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With the movement towards recovery-oriented mental health (MH) services, individuals with MH lived-experience are increasingly employed as peer providers (peers). Peers are unique in that they bring knowledge from experience and eye-level connection to service users that enhance the quality of services and humanize MH systems' culture. In Israel, hundreds of peers are employed in various roles and settings across the MH system. However, peer integration into MH services faces challenges. One issue involves the use of self-disclosure (SD) in MH services which varies with explicitness across roles and settings. This study sought to understand perspectives and experiences regarding peers' SD (use & sharing of knowledge from experience) among different stakeholders in MH health services. Six focus groups and 4 semi-structured interviews (N = 42) were conducted as a part of a larger international project (UPSIDES; ERC Horizon 2020, Moran et al., Trials 21:371, 2020). Data was transcribed verbatim and analyzed using thematic analysis. Four categories and 7 themes were identified regarding current perspectives and experiences with peers' SD in MH organizations: (i) Restrained or cautious organizational approach to SD; (ii) Attitudes of peers to SD approach; (iii) The influence of designated peer roles on SD; and (iv) Unwarranted SD of peers working in traditional roles. The findings reveal that peers' SD in MH services is a complex process. Organizational approaches were often controlling of non-designated peers' SD practices; participants had diverse attitudes for and against peers' SD; SD occurred according to personal preferences, specific peer role and the director's approach to peers' SD; Conflictual SD dilemmas emerged in relation to service users and staff. SD sometimes occurs unwarrantely due to ill mental health. The presence of peer-designated roles positively impacts peers' SD. We interpret the current mix of views and general conduct of peer SD practice in statutory MH services as related to three aspects: 1. The presence of a traditional therapeutic SD model vs. a peer SD model - with the former currently being dominant. 2. Insufficient proficiency and skill development in peers' SD. 3. Stigmatic notions about peer SD among service users and staff. Together, these aspects interrelate and sometimes create a negative cycle create tension and confusion.A need to develop professionalism of peer SD in statutory services is highlighted alongside enhancing staff and service user acknowledgement of the value of peer SD. Developing peer-designated roles can positively impacts peer SD in MH statutory services. Training, support, and organizational interventions are required to further support for peer-oriented SD and the enhancement of a person-centered and recovery orientation of MH services., (© 2024. The Author(s).)

The outburst of the COVID-19 pandemic challenged vulnerable populations such as individuals with significant mental illness. In this fresh focus, we describe the innovative development of the UPSIDES mental health peer support intervention, in face of the COVID-19 pandemic in Israel. While the research program is still ongoing, in this paper we focus on the processes and lessons learned from dealing with the rapidly changing circumstances of the pandemic. We portray additional activities conducted above and beyond the UPSIDES protocol in order to maintain continuation and prevent dropout. We learned that an essential combination of keeping a close adherence with the core peer principles and UPSIDES' systematic program and the use of flexible telecommunication means, helped to maintain social connection and service users' participation throughout these times. The sudden pandemic challenges appeared to level out power imbalances and accelerated the formation of reciprocal and supportive relational interactions within the intervention. These processes highlight experiential knowledge as a unique asset, and peer support services as useful in supporting individuals with significant mental illness throughout COVID-19., (© 2022. The Author(s).)

Objectives: Despite the established evidence base for mental health peer support work, widespread implementation remains a challenge. This study aimed to explore societal and organisational influences on the implementation of peer support work in low-income and high-income settings., Design: Study sites conducted two focus groups in local languages at each site, using a topic guide based on a conceptual framework describing eight peer support worker (PSW) principles and five implementation issues. Transcripts were translated into English and an inductive thematic analysis was conducted to characterise implementation influences., Setting: The study took place in two tertiary and three secondary mental healthcare sites as part of the Using Peer Support in Developing Empowering Mental Health Services (UPSIDES) study, comprising three high-income sites (Hamburg and Ulm, Germany; Be'er Sheva, Israel) and two low-income sites (Dar es Salaam, Tanzania; Kampala, Uganda) chosen for diversity both in region and in experience of peer support work., Participants: 12 focus groups were conducted (including a total of 86 participants), across sites in Ulm (n=2), Hamburg (n=2), Dar es Salaam (n=2), Be'er Sheva (n=2) and Kampala (n=4). Three individual interviews were also done in Kampala. All participants met the inclusion criteria: aged over 18 years; actual or potential PSW or mental health clinician or hospital/community manager or regional/national policy-maker; and able to give informed consent., Results: Six themes relating to implementation influences were identified: community and staff attitudes, resource availability, organisational culture, role definition, training and support and peer support network., Conclusions: This is the first multicountry study to explore societal attitudes and organisational culture influences on the implementation of peer support. Addressing community-level discrimination and developing a recovery orientation in mental health systems can contribute to effective implementation of peer support work. The relationship between societal stigma about mental health and resource allocation decisions warrants future investigation., Trial Registration Number: ISRCTN26008944., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY. Published by BMJ.)

Objective: Persons with serious mental illnesses are at increased risk for co-occurring physical comorbidities. Patient-reported outcome measures are increasingly used in routine assessments of persons with serious mental illnesses, yet the relation of patient-reported outcome measures to physical health outcomes has not been comprehensively investigated. We examined the association between patient-reported outcome measures and self-reported physical health at 1-year follow-up., Design: A retrospective cohort study., Setting: Data were collected as part of the Israeli Psychiatric Rehabilitation Patient-Reported Outcome Measurement program in Israel., Participants: A total of 2581 psychiatric rehabilitation service users assessed between April 2013 and January 2016., Main Outcome Measures: Self-reports on two consecutive years of physical health dichotomized as poor versus good., Results: More than one-third of participants reported having poor physical health. Multivariate regression analysis showed that quality of life (odds ratio [OR] = 0.71; 95% confidence interval [CI]: 0.60-0.84) and lack of effect of symptoms on functioning (OR = 0.81; 95%CI: 0.74-0.89) predict subsequent physical health, controlling for all other factors. Compared to a multivariate model with personal characteristics and self-reports on physical health at baseline (Model A), the model which also included patient-reported outcome measures (Model B) showed slightly better discrimination (c-statistic: 0.74 vs. 0.76, respectively)., Conclusions: These results suggest that patient-reported outcome measures contribute to the prediction of poor physical health and thus can be useful as an early screening tool for people with serious mental illnesses living in the community, who are at risk of physical health problems., (© The Author(s) 2020. Published by Oxford University Press in association with the International Society for Quality in Health Care. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Peer support is an established intervention involving a person recovering from mental illness supporting others with mental illness. Peer support is an under-used resource in global mental health. Building upon comprehensive formative research, this study will rigorously evaluate the impact of peer support at multiple levels, including service user outcomes (psychosocial and clinical), peer support worker outcomes (work role and empowerment), service outcomes (cost-effectiveness and return on investment), and implementation outcomes (adoption, sustainability and organisational change)., Methods: UPSIDES-RCT is a pragmatic, parallel-group, multicentre, randomised controlled trial assessing the effectiveness of using peer support in developing empowering mental health services (UPSIDES) at four measurement points over 1 year (baseline, 4-, 8- and 12-month follow-up), with embedded process evaluation and cost-effectiveness analysis. Research will take place in a range of high-, middle- and low-income countries (Germany, UK, Israel, India, Uganda and Tanzania). The primary outcome is social inclusion of service users with severe mental illness (N = 558; N = 93 per site) at 8-month follow-up, measured with the Social Inclusion Scale. Secondary outcomes include empowerment (using the Empowerment Scale), hope (using the HOPE scale), recovery (using Stages of Recovery) and health and social functioning (using the Health of the Nations Outcome Scales). Mixed-methods process evaluation will investigate mediators and moderators of effect and the implementation experiences of four UPSIDES stakeholder groups (service users, peer support workers, mental health workers and policy makers). A cost-effectiveness analysis examining cost-utility and health budget impact will estimate the value for money of UPSIDES peer support., Discussion: The UPSIDES-RCT will explore the essential components necessary to create a peer support model in mental health care, while providing the evidence required to sustain and eventually scale-up the intervention in different cultural, organisational and resource settings. By actively involving and empowering service users, UPSIDES will move mental health systems toward a recovery orientation, emphasising user-centredness, community participation and the realisation of mental health as a human right., Trial Registration: ISRCTN, ISRCTN26008944. Registered on 30 October 2019.

WHAT IS KNOWN ON THE SUBJECT?: Recovery-oriented care is a means of providing mental health treatment, focused on the patient's individual needs and active involvement in one's own care. However, this approach presents with challenges, particularly in psychiatric hospitals, which tend to be focused on symptom reduction. WHAT DOES THE PAPER ADDS TO EXISTING KNOWLEDGE?: This study examines the influence of three different recovery-oriented training programmes/interventions (namely, illness management and recovery, peer support, and psychiatric advance directives) on the attitudes and practice of mental health staff (including nurses) in an inpatient setting, using a mixed-methods methodology. We quantitatively assess the knowledge, attitudes and practices developed following recovery-oriented training, compared to staff not trained in these interventions. We interviewed staff exposed to the different interventions to learn about their personal views and characterized the benefits and challenges they experienced. Mainly, the illness management and recovery training created a positive change in the work attitude and some work-related practices of mental health staff and the increased presence of a person-centred approach supporting patient autonomy. However, and contrary to expectations, there was no increase in practices that support personal goals or provide individually tailored services. Peer support had an experiential impact among mental health staff, initiating a more humane, positive approach to patients. Psychiatric advance directives were reported as more challenging to implement and with limited impact. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Recovery-oriented trainings can be internalized and implemented by staff in medical model psychiatric settings. Despite recovery-oriented training, challenges do occur-notably, they are hardest to implement in acute wards/patient states and by psychiatric nurses. Using multiple recovery-oriented programmes/interventions can accelerate the momentum for change in traditional settings and promote positive practice. Ongoing comprehensive mental health staff training on recovery-oriented care programmes is essential in order to sustain change over time. Training is not enough in itself-hospital administrations need to be actively involved in promoting recovery-oriented policies. ABSTRACT: Introduction Developing person-centred recovery-oriented care is a challenge in mental health systems, particularly psychiatric hospitals. Aim To assess the knowledge, attitudes and practices developed following recovery-oriented training of nurses and other staff; to identify the benefits and challenges involved in the implementation of recovery-oriented intervention in psychiatric wards. Method A mixed-methods study compared recovery knowledge, attitudes and practices of 37 mental health ward staff trained in recovery-oriented intervention, against 35 staff not trained. Fifteen staff were interviewed about their experiences, and protocols were qualitatively analysed. Results The quantitative outcomes partially confirmed positive changes in attitudes and some practices. Qualitative interviews complemented these findings, revealing greater use of a person-centred approach and support for patient autonomy. However, we did not find differences between groups in quantitative outcomes pertaining to personal goals or providing individually tailored services. Discussion This study validates the implementation of recovery training and practices in psychiatric settings, and identifies the challenges involved. We discuss psychiatric nurse conflicts in implementation in acute wards. Implications for practice Our findings support the need for broader staff training in recovery-oriented interventions. Recruiting the support of the hospital administration for recovery-oriented intervention programmes is key, both ethically and structurally., (© 2018 John Wiley & Sons Ltd.)

Background: Epidemiological studies show disparities in the provision of physical health-care for people with severe mental illness. This observation includes countries with universal health insurance. However, there is limited in-depth data regarding the barriers preventing equality of physical health-care provision for this population. This study applied the capabilities approach to examine the interface between general practitioners and patients with severe mental illness. The capabilities approach provides a framework for health status which conceptualizes the internal and external factors relating to the available options (capabilities) and subsequent health outcomes (functioning)., Methods: Semi-structured in-depth interviews were conducted with 10 general practitioners and 15 patients with severe mental illness, and then thematically analyzed., Results: We identified factors manifesting across three levels: personal, relational-societal, and organizational. At the personal level, the utilization of physical health services was impaired by the exacerbation of psychiatric symptoms. At the relational level, both patients and physicians described the importance of a long-term and trusting relationship, and provided examples demonstrating the implications of relational ruptures. Finally, two structural-level impediments were described by the physicians: the absence of continuous monitoring of patients with severe mental illness, and the shortfall in psychosocial interventions., Conclusion: The capability approach facilitated the identification of barriers preventing equitable health-care provision for patients with severe mental illness. Based on our findings, we propose a number of practical suggestions to improve physical health-care for this population: 1. A proactive approach in monitoring patients' health status and utilization of services. 2. Acknowledgment of people with severe mental illness as a vulnerable population at risk, that need increased time for physician-patient consultations. 3. Training and support for general practitioners. 4. Increase collaboration between general practitioners and mental-health professionals. 5. Educational programs for health professionals to reduce prejudice against people with severe mental illness.

People with mental illnesses face the dilemma of whether to disclose or conceal their diagnosis, but this dilemma was scarcely researched. To gain in-depth understanding of this dilemma, we interviewed 29 individuals with mental illnesses: 16 with major depression/bipolar disorders and 13 with schizophrenia. Using a phenomenological design, we analyzed individuals' experiences, decision-making processes, and views of gains and costs regarding concealment and disclosure of mental illness. We found that participants employed both positive and negative disclosure/concealment practices. Positive practices included enhancing personal recovery, community integration, and/or supporting others. Negative practices occurred in forced, uncontrolled situations. We also identified various influencing factors, including familial norms of sharing, accumulated experiences with disclosure, and ascribed meaning to diagnosis. Based on these findings, we deepen the understanding about decision-making processes and the consequences of disclosing or concealing mental illness. We discuss how these finding can help consumers explore potential benefits and disadvantages of mental illness disclosure/concealment occurrences.

Personal goals/plans play a central role in personal recovery and psychiatric rehabilitation of persons with mental illnesses. Yet, few studies have explored whether perceiving practitioners' assistance towards the pursuit of goals are associated with personal recovery and other favorable rehabilitation outcomes. A total of 2121 mental health consumers, of which 1222 use supported-housing services and 899 use group-home services, completed self-report questionnaires as part of a larger quality-assurance study conducted during the years 2013-2014. Eighty percent of participants living in supported-housing and 72% living in group-homes reported having personal goals/plans for the forthcoming year. Furthermore, their type of goals was different. Irrespective of the type of goal or housing service, participants who reported having goals/plans (compared with those who did not) showed higher levels of personal recovery and more favorable psychosocial outcomes. Regression analyses showed that perceiving professional staff members (but not para-professionals) as assisting in pursuing goals/plans was positively associated with personal recovery. This study empirically validates the value of having personal goals and professionals' assistance in pursuing goals/plans in regards to personal recovery. We propose that recovery-oriented services should seek to enhance goal setting and goal-pursuit, and to train practitioners in these areas., (Copyright © 2017 Elsevier Ireland Ltd. All rights reserved.)

A recovery-oriented approach to mental health involves creating person centered services and enhancing engagement in psychiatric rehabilitation. Israel's Rehabilitation in the Community of Persons with Mental Disabilities Law is a progressive initiative that shifted the locus of psychiatric care to community care supporting individualized rehabilitation and recovery-oriented processes. Yet over a quarter of applicants do not implement their assigned rehabilitation plans and services. This qualitative study investigated reasons and experiences related to lack of utilization from applicants' perspectives. Fifteen service users were interviewed face to face in semi-structured interviews analyzed using Grounded theory approach. Seven categories emerged: (1) Lack of knowledge and orientation; (2) Negative perceptions about rehabilitation services (3) Lack of active participation/shared decision-making; (4) Not feeling heard by the committee; (5) Lack of congruence between participants' goals and committee's final decisions; (6) Lack of escorting professionals' competencies; and (7) Family members' influence. The results are interpreted at the structural and human process levels. Suggestions are provided for augmenting systemic procedures and human interactions processes.

Doctors' clear disclosure of diagnoses to patients is fundamental to patient autonomy and patient-centered approaches in health care. Although diagnosis disclosure is common in general health, it is less so in psychiatry. The aim of this study was to explore psychiatrists' experiences of schizophrenia diagnosis disclosure to patients and/or family members. We conducted in-depth interviews with 14 psychiatrists from hospital and community settings in Israel and used a phenomenological framework to analyze the interviews. Overall, psychiatrists experienced disclosure as problematic, unproductive, and harmful. We identified 10 themes of psychiatrist experiences and concerns conceptualized under three domains: (a) characteristics of schizophrenia, (b) the doctor-patient/family relationship, and (c) psychiatrists' difficulties with the disclosure task. We discuss the results suggesting a multilayered model of medical, relational, social, and personal disclosure challenges. We suggest that a constructive schizophrenia diagnosis disclosure needs to take into account psychiatrist- and patient-related factors and specify possible directions., (© The Author(s) 2014.)

Recovery is supported by relationships that are characterized by human centeredness, empowerment and a hopeful approach. The Recovery Promoting Relationships Scale (RPRS; Russinova, Rogers, & Ellison, 2006) assesses consumer-provider relationships from the consumer perspective. Here we present the adaptation and psychometric assessment of a Hebrew version of the RPRS. The RPRS was translated to Hebrew (RPRS-Heb) using multiple strategies to assure conceptual soundness. Then 216 mental health consumers were administered the RPRS-Heb as part of a larger project initiative implementing illness management and recovery intervention (IMR) in community settings. Psychometric testing included assessment of the factor structure, reliability, and validity using the Hope Scale, the Working Alliance Inventory, and the Recovery Assessment Scale. The RPRS-Heb factor structure replicated the two factor structures found in the original scale with minor exceptions. Reliability estimates were good: Cronbach's alpha for the total scale was 0.94. An estimate of 0.93 for the Recovery-Promoting Strategies factor, and 0.86 for the Core Relationship. Concurrent validity was confirmed using the Working Alliance Scale (rp = .51, p < .001) and the Hope Scale (rp = .43, p < .001). Criterion validity was examined using the Recovery Assessment Scale (rp = .355, p < .05). The study yielded a 23-item RPRS-Heb version with a psychometrically sound factor structure, satisfactory reliability, and concurrent validity tested against the Hope, Alliance, and Recovery Assessment scales. Outcomes are discussed in the context of the original scale properties and a similar Dutch initiative. The RPRS-Heb can serve as a valuable tool for studying recovery promoting relationships with Hebrew speaking population.

Introduction: Individuals with psychiatric disabilities have low rates of employment and occupational rehabilitation success. Mental health peer services are a new occupational modality that opened a promising occupational path: persons with serious mental illnesses employed to provide support to others with psychiatric conditions. However challenges to successful peer work exist. Work motivation is central to understanding and supporting peer workers, yet little is known about sources of motivation to work as mental health peer providers. The aim of this study was to identify what drives individuals to mental health peer work using self determination theory (SDT)., Methods: Motivations of 31 mental health peer workers were explored as part of a larger study. A theory driven approach was employed to emerging qualitative data using SDT concepts: external motivation and internally regulated motivations derived from basic needs (autonomy, competence, relatedness)., Results: External motivations included generic occupational goals and getting away from negative work experiences. Internal motivations corresponded with SDT basic needs: autonomy met-needs was reflected in having freedom to disclose and finding that work accords with personal values; competence met-needs was reflected in using personal experience as a resource to help others; and relatedness met-needs were reflected in having opportunity to connect intimately and reciprocate with consumers., Conclusion: This study identified external and internal motivations of persons with psychiatric disabilities to work as peer providers-a novel occupation in mental health. Employing personal experience and enabling peer contact emerge as major motivational tenets of mental health peer work. According to SDT instrumental occupational goals are considered more external than satisfaction of basic psychological needs. The study demonstrates the applicability of SDT in the design of autonomy supported environments to promote work engagement and sustenance of mental health peer providers.

Topic: This article suggests a positive psychology framework to strengthen and broaden psychiatric rehabilitation and recovery thought and practice., Purpose: We inform about positive psychology concepts and measures that can be used to further knowledge, enhance practice, and guide research., Sources Used: Foundational concepts are drawn from the published literature. Specific positive psychology concepts and measures are highlighted: complete mental health, well being, flourishing, positive emotions, flow, self-determination, posttraumatic growth, and resilience., Conclusion and Implications for Practice: Employing a positive psychology framework can advance research on recovery phenomena and be used to assess rehabilitation outcomes. In addition we advocate positive psychology interventions in education and training of service providers that will enhance a positive focus and the culture of recovery., ((PsycINFO Database Record (c) 2013 APA, all rights reserved).)

Peer providers are increasingly employed in mental health services. We explored challenges experienced by 31 peer providers in diverse settings and roles using in-depth interviews, as part of a larger study focusing on their recovery (Moran et al. in Qual Health Res, 2012). A grounded theory approach revealed three challenge domains: work environment, occupational path, and personal mental health. Challenges in the work environment differed between conventional mental health settings and consumer-run agencies. Occupational domain challenges included lack of clear job descriptions, lack of skills for using one's life story and lived experience, lack of helping skills, and negative aspects of carrying a peer provider label. Personal mental health challenges included overwork and symptom recurrence. Implications for all domains are discussed, with focus on training and skill development.

Objective: Peer providers experience unique recovery and growth processes. This study examines the relationship of these processes with multiple occupational characteristics related to peer work. Outcomes are examined using positive psychology concepts: psychological well-being, posttraumatic growth, and generativity, as well as established recovery and empowerment measures., Method: Thirty peer providers employed in a variety of mental-health agencies participated in the study and completed standardized measures of recovery and growth processes. Multiple past and present occupational characteristics were identified and coded based on a semistructured interview and a background questionnaire., Results: Multivariate analyses revealed a significant association between participants' generativity and past participation in peer-support/self-help groups, as well as past work in a helping profession. No associations were found between the characteristics of participants' present peer jobs and the examined recovery and growth processes., Conclusions and Implications for Practice: The present findings have implications for the expansion of the peer-provider workforce. They suggest that encouraging and enabling peer-support groups and peer-run organizations may have positive impact on the generativity of peer providers, and may draw generative individuals to this emerging occupational modality of mental-health recovery oriented service. Study findings underscore the need for future research on recovery processes from the perspective of positive psychology and highlight the value of peer exposure as a catalyst of recovery and growth., ((PsycINFO Database Record (c) 2012 APA, all rights reserved).)

Providing peer support to individuals with psychiatric disabilities has emerged as a promising modality of mental health services. These services are delivered by individuals who experience mental illnesses themselves. The purpose of this study was to explore how working as a peer provider can enhance personal recovery. The study was conducted with 31 peer providers employed in a variety of mental health agencies. Data were collected through face-to-face semistructured interviews and analyzed using a grounded theory approach. Qualitative analysis revealed a wide range of recovery benefits for the peer providers. The benefits span across five wellness domains: foundational, emotional, spiritual, social, and occupational. In addition, analysis revealed five role-related and five work-environment-related mechanisms of beneficial impact. The role of sharing one's personal story is highlighted as contributing to positively reauthoring one's self-narrative. Implications for peer training, job development, and workplace supports are discussed.

The cognitive constructions coding system (CCCS) was designed for coding clients' expressed problem constructions on four dimensions: intrapersonal-interpersonal, internal-external, responsible-not responsible, and linear-circular. This study introduces, and examines the reliability and validity of a modified version of the CCCS-a version that involves coding clients' problem constructions at the level of speech turn. Results indicate that the modified CCCS generated reliable ratings of clients' problem constructions in 15 sessions of family therapy. Validity was established by comparing 71 subjects' own ratings of over 250 self-generated problem constructions to the ratings of trained CCCS coders. The modified CCCS allows for identifying moment-to-moment changes in clients' problem constructions and, ultimately, examining the impact of therapist behaviors on such changes.

In this paper we explore the idea of aggression as a defence against threats to the psychological self. This aspect of the self allows reflection about people in psychological terms and develops, in the first three years of life, through appreciation of mental states in the other. When the object is unpredictable or hostile, recognition of this is painful to the child, and his reflective function will not be adequately established. The defences of aggression or avoidance will be invoked very frequently. In time, aggression may become an organising influence in the construction of the self; pathological destructiveness then takes the place of emotional relatedness and concern for the other. Psychoanalytic treatment no longer works primarily by addressing conflict. Instead, particularly through interpretations of transference and countertransference, the analyst recreates an intersubjective process which enhances the patient's reflective self, this time in the safety of a benign relationship.

In this paper we explore the idea of aggression as a defence against threats to the psychological self. This aspect of the self allows reflection about people in psychological terms and develops, in the first three years of life, through appreciation of mental states in the other. When the object is unpredictable or hostile, recognition of this is painful to the child, and his reflective function will not be adequately established. The defences of aggression or avoidance will be invoked very frequently. In time, aggression may become an organising influence in the construction of the self; pathological destructiveness then takes the place of emotional relatedness and concern for the other. Psychoanalytic treatment no longer works primarily by addressing conflict. Instead, particularly through interpretations of transference and countertransference, the analyst recreates an intersubjective process which enhances the patient's reflective self, this time in the safety of a benign relationship.

In this paper we describe two models of the psychoanalytic treatment of mental disturbance. The first describes the mechanism by which the patient is helped to recover threatening ideas and feelings which have been repudiated or distorted as a result of conflict and defense. The second points to the therapeutic effects of engaging previously inhibited mental processes within the psychoanalytic encounter. The two forms of therapeutic action imply two distinct means available to the individual to deal with psychological conflict. They highlight different aspects of the psychoanalytic process and technique in child and adult psychoanalysis.

This article summarizes 3 studies that evaluated the psychoanalytic psychotherapeutic treatment of diabetic children and adolescents with grossly abnormal blood glucose profiles necessitating repeated admissions to hospital. Study 1 used time series analysis to demonstrate that improvements in control were predicted by unconscious themes emerging in the analytic material. Study 2 compared the effect of psychotherapeutic treatment with that of minimal psychological intervention in two well-matched groups (n = 11). Patients in the treatment group were offered psychoanalytic psychotherapy 3-4 times per week on the hospital ward. The intervention was highly effective in improving the diabetic control of the children, and this improvement was maintained at 1-year follow-up. Study 3 used single-case experimental design to demonstrate the marked effect of psychotherapeutic help on growth in diabetic children with short stature.

This article describes the profound impact that diabetes and its treatment can have on the different aspects of the personality of the child. The succession of stages of development, their force, the nature of internalized conflicts, the kind of defenses and their equilibrium, the structuration of the super ego and object relations are at risk of being distorted as a result of psychological problems related to the treatment of the illness. The restrictions and the suffering resulting from the treatment can become charged with psychic meaning and become the object of fantasy elaboration. Poor management of the treatment can become a metaphor for the actualization of instinctual derivatives or of unacceptable feelings and at the same time serve as a defense against the consciousness of psychic conflict. Inversely, the defenses against drives can be utilized to avoid the awareness of the real dangers inherent in the disease. These defenses interfere with a clear understanding of the illness and can be inferred from the distortions in the distorted body images and the fantasies of these children.

Glycosylated haemoglobin concentrations, C peptide secretion, insulin dose, psychiatric state, intellectual functioning, and the extent to which the implementation of the diabetic regimen was shared between parent and child were studied in a cross sectional study of 50 children with diabetes aged 6-16. Indications of psychological disturbance in the children and their parents predicted low glycosylated haemoglobin concentrations in the children, and accounted for 44% of variance in blood glucose control. The child's early and independent participation in the implementation of the diabetic regimen was associated with poor control.

The records of the 3 1/2 year, five times weekly psychoanalysis of a diabetic teenager with recurrent diabetic imbalance were examined using non-experimental single-case design methodology. A selected set of analytic themes was operationalized and independently rated for each week of the psychoanalysis. A weekly index of the quality of diabetic balance was also obtained for the same period. Time series analysis was used to examine the relationship between psychoanalytic themes and glycosuria. Two themes of psychic conflict were found to predict short-term changes in diabetic control. In the long term the verbalization of conflict was strongly associated with improved diabetic control. The results are discussed in terms of a psychoanalytic model of adaptation to diabetes.