Trauma and Dream Work: Mending Tears in the Fabric of Time.

Working with dreams in the context of trauma can open unique avenues for healing, in particular for patients who report feelings of numbness or a loss of meaning in their lives. Dream exploration can make facing aspects of trauma and dissociated experience more tolerable than explicitly addressing them at a conscious level. It can also reignite the capacities for reflection and meaning making disrupted by trauma. Dreams also reconnect patients to aspects of their history that can provide context for and meaning to experiences from which they have come to feel emotionally disconnected. Finally, dreams offer a way of regaining the capacity to connect with wishes, hopes, and desires that have become difficult to access because of trauma. In this article, the authors present case examples of patients with trauma and discuss how therapists worked with dream material to unlock new possibilities for these patients' lives.

Recommendations for Dynamic Treatment of Identity-Based Trauma: Opening the "I" to Reflection.

Current treatments for trauma are ineffective for many patients. For traumas involving violence that targets aspects of patients' identities, treatments that do not address systemic factors involved in the trauma (e.g., past and ongoing experiences of identity-based oppression and marginalization, developmental sequelae of invalidation or policing of identity, and identity-related patterns of transference and countertransference) may be ineffective. Psychodynamic approaches can flexibly address the identity-related dynamics between therapist and patient and incorporate patients' experiences of their various identities, in the context of trauma, into clinical formulation and treatment. The authors present concepts relevant to the dynamics of intersectional identities that may arise between therapist and patient and provide a case study illustrating how a patient's various identities affect their symptom manifestation and treatment course. The authors advocate for cultural humility and self-exploration of biases and assumptions among clinicians, because therapists do not hold expert knowledge of their patients' cultural experiences.

Dynamic Interpersonal Therapy for U.S. Veterans in a Primary Care Setting.

OBJECTIVE: Brief dynamic interpersonal therapy (DIT) is an evidence-based psychodynamic intervention for depression offered by the U.K. National Health Service and previously studied in the context of a U.S. Department of Veterans Affairs medical center. This study assessed the clinical value of DIT in primary care for veterans with general medical conditions. METHODS: The authors examined outcome data of veterans (N=30; all but one had ≥1 comorbid general medical conditions) referred to DIT from primary care. RESULTS: Veterans who began treatment with clinically elevated depression or anxiety experienced a 42% reduction in symptom severity, as measured by the nine-item Patient Health Questionnaire or by the seven-item Generalized Anxiety Disorder questionnaire, respectively, representing large effect sizes. CONCLUSIONS: Significant decreases in depression and anxiety symptoms suggest the utility of DIT for veterans with comorbid general medical conditions. DIT's dynamically informed framework may improve patients' help seeking, which is relevant for patients experiencing comorbid medical conditions.

The impact of operational partnership on telemental health before, during, and after COVID-19.

The coronavirus disease (COVID-19) pandemic significantly accelerated the growth of telehealth services within the Veterans Health Administration (VHA), as the use of video conferencing to meet with Veterans in their homes increased tenfold in a 3-month period. A substantial portion of telehealth in VHA has traditionally comprised mental health services, and both the scope and volume of such services were significantly broadened in response to COVID-19 to allow for social distancing. The current article is a review of this mobilization from the framework of the People, Process, Technology, and Information model, with a particular highlight on the critical operational partnership between individual facilities providing care and the governing VHA program offices. Lessons learned and future goals for the sustainment and integration of telemental health services are also discussed. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Implementation of Telemental Health (TMH) psychological services for rural veterans at the VA New York Harbor Healthcare System.

Meeting the mental health needs of our current veteran population is one of the primary challenges facing the Veteran's Health Administration (VHA). Particularly for veterans residing in rural areas, the lack of providers, high provider turnover, and the burden of traveling long distances to VHA facilities may contribute to difficulties accessing mental health care. Telemental Health (TMH) services help bridge the geographic gap between mental health providers and veterans who need mental health services. The VHA TMH Hub initiative has attempted to leverage changes in technology-facilitated care by developing a model in which a facility "hub" could expand mental health resources to remote "spoke" clinics and veterans' residences. This paper describes the implementation of the VA New York Harbor Health care System (VA NYH) TMH Hub, which was one of 6 programs funded by the VHA Office of Rural Health (ORH) in September 2016. We will describe the structure of the program, services provided, veterans served, and our efforts to integrate quality improvement, research, and clinical training into the operations of the program. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

The impact of brief dynamic interpersonal therapy (DIT) on veteran depression and anxiety.

A significant proportion of veterans continue to experience depression or anxiety following treatment with the empirically supported psychotherapies offered by the Veterans Health Administration. Continued development and testing of new treatments may be useful. Brief dynamic interpersonal therapy (DIT) is a short-term psychodynamic therapy developed for depression in the United Kingdom and is being disseminated as an alternative to cognitive behavioral therapy within the National Health Service. This study represents the first evaluation of DIT in the United States, implemented at a veterans affairs medical center for veterans with depression and/or anxiety. Electronic medical records of veterans receiving DIT from 2012 to 2018 at a New York-based veterans affairs medical center were reviewed. Linear mixed-effects models were used to analyze depression and anxiety scores collected at each session from the Patient Health Questionnaire and the Generalized Anxiety Disorder seven-item scale. Following DIT, patients presenting with clinically significant depression and/or anxiety reported a 46% reduction in Patient Health Questionnaire-9 scores (N = 60) and a 43% reduction in Generalized Anxiety Disorder seven-item scale scores (N = 46). Large effect sizes on both measures were found (d = 1.17, 95% CI [0.88, 1.47], p < .0001; d = 1.24, 95% CI [0.90, 1.58], p < .0001, respectively). DIT is a promising alternative to currently offered psychotherapies for veterans with depression and anxiety. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Patient Extratherapeutic Interpersonal Problems and Response to Psychotherapy for Depression.

OBJECTIVES: This paper aimed to synthesize empirical findings of patient extratherapeutic interpersonal variables associated with individual psychotherapy treatment outcomes in adult outpatients with depression. METHODS: A systematic search strategy was used to identify relevant studies. Thematic analysis was used to identify recurring themes in the findings. RESULTS: Forty studies met search criteria. Three themes of patient extratherapeutic interpersonal variables were identified: capacity to engage with others, capacity to navigate relationships, and capacity to achieve intimacy, progressing from basic to advanced levels of interpersonal interaction. Interpersonal variables such as interpersonal distress and style, attachment orientation, and quality of object relations were particularly useful in predicting treatment outcomes, whereas access to social support and marital status provided mixed results, likely because they do not account for relationship quality. CONCLUSIONS: Recognizing variables associated with treatment response can help clinicians identify patients at risk for nonresponse and guide efforts for adapting existing therapies and developing new ones.

Predictors of Symptoms Remission Among Family Caregivers of Individuals With Dementia Receiving REACH VA.

Resources for Enhancing All Caregivers Health (REACH VA) is a behavioral intervention for caregivers of individuals with dementia disseminated in the VA. Although shown to improve caregiver and care recipient outcomes, some caregivers continue to experience depression or caregiver burden following the intervention. Factors that predict symptom remission following REACH VA are unknown. The present study investigated attachment, social support, and psychopathology as predictors of symptom remission for family caregivers who completed REACH VA. Caregivers who do not remit perceive lower levels of social support from loved ones, endorse poorer attachment quality, and have more personality disorder characteristics, particularly affective instability. These factors that impair caregivers' abilities to be effectively attuned to the needs of their care recipients and to reap benefits from a brief and focused behavioral intervention such as REACH VA. Interventions that target caregiver interpersonal functioning and emotion regulation skills may be helpful to those who do not respond to REACH VA.

Implementing brief Dynamic Interpersonal Therapy (DIT) in a VA Medical Center.

Background: Given increasing mental health needs in the VA, identifying strategies to deliver new services is critical.Aims: This paper describes the process of navigating provider, patient and systems barriers of an initiative to increase choice, access and quality of psychotherapy at the VA by incorporating an evidence-based short-term, psychodynamic psychotherapy.Methods: Brief Dynamic Interpersonal Therapy (DIT) was selected as a viable model for implementation. Data were gathered on the process of implementation, barriers, Veterans seen, and access to psychodynamic psychotherapy.Results: Nine psychologists and 22 masters level pre-doctoral psychology externs have delivered DIT to 73 Veterans. Veterans referred for psychodynamic psychotherapy annually increased 360%. Furthermore, DIT has become the dominant form of psychodynamic psychotherapy requested of the psychology service representing 70.1% of psychodynamic psychotherapy referrals. Strategies are presented for addressing: (1) provider ability, flexibility and motivation, (2) Veteran perception of relevance, distinctiveness and adaptability to complex presenting issues and (3) administrative support.Conclusions: Implementing an evidence-based short-term psychodynamic treatment option in the VA is feasible. VA mental health providers can be trained in brief psychodynamic psychotherapy and can successfully implement those approaches in VA settings. Finally, psychodynamic treatment approaches may serve as a promising alternative to currently available treatments.

How to address the needs of non-responders to REACH VA: a qualitative analysis.

Objective: This study used qualitative methods to understand how to further alleviate symptoms of depression and caregiver burden and address the needs of non-responders following a course of Resources for Enhancing Alzheimer's Caregiver Health in VA (REACH VA). Methods: Semi-structured interviews with caregivers and interventionists post-treatment were coded for themes related to ways to address the needs of non-responder caregivers. Results: The following suggestions recurred among non-responder caregivers and interventionists: (1) tailor skills and psychoeducation material to caregiver's needs; (2) provide greater overall support within the realm of caregiving; (3) explore and process caregiver's emotions around caregiving experience and grief; (4) address interpersonal difficulties and barriers to asking for help; (5) spend more time practicing skills to aid in implementing them at home. Conclusions: For many non-responders, a longer-term treatment targeting caregivers' emotional processing, interpersonal skills, social connection, acquisition and implementation of skills is indicated.

Episodic memories of relationship quality, procedural knowledge of attachment scripts, and the experience of daughters caring for a parent with dementia.

A caregiver's attachment history with their parents may affect the thoughts, feelings, and behavior they now have as they care for a parent with dementia. Participants were 77 daughters of a parent with dementia. The nature of participant conscious episodic memories of their parental figures and unconscious procedural knowledge of caregiving processes (secure base script knowledge) were identified as two aspects of the caregiver's relationship history that may impact their involvement in care, relationship conflict, critical attitudes, and strain. Our findings indicated that the nature of episodic memories of the caregiver relationship history with parental figures were significantly associated with stress and criticism of their parent. Greater unconscious procedural knowledge of the secure base script was associated with caregiver report of less conflict and less involvement in the caregiving tasks. Potential clinical implications of this pattern are also discussed.

The Relationship Between "What We Believe" and "How We Care" Among Daughters Caring for a Parent With Dementia.

This study attempted to better understand factors associated with relationship conflict between daughters and their parents with dementia. We examined data from 77 daughters self-identified as primary caregivers of a parent with dementia to test the hypothesis that daughters' belief that a parent with dementia can control their symptoms is associated with more conflict, defined as high expressed emotion (EE). Participants completed self-report questionnaires assessing beliefs about parents' ability to control symptoms, stress, relationship conflict, parent agitation, and cognitive status. Results indicated that greater intensity of daughters' belief that their parent can control dementia-related symptoms was associated with more relationship conflict or "high EE" (ß = 0.57, P < .001). Daughters' beliefs about parental behavior may contribute to caregiver stress and exacerbate negative behaviors exhibited by individuals with dementia. Educating caregivers about parental behaviors and examining factors underlying caregiver interpretations of these behaviors hold promise for reducing caregiver stress.

Effects of attachment quality on caregiving of a parent with dementia.

OBJECTIVES: The purpose of the current study was to examine the moderating role of attachment quality on the relationship between dementia-specific stressors and: (a) caregiver distress and (b) caregiver satisfaction. METHOD: Caregivers (N = 91) of a parent with dementia completed questionnaires that assessed caregiving stressors (parental cognitive impairment and behavioral problems), attachment (early and present-day attachment) and measures of caregiver distress and satisfaction. A series of regression analyses were conducted to test the hypothesis that better attachment quality may buffer the effects of cognitive impairment and behavioral problems on the caregiver's experience of distress and enhance caregiver satisfaction. RESULTS: Results did suggest that present-day attachment moderates the effects of both cognitive impairment and behavioral problems on global distress but, contrary to our hypotheses, attachment security did not buffer the negative impact associated with these demands. Instead, secure present-day attachment was positively associated with an increased risk for emotional distress at mild levels of care-recipient cognitive impairment. Most analyses indicated no significant relationship between caregiving stressors and caregiver distress or satisfaction and few interactions based on attachment quality were found. CONCLUSIONS: Our study indicates that attachment security does not always have a protective or stress-buffering function but may amplify the effect of stressors under certain conditions. Different ways of understanding the obtained pattern of findings are discussed and additional work is required to test if secure attachment may be associated with increased resilience when the disease is more advanced. Clinical implications of the present findings are discussed.

The secure base script and the task of caring for elderly parents: implications for attachment theory and clinical practice.

This study explores links between adults' attachment representations and the task of caring for elderly parents with dementia. Participants were 87 adults serving as primary caregivers of a parent or parent-in-law with dementia. Waters and Waters' ( 2006 ) Attachment Script Assessment was adapted to assess script-like attachment representation in the context of caring for their elderly parent. The quality of adult-elderly parent interactions was assessed using the Level of Expressed Emotions Scale (Cole & Kazarian, 1988 ) and self-report measures of caregivers' perception of caregiving as difficult. Caregivers' secure base script knowledge predicted lower levels of negative expressed emotion. This effect was moderated by the extent to which participants experienced caring for elderly parents as difficult. Attachment representations played a greater role in caregiving when caregiving tasks were perceived as more difficult. These results support the hypothesis that attachment representations influence the quality of care that adults provide their elderly parents. Clinical implications are discussed.

The importance of family relationships with nursing facility staff for family caregiver burden and depression.

We explore the association between family caregiver depression and the quality of staff-family relationships, and we test burden as a mediator of this relationship. Using structural equation modeling, we used data from a representative sample of 932 family members from 20 nursing homes in Central New York to examine the association between staff-family relationship quality and family caregiver depression. We then tested family caregiver burden as a mediator of the relationship between staff-family relationship quality and family caregiver depression. Staff-family relationship quality, specifically perceived conflict with staff, is significantly associated with family caregiver depression. Further, caregiver burden mediates this relationship. Interventions to improve staff-family relationships may impact family caregiver depression by reducing the stress that family caregivers experience.

An observation of assisted living environments: space use and behavior.

Assisted living facilities have become increasingly popular for older adults needing assistance. They are intended to enable privacy and provide support, but the extent to which they do so, and the degree to which these relate to residents' needs, are unknown. This observational study of 1830 residents in 182 facilities indicates that, during the mid-afternoon, the majority of residents are awake (79%), and one-half (49%) are awake and in public spaces. Residents who are cognitively and functionally impaired are more likely to be in public spaces, but less likely to be engaged. Residents who are awake and alone in private spaces are less likely to be impaired, but more likely to have medical conditions. Thus, residents needing more oversight seem to be positioned to obtain that oversight.

Assisted living policies promoting autonomy and their relationship to resident depressive symptoms.

OBJECTIVE: The objective of this study is to determine the relationship between facility policies regarding autonomy and depression among residents of residential care/assisted living (RC/AL) facilities. METHOD: A stratified sample of RC/AL facilities in Florida, Maryland, New Jersey, and North Carolina participated in the study. Patient characteristics for individuals 65 years and older were obtained from medical record reviews and in-person interviews. Facility administrators provided data on facility characteristics. Data on 1,098 residents were used to examine the relationship between facility policies as measured by domains of the Policy and Program Information Form and resident depressive symptoms and its factors as measured by the Cornell Scale for Depression in Dementia. Generalized estimating equation regression analysis was used to examine this relationship and control for other explanatory variables and clustering. RESULTS: Among the policy variables examined, only the degree to which residents were involved in facility administration was consistently associated with depressive symptoms. Greater resident influence over facility policies and involvement in facility administration was significantly associated with lower levels of depressive symptoms. Resident control over their daily activities, the facility's tolerance for disruptive behavior, and the extent to which facilities had formal mechanisms for defining expected behavior were not significantly associated with levels of depressive symptoms. CONCLUSIONS: Although some facilities provide residents with opportunities to select activities or meal times, these policies were not associated with depressive symptoms. However, results are consistent with the hypothesis that resident involvement in facility administrative decision-making is associated with fewer depressive symptoms. Future research should explore the causal nature of this relationship and might provide guidance for policy and practice.

How good is assisted living? Findings and implications from an outcomes study.

OBJECTIVES: The objective of this work was to determine 1-year medical outcomes, nursing home transfer, and functional change of assisted living (AL) residents and their relationship to care. METHODS: On-site interviews and observations regarding the status and care of 2,078 residents in 193 facilities across four states were conducted; follow-up was by telephone interview with care providers. RESULTS: Annual mortality and transfer rates were 14.4 and 21.3 per 100 residents. The probability of hospitalization and new/worsening morbidities over a standardized quarter per 100 residents was 12.7 and 22.7. Standardized change in function was notable among those who were transferred or died and small among others. Facility characteristics did not generally relate to medical outcomes and transfer, and those that related to functional change were small and occurred across multiple functions. Facilities that are affiliated with another level of care were more likely to transfer; nurse staffing was favorable for hospitalization but not transfer; and aide turnover was protective for mortality. DISCUSSION: No single component defines "good" AL care. Predictors and outcomes are inconsistent, and effect sizes are small. Therefore, practice and policy should not focus narrowly on any one area or restrict the type of care-this being welcome news that supports diversity to accommodate individual preferences.