A multidisciplinary reference framework to support innovative design, implementation and assessment of chronic care models

Hoy en día, por primera vez en la historia, la mayor parte de la población podrá vivir hasta los sesenta años y más (United Nations, 2015). Sin embargo, todavía existe poca evidencia que demuestre que las personas mayores, estén viviendo con mejor salud que sus padres, a la misma edad, ya que la mayoría de los problemas de salud en edades avanzadas están asociados a las enfermedades crónicas (WHO, 2015). Los sistemas sanitarios de los países desarrollados funcionan adecuadamente cuando se trata del cuidado de enfermedades agudas, pero no son lo suficientemente eficaces en la gestión de las enfermedades crónicas. Durante la última década, se han realizado esfuerzos para mejorar esta gestión, por medio de la utilización de estrategias de prevención y de reenfoque de la provisión de los servicios de atención para la salud (Kane et al. 2005). Según una revisión sistemática de modelos de cuidado de salud, comisionada por el sistema nacional de salud Británico, pocos modelos han conceptualizado cuáles son los componentes que hay que utilizar para proporcionar un cuidado crónico efectivo, y estos componentes no han sido suficientemente estructurados y articulados. Por lo tanto, no hay suficiente evidencia sobre el impacto real de cualquier modelo existente en la actualidad (Ham, 2006). Las innovaciones podrían ayudar a conseguir mejores diagnósticos, tratamientos y gestión de pacientes crónicos, así como a dar soporte a los profesionales y a los pacientes en el cuidado. Sin embargo, la forma en las que estas innovaciones se proporcionan no es lo suficientemente eficiente, efectiva y amigable para el usuario. Para mejorar esto, hace falta crear equipos de trabajo y estrategias multidisciplinares. En conclusión, hacen falta actividades que permitan conseguir que las innovaciones sean utilizadas en los sistemas de salud que quieren mejorar la gestión del cuidado crónico, para que sea posible: 1) traducir la “atención sanitaria basada en la evidencia” en “conocimiento factible”; 2) hacer frente a la complejidad de la atención sanitaria a través de una investigación multidisciplinaria; 3) identificar una aproximación sistemática para que se establezcan intervenciones innovadoras en el cuidado de salud. El marco de referencia desarrollado en este trabajo de investigación es un intento de aportar estas mejoras. Las siguientes hipótesis han sido propuestas: Hipótesis 1: es posible definir un proceso de traducción que convierta un modelo de cuidado crónico en una descripción estructurada de objetivos, requisitos e indicadores clave de rendimiento. Hipótesis 2: el proceso de traducción, si se ejecuta a través de elementos basados en la evidencia, multidisciplinares y de orientación económica, puede convertir un modelo de cuidado crónico en un marco descriptivo, que define el ciclo de vida de soluciones innovadoras para el cuidado de enfermedades crónicas. Hipótesis 3: es posible definir un método para evaluar procesos, resultados y capacidad de desarrollar habilidades, y asistir equipos multidisciplinares en la creación de soluciones innovadoras para el cuidado crónico. Hipótesis 4: es posible dar soporte al desarrollo de soluciones innovadoras para el cuidado crónico a través de un marco de referencia y conseguir efectos positivos, medidos en indicadores clave de rendimiento. Para verificar las hipótesis, se ha definido una aproximación metodológica compuesta de cuatro Fases, cada una asociada a una hipótesis. Antes de esto, se ha llevado a cabo una “Fase 0”, donde se han analizado los antecedentes sobre el problema (i.e. adopción sistemática de la innovación en el cuidado crónico) desde una perspectiva multi-dominio y multi-disciplinar. Durante la fase 1, se ha desarrollado un Proceso de Traducción del Conocimiento, elaborado a partir del JBI Joanna Briggs Institute (JBI) model of evidence-based healthcare (Pearson, 2005), y sobre el cual se han definido cuatro Bloques de Innovación. Estos bloques consisten en una descripción de elementos innovadores, definidos en la fase 0, que han sido añadidos a los cuatros elementos que componen el modelo JBI. El trabajo llevado a cabo en esta fase ha servido también para definir los materiales que el proceso de traducción tiene que ejecutar. La traducción que se ha llevado a cabo en la fase 2, y que traduce la mejor evidencia disponible de cuidado crónico en acción: resultado de este proceso de traducción es la parte descriptiva del marco de referencia, que consiste en una descripción de un modelo de cuidado crónico (se ha elegido el Chronic Care Model, Wagner, 1996) en términos de objetivos, especificaciones e indicadores clave de rendimiento y organizada en tres ciclos de innovación (diseño, implementación y evaluación). Este resultado ha permitido verificar la segunda hipótesis. Durante la fase 3, para demostrar la tercera hipótesis, se ha desarrollado un método-mixto de evaluación de equipos multidisciplinares que trabajan en innovaciones para el cuidado crónico. Este método se ha creado a partir del método mixto usado para la evaluación de equipo multidisciplinares translacionales (Wooden, 2013). El método creado añade una dimensión procedural al marco. El resultado de esta fase consiste, por lo tanto, en una primera versión del marco de referencia, lista para ser experimentada. En la fase 4, se ha validado el marco a través de un caso de estudio multinivel y con técnicas de observación-participante como método de recolección de datos. Como caso de estudio se han elegido las actividades de investigación que el grupo de investigación LifeStech ha desarrollado desde el 2008 para mejorar la gestión de la diabetes, actividades realizadas en un contexto internacional. Los resultados demuestran que el marco ha permitido mejorar las actividades de trabajo en distintos niveles: 1) la calidad y cantidad de las publicaciones; 2) se han conseguido dos contratos de investigación sobre diabetes: el primero es un proyecto de investigación aplicada, el segundo es un proyecto financiado para acelerar las innovaciones en el mercado; 3) a través de los indicadores claves de rendimiento propuestos en el marco, una prueba de concepto de un prototipo desarrollado en un proyecto de investigación ha sido transformada en una evaluación temprana de una intervención eHealth para el manejo de la diabetes, que ha sido recientemente incluida en Repositorio de prácticas innovadoras del Partenariado de Innovación Europeo en Envejecimiento saludable y activo. La verificación de las 4 hipótesis ha permitido demonstrar la hipótesis principal de este trabajo de investigación: es posible contribuir a crear un puente entre la atención sanitaria y la innovación y, por lo tanto, mejorar la manera en que el cuidado crónico sea procurado en los sistemas sanitarios. ABSTRACT Nowadays, for the first time in history, most people can expect to live into their sixties and beyond (United Nations, 2015). However, little evidence suggests that older people are experiencing better health than their parents, and most of the health problems of older age are linked to Chronic Diseases (WHO, 2015). The established health care systems in developed countries are well suited to the treatment of acute diseases but are mostly inadequate for dealing with CDs. Healthcare systems are challenging the burden of chronic diseases by putting more emphasis on the prevention of disease and by looking for new ways to reorient the provision of care (Kane et al., 2005). According to an evidence-based review commissioned by the British NHS Institute, few models have conceptualized effective components of care for CDs and these components have been not structured and articulated. “Consequently, there is limited evidence about the real impact of any of the existing models” (Ham, 2006). Innovations could support to achieve better diagnosis, treatment and management for patients across the continuum of care, by supporting health professionals and empowering patients to take responsibility. However, the way they are delivered is not sufficiently efficient, effective and consumer friendly. The improvement of innovation delivery, involves the creation of multidisciplinary research teams and taskforces, rather than just working teams. There are several actions to improve the adoption of innovations from healthcare systems that are tackling the epidemics of CDs: 1) Translate Evidence-Based Healthcare (EBH) into actionable knowledge; 2) Face the complexity of healthcare through multidisciplinary research; 3) Identify a systematic approach to support effective implementation of healthcare interventions through innovation. The framework proposed in this research work is an attempt to provide these improvements. The following hypotheses have been drafted: Hypothesis 1: it is possible to define a translation process to convert a model of chronic care into a structured description of goals, requirements and key performance indicators. Hypothesis 2: a translation process, if executed through evidence-based, multidisciplinary, holistic and business-oriented elements, can convert a model of chronic care in a descriptive framework, which defines the whole development cycle of innovative solutions for chronic disease management. Hypothesis 3: it is possible to design a method to evaluate processes, outcomes and skill acquisition capacities, and assist multidisciplinary research teams in the creation of innovative solutions for chronic disease management. Hypothesis 4: it is possible to assist the development of innovative solutions for chronic disease management through a reference framework and produce positive effects, measured through key performance indicators. In order to verify the hypotheses, a methodological approach, composed of four Phases that correspond to each one of the stated hypothesis, was defined. Prior to this, a “Phase 0”, consisting in a multi-domain and multi-disciplinary background analysis of the problem (i.e.: systematic adoption of innovation to chronic care), was carried out. During phase 1, in order to verify the first hypothesis, a Knowledge Translation Process (KTP) was developed, starting from the JBI Joanna Briggs Institute (JBI) model of evidence-based healthcare was used (Pearson, 2005) and adding Four Innovation Blocks. These blocks represent an enriched description, added to the JBI model, to accelerate the transformation of evidence-healthcare through innovation; the innovation blocks are built on top of the conclusions drawn after Phase 0. The background analysis gave also indication on the materials and methods to be used for the execution of the KTP, carried out during phase 2, that translates the actual best available evidence for chronic care into action: this resulted in a descriptive Framework, which is a description of a model of chronic care (the Chronic Care Model was chosen, Wagner, 1996) in terms of goals, specified requirements and Key Performance Indicators, and articulated in the three development cycles of innovation (i.e. design, implementation and evaluation). Thanks to this result the second hypothesis was verified. During phase 3, in order to verify the third hypothesis, a mixed-method to evaluate multidisciplinary teams working on innovations for chronic care, was created, based on a mixed-method used for the evaluation of Multidisciplinary Translational Teams (Wooden, 2013). This method adds a procedural dimension to the descriptive component of the Framework, The result of this phase consisted in a draft version of the framework, ready to be tested in a real scenario. During phase 4, a single and multilevel case study, with participant-observation data collection, was carried out, in order to have a complete but at the same time multi-sectorial evaluation of the framework. The activities that the LifeStech research group carried out since 2008 to improve the management of diabetes have been selected as case study. The results achieved showed that the framework allowed to improve the research activities in different directions: the quality and quantity of the research publications that LifeStech has issued, have increased substantially; 2 project grants to improve the management of diabetes, have been assigned: the first is a grant funding applied research while the second is about accelerating innovations into the market; by using the assessment KPIs of the framework, the proof of concept validation of a prototype developed in a research project was transformed into an early stage assessment of innovative eHealth intervention for Diabetes Management, which has been recently included in the repository of innovative practice of the European Innovation Partnership on Active and Health Ageing initiative. The verification of the 4 hypotheses lead to verify the main hypothesis of this research work: it is possible to contribute to bridge the gap between healthcare and innovation and, in turn, improve the way chronic care is delivered by healthcare systems.

Persuasive system design methods to deliver a cardio-rehabilitation program of post mi outpatients

Las enfermedades no transmisibles provocan cada ano 38 millones de fallecimientos en el mundo. Entre ellas, tan solo cuatro enfermedades son responsables del 82% de estas muertes: las enfermedades cardiovasculares, las enfermedades crónicas respiratorias, la diabetes, y el cáncer. Se prevé que estas cifras aumenten en los próximos anos, ya que las tendencias indican que en el año 2030 las muertes por esta causa ascenderán a 53 millones de personas. La Organización Mundial de la Salud (OMS) considera importante buscar soluciones para afrontar esta situación y ha solicitado a los gobiernos del mundo la implementación de intervenciones para mejorar los hábitos de vida de las personas y reducir así el riesgo de desarrollo de enfermedades no trasmisibles. Cada año se producen 32 millones de infartos de miocardio y derrames celebrales, de los cuales 12.5 son mortales. En el mundo entre el 40% y 75% de la víctimas de un infarto de miocardio mueren antes de su ingreso en el hospital. En los casos que sobreviven, la adopción de un estilo de vida saludable puede evitar infartos sucesivo, y supone un ahorro potencial de 6 billones de euros al año. La rehabilitación cardiaca es un programa individualizado que aplica un método multidisciplinar para ayudar al paciente a recuperar su condición física, a gestionar la enfermedad cardiovascular y sus comorbilidades, a adoptar hábitos de vida saludables, y a promover su salud mental. La rehabilitación cardiaca requiere la total involucración y motivación del paciente, solo de esta manera se podrán promover hábitos saludables y mejorar la gestión y prevención de su enfermedad. Aunque la participación en los programas de rehabilitación cardiaca es baja, hoy en día existen programas de rehabilitación cardiaca que el paciente puede realizar en su casa. Estos suponen una solución prometedora para aumentar la participación. La rehabilitación cardiaca se considera una intervención integral donde los modelos de psicología de la salud son aplicados para promover un cambio en el estilo de vida de las personas así como para ayudarles a afrontar su propia enfermedad. Existen métodos para implementar cambios de hábitos y de aptitud, y también se considera muy relevante promover no solo el bienestar físico sino también el mental. Existen tecnologías que promueven los cambios de comportamientos en los seres humanos. En concreto, las tecnologías persuasivas y los sistemas de apoyo al cambio de comportamientos modelan las características, las estrategias y los métodos de diseño para promover cambios usando la tecnología. Pero estos modelos tienen algunas limitaciones: todavía no se ha definido que rol tienen las emociones en el cambio de comportamientos y como traducir los métodos de la psicología de la salud en la tecnología. Esta tesis se centra en tres elementos que tienen un rol clave en los cambios de hábitos y actitud: el estado físico, el estado mental, y la tecnología. -Estado de salud: un estado de salud critico puede modificar la actitud del ser humano respecto al cambio. A la vez un buen estado de salud hace que la necesidad del cambio sea menos percibida. -Estado emocional: la actitud tiene un componente afectivo. Los estados emocionales negativos pueden reducir la habilidad de una persona para adoptar nuevos comportamientos. La salud mental es la situación ideal donde los individuos tienen predisposición a los cambios. La tecnología puede ayudar a las personas a adoptar nuevos hábitos, así como a mantener una salud física y mental. Este trabajo de investigación se centra en el diseño de tecnologías para la mejora del estado físico y emocional de las personas. Se ha propuesto un marco de diseño llamado “Well.Be.Sign”. El marco se basa en tres aspectos: El marco teórico: representa los elementos que se tienen que definir para diseñar tecnologías para promover el bienestar de las personas. -El diagrama de influencia: presenta las fuerzas de ‘persuasión’ en el contexto de la salud. El rol de las tecnologías persuasivas ha sido contextualizado en una dimensión donde otros elementos influencian el usuario.  El proceso de diseño: describe el proceso de diseño utilizando una metodología iterativa e incremental que aplica una combinación de métodos de diseño existentes (Diseño Orientado a Objetivos, Diseño de Sistemas Persuasivos) así como elementos originales de este trabajo de investigación. Los métodos se han aplicados para diseñar un sistema que ofrezca un programa de tele-rehabilitación cardiaca. Inicialmente se ha diseñado un prototipo de acuerdo con las necesidades del usuario. En segundo lugar, el prototipo se ha extendido especificando la intervención requerida para al programa de rehabilitación cardiaca. Finalmente el sistema se ha desarrollado y validado en un ensayo clínico con grupo control, donde se observaron las variaciones del estado cardiovascular, el nivel de conocimiento acerca de la enfermedad, la percepción de la enfermedad, la persistencia de hábitos saludables, y la aceptabilidad del sistema. Los resultados muestran que el grupo de intervención tiene una superior capacidad cardiovascular, mejor conocimiento acerca de la enfermedad, y más percepción de control de la enfermedad. Asimismo, en algunos casos se ha registrado persistencia de los hábitos de ejercicios 6 meses después del uso del sistema. Otros dos estudios se han presentado para demonstrar la relevancia del estado emocional del usuario en el diseño de aplicaciones para la promoción del bienestar.  En personas con una grave enfermedad crónica como la insuficiencia cardiaca, donde se ha presentado las conexiones entre estado de salud y estado emocional. En el estudio se ensena la relaciones que tienen los síntomas y las emociones negativas y como un estado negativo emocional puede empeorar la condición física del paciente. -Personas con trastornos del humor: el estudio muestra como las emociones pueden tener un impacto en la percepción de la tecnología por parte del usuario. ABSTRACT Noncommunicable diseases (NCDs) cause the death of 38 million people every year. Four major NCDs are responsible for 82% of these deaths: cardio vascular disease, chronic respiratory disease, diabetes and cancer. These pandemic numbers are projected to raise to 53 million deaths in 2030, and for this reason the assembly of the World Health Organization (WHO) considers communicable diseases as an urgent need to be addressed. It is also a trend to advocate the adoption of mobile technology to deliver health services and to promote healthy behaviours among citizens, but adopting healthS promoting lifestyle is still a difficult task facing human tendencies. Within this context, there is a promising opportunity: persuasive technologies. These technologies are intentionally designed to change a person’s attitudes or behaviours; when applied in this context, than can be used to change health-related attitudes, beliefs, and behaviours. Each year there are 32 million heart attacks and strokes globally, of which about 12.5 million are fatal. Worldwide between 40 and 75% of all heart-attack victims die before reaching hospital. Avoiding a second heart attack by improving adherence to lifestyle and medication regimens has a cost saving potential of around €6 billion per year. In most of the cases the cardiovascular event has been provoked by unhealthy lifestyle. Furthermore, after an MI event the patient's decision to adopt or not healthier behaviour will influence the progress of the disease. Cardio-rehabilitation is an individualized program that follows a multidisciplinary approach to support the user to recover from the Myocardial Infarction, manage the Cardio Vascular Disease and the comorbidities, adopt healthy habits, and cope with any emotional distress. Cardio- rehabilitation requires patient participation and willingness to perform behavioral modifications and change the attitude toward the management and prevention of the disease. Participation in the Cardio Rehabilitation program is not high; the home-based rehabilitation program is a promising solution to increase participation. Nowadays cardio rehabilitation is considered a comprehensive intervention in which models of health psychology are applied to promote the behaviour change of the individuals. Relevant methods that have been successfully applied to foster healthy habits include the Health Belief Model and the Trans Theoretical Model. Studies also demonstrate the importance to promote not only the physical but also the mental well being of the individuals. The idea of also promoting behaviour change using technologies has been defined by the literature as persuasive technologies or behaviour change support systems, in which the features, the strategies and the design method have been modelled to foster the behaviour change using technology. Limitations have been found in this model: there is still research to be done on the role of the emotions and how psychological health intervention can be translated into computer methods. This research focuses on three elements that could foster behaviour change in individuals: the physical and emotional status of the person, and the technology. Every component can influence the user's attitude and behaviour in the following ways: ' Physical status: bad physical status could change human attitude toward the necessity to adopt health behaviours; at the same time, good health status reduces the need to adopt healthy habits. ' Emotional status: the attitude has an affective component, negative emotional state can reduce the ability of a person to adopt new behaviours, and mental well being is the ideal situation in which individuals have a predisposition to adopt healthy behaviours. ' Technology: it can help users to adopt new behaviours and can also be support to promote physical and emotional status. Following this approach the idea driven in this research is that technology that is designed to improve the physical status and the emotional status of the individual could better foster behaviour change. According to this principle, the Well.Be.Sign framework has been proposed. The framework is based on three views: ' The theoretical framework: it represents the patterns that have to be defined to design the technologies to promote well being. ' The influence diagram: it shows the persuasive forces in the context of health care. The role of the persuasive technologies is contextualized in a wider universe where other factors and persuasive forces influence a patient. ' The design process: it shows the process of design using an iterative, incremental methodology that applies a combination of existing methodologies (Goal Directed Design and Persuasive System Design) and others that are original to this research. The methods have been applied to design a system to deliver cardio rehabilitation at home: first a prototype has been defined according to the user’s needs, then it has been extended with the specific intervention required for the cardio–rehabilitation, finally the system has been developed and validated in a controlled clinical study in which the cardiovascular fitness, the level of knowledge, the perception of the illness, the persistence of healthy habits and the system acceptance (only the intervention group) were measured. The results show that the intervention group increased cardiovascular capacity, knowledge, feeling of control of illness and perceived benefits of exercise at the end of the study. After six months of the study, a followSup of the exercise habits was performed. Some individuals of the intervention group continued to be engaged in the running exercise sessions promoted in the designed system. Two other cases have been presented to demonstrate the foundations of the Well.Be.Sign’s approach to promote both physical and emotional status: ' People affected by Heart Failure, in which a bidirectional connection between health status and emotions has been discussed with patients. Two correlations were demonstrated: the relationship between symptoms and negative emotional response, and that negative emotional status is correlated with worsening of chronic conditions. ' People with mood disorders: the study shows that emotions could also impact how the user perceives the technology.

Trust-ware: A Methodology to Analyze, Design, and Secure Trust and Reputation Systems

Entendemos por inteligencia colectiva una forma de inteligencia que surge de la colaboración y la participación de varios individuos o, siendo más estrictos, varias entidades. En base a esta sencilla definición podemos observar que este concepto es campo de estudio de las más diversas disciplinas como pueden ser la sociología, las tecnologías de la información o la biología, atendiendo cada una de ellas a un tipo de entidades diferentes: seres humanos, elementos de computación o animales. Como elemento común podríamos indicar que la inteligencia colectiva ha tenido como objetivo el ser capaz de fomentar una inteligencia de grupo que supere a la inteligencia individual de las entidades que lo forman a través de mecanismos de coordinación, cooperación, competencia, integración, diferenciación, etc. Sin embargo, aunque históricamente la inteligencia colectiva se ha podido desarrollar de forma paralela e independiente en las distintas disciplinas que la tratan, en la actualidad, los avances en las tecnologías de la información han provocado que esto ya no sea suficiente. Hoy en día seres humanos y máquinas a través de todo tipo de redes de comunicación e interfaces, conviven en un entorno en el que la inteligencia colectiva ha cobrado una nueva dimensión: ya no sólo puede intentar obtener un comportamiento superior al de sus entidades constituyentes sino que ahora, además, estas inteligencias individuales son completamente diferentes unas de otras y aparece por lo tanto el doble reto de ser capaces de gestionar esta gran heterogeneidad y al mismo tiempo ser capaces de obtener comportamientos aún más inteligentes gracias a las sinergias que los distintos tipos de inteligencias pueden generar. Dentro de las áreas de trabajo de la inteligencia colectiva existen varios campos abiertos en los que siempre se intenta obtener unas prestaciones superiores a las de los individuos. Por ejemplo: consciencia colectiva, memoria colectiva o sabiduría colectiva. Entre todos estos campos nosotros nos centraremos en uno que tiene presencia en la práctica totalidad de posibles comportamientos inteligentes: la toma de decisiones. El campo de estudio de la toma de decisiones es realmente amplio y dentro del mismo la evolución ha sido completamente paralela a la que citábamos anteriormente en referencia a la inteligencia colectiva. En primer lugar se centró en el individuo como entidad decisoria para posteriormente desarrollarse desde un punto de vista social, institucional, etc. La primera fase dentro del estudio de la toma de decisiones se basó en la utilización de paradigmas muy sencillos: análisis de ventajas e inconvenientes, priorización basada en la maximización de algún parámetro del resultado, capacidad para satisfacer los requisitos de forma mínima por parte de las alternativas, consultas a expertos o entidades autorizadas o incluso el azar. Sin embargo, al igual que el paso del estudio del individuo al grupo supone una nueva dimensión dentro la inteligencia colectiva la toma de decisiones colectiva supone un nuevo reto en todas las disciplinas relacionadas. Además, dentro de la decisión colectiva aparecen dos nuevos frentes: los sistemas de decisión centralizados y descentralizados. En el presente proyecto de tesis nos centraremos en este segundo, que es el que supone una mayor atractivo tanto por las posibilidades de generar nuevo conocimiento y trabajar con problemas abiertos actualmente así como en lo que respecta a la aplicabilidad de los resultados que puedan obtenerse. Ya por último, dentro del campo de los sistemas de decisión descentralizados existen varios mecanismos fundamentales que dan lugar a distintas aproximaciones a la problemática propia de este campo. Por ejemplo el liderazgo, la imitación, la prescripción o el miedo. Nosotros nos centraremos en uno de los más multidisciplinares y con mayor capacidad de aplicación en todo tipo de disciplinas y que, históricamente, ha demostrado que puede dar lugar a prestaciones muy superiores a otros tipos de mecanismos de decisión descentralizados: la confianza y la reputación. Resumidamente podríamos indicar que confianza es la creencia por parte de una entidad que otra va a realizar una determinada actividad de una forma concreta. En principio es algo subjetivo, ya que la confianza de dos entidades diferentes sobre una tercera no tiene porqué ser la misma. Por otro lado, la reputación es la idea colectiva (o evaluación social) que distintas entidades de un sistema tiene sobre otra entidad del mismo en lo que respecta a un determinado criterio. Es por tanto una información de carácter colectivo pero única dentro de un sistema, no asociada a cada una de las entidades del sistema sino por igual a todas ellas. En estas dos sencillas definiciones se basan la inmensa mayoría de sistemas colectivos. De hecho muchas disertaciones indican que ningún tipo de organización podría ser viable de no ser por la existencia y la utilización de los conceptos de confianza y reputación. A partir de ahora, a todo sistema que utilice de una u otra forma estos conceptos lo denominaremos como sistema de confianza y reputación (o TRS, Trust and Reputation System). Sin embargo, aunque los TRS son uno de los aspectos de nuestras vidas más cotidianos y con un mayor campo de aplicación, el conocimiento que existe actualmente sobre ellos no podría ser más disperso. Existen un gran número de trabajos científicos en todo tipo de áreas de conocimiento: filosofía, psicología, sociología, economía, política, tecnologías de la información, etc. Pero el principal problema es que no existe una visión completa de la confianza y reputación en su sentido más amplio. Cada disciplina focaliza sus estudios en unos aspectos u otros dentro de los TRS, pero ninguna de ellas trata de explotar el conocimiento generado en el resto para mejorar sus prestaciones en su campo de aplicación concreto. Aspectos muy detallados en algunas áreas de conocimiento son completamente obviados por otras, o incluso aspectos tratados por distintas disciplinas, al ser estudiados desde distintos puntos de vista arrojan resultados complementarios que, sin embargo, no son aprovechados fuera de dichas áreas de conocimiento. Esto nos lleva a una dispersión de conocimiento muy elevada y a una falta de reutilización de metodologías, políticas de actuación y técnicas de una disciplina a otra. Debido su vital importancia, esta alta dispersión de conocimiento se trata de uno de los principales problemas que se pretenden resolver con el presente trabajo de tesis. Por otro lado, cuando se trabaja con TRS, todos los aspectos relacionados con la seguridad están muy presentes ya que muy este es un tema vital dentro del campo de la toma de decisiones. Además también es habitual que los TRS se utilicen para desempeñar responsabilidades que aportan algún tipo de funcionalidad relacionada con el mundo de la seguridad. Por último no podemos olvidar que el acto de confiar está indefectiblemente unido al de delegar una determinada responsabilidad, y que al tratar estos conceptos siempre aparece la idea de riesgo, riesgo de que las expectativas generadas por el acto de la delegación no se cumplan o se cumplan de forma diferente. Podemos ver por lo tanto que cualquier sistema que utiliza la confianza para mejorar o posibilitar su funcionamiento, por su propia naturaleza, es especialmente vulnerable si las premisas en las que se basa son atacadas. En este sentido podemos comprobar (tal y como analizaremos en más detalle a lo largo del presente documento) que las aproximaciones que realizan las distintas disciplinas que tratan la violación de los sistemas de confianza es de lo más variado. únicamente dentro del área de las tecnologías de la información se ha intentado utilizar alguno de los enfoques de otras disciplinas de cara a afrontar problemas relacionados con la seguridad de TRS. Sin embargo se trata de una aproximación incompleta y, normalmente, realizada para cumplir requisitos de aplicaciones concretas y no con la idea de afianzar una base de conocimiento más general y reutilizable en otros entornos. Con todo esto en cuenta, podemos resumir contribuciones del presente trabajo de tesis en las siguientes. • La realización de un completo análisis del estado del arte dentro del mundo de la confianza y la reputación que nos permite comparar las ventajas e inconvenientes de las diferentes aproximación que se realizan a estos conceptos en distintas áreas de conocimiento. • La definición de una arquitectura de referencia para TRS que contempla todas las entidades y procesos que intervienen en este tipo de sistemas. • La definición de un marco de referencia para analizar la seguridad de TRS. Esto implica tanto identificar los principales activos de un TRS en lo que respecta a la seguridad, así como el crear una tipología de posibles ataques y contramedidas en base a dichos activos. • La propuesta de una metodología para el análisis, el diseño, el aseguramiento y el despliegue de un TRS en entornos reales. Adicionalmente se exponen los principales tipos de aplicaciones que pueden obtenerse de los TRS y los medios para maximizar sus prestaciones en cada una de ellas. • La generación de un software que permite simular cualquier tipo de TRS en base a la arquitectura propuesta previamente. Esto permite evaluar las prestaciones de un TRS bajo una determinada configuración en un entorno controlado previamente a su despliegue en un entorno real. Igualmente es de gran utilidad para evaluar la resistencia a distintos tipos de ataques o mal-funcionamientos del sistema. Además de las contribuciones realizadas directamente en el campo de los TRS, hemos realizado aportaciones originales a distintas áreas de conocimiento gracias a la aplicación de las metodologías de análisis y diseño citadas con anterioridad. • Detección de anomalías térmicas en Data Centers. Hemos implementado con éxito un sistema de deteción de anomalías térmicas basado en un TRS. Comparamos la detección de prestaciones de algoritmos de tipo Self-Organized Maps (SOM) y Growing Neural Gas (GNG). Mostramos como SOM ofrece mejores resultados para anomalías en los sistemas de refrigeración de la sala mientras que GNG es una opción más adecuada debido a sus tasas de detección y aislamiento para casos de anomalías provocadas por una carga de trabajo excesiva. • Mejora de las prestaciones de recolección de un sistema basado en swarm computing y odometría social. Gracias a la implementación de un TRS conseguimos mejorar las capacidades de coordinación de una red de robots autónomos distribuidos. La principal contribución reside en el análisis y la validación de las mejoras increméntales que pueden conseguirse con la utilización apropiada de la información existente en el sistema y que puede ser relevante desde el punto de vista de un TRS, y con la implementación de algoritmos de cálculo de confianza basados en dicha información. • Mejora de la seguridad de Wireless Mesh Networks contra ataques contra la integridad, la confidencialidad o la disponibilidad de los datos y / o comunicaciones soportadas por dichas redes. • Mejora de la seguridad de Wireless Sensor Networks contra ataques avanzamos, como insider attacks, ataques desconocidos, etc. Gracias a las metodologías presentadas implementamos contramedidas contra este tipo de ataques en entornos complejos. En base a los experimentos realizados, hemos demostrado que nuestra aproximación es capaz de detectar y confinar varios tipos de ataques que afectan a los protocoles esenciales de la red. La propuesta ofrece unas velocidades de detección muy altas así como demuestra que la inclusión de estos mecanismos de actuación temprana incrementa significativamente el esfuerzo que un atacante tiene que introducir para comprometer la red. Finalmente podríamos concluir que el presente trabajo de tesis supone la generación de un conocimiento útil y aplicable a entornos reales, que nos permite la maximización de las prestaciones resultantes de la utilización de TRS en cualquier tipo de campo de aplicación. De esta forma cubrimos la principal carencia existente actualmente en este campo, que es la falta de una base de conocimiento común y agregada y la inexistencia de una metodología para el desarrollo de TRS que nos permita analizar, diseñar, asegurar y desplegar TRS de una forma sistemática y no artesanal y ad-hoc como se hace en la actualidad. ABSTRACT By collective intelligence we understand a form of intelligence that emerges from the collaboration and competition of many individuals, or strictly speaking, many entities. Based on this simple definition, we can see how this concept is the field of study of a wide range of disciplines, such as sociology, information science or biology, each of them focused in different kinds of entities: human beings, computational resources, or animals. As a common factor, we can point that collective intelligence has always had the goal of being able of promoting a group intelligence that overcomes the individual intelligence of the basic entities that constitute it. This can be accomplished through different mechanisms such as coordination, cooperation, competence, integration, differentiation, etc. Collective intelligence has historically been developed in a parallel and independent way among the different disciplines that deal with it. However, this is not enough anymore due to the advances in information technologies. Nowadays, human beings and machines coexist in environments where collective intelligence has taken a new dimension: we yet have to achieve a better collective behavior than the individual one, but now we also have to deal with completely different kinds of individual intelligences. Therefore, we have a double goal: being able to deal with this heterogeneity and being able to get even more intelligent behaviors thanks to the synergies that the different kinds of intelligence can generate. Within the areas of collective intelligence there are several open topics where they always try to get better performances from groups than from the individuals. For example: collective consciousness, collective memory, or collective wisdom. Among all these topics we will focus on collective decision making, that has influence in most of the collective intelligent behaviors. The field of study of decision making is really wide, and its evolution has been completely parallel to the aforementioned collective intelligence. Firstly, it was focused on the individual as the main decision-making entity, but later it became involved in studying social and institutional groups as basic decision-making entities. The first studies within the decision-making discipline were based on simple paradigms, such as pros and cons analysis, criteria prioritization, fulfillment, following orders, or even chance. However, in the same way that studying the community instead of the individual meant a paradigm shift within collective intelligence, collective decision-making means a new challenge for all the related disciplines. Besides, two new main topics come up when dealing with collective decision-making: centralized and decentralized decision-making systems. In this thesis project we focus in the second one, because it is the most interesting based on the opportunities to generate new knowledge and deal with open issues in this area, as well as these results can be put into practice in a wider set of real-life environments. Finally, within the decentralized collective decision-making systems discipline, there are several basic mechanisms that lead to different approaches to the specific problems of this field, for example: leadership, imitation, prescription, or fear. We will focus on trust and reputation. They are one of the most multidisciplinary concepts and with more potential for applying them in every kind of environments. Besides, they have historically shown that they can generate better performance than other decentralized decision-making mechanisms. Shortly, we say trust is the belief of one entity that the outcome of other entities’ actions is going to be in a specific way. It is a subjective concept because the trust of two different entities in another one does not have to be the same. Reputation is the collective idea (or social evaluation) that a group of entities within a system have about another entity based on a specific criterion. Thus, it is a collective concept in its origin. It is important to say that the behavior of most of the collective systems are based on these two simple definitions. In fact, a lot of articles and essays describe how any organization would not be viable if the ideas of trust and reputation did not exist. From now on, we call Trust an Reputation System (TRS) to any kind of system that uses these concepts. Even though TRSs are one of the most common everyday aspects in our lives, the existing knowledge about them could not be more dispersed. There are thousands of scientific works in every field of study related to trust and reputation: philosophy, psychology, sociology, economics, politics, information sciences, etc. But the main issue is that a comprehensive vision of trust and reputation for all these disciplines does not exist. Every discipline focuses its studies on a specific set of topics but none of them tries to take advantage of the knowledge generated in the other disciplines to improve its behavior or performance. Detailed topics in some fields are completely obviated in others, and even though the study of some topics within several disciplines produces complementary results, these results are not used outside the discipline where they were generated. This leads us to a very high knowledge dispersion and to a lack in the reuse of methodologies, policies and techniques among disciplines. Due to its great importance, this high dispersion of trust and reputation knowledge is one of the main problems this thesis contributes to solve. When we work with TRSs, all the aspects related to security are a constant since it is a vital aspect within the decision-making systems. Besides, TRS are often used to perform some responsibilities related to security. Finally, we cannot forget that the act of trusting is invariably attached to the act of delegating a specific responsibility and, when we deal with these concepts, the idea of risk is always present. This refers to the risk of generated expectations not being accomplished or being accomplished in a different way we anticipated. Thus, we can see that any system using trust to improve or enable its behavior, because of its own nature, is especially vulnerable if the premises it is based on are attacked. Related to this topic, we can see that the approaches of the different disciplines that study attacks of trust and reputation are very diverse. Some attempts of using approaches of other disciplines have been made within the information science area of knowledge, but these approaches are usually incomplete, not systematic and oriented to achieve specific requirements of specific applications. They never try to consolidate a common base of knowledge that could be reusable in other context. Based on all these ideas, this work makes the following direct contributions to the field of TRS: • The compilation of the most relevant existing knowledge related to trust and reputation management systems focusing on their advantages and disadvantages. • We define a generic architecture for TRS, identifying the main entities and processes involved. • We define a generic security framework for TRS. We identify the main security assets and propose a complete taxonomy of attacks for TRS. • We propose and validate a methodology to analyze, design, secure and deploy TRS in real-life environments. Additionally we identify the principal kind of applications we can implement with TRS and how TRS can provide a specific functionality. • We develop a software component to validate and optimize the behavior of a TRS in order to achieve a specific functionality or performance. In addition to the contributions made directly to the field of the TRS, we have made original contributions to different areas of knowledge thanks to the application of the analysis, design and security methodologies previously presented: • Detection of thermal anomalies in Data Centers. Thanks to the application of the TRS analysis and design methodologies, we successfully implemented a thermal anomaly detection system based on a TRS.We compare the detection performance of Self-Organized- Maps and Growing Neural Gas algorithms. We show how SOM provides better results for Computer Room Air Conditioning anomaly detection, yielding detection rates of 100%, in training data with malfunctioning sensors. We also show that GNG yields better detection and isolation rates for workload anomaly detection, reducing the false positive rate when compared to SOM. • Improving the performance of a harvesting system based on swarm computing and social odometry. Through the implementation of a TRS, we achieved to improve the ability of coordinating a distributed network of autonomous robots. The main contribution lies in the analysis and validation of the incremental improvements that can be achieved with proper use information that exist in the system and that are relevant for the TRS, and the implementation of the appropriated trust algorithms based on such information. • Improving Wireless Mesh Networks security against attacks against the integrity, confidentiality or availability of data and communications supported by these networks. Thanks to the implementation of a TRS we improved the detection time rate against these kind of attacks and we limited their potential impact over the system. • We improved the security of Wireless Sensor Networks against advanced attacks, such as insider attacks, unknown attacks, etc. Thanks to the TRS analysis and design methodologies previously described, we implemented countermeasures against such attacks in a complex environment. In our experiments we have demonstrated that our system is capable of detecting and confining various attacks that affect the core network protocols. We have also demonstrated that our approach is capable of rapid attack detection. Also, it has been proven that the inclusion of the proposed detection mechanisms significantly increases the effort the attacker has to introduce in order to compromise the network. Finally we can conclude that, to all intents and purposes, this thesis offers a useful and applicable knowledge in real-life environments that allows us to maximize the performance of any system based on a TRS. Thus, we deal with the main deficiency of this discipline: the lack of a common and complete base of knowledge and the lack of a methodology for the development of TRS that allow us to analyze, design, secure and deploy TRS in a systematic way.

The multidisciplinary management of hip fractures in older patients

Acknowledgements The authors would like to thank our colleagues for valuable discussion and feedback on the article. These include Jane Thompson (Physiotherapy), Janet Christie (Occupational Therapy), Denise Donald (Discharge Coordinator) and James Duff (Orthogeriatric Specialist Nurse). Miss Riemen is supported by Wellcome Trust through the Scottish Translational Medicine and Therapeutics Initiative (Grant no. WT 085664) and through Clinical Research Fellowship Number 105424/Z/14/Z.

A multidisciplinary approach for improving services in primary care: randomised controlled trial of screening for haemoglobin disorders

Objective: To investigate the feasibility of improving screening for carriers of haemoglobin disorders in general practice by using a nurse facilitator to work with primary care teams and the relevant haematology laboratories; to identify problems in communication between all those involved in delivering the service, and to implement solutions.

Behavioral economics: Reunifying psychology and economics

“Behavioral economics” improves the realism of the psychological assumptions underlying economic theory, promising to reunify psychology and economics in the process. Reunification should lead to better predictions about economic behavior and better policy prescriptions.

Do psicólogo no programa de residência multiprofissional em saúde: posição-sujeito, análise de discurso e psicanálise lacaniana

A residência multiprofissional em saúde é uma modalidade de ensino de pós graduação lato sensu, voltada para a educação em serviço. Emerge no contexto brasileiro como uma proposta complementar a fim de se atingir as metas e os princípios preconizados pelo sistema único de saúde (SUS), principalmente quanto à integralidade. Além de trazer implicações e lançar desafios ao exercício profissional do psicólogo, inserindo-o no entrelaçamento de campos densos e complexos (saúde, educação e políticas públicas), a modalidade propõe que profissionais com formações diferentes atuem num mesmo campo, com discussões e intervenções conjuntas. A questão que move a pesquisa é a posição-sujeito no programa de residência multiprofissional face ao modelo de educação-saúde vinculado. Assevera-se que a posição-sujeito é objeto discursivo deslizante (de tessitura simbólica) que toma em consideração o sujeito constituído no claudicar da linguagem e interpelado pelo inconsciente e que se manifesta como efeito de significantes em direção ao grande Outro. Para tal, vale-se da interface dos aportes teóricos da análise de discurso pêchetiana e da psicanálise lacaniana. A análise de discurso sustenta o discurso como efeito de sentidos mediados pela ideologia e ocupa-se, especialmente, da incursão da alteridade do discurso-outro sobre o mesmo. A psicanálise lacaniana, por sua vez, reitera a primazia do inconsciente estruturado como linguagem diante de um eu imaginário e versa para o sujeito marcado como falta que, dividido, faz do discurso o estatuto do significado. Assim, é proeminente na análise do objeto a metodologia indiciária dada ao caráter simbólico e cambiante da posição-sujeito no discurso. A análise se realizou mediante o dispositivo da interpretação como gesto analítico, que acompanha as elações próprias do objeto. O corpora é constituído por uma materialidade escrita e por uma oral. A escrita compõe-se de recortes de leis, portarias e resoluções que fundam a modalidade de residência multiprofissional e reforçam os ideias do sistema único de saúde; a materialidade oral compõe-se de recortes e fragmentos discursivos advindos da transcrição de supervisões realizadas mediante a prática clínica do psicólogo-residente na cena hospitalar. Da análise, conclui-se que a materialidade escrita se posta como campo-Outro que ordena a estrutura política da residência multiprofissional e direciona a manutenção da ordem e reprodução das relações hierárquicas mediante ideologia assujeitante. Essa materialidade, por sua vez, age como intradiscurso e reverbera-se na memória discursiva e na prática clínica. A posição-sujeito, no plano da articulação significante, faz deslizar e produzir sentidos que denotam ora a manutenção e reprodução de uma posição fusionada ao discurso médico, científico-positivista; ora a posição-sujeito é marcada pelo saber condicionado ao fetiche da mercadoria, deflagrando a ordem do capital nas insígnias da multiprofissionalidade e da educação permanente. O trabalho propiciou, enfim, acompanhar as transmutações da posição-sujeito, independentemente do indivíduo ou da naturalização de sentidos provenientes da função que exerce. O objeto posição-sujeito reiterou a construção da realidade a partir da condição faltante. É essa condição faltante e incompleta que outorga ao desejo o modo de o sujeito se posicionar desta e outra maneira - na formação, no trabalho, na vida.

The Importance of the First Psychotherapy Case in the Development of the Therapist's Professional Self as Viewed Through the Lens of Self Psychology

This paper explores the gap in the literature between what is herein referred to as the "first psychotherapy case" and its impact on the development of the trainee psychotherapist's professional self. The self psychology concepts of identity development, selfobject needs and fulfillment, narcissism, shame, countertransference, and structuralization are incorporated into the theoretical framework from which this developmental milestone is viewed. The theory's emphasis on early experiences and the development of self highlight the distinctiveness of the first case for the therapist. The beginning psychotherapy case poses a unique context for selfobject experiences and the developing self, involving both the therapist's presumably mature needs (assuming an existing cohesive nuclear self) and more infantile needs as the professional, peripheral self develops. As a result, the potential and important implications for the psychotherapist, the patient, training implications for the supervisor, and the ensuing treatment through termination are identified. The intent is to shed light on an area that is understudied thus far, and to begin a conversation as to why and how the impact of the first case on the psychotherapist should be examined. Implications, limitations, and ideas for future exploratory and qualitative research are also discussed.

An Evaluation of Sport Psychology Service Delivery in Collegiate Athletics

Sport and Performance Psychology is an ever-evolving specialty. While its development continues, it has not been without its challenges. Sport and performance psychologists work in a variety of settings and often come from similar, yet inherently different, training backgrounds. Individuals from both sport sciences and psychology have made compelling arguments as to which approach provides quality services to their respective clients. The question that remains, however, is what are these quality services? Who are the clients and what do they need from professionals in the field?Collegiate student athletes inherently face a number of typical issues related to their age and development. They also face a number of atypical difficulties as a result of their status as student athletes. As such, they provide an adequate sample of potential presenting issues for sport and performance psychologists. This current study utilized a qualitative, exploratory method to evaluate the presenting issues that brought clients to seek services from professionals.This paper seeks to establish a foundation for the development of a theoretical basis of the psychology of human performance, including both performance and general mental health concerns, and how sport and performance psychologists can most effectively intervene in this process. This paper is based on an analysis of seven years of service delivery within a NCAA Division I athletic department.Results indicate that collegiate student athletes seek services related to performance enhancement and general mental health at relative equal frequency. As such, training and service delivery in both areas would be most beneficial and best serve this population.  

Multicultural education in Clinical Psychology Programs and the needs of racial minority trainees.

With more racial minorities entering the field of clinical psychology, the training needs of racial minority students in doctoral programs must be considered. Few studies address training in multicultural education from the perspective of racial minority students despite their increasing presence in the field. This may be due to assumptions educators make based on their level of competency in the area of multiculturalism. Thus, the goal of this exploratory study is to help determine the multicultural training needs of racial minorities enrolled in clinical psychology programs. This exploratory study was quantitative and used snowball sampling to survey racial minority trainees in doctoral programs in clinical psychology. Sixty one participants completed the survey. Results indicated that multicultural/diversity classes are valued by racial minority students and are relevant to them. However, the majority of students do not feel challenged, suggesting that their needs are not being fully met. It is recommended that their unique needs be included in the curriculum for multicultural education.

Utilizing Evidence-Based Psychology Practice in the University of Denver's Professional Psychology Center: A Proposal

As acceptance of the Evidence-based Psychology Practice (EBPP) model continues to grow (Pagoto, Spring, Coups, Mulvaney, Coutu, & Ozakinci, 2007), it seems pertinent to explore how this model can be applied in different settings. This topic is timely as practitioners in the field are being held ever more accountable for the efficacy of the treatments they employ (Pagoto et al., 2007). Increased scrutiny has resulted in a need to integrate research into practice in order to ensure continued relevance in the ever-changing realm of American health care (Luebbe, Radcliffe, Callands, Green & Thorn, 2007; Collins, Leffingwell & Belar, 2007; Chwalisz, 2003). This paper explores how the requirements set forth by the American Psychological Association Presidential Task Force on Evidence-Based Practice (2006) can be implemented at the University of Denver's (DU) Professional Psychology Center (PPC), a training clinic for students enrolled in the Psy.D. program at DU's Graduate School of Professional Psychology (GSPP). In doing so, the methods employed by Collins et al. (2007) at Oklahoma State University (OSU) are used as a template and modified to accommodate differences between these two institutions.

Understanding Mastectomy from a Self Psychology Perspective: The Breast as a Self Object

For many women, if not all, breasts are an important component of bodyself-image; a woman may love them or dislike them, but she is rarely neutral" (Young, 2003, p.152). Breast cancer may be one of the oldest forms of cancer known to humans (American Cancer Society, 2010), and in 2008 in the United States over 182,000 women and almost 2,000 men were diagnosed with some form of breast cancer (American Cancer Society, 2008). In that same year 40,480 women and 450 men died from the disease. While any type of cancer diagnosis can instill a fear of mortality and incapacitation in the recipient, breast cancer holds a special meaning for women because of the significance placed on the breast both personally and societally. Removal of the breast tissue and muscle, or mastectomy, remains one of the primary forms of treatment for this disease. The breast plays an important role in a woman's identity, and the loss of one or both breasts due to breast cancer can have a monumental impact on her sense of self. A mastectomy affectsnot only a woman's relationship with herself, but with her family, friends, and society. It changes her outlook on life, her perception of her roles in the world, and her interest in interacting with others. Exploring these issues is important to understanding how doctors, nurses, mental health professionals, family members and support networks can best assist patients in coping with their illness. This paper attempts to understand the psychological issues and injuriesassociated with mastectomy through the lens of Self Psychology. It postulates that the breast itself is a selfobject for most women, and that its loss results in the fragmentation of the self. I will focus particularly on women between the ages of 25 and 40 years of age, in the marital and parental phases of developmental (Wolf, 1988), as the effect of a mastectomy on body image, sexuality, and genderbased roles such as motherhood has been shown to differ according to the age of the patient, with younger patients experiencing more distress (Ashing-Giwa et al, 2004).

Applying Positive Psychology in Early Childhood.

The purpose of this paper is to introduce a framework for applying positive psychology in elementary classrooms. The target age group is children in grades K-3 (ages 5 to 8) because this age group can benefit the most from an early introduction to strategies that promote positive development (Cowne & Hightower, 1989; White, 1996). The following sections will: (a) introduce constructs of positive psychology; (b) present developmental data on how these constructs can be applied to children ages 5 to 8 years; (c) present ideas for incorporating positive psychology practice into K-3 classrooms; (d) present strategies for incorporating positive psychology with multicultural considerations; and (e) present ideas on how to implement strategies based on positive psychology that are compatible with grade level standards and sociopolitical teaching expectations.

Exploring How AFFECT (A Family Focused Emotion Communication Training) and Self Psychology Are Mutually Enhancing

This paper implicitly advocates for a rapprochement between psychodynamic and behavioral approaches to psychotherapy, by exploring the similarities and differences between self psychology and A Family Focused Emotion Communication Training (AFFECT), a behavioral parent training model. Self psychology, a theory with broad applicability, has been applied to several modalities besides behavioral ones. Generally speaking, self psychology and AFFECT are both relational approaches to psychotherapy that emphasize the impact of parent responsiveness, more specifically empathic attunement, on a child's emotional development and emotion regulation. Differentiating aspects of each model are identified to enhance the other model. AFFECT has relevance for pushing self psychology theory more in the direction of operations, which has implications for enhancing the research potential of self psychology, as well as for the training of the self-psychologist. Conversely, self psychology has relevance for coaching the parent with low self-esteem and decreased self-efficacy in AFFECT, which has potential implications for AFFECT treatment outcomes.