Patient-Therapeut-Bindung bei Drogenabhängigen: Instrumentenvalidierung und Therapieevaluation

In der vorliegenden Arbeit wird zum einen ein Instrument zur Erfassung der Patient-Therapeut-Bindung validiert (Client Attachment to Therapist Scale, CATS; Mallinckrodt, Coble & Gantt, 1995), zum anderen werden Hypothesen zu den Zusammenhängen zwischen Selbstwirksamkeitserwartung, allgemeinem Bindungsstil, therapeutischer Beziehung (bzw. Therapiezufriedenheit), Patient-Therapeut-Bindung und Therapieerfolg bei Drogen-abhängigen in stationärer Postakutbehandlung überprüft. In die Instrumentenvalidierung (einwöchiger Retest) wurden 119 Patienten aus 2 Kliniken und 13 Experten einbezogen. Die Gütekriterien des Instrumentes fallen sehr zufriedenstellend aus. An der naturalistischen Therapieevaluationsstudie (Prä-, Prozess-, Post-Messung: T0, T1, T2) nahmen 365 Patienten und 27 Therapeuten aus 4 Kliniken teil. Insgesamt beendeten 44,1% der Patienten ihren stationären Aufenthalt planmäßig. Auf Patientenseite erweisen sich Alter und Hauptdiagnose, auf Therapeutenseite die praktizierte Therapierichtung als Therapieerfolgsprädiktoren. Selbstwirksamkeitserwartung, allgemeiner Bindungsstil, Patient-Therapeut-Bindung und Therapiezufriedenheit eignen sich nicht zur Prognose des Therapieerfolgs. Die zu T0 stark unterdurchschnittlich ausgeprägte Selbstwirksamkeits-erwartung steigert sich über den Interventionszeitraum, wobei sich ein Moderatoreffekt der Patient-Therapeut-Bindung beobachten lässt. Es liegt eine hohe Prävalenz unsicherer allgemeiner Bindungsstile vor, welche sich über den Therapiezeitraum nicht verändern. Die patientenseitige Zufriedenheit mit der Therapie steigt von T1 zu T2 an. Die Interrater-Konkordanz (Patient/Therapeut) zur Einschätzung der Patient-Therapeut-Bindung erhöht sich leicht von T1 zu T2. Im Gegensatz dazu wird die Therapiezufriedenheit von Patienten und Therapeuten zu beiden Messzeitpunkten sehr unterschiedlich beurteilt. Die guten Testgütekriterien der CATS sprechen für eine Überlegenheit dieses Instrumentes gegenüber der Skala zur Erfassung der Therapiezufriedenheit. Deshalb sollte die Patient-Therapeut-Bindung anhand dieses Instrumentes in weiteren Forschungsarbeiten an anderen Patientenkollektiven untersucht werden, um generalisierbare Aussagen zur Validität treffen zu können.

Efficacy of a dilemma-focused intervention for unipolar depression: study protocol for a multicenter randomized controlled trial

BACKGROUND: Depression is one of the more severe and serious health problems because of its morbidity, disabling effects and for its societal and economic burden. Despite the variety of existing pharmacological and psychological treatments, most of the cases evolve with only partial remission, relapse and recurrence.Cognitive models have contributed significantly to the understanding of unipolar depression and its psychological treatment. However, success is only partial and many authors affirm the need to improve those models and also the treatment programs derived from them. One of the issues that requires further elaboration is the difficulty these patients experience in responding to treatment and in maintaining therapeutic gains across time without relapse or recurrence. Our research group has been working on the notion of cognitive conflict viewed as personal dilemmas according to personal construct theory. We use a novel method for identifying those conflicts using the repertory grid technique (RGT). Preliminary results with depressive patients show that about 90% of them have one or more of those conflicts. This fact might explain the blockage and the difficult progress of these patients, especially the more severe and/or chronic. These results justify the need for specific interventions focused on the resolution of these internal conflicts. This study aims to empirically test the hypothesis that an intervention focused on the dilemma(s) specifically detected for each patient will enhance the efficacy of cognitive behavioral therapy (CBT) for depression. DESIGN: A therapy manual for a dilemma-focused intervention will be tested using a randomized clinical trial by comparing the outcome of two treatment conditions: combined group CBT (eight, 2-hour weekly sessions) plus individual dilemma-focused therapy (eight, 1-hour weekly sessions) and CBT alone (eight, 2-hour group weekly sessions plus eight, 1-hour individual weekly sessions). METHOD: Participants are patients aged over 18 years meeting diagnostic criteria for major depressive disorder or dysthymic disorder, with a score of 19 or above on the Beck depression inventory, second edition (BDI-II) and presenting at least one cognitive conflict (implicative dilemma or dilemmatic construct) as assessed using the RGT. The BDI-II is the primary outcome measure, collected at baseline, at the end of therapy, and at 3- and 12-month follow-up; other secondary measures are also used. DISCUSSION: We expect that adding a dilemma-focused intervention to CBT will increase the efficacy of one of the more prestigious therapies for depression, thus resulting in a significant contribution to the psychological treatment of depression. TRIAL REGISTRATION: ISRCTN92443999; ClinicalTrials.gov Identifier: NCT01542957.

Depression in early adulthood: prevalence and psychosocial correlates among young Swiss men

QUESTION UNDER STUDY Depression in young adults is common, but data from Switzerland are scarce. Our study gives a point prevalence estimate of depression in young Swiss men, and describes the association between depression and education, material and social resources, and job/school satisfaction. METHODS We used data from the cross-sectional Swiss Federal Surveys of Adolescents (ch-x) from 2010 to 2011 comprising 9,066 males aged between 18 and 25 years. Depression was assessed by means of self-reports using the Patient Health Questionnaire (PHQ-9). Persons were categorised into three groups: depression, subthreshold depression, and no depression. We assessed the relationship between depression and education, material and social resources, and satisfaction with job/school. Differences according to depression status were tested with chi-square tests for categorical variables and one-way analyses of variance for continuous variables. RESULTS Point prevalence of depression (3.60%) and subthreshold depression (3.62%) was high. Poor mental health was associated with lower education in young adults (p <0.001), and with their parents' education (p = 0.024). Social resources in persons with depression and subthreshold depression were substantially reduced (i.e., social support and satisfaction with social relations; both p <0.001). Young men with depression and subthreshold depression also reported a current lack of satisfaction with job/school (p <0.001). CONCLUSIONS Prevalence of (subthreshold) depression is high in young Swiss men. Depression at this age might result in a bad long-term prognosis owing to its association with low satisfaction with job/school and low self-efficacy. Interventions should especially consider the lower social resources of young men with depression.

Resistance to Temptation: The Interaction of External and Internal Control on Alcohol Use During Residential Treatment for Alcohol Use Disorder

Background: There is evidence that drinking during residential treatment is related to various factors, such as patients’ general control beliefs and self-efficacy, as well as to external control of alcohol use by program’s staff and situations where there is temptation to drink. As alcohol use during treatment has been shown to be associated with the resumption of alcohol use after discharge from residential treatment, we aimed to investigate how these variables are related to alcohol use during abstinenceoriented residential treatment programs for alcohol use disorders (AUD). Methods: In total, 509 patients who entered 1 of 2 residential abstinence-oriented treatment programs for AUD were included in the study. After detoxification, patients completed a standardized diagnostic procedure including interviews and questionnaires. Drinking was assessed by patients’ selfreport of at least 1 standard drink or by positive breathalyzer testing. The 2 residential programs were categorized as high or low control according to the average number of tests per patient. Results: Regression analysis revealed a significant interaction effect between internal and external control suggesting that patients with high internal locus of control and high frequency of control by staff demonstrated the least alcohol use during treatment (16.7%) while patients with low internal locus of control in programs with low external control were more likely to use alcohol during Treatment (45.9%). No effects were found for self-efficacy and temptation. Conclusions: As alcohol use during treatment is most likely associated with poor treatment outcomes, external control may improve treatment outcomes and particularly support patients with low internal locus of control, who show the highest risk for alcohol use during treatment. High external control may complement high internal control to improve alcohol use prevention while in treatment. Key Words: Alcohol Dependence, Alcohol Use, Locus of Control, Alcohol Testing.

Does Trauma Impair Self-Control? Differences in Delaying Gratification Between Former Indentured Child Laborers and Nontraumatized Controls.

Traumatic experiences may affect an individual's ability to exercise self-control, which is an essential characteristic for successfully managing life. As a measure of self-control, we used the delay discounting paradigm, that is, the extent to which a person devalues delayed gratification. The aim of this study was to investigate the relationship between childhood trauma and delay discounting using a control group design with elderly participants with a mean age of 76.2 years. Swiss former indentured child laborers (n=103) who had been exposed to trauma during their childhood were compared with nontraumatized controls (n=50). The trauma exposure group showed a considerably higher preference for immediate smaller rewards than the controls, indicating their lower self-control. A hierarchical regression analysis revealed that a history of abuse, current self-efficacy, and education were significantly associated with delay discounting. Implications for future research are discussed.

Retombées du cirque social (Cirque du Soleil) en contexte de réadaptation sur la participation sociale de jeunes adultes avec déficiences physiques en transition vers la vie active : étude qualitative

Introduction : Les adolescents avec déficiences physiques en transition vers la vie adulte éprouvent des difficultés à établir une participation sociale optimale. Cette étude explore les retombées d'un programme de cirque social sur la participation sociale de ces jeunes selon leur point de vue et celui de leurs parents. Méthode : Étude qualitative exploratoire d’orientation phénoménologique. Neuf personnes avec déficiences physiques, âgées de 18 et 25 ans, ont participé au programme pendant neuf mois. Données recueillies : perceptions de leur qualité de participation sociale à partir d’entrevues semi-structurées en pré, mi-temps et post-intervention avec les participants et un de leurs parents. Le guide d’entrevue validé est ancré sur le Modèle du développement humain- Processus de production du handicap - 2 (HDM-PPH2). L’enregistrement audio des entretiens a été transcrit en verbatim. Le contenu a été analysé avec le logiciel Nvivo 9 à travers une grille de codage préalablement validée (co-codage, codage-inverse). Résultats : Corpus de 54 entrevues. L’âge moyen des jeunes était de 20,0 ± 1,4 années et de 51 ± 3,6 années pour les parents. Selon tous, la participation sociale des jeunes adultes a été optimisée, surtout sur le plan de la communication, des déplacements, des relations interpersonnelles, des responsabilités et de la vie communautaire. La perception de soi et les habiletés sociales, également améliorées, ont favorisé une plus grande auto-efficacité. Conclusion : Cette étude soutient donc le potentiel du cirque social comme approche novatrice et probante en réadaptation physique pour cette population, et appuie la pertinence d’autres études rigoureuses mesurant les diverses retombées possibles et identifiées.

The perceived benefits of the chronic disease self-management program among participants with stroke: A qualitative study

Despite the expense associated with rehabilitation following stroke, dissatisfaction with psychosocial outcomes is common (Thomas & Parry, 1996). The rehabilitation system has been critiqued as lacking a theoretical base for psychosocial interventions (Goldberg, Segal, Berk, Schall, & Gershkoff, 1997). The current paper examines the possible role of the Chronic Disease Self-Management Program ([CDSMP] Lorig, 1996) in contributing to the psychosocial rehabilitation of people with stroke. This paper focuses on the analysis of incidental comments made by participants about a version of the CDSMP, tailored for people with stroke. These comments, collected over an 18-month follow-up period, provide interesting insights into the key aspects of the program. Six informative themes emerged from the more specific comments, namely (1) the importance of social contact and comparison, (2) increased awareness and knowledge about stroke, (3) motivation to pursue goals and activities, (4) a sense of achievement, (5) maintenance of gains, and (6) the paradoxical nature of social support. According to participants, the program was associated with enhanced self-efficacy. Other reported benefits (such as social support and enhanced knowledge) were indirectly associated with the program and appeared to reflect social aspects of the group and its stroke-specific focus. Maintenance of gains made by participants was seen as a crucial issue.

Evaluating Patient Education Materials about Radiation Therapy

Targeted treatment education for cancer patients has the potential to promote adjustment through assisting patients to participate in treatment decision making, comply with treatment regimens and cope more effectively with treatment side effects. A quasi-experimental longitudinal pre-test post-test and follow-up design was used to assess the effect of a patient education video about radiation therapy on patients' psychological distress, knowledge about radiation therapy, self-efficacy about coping with treatment and physical symptoms. Patients with head and neck (n = 26) and breast cancer (n = 66) were recruited into the study and allocated into control and intervention groups. No significant differences were found between the control and intervention groups on any of the outcome variables. However, patients in the intervention group reported high levels of satisfaction with the video and all reported that they would recommend the video to other patients preparing for radiation therapy. As well, 90% of patients in the intervention group reported that some or all of the information in the video was new to them. Education materials that have excellent face validity and that are well received by patients may fail to produce significant change using standard controlled study designs. Future research in this area may need to consider alternative paradigms for evaluating the helpfulness of such materials. (C) 2003 Elsevier Science Ireland Ltd. All rights reserved.

The effectiveness of an inpatient group cognitive behavioral therapy program for alcohol dependence

The present study evaluated the effectiveness of attendance at a clinically based, short-term, in-patient group CBT program largely based on Monti, Abrams, Kadden, and Cooney(1) to treat problem drinking. Participants were 37 males and 34 females diagnosed with alcohol dependence. Patients attended 42 CBT sessions over three weeks, with each session being one hour in duration. Measures included the Khavari Alcohol Test (KAT), the Short Alcohol Dependence Data Questionnaire (SADD), the Beck Anxiety Index (BAI), the Symptom Checklist-90-Revised (SCL-90), a General Self-Efficacy scale (GSE), and the Drinking Expectancy Profile (DEP). Group attendance rates were monitored daily. Two structured phone calls were conducted at one month and three months post-discharge. Results showed that attendance rates at CBT group sessions were not associated with improvements found at the end of therapy or in drinking behaviors at three-month follow-up. Full support could not be found for the effectiveness of group CBT and cognitive models of problem drinking.

The association between number of homework assignments completed during a lifestyle physical activity intervention and scores on transtheoretical measures

An assumption of theory-based physical activity interventions is that active participation positively affects the theoretical constructs upon which the intervention is based. This assumption is rarely tested. This study assessed whether participation, defined as completion of homework, in a lifestyle physical activity intervention was associated with changes over 6 months in constructs the homework addressed: the behavioral and cognitive processes of change, self-efficacy, and decisional balance (the pros and cons). Participants were 244 sedentary adults aged 25 to 75 years. They completed an average of 12 of 20 homework assignments. Those completing at least two-thirds of the homework (n = 113) had greater changes in the theoretical constructs from pretest to posttest than those completing less (n = 90). Post-hoc analyses suggest that completing theory-based homework may impact the processes of change and self-efficacy in lifestyle physical activity interventions and, therefore, are warranted in future interventions.

IMPACTO DE FATORES PSICOSSOCIAIS SOBRE O DESEMPENHO: UM ESTUDO COM TUTORES EM EAD

Considerando a acelerada expansão da Educação a Distância (EaD) no Brasil e os desafios que ainda enfrenta, torna-se importante dedicar um olhar cuidadoso sobre as questões envolvidas. Do ponto de vista da Psicologia, o foco no indivíduo que trabalha com EaD é fundamental. Neste contexto, destaca-se o trabalho do tutor, um recorte deste complexo mundo do trabalho em EaD, alvo deste estudo. O desempenho profissional do tutor depende de fatores tecnológicos, ambientais e psicossociais. Neste este estudo, o objetivo foi verificar o impacto que as crenças de autoeficácia no trabalho, a percepção de suporte social e o engajamento no trabalho exercem sobre o desempenho de tutores de disciplinas oferecidas a distância. A pesquisa teve caráter transversal e foi desenvolvida em uma universidade brasileira com sede no Estado de São Paulo. Os 227 tutores participantes atuavam em diferentes localidades do Brasil; 62% eram mulheres, 65% casados, 66% possuíam idades entre 25 e 45 anos e 97% cursou pelo menos especialização. A coleta dos dados foi realizada por meio eletrônico. Foram aplicadas escalas válidas e confiáveis de autoeficácia, engajamento e percepção de suporte social no trabalho, além de um questionário de dados sociodemográficos. Foi ainda realizada pesquisa documental para levantar informações sobre desempenho. Cálculos de médias, desvios-padrão, medianas e quartis revelaram que os tutores possuem bons níveis de autoeficácia, engajamento no trabalho e desempenho. Mais de 75% deles percebem ter acesso a informações suficientes e importantes, bem como contar com relacionamentos confiáveis e afetivos no trabalho, enquanto metade percebe dispor de bons insumos materiais, financeiros, técnicos e gerenciais. Resultados de análises de variância revelaram não haver diferenças entre desempenho de grupos que exercem outras atividades profissionais além da tutoria e os que não exercem, nem entre grupos que possuem e não possuem formação específica para atuar em tutoria em EaD. Resultados de regressões lineares múltiplas revelaram que as crenças de autoeficácia no trabalho, a percepção de suporte social e o engajamento no trabalho não explicam significantemente a variância do desempenho de tutores. Os resultados foram discutidos, sustentados principalmente na pequena variabilidade das notas de desempenho, considerando que 98,8% dos tutores obtiveram pontuação superior à média do instrumento de avaliação utilizado pela instituição, o que pode revelar dificuldades no processo de avaliação ou problemas relativos à validade do instrumento. Discutiram-se, além disso, questões relacionadas ao desempenho humano, como fenômeno complexo e multidimensional, buscando abordar o papel das variáveis do estudo em sua determinação, à luz da literatura especializada. Ao final, foram apresentadas implicações metodológicas, teóricas e práticas, bem como limitações do estudo e agenda de pesquisa.

Potential risk factors for medication non-adherence in patients with chronic obstructive pulmonary disease (COPD)

Aims - To investigate the effect of a range of demographic and psychosocial variables on medication adherence in chronic obstructive pulmonary disease (COPD) patients managed in a secondary care setting. Methods - A total of 173 patients with a confirmed diagnosis of COPD, recruited from an outpatient clinic in Northern Ireland, participated in the study. Data collection was carried out via face-to-face interviews and through review of patients’ medical charts. Social and demographic variables, co-morbidity, self-reported drug adherence (Morisky scale), Hospital Anxiety and Depression (HAD) scale, COPD knowledge, Health Belief Model (HBM) and self-efficacy scales were determined for each patient. Results - Participants were aged 67 ± 9.7 (mean ± SD) years, 56 % female and took a mean (SD) of 8.2 ± 3.4 drugs. Low adherence with medications was present in 29.5 % of the patients. Demographic variables (gender, age, marital status, living arrangements and occupation) were not associated with adherence. A range of clinical and psychosocial variables, on the other hand, were found to be associated with medication adherence, i.e. beliefs regarding medication effectiveness, severity of COPD, smoking status, presence of co-morbid illness, depressed mood, self-efficacy, perceived susceptibility and perceived barriers within the HBM (p < 0.05). Logistic regression analysis showed that perceived ineffectiveness of medication, presence of co-morbid illness, depressed mood and perceived barriers were independently associated with medication non-adherence in the study (P < 0.05). Conclusions - Adherence in COPD patients is influenced more by patients’ perception of their health and medication effectiveness, the presence of depressed mood and co-morbid illness than by demographic factors or disease severity.

A pilot study to evaluate the self-medication system for liver transplant patients at the Queen Elizabeth Hospital in Birmingham

Background and Objective: Medication non-compliance is a considerable obstacle in achievinga therapeutic goal, whichcan result in poorerhealthcare outcomes, increased expenditure, wastage and potential for medication resistance. The UK Government’s Audit Commission’s publication ‘A Spoonful of Sugar’1 addresses these issues and promotes self-medication systems as a possible solution. The self-medication system within the Liver Transplant Unit (LTU) was implemented to induct patients onto new post- transplantation medication regimes ready for discharge. The system involves initial consultations with both the Liver Transplant Pharmacist and Trans- plant Co-ordinator, supported with additional advice as and when necessary. Design: Following ethical approval, evaluation of the self-medication sys- tem for liver transplant patients was conducted between January and March 2004 via two methods: audit and structured post-transplantation interview. The audit enabled any discrepancies between current Hospital guidelines and Liver Transplant Unit (LTU) practices to be highlighted. Patient interviews generated a retrospective insight into patient acceptance of the self-medication system. Setting: LTU, Queen Elizabeth Hospital, Birmingham, England. Main Outcome Measures: LTU compliance with Hospital self-medication guidelines and patient insight into self-medication system. Results: A total of seven patients were audited. Findings illustrated that self- medication by transplant patients is a complex process which was not fully addressed by current Hospital self-medication guidelines. Twenty-three patients were interviewed, showing an overwhelming positive attitude to- wards participating in their own care and a high level of understanding towards their individual medication regimes. Following a drugs counselling session, 100% of patients understood why they were taking their medica- tion, and their doses, 95% understood how to take their medication and 85% were aware of potential side effects. Conclusions: From this pilot evaluation it can be stated that the LTU self-medication system is appreciated by patients and assists them in fully understanding their medication regimes. There appear to be no major defects in the system. However areas such as communication barriers and on-going internet education were illustrated as areas for possible future investigation. References: 1. Audit Commission. A spoonful of sugar – medicines management in NHS hospitals. London: Audit Commission; 2001.

Health changes in Hispanic older adults in a Spanish arthritis self -management education program

Arthritis is the most common chronic condition affecting older people and is a major cause of limited activity. Arthritis education programs in English have demonstrated a positive impact on health but these programs have not reached the Hispanic communities where arthritis is the leading cause of disability. Minorities, such as Hispanics, have traditionally been reluctant to pursue self-help programs, and have been identified as an under-served population in terms of medical care. This study examined the effectiveness of one community health adult education program targeting Hispanic older adults with arthritis, the Spanish Arthritis Self Management Education Program (SASMEP), by evaluating changes in the participants' general health, pain, disability, self-efficacy, health perceptions, frequency of physician visits, and exercise. A pre and post control group experimental design and analyses of covariance were used to determine the pre and post differences in health status and health behaviors for a group participating in the SASMEP and a group who did not using gender and age as covariates. A repeated measures design was also used, and repeated measures analyses of variance and post hoc tests were done on health status and health behavior data collected pre, post and one-year post education to determine long-term differences. ^ Results indicated the participants' health status significantly improved in general health, significantly decreased in pain, and significantly decreased in arthritic disability immediately following the education. Self-efficacy and health perceptions increased for both groups but not significantly. The participants' health behaviors showed significantly fewer physician visits and significantly increased time spent performing stretching and strengthening exercise and time spent performing aerobic exercise. No group differences were found in the frequency of arthritis physician visits. ^ The improvements seen immediately after the SASMEP participation were not reflected in the post one-year scores. No significant differences were found for the participants' health status or health behaviors one year following the education. Health status and health behaviors did not return below baseline scores after one year suggesting the participants' health, although not improved, did not deteriorate. Therefore, the SASMEP education provided short-term health benefits for older Hispanic adults with arthritis, but not long-term health benefits. ^

Barriers and facilitators to asthma self-management in adolescents:a systematic review of qualitative and quantitative studies

BACKGROUND: Many adolescents have poor asthma control and impaired quality of life despite the availability of modern pharmacotherapy. Research suggests that poor adherence to treatment and limited engagement in self-management could be contributing factors. OBJECTIVE: To conduct a systematic review of the barriers and facilitators to self-management of asthma reported by adolescents using a narrative synthesis approach to integrate the findings. DESIGN: MEDLINE, EMBASE, CINAHL, and PsycINFO were searched for all types of study design. Full papers were retrieved for study abstracts that included data from participants aged 12-18 years referring to barriers or facilitators of asthma self-management behaviors. RESULTS: Sixteen studies (5 quantitative and 11 qualitative) underwent data extraction, quality appraisal, and thematic analysis. Six key themes were generated that encompassed barriers and/or facilitators to self-management of asthma in adolescents: Knowledge, Lifestyle, Beliefs and Attitudes, Relationships, Intrapersonal Characteristics, and Communication. CONCLUSIONS: There is a pressing need to prepare adolescents for self-management, using age-appropriate strategies that draw on the evidence we have synthesized. Current clinical practice should focus on ensuring adolescents have the correct knowledge, beliefs, and positive attitude to self-manage their illness. This needs to be delivered in a supportive environment that facilitates two-way communication, fosters adolescents' self-efficacy to manage their disease, and considers the wider social influences that impinge on self-management. Pediatr Pulmonol. 2016; 9999:XX-XX. © 2016 Wiley Periodicals, Inc.