*With the exception of programs from the ACCEL series, each of which qualifies for up to 4 Category 1 CME credits.
NEW Audio-Digest Psychology
Volume 02, Issue 02
January 21, 2013
Theory of Power-Load-Margin Patrick C. Hardigan, PhD
Learning Self-Regulation Through Play Cynthia A. Dodge, PhD
Dream Reports in Psychodynamically Oriented Treatment Myron L. Glucksman, MD
The following is an abstracted summary, not a verbatim transcript, of the lectures/discussions on this audio program.
Psychology Program Info Accreditation InfoCultural & Linguistic Competency Resources
Theory of Power-Load-Margin/Perpetual Play/Manifest Dreams
The goals of this program are to improve assessment of likelihood of academic success, creation of more effective therapeutic environments, and assessment of the progress of therapy through manifest dream reports (MDRs). After hearing and assimilating this program, the clinician will be better able to:
1. Make predictions of academic success through the use of simple testing instruments.
2. Evaluate the balance of stressors and supports in an individual’s life.
3. Use playfulness in the treatment of traumatized patients.
4. Implement evidence-based practices and exercises shown to foster “childlike” qualities, such as curiosity and wonder.
5. Assess the themes, narratives, and different forms of affect described in MDRs to evaluate treatment progress.
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning committee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, the faculty and planning committee reported nothing to disclose.
Theory of Power-Load-Margin
Patrick C. Hardigan, PhD, Professor of Public Health, Nova Southeastern University, Fort Lauderdale, FL
McClusky’s formula: derived from studies of adult education; consistent with ideas of stress; expressed as load (ie, life’s stressors) divided by power (ie, sources of personal strength); individuals with load-to-power margins of 50% to 80% have higher rates of academic success; recommended usage — identification of at-risk students
Day and James study of margins under instructor-generated loads (1984): assessed effects of helpful and unhelpful behaviors manifested by instructors; used qualitative approach; included 10 to 15 students; power-load-margin concept showed high levels of applicability
Instrument developed by Mikolaj: used data from adult community college students; effective at measuring power-load-margins
Stevenson’s study of power-load-margin in nursing (1983): considered highest-quality study of McClusky’s margin theory; used formula for developing effective measurement instrument; focused on adult nontraditional nursing students (eg, older, attending night school)
Speaker’s study of power-load-margin in traditional students: used focus groups and pilot testing in 3 health profession degree programs to develop new measurement instrument; focus groups identified relevant stressors and strengths encountered by first- and second-year students
Concepts included in power-load inventory: perceived ability (to, eg, demonstrate intellect necessary to complete programs); core strength load or power (eg, anticipating difficulty of courses and stressors associated with academics); external motivators (eg, family, friends, colleagues; may contribute to either power or load); overall health (includes both personal well-being and that of family members); instructor load (as manifested in, eg, quantity of tests given, respect shown to students); life events (primarily dictated by living environment [adequacy of, eg, housing, food, finances, activities, accommodations for spiritual needs]); internal motivation (eg, personal strength necessary to complete schooling); university resources (eg, structure, framework, support staff necessary for positive environment)
Power-load-margin inventory: classification of 70 items as sources of stress or strength (or neither); confusion arose surrounding items which acted as sources of both stress and strength (eg, children); in these cases, individuals instructed to identify family support structures available in present (or near future); administration requires 10 to 15 min; given to first- and second-year students in dental, medical, and pharmacy programs
Rasch analysis: used on results of inventory; useful for validating “scales”; provides multiple forms of high-quality criteria for evaluating instruments; similar to 2-item (difficulty and discrimination) analysis, but keeps discrimination consistent while measuring difficulty (in form of strengths, stressors, or neither); speaker uses rating scale model (instead of multiple choice item analysis)
Analysis structure: validity measured through “infit” (eg, how well items respond) and “outfit” criteria (identifies students who failed to fit into speaker’s model; filters out respondents who answer questions randomly or thoughtlessly); 7 questions eliminated due to failure to meet set parameters; universality — concept taken from Rasch; analysis attempts to incorporate entirety of single idea (power-load-margin); questions met criteria (ie, demonstrated consistency across subdimensions)
Ratings scale: items rated “-2” classified as stressors, items rated “0” neither stress nor strength, and items rated “+2” considered strengths; results validated 3-point (ie, stress vs neither vs strength) scale as effective
Reliability under Rasch analysis: inventory items met 95% of criteria, and “personability” of questions ranked at 90% (suggests instrument effective); differential item functioning — assesses whether different groups demonstrate different patterns of response; responses to questions varied slightly based on sex and medical specialty (not significant enough to invalidate items)
Efficacy at predicting student grades: students with higher strength scores upon starting class had superior grades
Implementation of inventory: to be used as first-level diagnostic by academic institutions in identifying at-risk students
Learning Self-Regulation Through Play
Cynthia A. Dodge, PhD, Director of Clinical Services, Spurwink Services, Portland, ME
Background on play: critical to all humans; relies on creativity, imagination, metaphor, and “mind sight” (critical lens focal point enabling individuals to assess their own experiences, plus experiences of others; promotes creativity and vitality); found in all species of animals and human cultures; individuals can attempt to focus on and enhance joyful aspects of play and mind sight during stress (in order to better self-regulate)
“Childlike” countenance when providing therapy: described as critical goal by Erikson; may be assessed in terms of neoteny (ie, retention of childlike features [eg, curiosity, wonder]); by feeling these childlike emotions, therapists may impart them to others
“Culture of play”: goal for speaker’s institution; potential alternative to manualized care (practice discouraged by National Child Traumatic Stress Network)
Work of Van der Kolk on treating trauma: describes treatments aimed at eradication or elimination of trauma as “woefully inadequate,” and emphasizes importance of components which expose patients to happiness; individuals who have survived trauma often congregate and relive their experiences, since these recollections excite their brains (thus making them feel “aliveness” and validating their existence); without this excitation, trauma often creates persistent “white imagery” (ie, sense of emptiness); focusing on importance of “happy” as treatment component leads to detrivialization of play; benefits of exposure to happiness — laughter; pride; imagination; joy; sense of connectivity
Evidence-based practices adopted by speaker: Social Communication-Emotional Regulation-Transactional Support; social thinking (valuable for children with pervasive developmental disorders and extreme behaviors); due to parallel processes involved in emotional regulation, dealing with extreme intense behaviors nearly always affects caregivers (as such, self-care and self-regulation for caregivers critical)
Representations of social thinking (Garcia Winner): exercises in which children can relate to action figures representing social situations; nonverbal children may be engaged via picture exchanges using characters; “space invader” — action figure who travels to earth in order to invade personal space and make others uncomfortable; recommended for children with autism spectrum disorders; “glass man” — character who attempts to “shatter” minds and prevent individuals from thinking clearly; “unwonderer” — character who attempts to prevent children from feeling curiosity and wonder (and thus interferes with healthy social exchanges)
Therapeutic environment: must promote playfulness and trust; laughter can defuse intense behaviors and support self-regulation; safety and health should be priority
Dream Reports in Psychodynamically Oriented Treatment
Myron L. Glucksman, MD, Clinical Professor of Psychiatry, New York Medical College, Valhalla
Background on manifest dream reports (MDRs): studies show greater degrees of negative affect in MDRs of patients who had recently initiated therapy, and decreased negative affect in MDRs from patients who had participated in psychotherapy over long periods of time (and, conversely, increase in positive affect)
Speaker’s latest MDR study: assessed initial dreams (concurrent with beginning of psychotherapy) in 63 patients
Subgroup: 30 subjects considered to have made substantial progress in their therapy (based on speaker’s subjective judgment), or had successfully terminated treatment; age range 35 to 76 yr; mean length of treatment 11.5 yr; all 30 participants under speaker’s care and selected from his practice; MDRs directly transcribed from speaker’s notes (with identifying information removed); treatment duration varied widely (ranged from 2 to >30 yr); 5 patients had ended treatment successfully; 25 in treatment but assessed as making satisfactory progress (under criteria developed by physicians who studied therapeutic outcomes)
Use of medication: participants divided on basis of duration of medication use (>6 mo vs >1 yr); only 3 women taking medications during initial MDRs, but by conclusion of study, 17 had been taking medications for >1 yr (speaker dismisses effects on dreams by end of study as minimal); men used medications at lower rates, but all men receiving them logged >1 yr of use before final MDRs collected
Establishing reliability: speaker and colleague independently rated MDRs (colleague rated blindly [had no details about patient]); evaluators showed high levels of agreement when assessing parameters based on affect and affect valence (positive vs negative); after reliability demonstrated, speaker’s colleague (ie, independent observer) did evaluation of affect in initial MDRs used in study
Results: in initial MDRs, many patients showed negative affect and few showed positive affect; final MDRs showed decreased negative affect and greater positive affect; outcomes substantiated correlations seen in earlier studies (eg, transition from negative to positive affect)
Affect in associations (latent content): speaker rated affect based on his confidential patient notes (raising potential issues with objectivity); ratings of affect valence and associations in initial MDRs showed high levels of negative affect and low levels of positive affect; final MDRs showed decreased associations in negative affect and increases in positive affect
Themes in associative content: rated by speaker (ie, potentially subjective) based on retrospective analysis of treatment notes and meticulous documentation of dreams and associations; initial MDRs showed high degrees of negative affect (with minimal positive affect); in final MDRs, negative affect decreased, and positive affect substantially increased
Dream narrative: ie, “story” told by dream’s manifest content; nonphenomenologic and unrelated to psychoanalytic theoretic model; narratives of dream imagery independently evaluated by speaker and colleague (with strong degree agreement after comparing data); initial MDRs showed high incidence of negativity in narratives and low incidence of positivity; conversely, final MDRs showed decreases in negative narratives and increases in positive narratives
Psychodynamic formulation of dreams: related to narratives; aims to describe dreams in dynamic terms, while avoiding partiality to any particular psychoanalytic theory; speaker’s and colleague’s independent analyses showed high level of agreement; initial MDRs showed high levels of negative formulations, while final MDRs showed decreased negative formulations and increased positive formulations
Transference dreams: defined by speaker (and study criteria) as dreams with any direct or indirect reference to therapist in manifest content; assessed by speaker (ie, potentially subjective); initial MDRs showed greater incidence of negative transference dreams; final MDRs showed marked decreases in total transference dreams and increases in positive transference dreams; women reported much higher incidences of transference dreams in initial MDRs (compared to men), but showed marked decreases in negative transference dreams in final MDR (women may have had greater difficulties with their perceptions and feelings about speaker early in treatment than at end of treatment)
Assessing dream themes: speaker broke down dreams into distinct thematic categories (eg, relational, injury or threats, control or loss of control, self-state, problem solving, frank sexual dreams, loss) before applying subjective ratings; high proportion of relational dreams reported (particularly in final MDRs); initial MDRs had substantially more content involving injury or threats (compared to final MDRs); most other categories lacked sufficient data for analysis; however, none of initial MDRs reported self-focused dreams, whereas final MDRs included self-focus in 5 patients; these dreams typically included more positive sense of self
Day M, James J: Margin and the adult learner. MPAEA Journal of Adult Education 13:1, 1984; Glucksman ML, Kramer M: The clinical and predictive value of the initial dream of treatment. J Am Acad Psychoanal Dyn Psychiatry 39:263, 2011; Glucksman ML, Kramer M: Using dreams to assess clinical change during treatment. J Am Acad Psychoanal Dyn Psychiatry 32:345, 2004; Glucksman ML: The dream: a psychodynamically informative instrument. J Psychother Pract Res 10:223, 2001; Kramer M, Glucksman ML: Changes in manifest dream affect during psychoanalytic treatment. J Am Acad Psychoanal Dyn Psychiatry 34:249, 2006; Nader-Grosbois N, Vieillevoye S: Variability of self-regulatory strategies in children with intellectual disability and typically developing children in pretend play situations. J Intellect Disabil Res 56:2, 140, 2012; Stevenson JS: Construction of a scale to measure load, power, and margin in life. Nurs Res 31:222, 1982; van der Kolk BA et al: Dissociation, somatization, and affect dysregulation: the complexity of adaptation of trauma. Am J Psychiatry 153:82, 1996; van der Kolk BA: The psychobiology of posttraumatic stress disorder. J Clin Psychiatry 58:16, 1997; Vieillevoye S, Nader-Grosbois N: Self-regulation during pretend play in children with intellectual disability and in normally developing children. Res Dev Disabil 29:256, 2008; Walworth DD et al: Using the SCERTS model assessment tool to identify music therapy goals for clients with autism spectrum disorder. J Music Ther 46:204, 2009.
Reproduction of this summary in whole or in part in any form or medium without express written permission is prohibited.