Psychopathology: Theory and Practice II

Unit 1 – Basic Psychopathology

First, some thoughts and discussion about how we respond as therapists to a client at serious risk of suicide, a situation that tests the limits of the underlying robustness of our theory and practice and our relational resilience.

The main content of the presentation will then be on Maytree, a unique short stay (100 hours) respite (and therapy) centre for those in suicidal crisis, of which I was a co-founder, and the principal architect of its model. In expounding its genesis and vision, and the gap in services it fills, I will focus on its ethos and the core values of its practice, namely containment and compassion – the essence surely of all our work. Finally, we’ll look at outcomes, successes, failures, inviting discussion on its merits and potential.

Unit 1 – Basic Psychopathology

In his lecture on PTSD Dr Sherry will take 20 years plus of expertise within the field of psychological traumatology that has literally taken him around the world and across multiple fields of training. 

His psychological traumatology work has evolved from his seven years treating traumatized soldiers when he headed the Clinical Psychology section for US Military inpatients for Europe. As a Consultant Clinical Psychologist with neuropsychology training, he is a specialist in traumatology (ESTSS Cert and an EMDR Consultant), a licensed Psychoanalytic Psychotherapist (BPC Reg.); he will take these expert insights to shed light on this diagnosable condition from the assessment and treatment across modalities. Much of his work has looked at extreme environments including gender based violence (GBV) and genocide as well as this he did his ethics training focused on re-examining the core ethical approaches within a disaster.  

In this lecture Dr Sherry will cover some of the history of what PTSD is, the assessment and diagnostic issues, including from a psychoanalytic vantage point, and the treatment issues including some of the innovations with very low resource environments. Much of his focus on PTSD will examine the question of identity and how can we transform issues of instability through expert leadership to create profound well-being. 

Unit 1 – Basic Psychopathology

In this talk there will be a brief introduction to forensic psychiatry settings, the Criminal Justice System and how these can interact. Some individuals suffering from mental disorders can end up involved in both systems. This talk will focus on the most prevalent disorders seen within these settings and suffered by the individuals. There is often a division and indeed, segregation, made between those suffering from psychoses and those suffering from personality disorders with dual and indeed triple diagnoses being made. Carine will describe the helpfulness of using a single entity diagnostic approach, illustrating the psychopathological presence of several features, some times more manifestly psychotic and at other times more manifestly personality disordered. An emphasis on the aetiological factors, particularly early environmental traumas, will be made. Many of the presenting features can evoke strong responses in others, which can influence the management and treatment of the patients and these will be referred to. There will be descriptions of the multi-disciplinary treatment approaches with special focus on the role of psychoanalytical psychotherapy. 

Unit 2 – Sub-Clinical Psychopathology

Sian will draw on her research into phobias. She will mainly be focusing on claustrophobia and agoraphobia. 

Claustraphobia as pathological fullness and agoraphobia as pathological emptiness, both defences against painful traumatic and unmourned losses, leading to a constriction of both internal and external space. She will explore the notion of transitional space within which loss and emptiness can be borne and transformed through the expression of creativity. 

Unit 2 – Sub-Clinical Psychopathology

Men and women diagnosed as suffering from personality disorders or those described as psychopathic or sociopathic commit the vast majority of serious offences, whether murder, arson, rape, paedophilia, or theft. But many individuals who do not function as formally identified forensic patients will, nevertheless, often perpetrate “unconscious crimes”, expressing violence – often deadly violence – through so-called “accidents”, whether by pushing loved ones down staircases, by transmitting infectious diseases, by killing family members through neglect, and so forth. In this seminar, Professor Brett Kahr will introduce the notion of “sub-clinical psychopathy”, exploring the unconscious motives and the manifestations of those who struggle with profound death wishes and who, in spite of a lack of a formally diagnosable mental illness, will, nevertheless, cause great harm.

Unit 2 – Sub-Clinical Psychopathology

In this talk, Gwen will discuss the implications of attachment theory for the understanding of those mental states which are involved in the commission of violent offending. There is growing evidence that early childhood adversity is a potent risk factor for persistent and severe violent crime. Gwen will explore how childhood adversity leads to disorganised attachment systems; and the parallel disorganisation of how relationships and the people in those relationships are represented in the mind. Specifically, Gwen will discuss the importance of attachment narratives; and the language that offenders use to describe themselves, their offences and their victims. Gwen will conclude with what these findings might imply for interventions for offenders and the services in which they are provided; and discuss recent relevant research.

Unit 2 – Sub-Clinical Psychopathology

Freud provided many interesting observations and perspectives in his classic 1914 paper On Narcissism. These were developed further in Kohut’s 1966 paper Forms and Transformations of Narcissism, in which he proposed a separate line of development of narcissism, from primitive to mature. The concept of narcissistic personality disorder did not emerge until the writings of Kernberg and Kohut in the 1970s. These authors presented contrasting, and seemingly incompatible views, a confusion compounded by their use of the same term (grandiose self) to mean quite different things – for Kohut a natural feature of childhood, for Kernberg a pathological structure consisting of a fusion of images of actual self, ideal self, and ideal other.

These contrasting visions of narcissism were later mirrored in Rosenfeld’s concepts of “thin-skinned” and “thick-skinned” narcissists. Rosenfeld observed that treating the “thin-skinned” narcissist as if they were “thick-skinned” could be very damaging. During the 1980s and 1990s, cognitive therapists, and schema therapists, began to develop concepts of narcissistic personality disorder, and the term became increasingly widely used – sometimes pejoratively and simplistically. This teaching will outline some of the core narcissistic dilemmas we all must navigate during childhood – and how these can become particularly pronounced in certain conditions, including ADHD. The realm of narcissism also interfaces with problems of human identity – and the ubiquitous tendency to become falsely identified with culturally and familiarly presented images.

Children and adults with an intellectual disability are more vulnerable to external trauma. In addition, the disability itself is difficult to emotionally process. This seminar reveals the key seminal themes that emerge from talking therapy with children and adults with mild, severe and profound multi-disability.

Unit 2 – Sub-Clinical Psychopathology

The world appears to be split into those that can be classed as neurotypicals and those that are neurodivergents. People with Autism Spectrum Disorder (ASD) are a part of the neurodivergent group and people with Asperger’s Syndrome are part of the spectrum of people with ASD. There is a long history of misunderstandings and mistreatment of people with ASD across the medical profession and often in the consulting room. This seminar will present current thinking about ASD from a psychoanalytic perspective and suggest applications of that thinking in the treatment of individuals.

Unit 2 – Sub-Clinical Psychopathology

Clients in psychotherapy may be happy to talk about relationship problems, but may find it difficult to talk about psychosexual concerns. Should psychotherapists encourage clients to open up about sexual difficulties? Is there a danger that talking about sex might stimulate erotic transference or voyeurism or expose the therapist’s ignorance about sexual functioning. This lecture will look at some of the blocks that might prevent the client or therapist talking about sex and will also provide information about sexual anatomy and common psychosexual dysfunctions.

Unit 2 – Sub-Clinical Psychopathology

Although Sigmund Freud pioneered the theory and practice of depth psychology, based predominantly on his work with neurotic patients, especially those struggling with hysteria and with obsessive-compulsive disorders, the concept of neurosis has become increasingly marginalised within the fields of psychiatry, psychopathology and, even psychoanalysis itself. In this seminar, Professor Brett Kahr will review the classical foundations of the theories of hysteria and obsessive-compulsive illness and will argue for the importance of a detailed understanding of these ongoingly important characterological states. We shall begin by exploring Freud’s original work on the Studien uber Hysterie – the Studies on Hysteria – co-authored by Dr. Josef Breuer, as well as his exploration of the famous case of the obsessional “Rat Man”. We shall then consider more recent psychodynamic investigations of these foundational mental states. 

Unit 3 – Developmental and Applied Psychopathology

The language of family psychopathology was established by the pioneering group of professionals working with Gregory Bateson in the 1950s who used the perspective of General Systems Theory as the basis of their observations to establish the ‘Double Bind Theory’ of schizophrenia. Concepts such as boundaries, homeostasis, reciprocal transactions, symmetrical and complementary communication, feedback loops, alliances, triangulation have entered shared language. The Family Therapy Movement differentiated from the pervasive psychodynamic orientation in the US, but as practitioners trained in psychodynamic approaches we attempted to link psychodynamic and systemic thinking. 

Based on our research on family functioning we introduced the Family Assessment model which provides the tools for practitioners to work with families. It describes the Family System as being made up of parts or sub-systems such as the parental partnership, and the parent-child subsystem which all contribute to the working or functioning of the system as a whole. Properties include how family members communicate, the nature of family alliances including attachments, and the management of boundaries and feeling states affect how the family system operates. The family system is more than the sum of its parts and there are characteristic patterns and core ways of relating and being – not so much cause and effect, but patterns of interaction. Families are located within the wider social system of extended family, local community and cultural norms and expectations. 

Conflict is inherent in family life as a result of significant differences in gender, age, and developmental stage of family members. The basic structure of the family needs to work optionally to manage differences. The experiences of the parents as children – inter-generational effects – have a profound impact on the way the family functions. Parents with a history of trauma, abuse and dysfunction may have distorted, complex relationships with partners – and children, with mutual dependence and high levels of conflict. Traumatic events ‘organise’ relationships justifying harsh, abusive or neglectful responses. Children may be organised into caring roles for parents with mental health and substance abuse, children with special needs can organise the lives of the family around their needs. 

A variety of therapeutic approaches have been developed to work with families including the SAAF Assessment approaches to determine whether the family is via-ble as an organisation or whether there is a potential for positive outcome, strengths which can be built on, goals which can be met. It is essential that practitioners develop skills to engage with children, young people and family members, joining, managing conflict in the here and now, using a variety of tasks to promote communication, allowing all family members to have a voice. “Structural approaches’ aim to intervene to change dysfunctional patterns, block dominating controlling voices, and promote and reinforce alternate patterns. Solution Focused approaches look for instances of appropriate responses – care rather than criticism, and helps the family to build on the positive – the solution. Attachment based approaches promote positive responsive, reflective key relationships to develop security and organisation of relationships. Mentalisation based approaches aims to help family members to begin to put themselves in each other’s shoes, and develop relationships based on understanding rather than beliefs. 

The Hope for Children and Families approach takes the key practice elements therapeutic procedures across the field to provide the practitioner with a step by step approach to working with families. The seminar will use video examples to explore the concepts of family psychopathology and introduce approaches to intervention. 

Unit 3 – Developmental and Applied Psychopathology

In this presentation, Dr. Oberstar will review the current understanding of the biological basis for certain psychopathology. Consideration will be given to the role of neurotransmitters in the expression of psychiatric symptoms. Commonly used psychiatric medications will be reviewed with a particular emphasis on “class” mechanisms of action and common effects and side effects. 

Unit 3 – Developmental and Applied Psychopathology

This lecture will outline the structure of provision of current UK child mental health services 

A number of the most frequently diagnosed child mental health disorders (eg ADHD, ASC, Conduct Disorder, Eating Disorders, Childhood Depression,) will be identified and briefly described, drawing on the most up-to-date diagnostic criteria of DSM 5 and the ICD 10/11 (ICD 11 due to be adopted in May 2019). 

Information will be critically considered with reference to ordinary child development and in the light of up to date research regarding the development of the brain in infancy and childhood. Close consideration will be given to what is known about how trauma and adverse childhood experiences may impact on a child’s emotional, relational, cognitive, behavioural and relational development. Bessell van der Kolk’s Model of Developmental Trauma Model (2005) will be considered. 

As well as talking about medication-based treatments, we will explore how child psychotherapy, informed by Attachment Theory and Object Relations Theory, may be an effective response to childhood disorders which have their roots in traumatic experiences. 

Unit 3 – Developmental and Applied Psychopathology

My talk will initially cover the common signs and symptoms of mental disorder in older people within the traditional psychiatric framework, including approaches to treatment and management within the biomedical model. A large part of working in old age psychiatry is working with the 3Ds as conditions ie depression, delirium and dementia. However I will also discuss and explore the wider backdrop of ageing and older people and how these factors and many others can affect someones individual mental health. This will lead into discussion about ways to understand and approach mental health in older age. I have a long term interest in psychodynamic approaches in working with patients, families and staff and will also discuss this in relation to older adults. 

Unit 3 – Developmental and Applied Psychopathology

Professor Brett Kahr will review key themes of the course and provide an overview of some of the principal findings.