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Particpation-Engagement
Shahar and Davidson
Participation-Engagement: A Philosophically
Based Heuristic for Prioritizing Clinical Interventions in the Treatment of Comorbid, Complex,
and Chronic Psychiatric Conditions
Golan Shahar and Larry Davidson
We propose Participation-Engagement (PAR-EN) as a philosophically based heuristic for prioritizing interventions in comorbid, complex, and chronic psychiatric
conditions. Drawing from 1) the sociologist Talcott Parsons, 2) the continentalphilosophical tradition, and 3) our own previous work (Davidson & Shahar,
2009; Shahar, 2004, 2006), we argue that participation in personally meaningful
life goals represents a hallmark of mental health. Symptoms and vulnerabilities
that impede such participation should therefore be targeted vigorously, whereas
others which do not pose such imminent threats should assume a secondary focus,
if at all. Winnicotts (1987) notion of the spontaneous gesture, the importance of
daily activities as reflecting patients participation, and the dialectics of interpersonal relatedness and self-definition, are introduced as guidelines for implementing PAR-EN. Implications for clinical assessment and the therapeutic relationship
are discussed.
Golan Shahar, PhD, is Professor of Psychology, Department of Psychology, Ben-Gurion University of the Negev,
Israel. Visiting Associate Professor of Psychiatry, Yale University Medical School. Larry Davidson, PhD, is Director
of the Program for Recovery and Community Health, Yale University Medical School.
Corresponding author: Golan Shahar, Ph.D. Department of Psychology and the Stress & Personality (StreP) Lab,
Ben-Gurion University of the Negev, Beer-Sheva 84105, Israel. E-mail: shaharg@bgu.ac.il, Golan.shahar@yale.edu
155
1. Jonathan is not a real individual. Rather, he is a composite of several patients of ours, all of whom presented with
comorbidity, chronicity, and treatment resistance, and for all of whom PAR-EN was found to be helpful. In fact,
these patients are the real originators of PAR-EN, and we wish to thank them for that.
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ments. Such an understanding was eventually gained through a close look at the link
between Jonathans interpersonal style and
transference-counter-transference exchanges,
as well as through findings from the projective tests. These suggested that Jonathan experienced significant others as domineering
and punitive, and himself as largely feeble
and weak. Also evident, was his tendency to
utilize defensive projection, projective identification, and turning against the self, while in
interpersonal confrontations, many of which
he himself generated.
What was a psychotherapist to do,
then? This is a frequently asked question
in commonly occurring situations in which
patients present comorbid, complex, and
chronic clinical conditions. The purpose
of this article is to address this problem by
proposing Participation-Engagement (henceforth, PAR-EN) as a philosophically based
heuristic for prioritizing clinical interventions in such cases. In what follows we 1)
briefly describe the role of comorbidity, case
complexity, and chronicity in psychiatric
practice; 2) define PAR-EN and present its
philosophical and clinical rationale; and 3)
locate PAR-EN within the broader context
of clinical assessment and the therapeutic relationship.
Comorbidity, case
complexity, and chronicity:
The unholy trinity of
psychiatric practice
The prevalence of psychiatric comorbidity is overwhelming (e.g., Angold, Costello, & Erkanli, 1999; Clark, Watson, &
Reynolds, 1995; Kendall & Clarkin, 1992;
Kessler et al., 1994; Kessler et al., 1996;
Reiger et al., 1990; Swendsen & Merikangas, 2000; Watson & Clark, 1998; for an
excellent overarching treatment of this issue,
see Maser & Cloninger, 1990, as well as the
special issue on comorbidity and treatment
implications of the 60[6] issue of the Journal
psychiatric picture. Similar to psychiatric comorbidity, case complexity has been shown
to seriously impede the delivery of evidencebased pharmacological and psychotherapeutic treatments (e.g., Blatt & Zuroff, 2005;
Westen et al., 2004; but see Kazdin & Whitley, 2006, for evidence that comorbidity and
case complexity do not impede outcome for
evidence based treatment of child disruptive
behavior).
Chronicity is a third participant in an
unholy trinity of obstacles for evidencebased psychiatric treatments. For obvious
reasons, personality disorders are, by definition, chronic conditions. However, many
DSM-IV Axis I disorders assume a chronic
course (e.g., Joiner, 2000; Leahy, 2007; Pettit
& Joiner, 2006; Strober, 2004), and chronicity is associated with poorer outcome (e.g.,
Fenton & McGlashan, 1987).2 What needs
to be appreciated is the fact that chronic
psychiatric cases are deeply embedded in patients social contexts and life situations. For
instance, personality disorders are likely to
generate interpersonal stress (Daley, Hammen, Davila, & Burge, 1998), and chronic
depression is likely to erode social support
(Joiner, 2000). Thus, the chronicity of caseness, which might be caused by comorbidity
and case complexity, is also likely to give rise
to these complications. Moreover, because
of previous treatment failures, people with
chronic psychiatric disorders are likely to be
demoralized, and are less likely to assume an
active role vis--vis their medical care.
It is probably clear from the above that
Jonathan constitutes an exemplar for the unholy trinity of psychiatric practice, namely,
comorbidity, case complexity, and chronicity. Specifically, this young man presents a
clinical picture that meets criteria for Panic
Disorder with Agoraphobia, Dysthemic Disorder, and a Paranoid Personality Disorder.
Such comorbidity is further complicated by
case complexity, namely, by the presence
of several risk factors, both contextual (the
157
2. In the present article we treat recurrent disorders as tantamount to chronic ones (e.g., Leahy, 2007).
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Particpation-Engagement
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well during the night. It was therefore apparent that this young man needed our help
first and foremostin getting some sleep.
Accordingly, Jonathan agreed to a
trial of cognitive-behavioral treatment for
insomnia. This, however, did not work.
While he followed the sleep hygiene instructions scrupulously, he still had trouble falling asleep because his mind was racing with
anxious thoughts, including thoughts of not
being able to sleep. In consultation with the
psychiatrist, we therefore resorted to a low
dose (.5 mg) of Lorazepam, instructed to
be taken two hours before bedtime. Fortunately, this worked, and enabled him to fall
asleep, which was his major nocturnal obstacle. When he woke up during the night,
he was quick to implement the sleep hygiene
instructions that had been given to him and
was able to go back to sleep. In the course of
the next five weeks, his sleep improved markedly in terms of both quantity and quality.
This, while not improving his mood, did improve his concentration and enabled him to
study better. Such an improvement, in turn,
helped persuade him that treatment, instead
of being potentially detrimental, actually had
something concrete to offer him.
What next? This is what we asked
Jonathan. He was still suffering from severe
panic attacks, alongside the aforementioned
depressive symptoms. Evidence-based psychotherapy for panic disorder is quite different from that employed for depression, the
former comprising interceptive exposure and
the latter, either cognitive behavioral treatment or interpersonal psychotherapy. It was
up to Jonathan to decide which syndrome he
wanted to address first. Again, he reached
this decision based on his prime personal
project.
Of all the debilitating symptoms he
suffered, negative depressive cognitions
were the most troublesome with respect to
his struggle for becoming (a philosopher).
Constant social comparison with classmates,
obsessive and depressive ruminations about
his (perceived meager) prospects of success,
as well as the potential of failure, pervaded
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Particpation-Engagement
pretty much contained, and that he was interested in moving forward in another direction. Its time for me to find a woman, he
said. Up to this point, Jonathan had never
had a stable, ongoing romantic relationship.
A major impediment to this quest was the
fact that Jonathan was extremely insecure in
approaching women, and he felt that there
was little chance they would be attracted to
him.
Concerned that Jonathans zeal to
find a woman would set him up for a failure (and most of Jonathans projects were
conceived, albeit secretly, with great zeal),
I (GS) proposed to Jonathan to view this
stage in the treatment as opening up to the
world. Consulting the manual for Interpersonal Therapy (IPT) for depression (Weissman, Markowitz, & Klerman, 2000), I construed Jonathans predicament at this stage as
that of interpersonal deficits, and proceeded,
vis--vis the manual, to (a) review past interpersonal relationships, (b) reexamine the
therapeutic relationship, but this time with a
focus on social skills rather than on unconscious, transference-countertransference exchanges, and (c) systematically employ communication analysis of Jonathans attempt
to form relationships, as well as role playing
pertaining to new friendships, in order to
help him acquire needed skills (for extensive
description, see Weissman et al., 2000, pp.
103-116).
This process is still ongoing. Jonathan
is currently in treatment, still having sporadic panic attacks, and has not yet found
a woman. I await his lead on working on
these issuesor, as often happens, on addressing something else based on the dictum
of his personal projects.
PAR-EN and patients
spontaneous gestures
165
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Particpation-Engagement
167
168
tion (TAF) as heuristic for clinical case formulation. The purpose of TAF is to identify
individuals actions on their social environment, with a focus on the interplay between
vicious, maladaptive, and risk-related interpersonal cycles (e.g., a person generates
life stress, which in turn increases her/his
depression, cf. Hammen, 1991, 2006) and
protective, adaptive, and resilience-related
ones (e.g., the very same person might generate social support in response to her/his
depression, which might alleviate the latter
condition; Shahar & Priel, 2003).
The action formulation relies on four
guidelines. The first guideline is to map the
clients social environment and the role it
plays in the pertinent outcome, particularly
as it is manifested by the presence of stress
(both acute and chronic), positive life events,
and social support. The second guideline is
to identify how the client, in the context of
her/his personality, psychopathology, and
strengths, shapes her/his own environment,
that is, how s/he generates stressful events,
contributes to the maintenance of chronic
stress, engages in positive life events, and
elicits social support. The third guideline, intimately tied to the second, is to differentiate
between maladaptive, risk-related, interpersonal cycles, and adaptive, protective, and
resilience-based ones, as well as to identify
the interplay between adaptive and maladaptive cycles.
These three guidelines are illustrated
in Figure 2, in which TAF is applied to Jonathans case. The figure, which only approximates the complexity of Jonathans difficulties, depicts several vicious cycles emanating
from Jonathans malevolent representations
of self and others (i.e., object relations) to
depression through two pathways: 1) attacking authority figures and 2) isolating himself.
Note that both lead to depression, that depression leads to academic setback, which itself strengthens malevolent representations,
and that depression is a likely contributor to
insomnia, which further leads to academic
setback. Note also that panic attacks exacerbate social isolation, thereby amalgamating
Particpation-Engagement
169
further improvement (e.g., Gilboa-Shechtman & Shahar, 2006). From a psychodynamic point of view, such an improvement
might constitute the therapist as a benevolent object, or selfobject, in the patients
inner world (Connors, 2001). Located in the
context of the present discussion, we submit
that these psychodynamic gains would be
particularly pronounced following a kind of
symptomatic improvement which is sensitive
to patients participation (i.e., to their pursuit of key personal projects).
On the other hand, the very vigor
characterizing patients participation might
also lead to psychotherapeutic ruptures. Shahar (2004) describes this two-person politics
as follows:
An AT [action theory] approach,
superimposed on the relational view of
transference and countertransference,
depicts patients and therapists as representatives of each others environment.
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Particpation-Engagement
He continues:
But most of all, I believe that the therapists function should be to help people
to be aware of and to experience their
possibilities. A psychological problem, I
have pointed out elsewhere, is like fever;
it indicates that something is wrong
within the structure of the person and
that a struggle is going on for survival.
This, in turn, is a proof to us that some
other way of behaving is possible . . .
Problems are the outward sign of unused
inner possibilities. (May, 1981, pp.
19-20, italics in the original)
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Particpation-Engagement
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