Building a truer self with Alex: a dialogue between authors about clinical case material

One of the challenges of psychoanalytic therapy with young children is finding more adaptive channels for the symbolic expression of bodily and feeling states expressed in motoric, sensory or visceral forms. The following case study, written in the format of a dialogue between the first and second authors as the article was being prepared, depicts processes of psychic transformation in twice weekly psychoanalytically-oriented psychotherapy with a 5 year old boy as he tried to linguistically integrate and represent his negative feelings and anxieties. Initially his emotions were aroused in pre-symbolic form dominated by sensory and somatic experiences that were disconnected from objects, events and words. The authors each reflect on Alex’s therapy experience as well as the specific kinds of therapeutic interventions that provided the opportunity for containing and transforming Alex’s emotional life. They conclude that as Alex’s threatening emotions were linked to objects and events in the play, a substantial emotional growth took place towards a shift to a greater capacity to comfortably maintain a “Truer Self”

Ebeveyn Gelişim Görüşmesi Üzerinden Yapılan Yansıtıcı İşleyiş Kodlama Sisteminin Psikometrik Özellikleri

Ebeveynin yansıtıcı işleyişi kendisi, çocuğu ve ikisi arasındaki ilişkiye dair zihin durumları hakkında düşünebilme, bunları birbirine bağlayabilme ve etkilerini tahmin etme becerisidir. Bu çalışmada, Ebeveyn Gelişim Görüşmesi üzerinden yapılan yansıtıcı işleyiş kodlama sisteminin psikometrik özellikleri incelenmiştir. Çalışmaya bir üniversite kliniğinde psikoterapi hizmetine başvurmuş 115 anne (Ortyaş = 36.01 yaş, SS = 4.96) ve çocukları (Ortyaş = 6.99 yaş, SS = 2.09, %41.7 kız) katılmıştır. Ebeveynlerle Ebeveyn Gelişim Görüşmesi yapılmış, görüşme yansıtıcı işleyiş kapasitesi kodlama sistemi üzerinden değerlendirilmiştir. Ayrıca, ebeveynlerin sosyo-demografik bilgileri ve bağlanma stili ile çocukların duygu düzenlemesi, ifade edici dil becerisi, çocukluk çağı deneyimleri ve davranış sorunları ile ilgili bilgiler toplanmıştır. Açımlayıcı ve Doğrulayıcı Faktör analizi sonuçları üç faktörlü bir yapı ortaya çıkarmış ve her faktörün iç tutarlılık değerlerinin yeterli olduğu görülmüştür. Bunlar kavramsal olarak, çocuk- (ebeveynin çocuğunun duygularını yansıtıcı işleyiş kapasitesi), ilişki- (ebeveynin anne-çocuk arasındaki ilişkiyle ilgili yansıtıcı işleyiş kapasitesi) ve kendi-odaklı (ebeveynin kendi duygularını yansıtıcı işleyiş kapasitesi) faktörler şeklinde isimlendirilmiştir. Çocuk-odaklı yansıtıcı işleyiş kapasitesi sosyoekonomik durum ile pozitif yönde ilişkilidir. İlişki-odaklı yansıtıcı işleyiş kapasitesi ebeveynin kaçınmacı bağlanma stili, eğitim seviyesi, sosyoekonomik durumu, annenin sahip olduğu çocuk sayısı ve çocuğun olumlu ve olumsuz deneyimleri ile ilişkilidir. Kendi-odaklı yansıtıcı işleyiş kapasitesi ise annenin sahip olduğu çocuk sayısı, çocuğun ifade edici dil becerisi, duygu düzenlemesi ve dışsallaştırma sorunlarıyla ilişkilidir. Sonuçlar Ebeveyn Gelişim Görüşmesi üzerinden yapılan yansıtıcı işleyiş kodlama sisteminin Türkiye’deki klinik örneklemde kendi-ve ilişki-odaklı yansıtıcı işleyiş kapasitesini ölçmek için yeterli olabileceğini, çocuk-odaklı yansıtıcı işleyiş kapasitesini ölçmek için geliştirilmesi gerektiğini göstermektedir.Publisher's Versio

The Non-linear Trajectory of Change in Play Profiles of Three Children in Psychodynamic Play Therapy

Aim: Even though there is substantial evidence that play based therapies produce significant change, the specific play processes in treatment remain unexamined. For that purpose, processes of change in long-term psychodynamic play therapy are assessed through a repeated systematic assessment of three children's "play profiles," which reflect patterns of organization among play variables that contribute to play activity in therapy, indicative of the children's coping strategies, and an expression of their internal world. The main aims of the study are to investigate the kinds of play profiles expressed in treatment, and to test whether there is emergence of new and more adaptive play profiles using dynamic systems theory as a methodological framework. Methods and Procedures: Each session from the long-term psychodynamic treatment (mean number of sessions = 55) of three 6-year-old good outcome cases presenting with Separation Anxiety were recorded, transcribed and coded using items from the Children's Play Therapy Instrument (CPTI), created to assess the play activity of children in psychotherapy, generating discrete and measurable units of play activity arranged along a continuum of four play profiles: "Adaptive," "Inhibited," "Impulsive," and "Disorganized." The play profiles were clustered through K-means Algorithm, generating seven discrete states characterizing the course of treatment and the transitions between these states were analyzed by Markov Transition Matrix, Recurrence Quantification Analysis (RQA) and odds ratios comparing the first and second halves of psychotherapy. Results: The Markov Transitions between the states scaled almost perfectly and also showed the ergodicity of the system, meaning that the child can reach any state or shift to another one in play. The RQA and odds ratios showed two trends of change, first concerning the decrease in the use of "less adaptive" strategies, second regarding the reduction of play interruptions. Conclusion: The results support that these children express different psychic states in play, which can be captured through the lens of play profiles, and begin to modify less dysfunctional profiles over the course of treatment. The methodology employed showed the productivity of treating psychodynamic play therapy as a complex system, taking advantage of non-linear methods to study psychotherapeutic play activity

From compulsion to structure: an empirical model to study invariant repetition and representation

Despite the central role that repetition plays in foundational analytic concepts such as instinct, transference, and regression, the presence of different kinds of repetitive forms and their relationship to representation and symbolization have only been subject to limited empirical investigation. The current article defines a continuum of repetitions from redundant, invariant repetitions, which remain closer to action, to symbolic repetitions that involve different modes of mental representation. Using a single-case study with a mixed quantitative/qualitative methodology, measures of repetition and symbolization were applied to verbatim recordings of psychoanalytic sessions. As verbs are the grammatical form that best track intention and motivation, invariant verb forms were chosen as a linguistic marker of repetition. Symbolic processes were evaluated by a computerized measure of referential activity, an empirical tool to measure imagistic language. There was an overall negative correlation between invariant repetitions and imagistic speech. Following the quantitative analysis, qualitative clinical illustrations indicated that when the patient constructed a narrative with a vivid, specific, and evocative representational structure (i.e., dream, fantasy, memory), the use of invariant repetitions decreased. Further qualitative analyses showed that a measure of repetition, when used in conjunction with a measure of symbolization, was able to identify different discourse patterns reflecting fluctuations in the patient’s thinking processes and affective states

The use of mentalization-based techniques in online psychodynamic child psychotherapy

Objective: Psychodynamic child psychotherapy is an evidence-based approach for a range of child mental health difficulties and needs to constantly adapt to meet the needs of children. This study is the first to investigate whether the use of mentalization-based interventions (i.e., a focus on promoting attention control, emotion regulation, and explicit mentalization) predicted a good therapeutic outcome in online psychodynamic child therapy sessions conducted during the COVID-19 pandemic. Methods: The sample included 51 Turkish children (Mage = 7.43, 49% girls) with mixed emotional and behavioral problems. Independent raters coded 203 sessions from different phases in each child’s treatment using the Mentalization-Based Treatment for Children Adherence Scale (MBT-CAS). Results: Multilevel modeling analyses showed children with higher emotional lability benefited more from attention control interventions compared to those with lower emotional lability. Discussion: Interventions that focus on developing the basic building blocks of mentalizing may be effective components of therapeutic action for online delivery of psychodynamic child psychotherapy, especially for children with greater emotional lability

Multimodal affect analysis of psychodynamic play therapy

Objective: We explore state of the art machine learning based tools for automatic facial and linguistic affect analysis to allow easier, faster, and more precise quantification and annotation of children’s verbal and non-verbal affective expressions in psychodynamic child psychotherapy. Method: The sample included 53 Turkish children: 41 with internalizing, externalizing and comorbid problems; 12 in the non-clinical range. We collected audio and video recordings of 148 sessions, which were manually transcribed. Independent raters coded children’s expressions of pleasure, anger, sadness and anxiety using the Children’s Play Therapy Instrument (CPTI). Automatic facial and linguistic affect analysis modalities were adapted, developed, and combined in a system that predicts affect. Statistical regression methods (linear and polynomial regression) and machine learning techniques (deep learning, support vector regression and extreme learning machine) were used for predicting CPTI affect dimensions. Results: Experimental results show significant associations between automated affect predictions and CPTI affect dimensions with small to medium effect sizes. Fusion of facial and linguistic features work best for pleasure predictions; however, for other affect predictions linguistic analyses outperform facial analyses. External validity analyses partially support anger and pleasure predictions. Discussion: The system enables retrieving affective expressions of children, but needs improvement for precision

The misleading Dodo Bird verdict. How much of the outcome variance is explained by common and specific factors?

The literature on psychotherapy research makes use of the so-called "Dodo Bird Verdict" to show that therapeutic change owes more to common factors than to specific techniques. According to the bulk of the empirical literature, common factors explain 30–70% of therapy outcome variance, while specific factors account for between 5% and 15%. This formulation is based on the assumption that common and specific factors are independent of each other. The present study uses a systematic review of the literature to empirically demonstrate that common and specific factors of change are actually correlated. In other words, the prevalent practice in the literature of using correlated common and specific factors as independent predictors in classical ANOVA models is both statistically unsound and conceptually distorted. We offer several alternative proposals for a sensible reevaluation of the Dodo Bird verdict

Monitoring nonlinear dynamics of change in a single case of psychodynamic play therapy

A systematic single case study with a mixed quantitative and qualitative methodology was conducted to investigate the nonlinear dynamics of change in play profiles of a child in psychodynamic play therapy. The first aim of the study was to cluster the different features of play characteristics (i.e., descriptive, cognitive, affective, and social characteristics of play, and the defensive strategies used in play) in order to construct the different play profiles of this child, and secondly to assess the transitions between profiles over the course of treatment. It was expected that there would be an increase in critical fluctuations during the transitions between the profiles and an increase in the variability of play profiles. Results showed that the child's play characteristics clustered into eight states and three attractors. The Markov Transition Matrix showed how play profiles evolved over time. Entropy analyses comparing the first and the second half of therapy showed an increase in variability. Qualitative analyses indicated the importance of expression of the child's underlying fear, and its integration with overt anger in the generation of the new play profiles. The results indicate an increase in variability, and a destabilization of old play profiles that were used towards generating new play profiles