Iberian journal of clinical & forensic neuroscience vol i nº 2 2013 by Luis Maia

Editor: Éditos Prometaicos – Portugal

Iberian Journal of Clinical and Forensic Neuroscience – IJCFN

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ISSN: 2182 -0290

Year 0, Vol. I, nº 2, 2013

Editor: Éditos Prometaicos – Portugal

ISSN: 2182 -0290

Iberian Journal of Clinical and Forensic Neuroscience – IJCFN

Year 0, Vol. I, nº 2, 2013

Editor: Éditos Prometaicos – Portugal

Iberian Journal of Clinical and Forensic Neuroscience – IJCFN

Editor-in-Chief Luis Alberto Coelho Rebelo Maia

Associated Editor Humberto Mendes Faria Rodrigues

Property Editora Éditos Prometaicos

GNPF

Gabinete de Neuropsicologia, Psicopedagogia e Formação Profissional

INTERNATIONAL ADRESS - Avenida da ANIL nº 7, 1º piso, Escritórios 9; 6200-502 Covilhã Telefones / Fax: (+351) 275 088 893, (+351) 91486 81 82. Email: luismaia.gabinete@gmail.com; Blog: http://gabinetedeneuropsicologialuismaia.blogspot.com/

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Editor: Éditos Prometaicos – Portugal

Iberian Journal of Clinical and Forensic Neuroscience – IJCFN

Scientific Board

- J.E. Pinto-da-Costa, PhD., Forensic Medicine, Professor of Neuropsypathololy, Psychofarmacology, Universidade Lusíada, Porto and Judicial Psychology and Forensic Medicine in University Portucalense Infante D. Henrique, Porto - Portugal - M. Joaquim Loureiro, PhD., Full Professor in Psychology, University of Beira Interior - Portugal - J.L. Sánchez Rodríguez. PhD., Dr. Medicina y Cirugía. University of Salamanca. Profesor de la Facultad de Psicología. Departamento de Psicología Básica, Psicobiología y Metodología de las C.C. - España - J. Marques-Teixeira, PhD., Psychiatrist and Psychotherapist, Professor of Neurosciences in University of Porto - Portugal - J.M. Barra da Costa, PhD., Former Inspector Chief of Judicial Police - University Professor and Criminal Profiler - Portugal - Jorge Oliveira, PhD., Professor School of Psychology and Life Sciences – ULHT - Director of Centre for the Study of Cognitive and Learning Psychology (ULHT) – Portugal - Luísa Soares, PhD, University of Madeira, M-iti (Madeira Interactive Technologies Institute) - Portugal - Nuno Cravo Barata, PhD., Research Assistant and Professor at Universidade Portucalense¸ Instituto Piaget; Faculdade de Medicina da Universidade do Porto - Portugal - Paulo Lopes, Psychologist, PhD., Neuropsychology Salamanca University, Professor at School of Psychology and Life Sciences and Director of the MSc of Applied Neuropsychology (ULHT); Ares do Pinhal - Addiction Rehabilitation Association – Portugal - Pedro Gamito, PhD., (University of Salford, UK), Title of Aggregate in Rehabilitation (Technical University of Lisbon, Portugal). Full Professor and Head of Computational Psychology Laboratory of Psychology School and Life Sciences and Associate Director of COPELABS – Portugal - Ricardo João Teixeira, PhD., Main Researcher at Aveiro University; Psychologist/Psychotherapist at Clínica MédicoPsiquiátrica da Ordem (Porto); Invited Assistant Lecturer at School of Allied Health Sciences, Polytechnic Institute of Porto; PhD in Psychology by Minho University - Portugal - Graziela Raupp Pereira, PhD., Professor at Santa Catarina State University - Brasil

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Iberian Journal of Clinical and Forensic Neuroscience – IJCFN

Author Guidelines

The

Iberian

Journal

Clinical

and

Forensic

Neuroscience publish papers on a broad range of topics of general interest to those working on the neuroscientific

Papers will be valued by the Editorial Board and referees in terms of scientific value, readability, and importance to a wide-ranging circulation.

field. Papers should be submitted following APA norms (APA The

Journal

Clinical

and

Forensic

Neuroscience publishes theory-driven patient studies, studies about forensic field applied to neuroscience as well as basic studies in the large neuroscience area.

Publication

Manual

published

the

American

Psychological Association), and preferentially presented in written English language. Abstracts should be available in English, Portuguese and Spanish idiom as well as key words.

The journal publishes group and case studies addressing fundamental issues concerning the brain functional relations with behavior, epidemiology, basic science, etc.

The journal is dedicated to a fast and proficient turnaround of papers, targeting to complete reviewing in under 60 days. Submissions should be made in a word format document (editable) to

The Journal operates in a policy of anonymous peer review.

Each submission should follow the procedure of sending by email two documents: a) a Title page with all information about authors’ affiliations and indications of the correspondent author; b) a second document, containing

the

entire

article,

WIHTOUT

ANY

IDENTIFICATION of the authors, to assure the blind review luismaia.gabinete@gmail.com

process.

(Luis Maia, Editor in Chief), or

After the effective publication of articles, authors assume

iberianneuroscience@gmail.com.

that the copyright are totally trespassed to Iberian Journal of

Clinical

and

Forensic

Neuroscience

editors.

We invite you to discuss, exchange ideas and have free access to the journal also in facebook page https://www.facebook.com/iberianjournalofclinicalandforensicneuroscience?fref=ts

or the official internet page http://luismaiagabinete.wix.com/iberianneuroscience

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Editor: Éditos Prometaicos – Portugal

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Iberian Journal of Clinical and Forensic Neuroscience – IJCFN

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Editor: Éditos Prometaicos – Portugal

Iberian Journal of Clinical and Forensic Neuroscience – IJCFN

Contents Editorial - Do you really think that psyche sciences, in 2013, are possible without a Huge Tear of Neuroscience? Luis Maia & Humberto Rodrigues…………………………………………………………….………………………………………… P.104-106

A brief analysis on crime in Portugal over the past 20 years (1993-2013) José Martins Barra da Costa……………………………………………………………………………………………...........……….P.107-120 Uma breve análise à criminalidade em Portugal nos últimos 20 anos (1993-2013) José Martins Barra da Costa……………………………………………………………………………………………………………….P.122-135 Fr on ta l lob e d y s fu n ct i o n in h er o in ad d ict s: E v id en ce fr om an em o tion al Str oop co lou r n am i n g ta sk Paulo Lopes, Jorge Oliveira, Pedro Gami to, Hélder T rig o, Paulo S a rgen to & Ana Paula S ilva … … …… … … … … …… … … … … … … … …… … … … … …… … … … … … … … …… … … … … …… … … … … … … ….. .. … P .1 37 - 14 8 Neurofeedback Training for Pure Apathy: a case study Francisco Marques-Teixeira, Hugo Sousa & João Marques-Teixeira………………………………......………………P.150-165 Something in the way she moves: Beyond beliefs and attitudes about hypnosis Carlos Lopes Pires, Catarina T. Pires & Maria Angeles Ludeña………………………….…………………………………P.167-193 If Old Fashion Psychotherapy did not work, don try harder. Just join a huge sprinkle of Neuroscience: Examples from two clinical cases Luis Maia & Humberto Rodrigues……………………………………………………………………………………………………..P.195-206 Narrative cognitive therapy and insecure/ambivalent attachment pattern: a clinical case of epilepsy Cristina Coelho & Luísa Soares…………………………………………………………………………………………………………….P.208-222 Dyadic Relationship and Quality of Life - Patients with Chronic Kidney Disease Nuno Cravo Barata & Emílio Gutiérrez………………………………………………………………………………………………..P.224-238 Third Generation Therapies for Treatment of Anxiety: A Clinical Case with Acceptance and Commitment Therapy (ACT) and Mindfulness Ricardo João Teixeira & Jorge Mota-Pereira………………………………………………………………………….…………….P.239-256 Inclusion of people with disabilities: Neuroscience and relevant aspects to teacher training – The Brazilian Experience in recent years Graziela Raupp Pereira & Jaime Monte…………………………………………………………………………………………….…P.258-268

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Iberian Journal of Clinical and Forensic Neuroscience – IJCFN

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Editor: Éditos Prometaicos – Portugal

Iberian Journal of Clinical and Forensic Neuroscience – IJCFN

Editorial Do you really think that psyche sciences, in 2013, are possible without a Huge Tear of Neuroscience? Luis Maia (1) & Humberto Rodrigues (2) (1) Auxiliar Professor - Beira Interior University; Clinical Neuropsychologist, PhD (USAL - Spain); Neuroscientist, MsC (Medicine School of Lisbon - Portugal) Medico Legal Specialist (Medicine Institute Abel Salazar - Oporto, Portugal); Graduation in Clinical Neuropsychology (USAL - Spain); Graduation in Investigative Proficiency on Psychobiology (USAL - Spain); Clinical Psychologist (Minho University - Portugal); Professional Card from Psychologist Portuguese norm, number 102. (2) Ph.D. Student – Salamanca University – Castilla y Leon Neuroscience Institute – Medicine College of Salamanca University. MsC and Psychology Degree in Aveiro University.

_________________________________________________________________________________

With the presentation of the second number of

As in the first number we pay a particular attention

Iberian Journal of Forensic & Clinical Neuroscience,

(although not exclusive) to case studies, because we

we humbly think that, definitely, a new era were

believe that this is the best way to achieve deep

projected

knowledge about not only the cases presented, but

Portugal,

friend

countries

and

researchers around the world.

also about the theoretical framework approached in

We began in a very modest way, although, as the

a given article.

readers could verify with this number (just the

It is not easy, in Portugal, to find the elevated

second one), we aggregated a lot of friends and

attitude for a researcher to publish in a project in

colleagues that will rise Neuroscience to the level

construction. But you know what? External

that “She” deserves.

evaluation characterized this project as freshening,

In this number we present such a variety of themes that could be encapsulated in Neuroscience, which the reader could become to be familiar with our

necessary, and very promising in terms of put Neuroscience as an aggregate area, in Portugal, obeying several classes of professionals to adapt themselves, to open their minds to what has been

editorial thinking.

discovered in the last 20 years, and particularly, in The

articles

range

from

criminology,

the last decade.

neurofeedback applied to forensic science, clinical neuroscience and models of educational approaches based on neuroscience.

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Let us take the example of Psychology, at least in Portugal. For several years... The struggles in

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intellectual and academic theories defending the

in the intellectual understanding of Mind – Body

theory of mind were huge. The problem (that in its

relationship!

essence, is not a problem) is that we know now, that is impossible, we repeat, is impossible understand the mechanisms of mind, their products, and other processes,

not

understand

what

Neuroscience is and, particularly, what are her

The articles that constitute this number are real examples (at least we believe so), in each particular article, and therefore in the entire Journal, that Neuroscience is not only another term. On contraire, it is far beyond of being only that!

contributions for mental paradigms. Neuroscience represents humbleness, cooperation Neuroscience is not a single discipline per se: Neuroscience deals with knowledge provided for a huge

variety

physiology,

specialties:

genetics,

neurofeedback,

neurology,

and sharing different academic point of views, all for the sake of a wonderful understanding of humankind NEURO essence.

psychiatry,

psychology, etc. (and the list will be so long!).

We will not be able to see if our visual system were affected. Because of that, we will not be able to read

In our humble opinion, the majority of psychologists in Portugal are not prepared to accept, and therefore, to practice and put in actions this actual knowledge.

this Journal. Then we will not be able to read the different opinions of the authors that had de courage to accept this challenge of cooperation with this new and humble project. At the same time, they were a

Both of the authors of this Editorial are

Bless and a Gift for US and readers that are, for too

psychologists, there is no doubt about that. But

many time, starving for a fresh scientific perception

along the way of our growth as two “academic child”

of neural processes applied to clinical and forensic

we started, (slowly, we take that for sure) to

practice!

understand that it is impossible to understand a “Psychological Disorder” without understanding the

Thus, we need, we want and specially, we love to say… thank you all!

subject as a whole. So, take note of this tinny particularity: We are only Well, we could launch this question: what is a human being, AS A WHOLE, in terms of psychological and psychiatric needs of help in his own problems? Certainly, today, in 2013, he is no more (just) seen as a psychological pure entity!

able to receive all these gifts if our visual system is functional. Subsequently we understand reality, neural

processes,

mind

and

body

umbilical

interconnection, and at last, we are blessed with the understanding of ourselves (obviously, those of us that were really blind, that really could not see, could

Because of what we stated, we want to start to believe that Portuguese researchers, as well from

receive this message with a possible braille edition of this publication).

other countries, are finally achieving a major change

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So, for how long some of us will be “mentally blind”,

We live know in the year 2013 AD (and not BC), and

perseverating in this Old Fashion Psyche Science way

it is time to, definitely, realize, that Human Being, is

of understanding?

a whole entity!

Every part of our body, every mental or emotional process, every physiological connection, every relationship that we have with other people, society,

Enjoy the reading, and thank all of you for making this project grow, standing in such engaged roots.

every time we have a date with ourselves (Yes, we mean it!), every of those marvelous mechanisms are

Neuroscience will definitely set us free!

at the same time Creators and Creatures of their interactions. Luis Maia, PhD, Editor-in-Chief & Humberto Rodrigues, PhD Student in Neuroscience and Associated Editor Iberian Journal of Clinical and Forensic Neuroscience

106

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Special Revision Article

Iberian Journal of Clinical and Forensic Neuroscience – IJCFN

Bilingual Article English-Portuguese

A brief analysis on crime in Portugal over the past 20 years (1993-2013) José Martins Barra da Costa Former Inspector Chief of Judicial Police - University Professor and Criminal Profiler - jbarra@netcabo.pt

_________________________________________________________________________________

To think on the criminology state of a society

Thus, referring for the effect of the numerical data

requires thinking the man and their operating

contained in the Annual Reports of Internal Security

models, almost always established from legislative

(RASI) published in recent years, it is possible to

texts, whose concern is more in reproducing systems

emphasize that, in terms of general crime reported

and less in structuring measures to reduce crime

to the National Republican Guard (GNR), Public

rates.

Security Police (PSP) and judicial police (PJ)-

Not discussing here the opportunity of penal legislation out of an understanding markedly repressive of its nature, we stress always that the importance of reading the data presented here has to be effected in the light of the new spirit of legislation resulting from the April 25th, 1974.

increased lately with the data collected by the Food and Economic Safety Authority (ASAE), Tax and Customs Authority (AT), Foreigners and Borders Service (SEF), Marine Police (PM) and Military Judicial Police (PJM), which, as a whole, yielded in 2012 a total of registered holdings 8,986 – were committed in the last two decades (1993-2013) a

Its numeric representation is clearly influenced by the numerous revisions of the “Special Part” of the Criminal Code (CP), which were being carried out since 1982, under an umbrella as comprehensive as

total of 7,446,967 crimes, value that translates an average of 372,348 crimes per year and represents for these last two decades an increase of approximately 5 thousand crimes per year.

the need to not abandon the delinquent to the negative effects of a pure line of serving sentence in prison, without this represents to turn it over to (re) socialization and pedagogies for which he doesn't always minimally feels motivated.

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Participated Criminality. Total-general: 1993-2012 450.000 400.000 350.000 300.000 250.000

200.000 150.000 100.000 50.000 0

Total Geral

C c Pessoas

C c Património

C c Vida Soc

C c Estado

Leg Avulsa

Total geral = Total General; C c Pessoas = Crime against Peoples; C c Património = Crime against Property; C c Vida Soc = Crime against Social life; C c Estado = Crimes against Government; Leg Avulsa = General Legislation.

108 In these terms, the way that will be made the distribution of crimes by large groups takes into

which this means at present, disregard of the interests and values of the State.

account the current nomenclature of «titles» of the

In all cases, these are criminal areas with great

2nd part of the C.P., except for this organization, for

impact on public opinion and is often through them

reasons of legislative change more often, Crimes

that the community raises certain values to the

provided In Legislation, more changeable.

category of goods, penal-forensic, competence

We opened precisely with the Crimes Against People

enshrined in auto mode in a plural and open society.

and left to the end the Crimes Against the State,

Thus, and putting in brackets, the most important

rather than what was happening before 1982, when

criminal offenses and statistics included in each

the «national State security» was legally more

designation

important than the dignity of the person, without

consideration, are here presented:

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for

the

period

time

under

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Total number of Crimes against persons: 1,705,419. Average per year: 85,270. (Murder; Offence to physical integrity; Domestic violence; Threat)

Total number of Crimes against property: 4,364,395. Average/year: 218,219. (Thefts; Robberies; Damage, computer Scams) 109

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Total Crimes against life in society: 821,727. Average / year: 40,086. (Driving with alcohol rate equal to or greater than 1.2 g/l; Fire, arson; Counterfeiting or forgery and passing counterfeit currency; Criminal association)

110 Total number of Crimes against the State: 87,915. Average/year: 4,395 (Disobedience; Resistance and duress on employee; Abuse of authority; Corruption)

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Total number of Crimes against Cultural identity and personal integrity (former Crimes against peace and Humanity): no statistical value.

Total number of Crimes provided in Legislation (since 1998): 461,604. Average/year: 30,733. (Driving without a license; Drug trafficking; Illegal immigration; Issuance of bad checks).

Having regard to this ordering it is possible to register during the period of 2001-2010, 3,986,336 crimes, where results for this first decade of the 21st century an average/year of 398,633 crimes. In terms of five-year periods we account on the first five-year

(801,115 crimes in the years 2011 and 2012) the second decade of the 21st century, then during the last 12 years (2001-2012), the number of crimes is 4,787,451, which were reported to average 398,954 per year.

period (2001-2005), 1,952,945 crimes, with an

Currently, Lisbon remains the most criminally

average per year: 390,589, while on the second five-

relevant District, noting 0,25 of total holdings. The

year period (2006-2010), we recorded 2,033,391

2nd District with more participation is of Oporto

crimes, with an average per year of 406,678 (that is,

(16% of the global). The districts of Lisbon, Oporto,

there are more on the second quinquennium 80,446

Setúbal, Faro, Braga and Aveiro, in the set, showed

than in the first five-year period).

about 69% of criminality reported.

Taking into account also the crimes recorded by the Criminal Police bodies (OPC) in the first two years

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(15) MORE REPORTED OFFENCES IN 2012 (Only those whose relative weight is equal to or greater than 2% overall).

• • • • • • • • • • • • • • •

Theft in motor vehicle Offence to physical integrity - simple voluntary Vehicle driving with alcohol rate equal or exceeding 1.2 Theft residence; forcing entrance, or false keys Domestic violence against a spouse or similar Other damage Driving without a legal license Motor vehicle theft Threat and coercion Theft of precious metals Other thefts Theft in commercial focus; forcing entrance, or false keys Pickpocket swipe Arson fire in forest, Woods, Grove or seara Opportunity theft of objects not stored

32.772 26.430 25.365 25.148 22.247 19.641 15.844 15.839 15.755 15.171 13.702 12.345 11.000 9.333 7.960 112

Total

268.552

Regarding the set of 25 crimes grouped under the

committed in the year 2012 is composed for theft, in

designation of “violent and serious crime”,

its various forms, namely, theft on public roads

depending on the social cause scaremongering, it

(except stretching), and theft by stretching - these

should be noted that a significant percentage (83%,

two crimes of theft represent 73% of all violent

i.e. 18,504 crimes) of the total (22,270) of crimes

crimes.

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VIOLENT and serious CRIMES (2012) • • • • • • • • • • • • • • • • • • • • • • • • •

Criminal associations Extortion Voluntary manslaughter consummated Mutiny, inciting or condoning public crime Volunteer offence to physical integrity Terrorist organizations and national terrorism Other terrorist organizations and international terrorism Air piracy and other crimes against aviation security Kidnapping, illegal restraint and hostage-taking Resistance and coercion on employee Theft by stretching (2) Theft on public roads, except for stretching (1) Theft in educational establishment Theft to other commercial or industrial buildings (3) Robbery in public transportation Theft in values transportation Theft residence Carjack Theft in bank or other credit institution Stealing the Treasury or post offices Pharmacy robbery Jewellers robbery Burglary at fuel filling station Other thefts Violation / Rape Total

22 222 149 11 701 419 1.863 7.067 7.385 53 977 424 26 995 341 123 36 82 164 232 599 375

22.270

This type of criminality continues to concentrate on metropolitan areas of Lisbon, Oporto and Setúbal, which together accounted for 71% of participations of this type of crime.

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Severe Criminality

114 Yet the issue is philosophical: when we calculate an index of violence, that is, the percentage of the

certainly not by reason of holidays, at least of official nature.

number of serious and violent crimes in relation to the total number of crimes reported, the residual value is: 5.1, currently. But, for example, for victims and for other less sensitive agents, this value will also be residual?

In terms of growth, in recent years there are some trends, in particular, on counts of theft in residence and

other

buildings,

with

escalation

housebreaking or using false keys, extortion,

As regards the time of year when they are committed

resistance and duress on employee, crimes of fraud,

some of the most violent crimes, including bank

crimes relating to narcotic drugs and computer

robberies,

stations,

crimes. Also the crime of "sexual abuse of people

residences and ATMs (Automatic Teller Machines),

incapable of resistance”, committed against victims

criminal agents appear more active in the winter

who find themselves in situations of physical and

months and less “hands-on” in the summer season,

mental debility, demonstrates a growing trend.

pharmacies,

shops,

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fuel

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As for the crime of murder in the last year, in the face

Interestingly in can be read in the RASI for year of

of 2011, there was an increase of 27.4% (32 cases),

1995 that the growth of the Group and juvenile

against some decrease that was checking in the last

delinquency was related to the "increase in insecurity

years, in this crime, practiced primarily in context

in the areas surrounding slums, perfectly located,

and relational intimacy, account for 37-homicide in

and where the majority of the population is black”.

conjugal context.

In 1998 the Office of the Republic General Attorney

As regards to group delinquency, this phenomenon

proclaimed that the phenomenon of juvenile

are directly associated with insecurity. The current

delinquency increased since the beginning of the

feature of this crime through the practice of various

Decade of 1990, height from which "Portugal saw a

crimes in a short period of time and territory (“crime

substantial growth in the number of young

spread” phenomenon), with a geographical focus on

offenders" that went already

the coast (Lisbon, Oporto and Setúbal) and a practice

thousands. It is not surprising why this year have

centered on the theft in the public highway, for

been identified or reported 3,614 minors’ suspects,

melee weapon, firearm and theft by stretching.

although the actual number of crimes was eight

We are talking about groups constituted mostly by

beyond three

times higher.

male (96%), between 16 and 24 years (85%), with use

At that time Paulo Portas (Minister of Interior)

of physical coercion, performance in discovered and

advanced with a project-law for minors criminally

hided face, by foot, and in 50% of these incidents the

chargeable from 14 years. Durão Barroso stablished

“gangs” were formed by three elements; 30% were

15 years. Both of them were “loaded“.

of four; and 8% of five elements, falling upon victims isolated in 87% of cases. In this field is notorious the lack of a policy of cooperation between the various bureaus and the various local authorities, applied to the reality of major metropolitan areas, with predictable growth of criminality, in particular the urban, in various aspects, to levels of developed countries.

The RASI for the year 2000 continued in this line: 8.5% increase in the number of children identified for the practice of crimes, in particular in Lisbon (large core), Oporto, Setúbal and Braga, with the particularity of increase of holdings were due to minors repeat offenders and to the growth in the number of authors. Imagine how many of these young people have progressed in his career, became

With regard to juvenile delinquency, the trend is also for a slight increase, confirming the emergence of criminal agents increasingly early, committing criminal acts more violent and severe. By the way, is in the small street crime that lies the problem of insecurity.

adults and face today the authorities. The RASI of the following year was paradigmatic: juvenile delinquency is one of the major factors that contributes to the feeling of insecurity that exists in society "and" the broadmindedness of the acts charged, hiding or externalizing revolts with various

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causes, being that the young leverage could face the

Still, we want to contribute with the necessary alerts

law, practice threats, insults, vandalism, assaults and

designed to avoid many accidents: i. Draw up list of

robberies, in urban centers and peripheries. What is

particularly dangerous locations (black dots) and flag

the origin of this disaster? - Social and cultural

them; ii. Impose on bus builders endowment of seat

uprooting;

resources;

belts; iii. Preventing dangerous behaviors; iv.

premature school drop-out; lack of family follow-up;

Develop exchanges of good practice, through actions

identification with juvenile delinquency in other

of training, especially for young people; v. Combating

countries, disclosed by the media; and, crucially, lack

alcohol behind the wheel and use of drugs and

of social institutions for integration and monitoring.

medicines; vi. Improving the system of training of

scarcity

economic

Instead, there is a tendency to stabilization in terms of the number of crimes for rape and sexual abuse of children and sexual acts with teenagers.

drivers;

and,

vii.

Promotion

systematic

investigation of the clinical causes of victims of road accidents and the type of defendant.

In the field of road accidents would only be stated that the records for crimes of driving with alcohol

We want here to deconstruct, so necessarily brief,

rate equal to / or greater than 1.2 g/l and «driving

the consequences of a system which gives the Man a

without legal qualification» provide numbers that

primordial place in the world to change expressions

prowl the 20 thousand crimes each.

of «property» for «heritage», which raises particular

Knowing us, first, that in the last year, of 93.4% (36,938) were recorded in men is unlawful; Second, that 42% (16,562) of the total (men and women) were driving with alcohol 1.2 g/l and that of 92% (15,343) were arrested, 41% (15,237) were not legally entitled to drive vehicles and that of these 41%, 67.5% were detained (10,922); and, third, we

protection for private life, who feel the need to criminalize conduct that violate new values recognized as essential for its development, among others, crimes against the family, sexual offenses or crimes of common danger which comes focusing a sharp neo crime classification. The best prevention is prevention.

have investigated that 54% of the total number of

Symmetrically and inverse, we cannot fail to surprise

defendants that drove without a license for that

us with another big trend in this field: the

purpose, were between 16-24 years; and were also

decriminalization, whose strong sense leads in some

young people between 16-24 years 13% of the total

cases to a generalized lowering of cobble, who raise

number of defendants that drove with a blood

from the “reform” of 2007, and came to recreate

alcohol level greater than or equal to 1, 2 g/l, we ask:

problems in combating violent crime, call a zone

why in recent years only 100 authors of each of these

where the offender must undergo a more intense

types of crimes were condemned to effective

disapproval. Many of these criminal behaviors cause

prison?!

damage to small parts, but these often resonate in dangerous results, concrete or abstract thus, this

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type of crime must be combated in severe form,

Moreover, the successive revisions of the Criminal

causing back their repression to the moment when

Codes and criminal procedure did not provide

the danger is manifested. The best prevention is

anything new for the resolution of the issues of

repression.

criminal

Closing the circle: criticize the abundant legislation, dispersed, sometimes

duplicate

and

justice

Fund.

The

prisons

remain

overcrowded.

bad

Illustrating this reality, prisons contain mostly,

Portuguese language. In fact, only in the year 2012

convicted of Crimes Against property (more than half

the most published laws was to revoke degrees out

of registered crime), Crimes against persons and

in the last six months.

Crimes relating to narcotic drugs (in relation to

As for criminal investigators-structured body and strong hierarchy, discipline relaxed, close link to try to fend off the still-Clock tower yoke of power, not only to maintain the autonomy necessary for

crimes of theft and robbery of the «heritage»). Interestingly, the average age of men inmates is lower than the women, being that these comply prison time in majority by “drug trafficking “.

effectiveness, but also to maintain a strong scientific

We must remember that the maximum prison

component and thus remain unscathed, a practice of

sentence is 25 years today, after having been 20

investigation

years in 1982 and 28 years in the 19th century;

overlooked, under penalty of jeopardizing the

Nevertheless, we continue to be one of the countries

security of the citizen.

with less repressive measures to combat crime, we

whose

reality

should

not

Judges, in turn, continue to wish for better salaries at the time they left over between dispatches US 1,000 procedures in charge.

present a crime rate lower than the average rate of European crime and, within this, we note a lower rate of serious crime. On the other hand, continues the system of being in jail for free days, the semi -

The Prosecutor seeks a new model of magistrates

detention regime and the fine alternative, feature of

and meanwhile uses the PJ in the same way that a

the Governments to solve the problem of

millionaire «cheap» uses your Ferrari.

overcrowding of prisons.

Judicial

officials’

dispute

this

system-slow,

In fact, we are the European country with the highest

cumbersome and bureaucratic - and the lack of

number of prisoners per 100 000 inhabitants, about

resources, and quick thinking of going to strike.

60% of the prisoners meet penalty less than two

In essence, the multiplication of legislation and

years in jail and only 9% were sentenced to penalties

codes should be replaced by a survey of the

greater than 8 years. More, the ideal capacity of

problems in the courts of crumpled up like that

7,500 inmates is an occupation that is around

without effective computerization processes.

13,500.

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There is also a sharp fluctuation in the context of

damage to automobiles); and the incidence rate of

suicides in prison (19 in 2010, 11 in 2011 and 16

victimization of families is about 50%.

2013), most likely as a result of the difficulty of preventing the phenomenon, in particular, in the field of early detection of signs and symptoms in inmates entered, and the signalization of those who were doing his time. It is symptomatic that, parallel to this situation it was noted an increase in the number of escaped prisoners and the seizure of

Anyway, we turn like a mob Italian regime. Bloom situations of unjust enrichment in a country persistently poor, who associate various exercises of objections and evidence linked to circles of power; and germinating the idea that the “thing is plunder” and, more often, to see approved a request must sell his soul to the devil!

more than 100 arms and 1,200 cell phones. This means, too, that we live in an objective situation As for the victims, who are also «people» in the city of Lisbon, the portrait is of concern, although levels of victimization are located between the ranges known to the European reality.

of insecurity, which creates concerns, but also a subjective situation of insecurity, substantially high. And between both navigates with a choice between the preferences, as we have seen, sometimes by the

In terms of gender, 65% of the total victims are men;

minor-victim

83% of the victims have more than 25 years; 13% of

defendant. Not to mention a third way, which holds

victims are between 16-24 years and 2% are under

that the State is not the holder of the right to

the age of 16 years. Despite all this, also the overall

revenge and that we're all good guys.

level of victimization is of the order of 15%, one of the lowest of the European reality.

the

delinquent-suspect-

In fact, as the democratization of crime was happening we were increasingly aware of the

In terms of incidence rate-36 crimes per 1,000

increased activity of people not worth even apply

inhabitants – we are not of the most overworked,

the theory of social reintegration. They are in the

pointing to this explanation the lack of confidence in

officers halls, in spectacles, in the flat. They merely

the performance of the police (in the RASI, 2001,

are administrators, businessmen, and ‘rulers’.

"fewer and fewer people are turning to the police to

Receive «only» the profits resulting from a true

lodge a formal complaint"); and discredit the judicial

market economy in terms of trafficking of influences,

system, which in the mid-90 justified the appearance

often based on crimes they do intervene on the

open from "popular militias".

ground smaller beings and unprotected.

It is estimated that in Lisbon 20% of residents have

This insecurity is a short jump. Is the increase in the

been victims of a crime (larceny by wallet, theft,

severity of crimes of juvenile delinquency; the

insult, slander, thefts of valuables in public places),

multiplication of cases of violent crime with use of

and the rate of victimization is around 40%; 30% of

firearms in illegal situation; and the persistence of

households have ever faced this problem (thefts and

drug-related crime.

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The feeling of insecurity translates the increased

We can then sustain that in these last 20 years there

subjective fear which is broadcast by the media.

was a trend towards stabilization of crimes against

Politicians, regardless of their ideological quadrant,

property, and a worsening of crimes against persons,

exploiting opportunistic and systematic manner,

crimes against life in society and, in charge of crimes

through speeches about insecurity, feelings of

against the State (2,562 to 5,807), what gives the

confidence of the population in relation to the

idea of how the State, public order and tranquility

authorities, because they know that this oratory

came to be regarded by the citizens.

gives votes. Meanwhile the fear increases as loneliness; the loneliness promotes insecurity; the feelings of insecurity vary depending on cultural concepts of individuals (for example, the fear of night refers to the fear of death).

What the RASI don't say is that in the year 2011, the 350 defendant’s accused/day, were only sentenced 140; of the 1,100 crimes (processes)/day, 800 were archived by MP, for lack of evidence; and they also say that the prisoners decreased 7% in 2012 and preventive prisoners in particular have decreased by

Salient points of statistical analysis: From 1993 to 2004 there has been a trend towards the growth of indicted crime, which add up to 100 thousand crimes during this period. The maximum was reached in 2003 with 409,509.

24%. Concluding. It is significant that, first, in the case of criminal proceedings, under the cover of a dangerous speech to combat alleged excess of «guaranteed moves», has been moving towards a real deletion of fundamental “rights, freedoms and

In 2005, 2006 and 2007 the values down to values that was around 387 thousand crimes, on average.

guarantees of citizens”; and then, increase the fear that a true police State that goes by the name of MP

In the period from 2007 to 2011 inclusive, the values

- a powerful force, uncontrollable and uncontrolled

exceeded again and the 400 thousand crimes in the

within the State apparatus and justice-serve to

year of 2008 stands today as an absolute landmark

“judge”, permanently, the anonymous citizen, but

(421,037).

leave out the powerful. In this context, we propose

In the year 2012 registered crimes had a slight

the complete change of the structure of criminal

regress (395,827).

proceedings, that is to say, “the logic of functioning

The crimes against the possessions constitute the largest volume of occurrences, i.e. between 60 and 70% of global, followed by crimes against persons, crimes against life in society, crimes provided in legislation and, lastly, crimes against the State.

of Justice”, in order to ensure a genuine adversarial nature of it, which allows the citizen the possibility to counter any real prosecution; the immediate withdrawal of enormous powers that the MP's and that transform an institution entirely undemocratic; Finally, put an end to a complete legislative pyrotechnics makes it impossible to know exactly

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what is in effect at every (given) time. And it causes

what are the rates of recidivism, which are, after all,

iniquity, and judicial errors, the worst of crimes,

the true foundation of a political crime, prison and

which are never convicted.

reinsertion.

Thus it was essential that we knew what the real action of State on crime are and, most importantly,

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Artigo Especial de Revisão

Iberian Journal of Clinical and Forensic Neuroscience – IJCFN

Artigo Bilíngue Inglês-Português

Uma breve análise à criminalidade em Portugal nos últimos 20 anos (1993-2013) José Martins Barra da Costa Ex-inspetor chefe da polícia judiciária - Professor Universitário e Profiler Criminal - jbarra@netcabo.pt

_________________________________________________________________________________

Refletir sobre o estado criminológico de uma sociedade exige pensar o Homem e os seus modelos de funcionamento, quase sempre estabelecidos a

quais ele nem sempre se sente minimamente motivado.

partir de textos legislativos, cuja preocupação passa

Assim, consultando para o efeito os dados numéricos

mais por reproduzir sistemas e menos por estruturar

constantes dos Relatórios Anuais de Segurança

medidas para diminuir os índices de criminalidade.

Interna (RASI) publicados nos últimos anos, é

Não

discutindo

aqui

oportunidade

das

coordenadas de uma legislação penal fora de uma compreensão marcadamente repressiva, sempre avivamos que a leitura dos dados que se apresentam tem de ser efetuada à luz do novo espírito legislativo resultante do 25 de Abril de 1974. A sua representação numérica é claramente influenciada pelas inúmeras revisões da «Parte especial» do Código Penal (CP), que foram sendo efetuadas desde 1982, debaixo de um guarda-chuva tão abrangente quanto a necessidade de não abandonar o delinquente ao efeitos negativos de um puro cumprimento de pena, sem que isso represente entregá-lo a pedagogias e ressocializações para as

possível sublinhar que, em termos de criminalidadegeral participada à Guarda Nacional Republicana (GNR), Polícia de Segurança Pública (PSP) e Polícia Judiciária (PJ) - ultimamente acrescida com os dados coligidos pela Autoridade de Segurança Alimentar e Económica

(ASAE),

Autoridade

Tributária

Aduaneira (AT), Serviço de Estrangeiros e Fronteiras (SEF), Polícia Marítima (PM) e Polícia Judiciária Militar (PJM), as quais, no seu conjunto, perfizeram em 2012 um total de 8.986 participações registadas – foram cometidos nas últimas duas décadas (19932013) um total-geral de 7.446.967 crimes, valor que traduz uma média de 372.348 crimes / ano e representa para estas duas últimas décadas uma subida aproximada de 5 mil crimes / ano.

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Nestes termos, o modo como vai ser feita a distribuição dos crimes por grandes grupos leva em conta a nomenclatura atual dos «títulos» da 2ª Parte

isto signifique na atualidade o menosprezar dos interesses e dos valores do Estado.

do C.P., excetuando-se a essa organização, por

Em todos os casos, trata-se de áreas criminais com

motivos de alteração legislativa mais frequente, os

grande impacto na opinião pública e é muitas vezes

Crimes Previstos em Legislação Avulsa, de carácter

através delas que a comunidade eleva determinados

mais mutável.

valores à categoria de bens jurídico-penais,

Abrimos justamente com os Crimes Contra as Pessoas e deixamos para o final os Crimes Contra o

competência consagrada de modo automático numa sociedade plural e aberta.

Estado, ao invés do que sucedia antes de 1982, em

Assim e colocando entre parêntesis os crimes de

que a «segurança do Estado» era juridicamente mais

maior relevância penal e estatística incluídos em

importante do que a dignidade da pessoa, sem que

cada designação para o período de tempo em apreço, apresentamos:

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Total dos Crimes Contra as Pessoas: 1.705.419. Média / ano: 85.270. (Homicídio; Ofensa à integridade física; Violência doméstica; Ameaça)

Total dos Crimes Contra o Património: 4.364.395. Média / ano: 218.219. (Furtos; Roubos; Danos, Burlas informáticas)

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Total dos Crimes Contra a Vida em Sociedade: 821.727. Média / ano: 40.086. (Condução com taxa de álcool igual ou superior a 1,2 g/l; Incêndio, fogo posto; Contrafação ou falsificação e passagem de moeda falsa; Associação criminosa)

Total dos Crimes Contra o Estado: 87.915. Média / ano: 4.395 (Desobediência; Resistência e coação sobre funcionário; Abuso de autoridade; Corrupção)

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Total dos Crimes Contra a Identidade Cultural e Integridade Pessoal (antigos Crimes Contra a Paz e Humanidade): sem valor estatístico.

Total dos Crimes Previstos em Legislação Avulsa (apenas desde 1998): 461.604. Média / ano: 30.733. (Condução sem habilitação legal; Tráfico de estupefacientes; Imigração ilegal; Emissão de cheques sem provisão).

Tendo em conta este ordenamento é possível

da 2ª década do século XXI, então nos últimos 12

registar no período de 2001-2010, 3.986.336 crimes,

anos (2001-2012) o número de crimes é de

de onde resulta para esta primeira década do século

4.787.451, os quais foram participados à média de

XXI uma média / ano de 398.633 crimes. Em termos

398.954 por ano.

de períodos de cinco anos contabilizamos no 1º quinquénio (2001-2005), 1.952.945 crimes, com uma média / ano: 390.589, enquanto no 2º quinquénio (2006-2010), registamos 2.033.391 crimes, com uma

Atualmente, Lisboa continua a ser o distrito criminalmente mais relevante, observando ¼ do total das participações. O 2º distrito com mais participações é o do Porto (16% do global).

média / ano de 406.678 (isto é, registam-se mais 80.446 no 2º quinquénio do que no 1º quinquénio).

Os distritos de Lisboa, Porto, Setúbal, Faro, Braga e Aveiro, no conjunto, apresentaram cerca de 69% da

Levando em conta, igualmente, os crimes registados

criminalidade participada.

pelos Órgãos de Polícia Criminal (OPC) nos primeiros dois anos (801.115 crimes nos anos de 2011 e 2012)

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(15) CRIMES MAIS PARTICIPADOS EM 2012 (apenas aqueles cujo peso relativo é igual ou superior a 2% no global).

• • • • • • • • • • • • • • •

Furto em veículo motorizado Ofensa à integridade física voluntária simples Condução veículo com taxa de álcool igual superior a 1,2 Furto residência c arromb escal ou chaves falsas Violência doméstica contra cônjuge ou análogos Outros danos Condução sem habilitação legal Furto de veículo motorizado Ameaça e coacção Furto de metais não preciosos Outros furtos Furto edif comerc ou indust c arromb escal ou chav falsa Furto por carteirista Incêndio fogo posto em floresta, mata, arvoredo ou seara Furto de oportunidade/de objectos não guardados Total

32.772 26.430 25.365 25.148 22.247 19.641 15.844 15.839 15.755 15.171 13.702 12.345 11.000 9.333 7.960 268.552

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No que diz respeito ao conjunto de 25 crimes agrupados sob a designação de «criminalidade violenta e grave», em função do alarmismo social que provocam, sublinhe-se que uma acentuada percentagem (83%, isto é, 18.504 crimes) da totalidade (22.270) dos crimes cometidos no ano 2012 é composta pelo roubo nas suas diversas formas, designadamente, roubo na via pública (exceto esticão) e roubo por esticão, sendo que estes dois crimes de roubo representam só por si 73% dos crimes violentos.

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CRIMINALIDADE VIOLENTA E GRAVE (2012) • • • • • • • • • • • • • • • • • • • • • • • • •

Associações criminosas Extorsão Homicídio voluntário consumado Motim, instigação ou apologia pública do crime Ofensa à integridade física voluntária grave Organizações terroristas e terrorismo nacional Outras organizações terroristas e terrorismo internacional Pirataria aérea e outros crimes contra a segurança da aviação Rapto, sequestro e tomada de reféns Resistência e coacção sobre funcionário Roubo por esticão (2) Roubo na via pública, excepto por esticão (1) Roubo em estabelecimento de ensino Roubo a outros edifícios comerciais ou industriais (3) Roubo em transportes públicos Roubo a transporte de valores Roubo a residência Roubo de viatura Roubo a banco ou outro estabelecimento de crédito Roubo a tesouraria ou estações de correio Roubo a farmácias Roubo a ourivesarias Roubo em posto de abastecimento de combustível Outros roubos Violação Total

22 222 149 11 701 419 1.863 7.067 7.385 53 977 424 26 995 341 123 36 82 164 232 599 375 22.270

Esta criminalidade continua a concentrar-se nas áreas metropolitanas de Lisboa, Porto e Setúbal, que, em conjunto, representaram 71% das participações deste tipo de criminalidade.

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Ainda assim a questão é filosófica: quando

tendências, nomeadamente, nos crimes de furto em

calculamos um índice de violência, isto é, a

residência

percentagem do número de crimes violentos e

arrombamento, escalamento ou chaves falsas;

graves em relação ao total dos crimes participados,

extorsão; resistência e coação sobre funcionário;

o valor é residual: 5,1, atualmente. Mas, por

crimes de burla; crimes relativos a estupefacientes e

exemplo, para as vítimas e para outros agentes

crimes informáticos. Também o crime de «abuso

menos sensíveis, esse valor também será residual?

sexual de pessoa incapaz de resistência», cometido

No que diz respeito à época do ano em que são cometidos alguns dos crimes mais violentos, designadamente, assaltos a farmácias, ourivesarias, postos

abastecimento

outros

edifícios,

com

contra vítimas que se encontram em situação de debilidade física e mental, demonstra uma tendência crescente. Quanto ao crime de homicídio, no último ano, face a

residências e ATMs (vulgo caixas multibanco), os

2011, registou-se um aumento de 27,4 % (32 casos),

agentes criminais aparecem mais ativos nos meses

contrariando assim algum decréscimo que se vinha

de Inverno e menos «participativos» na época de

verificando, Neste crime, praticado essencialmente

Verão, não certamente por motivos de férias, pelo

menos de cariz oficial. Em termos de crescimento,

contabilizam-se 37 homicídios em contexto conjugal.

últimos

anos

combustíveis,

nestes

observam-se

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contexto

relacional

intimidade,

algumas

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No que diz respeito à delinquência grupal, trata-se

insegurança nas áreas circundantes a bairros

degradados, perfeitamente localizados, e onde a

fenómeno

insegurança.

diretamente

associado

característica

atual

desta

delinquência passa pela prática de diversos crimes num curto espaço de tempo e território (fenómeno de 'crime spree'), com uma incidência geográfica no litoral (Lisboa, Porto e Setúbal) e uma prática centrada no roubo na via pública, por arma branca, arma de fogo e furto por esticão. Estamos

falar

maioria da população é negra”. Em 1998 o Gabinete do Procurador Geral da República

proclamava

que

fenómeno

delinquência juvenil aumentava desde o início da década de 1990, altura a partir da qual “Portugal via crescer significativamente o número de jovens delinquentes” que ultrapassava então já os três

grupos

constituídos

milhares. Não surpreende por isso que nesse ano

maioritariamente por elementos do sexo masculino

tenham sido identificados ou dados como suspeitos

(96%), entre 16 e 24 anos (85%), com utilização de

3.614 menores, embora “o número real de delitos

coação física, atuação de cara descoberta e a pé,

fosse oito vezes superior”.

sendo que em 50% destes incidentes os 'gangs' eram formados por três elementos; em 30% eram de quatro; e em 8% de cinco elementos, «caindo em cima de vítimas isoladas em 87% dos casos.

cooperação entre os diversos ministérios e as diversas autarquias, aplicada à realidade das grandes metropolitanas,

sendo

previsível

para menores imputáveis criminalmente a partir dos 14 anos. Durão Barroso ficou-se pelos 15 anos. Um e outro foram «chumbados».

Neste campo é notória a falta de uma política de

áreas

Na altura Paulo Portas avançou com um projeto-lei

crescimento da criminalidade, em especial a urbana, nas diversas vertentes, para níveis dos países desenvolvidos.

O RASI para o ano 2000 continuava nessa linha: aumento de 8,5% no número de menores identificados pela prática de crimes, em especial em Lisboa (grande núcleo), Porto, Setúbal e Braga, com a particularidade do aumento de participações fosse devido a menores reincidentes e não ao crescimento do número de autores. Imaginemos quantos desses

No tocante à delinquência juvenil a tendência é

jovens progrediram na carreira, se tornaram adultos

também para um ligeiro aumento, confirmando o

e enfrentam hoje as autoridades.

aparecimento de agentes criminais cada vez mais cedo, cometendo atos criminais mais violentos e graves. Aliás, é na pequena criminalidade de rua radica o problema da insegurança.

O RASI do ano seguinte era paradigmático: a delinquência juvenil é um dos fatores que mais contribui para o sentimento de insegurança existente na sociedade" e "a gratuitidade dos atos

Curiosamente em pode ler-se no RASI relativo ao ano

praticados,

de 1995 que o crescimento da delinquência grupal e

revoltas com diversas causas", sendo que os jovens

juvenil estava relacionado com o “aumento de

“aproveitam a inimputabilidade face à lei, para

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recalcamentos

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praticar ameaças, injúrias, vandalismo, agressões e

tipos de crimes acabaram condenados a prisão

roubos, nos centros urbanos e periferias”. Qual a

efetiva?!

origem desta catástrofe? - Desenraizamento social e cultural;

escassez

abandono

escolar

acompanhamento

recursos prematuro;

familiar;

económicos; falta

identificação

com

delinquência juvenil nos outros países, divulgada pelos media; e, fundamentalmente, insuficiência de instituições

sociais

para

integração

acompanhamento.

Ainda

assim,

queremos

contribuir

com

necessários alertas tendentes a evitar tantos acidentes: i. Elaborar lista de locais especialmente perigosos (pontos negros) e sinalizá-los; ii. Impor aos construtores de autocarros dotação de cintos de segurança; iii. Prevenir comportamentos perigosos; iv. Desenvolver intercâmbio de boas práticas, através de ações de formação, especialmente para

Ao invés, há uma tendência para a estabilização em

os jovens; v. Combate ao álcool ao volante e uso de

termos do número de crimes por violação e de abuso

drogas e medicamentos; vi. Aperfeiçoamento do

sexual de crianças e atos sexuais com adolescentes.

sistema de formação dos condutores; e, vii.

No campo da sinistralidade rodoviária gostaríamos apenas de consignar que os registos por crimes de «condução com taxa de álcool igual ou superior a 1,2

Promoção da investigação sistemática das causas clínicas das vítimas dos acidentes rodoviários e do tipo de arguido.

g/l» e «condução sem habilitação legal» fornecem números que rondam os 20 mil crimes cada. Sabendo nós, primeiro, que no último ano 93,4% (36.938) dos ilícitos foram registados em homens; segundo, que 42% (16.562) do total (homens e mulheres) conduziam com taxa de álcool no sangue» 1,2 g/l e que destes 92% (15.343) foram detidos, 41% (15.237) não estavam legalmente habilitados para a condução de veículos e que destes 41% foram detidos 67,5% (10.922); e, terceiro, tendo nós investigado que 54% do total dos arguidos que conduziam sem habilitação legal para o efeito, tinham entre 16-24 anos; e que também eram jovens entre os 16-24 anos 13% do total de arguidos que

Tratámos

aqui

desconstruir,

forma

necessariamente breve, as consequências de uma sistemática que concede ao Homem um lugar primordial no mundo normativo, que altera expressões de «propriedade» para «património», que suscita particular proteção para a vida privada, que sente necessidade de tipificar novas condutas que violam valores reconhecidos como essenciais ao seu desenvolvimento, entre outros, os crimes contra a família, crimes sexuais ou crimes de perigo comum, sobre os quais vem incidindo uma acentuada neocriminalização.

melhor

repressão

prevenção.

conduziam com uma taxa de alcoolemia igual ou

De forma simétrica e inversa, não podemos deixar de

superior a 1, 2 g/l, perguntamos: porque é que nos

nos surpreender com outra grande tendência neste

últimos anos apenas 100 autores de cada um destes

domínio: a descriminalização, cujo forte sentido conduz em alguns casos a um abaixamento

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generalizado da moldura penal, que a partir da

maneira que um milionário «forreta» utiliza o seu

«reforma» de 2007, veio a recriar problemas no

Ferrari.

combate à chamada criminalidade violenta, uma zona onde o criminoso deve sofrer uma reprovação mais intensa. Muitas destas condutas criminosas

Os funcionários judiciais contestam esse sistema lento, pesado e burocrático - e a falta de recursos, e depressa pensam em passar à greve.

provocam danos de pequena monta, mas estes com frequência repercutem-se em resultados perigosos, concretos

abstratos

Assim

sendo,

esta

criminalidade tem de ser combatida de forma severa, fazendo recuar a sua repressão ao momento em que o perigo se manifesta. A melhor prevenção é

No essencial, a multiplicação de diplomas legais e códigos

deveria

levantamento

dos

ser

substituída

problemas

nos

por

tribunais

atafulhados de processos, sem informatização eficaz. Aliás, as sucessivas revisões dos Códigos Penal e de

a repressão.

Processo Penal não adiantaram nada de novo para a resolução das questões de fundo da justiça criminal. Fechando

círculo:

criticamos

legislação

As Cadeias continuam sobrelotadas.

abundante, dispersa, às vezes em duplicado e em mau português. De facto, só no ano de 2012 a maioria das leis publicadas destinou-se a revogar

Ilustrando esta realidade, as prisões encerram, maioritariamente, condenados por Crimes Contra o Património (mais de metade da criminalidade

diplomas saídos nos últimos seis meses.

registada), Crimes Contra as Pessoas e Crimes Quanto aos investigadores criminais - corpo estruturado e de forte hierarquia, disciplina consentida, ligação estreita às magistraturas tentam ainda afastar o jugo do poder, não só para não perderem a autonomia necessária à eficácia, mas

também

componente

para

conservarem

científica

assim,

uma

Relativos a Estupefacientes (muito em relação com os crimes de furto e roubo do «património»). Curiosamente, a idade média dos homens reclusos é inferior à das mulheres, sendo que estas cumprem pena em maioria pelo «tráfico de estupefacientes».

forte

manterem

incólume, uma prática da investigação cuja realidade não deve ser menosprezada, sob pena de pôr em causa a segurança do cidadão.

Devemos recordar que o limite máximo da pena de prisão é hoje de 25 anos, depois de ter sido de 20 anos em 1982 e de 28 anos no século XIX; não obstante, continuamos a ser dos países com menos medidas repressivas no combate à criminalidade,

Os juízes, por sua vez, continuam a clamar por melhores vencimentos no tempo que lhes sobra entre despachos nos mil processos que têm a cargo.

apresentamos uma taxa de criminalidade inferior à taxa média de criminalidade europeia e, dentro desta, registamos uma menor taxa de criminalidade

O Ministério Público procura um novo modelo de

grave. Por outro lado, mantém-se a prisão por dias

magistrados e enquanto isso utiliza a PJ da mesma

livres, o regime de semidetenção e a multa

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alternativa, recurso dos Governos para resolver a

2001, “cada vez menos as pessoas recorrem à polícia

questão da sobrelotação das cadeias.

para apresentar queixa formal”); e o descrédito no

De facto, somos o país europeu com maior número de reclusos por 100 mil habitantes, cerca de 60% dos presos cumprem pena inferior a dois anos de cadeia

sistema judicial, que em meados da década de 90 justificou o aparecimento aberto das "milícias populares".

e apenas 9% foram condenados a penas superiores a

Calcula-se que em Lisboa 20% dos residentes já

8 anos. Mais, a uma lotação ideal de 7.500 reclusos

foram vítimas de um crime (furto por carteira, roubo,

corresponde uma ocupação que ronda os 13.500.

insulto, injúria, furtos de bens pessoais em locais

Observa-se, igualmente, uma acentuada oscilação no quadro dos suicídios em meio prisional (19 em 2010, 11 em 2011 e 16 em 2013), muito provavelmente em resultado da dificuldade de prevenção do fenómeno, designadamente, no

públicos), sendo que a taxa de vitimação ronda os 40%; 30% dos agregados familiares já enfrentaram este problema (furtos e danos em automóveis); e a taxa de incidência de vitimação de famílias é de cerca de 50%.

campo da deteção precoce de sinais e sintomas em

Enfim, italianizámo-nos. Florescem situações de

reclusos entrados, e da sinalização para os que

enriquecimento

cumprem pena. É sintomático que, paralelamente a

persistentemente pobre, a que se associam

esta situação se tenha assinalado um aumento do

exercícios vários de ilicitude e indícios ligados a

número de reclusos evadidos e da apreensão de mais

círculos do poder; e germina a ideia de que «a coisa

de 100 armas brancas e 1.200 telemóveis.

está a saque» e que, mais amiúde, para ver aprovado

Quanto às vítimas, que também são «gente», na

sem

causa

num

país

um requerimento é preciso vender a alma ao diabo!

cidade de Lisboa o retrato a fazer é de preocupação,

Significa isto, também, que vivemos uma situação

embora os níveis de vitimação se situem entre os

objetiva de insegurança, que cria preocupações,

intervalos conhecidos para a realidade Europeia.

mas,

Em termos de género, 65% do total vítimas são homens; 83% das vítimas têm mais de 25 anos; 13% das vítimas têm entre 16-24 anos e 2% são menores de 16 anos. Apesar de tudo isto, também o nível global de vitimação é da ordem dos 15%, um dos mais baixos da tabela europeia.

também,

uma

situação

subjetiva

insegurança, bastante mais elevada. E que entre ambas se navega com carácter de opção entre a preferência, como vimos, ora pela vítima-menor ora pelo delinquente-suspeito-arguido. Isto para não falar de uma terceira via, que sustenta que o Estado não é detentor do direito de vingança e que somos todos bons rapazes.

Em termos de taxa de incidência - 36 crimes por mil habitantes – não somos dos mais sobrecarregados, apontando-se para essa explicação a falta de confiança na atuação da polícia (na linha do RASI,

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De facto, à medida que a democratização do crime foi acontecendo fomos sendo cada vez mais alertados para o aumento de atividade de pessoas a

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quem não vale a pena aplicar nem sequer a teoria da

Em 205, 206 e 2007 os valores baixaram para valores

reinserção social. Elas estão nas receções oficiais,

que rondaram os 387 mil crimes, em média.

nos espetáculos, nas televisões. Limitam-se a ser administradores,

empresários,

«governantes».

Recebem «apenas» os lucros resultantes de uma autêntica economia de mercado em termos de

No período de 2007 a 2011, inclusive, os valores ultrapassaram de novo e em muito os 400 mil crimes sendo que o ano de 2008 se mantém ainda hoje como um marco absoluto (421.037).

tráfico de influências, assente muitas vezes na prática de crimes que fazem intervir no terreno seres

No ano de 2012 os crimes registados voltaram a regredir (395.827)

menores e desprotegidos Daqui à insegurança é um salto curto. É o aumento da gravidade dos crimes de delinquência juvenil; a multiplicação de casos de criminalidade violenta com utilização de armas de fogo em situação ilegal; e a persistência da criminalidade associada à droga.

Os crimes contra o património constituem o maior volume de ocorrências, ou seja, entre 60 e 70% do global, seguindo-se os crimes contra as pessoas, crimes contra vida em sociedade, crimes previstos em legislação avulsa e, por fim, crimes contra o Estado.

O sentimento de insegurança traduz o aumento do medo subjetivo que é transmitido pelos media. Os políticos, quadrante

independentemente ideológico,

exploram

respetivo de

modo

oportunista e sistemático, através de discursos sobre insegurança, os sentimentos de confiança da população em relação às autoridades, porque sabem que essa oratória dá votos. Enquanto isso o medo aumenta conforme a solidão; a solidão potencia a insegurança; os sentimentos de insegurança variam

Podemos então sustentar que nos 20 anos em apreço se verifica uma tendência para a estabilização dos crimes contra o património, e um agravamento dos crimes contra as pessoas, dos crimes contra a vida em sociedade e, em taxa, dos crimes contra o Estado (2.562 para 5.807, o que para estes dá bem a ideia da forma como o Estado, a ordem e a tranquilidade pública passaram a ser encaradas pelos cidadãos.

consoante os conceitos culturais dos indivíduos (por

O que os RASI não dizem é que no ano de 2011, dos

exemplo, o medo da noite remete para o medo da

350 arguidos acusados / dia, apenas foram

morte).

condenados 140; dos 1.100 crimes (processos) / dia, 800 foram arquivados pelo MP, por falta de provas; e não dizem ainda que os presos diminuíram 7% em

Pontos salientes da análise estatística: De 1993 a 2004 verificou-se uma tendência para o

2012 e os presos preventivos em particular diminuíram 24%.

crescimento da criminalidade denunciada, que rondou os 100 mil crimes nesse período. O máximo foi atingido em 2003 com 409.509.

Concluindo. É significativo que, primeiro, no caso do Processo Penal, sob a capa de um discurso perigoso

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de combate ao pretenso excesso de «garantismo»,

possibilidade real de contrariar uma eventual

se tenha caminhado para uma real supressão dos

acusação; a retirada imediata dos enormes poderes

«Direitos, Liberdades e Garantias» fundamentais dos

que o MP tem e que o transformam numa instituição

cidadãos; e depois, que se receie que uma

inteiramente antidemocrática; finalmente, pôr fim a

verdadeira polícia de Estado que dá pelo nome de

uma

MP - uma força poderosa, incontrolável e

impossibilita o saber-se exatamente o que é que está

incontrolada dentro dos aparelho de Estado e da

em vigor em cada momento. E é causa de iniquidade.

Justiça - sirva para «julgar», permanentemente, o

E de erro judiciário, o pior dos crimes, nunca

cidadão anónimo, mas deixe de fora os poderosos.

condenado.

Neste quadro, propomos a alteração completa da

Era por isso fundamental que se soubesse qual a

estrutura do Processo Penal, que é o mesmo que

verdadeira ação do Estado sobre o crime e,

dizer, «da lógica de funcionamento da Justiça», de

fundamentalmente, quais as taxas de reincidência,

forma

que são, afinal, o verdadeiro fundamento de uma

garantir

uma

verdadeira

natureza

contraditória do mesmo, que permita ao cidadão a

completa

pirotecnia

legislativa

que

política criminal, prisional e de reinserção.

135

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Original Article Frontal lobe dysfunction in heroin addicts: Evidence from an emotional Stroop colour-naming task Paulo Lopes (1,2), Jorge Oliveira (1), Pedro Gamito (1), Hélder Trigo (2,3), Paulo Sargento (4), & Ana Paula Silva (5) (1)

CEPCA,

University

Lusófona.

Campo

Grande,

376,

1749 -024

Lisbon

Corresponding

author:

paulo.jorge@u lusofona.pt (2) Ares do Pinhal Addiction Rehabilitation Association. Rua Gil Vicente, 62A, 1300 -286, Lisbon. (3) ARS Lisboa e Vale do Tejo – Equipa de Tratamento de Santarém, Ministry of Health of Portugal. (4) School of Psychology and of Life Sciences, University Lusófon a. Campo Grande, 376, 1749-024 Lisbon (5) Prof. Doutor Fernando Fonseca Hospital. Estrada IC19, Venteira, 2720 -276 Amadora

_________________________________________________________________________________ Abstract Th e n eu rop sy ch o lo gi cal con s eq u en c e s o f h e roi n d ep e n d e n c e ar e p ar ti c u lar ly e v id e n t in fro n ta l lo b e fu n ct ion s . In th e cu r ren t stu d y w e i n t en d ed t o a s s e s s g en era l cog n it i v e ab il iti e s of h ero in ad d i ct s, a s w e ll as e x ecu ti v e con t rol th r ou gh an e mot ion al S tr oop col or -n a m in g ta sk . Th e s amp l e c on si st ed of 7 7 p arti ci p an t s d i vid ed in th re e gro u p s, t wo grou p s of h er oin ad d i ct s in tr eat m en t in th erap e u tic co m mu n ity ( l e ss th an 18 0 d ay s an d mo re th a n 18 0 d a y s ) an d a gro u p o f m at ch e d c on tro l s. O v era ll r e su l t s sh o w ed a p oor e r cog n it i ve ab ili ty o f h e ro in ad d ic t s th a t w er e in ear li e r sta g e s o f th e rap eu t ic co m mu n ity (f or l e s s th an 18 0 d ay s) . A si mi la r p a tt ern w a s ob tain ed th rou gh th e e mot ion al St roop tas k th at r e v ea l ed p oo re r in h i b it ory c on tr ol i n th e s e s u b j ec t s. F in d i n g s su g ge s t th at cog n it i ve i mp a ir m en t s re su lti n g fr o m d ru g d e p en d en ce ca n b e s e ve r er in a d d i ct s a t ear li e r s tag e s o f th er ap e u tic co m mu n ity, b u t a l so th at th e se con s eq u en ce s ar e r e v er s ib l e d u rin g a s tag e -t re at m en t fo r op io id d ep en d en ce . Ke yw or d s: F ron t al Fu n c tion s ; In h ib i tory C on tr ol ; S tro op ; H ero in ; Ad d i ct ion .

Resumo As con s eq u ên cia s n eu r op s ic oló gi ca s d a d ep en d ên cia d e h ero ín a são p arti cu lar m en t e e vid en te s n a s fu n çõ e s d o lob o f ron ta l. N o atu al e stu d o, p r et en d eu - s e a v alia r h ab il id ad e s cog n it i va s ge ra i s d e d e p en d en t e s e m h e roín a, b e m co mo o c on t rol e e xe cu t i vo a tra v é s d e u m a t ar ef a d e n o m ea ção d e c or - S tro op e mo cion al . A a mo s tra f oi co n st itu íd a p or 7 7 p arti c ip an t e s d i v id id os e m tr ê s gru p o s: d o i s g ru p o s d e d ep en d en t e s e m h e roín a e m trata m en t o n a C om u n id ad e te rap êu t ic a ( m en os d e 18 0 d ia s e ma i s d e 18 0 d i a s) e u m gru p o d e co n t ro lo s. N o gl ob a l, o s r e su l tad o s s u ge r e m u ma c ap ac id ad e co gn it i va m ai s e mp ob re ci d a em heroínodependentes que se encontravam numa fase mais precoce de tratamento em comunidade terapêutica (p o r me n o s d e 18 0 d ia s ). U m p ad rã o s e me lh an te f o i ob t id o atr a vé s d a tar e fa d e St roop e m oci on al q u e re v e lou u m con tr ol e in ib i tór io ma i s em p ob r e cid o n e st e s su j eit os . A s con c l u sõ e s su g er e m q u e os deficits cog n it i vo s r e su lt an t e s da dependência de substâncias psicoactivas ilícitas podem ser mais acentuadas / intensas em dependentes e m f as e s p re co c es d e t rata m en to n a Co mu n id a d e t era p êu ti ca, ma s ta mb é m q u e e sta s con s eq u ên c ia s s ão re v e r sí v e i s no decorrer do tratamento em comunidade terapêutica, sugerindo uma eventual eficácia do programa terapêutico. Pa la vr as -ch a ve: Fu n çõ e s Fro n tai s ; Con tro lo I n ib itór io ; Stro op ; H ero ín a ; Ad i ção .

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Resumen La s c on se cu en cia s n eu r op s ic oló gi ca s d e la ad i cc ión a la h e roín a son p arti cu lar m en t e e vid en te s en l a s fu n ci on e s d e l l ób u l o f ron ta l. E n el p re s en te e stu d io, s e p ret en d e e va lu ar la s h ab il id ad e s co gn i ti v as p ar a ad ic to s a la h e roín a, a s í co mo e l Con t rol E j ecu ti vo a tra v é s d e u n tar ea - e m oci on al co lor n o mb ran d o St roop . La mu e str a con si st ió en 7 7 p arti c ip an t e s d i vid id o s en t r e s g ru p o s : d o s g ru p os d e ad ict o s a la h e roí n a en tr ata m ien to en co mu n id ad t er ap éu ti ca ( m en o s d e 1 80 d ía s y má s d e 1 80 d í a s) y u n g r u p o d e con t ro le s re lac ion ad o s. E n el g lob al, lo s re su lta d o s su gi er en u n a cap a cid ad co gn i ti va má s p ob re en su j et os ad i cto s a l a h e roín a q u e se en c on trab an en la s p ri m e ra s e tap a s d el trata m i en to en co mu n i d ad t e rap éu t ica (p or m en o s d e 18 0 d ía s ). Un p atrón si m ila r s e ob tu vo a t ra v é s d e la ta rea d e St roop em oc ion a l q u e r e ve ló u n con tro l in h ib ito rio má s e mp ob re ci d o e n e st o s s u jet o s. Lo s re su lta d o s s u gi er en q u e l a s d e fi ci e n cia s co gn it i va s re su ltan te s d e la ad i c c i ón a l a s d ro ga s p u ed en s er má s fu er t es e n f a se s t e mp ran a s d e l trata m i en to d e lo s ad i cto s en la co mu n i d ad tera p é u ti ca, sin o ta m b ié n q u e e sta s con s ecu en ci a s s on r e v er s ib l e s d u r an t e u n a f as e d e tr ata m ien to d i rig id o h ac ia l a d ep en d en cia d e op i ác eo s. Pa lab r a s c la ve : Fu n c ion e s fron tal e s ; Con t ro l I n h ib it or io; S troo p ; He ro í n a; Ad i cc ión .

_________________________________________________________________________________

The chronic use of illici t drugs may be

Executive

functioning

associated with a rather generalized profile

cognit ive

domains,

of neuro psychological deficit. Therefore, in

memory,

attention,

addition to whatever general cognitive

making and inhibitory control (Chan, Shum,

deficits may be asso ciated with chronic

Toulopoulou, & Chen, 2008). There are

drug

subtle

studies demonstrating that heroin abusers

differences associated with the abuse o f

have impaired frontal cognitive functions.

different

have

For example, Lee et al. (2005) describe

distinctive modes of actions (Mintzer &

heroin addicts as impulsive, producing

Stizer, 2002; Rogers & Robbins, 2001).

more false alarm rates in a suppressio n

misuse,

there

classes

may

drugs

that

The effects of opioid abuse are particularly evident in the prefro ntal structures (Pau, Lee,

Chan,

associated

with

2002),

being

deficits

therefore executive

function (Gruber, Silv eri, & Yurgelun -Todd,

comprise such

several

working

planning,

decision

task and reveal poorer impulse control than normal subjects (Lee & Pau, 2002) , and

these

consequences

may

last

for

months after heroin withdrawal (Fu et al., 2008).

2007; Verdejo, Torrecilas, Arcos, & García,

Cognitive impairments may contribute to

2005)

drug misuse and addiction in at least two

yielding

both

functio nal

behavioral consequences.

and

ways.

First,

likelihood

they of

may

increase

drug -seeking

the

behavior

through various kinds of cognitive deficits

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including, for example, failures of impulse

stimuli and respo nse inhibition, functions

control m echanisms. Second, they may

that rely on the anterior cingulate cortex

interfere with users’ capacity to assimilate

and

and participate in rehabilitation programs

(Laird et al., 2005).

that often have an educative and cognitive emphasis (Rogers & Robbins, 2001). Impulsivity

has

been

the

dorsolateral prefrontal cortex

studies

have

r evealed

attentional bias for stimuli with emotional

considered

content for several addicted po pulations,

pathological condition of drug addicts that

specifically,

may arise from the lack of inhibitory

(McCuskers & Gettings, 1997), internet

control.

addicted (Dong, Zhou, & Zhao, 2011) and

alcoholics (Lusher, Chandler, & Ball, 2004).

Interference effects were also reported for

cingulate cortex, being crucial to the ability

drug-related stim uli probably reflecting

of inhibiting inappropriate behavior (King,

impairment in attentional processing in

Tenney, Rossi, Colamussi, & Burdick, 2003).

cocaine (Hester, Dixon, & Garaven, 2006),

Nevertheless, impulsiv ity as well as the loss

cannabis (Verdejo et al., 2005) and heroin

of cognitive control seems to affect the

abusers (Franken, Kro on, Wiers, & Jansen,

attentional levels in drug addicts (Field &

2000). In agreement to Field and Cox

Cox, 2008). The Stroop task has been widely

(2008), this attentional bias is an outcome

used

of expectancy

The

neural

correlates

thought

impulsivity

are

mainly

dysfunction in the

study

attentional

bias

and

pathological

deliv ered by

gamblers

substance -

inhibitory control in addicts and other

related stimuli, which increase attentional

psychiatric populations. In the classical

errors

Stroop color-naming task (Stroop, 1935)

Nevertheless, there is also evidence that

naming colors of colo r words is faster and

negative and positive wo rds are processed

more accurate when words are printed in

faster and more accurately than neutral or

the same color of as its meaning. The

non-words (Kousta, Vinso n, & Vigliocco,

Stroop effect refers to an interference

2009). Other perspectives consider that

between

poorer performance on emotional Stroop

incongruent

trials

(i.e.,

word

and

tasks

interpreted as a result of two competing

neuropsychological deficits of drug addicts

neural pathways for word reading and color

than to emotional co ntent of stimuli. For

naming (Cohen, Dunbar, & McClelland,

example, Battisti et al. (2010) found that

1990). In this way, the Stroop task assesses

cannabis users showed increased errors for

interference

incongruent trials in a modified versio n of

from

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conflicting

crav ing.

“blue” printed in red), which has been

resulting

could

subjective

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the Stroop color-naming task without drug related words.

highlight the impact of drug abuse on executive control. In our study we have focused on the cognitive consequences of drug addiction in heroin addicted patients in therapeutic community. Co nsidering the of

al.

(2008),

that

cognitive effect of heroin abuse may last after drug discontinuation, the purpose of this study was to assess executive control between heroin addicted subjects previous to treatment or in different phases of therapeutic community to assess how lo ng these consequences are likely to last. Executive control was estimated according to

behavioral

accuracy

and

measures reaction

respo nse

times

color

identification of the emotional Stroop task. More

specifically,

affects

information

prefro ntal

cortex,

heroin

addictio n

proc essing

the

particularly

the

anterior cingulate and dorsolateral areas, the lack of inhibitory control sho uld be evident thro ugh an emotional Stroop task. Thus, we expected poorer performance on the

emotional

Stroop

task

for

heroin

addicts in earlier stages of therapeutic community in comparison to addicts in most

Method Participants

In any case, the findings p resented above

suggestions

Iberian Journal of Clinical and Forensic Neuroscience – IJCFN

advances

stages

therapeutic

The sample consisted of 77 participants from three different groups, two groups of heroin addicts, were recruited from a specialized institutio n for treatment of drug addiction, the Ares do Pinhal

–

associatio n of drug addicts recovering, Portugal,

treatm ent

therapeutic

community (TTC) with a mean age of 32 years (SD = 6.21) and 8 years o f formal education (SD = 2.73), and o ne group of age-

and

education -matched

controls.

Forty eight subjects in TTC were divided in two different gro ups (twenty -four subjects in TTC for less than 180 days, 19 males and 5 females; and twenty -four subjects in TTC for more than 180 days, 19 males and 5 females).

The

according

treatment.

gro ups the

These

were

Median two

divided days

groups

were

compared to twenty -nine healthy controls (12 males and 17 females). The exclusion criteria were: (1) not being Portuguese native speaker; (2) under 18 or above 50 years-old,

(3)

clinical

history

any

neurological or psychiatric disorder; (4) positive for urine cannabinoid metabo lites, cocaine metabo lites o r opiate metabolites; and (5) with alcohol dependence synd rome. See table 1 for all demographic data.

community and contro ls.

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Table 1. Demographic data TTC

TTC

< 180 days (n)

≥ 180 days (n)

Male

Female

Nonworker

Unemployed

Employed

Student

Hashish

Amphetamines

Cocaine

Heroin

Polysubstance

Non applicable

Positive

Negative

Always

Sometimes

Never

Non applicable

Controls (n)

Gender

Professional status

Substance of first use

HIV

Contraceptive use

Note: TTC – Treatment in Therapeutic Community

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TTC

< 180 days

≥ 180 days

Age

31.1±5.9

33.2±6.41

29.9±9.3

Years of schooling

8.9±2.3

11.8±2.8

10.8±3.7

15.7±3.0

15.1±3.9

Age of onset of drug use

Controls

Note: The data are presented as means ±standard deviations (SD).

Measures

in 38 point Arial fo nt in a white background

Given

the

consequences

neuropsycholo gical abuse

Each word was presented in four different

reported in the literature review, a brief

colors (i.e., red, green, blue and yellow),

neuropsychological assessment was carried

where the participants had to identify the

before the execution of the experimental

color of presented words. The trials were

task. Each patient was assessed through a

randomized across participants, each of

brief screening test, the Mini Mental State

them consisting in 3 events, the word

Examinatio n – MMSE (Folstein, Folstein, &

stimulus that remained on the screen until

McHugh,

previously

a response was given by the participant,

validated to the Portuguese population by

preceded by and an inter -stimulus interval

Guerreiro et al. (1994).

of 1000 milliseconds (ms) and a 500 ms

1975)

chronic

that

heroin

with 1024x768 pixels of screen resolutio n.

was

black fixation cross.

142

Materials and design A total of 30 Portuguese concrete nouns

Procedure

were collected from Marques, Fonseca,

After

Morais, and Pinto (2 007), 10 neutral, 10

assessment, each participant w as seated at

positive and 10 negative words with four to

a 60 cm distance of the 17 inches desktop

eight letters and high frequency of use in

screen. The emotional Stroop task started

the Portuguese lexicon.

with a 5 min preliminary task practice

The

experiment

SuperLab

was

software

Corporation)

and

was

designed (v.1.0.2; pres ented

using Cedrus in

desktop screen. All words were presented

brief

neuro psychological

phase with proper no uns followed by the experimental task where subjects were instructed

identify

presented

words.

They

the were

color

told

identify colors with a button press in the

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Iberian Journal of Clinical and Forensic Neuroscience – IJCFN

corresponding key using the index finger.

non-normal

distribution

the

The response hand was counterbalanced

dependent variables. Independent

non -

between subjects.

parametric tests based on Kruskal -Wallis H statistic were carried out in order to study differences between treatment groups. The

Results

dependent variables were related to the

Neuropsychological data The

variables

neuropsychological assessment carried o ut

assessed

neuropsychological

during

evaluation

the were

submitted to non-parametric statistics due

through the MMSE. The Table 2 depicts the neuropsychological

assessment

between

treatment gro ups.

Table 2. Total scores of the MMSE between groups

MMSE

TTC

< 180 days

≥ 180 days

27.6±2.0

total score

Controls

27.8±1.8

29.0±1.2

Note: The data are presented as means ±standard deviations (SD). TTC – Treatment in Therapeutic Community Emotional Stroop task The

one-way

analysis

The performance o n the experimental task

showed statistically significant differences

was assessed thro ugh the reactio n times

between treatment groups for the total

and

score from the MMSE ( H(2, 76) = 10.560; p

negative and neutral words. Non -normal

distributions of reaction time and hit rate

0.01).

Kruskal-Wallis

These

results

were

further

hit

percentage

explored using pairwise comparisons for

percentage

mean ranks between groups that have

parametric statistics.

indicated a lower cognitive function in

required

for each

the

use

positive,

non -

Reaction time

patients in TTC groups in comparison to controls ( p < 0.05).

Inferential statistics o n reaction time data were assessed through one -way Kruskal Wallis analysis between treatment group s independently for each word category. The results showed that reactio n times o n

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colour

identification

differed

between

Iberian Journal of Clinical and Forensic Neuroscience – IJCFN

categories.

Overall

results

suggested

treatment groups for all word categories,

slower respo nses for patients in earlier

namely for positive ( H(2, 76) = 9.529; p <

stages of TTC. Figu re 1, 2 and 3 illustrates

0.05), negative ( H(2, 7 6) = 6.191; p < 0.05)

the distributio n of response reaction times

and neutral words ( H(2, 76) = 9.682; p <

(in milliseconds) in the emotional Stroop

0.05). The pairwise comparisons for mean

task.

ranks revealed differences between the two groups of TTC (p < 0.05) for all word

Figure 1

Figure 2

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Figure 3

Hit rate percentage Hit

rates

were

task. The sampling o f heroin addicts at

submitted

one -way

Kruskal-Wallis H tests independently for each word category. The data o n hit rates showed differences

statistically between

TTC

significant groups

and

different phases for heroin dependence treatment was motivated by prior findings of Fu et al. (2008), which suggest that cognitive impairments associated to heroin dependence, may occur even after drug discontinuatio n.

controls ( p > 0.05).

The neuropsychological screening carried out in o ur study has suggested a poorer Discussion According

cognitive abili ty of heroin addicts that he roin

were in earlier stages of TTC. According to

information

Laird et al. (2005) it is possible to assess

processing in the prefrontal areas, such as

informatio n processing in the prefrontal

the dorsolateral prefrontal cortex and the

structures with the Stroop procedure. The

anterior cingulate cortex, that are thought

interference effect o n the experimental

to be related to executive functioning in

task was revealed especially through an

cognitive

fro m

increase in response latency. Again, these

attention a nd working memory to higher -

results have suggested poorer inhibitory

order functions of reasoning and decision

control leading to impulsiv ity in subjects at

making. Thus, in this study we intended to

earlier

evaluate inhibitory control and selective

treatment.

attention

function

performance

prefro ntal

cortex

addiction

previo us

may

studies,

impair

domains

that

of and

range

dorsolateral the

stages

heroin

Although on

the

the Stroop

dependence behavioral task

wa s

insensitive to the hedonic valence of word

cingulate through an emotional Stroop

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meanings, these results may give support

Iberian Journal of Clinical and Forensic Neuroscience – IJCFN

Refer ences

to prior neurobiological studies suggesting an influence of opioid abuse in brain structure and functio ns, particularly in the

Battisti, R.A., Roodenrys, S., Johnstone, S.J., Pesa, N., Hermens, D.F., & Solowij, N.(2010). Chronic cannabi s users show

prefro ntal structures (Pau et al., 2002).

altered neurophysiological functio ning Impulsivity and the loss of cognitive control is a key feature of frontal lo be dysfunction.

Stroop

task

conflict

reso lutio n.

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Bechara (2005) described the maintenance of inappropriate behaviors in drug addicts mainly due to unbalance between bottom up and top -down cognitive systems that control decisio n making. The amygdala that underlies bottom -up reactive respo nses triggers a drug seeking behaviour in the

Bechara,

(2005).

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Folstein, M.F., Folstein, S.E., & McHugh, P.R.

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grading

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emotional Stroop task. Drug and Alcohol Dependence, 81 (3), 251 –257. King, J.A., Tenney, J., Rossi, V., Colamussi,

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polarity, have a processing advantage

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Laird, A.R., McMillan, K.M., Lancaster, J.L.,

(2008). Impaired response inhibition

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Iberian Journal of Clinical and Forensic Neuroscience – IJCFN

Original Article

Clinical Case

Neurofeedback Training for Pure Apathy: a case study Francisco Marques-Teixeira (1,2), Hugo Sousa (2) & João Marques-Teixeira (1,2) (1) Laboratory of Neuropsychophysiology of Oporto University – Corresponding Author: J. Marques Teixeira; teixeira@fpce.up.pt (2) Neurobios – Institute of Neurosciences, Porto, Portugal

_________________________________________________________________________________ Abstract Apathy is an underdiagnosed disorder associated with significant problems: reduced functional level, decreased response to treatment, poor outcome, and chronicity. Frontal- subcortical system(s) dysfunction is implicated in the causation of apathy; apathy subtypes based on the various frontal-subcortical loops may thus exist. The diagnosis has been based on medical, neurological, and psychosocial history, and the treatment has been based on the pharmacological agents like dopaminergic drugs and amphetamines. The treatment of a case of pure apathy is presented using neurofeedback training (NFT) guided by quantitative electroencephalogram (qEEG). The patient underwent neuropsychological testing, clinical evaluation, and a qEEG, which was repeated after the first 8 NFT and at the end of the NFT (16 sessions). QEEG illustrated abnormal electrical brain patterns, mainly an asymmetry in the global and relative beta power, decreased in the right hemisphere and increased in the left, especially in frontotemporal regions and in the sensorimotor strip. These abnormalities normalized after 16 sessions of NFT, and all the symptoms remitted together with an improving in the patient feeling of wellbeing. Our results are promising for the development of more effective treatments for this disorder that involve training single or multiple EEG frequency bands. Key-words: Neurofeedback; Apathy; quantitative electroencepaholography; Frontotemporal Regions

Resumo A apatia é uma perturbação subdiagnosticada associada a vários problemas significativos: diminuição da funcionalidade, diminuição da resposta ao tratamento, fraca resposta à terapêutica e cronicidade. Uma disfunção dos sistemas fronto-subcorticais parece estar implicada nas causas da apatia; por isso, podem existir vários subtipos de apatia, com base nas diferentes ansas fronto-subcorticais. O diagnóstico tem-se baseado na história médica, neurológica e psicossocial, e o tratamento tem-se baseado na utilização de substâncias do tipo dopaminérgico e anfetaminas. Neste artigo é apresentado o resultado do tratamento de um caso de apatia pura com a utilização do treino de neurofeedback (NFT) orientado por eletroencefalograma quantitativo (qEEG). O doente foi submetido a testes neuropsicológicos, fez uma avaliação clínica e um qEEG, que foram repetido após as primeiras 8 sessões de NFT e no final do treino (16 sessões). Os padrões de qEEG apresentaram atividade elétrica anormal do cérebro, principalmente uma assimetria no poder global e relativo de beta, diminuídos no hemisfério direito e aumentados no esquerdo, especialmente nas regiões frontotemporais e na faixa sensoriomotora. Essas anomalias normalizaram após 16 sessões de NFT, tendo-se e verificado a remissão de todos os sintomas, conjuntamente com uma melhoria na percepção de bem-estar do doente. Os nossos resultados são promissores para o desenvolvimento de tratamentos mais eficazes para esta perturbação que envolvem o treino de bandas de frequências únicas ou múltiplas do EEG. Palavras-chave: Neurofeedback; Apatia; Electroencefalograma Quantitativo; Regiões Frontotemporais

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Iberian Journal of Clinical and Forensic Neuroscience – IJCFN

Resumen La apatía es una desorden poco diagnosticada asociada a problemas significativos: reducido nivel funcional, disminución de respuesta al tratamiento, pronóstico desalentador y cronicidad. La disfunción frontal en sistemas subcorticales está implicada en la causalidad de la apatía; por lo tanto pueden existir subtipos de apatía basados en los diversos lazos frontales subcorticales. El diagnóstico se ha basado en la historia médica, neurológica, y psicosocial, y el tratamiento se ha basado en los agentes farmacológicos como drogas dopaminérgicas y anfetaminas. Se presenta el tratamiento de un caso de apatía pura mediante entrenamiento por neurofeedback (NFT) guiado por electroencefalograma cuantitativo (qEEG). El paciente fué evaluado por pruebas neurofisiológicas, evaluación clínica y un examen electroencefalográfico cuantitativo, que se repitió después de los primeros 8 NFT y al final de la NFT (16 sesiones). El qEEG ilustró patrones cerebrales eléctricas anormales, principalmente una asimetría en la poder beta global y relativa, disminuidos en el hemisferio derecho y aumentados en el izquierdo, especialmente en las regiones frontotemporales y en la franja sensoriomotora. Estas anomalías normalizaron después de 16 sesiones de NFT, y todos los síntomas llegaran a remission junto con una mejora en la percepción de bienestar de lo paciente. Nuestros resultados son prometedores para el desarrollo de tratamientos más efectivos para esta desorden que involucran entrenamiento de frecuencia de bandas únicas o múltiplas de EEG. Palabras clave: Neurofeedback; Apatia; Electroencefalograma Quantitativo; Regiones Frontotemporales

_________________________________________________________________________________

One of the challenges of the modern psychiatry is the

apathy, although it is intuitive and commonly used in

treatment of the disorders that do not fit in the usual

clinical descriptions of patients with such traits,

nosography of the mental disorders. One of those

appears to be controversial. Indeed, Levy and

disorders is apathy, not as a symptom of depression

Czernecki (2006), Reekum, Stuss and Ostrander

or other major mental or neurological disorders, but

(2005) proposed other definitions focus more on

as a disorder in itself.

diminished self-initiated behavior rather than

The term ‘‘apathy’’ conventionally describes a lack of interest or emotion, although Marin (1991) proposed a more complete definition: “a syndrome defined as a lack of motivation, evidenced by diminished

goal-directed

overt

behavior

(as

indicated by lack of effort, initiative, perseverance, and

productivity),

diminished

reduced cognitive or emotional goal-directed ability to respond to a stimulus, which was considered an equally important constituent in Marin’s initial definition. In any way, to date there is no clear consensus as to what definition of apathy is appropriate and clinically easy to operationalize.

goal-directed

Apathy may present as a symptom of other

cognition (as indicated by diminished importance or

neurological and psychiatric syndromes, mainly as a

value, lack of interest and concern about one’s

symptom of depression in the youngest because the

personal, health, or financial problems), and

presence of diminished interest, psychomotor

diminished emotional concomitants of goal-directed

retardation, fatigue/hypersomnia, and a lack of

behavior (as indicated by unchanging affect, lack of

insight are common to both apathy and depression.

emotional responsivity to positive or negative

However, a number of studies have reported that a

events, absence of excitement)”. This definition of

certain group of patients had significant discrepancy

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between the levels of depression and apathy. This

Although the pathophysiology of pure apathy is still

discrepancy made it possible to categorize patients

partially unknown, both clinical observations and

as having ‘‘pure apathy,’’ ‘‘pure depression,’’ or

studies in animal models of motivated behavior

‘‘apathy and depression” (Levy et al., 1998). What

support the view that frontal-subcortical system

concerns us are those patients with “pure apathy”

dysfunction contributes to the appearance of apathy

often misdiagnosed as depressive, but that do not

(van Reekum et al., 2005; Levy & Dubois, 2006; Dellu,

respond to antidepressant treatment. These patients

Piazza, Mayo, Le Moal, & Simon, 1996; Peters et al.,

jump from psychiatrist to psychiatrist, often

2006; Farrar et al., 2007). The location and extent of

overmedicated, and with no positive outcomes of

neuronal dysfunction, not its etiology, are the crucial

those treatments. The reasons for this quest of help

determinants.

Most

have being reported in numerous studies that

neuroimaging

evaluations

document the deleterious consequences that apathy

abnormalities in specific regions of frontal lobe,

can

relationships,

cingulate gyros, and basal ganglia. The parallel

occupational functioning, and general health

organization of functionally segregated circuits

(Velligan, Ritch, Sui, DiCocco, & Huntzinger, 2002;

linking basal ganglia and frontal cortex was first

Mayo, Fellows, Scott, Cameron, & Wood-Dauphinee,

described by Alexander and coworkers and

2009). Apathy has the potential to impair activities of

subsequently shown to be intimately involved in

daily living, diminish the quality of life, increase

human behaviors including apathy (Alexander,

caregiver burden, and complicate the therapy of

DeLong, & Strick, 2006; Levy & Czernecki, 2006).

comorbidities.

Three

have

interpersonal

In this paper we will present one of these cases, which comes to our clinic with the diagnostic of major depression, but without recovery from his unique symptom: apathy! The major challenge in this type of patients with “pure apathy” is the making of a reliable diagnosis before the treatment is initiated. The medical, neurological, and psychosocial history is important. The psychosocial history will indicate the patient’s baseline level of motivation and facets of

adult

personality,

and

comprehensive

neuropsychological assessment to clarify cognitive function with particular attention to frontal lobe function is necessary.

major,

neuropathological

behaviorally

link

and

apathy

relevant

frontal-

subcortical systems are now recognized: the dorsolateral prefrontal circuit (implicated in the organization of information to facilitate a response and executive dysfunction); the orbitofrontal circuit (implicated in the integration of limbic and emotional information into behavioral responses, disinhibiting, and social conduct); and the medial frontal and anterior cingulate circuit (implicated in motivational states and apathy) (Tekin & Cummings, 2002; Bonelli & Cummings, 2007). Since there are multiple prefrontal-basal ganglia circuits, apathy may differ in accordance with the mix of circuits involved. It may thus be best to regard apathy not as a single entity but rather as a heterogeneous disorder, usefully divided into multiple subtypes.

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The diagnostic values of neuroimaging study for

(enhancement) (Heinrich, Gevensleben, & Strehl,

apathy have not been well assessed; however, an

2007).

anterior cingulate circuit has been shown to be involved

motivational

mechanisms

and

development of apathy, and imaging this area might prove

useful.

The

importance

reviewing

This paper will report on the treatment of one case of pure apathy with NFT. Following the initial history taking, a qEEG was registered to evaluate brain function, and guide NFT.

medications cannot be overemphasized, because adverse drug reactions are particularly common associated with serotonergic or cholinergic agents,

Method

which may interact with disturbances of motivation.

Participant

Antidepressants,

especially

SSRIs,

have

been

implicated in the development of apathy as shown in the results of some studies (Wongpakaran, van Reekum, Wongpakaran, & Clarke, 2007).

JS was a Caucasian 20-year-old male with no past medical history presented to the neuropsychiatric clinic for a lack of motivation as the dominant feature of his clinical picture. The patient had

Despite the results of these researches, diagnosis of

experienced a progressive reduction in the

pure apathy has been based on a combination of

motivation relative to his previous level of

clinical history, neuropsychological testing, and in

functioning as evidenced by the following: (1)

rare cases, with brain imaging. No study including

decision diminished goal-directed behavior, seen as

Quantitative EEG (qEEG) evaluation has been done;

lack of productivity, effort, time spent in activities of

however, considering that pure apathy must be

interest, initiative, diminished socialization; (2)

regarded as a heterogeneous disorder with multiple

diminished goal-directed cognition, seen as lack of

subtypes, the contribution of this technique could

interest in new experiences, diminished decision

help to define those subtypes and, more important,

making abilities, lack of interests, diminished

could be very helpful in guiding neurofeedback

importance attributed to socialization, recreation,

treatment, when other treatments failed. Indeed,

productivity, initiative, curiosity; (3) Diminished

being plausible the hypothesis of the presence of

emotional concomitants of goal-directed behavior,

dysfunctional qEEG patterns associated with apathy,

seen as unchanging affect, lack of emotional

neurofeedback training (NFT) is viewed as a

responsitivity to positive and negative events, and

potentially effective intervention for the treatment

absence of excitement. Review of the patient’s

of this disorder. In NFT individuals learn to self-

medical history failed to show any pre- and perinatal

regulate specific EEG parameters and/or patterns,

pathologies or psychomotor deficits. No other

e.g., the amplitude or coherence of a distinct

psychiatric or neurologic symptom was present.

frequency component of the EEG signal, through

There was no significant family history of psychiatric

down

or neurologic disorders. He had been treated

training

(reduction)

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unsuccessfully with serotoninergic antidepressants,

digitally stored EEG, 512 seconds of EEG were

and he had attended a psychotherapeutic program

subjected to quantitative spectral analysis.

for

results of spectral analysis from 0.39-19.14 Hz were

symptomatology. The Clinical Global Impression

displayed as computed color-graduated topographic

Scale (CGI), both client and physician versions, were

maps and compared via a Z-score transformation to

administered. Both versions scored 4 (in a 0-5 scale,

age-regressed databases of normal subjects (Szava

5 being the worse clinical state).

et al., 1994). The subject patient’s eyes-closed and

months

with

improvements

The

eyes-open EEG was also analyzed using Variable Resolution Electromagnetic Tomography (VARETA) Procedure

to provide an estimation of the localization of

Verbal informed consent was obtained from the

underlying

patient after the nature and the goal of the NFT

electrophysiological

protocol had been fully explained. The patient

waveforms were edited off-line in order to remove

provided assent to intervention. QEEG recordings in

segments containing muscle artifacts and eye

rest condition, and cognitive and clinical evaluations

movements.

were performed at pre-training and at re-

performed at three distinct times, with one

evaluations, except for cognitive evaluation because

recording performed at baseline (before the NFT),

of the negative findings at baseline.

one after 8 sessions of NFT, and another at the end

generators

Actual

the

patient’s

activity.

The

digitized

qEEG

recordings

were

of training, that consisted in 16 sessions, about 2 Physiological Recording

months after the baseline recording.

A digital EEG was carried out employing Neuronic (Neuronic SA) hardware and software, in a

Clinical Evaluation

soundproof room while awake and seated in a

The patient was explained how to fill out a self-

comfortable armchair. Approximately 20 minutes of

monitoring clinical impression scale (CGI, 0–5 range,

eyes-closed and eyes-open resting EEG were

with higher scores indicating greater severity) of the

recorded and edited to reduce artifact. The

subjective impression of his medical condition.

recordings were of good quality. The EEG was

Ratings were collected before NFT (baseline), after 8

recorded by means of a cap supported by the

sessions of NFT (first control), and at the end of

system, with the 19 cephalic electrodes distributed

treatment, after 16 sessions of NFT (final evaluation).

in a pattern based on the International 10-20 System

At the same time moments the physician version of

(Jasper, 1958). The electrode impedance was < 10

CGI scale was administered. The patient’s cognitive

Kohms and impedance was monitored throughout

functioning was assessed before treatment by a

the recording. The acquisition-sampling rate was 500

trained clinical neuropsychologist who was not

Hz with filter settings at 0.5 Hz and 30 Hz. From the

involved in the NFB protocol. The “Bateria de

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Avaliação

Cognitiva

Breve”

[Brief

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Cognitive

10/20 System) was implemented. This program

Assessment Battery] (BACB, Alvarez, Machado,

consisted in given positive feedback at 10 Hz in the

Pastor-Fernandes, Marins, & Marques-Teixeira,

10-15 Hz range for those electrodes keeping the

2005), was used for the assessment of cognitive

other electrodes controlled.

functioning.

Finally, the treatment finished by controlling the right/left asymmetry of beta band. Thus, in the last 4 sessions a beta ratio right/left hemisphere was

Research Design

implemented. This program was implemented in The patient’s treatment consisted in 16 sessions of 30 minutes, twice a week NFT with the low-cost, wireless and semi-dry Emotive EPOC BCI (Brain Computer Interface) EEG headset. Following the qEEG findings, showing an almost general decrease in beta activity, especially at 16 Hz, in the first 8

order to increase beta band in the right hemisphere and, at the same time, decrease that band in the left hemisphere. This was accomplished by the ratio 1320 Hz/20-13 Hz with positive feedback at 20 Hz in the right hemisphere and positive feedback at 13 Hz in the left.

sessions a program called Beta Max, which up training 13-20 Hz (with positive feedback at 20 Hz) while simultaneously controlling the relative power all the other bands, was implemented with Mind

Results

155

A. Baseline

Work Station program. The control of the relative power of other bands means that the patient only receives positive feedback when the relative power

1. Neuropsychological assessment showed normal performance in all the tests of BACB.

of beta band was greater than the relative power of

2. Clinical evaluation showed similar scores for CGI

all the others. This is one innovation comparing to

subject and physician versions (Score = 4), indicating

the classic neurofeedback programs, based on the

severe mental health state.

assumption that better and quick results should be

3. QEEG evaluation

obtained when we simultaneously control all the bands not object of reinforcement.

In the baseline qEEG a decrease in beta band (2.31 SD below norm for 16.41 Hz at T6) with a decrease in

After these 8 sessions a control qEEG was recorded

global and relative power in this same band was

(see Results), and a clinical check-up was done,

seen, in addition to a decrease in the mean

together with de administration of CGIs. Based on

frequency of beta band, especially in the right

the first re-evaluation qEEG, in the subsequent 4

hemisphere (Figure 1). In the left hemisphere beta is

sessions a program called SMR Max inhibition (down

higher than in the right, especially in frontotemporal

training 10-15Hz at FC7-T7 which are the Emotive

regions and in the sensorimotor strip (see Figure 1).

EPOC electrodes closer to C3 from the International

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Figure 1 - Spectral analysis at T6 and Z global power for 16.41 Hz, Z mean frequency, Z global and relative power for beta band. PG - Global Power; PR - Relative Power; FM -Mean frequency.

The peak activity (positive/negative) at this frequency was topographically distributed by right middle temporal gyros (negative peak) and left inferior frontal and left sensorimotor strip (positive peak) as indicated by Variable Resolution Electromagnetic Tomography (VARETA) representation (Figure 2).

Figure 2 - VARETA showing the peak activity at 16.41 Hz (left - positive and negative activity cortex distribution; right - positive and negative peaks).

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B. First re-evaluation (after 8 sessions of NFT)

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A second qEEG was recorded thought to demonstrate changes resulting from the

This re-evaluation was done only for clinical and qEEG assessment because the normal scores

obtained

neuropsychological

assessment at baseline.

administration of 8 sessions of neurofeedback treatment. Indeed, the frequency 16.41 Hz increased from 2,31 SD below the norm to the normal range (1.64 SD below the norm), as

1. Clinical evaluation showed a decrease in the

well as did all the other frequencies, with delta

CGI scores. Self-report CGI = 3; Physician CGI =

jumping much above the normal range (red

3. Although the patient reported feeling, in

line in Figure 3, left). In addition, the right

general, a little bit better, he still manifest

hemisphere decreased its former hyperactivity

salient behavior idleness.

at 16.41 Hz, seen both by a decrease in global

2. QEEG re-evaluation

and relative power of beta band, as well as an increase in mean frequency all over the cortex (Figure 3).

157

Figure 3 - Comparative spectral analysis at T6 and Z global power for 16.41 Hz, Z mean frequency, Z global and relative power for beta band after 8 sessions of neurofeedback treatment. PG - Global Power; PR - Relative Power; FM -Mean frequency.

The peak activity (positive/negative) seen in first qEEG was reduced to a negative activity, although less negative than in the baseline qEEG, at the right middle temporal gyros and right occipital pole. The left inferior frontal gyros and left sensorimotor strip beta hyperactivity becomes normal, as indicated by VARETA representation (Figure 4).

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Figure 4 - VARETA showing the peak activity at 16.41 Hz (left - cortex activity distribution; right negative peak).

As beta relative power showed an increase of activity at sensorimotor strip, this brain area being analyzed for the frequency range 13-15Hz (the range comprising for this brain region the sensorimotor rhythm - SMR), indicating an above normal increase for 15.63 frequency (2.28 SD above norm) (Figure 5). These results, indicating high SMR activity at C3, were congruent with the behavior idleness still manifested by the patient.

Figure 5 - Spectral analysis at C3 and Z global power for 15.63 Hz, Z mean frequency, global and Z relative power for beta band after 8 sessions of neurofeedback treatment. PG - Global Power; PR - Relative Power; FM -Mean frequency.

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C. Final Evaluation

years ago” (sic). This behavioral observation

1. In clinical evaluation, overall, the frequency and the severity of all categories of symptoms

was confirmed in CGI scales, which manifest scores of zero for both versions.

decreased from the pre-training to the final reevaluation. The reduction was clinically

2. Final qEEG evaluation

significant, the patient reporting that all the symptoms had disappear feeling “normal” as he was before. Thus he regains interest in all activities,

manifesting

initiative,

being

productive and involved in social activities (his goal-directed behavior became similar as before the beginning of the disorder). Simultaneously he regained interest in new experiences and interests, attributing more importance to socialization in a such way that the holidays were spent with friends, suggesting that his goal-directed cognition had improved for similar levels as before the beginning of the disorder. Emotionally the patient reacts normally to positive and negative events. These behavioral changes were confirmed by her mother, that comes to the clinic for confirming and expressing her

The final qEEG evaluation was performed in order to see if the changes in the NFT protocols have had any impact in electrophysiological patterns. Concerning the SMR protocol, we examine the changes occurring at C3 electrode placement. As we can see by Figure 6, after 8 session of SMR down training, the 15.63 Hz frequency decreased from 2.28 SD above the norm to the norm (0.43 SD). This was confirmed by the global power of that frequency at C3, that showed a substantial decrease comparing to the first control evaluation, as well as the global and relative power of beta, that showed also a substantial decrease in that site, together with a normalization of C3 beta mean frequency (Figure 6).

satisfaction for the huge change her son has suffer, becoming “the son she knew some

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Figure 6 - Comparative spectral analysis at C3 and Z global power for 15.63 Hz, Z mean frequency, global and Z relative power for beta band after 16 sessions of neurofeedback treatment. PG - Global Power; PR - Relative Power; FM -Mean frequency.

Concerning the asymmetries in beta band, we compared qEEG relative power of baseline registration with first and final re-evaluation. As shown in Figure 7, the hyperactivity seen in left hemisphere, especially in temporal and sensorimotor regions, was maintained at C3 in the

first

re-evaluation,

and

completely

predicted by the effect of SMR down training program. In addition, alpha band became normal, and theta band increased its power in the

first

re-evaluation, but

significantly

decreased in the final re-evaluation becoming close to normal. Delta band maintains unchanged (Figure 7).

disappeared in the final re-evaluation, as was

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Figure 7 - Comparing Z relative power for all frequency bands between baseline (upper line), first re-evaluation (median line), and final re-evaluation (bottom line). PR - Relative power.

The consequence of these changes at this particular frequency was its decrease in left frontotemporal brain regions becoming symmetrical in both hemispheres, as indicated by VARETA representation (Figure 8).

161

Figure 8 - VARETA showing the peak activity at 15.43 Hz (left - baseline registration; right - final registration).

Summing up, the evolution of beta band (at T6) and SMR (at C3) along the 16 sessions of NFT was a stable increase of beta at T6 from baseline to the end of 16 sessions, and an increase SMR from baseline to the end of the 8th session and a great decrease between this session to the end of training, as a consequence of C3 SMR down training (Figure 9).

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Figure 9 - Evolution of beta band and SMR (in SD of the norm) along the 3 time evaluation moments (T0, T1 and T2).

162 uptraining and left beta downtraining, the beta

Discussion

asymmetric distribution with respect to the preThe present manuscript reports the outcomes of a NFB protocol to treat symptoms in a patient with pure apathy. To our knowledge, there is no report of using NFT alone to treat that disorder, and the use of Emotiv EPOC Neuroheadset with Mind Work Station Neurofeedback is clearly innovative.

training

becomes

symmetrical

both

hemispheres, not only for the frequency trained but also to all the beta range frequencies. In addition, the power of all the other frequency bands, except delta, approaches the normal range with respect to the baseline evaluation. It is worth noting that the decrease in SMR power

In the present uncontrolled single case study we

after SMR-only training was accompanied by

observed that, overall, beta power was

further significant reduction in the higher

asymmetrically

both

frequencies of this band at C3. The topography of

hemispheres, with an abnormal decrease at T6,

these effects is an issue that future studies

and SMR relative power was abnormally

employing multiple EEG recording sites should

increased at C3.

explore in more detail, in order to clarify its

When beta and SMR were trained, both beta and

functional significance.

SMR power changed in the desired direction, but

Our finding of additional alpha and theta power

this effect was only significant at one site,

decrease after the second training, that did not

namely, C3 for SMR and T6 for beta. Therefore,

involve alpha up training or theta down training,

when the training involved concurrent right beta

suggests that changes in alpha and theta power

distributed

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might be easier to achieve and/or to maintain

such as developing interest in social activities,

compared to SMR, even when a complex training

increasing his general productivity, effort, time

protocol (namely, SMR training and concurrent

spent in activities of interest, and initiative to

control of both hemispheres beta activity) is

attend

used. Alternatively, it is possible that the

improvements in emotional responsitivity to

decrease in theta power occurred as a

positive and negative events.

secondary, non-specific result of the patient having to concentrate his attention on the training task. In fact, theta power decreased significantly as compared to the first reevaluation even after the training was aimed at modifying only SMR and beta asymmetry. Along the same line of reasoning, the amelioration in the patient’s clinical symptoms we observed both after SMR-only and after concurrent beta trainings suggests that clinical improvement after SMR-only training might, at least partially, derive

from

a more general attentional

improvement associated with theta reduction. The role of beta asymmetry in symptoms amelioration, other than the improving in general brain functioning, rests to understand. In short, the results of the present uncontrolled single case study might imply that decreasing SMR activity or learning its voluntary control

school

lessons,

together

with

There are some limitations to be recognized in interpreting

our

data.

effectiveness

SMR-only

The or

differential concurrent

left/right beta NFT remains to be clarified, and clinical assessment of their effects should include instruments and tasks aimed at specifically evaluating cognitive, emotional and behavioral abilities related with SMR and beta activity. Moreover, the duration of the combined SMRbeta training should be extended, in order to clarify whether simultaneous control of both rhythms can be learnt after prolonged training. A further limitation is that follow-up data to test for long-term retention of the obtained clinical outcomes were not available. Multiple pretraining qEEGs, a larger number of patients, and controlled studies should be also carried out in order to fully estimate the possible effectiveness of such NFT.

might be considered as the main target for NFT of pure apathy patients that manifest high SMR activity at C3 or C4.

In conclusion, the present uncontrolled case study provides evidence of the effectiveness of NFT in treating pure apathy disorder. Our results

The present results support that NFT has tangible effects on the ability of patients with pure apathy to engage in daily activities. Indeed, upon

may lead to the development of more effective treatments for this disorder that involve training single or multiple EEG frequency bands.

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References Alexander, G.E., DeLong, M.R., & Strick, P.L. (1986). Parallel organization of functionally segregated circuits linking basal ganglia and cortex. Annual Review of Neuroscience, 9(1), 357-381.

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Mayo, N.E., Fellows, L.K., Scott, S.C., Cameron, J., & Wood-Dauphinee, S.(2009). A longitudinal view of apathy and its impact after stroke. Stroke, 40(10), 3299–3307. Peters, F., Perani, D., Herholz, K., Holthoff, V., Beuthien-Baumann, B., Sorbi, S., ... & Salmon, E. (2006). Orbitofrontal dysfunction related to both apathy and disinhibition in

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Something in the way she moves: Beyond beliefs and attitudes about hypnosis Carlos Lopes Pires (1), Catarina T. Pires (2) & Maria Angeles Ludeña (3) (1) Institute of Cognitive Psychology, Faculty of Psychology, Coimbra University, Portugal - Private Practice; (2) PhD Student, Unit for the Study and Treatment of Pain – ALGOS, Research Center for Behavior Assessment (CRAMC), Department of Psychology and Institut d’Investigació Sanitària Pere Virgili, Universitat Rovira i Virgili Catalonia (Spain); (3) PhD Student, Institute of Cognitive Psychology, Faculty of Psychology, Coimbra University, Portugal - Private Practice. Corresponding author: cmlopires@gmail.com

_________________________________________________________________________________ Abstract Hypnosis has been explained as resulting from variables such as beliefs and attitudes towards hypnosis, as Gandhi and Oakley (2005) have suggested. The present investigation was conducted to address similar basic questions concerning such beliefs and attitudes, but included a measure for assessing various subjective experiences during hypnosis. This was operationalized by a hypnotic assessment procedure called the Phenomenology of Consciousness Inventory: Hypnotic Assessment Procedure (PCI-HAP: Pekala, 1995a, b). Participants were assigned to two experimental conditions: imagination (in which all words related to hypnosis during the PCI-HAP were substituted by words related to imagination) and hypnosis (using the original version). The results suggested that labeling the experimental conditions as hypnosis or imagination did not have a significant impact on phenomenology, as measured by the PCI dimension of altered state of consciousness and the hypnoidal state score (a composite measure of trance, a la Weitzenhoffer, 2002). Contrary to Gandhi and Oakley (2005), the findings also suggested that there was little influence of beliefs and attitudes on almost all variables of the study, and virtually no influence at all was found on the phenomenological variables. How these results contrast to those of Gandhi and Oakley (2005) are discussed, particularly in reference to that "phenomenological something" associated with hypnosis and how the "hypnosis" affects the mind of the participant.

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Keywords: Phenomenology; Beliefs; Attitudes; Hypnosis; Imagination; Labeling; Altered State; Consciousness; Hypnoidal State.

Resumo A hipnose tem sido explicada como resultante de variáveis, tais como crenças e atitudes em relação à hipnose, como Gandhi e Oakley (2005) sugeriram. O presente estudo foi realizado para responder a perguntas básicas semelhantes relativas a tais crenças e atitudes, contudo incluiu uma medida para avaliar várias experiências subjetivas durante a hipnose. Tal foi operacionalizado através de um processo de avaliação hipnótico chamado Inventário Fenomenológico da Consciência: procedimento de avaliação hipnótica (PCI-HAP: Pekala, 1995a, b). Os participantes foram divididos em duas condições experimentais: imaginação (em que todas as palavras relacionadas à hipnose durante o PCI-HAP foram substituídas por palavras relacionadas à imaginação) e hipnose (usando a versão original). Os resultados sugerem que rotular as condições experimentais como hipnose ou imaginação não teve um impacto significativo na fenomenologia, como medido pela dimensão PCI do estado alterado de consciência e a pontuação de estado hipnótico (uma medida intrincada de transe, a la Weitzenhoffer, 2002). Ao contrário de Gandhi e Oakley (2005), as conclusões também sugeriram que havia pouca influência de crenças e atitudes em quase todas as variáveis do estudo, e praticamente nenhuma influência em tudo que se refere às variáveis fenomenológicas. A forma como estes resultados contrastam com aqueles de Gandhi e Oakley (2005) é discutida, especialmente em referência ao que se possa denominar "algo fenomenológico" associado com a hipnose e como a "hipnose" afeta a mente do participante. Palavras-chave: Fenomenologia; Crenças; Atitudes; Hipnose; Imaginação; Rotulagem; Estado alterado; Consciência; Estado Hipnótico.

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Resumem Hipnosis ha sido explicada como resultado de variables, tales como las creencias y actitudes hacia la hipnosis, tal como sugieren Gandhi y Oakley (2005). El presente estudio se realizó para responder a las preguntas básicas similares relativas a tales creencias y actitudes, sin embargo incluye una medida para evaluar diversas experiencias subjetivas durante la hipnosis. Tal fue puesto en marcha a través de un proceso de evaluación hipnótica llamado Inventario de Conciencia Fenomenológica: procedimiento de evaluación hipnótico (CIPHAP: Pekala, 1995a y b). Los participantes fueron divididos en dos condiciones experimentales: imaginación (en la que todas las palabras relacionadas con la hipnosis durante los PCI-PAHS fueron substituidas con palabras relacionadas a la imaginación) y la hipnosis (usando la versión original). Los resultados sugieren que caracterizar las condiciones experimentales como hipnosis o imaginación no asumió un impacto significativo en la fenomenología, medida por el tamaño del estado PCI alterado de la conciencia y la puntuación del estado hipnótico (una medida intrincada del trance, a la Weitzenhoffer, 2002). Diferentemente de Gandhi y Oakley (2005), los resultados también sugieren que hubo poca influencia por las creencias y actitudes en casi todas las variables del estudio, y prácticamente ninguna influencia en todo lo que se refiere a las variables fenomenológicas. Se discute cómo estos resultados contrastan con los de Gandhi y Oakley (2005), especialmente en referencia a lo que podría llamarse "algo fenomenológica” asociada con la hipnosis y como la "hipnosis" afecta a la mente del participante. Palabras clave: Fenomenología; Creencias; Actitudes; Hipnosis; Imaginación; Etiquetado; Estado alterado; Conciencia; Estado hipnótico.

_______________________________________________________________________________

One main theoretical perspective on hypnosis

Accordingly, beliefs moderate the level of hypnotic

proposes that beliefs and attitudes about hypnosis

suggestionability and therapeutic changes (Kirsch &

determine the hypnotic reactions of people and

Braffman, 2001; Lynn & Kirsch, 2006; Mendoza et al.,

their subjective experience of hypnosis (Gandhi &

2009), and therapeutic improvement is mediated by

Oakley, 2005; Kirsch & Braffman, 2001; Lynn, Kirsch

a number of factors including beliefs about hypnosis

& Hallquist, 2008; Wagstaff, 2010; Yu, 2004, 2006).

(Lynn & Kirsch, 2006; Milling & Constantino, 2000).

Current empirical and theoretical assumptions in

Accordingly, these variables (especially beliefs and

this regard state that: (1) beliefs promote better

expectancies) are the essence of what happens in

hypnotic responses (Mendoza, Capafons, & Flores,

hypnosis (Barling & De Lucchi, 2004; Gandhi &

2009) with a majority of the variance related to

Oakley, 2005; Kirsch & Braffman, 2001; Lynn &

responsivity to suggestions being related to

Kirsch, 2005; Lynn & Kirsch, 2006).

expectancies, motivation, beliefs and attitudes

Cognitive-behavioral1

about hypnosis (Lynn, Meyer, & Schindler, 2004; Lynn & Kirsch, 2006); and (2) people with negative beliefs respond poorly to suggestions (Spanos, Rivers, & Ross, 1977).

approaches

suggest

168

that

attitudes, beliefs and expectancies about personal responsiveness are the principal ingredients for effective treatment with hypnosis (Barber, Spanos, & Chaves, 1974; Capafons, 2001, 2004; Chaves, 1999).

In this article we will use the designations “cognitivebehavioral” and “socio-cognitive” as interchangeable.

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Actually, it has been argued that positive attitudes

In general, studies reporting changes in beliefs and

concerning hypnosis at the beginning of the

attitudes about hypnosis (for example, the fear of

treatment are a better predictor of therapeutic

hypnosis or the belief that hypnosis is an altered

change

level

state) have found that some beliefs and attitudes

(Schoenberger, Kirsch, Gearan, Montgomery, &

change after participants are exposed to scientific

Pastyrnak, 1997) and even a necessary condition to

texts (or even conferences or workshops.)

obtain high levels of it (Perry, Nadon, & Button,

Therefore, it is also found in some of these studies

1992; Spanos, 1982; Spanos, Brett, Menary, & Cross,

(Martín et al, 2010; Mendoza et al., 2009; Molina &

1987). They are necessary to achieve better results

Mendoza, 2006) that there are differences in

in the therapeutic intervention or even to promote

beliefs and attitudes between people with

the hypnotic response (see Capafons et al., 2006).

different sources of information about hypnosis

than

hypnotic

suggestibility

All these conclusions lead to several conclusions regarding the use of clinical hypnosis. For example,

(e.g. university classes or scientific conferences versus television programs).

Lynn and Kirsch (2006), postulate the need to

Nevertheless, such conceptions about attitude

increase: (1) positive attitudes and beliefs about

change may have exaggerated the ease with which

hypnosis, (2) motivation and (3) response

people change their attitudes, by including only

expectancies. A major postulate of the cognitive-

explicit attitudes; people may still have their older,

behavioral

for

habitual, implicit attitudes that are not expressed

therapeutic proposes, is the claim that it is

in this way (Wilson, Lindsey & Schooler, 2000; Paik,

absolutely necessary to introduce and explain to

MacDougall, Fabrigar, Peach, & Jellons, 2009). The

patients what hypnosis is, and correct their wrong

process of attitude change may often require more

beliefs about it (Lynn et al., 2004; Green, 2003). All

time and practice than previously thought (Paik et

these “corrections” occur within the cognitive-

al., 2009). Additionally, attitude researchers have

behavioural perspective and accordingly, there is

recognized that distinctions can be made regarding

no hypnotic state, no trance state, and what is

persuasive information that is used to change

called

attitudes and that the efficacy of these different

suggestionability (see Weitzenhoffer, 2000, for a

types of persuasive messages are in part regulated

review). In this context, some authors propose the

by the type of information upon which the

necessary use of scales to evaluate the beliefs and

attitudes are based (Paik et al., 2009). Moreover,

attitudes

hypnotic

attitudes based on different functions have been

intervention is given in a clinical context (Capafons

found to be differentially susceptible to persuasive

et al., 2005; Capafons, 2009).

messages that target different attitude functions

interventions

hypnosis

with

simply

patients

before

hypnosis,

imagination

any

169

(e.g., Snyder & DeBono, 1985 in Paik et al., 2009).

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Of course, attitudes do not always serve as

and then assessed again about their responsivity to

indicators or predictors of the human behaviour

suggestions (i.e. suggestions are repeated). The

(e.g. Ajzen & Fishbein, 1977; Ajzen, 1991).

same scale was used to assess hypnotic

Furthermore, there are a number of identified

responsivity (only changed the order of items). The

variables, which should be taken into account that

impact of beliefs was assessed analyzing the

regulate beliefs` susceptibility to change as

changes between these two moments (i.e. before

demonstrated by Eagly and Chaiken (1993).

and after an induction manipulation) assessing

The research conducted by Gandhi and Oakley (2005) appeared to confirm a fundamental role concerning how beliefs may influence ones perception

hypnosis.

Briefly,

using

the

WATERLOO-STANFORD GROUP SCALE OF HYPNOTIC SUSCEPTIBILITY, FORM C,

they found that labelling an

induction as hypnotic caused differences in the hypnotic responsivity. Gandhi and Oakley (2005) reported that not labelling the procedure as “hypnosis” may decrease the effect of positive (therapeutic)

expectancies

about

hypnosis.

three dimensions: behavioral suggestionability (behavioural responses to suggestions), subjective suggestionability (subjective effects associated with

each

suggestion),

and

involuntariness

suggestionability. Results revealed that labeling a procedure as hypnosis produced differences in the behavioral, subjective feeling, and involuntariness with the "hypnotized" participants reporting increased responsivity. Thus, the significant effect that hypnotic inductions have on suggestionability was dependent on the label “hypnosis”.

However, this research has some features that are

Still, we think that this methodology does not really

common to much socio-cognitive experimental

test the influence of beliefs on the experience of

research in the context of hypnosis that, in our

hypnosis. Actually, what it measured was the

opinion, may bias the results in favor of such

relative influence of beliefs in a situation in which

perspective.

participants were led to believe about something

We would like to make some comments about Gandhi and Oakley`s article, specially about the methodology and the consequent problems of using it. But, firstly, let us describe the principal features of Gandhi and Oakley (2005) research: (1) participants are evaluated about their responsivity to suggestions (with the Waterloo Scale-Form C) before induction manipulation; (2) participants were informed that they would be assigned to a group (i.e. hypnosis, relaxation or control groups)

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that was going to happen. Consequently, two beliefs were assessed: one related to hypnosis (participants are said that a hypnotic procedure will be used to verify if it produced a better response to suggestions) and one related to relaxation (participants are said that a relaxation procedure will be used to verify if it produces a better response to suggestions); in a third condition in which participants were informed that they would be evaluated in their ability to experience the same

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suggestions. In this last condition there was no

label (e.g., that happened more involuntarily in the

assessment of beliefs (perhaps because the

second phase).

authors believed that there were not beliefs to be assessed).

It must be said that all variables in this study are “subjective” in the sense that participants were

Importantly, participants were informed that a

invited to evaluate if they responded to

certain procedure (relaxation or hypnosis) would

suggestions (behavioral responsivity), the intensity

be used to eventually increase the responsivity to

of their response (subjective suggestionability) and

the initial suggestions. In another words, by using

this methodology the influence of beliefs on the

subjectivity). We argue that these three variables

responsivity

are dependent of the interpretation participants

repeated

suggestions

was

evaluated.

they

felt

involuntariness

(involuntariness

made based in the researcher’s information. So, in

In fact, Gandhi and Oakley recognized the existence of certain limitations when they wrote: “A question that has yet to be addressed, however, is whether hypnotic inductions themselves continue to be as affective when not labeled ‘hypnosis’. To our knowledge, the effect of a standardized hypnotic inductions, independent of the label ‘hypnosis’ has

the hypnotic condition, participants are prone to interpret more their responses to suggestions as stronger if they believe that hypnosis can improve performance (a very common belief). Even the more apparently “objective” measure (behavioral responsivity) probably was not so objective. Indeed,

(as

clinicians)

have

observed

participants and patients who declare ideomotor

not been previously examined” (p. 206).

changes that observers do not see, and also the The principal finding of Gandhi and Oakley`s study

171

contrary.

was that participants of the hypnosis condition increased

significantly

their

responsivity

repeated suggestions compared to the relaxation condition (moderate to large versus small mean effect sizes). As with all studies in which suggestions are repeated, it can be argued that participants had learned how to interpret what would happen. By informing the participants that they will later be hypnotized, it is expected that when they are assessed on their subjective experience and feelings of involuntariness, they will be influenced to interpret according to the

We believe that if Gandhi and Oakley had used phenomenological measures, they would not have found changes in the phenomenology. We argue that the hypnotic phenomenology is a direct result of the inductions; hence such phenomenology should be no significantly different in both groups, regardless of labels. This is why we hypothesized that there would not be significant changes in phenomenology

across

the

hypnosis

and

imagination conditions in our study. Hence, the aims of this investigation are (1) to verify if labelling an experience as hypnotic causes

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changes in the phenomenology of consciousness;

for the labelling throughout the protocols as either

(2) to verify if labelling an experience as hypnotic

hypnotic or imaginative - see below).

causes changes in beliefs and attitudes; (3) to clarify if beliefs and attitudes change with the Participants

experience (phenomenology of consciousness) of hypnosis versus imagination, and (4) to study the

The sample of this investigation included students

influence of beliefs and attitudes on the

(n = 152) from the University of Coimbra, Faculty of

phenomenology

Psychology and Educational Sciences. They were

hypnotic experience (labelled imagination or

informed that this study was about psychometric

hypnosis).

proprieties of the presented instruments, and that

consciousness

during

for this reason some weeks later they would be invited to complete the same scales. So, between Method

two and four weeks later, after signing the consent

Design

form, participants were randomly assigned to one of two experimental conditions: (1) imagination, or

This investigation used an experimental design

(2) hypnosis.

with two experimental conditions: (1) imagination versus (2) hypnosis. Beliefs and attitudes about hypnosis and the phenomenology of consciousness

Procedure

(as measured by the variables of altered state of In the first of two sessions (see Figure 1), 152

consciousness and the hypnoidal state score, as obtained

from

the

Phenomenology

participants completed several scales (anxiety,

depression, and the one of interest for the present

Consciousness Inventory - PCI) were also assessed.

study: the Valencia Scale of Beliefs and Attitudes

Participants in both groups were informed about

about Hypnosis-client version2).3 In a second

the type of intervention they were to receive, i.e.

session (between two and four weeks after the first

hypnosis was labelled as hypnosis and hypnosis was

session)

labelled as imagination (identical conditions except

115

Phenomenology

VBAHS-C (Portuguese version: Escala de Valência de Atitudes e Crenças sobre Hipnose: versão cliente- EVACH-C) Carvalho et al. (2007). 3 There was also a scale measuring expectancies, and other related variables, that will be reported in another article. The end of the experiment there was also a short questionnaire asking what was about the experience: relaxation, imagery, hypnosis, memory, intelligence.

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participants4 of

completed

Consciousness

the

Inventory:

115 out of 152 participants constituted the sample; i.e. 31 participants did not show up in the second moment, and 6 were excluded by different reasons (e.g., items not answered, or responded to the items in an unreliable way, or suspect the experiment is about hypnosis- group imagination).

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Hypnotic Assessment Procedure (PCI-HAP) of

mention anything about whether hypnosis involves

Pekala et al. (2010b). In the imagination condition

“trance” or an altered state of consciousness; we

all words related to hypnosis were substituted by

simply presented the Pekala’s procedure (Pekala et

words associated with imagination (e.g. imagine,

al, 2009)6, which has no mention of such concepts.

imagination, images), and participants were

Essentially, we planned for 2-4 weeks between the

informed that the experiment had as main aim the

two sessions, because we wanted participants’

study of individual differences in imagination. On

naïve experiences without having preconceptions

the other hand, participants in the hypnosis

affecting such experiences.

condition were informed that the experiment intended to study the individual differences in hypnosis, using the PCI-HAP in its original hypnotic procedure.5 It is important to clarify that we did not

173

Instruments

Beliefs and attitudes about hypnosis were measured by the Valencia Scale of Beliefs and

After this explanation participants are invited to sign a Consent Form.

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Audio taped.

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Attitudes about Hypnosis-client version (VBAHS-C)

hypnotized and to what degree, and their imagery

(Capafons, Cabañas & Espejo, 2003; Mendoza et

vividness. After finishing the hypnotic induction

al., 2009). This scale contains a page where

protocol,

participants identified themselves with the initials

Phenomenology of Consciousness Inventory (PCI)

of their name (to associate with data from the

in reference to a two minute sitting quietly period

second session), demographic data and more data

embedded in the protocol, in agreement with

of interest (e.g. questions about previous contacts

Pekala et al. (2009). The PCI is a 53-item Likert scale

with hypnosis, sources of information about

(0 to 6) self-report inventory. Each item consists of

hypnosis, and so on). The VBAHS-C is constituted by

two dipole statements, in which the participant

37 items in a 1-6 Likert point scale (1 - to

must rate on a 7-point scale. For example: “I felt

completely disagree to 6 - completely agree). The

very calm" ( 0 1 2 3 4 5 6 ) "I felt very anxious”.

VBAHS-C contains eight factors (Capafons et al.,

Moreover,

2008; Mendoza et al., 2009)7: (1) interest, (2)

dimensions of subjective experience: (1) positive

memory, (3) help, (4) personal control, (5)

affect, (2) negative affect, (3) altered experience,

cooperation, (6) marginal, (7) fear, and (8) magical

(4) rationality , (5) visual imagery, (6) volitional

solution. According to Mendoza et al. (2009), the

control, (7) attention, (8) self-awareness, (9)

VBAHS-C is a valid instrument to measure beliefs

arousal, (10) altered state of awareness, (11)

and attitudes about hypnosis.

internal dialogue , and (12) memory . 10

The Phenomenology of Consciousness Inventory –

The PCI also generates a measure called the

(PCI-HAP)8

hypnoidal ("trance") state score, also called a

includes several parts: relaxation instructions

predicted Harvard Group Scale (pHGS) score. It is

(called a “body scan”), a hypnotic induction

based on a regression equation using the PCI

procedure (called a “mind calm”), suggestions to

(Pekala & Kumar, 1984, 1987) to predict the total

have a vivid hypnotic dream, and several other

Havard Group Scale (Shor & Orne, 1962), and is

items.

used as a means to measure the depth of

Hypnotic

Assessment

Before

the

Procedure

induction,

participants

the

PCI9

completed

generates

the

major

completed a pre-assessment form in which they

"hypnosis," à la Weitzenhoffer (2002).

are asked if they have been hypnotized before and

hypnoidal state score was found to generate a

also about their expectancies about being

validity coefficient of 0.86 with the Stanford

We use the more recent version of VBAHS-C, revised in detail by Mendoza et al. (2009). 8 The validity of PCI-HAP is only beginning to be established. The authors acknowledge that the Portuguese version used in the current research is yet to be fully validated. The current version was adapted to Portuguese by Ludeña (2013,

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The

not published, being part of the PhD project of the third author of the present article). 9 And more 13 sub dimensions that are not considered in the present work. 10 The HAP includes as well an additional item to evaluate the imagery vividness of a hypnotic dream embedded in the HAP.

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Hypnotic Susceptibility Scale: Form A, and between

A one-way analysis of variance between groups

0.62-0.67 with the Harvard Group Scale of Hypnotic

was conducted to assess for differences in gender

Susceptibility: Form A (see Pekala & Kumar, 2007).

on the eight factors of VBAHS before the

Recent research by Pekala and colleagues (Pekala,

experiment.

2010, 2011: Pekala et al. (2010a, 2010b, in press)

differences between women and men11 on the

has generated some support for the hypnoidal

eight factors of VBAHS.

Results

showed

significant

state score as a measure or estimate of "trance." Sources of information and beliefs and attitudes Data analyses

A one-way analysis of variance between groups

Several tests of analysis of variance (one way, two

(hypnosis versus imagination) was conducted to

way, mixed) and the Wilcoxon Sign Test were

assess for differences on the eight factors of the

conducted to compare all variables (type of

VBAHS depending on the source of information

condition,

information,

before the experiment. There were significant

experimental conditions, levels of beliefs, relations

statistical differences in five factors related to the

between beliefs and PCI dimensions). Additionally,

source of information.12

the effect sizes were calculated. Therefore, in the

following: Personal control, F (3, 113)= 6.14, p<

present research, besides obtaining p values, we

0.001, with a large effect size (0.13); Magical

will accept as meaningful changes, changes

solution, F (3, 113)= 3.74, p< 0.01, with a moderate

representing a p value <= 0.05 that also has a

size (0.08); Memory and Trance F (3, 113)= 3.09, p<

moderate/large effects sizes. Except for Wilcoxon

0.03, also with a moderate effect size (0.06);

Sign Test, all measures of effect sizes are omega

Marginal, F (3, 113)= 11.69, p< 0.005, with a large

squared, considered more exigent (Field, 2010).

effect size (0.22).

gender,

sources

175

Factors were the

Furthermore, there were relevant differences for personal control and marginal factors: people who

Results

have obtained information from the university Changes in the beliefs and attitudes with the

believed at a greater extent that someone who was

experience of hypnosis versus imagination

hypnotized had personal control in hypnosis as compared to those who had no information. For marginal factor, the differences were between

Gender differences in beliefs

The number of men was low (n= 14).

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Only one subject referred “conferences” as a source of information and consequently was eliminated from these calculations.

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those who received information from the

previously did with all the VBAHS-C factors, the

University and those without information, and

differences depending on sources of information

between those who received information from the

and gender were analyzed.

University and those who obtained information

Sources of information on belief of hypnosis as an

from television.

altered state of consciousness A one-way analysis of variance between groups

Experimental conditions and changes in beliefs

(hypnosis versus imagination) was conducted to

and attitudes

explore differences in the belief of hypnosis as an altered state of consciousness resulting from

A one-way analysis of variance between groups

different sources of information. Results revealed

(hypnosis versus imagination) was conducted for

that no differences among sources of information

all the 115 participants in the experiment on the

on altered state of consciousness were found.

eight factors of the VBAHS. In none of these variables were found moderate or large effect sizes that were also significant.

Gender differences on belief of hypnosis as an altered state of consciousness

Hypnosis as an altered state of consciousness

A one-way analysis of variance between groups was conducted to explore differences in the belief

For this study we intended to explore the particular

of hypnosis as an altered state of consciousness as

belief of hypnosis as an altered state of

a function of gender. Results indicated no

consciousness, as measured by the VBAHS-C. Since

significant statistical differences between women

the VBAHS-C does not have a factor or dimension

and men. Respectively, based in our findings, no

so named, we created a dimension called altered

significant differences for gender and information

state of consciousness that combined two factors

sources concerning the dimension (belief) altered

from the aforementioned scale: personal control

state of consciousness were found. For this reason

and memory/trance.13 In order to test the

no additional statistical analyses were conducted.

hypothesis that beliefs determine what people say

In the following section, we intend to evaluate the

about believing and being (experiencing) in an

relationships between the level of beliefs about

altered state of consciousness, we focused in the

hypnosis, the experimental groups, and the

evaluation of this particular belief.14 As we

In accordance with the belief of hypnosis as an altered state of consciousness, it is proffered that the person loses self-control and also that experiences trance and changes in memory (see also Mendoza et al., 2009).

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The experience of being in an altered state of consciousness is explored later with the PCI.

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dimension altered state of consciousness. Firstly,

been subjected to either of the experimental

we compared all participants (1) before and (2)

conditions.

after the experimental conditions. Differences in the belief of hypnosis as an altered state of consciousness before and after the experimental conditions A one-way analysis of variance between groups (hypnosis versus imagination) was conducted to evaluate the impact of the experiment in the belief of hypnosis as an altered state of consciousness. There was a statistically significant increase in that belief from Before (M= 30. 22, SD= 3.54) to After the experiment (M= 32.2, SD= 4.71), F (114)= 12.761, p< .005 (two-tailed) with a large effect size (0. 13).

Comparing the levels of beliefs of hypnosis as an altered state of consciousness before and after the experimental conditions Because beliefs and attitudes can be stable, defining a general disposition to think and behave (Hogg & Vaughan, 2005), it seemed essential to compare the levels of beliefs. Therefore, in order to compare the levels of belief (not a continuous variable) we constituted three levels: high, moderate and low. This was based on one standard deviation from the adjusted median in order to have an identical number of participants on high

When comparing all participants, but considering

and low levels. As a result, we ended up with 17

the experimental groups, the above result was

participants on the high level (34 or more in

maintained. A one-way repeated measures ANOVA

scoring), 81 participants on the moderate level

was conducted to compare this belief in both

(between 35 and 25 in scoring), and 17 participants

groups (imagination and hypnosis). There was a

on the level low (24 or less in scoring). The last level

statistically significant increase in the belief of

represented the participants who believed that

hypnosis as an altered state of consciousness from

hypnosis was not an altered state of consciousness.

Before to After in both groups. For the imagination

Eventually, the levels of beliefs were those

group: Before (M= 30. 58, SD= 3.79) to After (M=

obtained in the moment before the experiment.

31.78, SD= 4.15), F (59)= 6.12, p< .01, with a moderate effect size (0.09); and for the hypnosis group: Before (M= 29.83, SD= 3.38) to After (M= 32. 14, SD= 5.24), F (54)=-11.83, p= .001, with a large effect size (0.2).

177

A one-way analysis of variance between-groups was conducted to evaluate the impact of the level of belief of hypnosis as an altered state in this same belief after the experiment. As already mentioned, the level of belief had three levels: Level 1 (who

In conclusion, the belief of hypnosis as an altered

believed more), Level 2 (who did not have a

state of hypnosis increased after participants had

definitive opinion), and Level 3 (who did not believe). Results revealed in level 2 a significant

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increase from Before (M= 30. 48, SD= 1.64) to After

moderate belief levels of hypnosis as an altered

(M= 32.04, SD= 4.3), F (80)= 11.18, p< .001, with a

state of consciousness.

moderate effect size (0.12). In Level 3 there was a statistically significant increase from Before (M= 24. 29, SD= 2.33) to After (M= 29.23, SD= 4.84), F (16)= 21.77, p< .005, with a very large effect size (0.58). In conclusion, there were increases from

An interesting outcome was related to the number of participants classified in each level of belief. From before to after the experiment, the number of participants in level 1 increased from 17 to 38 (Table 1).

before to after the experiment in the low and

In order to compare possible influences from

A two-way analysis of variance between-groups

belonging to one group or another (i.e.

was conducted to analyze the impact of being in

imagination versus hypnosis) in this belief, a

one or another group. Therefore, there were two

two-way analysis of variance between-groups

independent

variables:

(1)

178

group

(Imagination/Hypnosis) and (2) level of belief of

was conducted.

hypnosis as an altered state. The interaction effect

Accordingly, participants were divided in two

between Group and Level of Belief was not

groups regarding this belief: (1) low and (2)

statistical significant. There was a significant main

high belief about hypnosis as an altered state.

effect for level of belief, F (2, 30)= 13.49, p< .001,

We decided to use the two extreme levels (low

with a large effect size (0.31). The contribution of

and high), ignoring the intermediate level, as in

Group was not statistically significant.

theory these two levels are best conceptualized as

In conclusion, the level of belief before the

a test of our experimental hypothesis due to the

experiment had a significant influence on the belief

greater contrast.

of hypnosis as an altered state of consciousness for

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experimental

groups

despite

the

experimental condition.

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between group and level of the belief of hypnosis as an altered state; i.e. Wilks Lambda= 0.69, F(3,30)= 4.37, p< 0.01, with a very large effect size (0.3) for both groups (Imagination and Hypnosis

Combining

the

level

belief

with

the

experimental conditions

altered state) showing an increase after being

The level of belief before seems to determine the level of belief after the experiment. As we reported previously, changes were found in this belief from before to after. This is why we decided to combine the level of belief with being a participant in the experiment. From this combination four groups emerged, i.e. (1) low belief/imagination group; (2) low

belief/hypnosis

belief/imagination

with low levels on the belief of hypnosis as an

group;

(3)

and

(4)

high high

belief/hypnosis group. These four groups were measured twice in the belief of hypnosis as an altered state: before and after the experimental conditions.

exposed to the experimental condition. The increase in altered state was significant, with Wilks Lambda= 0.72, F(1,30)= 11.27, p< 0.002, with a very large effect size (0.27). The main effect when comparing the groups was also significant, F (3,30)= 23.85, p< 0.005, with a very large effect size (0.7) in this belief for both groups (i.e. individuals in a low level of belief of hypnosis as an altered state). So, as you can see in Graph 1, this belief increased after participants

have

been

exposed

the

experimental conditions, but the level of belief before experience influenced that belief after experience.

179

A mixed between by within analysis of variance was conducted to assess the impact of being in the Imagination or the hypnosis groups with previous high or low levels on the belief of hypnosis as an altered state. There was a significant interaction

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180 part of a particular experimental group did not

Consequently, a Wilcoxon Sign Test15 was

change the belief.

conducted to evaluate the impact of the experiment

each

level

belief.

For

What appears to change this particular effect was

imagination/ low belief we found a statistically

the level of belief of hypnosis as an altered state.

significant increase in that belief from Before (M= 24.44, SD= 2.12) to After (M= 27.88, SD= 4.59), z= Altered state of consciousness measured by the

1.9 p< .05, with a moderate effect size (r= 0.11).16

PCI

For the hypnosis/low belief group there was a statistically significant increase in that belief from

Hence, it was also our aim to explore the potential

Before (M= 26.5, SD= 4.14) to After (M= 31.625,

relations between the level of beliefs about

SD= 4.13), z= -2.03, p< 0.05, with a large effect size

hypnosis, the experimental groups (imagination

(r= 0.36). Furthermore, findings revealed that being

versus hypnosis), the PCI altered state of

Due to the number of participants in each group are very small (between 5 and 12 participants in each group).

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The effect sizes for the Wilcoxon Sign Test have been calculated according to Pallant (2007, based in Cohen, 1988).

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dimension,

and

finally,

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the

experimental conditions (hypnosis, imagination).

hypnoidal state as a composite, measure of trance,

Four groups resulted from this combination: (1)

score from the Phenomenology of Consciousness

high

Inventory (Pekala et al., 2009). Actually, if beliefs

belief/hypnosis group; (3) low belief/imagination

are associated with changes concerning the

group; and (4) low belief/hypnosis group.

subjective experience of hypnosis, as it has been argued by some authors,

then it would be

expected to be associated with changes in the phenomenology of consciousness (various selfreported subjective experiences).

belief/imagination

group;

(2)

high

Results showed that differences between groups did not reach statistical significance. Thus, neither the level of beliefs, nor the experimental group, or the combination of both, had an influence in the PCI altered state of consciousness dimension.

Relations between beliefs and altered state of

Relations between beliefs and hypnoidal state

consciousness Hypnoidal state is a dimension conceptualized by A two-way between-groups analysis of variance was conducted to analyze the impact of the level of belief of hypnosis as an altered state of consciousness and the experimental condition (imagination and hypnosis) in reference to the PCI altered

state

consciousness

Pekala et al. (2010a) as an overall measure of trance depth, i.e. hypnosis a la Weitzenhoffer (2002). Hence, the influence of the experimental context (“imagination” versus “hypnosis”) in the 181

hypnoidal state was tested.

dimension.

Participants were divided in two extreme groups as we have described before (i.e. level 3 - high level of belief of hypnosis as an altered state of consciousness, and level 1 - low level of belief of hypnosis as an altered state of consciousness). The interaction effect between Level of belief and Group was not statistically significant.

A two-way between-groups analysis of variance was conducted to explore the impact of the level of belief of hypnosis as an altered state of consciousness and the Group (imagination and hypnosis) in reference to the hypnoidal state score. Participants were divided into two extreme groups (i. e. high and low) and different belief levels: Level 3 (high level of belief of hypnosis as an altered state

Next we conducted a one-way analysis of variance between-groups to explore the combination of the level of belief with being subject to the

“The capacity of people’s beliefs and expectations to bring about changes in experience may be the ‘essence’ of hypnosis” (Kirsch, 1991; page 461). As we said before, also

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of consciousness) and Level 1 (low level of belief of hypnosis as an altered state of consciousness). The interaction effect between the variables level of

Wagstaff (2010) predicted such effects at the phenomenological level.

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belief and group was not significant. Also the level

case, the hypnoidal state and altered state of

of belief did not have a significant effect on altered

consciousness), as can be expected from Gandhi

state of consciousness dimension of the PCI.

and Oakley research (as also predicted by Wagstaff,

order

analyze

interaction

between

experimental groups and levels of the belief in hypnosis as an altered state of consciousness, a one-way between-groups analysis of variance was conducted. Therefore, the combination of the level of belief with being subject to an experimental

2010)? And additionally, (2) is it true that beliefs and attitudes simply change, in the direction predicted by its proponents, with a hypnotic experience? In general, our results indicated a very modest role played by beliefs and attitudes in all the variables of this study.

condition (hypnosis, imagination) was explored.

As a matter of fact, considering the results

From this combination four groups emerged: (1)

obtained, participants who received information

high

(about hypnosis) from the University context,

belief/hypnosis group; (3) low belief/imagination

believed more than others (e.g. compared with

group; (4) low belief/hypnosis group. We found no

those who were informed by TV) that hypnotized

statistical differences between groups. Further,

people have personal control and that hypnosis is

neither the level of beliefs, nor the experimental

not a marginal domain of study. However, when

group, or the combination of the two had influence

considering the dimension belief of hypnosis as an

on hypnoidal state.

altered state of consciousness, which is such an

belief/imagination

group;

(2)

182

important issue for the authors who defend the beliefs and attitudes` evaluation by its clinical Discussion

importance,18 we found no differences.

Main results

Rather interestingly, participants did not change

A) Beliefs and attitudes about hypnosis

their beliefs and attitudes, in the “right” direction,

At the beginning of this paper we had two general

as measured by the eight factors of VBAHS after

endeavors: (1) can the results of Gandhi and Oakley

being subjected to an experimental condition, no

(2005) be confirmed at the phenomenological level

matter what condition they were in.

using another methodology? Do beliefs/attitudes,

contrary, they increased the belief of hypnosis as

in a broad sense, affect the phenomenology (in this

an altered state of conscience, being that the

For example, Capafons et al. (2005) mentioned that: “The creation of positive attitudes and the eradication of myths about hypnosis are essential steps in establishing the

preconditions for effective intervention with hypnosis” (p. 68).

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On the

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and

B) Relations between beliefs and attitudes about

imagination groups had a great (large effect size)

hypnosis and altered state of consciousness and

and a moderate increase (moderate effect size),

hypnoidal state (PCI)

participants

from

both

the

hypnotic

respectively, in this belief. This trend is confirmed when we compare the three levels of the belief of hypnosis as an altered state of consciousness. Actually, participants of levels 2 and 1 (moderate

We found no changes in the PCI phenomenological variables of altered state of consciousness and hypnoidal state resulting from beliefs and attitudes about hypnosis.

and low believers on hypnosis as an altered state of consciousness) increased this belief moderately (moderate effect size in group imagination) and

Comparisons with other results

highly (large effect size in group hypnosis) from

First of all, it seems that having a particular belief

before to after the experiment.

about hypnosis (such as the belief that hypnosis is

Consequently, when comparing only the two

an altered state of consciousness), is not

extreme groups (1 and 3) large effect sizes were

necessarily associated with the phenomenological

observed, and the contribution of being in any of

experience related to this belief. As a matter of

the experimental groups was not significant. When

fact, these results are opposite to what could be

we undertook a more detailed analysis, considering

expected based on those results obtained by

participants classified by the level of belief prior to

Gandhi and Oakley (2005) and also predicted by

placement in the experimental groups, we found

Wagstaff (2010). The phenomenological aspects of

that having undergone an imaginative/hypnotic

participants'

experience, in and of itself, increases the belief.

evaluated and no differences between the two

This impact was moderated by prior level of belief:

groups emerged. This suggests that more

participants with low belief in hypnosis as an

important than the name of the procedure is the

altered state of consciousness, in any of the

procedure itself: the same hypnotic procedure,

experimental conditions, increased this same belief

with different names (i.e. labeled as different

(the sharpest increase it was in the hypnosis

conditions)

group). It is relevant to mention that the number of

phenomenological experiences. As we mentioned

participants who that believe hypnosis is an altered

on the introduction section, the subjective

state of consciousness increased from 17 to 39

measures used by Gandhi and Oakley are

(from before to after experiment).

susceptible to produce results that could be an

subjective

led

experiences

significant

183

were

different

artifact created by the information given to participants. Really, these subjective measures are from the same level of the beliefs and attitudes: i.e.

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they are conscious representations, “hot states” in

So, we may say that contrary to what could be

the sense of Rosenthal (2005). Hence, if someone

expected by the socio-cognitive hypothesis, not

has the information that he or she is in a hypnotic

only have the participants not changed their beliefs

condition and believes that hypnosis involves

or attitudes in the "right" direction, but rather they

involuntariness, he/she will interpret in this way

have increased the belief that hypnosis is an

what he/she feels: they are cognitive events that

altered state of consciousness. Therefore, our

happen

findings indicate that the belief of hypnosis as an

the

same

(cognitive)

level

consciousness.

altered state of consciousness increased after the

According to Lynn and Kirsch (2006) and Capafons (2004), introducing hypnosis as an altered state of consciousness or trance may result in patients being reluctant to use this technique because they are afraid of it. Also, it can generate fears and inhibit the responses of those who were not afraid of hypnosis initially and who would otherwise be willing to collaborate. Additionally, Lynn et al. (2004) found that presenting hypnosis in trance terms can raise the criterion used by participant to feel hypnotized, decrementing such experience. The idea is that believing that hypnosis is a trance or an altered state of consciousness would have

participants were subjected to the experimental conditions:

either

hypnosis

(labelled

“hypnosis”), or imagination, (“hypnosis” not labelled as such).

Additionally, the number of

participants who believed also increased after this experience. On the other hand, other beliefs and attitudes, such as the fear to be hypnotized, were not changed. Therefore, from these results it

184

seems that these are independent beliefs (e.g., the fear to be hypnotized and the belief that hypnosis is an altered state). Thus, believing that hypnosis is an altered state does not lead essentially to fear or to a hypnotic response inhibition. On the contrary, participants not only increased the belief of

harmful effects.

hypnosis as an altered state, but also reported the Our results show that those who believed from low to moderately that hypnosis is an altered state of

same phenomenological characteristics during hypnosis as measured by the PCI.

consciousness, before being subjected to either experimental condition, increased this belief. This implies that having information coming from the hypnotic experience (being so named or not) and not having “corrective” information about any myths (i.e. preparatory information to generate positive attitudes and beliefs at the start of the induction) does not seem to cause harmful effects.

It seems to us that informing participants that there is nothing like trance or a hypnotic state may represent a methodological bias that leads participants to interpret their phenomenology in the

direction desired by

researchers.

This

“correction” of myths about hypnosis leads participants to conform, explicitly, to these “corrections”, like someone does when in a

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workshop receiving credible information, but

the variable belief in hypnosis as an altered state of

leaving

consciousness has been operated by us, we

unchanged

his

her

experiential/phenomenological level of hypnosis.

believe, so conceptually correct, this may be the target of criticism. Also to make a more direct

This is exactly what we observe in the clinical

comparison to the Gandhi and Oakley (2005)

context: we explain something about hypnosis (for

research, the use of the same instrument of

example, that there is no such "thing" as trance).

hypnotic induction (Waterloo Scale-Form C), as was

The patient declares that he or she understands,

used in the Gandhi and Oakley research, would be

when later we proceed with hypnosis, he or she may

declare

changes

consciousness

recommended.

alterations in their subjective experience during

We believe that these results are congruent with

hypnosis. Thus, the person feels “something”

some aspects of that of Gandhi and Oakley:

that we can call changes in their state of

actually, beliefs and attitudes seem to have some

consciousness, or from the client's perspective,

(modest) influence in the evaluations that

simply "hypnosis". Perhaps for this reason, a recent

participants had reported about beliefs and

survey (Christensen, 2005) found that hypnosis was

attitudes, not in the subjective experience of

conceptualized by a number of members and

hypnosis itself. These results are consistent with

fellows of the Society for Clinical and Experimental

data of social psychology (see Wilson et al., 2000).

Hypnosis as primarily an “identifiable state” (4

Indeed, as we said in the introduction, the

times more frequently than the socio-cognitive

cognitive-behavioral/sociocognitive

version).

about hypnosis, which assumes that beliefs and

185

perspective

attitudes about hypnosis can be easily changed through verbal persuasion, lectures, and so the Limitations and speculations

subjective/phenomenological

experience,19

First of all, in some of the comparisons between

leads to some theoretical and empirical problems.

groups we had few participants, as happened when

The attitude-behaviour relationship is likely to

comparing levels of beliefs and experimental

depend on the type of attitude involved (an implicit

conditions (eg. low believers in the hypnotic

or an explicit attitude) and the type of behaviour

condition, n = 5). Also male participants were fewer

involved (implicit vs. explicit behaviour) (Wilson et

compared to female (n = 14, n = 101). Even though

al., 2000). In order to change attitudes and beliefs

And, of course, the experience of hypnosis by itself, being that in this case, it is proposed that the change occurred in the “right” direction, leaving to believe that hypnosis is an altered state (Capafons et al., 2006).

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So the idea is that beliefs and attitudes became mental/phenomenological.

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we need something more than explanations or the

dissonance is a motivational aversive state, which

reading of some texts: people's attitudes are often

motives the person to reduce it, and in general,

established habits that tend to be resistant to

predicts if the person is motivated to expose

change (Perloff, 2008).

herself/himself to consonant information or avoid

Participants in both groups increased the belief of hypnosis as an altered state of consciousness after

the dissonant information aiming to have a stable decision or existing attitude, and thus, maintain the

either experimental condition.21 We believe that

consonance or avoid the cognitive dissonance.

this may have occurred for a main reason: after

When participants are exposed to a condition

experiencing some subjective changes participants

labeled as “hypnosis” they are forced to change

concluded that hypnotized people experience

their belief on the basis of their experience. Indeed,

changes in consciousness. We believe that the

both groups (imagination and hypnosis) reported a

reason for the greatest change in the hypnosis

similar altered state of consciousness, and

group is obvious, i.e. the extent to which they were

hypnoidal state score. Being in a condition labeled

told they were in a group of hypnosis confirmed to

as hypnotic and experiencing something that can

them

be appreciated as hypnotic allowed participants to

consciousness. Therefore, only participants from

increase their belief of hypnosis as an altered state

the hypnosis group could think that what they

of consciousness. Both groups increased their

experienced was related to hypnosis, though at the

belief, but the hypnosis group more (large effect

phenomenological level the groups were not

size) then the imagination group (moderate effect

significantly different.

size)

These results can be predicted from the social

We believe that the preferential use of scales and

psychology of persuasion and attitude change, in

procedures based on behavioral observations,

general (Bohner, Moskowitz, & Chaiken, 1995), or

albeit involving some subjective evaluation, as with

specifically, by the contrast between the belief

the Waterloo Scale (in which people are asked to

someone holds and her/his experience, as it is

evaluate their behaviour from a more subjective

postulated by cognitive dissonance theory (Cooper,

perspective), does not do justice with the

1999; Festinger, 1957). Therefore and according to

complexity of the mental events occurring during

Festinger`s theory there is an active search of

hypnotic procedures as there are different

relevant information regarding the attitude. The

intensities

that

hypnosis

involves

changes

As we argue at several points in this paper we believe that providing information intending to correct myths or misconceptions about hypnosis, as the authors mentioned above done, affects the evaluation made at an explicit,

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and

patterns

186

of mental events

conscious or hot level (Rosenthal, 2005) leading to compliance with researchers by participants, artificially increasing the importance of beliefs and attitudes.

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occurring. As Damásio (2010) explained: the self is

hypnosis is the premise that people know what

an indispensable viewer of the events occurring in

they consciously think about hypnosis, and that this

the planning and content of consciousness. Taking

way of thinking will directly cause what they will

into account that the person is the one that has this

feel and do.

kind of access on what is happening within her/his mind, suggests that we cannot ignore the phenomenology of being hypnotized. This is why we used the PCI-HAP (Pekala, 1991; Pekala et al., 2010a; Pekala et al., 2010b) as it seems a more comprehensive measure for assessing such subjective experiences.

According to this perspective, people experience themselves as being the agent of their behaviors and goals pursuits, as these experiences of selfagency are the result of consciously forming, pursuing, and attaining one’s goals (Dijksterhuis and Aarts, 2010).

However, what people

consciously do not know, but unconsciously think

The methodologies usually used to correct the "so-

(Dijksterhuis & Nordgren, 2006), can be very

called" myths or misconceptions about hypnosis

promising for a better understanding of hypnosis,

may contribute to inflate the importance of certain

as well as for clinical use. Actually, as happens in all

beliefs: in exposing what are the "correct ideas"

areas of human behavior, hypnosis can involve

about hypnosis, people are persuaded to verbally

several levels of operation, requiring integration of

agree. So, after being told that hypnosis is not an

various levels or perspectives.

altered state, or that there is no loss of self-control,

recently argued about the need to integrate

a person can explicitly (in a scale like the VBAHS-C)

phenomenological measures with other types of

declare that. Does this mean that this change will

measures: "The aforementioned approach allows

have a significant phenomenological impact?

for the phenomenological level of mind to be

Based on the aforementioned data, we do not

quantified and then compared with other levels of

believe so.

traditional

We hope that more recent theories about hypnosis

Pekala (2011)

cognitive-behavioral

187

and

neurophysiological analyses" (p. 24).

(Dienes & Perner, 2007; Barnier & Mitchell, 2005; 2008), as well research outside the hypnotic

Conclusions

domain, i.e. research showing a split or a general independence between conscious and unconscious functioning (namely about goals, intentions and motivation - Dijksterhuis & Aarts, 2010) may be a great contribution to a better understanding of hypnosis. For example, on the basis of asking people about their beliefs and attitudes concerning

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This paper intended to contribute to the literature`s debate about the role of beliefs and attitudes in the hypnotic experience. We can draw several conclusions from it. Firstly, beliefs and attitudes about hypnosis did not have a significant impact on the phenomenological level after a

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hypnotic induction, whether this induction was

Interesting,

labeled hypnosis or imagination. From our point of

significantly different across both experimental

view, this is the most relevant conclusion, showing

groups. Additionally the evaluation of beliefs and

that something in the induction results in changes

attitudes about hypnosis, previous to therapy with

felt at the phenomenological level. Curiously,

hypnosis, did not have a clinically meaningful

Oakley (2008) writes that ". . . it may be that the

interest because what the participants experienced

hypnosis induction, with or without the label

through a hypnotic induction did not increase

“hypnosis”, subtly alters the mechanisms by which

beliefs or attitudes that could eventually have had

suggested effects are brought about.”22 Our study

a harmful effect. In conclusion, what happens

suggests that this may indeed be the case.

phenomenologically during hypnosis (or a very

Secondly, beliefs and attitudes about hypnosis, such as beliefs and attitudes in general, seem to not change much, as in real life and the little they

this

phenomenology

was

not

similar protocol labeled as imagination) does not appear to be significantly affected by how that protocol is labeled.

changed was in the opposite direction to what the socio-cognitive theorist predicted.

Rather they

Aknowledgments

changed accordingly the participants' experiences, as data from psychological research about changes of beliefs/attitudes predicts (Stroebe & Jonas,

The authors wish to thank Ron Pekala, Ph.D., for his helpful comments on earlier versions of this manuscript. 188

1990). Fazio and Zanna (1981) pointed that attitudes obtained through direct experience are clearer and with a larger temporal stability and having a bigger influence on the person (attitudes are more defined and available, and present a stronger relationship with behaviour). So, in our research, ones belief in hypnosis as an altered state of consciousness increased from before to after a hypnotic/imaginative induction procedure. It is unknown if this change was related

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Clinical Cases If Old Fashion Psychotherapy did not work, don try harder. Just join a huge sprinkle of Neuroscience: Examples from two clinical cases Luis Maia (1) & Humberto Rodrigues (2) (1) Auxiliar Professor - Beira Interior University; Clinical Neuropsychologist, PhD (USAL - Spain); Neuroscientist, MsC (Medicine School of Lisbon Portugal); Medico Legal Perit (Medicine Institute Abel Salazar - Oporto, Portugal); Graduation in Clinical Neuropsychology (USAL - Spain); Graduation in Investigative Proficiency on Psychobiology (USAL - Spain); Clinical Psychologist (Minho University - Portugal); Professional Card from Psychologist Portuguese norm, number 102. All correspondence about this article should be sent to luismaia.gabinete@gmail.com. (2) Ph.D. Student – Salamanca University – Castilla y Leon Neuroscience Institute – Medicine College of Salamanca University. MsC and Psychology Degree in Aveiro University.

_________________________________________________________________________________ Abstract In the last 10 years, but particularly in the last 5 ones, there was a huge amount of opinions and evidences that, what we call Old Fashion Psychotherapy (OFP), needs to accept that without neuroscientific knowledge, psychotherapists are damned to suffering and have an incomplete understanding of psychotherapeutic processes. Supporting this article in two clinical cases, we present the major justifications to join OFP with neuroscientific knowledge. We conclude that the faster psychotherapists embrace this personal challenge, the earlier patients will start to get a better and more integrated help! Key words: Neuroscience & Psychotherapy; Old Fashion Psychotherapy; Clinical Cases.

195 Resumo Nos últimos 10 anos, mas particularmente nos últimos 5 anos, surgiu uma enorme quantidade de opiniões e evidências de que, o que consideramos de psicoterapia clássica, precisa aceitar que sem conhecimentos neurocientíficos, os psicoterapeutas estão condenados ao sofrimento e tem uma compreensão incompleta dos processos psicoterapêuticos. Em dois casos clínicos em que apoiamos este artigo, apresentamos as principais justificações para associar os conhecimentos neurocientíficos à psicoterapia clássica. Podemos concluir que quanto mais rápido os psicoterapeutas abraçarem este desafio pessoal, mais rapidamente os pacientes vão começar a obter uma melhor e mais integrada ajuda! Palavras-chave: Neurociência & Psicoterapia; Psicoterapia Clássica; Casos clínicos.

Resumen En los últimos 10 años, pero particularmente en los últimos 5 años, surgió una enorme cantidad de opiniones y evidencias de que lo que consideramos ser la psicoterapia clásica, necesita aceptar que sin conocimientos neurocientíficos, los psicoterapeutas están condenados al sufrimiento y tienen una comprensión incompleta del proceso de psicoterapia. En dos casos clínicos en que apoyamos este artículo, presentamos las principales justificaciones para asociar los conocimientos neurocientíficos a la psicoterapia clásica. Podemos concluir que más rápido los psicoterapeutas abracen a este reto personal, más rápidamente los pacientes comenzarán a recibir una ayuda mejor y más integrada! Palabras clave: Neurociencia & Psicoterapia; Psicoterapia Clásica; Casos Clínicos.

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not prepare them to that; but at the same time, the

Asserting the point

ideas about what is therapy are very crystallized and In the last 10 years, but particularly in the last 5 ones,

it is very hard to change minds.

there was a huge amount of opinions and evidences that, what we call Old Fashion Psychotherapy (OFP), needs to accept that without neuroscientific knowledge,

psychotherapists

are

damned

suffering and have an incomplete understanding of psychotherapeutic processes (see Ellis, 2012; Linford

If our patients have difficulties in changing ideas – and that is why they need our help – why we should be seen has Illuminated People, able to do what we call the Holy Trinity of Psychotherapy: Insight – Acceptation – Change!?

& Arden, 2009; Peres & Nasello, 2007). In many

Let us support the theme with some examples and

countries, psychotherapy is thought to represent a

opinions.

process in which patient is helped to discover the inner and outer relationship between terms like mind, emotion, cognition, behavior, and social relationship (see Beck, 1975; Ellis, 1994; Freud, 1925; and others). The question is: are psychotherapists trained to understand patients (and subsequently psychotherapy) Medica”?:

“The

an integrative mnemonic

“New

‘BASE’—

Pax brain,

attunement, systems of care and evidence-based treatment — is a useful framework to assist

Authors like Broca (1861), Jackson (1931), Penfield, Rasmussen (1952) and Wernicke (in Hébert, Racette, Gagnon, & Peretz) are some of the most relevant striking authors demonstrating that there is no Human Experience, if that experience is not supported by a Nervous System (Central and Peripheral), in a word: a Brain! And what is wonderful is that this Human Experience has the ability to change our brains, in all of us (and not only 196

in our patients!).

practitioners in the transition from the old world of the ‘pax medica’ to a new model that incorporates current neuroscience, developmental psychology, psychodynamic theory, cognitive psychology and psychotherapy research” (Linford & Arden, 2009, p.

understand Humanity in the direction of this relationship From Synapsis to Psychotherapy and since Psychotherapy to Synaptic plasticity, things could be so much easier!

16). In our humble opinion, most of therapists are not prepared to the pitfalls related with the entire process of helping a people (his mind, his emotions, his cognitions, his body responses, his physiology, his brain activity, the medication that is being prescribed,

If therapists were willing to accept that we have to

side

effects

medication,

neuroimaging, etc.). The curricula in Universities do

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Donald Hebb (1949) (a psychobiologic researcher) easily understood that neuron plays a fundamental role in our lives. After the publication of his work, The Organization of Behavior (1949), colleagues around the world stated that a new postulate was generated: Hebb's rule and / or cell assembly theory, where he states:

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"Let us assume that the persistence or repetition of a

of her General Practioner (Family Doctor). The

reverberatory activity (or "trace") tends to induce

patient was being treated by several colleagues (she

lasting cellular changes that add to its stability.…

saw four different therapists in the previous three

When an axon of cell A is near enough to excite a

years, before she come to us). The diagnoses was a

cell B and repeatedly or persistently takes part in

severe Obsessive Compulsive Disorder (OCD),

firing it, some growth process or metabolic change takes place in one or both cells such that A's efficiency, as one of the cells firing B, is increased.” (p. 32).

turning impossible to her to have a normal life (she had a lot of difficulties in finishing College and her days were passed in the traditional ritualization processes, and almost nothing else!). Although she was well medicated for the OCD and had always

Taken to the bottom, this led to a worldwide recognition of his contribution to the understanding of human mind, parting from the study of synapsis!

support by several therapists, his face, verbal messages and non-verbal behavior presented to us a highly debilitated young woman, paralyzed by her

Grosjean (2005) make note of that in the article From

own rituals, stress, mood, and poor familiar and

Synapse to Psychotherapy - The Fascinating

social relationships!

Evolution of Neuroscience, where it is stressed the relevance

integrate

knowledge

about

psychotherapy and the “new potential insights into understanding the biology of the psychotherapeutic processes …. The mechanisms involved in learning processes, such as memory and priming, attachment, and long term consequences of early life trauma and how

brain

structures

can

affected

environmental changes” (p. 181). The author call attention also to the following proposition: “verbal and non-verbal aspects of the psychotherapeutic

After some minutes talking with the patient, we understood that OCD where not the only problem. Their rituals where too much generalized and tended to follow his states of anxiety and mood. Having the proposition cited above we tried to have clear in our mind that “verbal and non-verbal aspects of the psychotherapeutic

processes

mediate

their

therapeutic effects through biological changes as they work on primitive emotional reflexes and stimulate metallization processes.” (Grosjean, 2005, p. 181).

processes mediate their therapeutic effects through biological changes as they work on primitive emotional reflexes and stimulate metallization processes.” (p. 181).

We invited the patient to talk about other aspects of his life, her relations with others, her personality, and so on. Later in the same first contact with the patient, we restarted to try to understand this OCD diagnose. Finally, we prompt this simple question

Clinical Example 1

“We see that your throat is a bit bloated. You know if

We remember this young female patient (21 years of

you suffer from any physical illness? May we examine

age), which comes to our clinical office with a letter

your throat by palpation just outside in the area of

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the throat?” She said that she did not know about

b) To us, it was clear that OCD diagnose, in this

any biomedical condition. We proceeded the

patient (with all information that we could collect, of

examination of her throat (just by palpation of the

course), caused us a sense of oddity;

outside anterior area). She said that, in that moment, with the touch of a particular area, she felt a little discomfort (“not really a pain”, she said). We felt

c) She said that the OCD goes with the flow of anxiety and humor, and present several variations inside a single day;

some lumps in the area adjacent to Thyroid Gland. Once the session had already taken a long time, we explained that in the first contact we work with patients in order to have a good functional and

d) We saw that her throat was a bit bloated and we felt some lumps in the area adjacent to Thyroid Gland;

behavioral diagnose. We have done that yet, but we

e) Back in our past, we studied a lot, so we learned

strongly suggest that she should realize a set of blood

that hormonal changes are one of the first causes of

tests. We wrote back a letter to the doctor that send

alternated states of anxiety and mood;

the patient to us and shared with him the opinion of

f) We strongly believe that none patient with severe

making a differential diagnose, in biomedical terms,

OCD should be attended without make some

not only about her mental health.

medical tests;

About three weeks later the patient comes to a

g) She was well medicated for OCD and yet she did

second consultation and had already the results of

not felt any effect of them (Paroxetine, Alprazolam

blood tests. Her doctor diagnosed her with

and Diazepam);

Hashimoto's thyroiditis (by the first time in her life – please dear reader, do not forget that this patient was being attended by several psychologists in her previous three years)! As a matter of fact, his doctor immediately

medicated

her

with

Thyrax

h) She failed repeatedly to make that the psychotherapeutic strategies learned with the last four psychologists that she saw make her to feel better.

(levothyroxine), to treat the major consequence of

In our mind, a biomedical differential diagnosis

this disease: hypothyroidism.

should be made! (Why do more of the same? Why

There are a lot of points to be stressed in this case, if we try to look for a real integration of Psychotherapy and Neuroscience: a) Patient came to us with a Severe OCD diagnose, supported by, at least, four colleagues;

do not put the hypothesis that in these cases, alterations in Thyroid Gland are very common? Could we feel threatened by asking an opinion of a specialist in hormonal disorders? Why?). Her condition, Hashimoto's thyroiditis, was the first disease to be recognized as an autoimmune disease (Nakazawa, 2008) and most of the times cause hypothyroidism (with stretches of hyperthyroidism –

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AACE, 2008). The relation about Hashimoto's

personality structure see Lougee, Perlmutter,

thyroiditis and OCD has been related and reported

Nicolson, Garvey, Swedo, 2000; Leonard & Swedo,

by several clinicians and researchers (see Placidi et

2001; Sansone & Sansone, 2004; Freese, 2011).

al., 1998).

By this integrative approach (Neuroscience and

We do not know if therapists that could be reading

Classical Psychotherapy), hope and faith did rise up

this article agree that a psychologist have the

again in this patient´s life!

obligation to have vast neuroscientific knowledge. We do! Because of this approach, patient was treated with Thyrax (to thyroid), mood stabilizers,

What we want to state with the clinical example and previous considerations is that we have, as

SSRI anti depressive and benzodiazepines.

psychotherapists, In no more than two months patient started to feel a great improvement in her life. Today, she runs her own business, with a lot of collaborators and responsibility, understood that the shift pattern in her anxiety and mood state were caused by hormonal changes, and is able to run her life almost normally. We both agree that the Hashimoto's thyroiditis was supporting (erroneously, in our modest opinion) a diagnoses of OCD. Today,

the

inevitable

incorporation of Neuropsychology and, in a large view, the introduction of Neuroscience in the practice of Psychotherapy. Stauffer (2008), in his article Neuroscience Update - Can neuroscience help to make psychotherapy more acceptable?, strength the idea that not only Neuroscience is necessary as it could contribute to the practice of Psychotherapy as well as the role of Therapists themselves. Stauffer (2008, p. 225) states that:

patient’s life is almost normal and we also agreed to change the diagnose from Severe OCD (Axis I – DSMIV-tr, American Psychiatrist Association, 2000) to

“As far as I can see, there are two specific aims that

Generalized Anxiety Disorder, due to a clinical

we might hope for. Either neuroscience might show

condition,

that

contributed

develop

characteristics of OCD Personality Disorder (Axis II – DSM-IV-tr, American Psychiatrist Association, 2000).

that psychotherapy ‘works’ – that is, show measurable, structural, visible, graphic changes on people’s nervous systems following therapy. Or it might elucidate mechanisms by which psychotherapy

With this change, patient was able to look to herself

works – this would strengthen its plausibility and

in a very constructive and positive way, once she

thereby the case for its efficacy. Quite probably, the

understood that personality could be shaped and

hope is that neuroscience will show both that

also she could be happy, once she accept that she

psychotherapy works and how it works”.

has an autoimmune disease that increases a lot characteristics

his

personality

(like

OCD

personality), and by this, it is treatable (about the

We also hope so! We desire to know “If it works” and “how it works”. We already knows that at some

impact of autoimmune disorders in neurotic

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extent Psychotherapy do works (it could not be the

should be able to answer first to any of this sub-

only answer, but is one of the most eligible choice if

questions.

someone needs “Human” help – for the efficacy of psychotherapy see Chambless et al., 1998; Lambert & Ogles, 2004; Baldwin, Wampold & Imel, 2007; Druss, et al., 2007; Cuijpers, van Straten, Andersson & van Oppen, 2008; Anderson, Ogles, Patterson, Lambert & Vermeersch, 2009; Duncan, Miller,

Don’t you know how to relate those terms presented before with a depressive patient? It is real amazing, because some of us know! Don’t you see the relevance of this to introduce in your psychotherapeutic

repertoire?

disappointment, because we see that relevance!

Hubble & Wampold, 2010). But what about “how it works?” It is not the objective of this article to discuss “how therapy

Clinical Example 2

works”. In fact, we strongly believe that that kind of

We believe that, as in every therapeutic processes,

question, several times, too many times we shall say,

we have to start to know most of the circumstances

is only presented to create a shadow in the role of

and determinants that bring people to a given stage

neuroscience as a week effective strategy, regarding

of suffering. Let us exemplify with a very simple and

to psychotherapy.

common example. As Professors of Psychology, Psychotherapy

Methods and Neuropsychology

(amongst other subjects) we see that the majority of How can a psychologist without any training in Neuroscience, and particularly, disciplines like Neuropsychology, Psychophysiology, Psychobiology, Neuropharmacology, Neuroimaging, etc., answer to this simple question: Please, explain to me, what is the relationship of Cognitive Ruminations, Depressive Negative Self Prophecies, Sad Mood, Anxiety, Phonological Looping, Luria’s Functional Cerebral Areas, Cognitive Functions, Pre-frontal Cortex, Adrenal

–

Cortical

Thophic

Axis,

Neuropharmacology and so on. Now, please, think that you have a real depressed patient in front of you and tell us, please, how can you integrate all this

students are trained in Imagery Relaxation (see the most used models in Coleman, 1934; Griffith, 1934; Benson, 1985; Bernstein, 2000; Rossman, 2000). Our question is: do they know what they are really doing when they suggest relaxation to treat anxiety? In our opinion, most of psychotherapists do not know the entire bio – psycho – social relation that the evocation of Imagering Relaxation allows. At the same time, it is only or impression, or students (that will be the actual psychotherapists) learn to use several techniques of relaxation, but not how to differentiate “when”, “in what kind of patient” a particular model should be chosen?

concepts, and use them in practical strategies in psychotherapeutic process? So, those of ones that ask “how therapy works, in terms of neuroscience?”

To sustain our idea, and parting from our neuropsychology experience, we do know that if we have a patient suffering from a severe anxiety

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disorder, if his cognitive skills and literacy are low, if

The authors invite all psychotherapists to think about

the patient comes from a rural and modest

what they classified as “The Seven of Brain-Based

environment and is not used (or even do not believe)

Psychotherapy” (pp. 375 – 381):

psychotherapy,

immediately

choose

Diaphragmatic strategies to facilitate Therapeutic Adherence. It is easier, faster, much more under

Principle 1: Genetics and Environment Interact in the Brain to Shape the Individual

control of patient to do at home, the effects tend to

Principle 2: Experience Transforms the Brain

be immediate, and patient understand that we will

Principle 3: Memory Systems in the Brain Are Interactive

not try, in a first phase of Psychotherapy, to mislead and make him foolish with all that so called Psychologist’s “bull sheet”. In this case we can decide to use pragmatic strategies and we are able to explain why does Diaphragmatic strategies works (alterations in level of PH in Brain and subsequent

Principle 4: Cognitive and Emotional Processes Work in Partnership Principle 5: Bonding and Attachment Provide the Foundation for Change Principle 6: Imagery Activates and Stimulates the Same Brain Systems as Does Real Perception

relaxation – Hughes, 1979).

Principle 7: The Brain Can Process Nonverbal and Unconscious Information

Integration

We believe that it is not necessary develop these

Now that we presented two clinical examples and

points. The titles speak by themselves. The authors,

the importance of Neuroscience in them, we will

having these seven principles in mind, suggests that

quote some of the most relevant studies about the

his

integration of Neuroscience, Neuropsychology and

enormous. Cappas, Andres-Hyman and Davidson

Psychotherapy.

(2005) states that:

implication

for

psychotherapy

could

“Given that a previously perceived stimulus disposes one to future responses, as in priming, a fertile area of

Cappas, Andres-Hyman and Davidson (2005), in his

research may be exploring the impact of a diagnostic

paper “Advances in neuroscience provide guidance

clinical interview using a deficits-based approach.

for

psychological

During diagnostic interviews, patients are asked to

conceptualizations of mental illness and treatment

report symptoms and signs of impairment. Although

that go beyond a reductionist biological etiology”,

informative, eliciting accounts of disability and

sustain that development in neuroscience offer

distress from patients may exacerbate negative

assistance for the improvement of psychological

perceptions of self. Similarly, the finding that

the

development

conceptualizations of psychological illness and treatment that go further than a simple reductionist biological etiology (p. 374).

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unconscious perception has the capacity to bring forth behavior may have implications for the physical environment.

For

example,

researchers

have

recommended modifying the decor of mental health

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centers to render the atmosphere more inviting to

interpersonal neurobiology provide evidence about

underserved populations. Furthermore, outpatient

why Focusing works” (p. 36).

clinics are often overflowing with brochures depicting numerous problems and symptomatology. According to this principle, an environment filled with positive

Morgan (2006) reviews assemblies of the Lurias’s three part brain together with hemispheric functions

information as opposed to one full of such negative

and debates transformations of the brain and the

content may render more positive results during the

mind in terms of intricacy concept. She also makes

therapeutic session. Finally, unconscious perception

references to several memory systems in relation to

suggests the importance of a genuine approach to

attachment theory and discusses social engagement

therapy. Although practitioners customarily attend to

theory and consequences for communication and

the various forms of nonverbal communication of

loving attendance applied to psychotherapy.

others, awareness of one’s own idiosyncrasies may be more elusive, though apparent even to the untrained

Morgan (2006) sustains that brain mirrors our

eye. Therefore, it becomes particularly important

multifaceted human schemes. She gives the example

even through unspoken gestures to communicate

in the avoidant attached kid there looks to exist a

positive regard for the patient”. (p. 381)

suspension in the integrative operative of the two hemispheres that is equivalent to the emotional

Ellis (2012), in her work “The Attuned Brain: Crossings

Focusing-oriented

Therapy

and

Neuroscience”, clarify that the needs of that kind of integration relies on the perception that “current findings in interpersonal neurobiology are providing scientific support for more emphasis on whole-brain approaches in clinical practice that use empathy, emotion, attachment theory and other relational approaches

psychotherapy.

These

‘softer’

approaches have previously been largely ignored as brain researchers favored study of the more cognitive aspects of the brain functioning in isolation” (p. 36).

disconnection in the mother-child relationship (citing Daniel J. Siegel, 1999, p190). When the father or mother becomes available to the child, and the baby fixes his look in the parent, “nerve endings and dendrites reach out to each other in the microscopic landscape of the brain forming neural bonds that match the human bonds” (p. 21). The author finish stating that “there is so much more richness to be explored in linking brain research to psychotherapy processes and understanding our clients’ mental and emotional experiences. There is the exploration of chemicals and neuropeptides and how they influence emotion and behavior. There are exciting ideas

Because of the initial idea of a reductionist

postulated in The Hearts Code on the information

contribution of Neuroscience to Psychotherapy, Ellis

communicated by the heart and the flow of

(2012) “presents an approach overview of current

information from the brain to the heart and the heart

affective neuroscientific research with an emphasis

to the brain” (p. 21), that we have to continue to

on how it supports the use of Focusing-Oriented

explore the need, the obligation we should say, of

Therapy (…) and explain how some aspects of

Neuroscience with Psychotherapy.

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Considering pharmacology and neuroimaging (for

in the treatment of several disorders of personality,

example),

particularly,

elevating

our

mechanisms

Psychopathy, and other conditions. He states that at

antidepressants (just take this as one in a million of

this time we have to accept that Psychotherapy

possible different examples), it is shifting our model

without Neuroscience, Sociology, Social Psychology

of psychotherapeutic action just as intensely once

knowledge (and others) hardly will be sustainable, as

the brain-based model massively expands the

the time will pass and the scientific, empirical and

evidence-basis for psychotherapy. We know now

intuitive knowledge about normal and abnormal

that PET imaging studies with brains of depressed

psychology and psychiatry grows, and invite us, as

patients, show significant post - psychotherapy

psychotherapists to accept this new approach.

understanding

neuroscience of

the

Antisocial

Personality

Disorder,

alterations in areas reaching from the prefrontal cortex to the hippocampus, anterior cingulate and amygdala, and these alterations can be summarized as a down regulation of areas relating to overthinking and an improved capacity for capturing and encoding new experience (Mayberg, 2006).

What becomes clear at this point, is that a psychotherapist have to be prepared to think if it is possible, in nowadays, to understand the relevant psychotherapeutic process without the contribution of Neuroscience. We believe that it is impossible. A

Still in this point Fuchs (2004) sustain that investigation on the field of neuroplasticity (see Hebb, 1949), “the role of explicit and implicit memory systems, early attachment processes, as well as the biological underpinnings of mental disorders has considerably influenced psychotherapeutic concepts, shifting the emphasis to implicit learning in the therapeutic relationship (…) recent neuroimaging studies have also demonstrated that psychotherapy significantly changes functions and structures of the

human being, with a psychological disorder or not is not only made by an untouchable mind. Their problems are real, their pain is subjective but also objective, they perception of life relies on subjective interpretations of objective and real things. By all this, Neuroscience is growing in importance in what matters

help

patients

attending

psychotherapeutic processes (Ivey, D’Andrea & Ivey, 2013; Rossi & Rossi, 2008; Peres & Nasello, 2007; de Raedt, 2006; Colozino, 2002).

brain, in a manner that seems to be different from the effects of pharmacotherapy” (p. 479). The faster psychotherapists embrace this personal challenge, the earlier patients will start to get a Pickersgill (2011), in his work “‘Promising’ therapies:

better and more integrated help!

neuroscience, clinical practice, and the treatment of psychopathy”, presents a profound paper about the optimism and pessimism related with the actual possibility to use neuroscientific knowledge to help

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Clinical Case Narrative cognitive therapy and insecure/ambivalent attachment pattern: a clinical case of epilepsy Cristina Coelho & Luísa Soares University of Madeira – Corresponding Author – Luísa Soares: lsoares@uma.pt (University of Madeira, M-iti - Madeira Interactive Technologies Institute)

_________________________________________________________________________________ Summary We share a clinical case study of an adult with epilepsy, who has developed an insecure/ambivalent attachment pattern. Literature analysis indicate that attachment relationship experienced in childhood tends to expand into adulthood. The practical approach used was based on cognitive narrative therapy. The main goal is the (re)signification of experience and the construction of multiple meanings, promoting understanding of the personal role and impact of the experience for the Self. Cognitive narrative therapy can empower clients into understanding experiences and overcome relational difficulties that were inhibiting new experiences in a positive way. The client gradually began to to construct different narratives around her emotional experience in many aspects of her personal and emotional life, trying to build a progressively more organized narrative meanings. Key words: Attachment; Cognitive Narrative Therapy; Meaning; Experience Resumo Apresenta-se um estudo de caso clínico de um adulto com epilepsia, que desenvolveu um padrão de apego inseguro/ambivalente. A análise da literatura indica que a relação de apego experimentada na infância tende a expandir-se na idade adulta. A abordagem prática usada neste caso foi baseada na terapia cognitiva narrativa, cujo objetivo principal é a (re) significação da experiência e a construção de múltiplos significados, promovendo a compreensão da função pessoal e o impacto da experiência para o Self. A terapia cognitiva narrativa pode capacitar os clientes para a compreensão de experiências e superar dificuldades relacionais que estavam a inibir novas experiências de forma positiva. Verificou-se que o cliente começou gradualmente a ser capaz de construir narrativas diferentes em torno de sua experiência emocional em muitos aspetos de sua vida pessoal e emocional, tentando construir uma narrativa progressivamente mais organizada e cheia de significados. Palavras-chave: Apego; Terapia Cognitiva Narrativa; Significação; Experiência Resumem En este artículo presentamos un estudio de caso clínico de un adulto con epilepsia, que desarrolló un patrón de apego inseguro/ambivalente. El análisis de la literatura indica que la relación de apego experimentada en la infancia tiende a expandirse en la edad adulta. El enfoque práctico utilizado en este caso se basó en la narrativa de la terapia cognitiva, cuyo propósito principal es la (re) significación de la experiencia y la construcción de significados múltiples, promoviendo la comprensión del papel y el impacto de la experiencia personal de Self. La terapia cognitiva narrativa puede facultar a los clientes la comprensión de experiencias y superar dificultades relacionales que inhiben nuevas experiencias de una manera positiva. Se hay verificado que el cliente comenzó gradualmente a ser capaz de construir narrativas diferentes alrededor de su experiencia emocional en muchos aspectos de su vida personal y emocional, tratando de construir una narrativa progresivamente más organizada y llena de significados. Palabras clave: apego, terapia narrativa cognitiva, significación, experiencia.

_________________________________________________________________________________

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Family is the first source of knowledge that the individual has in the world. The way people relate and interact with each other will help the child build an

Iberian Journal of Clinical and Forensic Neuroscience – IJCFN

that affective bonds formed in childhood could extend to romantic relationships and even attitudes towards work.

internal representation about herself and others. It is

Simões (2007) developed a study about the

from the moment of birth that the individual initiates

theoretical evidences on the relationship between

the development of attachment patterns with the

attachment and narratives. It was found that the use

attachment figures. Caregivers or parents are usually

of cognitive narrative therapy can be an effective

those who serve as attachment models for the child.

intervention

When models do not adequately respond to the child

elaboration of personal experiences works not only as

needs, they do not facilitate the development of a

a way of giving meaning to the experience itself but

trust relationship (or a secure attachment system)

also as a way of creating and strengthening social and

and, as a result, the child may develop some pattern

emotional bonds.

of dysfunctional attachment, such as insecure ambivalent, anxious or avoidant coping styles.

strategy,

since

the

sharing

and

In this paper we take a brief tour through the fields of the theoretical attachment framework and its impact

Without a secure attachment, i.e., when the child

in adult relationships. The case study is about a

does not feel loved or capable of being loved, when

woman, in her thirties, who seems to develop an

her needs are not recognized or met by the caregiver,

insecure/ambivalent attachment pattern, showing

when she doesn’t use the attachment figures (father

difficulties in creating and maintaining healthy

/ mother) as a secure base, in order to proceed with

relationships, especially romantic ones. She considers

the exploration of the environment, she could

herself as being neglected in her childhood, and

develop an anxious or ambivalent attachment

nowadays easily feels abandoned, thus this could

pattern. Once felt the lack of response to her needs,

be one of the reasons why she feels insecure in her

the child blocks, or excessively activates, biological

adult relationships. This paper also aims to discuss the

protection responses, making her more exposed to

benefits of the use of cognitive narrative therapy in

risks of diseases or psychological disorders. Stress and

similar cases, when clients’ describe experiences as a

anxiety have been related to attachment patterns

chaotic trait. Psychotherapy intends to help the

developed in childhood resulting, for the adulthood,

patient to reorganize his own narratives in a

in experiencing difficulties in future relationships, as

structured sequence and, in a long term, facilitate the

they may develop an excessive anxiety, severe pursuit

construction of brand new and well-structured

of social support and affection, or excessive fear of

narratives.

rejection. Liotti (1991, cited by Abreu, 2005) reported

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Attachment – impact in adulthood

hyper

Mallinckrodt (2000) states that the perception of low

activation

the

attachment

system

(Canavarro, Dias, & Lima, 2006).

parental support can lead to insecure attachment,

Bowlby (1988) proposed that children develop a set

which may result in some difficulties in social

of expectations about themselves, about others and

interaction, less ability to seek and establish

the

friendships and difficulties in solving interpersonal

representational models or internal working models.

conflicts. Other authors, such as Kanning (2006)

These internal models or representations allow the

suggests that an alienated relationship with parents

child to predict and interpret the behavior of the

does not create conditions to the development of

attachment figure and would be used throughout life

interpersonal

as an interpretative basis of her

skills

young

people

and,

world

around

them,

what

they

called

relational

consequently, these difficulties affect attachment in

experiences (Canavarro, Dias, & Lima, 2006). These

romantic relationships. A study by Assunção (2009)

cognitive representations of the main attachment

revealed that the better the quality of bonds created

figure (parent), or relational schemas, shape the

with both parents and youths, less is the dependency

expectations of the adult in relation to subsequent

in youth romantic relationships.

relationships with peers and also to romantic

The

study

of attachment

theory

had

large

contributions from authors such as Mary Ainsworth (1969) and Bowlby (1988). The original model of Mary Ainsworth and colleagues point out some attachment styles or patterns that individuals begin to form in childhood, and these patterns can be secure or insecure. Within the insecure pattern there is the "avoidant" style and "anxious/ambivalent" style. These patterns seem to emerge in insecure contexts

relationships, guiding his behavioral responses towards a real or imagined separation of his new attachment figures (Pearson, 2006). When the individual spends his early life, in a family that shows low affection, with weak emotional resources, he or she could develop a poor perception of his ability to build and maintain personal relationships, thinking the problem is on them and the lack of ability to receive affection or even in weak "attractiveness".

of social interaction and the child’s attachment

Hazen and Shaver (1994) also argue about a relation

behavior is followed by rejection or inconsistency

between the bonds that adults create in intimate

from the attachment figure (i.e. parents or other

relationships with those established with early

caregivers). According to the attachment theory,

attachment figures. As mentioned early, an insecure

these situations of inconsistency or rejection may

relationship towards caregivers may extend into

result in some strategic child’s responses of hypo or

adulthood, leading to insecure patterns in romantic relationships, which may result in constant search for

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affection and dissatisfaction about the emotional

therefore not processed or not included in the

response from others. Moreover, this uncertainty

narrative. Bretherton (1990) also believes that secure

may result in some adult emotional dependency,

attachment is associated with a style of flowing and

hesitant

emotionally open communication, in which child can

and

ineffective

behaviors

later

relationships.

express a variety of emotions, thoughts and needs, both in the context of the attachment relationship, or in the speech about this relationship.

Narrative and Attachment A study developed by Flores (1993) showed that Simões (2007) refers to authors like Fivush and Vasudeva (2002), Nelson (1993) or Pillemer (1998), who propose that the function of remembering and sharing personal experiences with others is useful not only for searching the meaning of existence but also for the creation and strengthening of social and emotional bonds. Moreover, they propose that it is through the (co-)narrating past experiences, i.e.

children who lived in a chaotic environment were unable to describe events or narratives in a temporal structure, compared with other children with the same age. According to these studies, it is in the relationship with parents (or the main attachment figure) that children begin to construct a conjoint narrative, organizing experiences and meanings in their life.

constructing a story with others, that we organize our 211

knowledge and give a sense of temporal and personal coherence on the Self and the world.

Narrative cognitive therapy – the influence of

Simões (2007) also points out that other authors have

constructivism

conducted studies with dyads of children and parents,

The human being has been considered, by several

in order to investigate the attachment and narrative

theoretical frameworks, as a meaning creator. In this

(such as Bowlby, 1988; Bretherton, 1985, 1990, 1999,

sense, the construction and development identity will

Thompson, 2000), suggesting that there are

depend on the interpretations and representations

associations

and

that he makes about reality and his own experience.

communication skills (either with attachment figures,

In fact, humans are authentic storytellers, and this

or with others). Bowlby (1988) argues that one of the

activity involves the maintenance and development

biggest aspects he found is that children with

of thought, which is essentially metaphorical and

insecure attachment tend to exhibit difficulties in

imaginative (Gonçalves, 1998). It is assumed that by

communication,

the way the individual tells his own experience, it is

defensive exclusion, when too painful subjects for the

possible to understand the multiple meanings that

between

secure

emphasizing

attachment

the

concept

child are erased from her consciousness and

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arise and the interpretations that he creates in each

intentionally, build new modes of subjective

experienced situation.

experience." As mentioned above, the temporal

Cognitive narrative therapy is, in a few words, an updated version of cognitive therapy, being an approach that takes into consideration several cognitive domains. This approach considers the importance of taking into account the five senses to describe the experiences of life, as well as the description of feelings and thoughts and the use of metaphors to give those experiences a meaning

organization of life events is jeopardized in people with attachment disorders, thus, it is a real challenge to think about and plan the future. As Mahoney (1998) said, an individual with insecure attachment pattern can only project for the future experiences that can be reminded in the present. So, he can only imagine receiving affection if he can also remember that same experience from his past.

(Soares, 2012). It gives language a special focus, in the therapeutic process, emphasizing the organization of

Psychotherapy and attachment

discourse, the strategic use of words and concepts, which help describe the painful situation. A constructivist cognitive perspective, considers that when

there

psychological

dysfunction,

disturbance remains essentially in the Self. In the eminence of this dysfunction, when the individual is unable to understand the connections of the events of his past and his present life, or when there are critical aspects of the experiences that are not integrated into the narrative of his life, these personal narratives shatter and disintegrate (Neimeyer &

Adult attachment is a concept that has been adopted in clinical psychology because of the growing number of studies that show a connection between insecure attachment patterns and psychological disorders (Daniel, 2006). One of the reasons that shapes the importance of working in attachment relationships in psychotherapy is that the client may reject or neglect his own suffering, i.e., he may use what Bowlby (1980) called defensive exclusion, putting back his attachment-related thoughts and feelings, which can

Raskin, 2001).

make him more vulnerable to future psychological The main goal of using narrative cognitive therapy is, according to Óscar Gonçalves (2000, p.142), "to make the patient stop the vicious and apparently deterministic cycle of certain emotional and cognitive sets, leading him to the symbolization of a diverse number of internal experiences, to place them in a conversational

and

narrative

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context

and,

problems (Goodwin, 2003). It is known that internalizing the disturbance may constitute a risk factor for mental illness and influence subsequent relationships in a way that makes the individual more exposed and vulnerable to stress. Thus, an important aim of psychotherapy involves helping client to mourn his loss. This behavior of openness from client

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to therapist begins to shape itself as an attachment

and present experiences; looking over internal

relationship, what we might call in psychotherapy the

working models and help the client to feel, think and

therapeutic alliance.

act in different ways from his past experiences.

Therapeutic alliance, according to Shaw, McMahon, Chan and Hannold (2004), is a collaboration process characterized by shared goals, tasks and attachment bonds, and is the best predictor of benefit in therapy (Platts, Tyson and Mason, 2002). Thus, the therapeutic relation, in psychotherapy, covers the basic human need of attachment, as well as the individual basic skill of learning through and inside a

Simões (2007) emphasizes that these internal models can be updated, taking into account the new experience

that

the

therapeutic

relationship

constitutes. The change will be possible through interpersonal communication, in which narratives may offer the possibility of (re)defining the attachment experiences.

human relationship (Strupp, 1989). Bowlby (1988) considers that, in psychotherapy, the therapist assumes the role of an attachment figure,

Clinical case study

allowing the establishment of a trusting relationship

Anna is a single woman around thirty years old,

and providing the client a secure base from which he

working in a management position. She shows

can explore his internal working models, also giving

difficulties in maintaining relationships. Anna has

him the opportunity to reformulate them in this

been adopted when she was around 5 years old, by

relationship. In this sense, the therapist should

a family with other children. Nowadays, she lives

constitute a secure base for the client to explore more

away from her adopted family because of her work,

painful aspects of his life, which he couldn’t be able

and admits that she hasn’t had a sense of belonging

to deal with, without someone who he truly believes

to that family. Although they have adopted her and

and

encouragement and

took care of her, the best way they could, they show

orientation. Bowlby also formulated (as Davila and

very few emotional content, which makes Anna feel

Levy,

for

unworthy and unloved, saying that she wishes a real

psychotherapy, like, as mentioned above, the

family and, most of all, a father figure. Anna admitted

establishment of a secure base; the exploration of

that she shows opposite behaviors towards people

past

and

she loves, such as compulsive caregiving or rejection,

behaviors; exploration of therapeutic relationship

depending on the way she comprehends other

and the analysis of how it may be related to other

people’s actions or intentions towards herself.

relationships; exploration of the connection of past

However, she thinks that she is more likely to move

gives

2006,

him

support,

refer)

attachments,

some

essential

expectations,

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keys

feelings

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away from people that show some affection for her,

tries to be strong and avoid showing suffering and

not being able to receive that fondness.

anger towards her life events. Anna asks for help in

Anna searched for help, initially, because of problems with her boyfriend, who also lives distant from her.

order to be happy and build a family, without being afraid of suffering or being abandoned again.

She states she has trust issues and argues a lot with her. After some critical periods in the relation, Anna

Symptomatology and diagnosis hypothesis

and her boyfriend tried to revitalize the relationship but with no success, since both started to blame each other for the failure of their attempts at

Anna

seems

have

developed

depression

symptoms, compulsive crying, isolation, panic attacks, showing sadness and no motivation on doing

reconciliation.

pleasure activities. Also, she shows difficulties in Anna shows insecurity in her decision making about relationships. Her past relationships were never well resolved, which can be related to her constant search, although not in a conscious way, for a father figure. Curiously, Anna says that she has few friends, because during her life course she lost some of them,

interpersonal

relationships.

After

starting

the

therapy, Anna said that her panic attacks became different, since she had seizures and lost conscience. After going to the hospital, Anna said that doctors suspect from epilepsy, although the exams are still not conclusive.

as she moved around a lot, or maybe because they weren’t “friends enough”. She shows lack of confidence and ambivalent feelings towards others, thinking that she gives much more than she receives. These thoughts, feelings and behaviors, like inhibiting or hyper activating emotional expressions towards the attachment figure are typically presented in individuals with insecure ambivalent attachment patterns (Berlin & Cassidy, 1999).

In relation to her depressive symptoms, it is not possible to diagnose for mood disorders, since symptoms doesn’t seem to be clinically significant, mostly because of the duration of the events, which doesn’t correspond to the criteria for mood disorder. Also, her panic attacks doesn’t seem to correspond to anxiety disorder, because of the intensity and duration of the events. Anna says that her panic attacks don’t occur frequently and are often

Anna tried to communicate with her biological family but it has resulted in more defrauded expectations,

developed after a critical period (e.g. anger, fear, discussion).

since her mother doesn’t want to maintain a connection with her. These constant losses and deceptions made her even more insecure, worry and suspicious of her relationships, although she always

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Considering the symptomatology it is important to note that, hypothetically, her symptoms (crying, isolation, panic attacks) may be a response to an

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attachment disorder, more specifically, because of

but, in EEG analysis there are no signals of excessive

her insecure/ambivalent attachment. Anna shows

electrical discharge of brain cells, which indicates

typical characteristics of a person who have

truly epilepsy. In a literature review, Francis and

developed an insecure attachment pattern, more

Baker (1999) showed, through the results of other

specifically with an ambivalent style, such as the

studies, that there are several differences between

feeling of not being good enough, the constant

non-epileptic events and true epileptic seizures.

looking for affection, the feeling of being neglected or

These differences are, for example, the fact that

rejected when attachment figure is not completely

many non-epileptic attacks may be precipitated by a

present or available, easily forming unrealistic

trauma,

expectations, excessive preoccupation and suspicious

beginning, in non-epileptic event, is sudden, and

towards partner, compulsive caregiving and so on.

gradual in epileptic seizure; the duration of seizures

Investigations in the twenty century, about childhood

are higher in non-epileptic events; cyanosis is unusual

and adult attachment, suggested that, in Western

in non-epileptic attacks and common in epileptic

society, around one third of adults have relationships

seizures; also, weeping is present in non-epileptic

characterized by anxious and insecure attachment

events and absent in epileptic seizures.

(Holmes, 1993).

contrarily

epileptic

seizures;

the

In a psychiatric perspective, non-epileptic attacks

Other interesting aspect in Anna’s case is the

disorder were related to dissociative and converse

emergence of the epileptic seizures. We may

disorders, which are linked to the concept of

hypothesize that this recent condition may be a

hysteria. From the eighties onwards, the interest in

symptom, related to the difficulty on talking about

dissociation as a response to trauma had begun

and bringing around her past traumas. Recently, a

(Fiszman, 2007). Several authors, such as Carton,

few studies have found a condition in which there is

Thompson and Duncan (2003), consider that there

a sudden disruptive change in a person’s behavior,

are psychiatric morbidity in non-epileptic attack

perception, thinking or feeling, and these factors have

disorder, being depression the most common

been mistaken for an epileptic seizure, although it

diagnosis.

doesn’t have the electrophysiological changes which accompany

true

epileptic

seizure

(Carton,

Thompson & Duncan, 2003). Therefore, these conditions seem to have a psychological etiology.

Not having the medical confirmation about epilepsy, as Anna says that doctors didn’t find deviations in her exams, this hypothesis may be important to understand her clinical case. A study developed by

People with non-epileptic attack disorder present

Akyuz and colleagues (Akyuz, Kugu, Akyuz & Dogan,

with episodes which are similar to epileptic seizures

2004) revealed that experiences of childhood neglect

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may be related to non-epileptic attacks. Also,

Therefore, the psychotherapeutic goals should

interpersonal difficulties, family dysfunction and early

include the development of a trust relationship with

traumatic experiences are common in patients with

the therapist; the construction of a secure base

non-epileptic attack disorder. This condition seems to

system, where the client can feel comfortable to talk

be more frequent in fearful (or insecure) attachment

and share fears and experiences; the insight of what

styles (Holman, Kirkby, Duncan & Brown, 2008). In

is happening with her internal working models; help

fact, it is not clear that the development of non-

her to understand why she relates to others with an

epileptic attacks is influenced by trauma itself or if

insecure pattern; develop a positive view of herself

there has an indirect effect through the development

and her skills for give love and being loved; develop

of other psychopathology (e.g. anxiety).

narrative skills that will help her to express feelings, thoughts, experiences and to facilitate the meaning

Psychotherapeutic goals

attribution; the construction of a positive and Research about attachment theory and psychological treatment services for people encountering mental

constructive life project, mentally outlining positive future experiences.

health problems, as a result of insecure attachments, focus on the psychotherapeutic process and relationship. Psychotherapy can be conceived as being based on the movement from insecure to secure

attachment

psychotherapeutic

(Holmes,

1994),

the

relationship

may

opportunity to develop security, intimacy and autonomy for the patient (Holmes, 1997). However, this relationship construction is also a challenge, since

216

Intervention The intervention, which is still in progress, is based on cognitive narrative therapy, since several authors [such as Bowlby (1988), Bretherton (1985, 1990, 1999) or Thompson, 2000] consider that there is a clear relation between cognitive narrative therapy and attachment styles.

the therapeutic process may be seen as a microcosm of attachment and separation, as the sessions are punctuated by endings and breaks (Holmes, 1997). Gonçalves (2008) presented a study where it was found that there is a positive correlation between secure attachment and therapeutic alliance, thus, insecure attachment might be a challenge for this

In this particular case, it is extremely important that therapeutic relationship is established, and that the therapist acts like a secure base. Also, this relationship will be important in order for the client to start learning to construct a coherent narrative, processing emotional content (such as anger and sadness) and being confident to share those kinds of

alliance.

emotions in the therapeutic relationship. These aspects, as well as the facilitation of self-exploration

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within the therapeutic relational context, have been

able to identify and control these situations and to

considered as essential ingredients of psychotherapy

also find a metaphor that can easily help her express

with insecure clients (Holmes, 1994).

her own thoughts and feelings. The therapist also

According to Cassidy (2001), there are two fundamental aspects to develop a safe and functional attachment system, both aspects concerning the matter of trust. Firstly, it is imperious that the individual trust and believe that the other (the therapist, in this case) is available, sensitive and responsive to his needs. Second, and also important, it is imperative that the individual believes that he is lovable, that is, he must perceive himself as someone who can be loved and valued by others. Therefore, it was very important to develop these aspects in the very first contacts with Anna. The therapist clearly pointed out that the therapeutic context is absolutely secure, and encouraged Anna to develop a trust relationship with him.

was

suggested

down what she felt and thought in difficult situations. This kind of exercise would help her be more proficient in characterizing her own experience with adjectives, helping her to be able to identify specific reactions of her mind and body, to know herself better and develop trust in herself, since it would help her to know how to control her own behavior. Still, Anna showed some initial difficulty in finding time to write but, gradually, she seemed to recognize that it might be helpful and started to write in intense moments, saying that writing was like an escape, just like if she was telling others her feelings, and that 217

felt really good. Her narratives, oral or written, were very reflexive.

The first sessions, after establishing the therapeutic goals,

suggested Anna to keep a diary, where she writes

some

exercises

adjectivation of experience, as well as an exercise for selecting a particularly important event for each year of life. It was noticed that Anna reveals some difficulties in those kinds of exercises, which can be justified by her tendency for defensive exclusion, and because of her lack of temporal organization. Moreover, it was noticed some difficulties to identify emotions, feelings and thoughts particularly in painful situations, for example the moment of a panic attack. In the following sessions the same kind of exercise was proposed, so that the client could be

She started to understand that the way she relates to others is a reflection of what she has lived in early years, and that her behavior towards others can change if she believes in herself as a person who is capable to be loved, trying to change her problematic narrative to a positive one. Also, it was important to work with Anna her losses, as she needs to understand that they are very similar to the death of someone she loved, since the idea and the expectations that she had towards her two families, boyfriends and friends, have been broken, and so she needs to initiate a grief process. This new meaning construction and the use of metaphors to understand her own experience is considered a central aspect for

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the psychotherapeutic change (White & Epston,

narratives, making a proactive construction of a

1990).

greater variety of content. Gonçalves (2000) also

To truly move on to a brand new narrative, it is important that the client identifies and recognizes every single loss as an attempt to revive the anger, the pain, the anxiety, since that helps to give a meaning to that loss. An important author in the field of losses and grief, Neimeyer (2001, 2006, 2012), states that it is important that the person must be capable of reformulating meanings, so she can

speaks on the concept of "projection", where the term "project" refers to the notion of a moving object, since the individual is himself that object, an active participant of his own experience, a constructor of multiple narratives. Thus, the therapeutic work with Anna, also focus this aspect of projection, helping her to visualize herself in positive scenarios and engage in constructive narratives.

integrate the loss. Also, he argues that as a novel that

Therapeutic change is still occurring, and narratives

loses a central character in the middle of the action,

are being progressively more adaptive and positive,

life stories affected by losses have to be reorganized

as the client starts to understand her importance in

and rewritten to find a new future. Neimeyer

changing and creating her own future.

consider that unsent letters may be a relevant

218

therapeutic writing activity, since it reopens the dialogue with people who the client lost, addressing

Discussion and conclusion

some questions, fears or thoughts. Such exercises

The narrative gained importance in the field of

would help Anna in giving new meanings to her

psychotherapy, as it is acknowledged that finding

losses, to close unresolved chapters in her life and to

new meanings for experiences is a good predictor of

bring some peacefulness to her, facilitating the

therapeutic change. Moreover, trust and confidence

construction of new relationships.

are central keys for individuals to relate positively, so

Simultaneously, it is important to help the client to design new and positive future goals, which is a real challenge, as mentioned above. Óscar Gonçalves (2000) mentioned the challenge of thinking about future goals in a particular phase of narrative therapy described by him, citing a few authors such as Markus and Nurius. They refer to the importance of exploring "possible selves", focusing on the possibility for the

a truly attachment relationship is needed in the therapeutic

context.

People

with

insecure/ambivalent attachment pattern tend to present a disorganized narrative as well as feelings of insecure and lack of love. These disruptive situations, adding to important losses in life, may lead to difficulties in the relationship with others, as the individual will not believe in positive events in his life.

client to open himself to experience, to create new

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This work shows a clinical case study where the client

Akyuz, G., Kugu, N., Akyuz, A., Dogan, O., 2004.

lost some of the most important bonds in her life, and

Dissociation and childhood abuse history in

seemed

epileptic and pseudoseizure patients. Epileptic

develop

insecure/ambivalent

attachment pattern. Because of that, some important symptoms emerged and they are important signs of dysfunction and suffering. The psychotherapeutic intervention focused on cognitive narrative therapy, where constructivism and attachment theory play an important role, helping the client to redefine,

Disord. 6, 187-192. Assunção, R. (2009). Associação entre vinculação parental e amorosa: o papel da competência interpessoal e da tomada de perspetiva. Master thesis. University of Porto: Faculty of Psychology and Educational Sciences.

reorganize and reinterpret her meanings of her life events. It´s an opportunity to rediscover herself in a brand new and positive relationship in the therapeutic setting, since she started to feel more capable to relate with the therapist and talk about herself and her experiences in a constructive way. This relationship is almost a training process, where the client knows herself better and visualizes, with

Berlin, L.J., & Cassidy, J. (1999). Relations among relationships: Contributions from attachment theory and research. In J. Cassidy & P.R. Shaver (Eds.), Handbook of attachment: Theory, research and clinical applications (p. 688-712). New York: The Guilford Press. 219 Bowlby, J. (1988). A secure base: Parent-child

the therapist help, how she relates to others, and how

attachment and healthy human development.

she can change the way she sees others’ intentions

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Bowlby, J. (1980). Attachment and Loss (Volume 3) Loss, Sadness and Depression. London: Hogarth. Bretherton, I. (1999). Updating the ‘internal working

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Dyadic Relationship and Quality of Life Patients with Chronic Kidney Disease Nuno Cravo Barata (1) & Emílio Gutiérrez (2)

(1) Faculdade de Medicina do Hospital de S. João do Porto, Portugal – Correspondent author: nbarata@med.up.pt, (2) Departamento de Psicologia Clínica e Psicobiologia da Faculdade de Psicologia de Santiago de Compostela, Espanha)

_________________________________________________________________________________ Abstract This is a cross-sectional study of a descriptive nature through surveys, exploratory and correlational with the following objectives: (1) verify the existence of differences of dyadic adjustment (AD) according to renal replacement treatment (RRT) and (2) verify the existence of differences quality of life (QOL) in accordance with the RRT. The sample consisted of 125 participants. Of these, 31 were to be made RRT by automated peritoneal dialysis (APD) and 94 hemodialysis (HD). Participants were selected from three renal centers: (1) Centro Renal da Prelada (Porto, Portugal), (2) Centrodial (S. João da Madeira, Portugal) and Centro Renal da Misericórdia de Paredes (Paredes, Portugal). The study was carried out for 6 months. The following instruments were applied: Socio-demographic and clinical questionnaire (SDCQ), Dyadic Adjustment Scale (DAS), World Health Organization Quality of Life (WHOQOL-Bref). The results demonstrate the existence of statistically significant differences between the type of RRT and most areas of QOL, as well as the existence of statistically significant differences between the subscales of the DAS evaluated and the type of RRT. Keywords: Chronic Kidney Disease; Renal Replacement Treatment; Quality of Life; Dyadic Adjustment; Survey Descriptive Study.

224

Resumo O presente estudo transversal de carácter descritivo mediante inquéritos, exploratório e correlacional teve como objectivos: (1) verificar a existência de diferenças do ajuste diádico (AD) de acordo com o Tratamento Substitutivo Renal (TSR) e (2) verificar a existência de diferenças da qualidade de vida (QDV) de acordo com o TSR. A amostra é constituída por 125 participantes. Destes, 31 encontravam-se a efetuar TSR por diálise peritoneal automatizada (DPA) e 94 por hemodiálise (HD). Os participantes foram selecionados de três centros renais: (1) Centro Renal da Prelada (Porto); (2) Centrodial (São João da Madeira); e Centro Renal da Misericórdia de Paredes (Paredes). O estudo realizou-se durante 6 meses. Aplicou-se os seguintes instrumentos: Questionário Sócio-demográfico e clínico (QSD&C); Dyadic Adjustment Scale (DAS); World Health Organization Quality of Life (WHOQOL-Bref). Os resultados demonstram a existência de diferenças estatisticamente significativas entre o tipo de TSR e a maioria dos domínios de QDV, bem como, a existência de diferenças estatisticamente significativas entre as subescalas do Ajuste Diádico avaliadas e o tipo de TSR. Palavras-chave: Tratamento Substitutivo Renal; Qualidade de Vida; Ajuste Diádico; Estudo Descritivo Mediante Inquéritos.

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Resumen Este es un estudio transversal de carácter descriptivo a través de encuestas, exploratorio y correlacional con los siguientes objetivos: (1) verificar la existencia de diferencias de regulación diádica (AD) según el tratamiento de reemplazo renal (RRT) y (2) verificar la existencia de diferencias de calidad de vida (CDV) según el RRT. La muestra consistió de 125 participantes. De ellos, 31 realizaron RRT por diálisis peritoneal automatizada (APD) y 94 hemodialisis (HD). Los participantes fueron seleccionados de tres centros renales: (1) Centro Renal da Prelada (Porto, Portugal), (2) Centrodial (S. João da Madeira, Portugal) e Centro Renal da Misericórdia de Paredes (Paredes, Portugal). El estudio se llevó a cabo durante 6 meses. Se aplicaron los siguientes instrumentos: Cuestionario sociodemográfico y clínico (SDCQ), Escala de ajustamento Diádico (DAS), World Health Organization Quality of Life (WHOQOL-Bref). Los resultados demuestran la existencia de diferencias estadísticamente significativas entre el tipo de RRT y la mayoría de las áreas de la QOL, así como la existencia de diferencias estadísticamente significativas entre las subescalas del DAS evaluadas y el tipo de TRR. Palabras clave: Enfermedad Renal Crónica; Tratamiento de Reemplazo Renal; Calidad de Vida; Ajuste Diádico; Estudio Descriptivo de la Encuesta.

_________________________________________________________________________________

Introduction

All aspects of life are affected by kidney disease and

Chronic Renal insufficiency (CRI) and dialysis treatment lead to a succession of situations for kidney chronic patient, which compromises his aspect, not only physically, and psychologically, with personal, family and social repercussions. For Riella (1996), chronic renal patient experiences a sudden change in life, live with limitations, with the painful treatment that is hemodialysis, spend time thinking about death, but coexists with the possibility to undergo a kidney transplant and the expectation of improving their quality of life. Consequently, Lima and Guarda (2000) report that chronic renal patients

its treatment, and the effects extend to all people who have a closer involvement with the patient (Bradley, & McGee, 1994). A better understanding of the anxieties and concerns of patients on a daily basis allows professionals who work in Nephrology units responding with appropriate support (Williams, 1985). It has to start as early as possible to avoid problems, both practical and material (for example related with employment or financial situation) or emotionally (as is the case of the problems in personal relations and unnecessary fears prognosis and treatment) (Bradley, & MacGee, 1994).

end up getting discouraged, desperate and often, for

So, faced with a crisis or illness, the subject tends to

these reasons or for lack of guidance, eventually

make use of all its resources available, struggling to

abandoning the treatment or do not give importance

promote his self-balance, which was supposed to

to the constant care that should have. It is therefore

possess and how he feels being threatened.

necessary to stimulate their abilities to adapt

Therefore, it seems more or less clear that the social

positively to new lifestyle and take control of their

network of support is one of the important variables

treatment.

that can intervene in a beneficial or malevolent way in a crisis or illness (Silva, 1997). It is therefore very

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important to assess the level of social support and

the disease and treatments, and either indirectly by

dyadic adjustment perceived by patients with CRI,

the implications of these same effects on personal

providing relevant information for the knowledge of

performance. Recently, the attention of health

variations in terms of psychological well-being

professionals began to turn to a therapy aimed at

related to health and disease, and also with the

improving chronic renal patient QOL as a relevant

quality of life from variables such as depression, self-

factor in the setting of renal therapy, and not only

esteem

the extension of his life.

preserved

and

acceptance

renal

substitutive treatment. Given this, it seems clear that the supportive family and friends acts as a lever for the maintenance of the balance of the patient, taking into account changes of individual habits and the continued promotion of behaviors that improve overall health, involving people who also give assistance to the patient (Kaveh, & Kimmel, 2001).

In relation to chronic renal patient to achieve a better QOL, this goal is always present in your everyday life, and its indicator of QOL or wellbeing is extremely different from an individual considered healthy, because their health goals focus on achieving a level of life/health compatible with a life with dignity and independence (Collier, & Watson,

One can consider, that social support (SS) is the

1994). It is obvious that in recent decades, due to the

result of positive or negative action of the

onset of renal substitutive treatment (RST) and

relationships perceived by individuals, which meets

adjuvant therapy (Collier, & Watson, 1994), there

definitions of Sarason, Levine, Basham, and Sarason

have been technological advances and considerable

(1983). Roughly speaking, it seems apparent that the

therapeutic allowing a better well-being of these

in SS, the dyadic adjustment may function as

patients, particularly in racing to his longevity and

precursor of a better adaptability of individuals

permanence of some of its capabilities (even if it is

suffering from CRI, likely to increase optimism and

not possible to enjoy a full quality).

positivity, as well as the quality of life of these same individuals have strong relationship between everyone, since the renal treatment strongly influence the physical and mental level (Herek, Levy, & Maddi, 1990).

The problem of CRI and its influence on QOL of individuals can be better understood if Complete with brief patho-physiological considerations of CRI framework, therefore, reach a certain level of health and QOL depends a lot of uncertainties and fears

As noted earlier, it seems appropriate to systemize

about the future; family concerns; sleep disturbance;

the psychosocial implications inherent in this health

occupational limitations due to dialysis; lack of

problem, since people who face CRI suffer a

vitality; too much time spent on treatments; dietary

devastating impact on the social and psychological

restrictions; medicated schemes; technical problems

state, either as a direct consequence of the effects of

with equipment; and fear of complications during

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dialysis. Similarly, several authors point to the

about your diagnosis; 5. Do not present a

persistence of depressive symptoms, low self-

disturbance state of consciousness; 6. Do not submit

esteem, fear of rejection and side effects of renal

most significant disease than CRI, except those

substitutive therapy, influencing individual's CRI

resulting from the CRI itself; 7. Have given consent to

carrier QOL (Altschuler, 1997; Fedewa, & Obserst,

participate in the study (informed consent).

1996; Eiser, 1993).

A total of 125 individuals were evaluated, who fulfilled the inclusion criteria of the study. Sociodemographic characteristics of 125 individuals are

Method

expressed in table 1. In the present study, there will be an analysis of the relationship between the AD and the QOL of people with CRI. It is thus a transversal study of descriptive nature, exploratory and correlational with the sense of contributing to a greater understanding of the

It turns out that there is a balanced distribution between the two sexes in the sample studied, and there is a huge variability in terms of age and schooling.

importance of the AD in the QOL of people with CRI and the alleged predictive values of AD.

The vast majority is in a situation of no activity, i.e. can be retired (in advance or not) or unemployed. It should be noted, also, that the majority of the

Sample

sample resides or carries out treatments in the Porto The sample consists of 125 participants with CRI. Of these, 31 were using RST by CAPD and 94 are effecting RST for HD. participants were selected from three kidney centers: (1) Renal Center of Prelate (Porto); (2) Centrodial (São João da Madeira); and (3) Kidney Center of Misericórdia da Paredes (Paredes). The study took place during six months (24 weeks). It should be noted at the outset that the sample is not probabilistic, being the type of sampling by rational selection.

district. An analysis to the clinical variables we can mention that 75 of the patients interviewed have a pathology, diabetes mellitus, in co-morbidity, representing 60% sample. Note, also, that diseases which may have caused the CRI most representative in this population were arterial hypertension in 40 patients and diabetes mellitus in 35 patients. Reading the table indicates that 94 of the individuals participating in the study are on Hemodialysis and 31

All participants obeyed the following inclusion

individuals in APD. Of the total of 125 individuals that

criteria: 1. Have CRI diagnosis; 2. Have more than 18

make up the sample more than half (52.8%) presents

years of age; 3. Live in cohabitation in whole or in

the clinical parameters changed. (Table 2)

part; 4. Have full knowledge and be well informed

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Table 1. Description of the sample – socio-demography Demographic variables

Values obtained

(N=125)

Gender Female

64 (51,2%)

Male

61 (48,8%)

Age (average)

61,06

Amplitude

24-87

15,60

Years of average school attendance

5,38

Amplitude

0-17

4,20

Cohabitation Cohabitation - total (marriage, domestic partnership)

76 (60,8%)

Partial cohabitation (girlfriend, lover)

49 (39,2%)

Profession Active

35 (28%)

Employees

26 (20,8%)

Full-time

21 (16,8%)

Part-time

5 (4%)

Domestic workers Not Active Pensioners

9 (7,2%) 90 (72%) 71 (70%)

In Advance

43 (34,4%)

Not in Advance

38(30,4%)

Unemployed

9 (7,2%)

Unemployed Porto

97 (77,6%)

Aveiro

28 (22,4%)

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Table 2. Description of the sample in clinical terms Clinical variables

Values obtained (N=125; %)

Associated commorbility (diabetes mellitus) Yes

75 (60%)

50 (40%)

Type of disease related to causes of IRC Arterial Hypertension

40 (32%)

Diabetes Mellitus

35 (28%)

Glomerulonephritis

30 (24%)

Obstructive Uropathy

4 (3,2%)

Polychistic Kidney

8 (6,4%)

Hereditary Disease

7 (5,6%)

Another

1 (0,8%)

Renal substitutive treatment type Hemodialysis

94 (75,2%)

Automated Peritoneal Dialysis

31 (24,8%)

Clinical parameters Normal

59 (47,2%)

Abnormal

66 (52,8%)

Material Social-demographic and clinical questionnaire: For

Adjustment Dyadic Assessment Questionnaire: to

collection and evaluation of socio-demographic and

evaluate the AD appealed to the Dyadic adjustment

clinical data was constructed a questionnaire taking

Scale (EAD) Spanier (1976, 1985). This scale

into account the preferential items of this

pioneered by integrating all cohabiting couples,

investigation. In order to characterize the sample,

whether married or not. The EAD is composed of 32

we proceeded to the elaboration of a social-

items, which seek to assess marital adjustment,

demographic and clinical questionnaire (QSD&C). It

using Likert-type scales: scales are used five, six and

consists of 24 items: 3 items are of a general nature,

seven points. Generally speaking, the extreme points

8 item are socio-demographic in nature, 11 item are

of the scales mean «never» and «all time»,

clinical in nature and last items 2 that allow the

respectively. The items 29 and 30 have only two

interviewee to talk about the study and on the

options, 'yes' or 'no'. So, to increase the reliability of

QSD&C.

the scale, some items are positive affirmations and

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other are negative remarks. The total scale can vary

Mood assessment questionnaire: For evaluation of

from 0 to 151 and is obtained by summing the values

psychological variables – anxiety, depression and

obtained in the four scales. To Spanier (1976),

negative affection, we used the depression and

individuals who obtain 101 points or less must be

anxiety scale Hospital (Hospital Anxiety and

classified as in the experience of a relationship of

Depression Scale HADS-) Zigmond and Snaith (1983).

suffering or misfit and people who reach 102 points

It consists of 14 multiple-choice items, divided

or more would be experiencing a relationship

evenly into two subscales (Anxiety and Depression)

without suffering or well adjusted. The DAS seeks to

with quote (Snaith, & Zigmond, 1994), which jointly

measure the following dimensions: (a) dyadic

produce a total result. Is a self-assessment scale,

consensus, which assesses the dyadic level of lack of

frequently used and developed for use in hospitals.

concordance of the couple on a variety of key issues

According to Zigmond and Snaith (1983), the scale

financial,

takes, on average, about 20 minutes to be filled in,

friendships, conventionality, philosophy of life,

constituting an instrument easy to administer, easy

business with relatives, goals, time spent together,

to reply and faithful to assess clinically significant

decision-making, housework, leisure time and

anxiety and depression.

relationship

(leisure,

religious,

occupational decisions; (2) dyadic satisfaction, measuring the lack of discussion issues of divorce, out of the House after an argument, to repentance with the marriage, the mutual pet peeve, quarrels, the well-being, confidence in the spouse, to kiss the spouse,

the

degree

happiness

and

the

commitment to the future relationship; (3) dyadic cohesion, which examines sense of emotional couple shares, measuring the relative lack of mutual interests, the stimulation of ideas, the fun set, quiet discussion and to work together on projects; (4) dyadic expression of affection, which measures lack of agreement of spouses on demonstrations of affection, sexual relations, lack of love and refusals to sex (Spanier, & Cole, 1975; Spanier, & Thompson, 1982; Hernandez, 2008).

Quality of life survey: quality of life was evaluated through the Whoqol-Bref (Whoqol-Group, 1998). O WHOQOL-Bref consists of 26 questions: two on global health and illness (QOL) and the other representing each one of the 24 facets that make up the WHOQOL-100 (Pain and discomfort; Energy and fatigue; Sleep and rest; Mobility; Activities of daily life; Dependence on medication or treatments; Ability to work; Positive feelings; Think, Learn, Memory and concentration; Self-esteem; Body image

and

appearance;

Negative

feelings;

Spirituality/Religion/personal

beliefs;

Personal

relationships; Social support; Sexual activity; Physical security and protection;

Home environment;

Financial resources; Health and social care: availability and quality; Opportunities to acquire new

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and

same when find timely; (e) all questionnaires were

Physical

filled in by the investigator due to postural

environment (pollution/noise/traffic/weather); and

difficulties of the participants throughout the

Transportation). All these items can be grouped into

treatment

four areas: Area 1 – physical Domain (items 1, 2, 3, 9,

technique. Therefore, we decided to do the same for

10, 11 and 12); Area 2 – psychological Domain (items

the participants, who have renal substitutive

4, 5, 6, 7, 8 and 24); Field 3 – social relationships

treatment for automated peritoneal dialysis, thus

(items 13, 14 and 15); 4 domain-environment (16,

giving a certain consistency to this research; (f) when

17, 18, 19, 20, 21, 22 and 23). The abridged version

a subject did not understand some of the issues

such as the WHOQOL-100 (long version) presents a

raised by the investigator, it was given the right to

Lickert scale type response, in which the total values

explain as many times as necessary until the

oscillate between 0 and 100, with higher values of

complete understanding and reasoning; (g) for the

QOL synonyms (Canavarro, et al., 2005; Pereira et al.,

optimization of best results in the responses given by

2005).

participants, account has been taken of the physical

recreation/leisure

skills;

Iberian Journal of Clinical and Forensic Neuroscience – IJCFN

Participation

opportunities;

for

renal

dialysis

substitutionary

and mental suffering throughout the interview, being that, in some situations we decided to evaluate Procedure

the same subject for two days; (h) all participants

The investigation began with the request and

have been selected in accordance with the consent

subsequent authorization for the use of instruments

of the same in collaborating, as well as according to

used. Then it was settled a protocol establishing the

their physical and mental capabilities. The collection

principles and procedures inherent in the present

of data, in present study, was carried out between

investigation; the research project was initiated with

September 2008 and May 2009. Data were related

the (a) presentation to the Clinical centers, to be

with the last six months and the interviews were

granted authorization to start the study; (b) the

conducted in the last month of investigation.

investigation followed the fundamental principles such as the right to dignity, security and well-being of the respondent, as well as the respect for him; (c) in addition, the participants were informed about the purpose and procedures of investigation involving, if they so wish, in the absence of any pressure or coercion on its participation; (d) the interview is confidential and the participant does not had the obligation to respond, and could end the

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Patients undergoing treatment for HD were interviewed during the renal substitutive treatment and patients undergoing treatment for APD were interviewed after a pre schedulling of time and place. Furthermore, all patients had to answer questions from QSD&C, DAS, Whoqol-Bref and HADS. The interview took, on average, 40 minutes (23-79 minutes) (41 minutes for individuals in TSR for HD and 36 minutes for individuals in TSR by APD), being

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that, given the specificity and duration of treatment of patients in HD, the interviews tended to be longer

Results Differences between QDV and the TSR type

given that, sometimes, the rhythm of the same would have to be slowed down depending on the patient's conditions and generally, corresponded to cases in which individuals asked for help to clarify

There was no missing data in the Whoqol-Bref. In table 3 are expressed the mean values, standard deviations, as well as the significance value obtained from the differences between the subjects on

some issues about their problems.

Automated Peritoneal Dialysis and Hemodialysis. To assure that responses were feasible, the investigator was always the same throughout the interview and the fact that it is completed by the

It should be noted, that the scales of the Whoqol-

investigator himself may possibly have diminished

Bref are coded so that higher values correspond to

some limitations inherent in the fills of the

better QOL. There are statistically significant

questionnaires, such as: (I) the retrospective bias

differences in the various Domains of the Whoqol-

(tendency

the

Bref, being that the subjects who underwent

symptomatic subject perception at the time of

treatment by DPA always obtain higher values than

inventory administration); (II) the social desirability

the subjects who underwent treatment for HD.

minimize

exaggerate

bias (tendency to respond to the inventory according to what's socially correct and expected); (III) the random responses bias (when the responder is not motivated or when it is not able to respond. In this case, the subject select the reply in an almost randomized way, without any criteria). We also shall state that the fact that the investigator administer and quote the instruments items, can possibly have diminished the impact of issues related to fidelity.

Differences between the perceived dyadic adjustment and dialysis modality that patient with CRI are submitted. The results show an analysis of dichotomized AD, an important relationship between the AD and the kind of TSR (Table 4). Therefore, the results allow us to highlight the dependence of both variables, being that one is always predictive of another. In this sense, and so that we can have more concrete results we decided to analyze the subscales of the DAS (not dichotomized) in relation to the type of TSR, and the results achieved through the t student test suggests the existence of statistically significant differences, revealing the existence of a relationship between the variables evaluated (Table 5).

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Table 3. Values obtained in the Whoqol-Bref instrument according to the TSR type Whoqol-Bref

Type of TSR

Hemodialysis

40,85

14,07

General Health Domain

.000** Automated Peritoneal Dialysis

54,87

14,31

Hemodialysis

43,69

13,89

Physical Domain

.000** Automated Peritoneal Dialysis

61,65

12,65

Hemodialysis

45,96

12,21

Psychological Domain

.000** Automated Peritoneal Dialysis

56,06

11,39

Hemodialysis

48,87

12,76

Social Relationships

.001**

Domain

Automated Peritoneal Dialysis

57,81

11,25

Hemodialysis

45,23

12,16

Environment Domain

.000** Automated Peritoneal Dialysis

60,58

15,58

Legend: * significance; a p<.01; ** significance a p<.05 Table 4. Relationship between AD (dichotomized) and TSR type Renal Substitutive Treatment type

Bad adjustment

DPA

55,6

18,4

74,0

94,6%

5,4%

100,0%

Adjusted waste

6,0

-6,0

Mesure

38,4

12,6

47,1%

52,9%

Adjusted waste

-6,0

6,0

Mesure

75,2%

24,8%

Mesure Expected frequencies % in line

Good adjustment Dyadic

Expected frequencies

Adjustment

% in line

Total

% in line

Total

.000**

51,0 100,0%

125 100,0%

Legend: * significance a p<.01; ** significance a p<.05

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Table 5. Values obtained in the EAD instrument according to the TSR type EAD

TSR type

Hemodialysis

35,47

13,82

EAD Cons.

.000** Automated Peritoneal Dialysis

49,32

7,61

Hemodialysis

24,60

12,20

EAD Sat.

.000** Automated Peritoneal Dialysis

39,61

7,88

Hemodialysis

12,98

4,36

EAD Coes.

.000** Automated Peritoneal Dialysis

16,97

3,72

Hemodialysis

7,06

2,54

EAD Exp.

.050* Automated Peritoneal Dialysis

8,06

2,10

Hemodiálise

80,03

23,84

EAD Tot.

.000** Automated Peritoneal Dialysis

113,81

9,25

Legend: EAD Cons. – Consensus Dyadic adjustment scale; EAD Sat. – Dyadic adjustment scale Satisfaction; EAD Coes. – Cohesion, Dyadic adjustment scale; EAD Exp. - Dyadic adjustment scale Expression of affection; EAD Tot. – Total Dyadic adjustment scale; * significance a p<.01; ** significance a p<.05

The

present

study

demonstrates

greater

commitment in terms of QOL of individuals undergoing treatment for HD when compared with

Discussion

those subjected to APD. This may be due to the In relation to demographic variables, there is a balanced percentage of women and men, what is in accordance with some studies (Barata & Meneses, 2009). The variability in terms of education reflects well the heterogeneity of users of Kidney Centers. However, the average schooling of the sample seems to mirror some of the usual difficulties that users of the Renal Centers have in filling of self-report instruments, by which, we opted for assisted administration of instruments used in this study.

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commitment that the kind of treatment takes, since, during that period the activity is null, being systematically

dependent

the

treatment,

whereas in the APD individuals can maintain their daily routines (Barata & Meneses, 2009). Therefore, there is a greater commitment in the fields of QOL (Trentini, Corradi, Araldi, & Tigrinho, 2004) with significant losses in terms of physical dimensions and is also patent the commitment of some physical, social and emotional aspects. Thus, the CRI and the

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HD treatment and APD are a medical condition with

sexual function, among others (DeOreo, 1997) with

a significant impact on patient's QOL and also

highly painful reflections on dyadic relationship of

physical conditions are typically affected (DeOreo,

these patients. Given the changes highlighted, there

1997; Mingardi et al., 1999; Romão, Canziani,

is in many cases a desperate resignation that

Praxedes, Santello, & Moreira, 2003). All the CRI

influences negatively in overcoming traumatic

experience may suffer major changes, especially in

situation.

the patient in HD, since changes are present in everyday bodily activities as well as recreational (Castro, 2003).

This research is limited, because the results obtained should not be regarded as representative of the Portuguese population with CRI, since the process of

It turns out, also, that AD is most strongly perceived

selection of the participants for the study was

by patients in APD than with HD, once that the

restricted to only three kidney centers, which may

treatment could be not as negative for the

have caused a bias in the results obtained

subsystem of the couple adopting an affective

(Ramalheira & Varandas, 2000). Another limitation

protection and where the healthy spouse offers

concerns the transverse nature of study what

support and help and increase self-confidence and

inhibits from making any statement with respect to

the ability to implement adjusted behavior.

directionality and causality. It would be essential to

Consequently, and in accordance with the present

draw longitudinal character studies, which make it

study, a smaller dyadic adjustment, present in HD

possible to infer causality relationships between the

patients, may be synonymous of less protection

variables studied. Thus, it will be important to follow

factor against stress and vulnerability that this

individuals with CRI and evaluate them for a certain

individuals are exposed. It also noted the existence

period of time. Therefore, we will try to obtain a

of severe loss, and this is usually huge and lasting for

temporal relationship between the factors of

the patient with kidney disease in HD, renal function,

exposure and the characteristic being studied.

sense of well-being, of its role both in the family and at work, loss of time, financial resources, sources of References

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Fedewa, M. M, & Oberst, M. T. (1996). Family care giving in pediatric renal transplant population. Pediatric Nursing, 22(5), 402-525. Herek, G. M., Levy, S. M., & Maddi, S. R. (1990). Psychological aspects of serious illness: chronic conditions, fatal diseases, and clinical case. Washington: Rand. Hernandéz, J. (2008). Avaliação Estrutural da Escala de Ajustamento Diádico. Psicologia em Estudo 13(3), 593-601.

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Snaith, P. (1994). Anxiety control training. Advances in Psychiatric Treatment, 1, 57-61. Spanier, G. B. (1976). Measuring dyadic adjustment: New scales for assessing the quality of marriage and similar dyads. Journal of Marriage and the Family, 38(1), 15-28.

WHOQOL-Group (1998). Development of World Health Organization WHOQOL-Brief Quality of Life Assessment. Psychological Medicine, 28, 551-558. Williams, A. (1985). Economics of coronary artery bypass grafting. British Medical Journal, 291,327.

Spanier, G. B. (1985). Improve, refine, recast,

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Third Generation Therapies for Treatment of Anxiety: A Clinical Case with Acceptance and Commitment Therapy (ACT) and Mindfulness Ricardo João Teixeira (1) & Jorge Mota-Pereira (2) (1) Psychologist/Psychotherapist at Clínica Médico-Psiquiátrica da Ordem (Porto); Invited Assistant Lecturer at School of Allied Health Sciences, Institute Polytechnic of Porto; PhD in Psychology (University of Minho). All correspondence about this article should be sent to: Dr. Ricardo J. Teixeira, Clínica MédicoPsiquiátrica da Ordem, Rua Gonçalo Cristóvão, 347, 2º andar, sala 202, 4000-270, Porto (Portugal); Tlf: 223321527. E-mail: rjteixeira.psic@gmail.com (2) Clinical Director and Psychiatrist at Clínica Médico-Psiquiátrica da Ordem (Porto); PhD in Psychology (University of Minho).

____________________________________________________________________________________ Abstract This paper briefly describes what is the third generation of cognitive-behavioral therapies, focusing on Acceptance and Commitment Therapy (ACT), its underlying models and effectiveness, especially when combined with mindfulness techniques. This therapy, in anxiety disorders, focuses on the reduction of the function of anxiety concerning behavioral regulation and cognition, and strongly focuses on behavioral modification centered on the values of the patient as well as in the promotion of psychological flexibility. A clinical case of a patient with panic disorder (with agoraphobia) is presented, treated with ACT processes, and showing promising outcomes. Keywords: third generation therapies; anxiety; acceptance and commitment therapy (ACT); treatment.

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Resumo Este artigo descreve sucintamente no que consiste a terceira geração de terapias cognitivo-comportamentais, focando-se na Terapia de Aceitação e Compromisso (ACT), modelos subjacentes e eficácia, sobretudo quando aliada a técnicas de mindfulness. Esta terapia, nas perturbações da ansiedade, centra-se na diminuição da função da ansiedade ao nível da regulação comportamental e das cognições, sendo que se foca fortemente na mudança comportamental centrada nos valores do paciente, assim como na promoção da flexibilidade psicológica. É apresentado um caso clínico de um paciente com perturbação de pânico (com agorafobia), com o qual foram trabalhados processos da ACT com resultados promissores. Palavras-chave: terapias de terceira geração; ansiedade; terapia de aceitação e compromisso; tratamento. Resumen En este artículo se describe brevemente lo que es la tercera generación de terapias cognitivo-conductuales, centrándose en la Terapia de Aceptación y Compromiso (ACT), los modelos subyacentes y eficacia, especialmente cuando se combina con técnicas de mindfulness. Esta terapia, en los trastornos de ansiedad, se centra en la reducción de la función de la ansiedad en el nivel de regulación del comportamiento y la cognición, y fuertemente se centra en la modificación de la conducta centrada en los valores de lo paciente, así como en la promoción de la flexibilidad psicológica. Este reporte describe un caso de un paciente con trastorno de pánico (con agorafobia), con el que se trabajó los procesos de ACT con resultados prometedores. Palabras clave: terapias de tercera generación; ansiedad; terapia de aceptación y compromiso; tratamiento.

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Introduction

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techniques focused on modifying contingencies, but

The behavioral therapy movement known three great waves. At first, the classical model guided by the Pavlovian theory, in which exposure techniques dominated treatments. The second wave was characterized by a rationalist-cognitive model, based on psychological processes that were mediated by

also taking into account the role of cognitive events as a causal axis behavior. Second-generation therapies are focused on the modification of cognitive events, as a mean to change the actions of people with psychological disturbances (HernándezArdieta & Porres, 2007).

underlying belief systems. These are the cognitive-

The emergence of third-generation therapies

behavioral therapies. The third wave searched for

occurred mainly for two reasons: (1) ignorance about

different

cognitive-

the success or failure of cognitive therapy, and (2)

constructivism, contextualist readings of radical

the existence of functional conceptions of human

behaviorism, or several new cognitive models more

behavior (Hernández-Ardieta & Porres, 2007; Kahl et

interactive and less linear. It is guided by a contextual

al., 2012). This third generation thus represents a

view

interpersonal

qualitative leap, considering that the techniques are

relationships (Hayes, 2004; Zettle, 2011), different

geared not to include avoidance or reduction of

from direct attempts to change thoughts or feelings,

symptoms, but for the patient to act with

as was the practice of the previous two generations.

responsibility

A central tenet of the third-generation therapies is

acceptation of private events.

epistemologies,

private

events

such

and

that thoughts should not directly control actions, i.e. the person must act according to their values.

and personal choice with the

Third-generation

cognitive-behavioral

240 therapies

focus on the gap between form and function of

According to a recent review (Kahl, Winter, &

internal experiences. This means that more than

Schweiger, 2012), the first generation refers to the

trying to change the content, frequency and/or the

classical behavioral therapies supported by the

shape of the inner experiences, these therapies are

direct change of behavior through the manipulation

based on changing the context and function of the

of contingencies. Despite its advances and successes,

internal phenomenon (Kahl et al., 2012; Pérez-

these therapies have not proven to be effective in

Álvarez, 2012). Thus, the focus of these approaches

treating some adult psychopathologies. So there was

is a functional change of the psychological events,

a need to focus on the cognitive dimensions, and

and a change of the individual relationship with that

formalize these clinical approaches, and that's how

event (rather than directly changing the event).

cognitive-behavioral therapies emerged. These are

According to Hayes, Strosahl, and Wilson (1999),

the second-generation therapies, which took the

language also has an additional counterproductive

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effect. Individuals tend to lose contact with the

(Dougher & Hayes, 2000; Luciano, Valdivia,

present-moment, mainly because they report to

Gutiérrez, & Páez-Blarrina, 2006; Twohig, 2012). Its

conceptualizations of the past and the future. Thus,

unit of analysis is the organism as a whole, behaving

people become ‘hostages’ of their own stories and of

according to historical and contextual elements -

their ‘conceptual-self’, and this fact becomes more

thoughts, feelings and actions – developed over time

relevant in self-verbal descriptions (e.g., being a

and emerging in specific contexts in accordance with

victim), rather than in a commitment to more

an individual history and with a given function in

effective ways of behavior (Pérez-Álvarez, 2006;

behavior regulation (Dougher & Hayes, 2000;

Vandenberghe, 2011). Psychological inflexibility is

Luciano et al., 2006). ACT practitioners reject the

the result of this process, as desired qualities (values)

idea that thoughts cause feelings and actions,

and compromise for such actions are omitted by

because private events are embedded in a context,

more immediate objectives of well-being or in

and while this context needs to be specified, the

defense of the ‘conceptual-self’ (Kahl et al., 2012;

objective of predicting and influence the behavior

Pérez-Álvarez, 2012).

cannot be achieved. Once the context is specified,

Some of the most relevant third-generation therapies are Functional Analytic Psychotherapy (Kohlenberg & Tsai, 1991), Dialectical Behavior Therapy (Linehan et al., 1999), and Acceptance and Commitment Therapy (Hayes et al., 1999). However, increasingly, the Acceptance and Commitment Therapy (ACT) is assumed to be more representative of the therapies of this third wave (Hayes, Luoma, Bond, Masuda, & Lillis, 2006; Vandenberghe, 2011). Although only recently is becoming widely known and applied, ACT is not itself new, since it has been developed over almost the past 30 years (Hayes,

the very fact that these private events have specific meanings in certain contexts, demonstrates that they are dependent variables (such as actions). Thus, private events are responses to environmental events, without an independent causal relationship. Additionally, the mental causes of such behavior are accepted as inherently incomplete until the contextual variables are specified. The interest is directed to the historical context, that originates situational private events, and how thoughts, feelings and actions are related to each other (Hayes, Strosahl, & Wilson, 2011). Thus, an environmental event may invoke a specific private event and this, in

1984).

turn, can influence a particular action, but the cause ACT is based on a philosophical approach called Functional Contextualism (Hayes, Hayes, & Reese, 1988).

This

philosophical

perspective

characterized by being monistic, not mentalist, functional,

non-reductionist,

and

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ideographic

of the behavior is still in the environment. For this reason, thoughts and feelings are elaborated through mindfulness and acceptance techniques, rather than, for example, cognitive restructuring. Not assuming that private events are the cause of

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the behavior, ACT asserts that the focus is not on

There are six core processes of intervention in ACT,

changing such events, but to change individual’s

being that the combination of these aims for greater

relationships with their private worlds. For this to

psychological flexibility, i.e. the ability of a conscious

occur, the individual is taught to respond to external

human to entirely experience emotional and

events (such as doing things that matter to he/she),

cognitive outcomes, and change the behavior in

while private response succeed (whether aversive or

favor of chosen values. These six processes are:

not). The ultimate aim is to make the individual less

acceptance, cognitive defusion, being present, self as

sensitive to such private events, and more

context, values, and committed actions (Hayes et al.,

responsive to actual contingencies (Twohig, 2012).

1999).

ACT combines processes of acceptance and

The aim is that patients could experience the world

attention to processes of commitment and behavior

more directly, so that their behaviors becomes more

change in order to create/promote psychological

flexible and their actions more consistent with their

flexibility. In this approach, human suffering is the

values. This is achieved by allowing the dynamic of

result of language. This is understood based on

the therapy to exert greater control over the

studies about Relational Frame Theory (Hayes,

behavior, and using language more as a tool for the

Barnes-Holmes, & Roche, 2001), an assumption of

description of events rather than a tool for

language and cognition as precise, and empirically

predicting and judging events (Hayes, Masuda, et

solid, beyond its extension to psychopathology.

al., 2004). Values are qualities chosen with the

There is a significant and growing body of evidence

purpose that they may never exist as ‘objects’, but

about the efficacy of ACT in a wide range of disorders

rather as examples to be achieved step-by-step. ACT

(Hayes et al., 2006; Hayes, Masuda, Bissett, Luoma,

includes a variety of exercises that help the patient

& Guerrero, 2004), an issue that will be addressed

to choose life directions in different areas, in order

below. The underlying theory of ACT is relatively well

to reduce verbalization processes that may lead to

specified and researched, being that the processes of

choices based on avoidance, social connivance or

change mediate the therapy outcomes (Hayes et al.,

fusion. In this therapy, acceptance, defusion, and

2006). With a robust empirical level, it becomes

being present, do not have a proposed aim, although

possible to use data from behavioral problems as a

these processes appear as the most effective for

guide for the application of ACT in new areas. Once

experience a meaningful life, consistent with crucial

the model fits conceptually in the problem, and the

values. By

processes of change relate to this empirically, there

procedures, ACT proved to be one of the most

is a high likelihood of the therapy to become

flexible form of treatment since it stimulates the

effective.

development of broader patterns of effective action,

demonstrating

its

principles

and

based on chosen values (Wilson & Soriano, 2011). In

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this issue, ACT resembles to traditional behavioral

negative experience of anxiety. However, when it

therapies, and almost any method of coherent

happens in a generalized way, chronicity can

behavioral change can be adapted to ACT protocol,

produce severe limitations in a person’s quality of

including exposure, skills acquisition, training

life (Hayes, Strosahl, & Wilson, 2003). The immediate

methods, goal setting, etc. (Bach & Moran, 2008;

consequences that follows avoidance adjust, in part,

Hayes & Smith, 2005; Hayes & Strosahl, 2004;

to the aim pursued by the person (the reduction or

Luoma, Hayes, & Walser, 2007).

avoidance of something aversive which generates anxiety), but limits the person’s life causing that this does not reach to feel wellness (Hayes et al., 2003).

Experiential Avoidance and Anxiety

The second characteristic of experiential avoidance

ACT states that for thoughts, feelings and emotions

relates to the fact that it is limiting in functional

that are included in an anxiety response, control is

terms, i.e. the person in avoidance learned to

the problem, not the solution (Higuera, 2006).

respond to private events with aversion. Thus, the

Contrariwise, the suppression attempt of our

key aspect is that in almost all experiences, the

thoughts, feelings, emotions, and sensations leads us

person tends to try to control private events (Wilson

to raise the frequency of anxiety (Wegner, 1994;

& Soriano, 2011).

Wenzlaff & Wegner, 2000). A person living in a recurring pattern of avoidance is immersed in a vicious circle in which, in the presence of some disorder or distress or any aversive situation, takes place the need for a functional block. To face this avoidance, the person should do what feels right according to his personal history (Wilson & Soriano, 2011).

The paradoxical nature of experiential avoidance lies in the fact that the person who suffers from anxiety is implicated in making what he/she understands in order to eliminate it (applying time and effort for such purpose). However, this continuous avoidance/escape alters the function of any other event since the person wants to do the right thing, but is not getting the desired effect. This

The first characteristic of experiential avoidance is its

cyclic form of acting that involves effort as ‘the right

verbal nature. That is, this type of avoidance is

way’ to solve the problem is precisely the essential

present when a person is not willing to make contact

component of the disturbance rather than its

with their private experiences that were lived as so

solution (Hayes et al., 1999, 2003; Wilson & Soriano,

aversive anxious, and behaves deliberately to change

2011).

either the form or frequency of these experiences as well as the conditions that originate them. Thus, this behavior pattern often shows itself as apparently viable in the short-term, since it alleviates the

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The Role of Mindfulness in ACT

and emotions, and improves the ability to make

Mindfulness is usually conceived as an awareness of knowledge that emerges of paying attention with a

adaptive choices in the presence of aversive experiences (Baer, Fischer, & Huss, 2005).

purpose, in the present moment, moment-by-

The core components of mindfulness are: (1) observe

moment, and without making any value judgment

- be aware of events, emotions and the various

about the experience (Kabat-Zinn, 1990). Being a

aspects of behavior. This skill promotes learning to

relatively unknown concept in Western culture, in

detect and recognize these events and not to use

recent years its benefits have generated a growing

avoidant strategies or control emotions. The person

curiosity in the scientific community and have given

must observe the contents as separate from himself

rise to many empirical studies (Baer, 2003).

(defusion). With this, aversive feelings and thoughts

With third-generation therapies, new models of treatment and psychological interventions emerged, putting the emphasis on the role of problematic cognitions, emotions and physical sensations, rather than the content, form or frequency thereof; adopting strategies for personal change that are more

experiential.

Interventions

based

mindfulness skills have become amazingly popular and apply to a wide range of populations, from mental disorders or medical problems, to people who seek to reduce stress and promote well-being (Baer, 2003; Vandenberghe & Sousa, 2006). Currently there are mindfulness-based intervention

cease to be threatening; (2) describe - refers to the verbal report of the events and their own reactions to them. Here, choosing a language that is really descriptive, and not evaluative or explanatory, is very important; and (3) participate fully without promoting parallel activities to rationalize or justify (Bishop et al., 2004; Shapiro, Bootzin, Figueiredo, Lopez, & Schwartz, 2003). The qualities that define these skills are: (1) non-judgment: not evaluate or categorize; (2) be aware, in full, with one thing at a time; and (3) act in an effective manner, in full compliance with personal values and life goals (Hayes, 2004; Hayes et al., 2006).

programs being implemented in hospitals, clinics, schools, businesses, prisons, community centers, among

others,

worldwide.

The

efficacy

Efficacy of ACT in Anxiety Disorders

mindfulness-based interventions, i.e. those that encourage acceptance of the experience without judgment, is growing with great empirical support (Baer, 2003). It is thought that the practice of mindfulness, resulting in increased self-knowledge and acceptance, reduces the reactivity to thoughts

The body of evidence about the effectiveness of ACT is growing in a wide spectrum of disorders (Hayes et al., 2006; Hayes, Masuda, et al., 2004), including: depression (Zettle & Hayes, 1986), psychotic disorders (Bach & Hayes, 2002; García & Pérez, 2001), work stress (Bond & Bunce, 2000), eating disorders (Heffner, Sperry, Eiftert, & Detweiler,

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2002), addictions (Hayes, Wilson, et al., 2004;

acceptance

Luciano, Gómez, Hernández, & Cabello, 2001),

symptoms of anxiety and anxious cognitions, when

suicide (Hayes, Pistorello, & Biglan, 2008), as well as

compared to inspiration exercises (Eifert & Heffner,

in the management of medical and family problems

2003). In another study, Feldner, Zvolensky, Eifert,

(Biglan,

Montesinos,

and Spira (2003) demonstrated that subjects with

Hernandez, & Luciano, 2001). Additionally, one of

higher scores in emotional avoidance showed more

the areas where ACT has shown great relevance is in

anxiety reacting with CO2 and being instructed to

pain, with extremely encouraging results about

suppress their emotions. In patients with panic

changes in acceptance on issues related to pain and

disorder, methods of acceptance (Hayes et al., 1999)

psychological flexibility (Dahl, Wilson, & Nilsson,

were more profitable than control strategies (Levitt,

2004; McCracken, Vowles, & Eccleston, 2005;

Brown, Orsillo, & Barlow, 2004), when exposed to

Vowles, McCracken, & Eccleston, 2008). It is also

CO2.

Lewin,

Hops,

1990;

noteworthy that the efficacy of ACT has been shown to be cross-cultural (Wilson & Soriano, 2011).

reduced

experiential

avoidance,

In a similar study with anxious and depressed individuals, Campbell-Sills, Barlow, Brown, and

Within the scope of the present paper, concerning

Hofmann (2006) revealed that acceptance methods

anxiety disorders, the results are extremely positive

led either to a lower acceleration of the heart rate,

(Forsyth & Eifert, 2007; Hayes, 1987; Hayes et al.,

during the presentation of an aversive movie, as well

2008; Luciano & Gutiérrez, 2001; Orsillo, Roemer,

as to a more comfortable post-movie period, when

Block-Lerner, LeJeune, & Herbert, 2005; Twohig,

compared with control strategies applied in other

Hayes, & Masuda, 2006; see Sharp, 2012 for a recent

patients with the same problem. In Marcks and

review). Studies show that ACT can be effective in

Woods (2005) correlational study, results pointed to

the treatment of generalized anxiety disorder

a connection between the suppression of personal

(Roemer, Orsillo, & Salters-Pedneault, 2008),

intrusive thoughts and an increase in these thoughts,

obsessive-compulsive disorder (Twohig et al., 2006),

disturbances and the pressing need to do something

and posttraumatic stress disorder (Orsillo & Batten,

about the problem. Those who were more receptive

2005).

to negative thoughts were less obsessed, depressed

According to Eifert and Forsyth (2005), ACT can have an integrated application for use with any of the major anxiety disorders. For example, a randomized trial with anxious patients comparing control strategies versus acceptance, during a test inhalation of CO2, showed that an exercise oriented for

and anxious. In a second experiment, the authors found that instructions for suppression led to a high level of disturbance, while guidelines for acceptance - using small metaphors (cf. Hayes et al., 1999) - have reduced the discomfort but not the frequency of thoughts. ACT methods appear to have more comprehensive results that relate to the therapy

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model. Until now, and for the first time in the

years ago his father had a heart problem and the

psychotherapeutic literature, meditational studies

patient showed an anxiety peak. V.M.’s father died

are consistently positive, and are also compatible

about a year ago, and since then the patient’s anxiety

with positive clinical outcomes. This creates an

worsened. Despite being told by doctors that his

opportunity: now it is possible to examine the

father would die from the disease, he could not

efficacy of interventions in disorders, and ascertain if

accept the loss. The patient expresses a concern

ACT relates to it.

about its grieving process.

Based on the therapeutic process centered on ACT

About a month ago, V.M. ended a 4-year conflicting

and mindfulness, is presented a case of panic

romantic relationship. The patient sees himself as a

disorder with agoraphobia after psychotherapeutic 5

very anxious person about everything. About 6 years

sessions (but still in follow-up).

ago, the patient experienced a panic attack with a fainting episode, experience that he feels to be extremely awkward and limiting. V.M. reports to

Description, Evaluation, and Diagnosis of the Clinical Case

have a good social support network and enjoying his labor occupation. He would like to improve his

V.M. is a male patient with 33 years old, that begun

quality of life, not to feel so conditioned due to panic

a psychotherapeutic process (adjunct to psychiatric

attacks, and decrease contextual avoidances.

treatment), and presenting as core complaints at the beginning of treatment: anxiety, panic attacks, negative emotions associated with the loss of his father. He is medicated with Clonazepam 0.5mg and Venlafaxine 150mg. The patient was previously accompanied in a Psychiatry Service of a public hospital, but without significant clinical outcomes. V.M. had a childhood and adolescence without traumatic episodes, thus excluding a developmental etiology of panic attacks associated with adversity. He is employed and, in recent weeks, reported increasing responsibilities accompanied by great stress and anxiety. Refers having a ‘normal’ relationship with his mother. Recalls that despite having an ‘absent’

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The psychological evaluation of the clinical case, consisted in different measures. The Symptom Checklist-90-Revised (Derogatis & Savitz, 2000) was used as a general measure of psychopathology. The patient

presented

values

indicative

‘moderate/severe’ disorder in the dimension of phobic anxiety, and ‘mild/moderate’ disorder in the dimension of anxiety. The overall severity index is below the cutoff. In the Zung Self-Rating Anxiety Scale (Zung, 1971), the patient showed clinically significant general anxiety, especially at the level of cognitive, motor, and central nervous system anxiety. For the evaluation of specific aspects of panic symptoms, different measures were used. In the

father, always treated him with affection. A few

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Body Sensations Questionnaire (Chambless, Caputo,

life, intimate relationships, and work. In the

Bright, & Gallagher, 1984) the patient reported

Acceptance and Action Questionnaire - II (Bond et al.,

dizziness, floating sensation and balance as the main

2011), a measure that assesses the psychological

‘serious’ symptoms in feared situations. In the Fears

inflexibility and experiential avoidance, the patient

and Phobias Questionnaire (Marks & Mathews,

showed ‘significant avoidance’.

1979), he revealed ‘avoid almost always’ situations related to: injections or minor surgery, hospitals, and enter shops or crowded places. He also revealed ‘avoid very frequently’ the following situations: traveling alone by car, bus or train, walk alone on busy streets, and to speak with superiors or

Using the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR; American Psychiatric Association, 2000), the patient was diagnosed with panic disorder with agoraphobia. An additional concern was registered on the process of mourning concerning V.M.’s father’s loss.

authorities. Finally, in the Agoraphobic Cognitions Questionnaire (Chambless et al., 1984), the patient revealed an ‘extremely common’ occurrence of the

Psychotherapeutic Intervention

cognition ‘I will pass out’ when he’s nervous or

Taking into account data from the clinical interview

afraid. He also revealed a ‘frequent’ occurrence of

and the results of the psychological evaluation, the

the following cognitions, in the same situation: ‘I

psychotherapeutic intervention begun focused on

have a brain tumor’, ‘I will have a heart attack’, ‘I will

cognitive-behavioral models, especially on ACT and

not be able to control myself’, ‘I will have a stroke’,

mindfulness processes. The overall goals of the

and ‘I’m going insane’.

intervention were: 1) management of anxiety

To evaluate the emotional and social aspects of self-

symptoms associated with panic with agoraphobia;

concept, the Clinical Inventory of Self-Concept (Vaz-

2) intervention on grief and emotional management

Serra, 1986) was used. The results reveal that the

of self-concept; and 3) consideration of personal

patient has a self-concept slightly below the global

values, and main avoidance processes, so that the

average. In the specific dimensions, he presents a

patient could achieve greater psychological well-

low perception of self-efficacy and psychological

being.

maturity, as well as some impulsiveness.

More specifically, and considering ACT for anxiety

Two measures were selected in order to assess some

disorders (Eifert & Forsyth, 2005; Twohig et al.,

specific processes of ACT. In the Valued Living

2006), six basic processes (mentioned above) were

Questionnaire (Wilson, Sandoz, Kitchens, & Roberts,

worked with the patient: (a) acceptance -

2010), the patient reported as the most important

acknowledgement of and willingness to experience

areas in his life: family of origin, friends and social

all private events (i.e., thoughts, feelings, physical sensations); (b) cognitive defusion - decreasing the

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literal function of language/thoughts in their

change of dysfunctional beliefs about bodily

influence on behavior; (c) contact with the present

functioning and the consequences of sensations.

moment - recognition and engagement with present

Also, it was intended to familiarize the patient with

experience instead of behavior regulated by

the

thoughts about the past or the future; (d) self as

engagement with the therapeutic process. After

context - recognition of the self as a context in which

developing the ability of self-relaxation and have

private events occur, not as the product of their

modified he’s main interpretation distortions, it was

content; (e) values - clarification of values to provide

proposed to the patient to gradually exposure to

guidance and purpose to life instead of reliance on

internal/external stimuli that evoke fear.

private experiences; and (f) committed action behavioral commitments to follow chosen values instead of a life of inaction or impulsive choice based on the content of private experiences (Hayes et al., 1999).

cognitive model, in order to facilitate

This exposure was, initially, directed to the identified bodily sensations that triggers the attacks, and posteriorly

agoraphobic

contexts

identified in the psychological assessment of the patient. Thereafter, treatment was based on three

Because ACT is a process-based approach, therapy

main components, involving (1) autonomic reactions

was not provided using a standardized session-by-

(e.g., through diaphragmatic breathing, body scan,

session treatment protocol. Instead, therapy focused

progressive muscle relaxation, etc.), (2) cognitive

on the six target ACT processes flexibly and as

restructuring, and (3) gradual exposures. Using ACT,

needed for this specific case. V.M. was seen for 5

the overall effectiveness of attempts to control or

weekly 90-minute sessions (although the treatment

regulate anxiety in general was discussed. For

is still ongoing). ACT, as delivered to this patient, can

example, V.M. was stimulated to produce a list of all

be summarized in four steps, accordingly to previous

the techniques and strategies he had used to control

reports (e.g., Codd, Twohig, Crosby, & Enno, 2011;

anxiety. These would then be rated according to

Eifert et al., 2009).

short-term and then long-term effectiveness. Then,

The first step of treatment involved a collaborative, supportive, and detailed examination of patient typical responses to and ways of coping with anxiety. Thus, the psychotherapeutic process began with the therapist devoting sufficient time to answer patient questions/doubts, but also to provide information about anxiety and panic disorder (with agoraphobia). The objective was to promote, from the beginning, a

the patient was asked to notice the negative effects resulting from the attempts to control anxiety (e.g., the negative effects of avoidance). V.M. generally concluded that responding to anxious experiences by trying to control or eliminate them was somewhat effective in the short term but not effective in the long term, and often had negative consequences. V.M. was also asked to evaluate his experiences of attempting to regulate or control anxiety between

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therapy sessions. Eventually, he acknowledged the

followed based on how useful they are in guiding

limited success of these strategies and was willing to

responses

consider alternative responses to anxiety.

diaphragmatic breathing as a baseline, the patient

In the second step of treatment, acceptance was introduced as an alternative response to anxiety in place of the traditional attempts to control or regulate anxiety. The focus of therapy shifted from regulating anxiety to mindfully accepting the presence of anxiety and anxiety-related inner experiences while working to improve daily functioning and overall quality of life. The patient was taught how to allow anxiety to occur without needing to regulate or control it through the use of metaphors and experiential exercises. For example, the struggle with anxiety was compared to being stuck in quicksand. It was suggested that the more V.M. struggled against the quicksand (the anxiety), the faster he would sink. It was suggested that acceptance was comparable to letting go of the struggle against the quicksand and increasing contact or surface area with the very thing the patient

trying

escape

(i.e.,

the

quicksand/anxiety). This allowed V.M. to consider some exposure to aversive stimulus/contexts previously avoided. In step three, the focus was on defusion and self as context. Rather than helping V.M to develop skills to determine whether any particular thought was accurate or meaningful, he learned when to follow or respond to thoughts and when to just let them occur without responding to them. This occurs as a form of discrimination training, where thoughts are

any

given

moment.

Using

experienced for the first time a mindfulness exercise (sensations, sounds and thoughts). In other words, the focus shifted from the content of thoughts to the function of thoughts. This was also taught through metaphors and discussions. An example of a defusion metaphor was comparing private events to passengers on a bus driven by the patient. V.M. was encouraged to notice the passengers and realize that although they may appear threatening and influence the route taken, the passengers cannot actually change where he chooses to drive. Self as context is similar to defusion in that it focuses on the way the patient responded to inner experiences. Self as context particularly has to do with experiencing inner experiences as events that occur within us but are not defining of us. For example, it was told to V.M. that anxiety is something we all experience, not something we are. This is often compared to a game of chess in which the pieces represent private experiences, and it is suggested that the patient is the chessboard - the place or context in which the pieces are experienced. As the patient continued to practice acceptance, defusion, and self as context, step four was conducted in the fifth session, shifting to the development

values-driven

behavior.

This

involved the identification of idiosyncratic-valued behavioral ‘directions’ and behavioral commitment strategies designed to increase behavior controlled by these valued directions rather than behavior

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functioning to avoid or escape anxious experience.

The therapeutic process is not yet finished, but

As referred, values are defined in ACT as areas of life

V.M.’s prognosis is encouraging. The patient,

that are meaningful that one would be willing to

meanwhile, reduced medication advised by the

work toward. Values can never be accomplished

Psychiatrist, being more stable and confident in

(e.g., valuing education vs. obtaining a college

treatment success of treatment.

degree), thus they have the ability to guide behavior over long periods of time and continue to motivate actions well after therapy. Values were addressed at

Conclusion

this period in order to replace the focus on anxiety

The present report intended to highlight the

regulation. Weekly commitments were made to

potential benefits of one of the most prominent

follow V.M. values instead of controlling anxiety. The

third-generation therapies, the ACT procedures

patient was also instructed to practice acceptance,

along with mindfulness techniques, in the treatment

defusion, and self as context while engaging in these

of a case of panic disorder with agoraphobia. Besides

actions.

more ‘classical’ procedures, with proven efficacy

At this point, was given focus to the perception that the patient has about his own symptoms related to the father’s loss (family values). It proved necessary to work aspects of unresolved grief, since this was manifested in psychological distress in the patient, i.e., maladaptive interpretations were worked, that

(e.g., Salkovskis, 2007), for the psychotherapeutic treatment of this disorder, the present work aims to demonstrate how ACT can actually help in the emotional well-being recovery and quality of life of patients suffering from the physiological and cognitive vicissitudes of anxiety disorders.

interfered in the elaboration process of the loss. Subsequently, focus was given to experiential avoidance caused by anxiety, and the need to manage it in order to promote a social life (be with friends), and for example, to do sports without anxious ruminations (value of social relationships). At the same time, V.M. started approaching attractive women and initiating conversations. These activities may appear similar to traditional exposure exercises or behavioral experiments, but they aim to be functionally different in that the patient focuses on acceptance and defusion of anxiety-related inner experiences.

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Clinical Psychology: Science and Practice, 11(3), 230-241.

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Opinion article Inclusion of people with disabilities: Neuroscience and relevant aspects to teacher training – The Brazilian Experience in recent years Graziela Raupp Pereira (1) & Jaime Monte (2) (1). Post-doctorate and Doctor in education from the University of Aveiro. Didactic Research Center researcher and technology in the training of trainers of CIDTFF/AU and of the research group training of educators and sex education (EDUSEX/CNPq). Faculty of distance education Centre of the University of the State of Santa Catarina / Brasil. Corresponding Author: graziela.pereira@ua.pt (2). Doctor of education. Coordinator of the postgraduate course in Pedagogy and Learning laboratory and Social inclusion (LAPIS) from City University of Palhoça. Brasil. Contact: psicojaimemonte@gmail.com.br

____________________________________________________________________________________

The historic changes that have occurred in the Brazilian education in the decades of 80 and 90 of

training courses proliferated to work with the disabled person.

20th century pointed to the need for policies of

The proposal of an inclusive school won supporters

inclusion of people with disabilities in the regular

and opponents. Some teachers placed themselves

school network, with the goal to remove the subject

against the idea of inclusion because they

of special education schools.

understood that the Brazilian Government didn't

The law of Guidelines and Bases of Brazilian Education (LDB) of 1996, in articles 58 and 59 states that the disabled student must be serviced on regular teaching by professionals trained in undergraduate and postgraduate level. States also that the teaching methodology adopted by regular educational network must be focused and suited to the needs of the individual with disabilities. The requirements of LDB and the need to understand the subject with disabilities led teachers to review their educational values to serve the new population that went on to attend the school space outside of special education. In this way, teacher

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bother to restructure the education system to meet the LDB and the subject with disabilities. In the process of building an inclusive school some questions needed to be answered: what is, in fact, the inclusion? What is the profile of the subject that could benefit from an inclusive school? How to update the knowledge of teachers for the construction of an inclusive school? To define what school inclusion is we need before, differentiate the inclusive movement of school integration process. During the Decade of 90 of last century Brazilian school went on to meet the eligible subject to integration in network for regular school

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teaching. Who defined the profile of the subject that

architectural plan and on the pedagogical aspect.

was eligible for regular education network was the

Need to reorganize and adapt teaching methods in

special school. The handicapped was enrolled in

such a way as to enable the handicapped the

special school and when presented an intellectual

acquisition of academic content.

and academic achievement that would follow other students of regular education network, was ready to be integrated and used to attend regular education network.

The idea of school inclusion is within a conception of inclusive society that seeks a more just and egalitarian society. According to Carneiro (2007) an inclusive society turns to production of egalitarian

Initially the student attended special school in one

relationships and includes every person and when

shift and the other would shift to the regular

facing the field of individuality allows the subject

education, and, little by little he was definitely off the

perform choices and build your private and social

special school. The purpose of integration was the

identity. The inclusive society is one that recognizes

adaptation of the subject to the education system

the differences and respect in order to adapt with

and the culture of the school to which he belonged.

views to equality of rights and opportunity of socially

Brazilian educators noted that school integration of the disabled was inadequate because it did not consider the particularities of the disabled: the idea

produced services to all citizens. The design of inclusive society enables educators to think in an inclusive school.

was that "If the subject with disabilities could adapt

For Silva (2007) the school inclusion is a process that

to regular educational network he wouldn't need a

is being built over time. The inclusion is perceived

special school and his disability

as a process, requires attention since each

would be

questionable."

inclusive action is unique, and relates to the needs of

Another element discussed was how the school worked in the process of integration, generate social inequality and was used as an ideological State

each institution, and relates to the characteristics of the subject to whom the inclusive actions are directed.

apparatus (Althusser, 1985). Integration valued the

When you think the inclusion process, there's no way

school and forgot the subject in the process of

to decouples it from the process of social exclusion

schooling. In this way, it was opposed to the inclusive

constituted historically. The inequality of rights of

movement integration.

people with disabilities, on Brazilian soil, leads to

The inclusive movement assumes that the subject is the Centre of the teaching process, so the school must adapt to the needs of the subject. This reorganization of the school occurs in the

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special school which acts as agent of social exclusion. Special schools of Brazil brings in their culture the habit using school bus to pick up the student at his home and at the end of turn the school students is

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taken home. This practice is considered exclusionary

for decades, about the impossibility of developing

because it avoids the visibility of the disabled and

the subject with disabilities. As stated by Heller

restricts social conviviality of the disabled. The

(1990) the prejudice is a false value judgment that is

special school that do not offers courses organized

crystallized in the culture that got the truth value.

and systematized as the regular schools, the uncertainty regarding the beginning and end of schooling, etc., take the handicapped to attend

Identify the potential for development of people with disabilities has been the challenge for regular school teachers.

special schools from start to the end of their lives. The school began to receive people with disabilities The special Brazilian school turns out to have a paternalistic function rather than educate the subject for new acquisitions. This characteristic of the special school is associated with the Foundation of the first institutions of service to disabled persons, these institutions offered rehabilitation and medical assistance and over the years tried to keep up as school space, but collide in parents ' wishes that require therapy and rehabilitation efforts. The institutionalization process along with the poor educational goal of handicapped person, required a higher level training focused on specialization for special education. Thus arose the upper courses which enabled to work in special school. Was set that the teacher in special education work in special schools and teachers with other qualifications would work in regular educational network. From the 21st century, the Brazilian education sought to break away from the dichotomy: special school teacher and teacher of regular teaching network in harmony with inclusive ideals thus fostering inclusion is more than adapting the architectural structure and the method of teaching is to break with the prejudice, historically constituted

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of all nature: Down's Syndromes, intense upward, mentally handicapped and subjects with multiple deficiencies and brain palsy. When working with a student population that was not prepared, the teacher faced with the uncertainty of how to conduct the teaching process with regard to the teaching method and the way the handicapped would be evaluated in relation to students who do not have disabilities. The insecurities of teachers under the training process arose and, with the exception of professors with higher training in pedagogy who works in the initial years of schooling process, teachers of mathematics, history, mother language and other areas of knowledge, little knew about the normal development of the subject and how are configured the shortcomings of congenital and evolutionary origin. Trevizan (2008), when performing his research with teachers on teacher education, noted that its population pointed out the need for more information about the inclusive process of person with disabilities. The concern of teachers generated discussions about the work to be performed in the

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classroom. The professor felt helpless because there

In 2011 the first course was held for Neuroscience

was no inside the school other professionals who

applied to education. The course is the product of a

could contribute to the understanding of the various

partnership between teachers of the Universidade

expressions

Other

do Estado de Santa Catarina (UDESC) and teacher at

professionals (audiologist, psychologist, counselors)

the Federal University of Santa Catarina for the

that could assist the educator to take ownership of

accomplishment of the first course that could

the knowledge about the type of disability that the

empower teachers, regular education network, in

student had. Inside the classroom, the teacher only

the area of neuroscience. The course was

knew the type of disability of the student while the

coordinated by Isabel Cristina da Cunha, aimed to

educating process in was ongoing.

bring teachers to take ownership of knowledge of

the

shortcomings.

It is in this context that the knowledge produced by Neuroscience is asked to collaborate with the teacher training. Initially, the teacher had to take

neuroscience in order to carry out the understanding of students' bio psychological manifestations of the subject with disabilities into school context.

ownership of the characteristics of each type of

The Applied Neuroscience course education takes

disability, understanding that are associated and

place annually and leads with: understanding of

multiple disabilities. The teacher need, too, to take

basic neurophysiology, General Organization of the

ownership of the knowledge about the behavioral

central

changes, caused by the use of drugs.

motivational Systems of the brain. The course was

The teacher in the classroom, cannot differentiate the behavioral expressions of student disabilities related to the type of disability, behavioral

nervous

system,

behavioral

and

attended by 24 participants and five teachers and occurred once a week for four months, characterized as a bimodal course – classroom and distance.

expressions and changes of conduct caused by the

During the realization of this course was possible to

use of remedies that aimed to inhibit seizures, help

work various types of disabilities and syndromes. In

the person in the control of sphincters control, as

particular a theme mobilized the desire and

well as the mood and behavior of the subjects with

attention of the group. The group brought a question

one or with disabilities.

for reflection: why for some teachers the inclusion of

The inclusion movement highlights the shortcomings in the training of teachers and states that it takes the dialogue between various areas of knowledge for the creation of a teachers' training programs meet the heterogeneous population that the school began to

people with disabilities is a challenging and motivating work and allows them to test their creativity and sharpens your curiosity while for other teachers working with the handicapped is perceived workload and leads to discouragement? The answer to this question is related to the bio psychological

receive.

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Constitution of the subject in interaction with

dopamine, noradrenalin and others are insufficient

working conditions.

and participate in the Organization of the

According to Bergamine (2007), motivated behavior

depression.

is the vital impulse of the subject and is directed to a target aware. For Maslow, in Bergamini (2007), the motivation originates in the survival needs of the subject. For this author, the behavior of satisfaction and the motivational behavior obey an ascending hierarchy: first the subject seeks to satisfy their physiological needs, then look for safety, social and affective

interaction,

actualization.

self-esteem

and

self-

When the person has material

conditions to satisfy their physiological needs, safety is balanced in the affective and social factors and increase the probability of the subject feel motivated in the face of challenging situations, this is because his need is of search actions that feed their selfesteem and self-actualization.

“For more than three decades, the biological bases of depressive disorders have been explained by means of the monoamine hypothesis of depression. This theory proposes that depression is a consequence of reduced availability

brain

biogenic

amines,

particularly of serotonin, norepinephrine and/or dopamine. Such proposition is enhanced by the knowledge of the mechanism of action of antidepressants, increasing

the

which

based

availability

mainly of

these

neurotransmitters in the synaptic cleft, either by inhibition (selective or not) of their reuptake, either by inhibition of the enzyme responsible

From the point of view of biology, motivated

for its degradation (treatment with irreversible

behaviors are related to the survival of the

monoamine oxidase inhibitors)” (Vismari, et al.

individual. Relates to feeding behavior, and

p. 197). 262

defensive player. So, experimental studies are performed with animals on the conduction of the nerve impulse and neurochemical summaries on food needs, and reproductive of self-defense. In humans it is possible to observe the absence of motivation in psychopathological frames like in the depression. In depression the subject has low selfesteem and little energy for everyday actions. In the pathophysiology of depression the brain modifies the production of neurochemical substances. The production of neurochemicals like serotonin,

For Rubinstein (1967), motivation is the result of the interaction between the subject and the social and cultural environment. According to the author, the basic needs becomes conscious interests. The needs and interests of the subject make up the motivation. Rubinstein (1967) states that the elements that motivate the subject are associated with the historical context, the values socially mediated. Therefore, the work of teacher training is an ongoing process, which begins at graduation.

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Alarcão and Tavares contend that the pedagogical

Pimenta (2005) asserts that the school organizations

practice "is a slow process that started in the so-

are producing social practices, values, beliefs and

called initial training, should not end with the

knowledge, moved by the effort to seek new

professionalization, but linger without breach of

solutions to the problems experienced. Thus, the

continuity in the so-called and so little considered

way that the educational process adopts in each

continuing education" (2007, p. 11).

historical moment will always be provisional result of conflicting relations of that time.

The inclusion as a fundamental theme in education refers to the need for specific training, which is of paramount importance that teachers get in touch with their own difficulties facing situations that don't know how to respond, with theoretical questions, discussions, readings concerning the theme.

Faced with this reality, gain equal importance the dynamics resulting from the motivation and teacher practice, whether in any level of education, involving understanding and decision of various problems. These, of course, always expressing respect to the circumstances of the Organization of the education system, the shortcomings of the students, their

So, provide spaces for discussion and reflection is essential. Deconstruct myths is only a first step towards the construction of new knowledge to an intentional inclusion motivating. Allied to these issues,

emerges another

one

regarding the

pedagogical practice of teachers to work with their

personal needs, as well as their social and political relations. We have to stress that educators, in your act and work, develops professional perfection and a vast knowledge, as well as an in-depth reflection in educational policies and practices of numerous countries.

students. All these questions are present in the daily life of the classroom where teachers are faced with the reality of schools. In this context, a system of application in the training of teachers on inclusive education in higher education institutions will constitute a decisive step towards the students like right to information on the subject of integration and welfare of students with disabilities.

263 Perrenoud (1999) states that: “The conditions and contexts of teaching evolve faster and faster, making it impossible to live with the purchase of an initial formation that quickly becomes obsolete and it is more realistic to imagine that a well-thought-out

In this context, intervention in the process of training

training will give new recipes when the old

of teachers for inclusive education, education

ones no longer work; the teacher should

institutions, will constitute a decisive step towards

become someone who designs his own

the students with disabilities, thus promoting the

practice to tackle effectively the variability

right to information and their well-being.

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and the transformation of their working

problems is necessary for thought reform". It is

conditions” (p. 11).

essential, in the process of knowledge, to meet information, data and opinions from this knowledge, or for teaching and learning. Thus is necessary

Several authors share the same idea, arguing that no training is built by accumulation of knowledge, courses or techniques, but a work of critical and systematic reflection on practices. This means that the model of continuing education is the reflection made by teachers on their daily practice (Alarcão & Tavares, 2007; Pereira, 2009, 2013). In this way, the way of acting of the teacher needs to be constantly revisited, i.e. continuing training as a dynamic process should allow the teacher consider and

specify the studies that comprise the greatness of the puzzles of science that characterize and closing skills to answer the tangled social dynamics. An example of this are the universities and other institutions of higher education, to which competes the responsibility to answer for the training of its teachers. In this time of accelerated changes, this responsibility can be seen as a producer of consequences in the future, but that may or should be viewed, at least partly, in actuality.

reconsider their pedagogical practice, in such a way that can rearrange it to fit and integrate all its students. Thus, knowledge sharing and the exchange of experiences is fundamental in the formation of the teacher, since each one of them is designated to undertake jointly the role of trainer and forming

Besides, the University is indirectly responsible for the quality of basic education, because the Faculty of this segment is formed in degrees. The interaction University/School always presented aspects both professional

and

technical

participation

and

involvement with regard to citizenship. The school,

(Nóvoa, 1995).

in addition to preparing their students for Teacher's role is much more complex and cannot be reduced to the simple transmission of knowledge

citizenship, need to understand the various realities of their students, including students with disabilities.

ever produced. Throughout her training (initial and continuing), he needs to get subsidies to understand the construction of knowledge, educational school, as an area of knowledge sharing, cultures, values, and skills development, changes can and should be a place for an inclusive education.

In this perspective, the interaction between higher education and basic education went on to be an important topic of debate in the analysis of teacher education for inclusive education, intentional, primarily from the late 1980s. From that period, began to appear the first training courses. These,

Morin (2002, p. 35), for whom "the knowledge of the world as world's need, at the same time intellectual and vital", he adds that "to articulate and organize

however, are still considered disabled because, are, in most cases, falling short of the needs of teachers. For continued effective training, teacher needs to

knowledge and thus recognize and meet the world's

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question his pedagogical practice in pursuit of

For example, in Brazil, after the publication of the

resolution of their difficulties. The higher the

current guidelines and Bases for national education

questioning, the better their training. For this to

(Brazil, law No. 9,394 of December 20, 1996),

occur, the role of the teacher has to include certain

opinions and resolutions approved by the Full Board

postures. Must be a professional one, in addition to

of the National Council of Education support, at least

scientific knowledge, develop diverse social, political

in two major theoretical bases: the notion of

skills, among others. Considerations about the

reflective teacher, diffused by Schön; and the notion

continuous formation of professors contributes to

of professional competencies, Perrenoud (1999). In

the sense that the formation of a trader starts even

the documents previously mentioned, emphasizes

before their academic training and lasts throughout

the impossibility of leaving the future professor to

his professional activity.

assess function and overcome its "know-how" to

In a broader sense, the integration between the continuing training of the teacher and their initial

"do", without opportunity to participate in a collective and systematic reflection on this process.

training helps in understanding that studies on

With this in mind, the training courses need to

formation of teachers should associate academic

anticipate situations in which teachers put in use the

and professional practices of teachers with their

knowledge gained, while they can mobilize others, of

personal experiences, in order to catch as they're

different

being building values and attitudes in relation to the

experiences, in different times and spaces.

profession and to inclusive education.

natures

and

come

from

different

Although being indisputable prominence at the

According to Morin (2002), "the fundamental

University, being the main forum teachers' trainer,

problems

absent

this went on to receive harsh criticism for its

disciplinary Sciences". The goal, then, is to overcome

inadequacy in the fulfilment of this function. Their

this reality, which will only be possible when you

questioning and your question should be, how we

start to think differently, from mutations of

feel about the pedagogical practice, although yet

paradigms and theoretical and practical approaches

little experienced. It is proposed, therefore, that

that guide the formation and practice of teachers. It

students in teacher training are inserted in situations

is clear then the concern to combine the vision,

of direct experience as before, shortening the gap

"theory" and "practice" in the discussion about

between theory and practice.

and

global

problems

are

teacher training. The inadequate relationship between "theory" and "practice" is still one of the problems that most strongly appear in the discussion of teacher training (Candau, 2005).

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It is important to note that this view of study in teacher education has considerable usefulness of study of reflective thinking on teachers as a factor that influences and determines the educational

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practice. It turns out that teachers possess practical

where educational situations and/or concerns with

theories of action, what is elementary.

the personal and professional development of

Dewey, in the 30rs (last century), argues that "the mere knowledge of the methods is not enough, because we need to have the desire and the will to

teachers, to understand the reality of and the progress of the critical conscience of human beings are truly necessary.

employ" (1989, p. 43). The first attitude required for

The

a reflective teaching is the open-mindedness, which

modifications that need to be understood and

Dewey defines as:

incorporated. In this context, it will be necessary

“The absence of prejudices, bias and any habit that limit the mind and stop to consider new problems and to take on new ideas and that integrates an active desire to hear more than one hand to welcome the facts regardless of its source, to watch without sensitive to all alternatives, to recognize

current

society

undergoes

profound

pedagogical practices that encourage and instigate future teachers to think about their insertion in the educational area, so that they can act with competence and professionalism. It is important to a deepening of the themes addressed in school, allowing to follow these transformations, as well as its conscious and positive contribution.

the error even on what in what we believe”

Facing the recognition of the important role that the

(1989, p. 43).

professor must play, we would stress the idea that globalization brings us back to the vision of global knowledge,

As can be seen, this approach imposes a look under diverse perspectives, to devote attention to the options available, to find out the possibilities of error, to inquire, reflect conflicting evidence about how to improve what already exists.

unsegmented,

and

that

their

fragmentation into disciplines is only part of the moment of its production. You can tell that the modern posing challenges to educators and future teachers the need to break away from the confines of the fragmented training and to rebuild the

We add the importance of teachers adopt attitudes

relationships of the specific area of knowledge with

and reflective capacity, to become able to carry out

other corresponding areas of knowledge.

systematic and continuous transformations and discover the pleasure by motivation and constant modernization.

In addition to inclusion, the curricular structure itself needs to be frequently revisited. Whereas, in turn, the diversity of areas and courses, students,

In this way, it becomes no doubt, nowadays, that the

professors

initial and continued training of teachers to organize

methodologies: it could be applied in a pedagogy for

about reflective practice, seeking concerns in areas

motivation during the General schooling, requiring a

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and

teachers,

educators

and

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considerable transformation of the relation of

the brainstorming exercise in Group and the

teachers with knowledge of his way of teaching, of

development of skills to address this issue.

their identity and of their own professional skills. Thus, the selection of a strategy for the development of a given jurisdiction must include a set of learning objectives associated to it. With a view to integral development of forming, we need a resume for competence, i.e. a new educational paradigm that bet on motivation, active methodologies to develop

Education is a basic human right, is considered essential to accomplish the political, social and economic changes. The inclusive education doesn't escape that reality. Teachers, although constrained by the limits and possibilities of the structure of the educational system, should not remain indifferent to it.

the pupil, in particular, and in competence of "learning to learn". Therefore, the teacher should take a questioning of his own practice and seek educational experiences

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that can be successful and dynamic in teaching

Prática

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Estado. Rio de Janeiro: Editora Graal.

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