Book: The Last Asylum

INTERPERSONAL : SCIENCES
humanistic ------------------------------------------- mechanistic
SOCIOLOGY : POLITICAL

individual

The Last Asylum	-sociology -medicine
medical- social-

group - population

Winwick Hospital remembered

Image source: Metro

Book review "Clinical Intuition in Psychotherapy: The Neurobiology of Embodied Response"

Clinical intuition is something that in formal learning terms is intangible, but in practice is earned and relied upon as a gift of experience. When I first received this book from the author Terry Marks-Tarlow, leafing through I thought the emphasis was on the neurobiology presaging a rather technical read. The references to brain structures, neocortex, brain waves ... seemed to suggest a reductive approach, remote from my conception of intuition in clinical practice. I need not have worried, the initial discussion on the brain and evolutionary development is not just a foundation for what follows but as the title suggests underpins and integrates the whole text. Despite the title and as the foreward advises you do not have to be a psychotherapist to read and appreciate this book. The stall is set from the outset in the introduction which explains that chapter one defines clinical intuition:

Clinical intuition is defined from a neurobiological perspective as a right-brain, fully embodied mode of perceiving, relating, and responding to the ongoing flows and changing dynamics of psychotherapy. (p.3)

The introductory material here is essential foundation reading for people starting a career in psychology and mental health related disciplines. The evolutionary development of the brain from reptile through to the mammalian brain is invaluable. Tying this to specific brain functions and circuits - care, fear, panic, play, lust, rage and seeking - helps integrate brain anatomy, perception, emotion, and behaviour. The advances in neurobiology to follow will no doubt demand that we all extend our understanding of this interdisciplinary fusion.

The book itself (hardback edition) is very well produced, the type face easy to read and the book well structured and with a well balanced mix of illustrations and photographs. The reference listing at the end runs over thirteen pages and is well grounded historically and in having regard to ongoing research. The index is comprehensive (fourteen pages) and a resource itself providing a look-up approach. The book's use of case studies, thirteen in total informs the text and provides some continuity through the book. Dialogue between therapist and client is easy to follow and illustrations are provided with ample explanation in situ. The references also utilize web-based resources.

I recall intuition coming up as a thread on several occasions on the psychiatric-nursing list especially between 1998 and 2004. Intuition is a central quality for all personnel working in health and social care. We must also recognise intuition as a human trait as when non-health professionals exercise the judgement that: "Wait a minute, we need a clinical opinion here." Self-care is also discussed. I had a Pythonesque moment - "Is this the right room for an argument?" - considering psychotherapy as a therapeutic modality within therapies as a whole. Here in the UK (and no doubt elsewhere) self, brief and solution based therapies rule economically. Even though the shortage of psychological intervention is recognised in the UK through IAPT improving access to psychological therapies, we need to ask: how does psychotherapy fare in the current (austerity) climate? To what extent can clinicians exercise intuition? Therapy relies on caseness, relationships and narrative, but to what extent can these be acknowledged and delivered within the economical time frames that frequently operate? 

Although there's no specific chapter on training for clinical intuition, Marks-Tarlow provides a list of how researchers have characterized clinical intuition (more recently in the 1980-1990s); five characteristics are proposed:

• Sudden recognition;
• Immediate knowledge;
• Emergent awareness;
• Non-verbal insight; and 
• Holistic integrative sensibilities. (pp.42-43).

 Of the first two sudden recognition and immediate knowledge, I thought of the intuitive sense that is applied upon receiving a referral. That is the assumptions (not always helpful) that arise from the information provided (and missing) and where this leads you? But of course, is this clinical intuition? Intuition as the author makes clear (p.3 and) throughout the book is in psychotherapy. Intuition here (and for me) depends on interpersonal - therapeutic - interaction. What precedes is something else (data integration, hypothesizing, reasoning...?). I can however still see explanatory avenues in the above that can help us travel from the conceptual (reduced) to a holistic whole. I did wonder about the role of intuition in suicidal ideation and risk management, but this is also a question of referral criteria and caseness.

I would very much like to write myself about information and complexity and these themes recur in the text, especially the latter. Several 'spaces' are discussed too: social, physical and spatial schemas. The work of Buzsáki on the hippocampus, navigation and maps - landmark navigation - is fascinating in chapter 7 Navigating the Seas. I have likened Hodges' model to a cognitive periplus - an ancient maritime map. Over the next few months I'll post some quotes from the book.

This is an excellent book that I heartily recommend. The discussion of what is implicit in the brain and so in therapy, what is embodied and wisdom in mentoring invites re-reading. Finally but vitally there is much humour and humanity here too.

Many thanks to Terry Marks-Tarlow for the review copy.

New Scientist: Article on Cotard's syndrome [ and Hodges' model ]

Nine years ago, Graham woke up and discovered he was dead.

He was in the grip of Cotard's syndrome. People with this rare condition believe that they, or parts of their body, no longer exist.

... more

INTERPERSONAL : SCIENCES

SOCIOLOGY : POLITICAL

individual

Cotard's syndrome Belief    "I am dead"   delusion (or?) depression      self                                   suicide  "I have no brain"    theory of mind         consc psychotherapy                            senses - taste smell	PET - positron emission tomography ICD 11 - classification?  attempts               'default network mode' iousness          body (parts)        brain function frontal and parietal lobes  anaesthesia  low metabolic activity   physiology
social impact, family, friends, carers sense making  social understanding stigma      interview Jules Cotard (1840–1889), a French neurologist	media      unemployment quality of life   autonomy   control research funding      access to treatment specialist services     referral processes

group - population

Source: New Scientist, 1 June 2013.
Mindscapes: First interview with a dead man

Wikipedia: Cotard delusion

Papers, case formulation and hyperbole

I am enjoying a three night break in Keswick where it is dry, windy and chilly. Invigorating for all that.

In between taking in the hills and the atmospherics of the skies I am working on completing the revision to the - scope of nursing - paper. There is still a paragraph to lose to reduce the length for the target journal.

The case formulation and h2cm paper is taking shape too - 5,000 words. I am sure the ongoing advice and thoughts of my co-author on the scope effort is making a difference. As a result the case formulation paper will be in final draft form soon. Then I'll seek some feedback from a CBT therapist before trying to locate a journalistic home. Here's a snippet from the draft:

... If the talking therapies are specialised forms of conversation then we should also be able see case formulation as being on a continuum, derived from narratives that can include extreme case formulation, and hyperbole (Norrick, 2004). The specific therapies discussed here [cognitive behavioural therapy and cognitive analytical therapy] are concerned with overstatement and exaggeration in thought not just speech. Things may be said in everyday speech that are rhetorical and not necessarily indicative of deeply held core, dysfunctional beliefs. ...

Norrick, N.R. (2004). Hyperbole, extreme case formulation. Journal of Pragmatics 36. 1727–1739.

I receive regular reminders about a part time PhD application that remains incomplete. So I will address this too (and check other opportunities) over the next few days.

Post on a new laptop and a socio-technical-existential addiction to follow ....

Dialectics in therapy, case formulation, h2cm and a tree

Kuyken et al. (2009) propose three dialectics that are useful in an evaluation of their model for case conceptualization, these are:

Released today - 28th Jan 2013

nomothetic – idiopathic; 
simple – complex; 
and subjective – objective.

This act of identifying polarities can be described as a diagrammatic formulation in itself.

These dialectics and many others can be readily incorporated into h2cm: for example;

socio – technical,
macro – micro.
...

Kuyken, W., Padesky, C., Dudley, R. (2009). Collaborative case conceptualization. New York, The Guilford Press.

Case formulation and Reflection in Hodges' model

Case formulation is a process in which I believe Hodges’ model can be used. Johnstone and Dallos (2006) help conjoin case formulation with an original purpose of Hodges’ model, that of supporting reflective practice, as follows:

Formulation and reflective practice. The notion of reflective practice is becoming increasingly important in all therapeutic traditions; that is, the necessity of being aware of one’s own feelings and reactions as a therapist as well as one’s own position in terms of professional status, gender, class, ethnicity and so on, and how these impact upon the therapeutic process. How might these ideas be taken on board in formation? What kind of biases is formulation open to, and how can we minimise them? p.2.

There are of course many concepts mentioned above that are key in staging a therapeutic interaction. As a series of conjoined conceptual spaces Hodges’ model provides a stage were reflections can be made personally, professionally and therapeutically moving to the development of formulations that are shared with clients.

Johnstone, Dallos and contributors also describe the issue of integrative formulation an aspect also of relevance to further study of Hodges' model.

Johnstone L., Dallos, R., (Eds.) (2006). Formulation in Psychology and Psychotherapy: Making Sense of People's Problems, Routledge, Oxford.