In their thought-provoking article, Sedlakova and Trachsel (2023) defend the view that the status—both epistemic and ethical—of Conversational Artificial Intelligence (CAI) used in psychotherapy is complicated. While therapeutic CAI seems to be more than a mere tool implementing particular therapeutic techniques, it falls short of being a “digital therapist.” One of the main arguments supporting the latter claim is that even though “the interaction with CAI happens in the course of conversation… the conversation is profoundly different (...) from a conversation with a human therapist” (Sedlakova and Trachsel 2023, 8). In particular, unlike a human therapist, CAI cannot help its users gain new insight and self-understanding (Sedlakova and Trachsel 2023). We agree that currently available therapeutic CAI cannot be considered a “digital therapist,” however, we think that the issue surrounding the acquisition of new self-understanding in the interaction with therapeutic CAI is more complicated than Sedlakova and Trachsel suggest. (shrink)

This paper inspects the relationship between problem analysis—a fundamental part of many therapeutic approaches—and meaning. In the first part, I argue that problem analysis emerges from the representational theory of meaning. I introduce Wittgenstein’s version of this theory as presented in the Tractatus Logico-Philosophicus, and examine its difficulties. Later, I focus on two fundamental themes of late Wittgenstein’s Philosophical Investigations: private language and rule-following. I argue that the rule-following paradox has disproven the representational theory of meaning. I briefly describe (...) the private language argument and rule-following paradox—a sceptical paradox. Then I provide my reading of Kripke’s sceptical solution to it. I present its implications regarding the meaning and how this is relevant to problem analysis and therapeutic conversations in general. (shrink)

Based on conversations between 10 Chinese children with Autism Spectrum Disorders and five therapists in the context of Naturalistic Intervention, this study investigated the therapists’ agreement expressions in this typical setting. The study found that the therapists mainly used four agreement strategies: acknowledgment, positive evaluation, repetition and blending. These four strategies could be used individually or in combination. The first three strategies and their combinations were used frequently during the therapeutic conversation. With the major occurrences in the post-expansion (...) position, the agreement expressions in the therapeutic conversation mainly performed three functions, namely, creating a supportive therapeutic relationship, serving as positive reinforcers and implementing interventions pertinent to communication skills. This study proposed that the therapists’ preferred use of agreement expressions in the intervention process could be explained by the features of Naturalistic Intervention. (shrink)

Conversational artificial intelligence (CAI) presents many opportunities in the psychotherapeutic landscape—such as therapeutic support for people with mental health problems and without access to care. The adoption of CAI poses many risks that need in-depth ethical scrutiny. The objective of this paper is to complement current research on the ethics of AI for mental health by proposing a holistic, ethical, and epistemic analysis of CAI adoption. First, we focus on the question of whether CAI is rather a tool or (...) an agent. This question serves as a framework for the subsequent ethical analysis of CAI focusing on topics of (self-) knowledge, (self-)understanding, and relationships. Second, we propose further conceptual and ethical analysis regarding human-AI interaction and argue that CAI cannot be considered as an equal partner in a conversation as is the case with a human therapist. Instead, CAI’s role in a conversation should be restricted to specific functions. (shrink)

Sedlakova and Traschel argue that conversational artificial intelligence (CAI) is more than a mere tool, but not quite an agent, as it “simulates having a therapeutic conversation [but] does not re...

Conserving the vitality of suffering: addressing family constraints to illness conversationsWhen persons are confronted with life‐threatening or chronic illness, there is always a possibility that family members other than the person experiencing the illness also suffer as they attempt to manage their own distress. This paper describes exemplars from a hermeneutic study that explored therapeutic conversations between nurses and families who were living with a member experiencing ischaemic heart disease. These conversations uncovered the complexity of both individual and family (...) suffering following acute cardiac illness events, and called attention to nursing practices that addressed some of the ways that family members were constrained from having conversations about the illness. When spaces were created for these conversations to occur, possibilities for making sense of illness and suffering were revealed as vital. These understandings support the efforts of family members to sustain and conserve family relationships in the face of illness and suffering, and inform both the professional and personal lives of nurses. (shrink)

In this paper we use the concept of the person to examine person‐centred dialogue and show how person‐centred dialogue is different from and significantly more than transfer of information, which is the dominant notion in health care. A further motivation for the study is that although person‐centredness as an idea has a strong heritage in nursing and the broader healthcare discourse, person‐centred conversation is usually discussed as a distinct and unitary approach to communication, primarily related to the philosophy of (...) dialogue—the philosophy of Martin Buber. In this paper we start with the concept of person to critically reflect on theoretical perspectives on communication to understand person‐centred conversations in the context of nursing and health. We position the concept of the person through the use of Paul Ricoeur's philosophy and follow by distinguishing four theoretical perspectives on communication before reflecting on the relevance of each of these for person‐centred communication. These perspectives are: a linear view of communication as transfer of information, communication as a relation in the sense of philosophy of dialogue, practice‐based communication on constructionist grounds, and communication as a practice to create social community. In relation to the concept of the person, we do not find transfer of information relevant as a theoretical underpinning for person‐centred conversations. From the other three perspectives that are relevant we distinguish five types of person‐centred conversations pertinent to nursing and health: problem identifying conversations, instructive conversations, guiding and supportive conversations, caring and existential conversations, and therapeutic conversations. Through this analysis it is argued that person‐centred communication and conversations are substantially different to transfer of information. We also discuss the significance of communication adjusted to specific situations, including emphasis on how we speak in relation to the aim or topic of a conversation. (shrink)

Conversational Artificial Intelligence (CAI) systems (also known as AI “chatbots”) are among the most promising examples of the use of technology in mental health care. With already millions of users worldwide, CAI is likely to change the landscape of psychological help. Most researchers agree that existing CAIs are not “digital therapists” and using them is not a substitute for psychotherapy delivered by a human. But if they are not therapists, what are they, and what role can they play in mental (...) health care? To answer these questions, we appeal to two well-established and widely discussed concepts: cognitive and affective artifacts. Cognitive artifacts are artificial devices contributing functionally to the performance of a cognitive task. Affective artifacts are objects which have the capacity to alter subjects’ affective state. We argue that therapeutic CAIs are a kind of cognitive-affective artifacts which contribute to positive therapeutic change by (i) simulating a (quasi-)therapeutic interaction, (ii) supporting the performance of cognitive tasks, and (iii) altering the affective condition of their users. This sheds new light on why virtually all existing mental health CAIs implement principles and techniques of Cognitive Behavioral Therapy — a therapeutic orientation according to which affective change and, ultimately, positive therapeutic change is mediated by cognitive change. Simultaneously, it allows us to conceptualize better the potential and limitations of applying these technologies in therapy. (shrink)

New class of therapies, including bipolar therapies (BPT) and paradoxical unipolar therapies (PUT) were firstly proposed in relation to a clinical insight and to some results of biological investigations, then they gave rise to mathematical modeling which brought a justification of these therapies, at least from a theoretical point of view. After recalling the mathematical model for the regulation of agonistic antagonistic couples, and reporting the fundamental types of control simulation by means of it, we point out the validity of (...) therapeutical applications inferred from this model. These therapy modalities, including BPT and PUT, now concern the following diseases: astrocytomas, epilepsia and trials on multiple sclerosis. Even if such attempts are in their early stage, noticeably for the last case where biological changes have mainly been studied, it seems that a large span of treatments is open to BPT and PUT. Improvement of these techniques in the future depends, in our opinion, on a parallel working on the dynamics of the mathematical model and the dynamics, perceived by clinical insight and confirmed by biological investigations, of the body reactions to such strategies. Justification of BPT and PUT was given, by resorting to the notion of pathological homeostasis which, too often, intervenes in order to nullify the effects of unilateral (not paradoxical) therapies. This research has elicited some therapies which use two agents with antagonistic effects or only an agent with effects similar to the agent already in excess in the body - in both cases at nearly physiological doses. (shrink)

In their paper, “Conversational Artificial Intelligence in Psychotherapy: A New Therapeutic Tool or Agent?” Sedlakova and Trachsel (2023) claim that therapeutic insights and therapeutic changes are...

Therapeutic alliance is a central concept in psychotherapeutic work. The relationship between the therapist and the patient plays an important role in the therapeutic process and outcome. In this article, we investigate how therapists work with disaffiliation resulting from enduring disagreement while maintaining an orientation to the psychotherapeutic project at hand. Data come from a total of 18 sessions of two dyads undergoing psychoanalytic psychotherapy and is analyzed with conversation analysis. We found that collaborative moves deployed amidst (...) enduring disagreement can assist the therapist in furthering the disagreement as part of the ongoing psychotherapeutic project. Relying on their collaborative format, therapists utilize collaborative moves to temporarily mend the disaffiliation without necessarily changing their position and re-affiliating with the patient. We show how the relation between the therapist and the patient gets transformed in the moment-by-moment work accomplished in the psychotherapeutic talk. (shrink)

This study is part of a larger exploration of ‘talk and cure’ that combines the examination of talk-in-interaction, with nonverbal displays, and measurements of the client’s and therapist’s autonomic arousal during therapy sessions. A key assumption of the study is that psychotherapy entails processes of intersubjective meaning-making that occur across different modalities and take place in both verbal/explicit and nonverbal/implicit domains. A single session of a psychodynamic psychotherapy is analysed with a focus on the expression and management of affect, with (...) an aim to describe key interactive events that promote change in both semantic and procedural domains. The clinical dialogue is analysed discursively, with a focus on the conversational processes through which new meanings are jointly constructed and affective states shared; detailed attention is paid to nonverbal displays of affiliation and affect. Furthermore, we explore whether the interactional patterns implicated in joint meaning-making, as revealed by analysing the therapeutic conversation, have correlates in the autonomic arousal of the two protagonists, as reflected in their heart rates. Conversation analysis has still untapped potential to illuminate interactional patterns that underlie the practice of psychotherapy. In this exploratory study we suggest that discursive analyses of talk-in-interaction can be enriched through detailed focus on nonverbal displays as well as measures of physiological arousal. Drawing upon the analysis, we suggest that bringing the methodological strengths of language-based analysis into fertile dialogue with embodied quantitative data can help our explorations of what’s really going on in psychotherapy. (shrink)

By analyzing session exchanges and questionnaires administered to family therapy clients, this article examines questioning as conversational practice grounded in institutional goals that are therapist-directed and therapist-conceived. In their manifestation in talk and text, therapeutic questions function to replace client accounts with the nosological accounts of institutional psychiatry. The analysis illuminates three ways in which questioning works in the session and then locates these in therapy's professional and institutional logic. A critical reflection on psychotherapy's questioning practices in a social (...) context concludes the article. (shrink)

Prayer is not just about the composition of a message from the sender to God the receiver. I say this because I believe that prayer is not primarily conversation but fellowship and communion. There is a relation of trust in which the recipient of trust is true and faithful. Prayer loses its theological character and becomes a psychological phenomenon that is an introspection into oneself if there is no trusting faith and God who is faithful. Prayer is far more (...) than human communication; prayer is true communion that expresses faith in God's trustworthiness. (shrink)

Digital records, from chat transcripts to social media posts, are being used to create chatbots that recreate the conversational style of deceased individuals. Some maintain that this is merely a new form of digital memorial, while others argue that they pose a variety of moral hazards. To resolve this, I turn to classical Chinese philosophy to make use of a debate over the ethics of funerals and mourning. This ancient argument includes much of interest for the contemporary issue at hand, (...) including the use of impersonators of the dead to help the bereaved to deal well with their grief. I connect this historical discussion with a modern trend in clinical psychology that reframes therapeutic interventions with bereaved individuals. The trend directs practitioners away from facilitating detachment and toward affirming continuing bonds. I conclude that these chatbots can offer an important source of support to mourners, but also discuss parameters and features of social context that will be important to avoid the moral hazards identified by sceptics. (shrink)

Conversational agents (CA) are thought to be promising for psychotherapy because they give the impression of being able to engage in conversations with human users. However, given the high risk for therapy patients who are already in a vulnerable situation, there is a need to investigate the extent to which CA are able to contribute to therapy goals and to discuss CA’s limitations, especially in complex cases. In this paper, we understand psychotherapy as a way of dealing with existential situations (...) and position CAs in the context of the therapeutic experience of patients. This experience is determined by the patient’s unique personal context and specific therapy goals. We suggest that psychotherapy is a fundamentally dialogical activity, because it crucially involves work on the self and one’s self-narrative. This brings us to our central question: is it possible for CAs to engage in a productive therapeutic dialogue, given their limitations as epistemic agents? We will discuss several of those limitations, show how these undermine the possibility of engaging in a therapeutic dialogue, and illustrate those limitations through discussions of the cases of grief and abuse. (shrink)

Conversation analysis (CA) of children-adult—interaction in various contexts has become an established field of research. However,child therapyhas received limited attention in CA. In child therapy, the general psychotherapeutic practice of achieving empathy faces particular challenges. In relation to this, our contribution sets out three issues for investigation and analysis: the first one is that practices of achieving empathy must be preceded by efforts aiming to establish which kind of individualized conversation works with this child (Midgley,2006). Psychotherapy process researchers (...) in adult therapy (Stiles et al.,2015) have found that therapists “invent” a new therapy for each patient (Norcross and Wampold,2018). The second issue is that it can be difficult for adults to understand the ways in which children express their conflicts and issues. In particular, play activities in therapy, e.g., with dolls, can open up additional scenarios of interaction. The play scenario can be used to disclose unformulated problems masked in everyday and family interactions. The third issue is how to respect the child's higher degree of vulnerability, compared with adult patients. How is it communicated and dealt with in therapy? We present an interaction analysis of a single case study of the first 20 min of a child therapy session with an adopted girl aged 4 years brought to treatment because of “unexplainable rage.” The session was videotaped; parents granted permission. We analyze this session using an applied version of CA. In our analysis, we describe “doing contrariness,” as a conversational practice producing epistemic and affiliative disruptions, while “avoiding doing contrariness” and “remedying contrariness” are strategies for preserving or restoring the affiliative dimension of a relationship (in child therapy). We show how these practices operate in various modes and how they are used by both parties in our case study to variously aid and impedethe achievement of empathy and understanding. (shrink)

The case of Xiang as described by Jane Carroll is indeed disconcerting well beyond the immediately apparent factors contained within the article. While Xiang’s direct medical expenses are excessive and his inability to pay for those expenses and further support his noncustodial family seem to be the main issues up for debate, Xiang, however, is likely going to need much more psychosocial support if he is to regain his previous independent functionality or retain any aspect of a quality of life (...) whilst continuing his indefinitely isolated treatment. In this response, I briefly outline the probable effects of Xiang’s current situation on his social identity and mental health as well as a potential way that we can minimize these adverse effects. (shrink)

The purpose of this paper is to evaluate the significance of the existential notion of authenticity for medical ethics. This is done by analyzing authenticity and examining its implications for the patient-professional relationship and for ethical decision-making in medical situations. It is argued that while authenticity implies important demand for individual responsibility, which has therapeutic significance, it perpetuates ideas which are antithetical both to authentic interaction between patients and professionals and to fruitful deliberation of moral dilemmas. In order to (...) counteract these consequences, an alternative idea of authenticity is introduced. According to this idea, authenticity is not regarded primarily as individual sovereignty, but as an ability to participate in a dialogue in which the subjectivity of both partners is respected. Such practice, based on mutual trust and responsibility, would enhance common decision-making and overcome the alienation between patients and professionals. (shrink)

Persons who identity as LGBTQ+ should be treated with respect, compassion, and sensitivity. Under the guise of helping such persons, legislation is surreptitiously appearing in several countries seeking to ban so-called conversion therapy. While the definition of the term remains concerningly vague, the terms of enforcement for alleged offences tend to be precisely delineated, often including provisions that curtail Christian catechesis, teaching, and preaching in the areas of human dignity and sexuality. These problematic and repressive initiatives can prevent access to (...) any psychotherapy that is not strictly gender-affirming. This article reviews and assesses conversion therapy in support of a judicious approach to the practice, accurately understood. It reviews past abuses and misunderstandings while considering the merits of conversion therapy and related therapeutic and pastoral approaches. Concerns about gender-affirming interventions are considered, especially for youth and teenagers, and efficacy claims around conversion therapies and related psychotherapies are also discussed. (shrink)

This text, the first of a planned series, sets out a general theory of psychotherapy and therapeutic change. It borrows from developmental, cognitive and social psychology, and mingles theories of human development, conversation, memory and construction theories of the self.

The aim of this article1 is to provide insight into the anthropological framework that could inform the pastoral and therapeutic care of those we encounter, professionally or in our personal lives, who experience same-sex attraction. Our question here is not whether or not persons are free to ignore the natural order but to consider how to minister to those who wish to engage in the struggle to conform themselves to it—or those whom we hope to persuade to do so. (...) Since entering into such conversations often requires a starting place in experience, we need an approach that will permit us to integrate human experience into a fuller account of the human person. The thesis of this article is that the account of the human person proposed by Pope St. John Paul II, as the philosopher Karol Wojtyła provides the answers we need. I demonstrate that his approach permits us to acknowledge the experience of actual existing persons without compromising the more properly “ontological” framework that we know reveals the unchanging truth about human personhood.2 I show that his account gives us the foothold we are seeking in our efforts to help those struggling with SSA. (shrink)

The present narrative review seeks to unravel where we are now, and where we need to go to delineate the active ingredients in psychotherapy delivered by conversational agents (e.g., chatbots). While psychotherapy delivered by conversational agents has shown promising effectiveness for depression, anxiety, and psychological distress across several randomized controlled trials, little emphasis has been placed on the therapeutic processes in these interventions. The theoretical framework of this narrative review is grounded in prominent perspectives on the active ingredients in (...) psychotherapy. Based on search terms derived from various theoretical perspectives, we conducted a systematic literature search of four scientific databases and identified 17 studies. Across the selected studies, three themes emerged: relationship variables, emotional venting, and cognitive factors. While methodological issues compromise the epistemic value of this evidence base, core questions also remain to be answered. Such questions include, but are not limited to, whether humans can form affectionate bonds to inanimate beings and whether these kind of mental health treatments should be understood as psychotherapy or something else. Researchers should therefore be cautious when applying theories of psychotherapy in the realm of conversational agents. We conclude the paper by introducing recommendations for future research, which we hope will help instigate methodologically sound studies in this field. (shrink)

The American Psychological Association's (APA's) as well as other professional organizations' (e.g., American Psychiatric Association) removal of homosexuality as a mental disorder represented a paradigmatic shift in thinking about exual orientation. Since then, APA (2000) disseminated guidelines for working with lesbian, gay, and bisexual (LGB) clients, and a variety of scholars and researchers alike have advocated affirmative therapeutic interventions with LGB individuals. Despite these efforts, the controversy over treating individuals with LGB orientations using nonaffirmative techniques continues. In this discussion, (...) the limited evidence regarding the efficacy and effects of conversion therapy is surveyed, particularly in the context of empirically supported treatment criteria summarized by Division 12 (clinical psychology) of the APA. Authors then consider the resulting ethical considerations in performing conversion therapy and propose alternative uses of affirmative therapy on the basis of ethical standards defined by APA. Finally, options for treating LGB individuals who are coming to terms with their sexual orientations are discussed. (shrink)

Summary This paper starts with a short review of recent developments in psychotherapy process research and analyzes that a medical, or better, technical approach in process research – using words such as ‘intervention’, ‘effect’ and ‘outcome’ – is gradually acknowledged as only one side of psychotherapy; the other, more human or ‘humanistic’ side, is ‘conversation’, described by prominent authors as ‘low technology’. Conversation analysis cannot study psychotherapy as a whole. Sessions are subdivided into ‘situations’. What are situations? I (...) make a proposal to answer this question by three components: open up, select and control options. Then, 11 transcribed extracts from psychoanalytical therapy sessions are used to describe three types of situations and the special kind of requirements they demand from a therapist. Obviously, such situations appear during a session, they can be handled if therapists are sensitized for certain difficulties to arise. Shift-of-situation and double meaning are new observations in this approach to define the situational gestalt and train ‘seeing’ it. (shrink)

Silence has gained a prominent role in the field of psychotherapy because of its potential to facilitate a plethora of therapeutically beneficial processes within patients’ inner dynamics. This study examined the phenomenon from a conversation analytical perspective in order to investigate how silence emerges as an interactional accomplishment and how it attains interactional meaning by the speakers’ adjacent turns. We restricted our attention to one particular sequential context in which a patient’s turn comes to a point of possible completion (...) and receives a continuer by the therapist upon which a substantial silence follows. The data collection consisted of 74 instances of such post-continuer silences. The analysis revealed that silence can retroactively become part of a topic closure sequence, can become shaped as an intra-topic silence, and can be explicitly characterized as an activity in itself that is relevant for the therapy in process. Only in this last case, the absence of talk is actually treated as disruptive to the ongoing talk. Although silence is often seen as a therapeutic instrument that can be implemented intentionally and purposefully, our analysis demonstrated how it is co-constructed by speakers and indexically obtains meaning by adjacent turns of talk. In the ensuing turns, silence indeed shows to facilitate access to the patient’s subjective experience at unconscious levels. (shrink)

The primary means for psychotherapy interaction is language. Since talk-in-interaction is accomplished and rendered interpretable by the systematic use of linguistic resources, this study focuses on one of the central issues in psychotherapy, namely agency, and the ways in which linguistic resources, person references in particular, are used for constructing different types of agency in psychotherapy interaction. The study investigates therapists' responses to turns where the client complains about a third party. It focuses on the way therapists' responses distribute experience (...) and agency between the therapist and the client by comparing responses formulated with the zero-person to responses formulated with a second person singular pronoun that refers to the client. The study thus approaches agency as situated, dynamic and interactional: an agent is a social unit whose elements are distributed in the therapist-client interaction. The data consist of 70 audio-recorded sessions of cognitive psychotherapy and psychoanalysis, and the method of analysis is conversation analysis and interactional linguistics. The main findings are that therapists use the zero-person for two types of responses: affiliating and empathetic responses that distribute the emotional experience between the client and the therapist, and responses that invite clients to interpret their own experiences, thereby distributing control and responsibility to the clients. In contrast, the second person references are used for re-constructing the client's past history. The conclusion is that therapists use the zero-person for both immediate emotional work and interpretative co-work on the client's experiences. The study suggests that therapists' use of the zero-person does not necessarily attribute “weak agency” to the client but instead might strengthen the clients' agency in the sense of control and responsibility in the long term. (shrink)

Using therapeutic conversations from a televised talk show as the source data, this article investigates how people solve emotional problems in an institutional setting within a specific social cultural context. In light of the genre framework and the Systemic Functional Linguistics, the investigation considers the TV talk show therapy under examination a distinct genre. The claim is based on the linguistic evidence drawn from the analytical work. As a valid genre the talk show therapy has been characterized with the (...) communicative intentionality to resolve emotional problems and to promote mental health to the public. These components in turn have shaped the generic structures, which become the crucial criteria that constitute a text as a genre. The article proposes that a broader conception of genre framework is an effective research method to describe the textual typologies and interpret the semantic structures of the social interaction in postmodern society. (shrink)

BackgroundThe ethical concerns associated with HIV prevention and treatment research have been widely explored in South Africa over the past 3 decades. However, HIV cure research is relatively new to the region and significant ethical and social challenges are anticipated. There has been no published empirical enquiry in Africa into key informant perspectives on HIV cure research. Consequently, this study was conducted to gain preliminary data from South African HIV clinicians, researchers and activists.MethodsIn-depth interviews were conducted on a purposive sample (...) of fourteen key informants in South Africa. Audiotaped interviews were transcribed verbatim with concurrent thematic analysis. The perspectives of HIV clinicians, researchers and activists were captured. Analyst triangulation occurred as the data were analysed by three authors independently.ResultsThe rapid evolution of HIV cure research agendas was prominent with participants expressing some concern that the global North was driving the cure agenda. Participants described a symbiotic relationship between cure, treatment and prevention research necessitating collaboration. Assessing and managing knowledge and expectations around HIV cure research emerged as a central theme related to challenges to constructing ‘cure’ - how patients understand the idea of cure is important in explaining the complexity of cure research especially in the South African context where understanding of science is often challenging. Managing expectations and avoiding curative misconception will have implications for consent processes. Unique strategies in cure research could include treatment interruption, which has the potential to create therapeutic and ethical conflict and will be perceived as a significant risk. Ethical challenges in cure research will impact on informed consent and community engagement.ConclusionsIt was encouraging to note the desire for synergy amongst researchers and clinicians working in the fields of prevention, treatment and cure. Translation of complex HIV cure science into lay language is critical. Moving forward, RECs must be adequately constituted with scientific expertise and community representation when reviewing cure protocols. It is hoped that knowledge and resource sharing in the context of collaboration between research scientists working in cure and those working in treatment and prevention will accelerate progress towards cure. (shrink)

Psychedelics such as psilocybin reliably produce significantly altered states of consciousness with a variety of subjectively experienced effects. These include certain changes to perception, cognition, and affect,1 which we refer to here as the acute subjective effects of psychedelics. In recent years, psychedelics such as psilocybin have also shown considerable promise as therapeutic agents when combined with talk therapy, for example, in the treatment of major depression or substance use disorder.2 However, it is currently unclear whether the aforementioned acute (...) subjective effects are necessary to bring about the observed therapeutic effects of psilocybin and other psychedelics. This uncertainty has sparked a lively—though still largely hypothetical—debate on whether psychedelics without subjective effects (“nonsubjective psychedelics” or “non-hallucinogenic psychedelics”) could still have the same therapeutic impact, or whether the acute subjective effects are in fact necessary for this impact to be fully realized.3,4,5. (shrink)

This book explores numerous ways in which vulgar language, grotesque appearances, and horrific experiences affect us in our relationships with others and with ourselves. Its compelling case studies and revealing interviews bring together ideas and issues that are a lingering, but unexplored, focus in psychotherapy literature. The grotesque and the vulgar are major inhabitants of the vast unconscious. Their variations and haunting presence are anticipated and reflected in the transactions of everyday life. So too do they manifest themselves in our (...) social institutions, maintaining their presence in the seven lively arts as much as in mental hospitals, rehabilitation facilities, and psychotherapy practices. Most of all, the grotesque and vulgar challenge the contemporary search for meaning and sanity. This book will help the psychotherapist better deal with the rich soil of grotesqueness and vulgarity in the interplay between the psychotherapy patient and the experiential world. Reading it will open new vistas of treatment possibilities. As each contributing author explores the potentialities and obstacles inherent in the competing and complementing forces of the grotesque and socially condoned sensibilities, you will learn about the value of the grotesque in the consultation room. You will further learn how the flaunted and unconscious vulgarities of everyday life enrich the creative vision inherent in therapeutic conversations. Most important, you will be challenged by what it means to abide with the sometimes pesky vulgar and grotesque guises in each of your client's lives. Here's a sample of what you'll find in Inhabitants of the Unconscious: The Grotesque and the Vulgar in Everyday Life: Louis Fierman's recollection of his treatment of a Nazi soldier, which offers fascinating therapeutic possibilities when issues of the grotesqueare at hand an extraordinary analysis of the role of the grotesque in artwork, with special attention paid to the work of Hieronymus Bosch a fascinating look at Sigmund Freud's perspective on the grotesque&#; and what it says about Freud himself the remarkable formative experiences of children with craniofacial difference &#;an exposition that will enrich your therapeutic interventions with children and adolescents who face atypical challenges extraordinary case studies&#;by Robert Marchesani about his therapeutic endeavors with a Vietnam veteran caught in the aftermath of his incestuous past and by E. Mark Stern about a dying woman who was unable to detach from, but ultimately vivified by an unyielding masochistic fixation. (shrink)

This paper discusses the meaning that interactive software agents and robots have in the context of mental therapy. This theoretical discussion is undertaken from a psychological and sociological perspective. It investigates what happens when interactive agents are introduced into current social situations. Methods of mental therapy vary from therapeutic conversation between clients and human therapists to interaction between clients and therapeutic animals such as dogs. This paper focuses on applications of interactive software agents and robots that substitute (...) as autonomous artifacts behaving like humans for human therapists. In addition, some implications and policies for applications of interactive software agents and robots in mental therapy are discussed. (shrink)

Conversation analysts have noted that, in psychotherapy, formulations of the client's talk can be a vehicle for offering a psychological interpretation of the client's circumstances. But we notice that not all formulations in psychotherapy offer interpretations. We offer an analysis of formulations that are diagnostic: that is, used by the professional to sharpen, clarify or refine the client's account and make it better able to provide what the professional needs to know about the client's history and symptoms. In doing (...) so, these formulations also have the effect of shepherding the client's account towards subsequent therapeutic interpretation. In a coda, we notice that sometimes the formulations are designed discreetly. We examine one such discreet formulation in detail, and show how its very ambiguity can lead to its failure as a diagnostic probe. (shrink)

This article examines how therapists and patients start building and managing relationships and pursue institutional goals at the same time. Based on a corpus of 6 audio-recorded therapies (client-centered therapy and psychodynamic therapy), I investigate first encounters between therapists and patients as the starting points of any therapeutical process and the place where a relationship between the interactants is established for the first time. Following a microlinguistic qualitative approach and applying methods from conversation analysis and discourse analysis, I show (...) how therapists, on the one hand, try to align with patients to build a positive working alliance and, on the other hand, work to fulfill specific interactive tasks of therapeutic discourse which demand disaligning with the patients’ communicative activity and their interactive expectations. Specific interactive “jobs” that need to be fulfilled in psychotherapy are identified, namely the performance of institutional roles by the interactants, the establishment of an interaction structure and the pursuit of helpful change in the patient. I show at which places in the interaction therapists (dis-)align with the patients’ projected communicative activity and how aligning and disaligning are related to the interactive process and the establishment and performance of these interactive jobs. The analysis shows that, at the beginning of therapy, alignment and disalignment are both important processes for the following reasons: Aligning with the patient contributes to a positive relationship, which has been shown to be vital for successful psychotherapy, while disaligning introduces the patient to the specific discursive mechanisms that characterize therapeutic discourse and constitute the basis for its effectiveness. Overall, the paper argues that reducing therapy to a dichotomy between relationship and “technique” seems overly simplistic, as both aspects need to be handled and managed at the same time. (shrink)

Using Conversation Analytic methods, the present study attempts to analyze the various functions of face-based therapist empathy, and how they are sequentially realized in different psychotherapeutic settings. Four types of face-based therapeutic functions are discussed; more specifically, it is illustrated how therapist empathy may serve to maintain, enhance, threaten or even save the client’s face. The findings gained could contribute to a better understanding of the face-based therapeutic functions of empathy; also, the study may inspire researchers to (...) further investigate other functions of therapist empathy in psychotherapy. (shrink)

Admitting hospital patients: a qualitative study of an everyday nursing task In recent years new modes of nursing work have been introduced globally in response to radical changes in healthcare policies, technology and new ideologies of citizenship. These transformations have redefined orthodox nurse–patient relationships and further complicated the division of labour within health‐care. One distinctive feature of the work of registered nurses has been their initial assessment of patients being admitted to hospital, and it is of interest that this area (...) of nursing practice remains central to the registered nurse's role at a time where other areas of practice have been relinquished to other occupational groups. This qualitative study, drawing on conversation analysis and ethnographic techniques, explores this area of everyday nursing work. Initial nursing assessments have attracted considerable interest in the nursing literature, where it is clearly stated that assessments should be patient centred and seen as the important first step on the road to a therapeutic nurse–patient relationship. Results from this study lead to the conclusion that the actual nursing practice of patient assessment on admission to hospital is at odds with the recommendations of the literature and that a more routinised, bureaucratic form of work is devised by nurses as a means of expediting the process of admission. (shrink)

Looking at Paul B. Preciado’s relationship to psychoanalysis across texts, but especially the recent book Can the Monster Speak?: A Report to an Academy of Psychoanalysts, I seek to disentangle a possible vision for a new psychoanalysis from Preciado’s concerns, ambivalence and disgust with the professional field. I call this a somato-militant psychoanalysis that leans on Freud’s notion of conversion as the creation of a parasitic traumatic kernel that insists on the side of the body and shows a potential for (...) mutuation, transference, amplified potentia gaudendi, surgical intervention and a radical exteriorization of the subject through access to desire. This somatic archival work runs against an idea of psychoanalysis as merely a privatization and interiorization of the subject, a site for upholding the colonial-patriarchal regime of gender norms and an attempt at therapeutic re-territorialization. In the end, the meeting between Preciado and psychoanalysis is given a name: terminal, meaning both at the very limit, the end point, and incurable. (shrink)

This study examines thirteenth to twentieth century Tibetan and Mongolian monastic memorializations of the bodily violence enacted upon Köten Ejen at the center of the “Buddhist conversion of the Mongols.” Koten Ejen (Tib. Lha sras go tan rgyal po, 1206–1251) was Chinggis Khan’s grandson and a military leader involved in Mongol campaigns against the Song Dynasty and against Buddhist monasteries in eastern Tibet. In 1240, Koten famously summoned the Central Tibetan Buddhist polymath Sakya Pandita, by then already an old man, (...) to his court at Liangzhou. Examining Tibetan and Mongolian accounts about their meeting from the last seven centuries, this study shows that it was neither compelling philosophy nor some turn of faith that converted the Mongols. It was, rather, Sakya Pandita’s violent therapeutic intervention into the space of Koten’s ill body that wrenched the Mongol body politic into the Dharmic fold. (shrink)

McCabe & Healey argue that in patient‐psychiatrist interaction, the more the participants engage in repair, i.e., trying to fix potential misunderstandings, the better the outcomes of the interaction, as measured by treatment adherence and the quality of the Dr – patient relationship. This holds both for self‐repair, when psychiatrists fix their own utterances, as well as other‐repair, where patients try to fix the understanding displayed by the psychiatrist.

Telepsychiatry has long been discussed as a supplement to or substitute for face-to-face therapeutic consultations. The current pandemic crisis has fueled the development in an unprecedented way. More and more psychiatric consultations are now carried out online as video-based consultations. Treatment results appear to be comparable with those of face-to-face care in terms of clinical outcome, acceptance, adherence and patient satisfaction. However, evidence on videoconferencing in a variety of different fields indicates that there are extensive changes in the communication (...) behaviour in online conversations. We hypothesise that this might impact ethically relevant aspects of the therapeutic relationship, which plays a prominent role in psychiatry. In this paper, we review effects of video-based consultations on communication between therapists and patients in psychiatry. Based on a common understanding of video-based consultations as changing the lived experience of communication, we categorise these effects according to sensory, spatial and technical aspects. Departing from a power-based model of therapeutic relationships, we then discuss the ethical significance of this changed communication situation, based on dimensions of respect for autonomy, lucidity, fidelity, justice and humanity. We conclude that there is evidence for ethically relevant changes of the therapeutic relationship in video-based telepsychiatric consultations. These changes need to be more carefully considered in psychiatric practice and future studies. (shrink)

The recent successful conversion of adult cells into induced pluripotent stem (iPS) cells through direct reprogramming opens a new chapter in the study of disease and the development of regenerative medicine. It also provides a historic opportunity to turn away from the ethically problematic use of embryonic stem cells isolated through the destruction of human embryos. Moreover, because iPS cells are patient specific, they render therapeutic cloning unnecessary. To maximize therapeutic benefit, adult stem cell research will need to (...) be pursued in parallel with studies using iPS cells. Among the four alternative methods presented by the President’s Council on Bioethics, direct reprogram- ming is the most ethically acceptable. Nonetheless, iPS cells are tainted by their association with the human embryonic stem cell lines, derived in the past, which will be required for their validation. This concern is one that can be resolved. Human iPS cells will serve to stem the tide of human embryonic stem cell research, changing it and diverting stem cell research in a more ethical direction. (shrink)

The ease and applicability of CRISPR/Cas9––a new and precise gene editing and reproductive technology––have garnered hype and heightened concern about its potential ‘unprecedented and horrific consequences’ and have led many scientific leaders to call for a moratorium on its research and use. CRISPR appears distinctly more controversial than previous technological innovations, with a greater reach and speed of human treatment and enhancement; however, we have seen similarly inflated hopes and fears in response to other medical innovations for well over a (...) century. One intervention that has both historically and recently incited alarm––vaccines––serves as a pertinent example of what could go wrong if a technology's reach is shortened due to inflated fears. By comparing the vaccine controversy and the CRISPR debate, we can help separate the hype from the realistic potential of these technologies. How our society grapples with such innovations will determine the extent to which their impact on our individual and collective health will be beneficial. We must recognise the need for a tempered approach to CRISPR conversation leading to regulation and ethical application. Although CRISPR's reach will continue expanding with ongoing research, thus requiring continuous evaluation, the lessons we have learned from the vaccine controversy demonstrate that our approach must not be to shut down regulation and application now, but to thoughtfully conjoin productive debate and action so that therapeutic gene editing can alleviate suffering as soon as possible without precipitating social outcomes we would belatedly deplore. (shrink)

Cell therapy means treating diseases with the body's own cells. One of the cell types most in demand for therapeutic purposes is the pancreatic β‐cell. This is because diabetes is one of the major healthcare problems in the world. Diabetes can be treated by islet transplantation but the major limitation is the shortage of organ donors. To overcome the shortfall in donors, alternative sources of pancreatic β‐cells must be found. Potential sources include embryonic or adult stem cells or, from (...) existing β‐cells. There is now a startling new addition to this list of therapies: the pancreatic α‐cell. Thorel and colleagues recently showed that under circumstances of extreme pancreatic β‐cell loss, α‐cells may serve to replenish the insulin‐producing compartment. This conversion of α‐cells to β‐cells represents an example of transdifferentiation. Understanding the molecular basis for transdifferentiation may help to enhance the generation of β‐cells for the treatment of diabetes. (shrink)

Ethics and the Clinical Encounter explores the moral dimensions of clinical medicine and the phenomenon of illness, to determine what ethics must be in order to be fully responsive to clinical encounters. Written in a lively and conversational style with minimal technical terminology, and enhanced by actual experience or real clinical situations, this volume lays out a clinical ethics methodology both in practical and theoretical terms. Here's what the experts had to say: Professor Zaner has provided us with a remarkably (...) lucid and trenchant discussion of the interface of philosophy and the field of medicine. He brings into play an extraordinary range of historial knowledge, extensive observations based on firsthand experience with medical practices, and an acute sense of philosophical argumentation. This is a work that will be an exemplary and indispensable text in the philosophy of medicine for years to come. -- Calvin Schrag... it is a highly original contribution usable in a number of fields.... It really has no competition.... The genius of Zaner's approach is to ground ethics from the 'bottom up' and to direct us to the concrete particulars of therapeutic encounters wherein lie moral and ethical matters... meaty, challenging, and ultimately rewarding.... -- Paul R. Dokecki Richard M. Zaner founded the Center for Clinical and Research Ethics at Vanderbilt University Medical Center. Having established Vanderbilt's first Hospital Ethics Committee (1985), he served as co-chair of VUMC's Ethics Committee since its inception in 1990. Zaner has published five original books, edited ten, and translated four more, and has published more than 100 sections of books and professional journals. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:ConclusionNeil PickeringAs mentioned in my Introduction, and I am delighted to repeat now, the commentaries provided by Calvin Ho and Chua Hong Choon are both excellent. In reading them, some further thoughts were raised for me, and I briefly reflect on these now.In his legal commentary, Calvin Ho makes a plausible argument that Mr. T has the capacity (and hence the right) to make decisions in his current state (...) about his healthcare, and refers to two legal tests of decision-making competency laid down in the Singapore Mental Capacity Act (2008), which he believes Mr. T would pass. A question arises from each of the legal tests which Ho described.The first test involves the question of whether there is any “impairment of, or disturbance in the functioning of Mr. T’s mind or brain”. The claim made by Ho is that there is no impairment or dysfunction of Mr. T’s mind or brain. But, this raises a question: what are the functions of the mind? Christopher Boorse suggested that “We may surely assume … that the main function of perceptual and intellectual processes is to give us knowledge about the world” and against this standard “schizophrenia and all other psychoses with thought disorders look objectively unhealthy”.1 Further — and here is the specific point of discussion in relation to Mr. T — does his continuing denial that he is ill (his lack of insight) also constitute such a dysfunction? Is one function of our mind to tell us things about the functioning of our minds — to correct errors, spot illusions and self-deceptions, and respond to beliefs which are odd? If so, then perhaps Mr. T’s lack of insight indicates the presence of a dysfunction.The second test which (mainly for the sake of completeness) Calvin Ho refers to comprises a list of requirements for decision-making capacity. These are relevant if a dysfunction is identified by the first test. These are:(1). Understand information given to him;(2). Retain that information long enough to make the decision;(3). Use or weigh up that information as part of the process of decision-making; and(4). Communicate his decision.These requirements are familiar from other accounts of decision [End Page 222] making capacity, but at least some of these accounts have added a further requirement, “the ability to appreciate the nature of the situation and its likely consequences”.2 This is not merely the ability to understand what one is being told but also the ability “to apply the information abstractly understood to [one’s] own situation”. Potentially, Mr. T would fail this test. He frequently lacks insight into the fact that he is unwell, that is to say, he does not seem to appreciate that the information he is being given is true of him.I turn now to the clinical commentary by Dr. Chua. What chiefly struck me from this was the determination to engage with the patient as a person. Medication is not the first resort; rather, many other interpersonal approaches can and should be tried first. Medication is of course one aspect of treatment — and in some cases, any hope of any sort of engagement with a patient may rely upon some medical intervention succeeding. Perhaps Mr. T will turn out to be a patient of this kind, who can only be engaged in conversation about his experiences and the state of his mind if he has first taken a course of pills. But it has, over a number of years of speaking to psychiatrist colleagues, been borne in upon me that the psychiatrist himself or herself is a fundamental element of mental healthcare. The psychiatrist is not merely a route to help, the dispenser of prescriptions for pills, but someone with whom the patient can talk to and explore his or her experiences. In short, part of the therapeutic relationship which psychiatrists seek to establish is just a personal relationship. I am sure this is simply obvious to most clinicians and indeed to those who suffer from mental ill health and their caregivers. But sometimes, the obvious is worth pointing out.Indeed, the desire to engage with Mr. T as a person... (shrink)

From the tape-recording of naturally occurring Chinese psychotherapy sessions, this article explores how repeated occurrences of resistance are managed in the course of interactional sequences and the participants’ actions within these sequences. By employing the methods of conversation analysis, we discuss the main discursive strategies employed by the clients to express their resistance and investigate how the therapist manages this. We find that clients show their resistance to the therapist’s questions in four ways: keeping silence, providing minimal response, making (...) non-answer responses, and being over-talkative. Persistent asking is the main technique we identify in the data for the therapist to manage the resistance; in the meantime, asking questions in a stepwise way, making requests after facing resistance to questions, active retreating and reformulating of the client’s words are employed as subsidiary techniques. The successful management of resistance leads to a smooth sequential development of the psychotherapy, while inappropriate strategies might result in a halt or even breakdown of the therapeutic work. In psychotherapy, resistance is a result of the shared interaction between client and therapist. It is such a complex issue that, in order to understand and manage it, we also take into consideration the broader social and cultural context in which it occurs. (shrink)

This paper focuses on one of the mainstays of Japanese psychiatrist and philosopher Kimura Bin’s (1931–2021) philosophical approach. Kimura’s work is characterized by the intersection of therapeutic, philosophical, and intercultural dimensions in ways that enable his clinical practice and philosophical investigations to mutually inform one another. I examine how this dialectic comes together with his conversion of ordinary Japanese words into philosophical concepts. Explicating the concepts Kimura deploys in developing a phenomenology of the self allows us to make new (...) sense of phenomena ranging from the process of individuation to the collective subjectivity of group life, from the breakdown of the self to its fuller realization. (shrink)

ObjectiveHopelessness and depression are strongly associated with suicidality. Given that physical and psychological outcomes can be altered with hope, hope is a therapeutic goal of increasing importance in the treatment of brain tumor patients. Moreover, it is not yet understood which factors affect the perception of hope in brain tumor patients. In addition, it remains uncertain whether lower-grade brain tumor patients suffer less from psycho-oncological distress than higher-grade brain tumor patients.MethodsNeuro-oncological patients were examined perioperatively with the Distress Thermometer and (...) the Herth Hope Index. In addition, psychological comorbidities and an assessment of general psycho-oncological distress were recorded.ResultsSixty-six brain tumor patients were included. No differences between higher- and lower-grade brain tumor patients were observed for general psycho-oncological distress and hope. However, higher-grade brain tumor patients showed a significantly higher level of depression and more negative expectations regarding therapeutic success. The extent of depression correlated negatively with hope.ConclusionUnexpectedly, higher-grade brain tumor patients remained as hopeful as lower-grade brain tumor patients despite the devastating diagnosis, higher levels of depression, and a worse expectation of therapeutic success. Conversely, lower-grade brain tumor patients experience as much psycho-oncological distress as patients with a higher-grade brain tumor, underpinning the imperative need for comprehensive psycho-oncological screening. For all brain tumor patients, considering hope is important to avoid suicides resulting from hopelessness and depression. (shrink)

High‐precision tumor targeting with conventional therapeutics is based on the concept of the ideal drug as a “magic bullet”; this became possible after techniques were developed for production of monoclonal antibodies (mAbs). Innovative DNA technologies have revolutionized this area and enhanced clinical efficiency of mAbs. The experience of applying small‐size recombinant antibodies (monovalent binding fragments and their derivatives) to cancer targeting showed that even high‐affinity monovalent interactions provide fast blood clearance but only modest retention time on the target antigen. Conversion (...) of recombinant antibodies into multivalent format increases their functional affinity, decreases dissociation rates for cell‐surface and optimizes biodistribution. In addition, it allows the creation of bispecific antibody molecules that can target two different antigens simultaneously and do not exist in nature. Different multimerization strategies used now in antibody engineering make it possible to optimize biodistribution and tumor targeting of recombinant antibody constructs for cancer diagnostics and therapy. BioEssays 30:904–918, 2008. © 2008 Wiley Periodicals, Inc. (shrink)