates that these youth
generally have a greater expectation of positive outcomes for aggressive
behaviors and, in fact callousness in adolescents has been found to predict
psychopathy evaluations later in life (Burke, Loeber & Lahey, 2007). While this is the case, youth higher in CU
traits have been found to have better problem solving, relationship and verbal
intelligence skills than similarly acting out youth that do not present with CU
traits. Conduct disordered youth high in
CU traits have also been found to be better at forming a therapeutic alliance
than their low CU trait counterparts but the alliances formed under this
condition did not necessarily translate into improved outcomes; it is suggested
that high CU trait engagement may have a manipulative intent.
As with these
previous studies, the Mattos (2017) team found that high CU trait youth rated
therapeutic alliances more positively supporting previous findings that those
with high CU traits have an improved ability to form a positive working alliance. Inconsistent with previous findings, the
Mattos team found that high CU trait youth reporting a poor working alliance also
had poorer outcomes (fewer reductions in delinquent acts), while those reporting
a positive alliance showed significant improvements (reduced delinquent acts).
These are
clearly contradictory findings and the Mattos team did not suggest a reason for
the contradiction. The work of Matthews
(2014) and others may have some insight into a possible reason for the
different outcomes. He cites previous
research that suggests that there are differences in the rational decision
making traits and skills of psychopaths where some may
act impulsively and lack an ability to connect with their own self-interest
whereas others may be acting fully rationally and on the basis of a “means by
any ends” self interest without regard for others. The difference in outcome between the studies
above may relate to the facilitation of a functional engagement that allows for
making a meaningful connection between improvements in behavior, social
consciousness and personal self interest.
It would seem that we have an even better opportunity with adolescents
to turn this corner by working closely with developmental impulsivity as well
as with an improved understanding of individual self interest to facilitate better
ways for adolescents to get what it is that they want out of life both short
and long term. Again it appears that a
solid working alliance is key to making this happen.
Burke, J. D., Loeber, R., & Lahey, B. B.
(2007). Adolescent conduct disorder and interpersonal callousness as predictors
of psychopathy in young adults. Journal
of Clinical Child and Adolescent Psychology, 36(3),
334-346. http://dx.doi.org/10.1080/15374410701444223
Matthews, E. (2014). Psychopathy and moral
rationality. In T. Schramme (Ed.), Philosophical
psychopathology. Being amoral: Psychopathy and moral incapacity (pp.
71-89). Cambridge, MA: MIT Press.
Mattos, L. A., Schmidt, A. T., Henderson, C.
E., & Hogue, A. (2017). Therapeutic alliance and treatment outcome in the
outpatient treatment of urban adolescents: The role of callous–unemotional
traits. Psychotherapy, 54(2),
136-147. http://dx.doi.org/10.1037/pst0000093
Lawrence,
Nangle, Schwartz-Mette, & Erdley (2017) reviewed the literature on the use
of medications for adolescent depression and provided practical suggestions for
the clinical practice of non-prescribers.
They found that only SSRIs have been found to be effective in treating
depression in youth, but that response rates are similar to the response
experienced for adults; approximately 60% respond positively. They also found that 50% of depressed youth
also respond to placebo, and the fact that that response to an active drug is
greater than placebo is significant.
Taking all of this into consideration, the exact mechanism that reduces
depression is not clear. For example,
“…70 to 87% of symptom reduction seen in antidepressant groups is also seen in
placebo groups.” The Lawrence team cited
outcome measures selected, inadequate study design, and publication bias
against studies with null or negative findings left out of meta-analyses as
well founded reasons to raise the question of whether SSRIs do in fact
outperform placebo.
Whether
antidepressants or psychotherapy (Cognitive Behavioral, or Interpersonal for
adolescents, CBY, IPT) individually or in combination are superior was also not
clear in research reviewed and further research was called for. One study suggested that adding CBT to antidepressant
therapy may improve treatment response, but this did not result in greater
improvement over time. It was also
suggested that the combination may result in reduced relapse rates and allow
for lower dose medication. In
combination, the findings of studies comparing psychotherapy, antidepressants
and their combination were found to be inconsistent in part because of
different outcomes reported and inconsistent follow-up times.
There is also
little known about how antidepressants affect rates of depression relapse. There was one trial that suggested that
fluoxetine may lower relapse risk, but contra indications that antidepressants
actually increase the risk of relapse over placebo and CBT interventions were
cited. A theory of why this proposed by
Whitaker (2015) is cited suggesting that the increased relapse risk may be based
in a “compensatory adaptation” where the brain adapts to the SSRI blocking of
serotonin uptake that make more available, by reducing natural serotonin
production. In contrast to this, it is
also interesting to note that “…no research has found a causal link between
serotonin deficits and depression.”
While this is
the case, the FDA has approved two antidepressants for use with youth. Fluoxetine (Prozac) is approved for 8-17 year
olds and escitalopram (Lexapro) for 12-17 year olds. These two approvals were based on FDA rules
requiring at least two adequately completed clinical trials showing a
significant difference between drug and placebo. There appear to be some loop holes in this
process however, as the review of other studies, length of study, amount of
symptom change, statistical difference (significance defined) and the fact that
most of these studies are completed by the drug manufacturers are not taken
into consideration in this process.
In 2005 the
FDA convened a panel of experts to respond to concerns raised that
antidepressants may increase the risk of suicidality in youth. The panel concluded that there was an
increased risk and a black box warning was added to all antidepressants
relating this increased risk with youth.
While this is the case, the panel’s decision is not consistent with
empirical evidence that there is not an increased risk; Wagner (2005) found the
risk to be 4% in antidepressant treated youth and 2% in those treated with
placebo. The 2% difference does not rise
to the level of significance. It is also
suggested that the black box warning may have had a chilling effect overall on
the treatment of youth depression; depression diagnoses with youth decreased
after the warning was implemented and suicides increased.
So what does
this mean for us non prescribing mental health clinicians? It seems many of us are not comfortable
discussing medications out of fear of crossing some ethical boundary relating
to scope of practice. While this is a
healthy attitude it is also short cited from the standpoint of our
responsibility to take a whole person perspective on the individuals in our
care. This includes our staying current
with all aspects of mental health treatments including the potential benefits
of medication when other therapies are not working. We can and should be able to communicate
effectively about the potential efficacy and downsides of medications in
relation to the problems that our clients are dealing with. After all, they are likely already looking
things up on the internet and we should be able to serve as filters to help
them better understand what it is they are finding. This is also remembering that clients are
ultimately responsible for making treatment decisions and that we can help them
in that process by providing relevant information including knowing when a
consult with a prescribing practitioner is called for.
We also need
to be able to collaborate effectively with prescribers and it is important that
we be able to communicate with them in terms and ways that they will
understand. We most likely see our
clients far more frequently than prescribers and thus are in a better position
to monitor to see if medications prescribed are working as they should. When we communicate our observations and
concerns in language that a prescriber is used to, we strengthen that
relationship, make it more likely that appropriate actions will be taken and
our clients ultimately get better care.
Lawrence, H. R.,
Nangle, D. W., Schwartz-Mette, R. A., & Erdley, C. A. (2017). Medication
for child and adolescent depression: Questions, answers, clarifications, and
caveats. Practice
Innovations, 2(1), 39-53. http://dx.doi.org/10.1037/pri0000042
Wagner, K. D. (2005). Pharmacotherapy for
major depression in children and adolescents. Progress in Neuro-Psychopharmacology & Biological
Psychiatry, 29(5), 819-826. http://dx.doi.org/10.1016/j.pnpbp.2005.03.005
Vanhooren, Leijssen & Dezutter (2017) interviewed 10-
prisoners to build on previous literature that indicated differences in
offender post incarceration recidivism were related to the continuation of
empty meanings vs. the development of “self-transcendent values and the desire
to mean something for others. “ They
wanted to find out if the development of new meaning is related to the losses
experienced and the possible way that prisoners cope as a pathway to
posttraumatic growth; experienced loss, search for and the finding of new
meaning through an experience of existential guilt and despair that leads to an
ability to choose otherwise and to take responsibility through a new or renewed
self efficacy.
They did in fact find that the experience of incarceration
after the commission of a crime was initially experienced as dehumanizing;
physical discomfort, concerns for safety, and harsh treatment by prison guards
was found to lead to despair and a more general loss of meaning in life. Being imprisoned also appears to reinforce
guilt and shame. Inevitably these
prisoners struggled to cope primarily through seeking social and emotional
support and the minds work to make sense of and give meaning to their
experiences. More pragmatic coping
included the avoidance of contact with other prisoners, isolating/ sleeping
more and the use of drugs and medications.
Given a great deal of unstructured time, these prisoners began to
reflect on the meaning of their lives, found emotional support in religious
pursuits and engagement in therapy; coping became a matter of exercising
choice, the facilitation of a sense of
self efficacy and an improved sense of self worth. Collectively the experiences appear to have
shed light on histories that suggest an avoiding the task or I-it approach to engaging
life vs. the practice of an I-thou true engagement with life; improved self
worth, autonomy, connectedness, responsibility to, acceptance of and openness and these processes
appear to suggest that post traumatic growth actually positively affects what
otherwise may be seen as relatively fixed personality traits.
While the collective literature suggests that post traumatic
growth could take place, it does not necessarily have to and the question is
raised as to whether it can be facilitated in any way. While this is a question for further
research, it would seem to make sense for post incarceration treatment and
rehabilitation settings to assess for and reinforce any post traumatic growth identified. This might be accomplished by exploring the
Vanhooren team findings in a series of groups or individual sessions, or therapy
exploring:
- · Insight into one’s personal story and dynamics – shift in past experience of self and current
- · Levels of self worth – ratings and descriptions of self respect, self care and felt autonomy
- · Perceived strengths – perceptions of seeking and accepting help, conscientiousness, responsibility for and to
- · Ways of thinking – narrow, impulsive vs. expanded and nuanced
- · Meaning in life, and
- · Continued struggles and anxieties about the future
It is expected that these explorations may serve to highlight
the processes of recovery from real losses experienced, reinforce some of the
resilience skills that served that coping, and build upon new ways of being and
thinking that will support a continued recovery trajectory.
Vanhooren, S., Leijssen, M., & Dezutter,
J. (2017). Ten prisoners on a search for meaning: A qualitative study of loss
and growth during incarceration. The Humanistic
Psychologist, 45(2), 162-178. http://dx.doi.org/10.1037/hum0000055
