Positioning Shifts From Told Self to Performative Self in Psychotherapy

According to Positioning Theory, participants in narrative interaction can position themselves on a representational level concerning the autobiographical, told self, and a performative level concerning the interactive and emotional self of the tellers. The performative self is usually much harder to pin down, because it is a non-propositional, enacted self. In contrast to everyday interaction, psychotherapists regularly topicalize the performative self explicitly. In our paper, we study how therapists respond to clients' narratives by interpretations of the client's conduct, shifting from the autobiographical identity of the told self, which is the focus of the client's story, to the present performative self of the client. Drawing on video recordings from three psychodynamic therapies (tiefenpsychologisch fundierte Psychotherapie) with 25 sessions each, we will analyze in detail five extracts of therapists' shifts from the representational to the performative self. We highlight four findings:• Whereas, clients' narratives often serve to support identity claims in terms of personal psychological and moral characteristics, therapists rather tend to focus on clients' feelings, motives, current behavior, and ways of interacting.• In response to clients' stories, therapists first show empathy and confirm clients' accounts, before shifting to clients' performative self.• Therapists ground the shift to clients' performative self by references to clients' observable behavior.• Therapists do not simply expect affiliation with their views on clients' performative self. Rather, they use such shifts to promote the clients' self-exploration. Yet, if clients resist to explore their selves in more detail, therapists more explicitly ascribe motives and feelings that clients do not seem to be aware of. The shift in positioning levels thus seems to have a preparatory function for engendering therapeutic insights.Peer reviewe

The relationship between alexithymia and salivary cortisol levels in somatoform disorders

The purpose of this study was to investigate cortisol levels as a function of the hypothalamic-pituitary-adrenal axis (HPA) in relation to alexithymia in patients with somatoform disorders (SFD). Diurnal salivary cortisol was sampled in 32 patients with SFD who also underwent a psychiatric examination and filled in questionnaires (Toronto Alexithymia Scale, TAS scale; Screening for Somatoform Symptoms, SOMS scale; Hamilton Depression Scale, HAMD). The mean TAS total score in the sample was 55.69.6, 32% of patients being classified as alexithymic on the basis of their TAS scores. Depression scores were moderate (HAMD=13.2, Beck Depression Inventory, BDI=16.5). The patients' alexithymia scores (TAS scale Difficulty identifying feelings) correlated significantly positively with their somatization scale scores (Symptom Checklist-90 Revised, SCL-90-R); r=0.3438 (P0.05) and their scores on the Global Severity Index (GSI) on the SCL-90-R; r=0.781 (P0.01). Regression analysis was performed with cortisol variables as the dependent variables. Cortisol levels [measured by the area under the curve-ground (AUC-G), area under the curve-increase (AUC-I) and morning cortisol (MCS)] were best predicted in a multiple linear regression model by lower depressive scores (HAMD) and more psychopathological symptoms (SCL-90-R). No significant correlations were found between the patients' alexithymia scores (TAS) and cortisol levels. The healthy control group (n=25) demonstrated significantly higher cortisol levels than did the patients with SFD; in both tests P0.001 for AUC-G and AUC-I. However, the two groups did not differ in terms of their mean morning cortisol levels (P0.05). The results suggest that pre-existing hypocortisolism might possibly be associated with SFD

Psychosomatic Medicine in Germany

Psychosomatic medicine developed in Germany after the Second World War as a multifaceted system of inpatient, day-patient, and outpatient treatment. The conceptual roots of post war psychosomatic medicine in Germany were in internal medicine (Victor von Weizäcker and Thure von Uexkuell) and in the psychodynamic and psychoanalytic tradition of G. Engels, Franz Alexander, and others. The implementation of psychosomatic medicine as a speciality of medicine in addition to psychiatry supported an integration of psychotherapeutic methods and interventions in medicine. Consultation-liaison (CL) services have contributed to the dissemination of psychosocial skills and interventions in the medical setting. Psychosomatic basic care curricula have improved the recognition  and treatment of psychosomatic problems and disorders in primary care

Pain, Affect, and Attachment

Various psychodynamic processes may underlie the development of psychogenic pain disorder such as conversion, the displacement of affect, or narcissistic defenses. However, many of the processes suggested are related to a disorder of affect regulation. The term affect regulation in psychoanalytic literature refers to phenomena which are often described by the concept of alexithymia. Empirical observations suggest that alexithymia is correlated to insecure attachment, especially an insecure dismissing representation of attachment. Psychodynamic psychotherapy in psychogenic pain disorder should focus on the reintegration of split-off affects which may provoke intensive counter-transference and which in order to be used therapeutically must be linked to attachment experiences within and outside of the therapeutic relationship.</p

From Biomedical to Psychosomatic Reasoning: A Theoretical Framework

Despite a general acceptance of the biopsychosocial model, medical education and patient care are still largely biomedical in focus, and physicians have many deficiencies in biopsychosocial formulations and care. Education in medical schools puts more emphasis on providing biomedical education (BM) than biopsychosocial education (BPS); the initial knowledge formed in medical students is mainly with a biomedical approach. Therefore, it seems that psychosocial aspects play a minor role at this level and PSM knowledge will lag behind BM knowledge. However, it seems that the integration of biomedical and psychosocial-knowledge is crucial for a successful and efficient patient encounter. In this paper, based on the theory of medical expertise development, the steps through which biomedical reasoning transforms to psychosomatic reasoning will be discussed.</div

The art of tentativity: Delivering interpretations in psychodynamic psychotherapy

In psychotherapy, therapists often formulate interpretations of clients' prior talk which are ‘unilateral’ in the sense that therapists index that they are themselves the author of an interpretive inference which may not be acceptable to the client. Based on 100 German-language recordings of brief psychodynamic psychotherapy (4 clients with 25 sessions each), we describe a multimodal practice of constructing extended multi-unit turns of delivering therapeutic interpretations. The practice includes gaze aversion until the main point of the interpretation is reached, perceptive and cognitive formulae, epistemic hedges, inserted accounts, parenthesis, self-repair, and self-reformulations. These design-features work together to index that the therapist produces an interpretation that can be heard as being tentative. The design of the therapists' turns reflexively indexes the expectation that the client might resist the interpretation; at the same time they are constructed to avoid resistance and to invite the client's self-exploration into new directions, often with a focus on emotions

The Role of Locus of Control and Attributional Style in Coping Strategies and Quality of Life among Iranian Breast Cancer and Colorectal Cancer Patients: A Pilot Study

Background: The influence of various psychological factors and coping mechanisms on quality of life (QOL) in cancer patients has been well established. We evaluated locus of control and attributional styles, and their association with coping styles and quality of life (QOL) among Iranian cancer patients. Methods: This cross-sectional study was conducted on patients with breast cancer and patients with colorectal cancer in stage I to III. Patients were assessed for demographic and disease characteristics, cancer-related symptoms, locus of control, attributional styles, coping styles, and QOL. Results: From 140 invited patients, 100 patients participated in the study. Data of 55 patients with breast cancer and 22 patients with colorectal cancer were appropriate and included for analysis (mean age of 47.5 ± 7.9 years, 89.6% female). Factors positively associated with QOL included educational level, internal locus of control, overall hopefulness, and confrontive, optimistic, and self-reliant coping styles (r = 0.228 to 0.426). Factors negatively associated with QOL included age, symptoms severity, overall hopelessness, and fatalistic and emotive coping styles (r = -0.221 to -0.674). Internal locus of control and hopefulness were associated with confrontive/adaptive coping styles (r = 0.226 to 0.381), while external locus of control and hopelessness were associated with evasive/maladaptive coping styles (r = 0.208 to 0.381). Conclusion: These results indicate that internal locus of control, hopefulness, and positive attributional styles are associated with more adaptive/confrontive coping strategies and better QOL in Iranian cancer patients. Further studies with more comprehensive psychosocial evaluation in a larger sample of cancer patients are warranted.</div