Stress management interventions for HIV+ adults: a meta-analysis of randomized controlled trials, 1989 to 2006.

OBJECTIVE: Numerous studies document that stress accelerates disease processes in a variety of diseases including HIV. As a result, investigators have developed and evaluated interventions to reduce stress as a means to improve health among persons living with HIV. Therefore, the current meta-analysis examines the impact of stress-management interventions at improving psychological, immunological, hormonal, and other behavioral health outcomes among HIV+ adults. DESIGN: This meta-analytic review integrated the results of 35 randomized controlled trials examining the efficacy of 46 separate stress management interventions for HIV+ adults (N=3,077). MAIN OUTCOME MEASURES: Effect sizes were calculated for stress processes (coping and social support), psychological/psychosocial (anxiety, depression, distress, and quality of life), immunological (CD4+ counts and viral load), hormonal (cortisol, dehydroepiandrosterone sulfate [DHEA-S], cortisol/DHEA-S ratio, and testosterone) and other behavioral health outcomes (fatigue). RESULTS: Compared to controls, stress-management interventions reduce anxiety, depression, distress, and fatigue and improve quality of life (d+s=0.16 to 0.38). Stress-management interventions do not appear to improve CD4+ counts, viral load, or hormonal outcomes compared with controls. CONCLUSION: Overall, stress-management interventions for HIV+ adults significantly improve mental health and quality of life but do not alter immunological or hormonal processes. The absence of immunological or hormonal benefits may reflect the studies' limited assessment period (measured typically within 1-week postintervention), participants' advanced stage of HIV (HIV+ status known for an average of 5 years), and/or sample characteristics (predominately male and White participants). Future research might test these hypotheses and refine our understanding of stress processes and their amelioration.     

Behavioral Versus Nonbehavioral Guided Self-Help for Parents of Children With Externalizing Disorders in a Randomized Controlled Trial

Self-help interventions for parents, which have a behavioral basis, are considered to be an effective treatment option for children with externalizing disorders. Nonbehavioral approaches are widely used but have little empirical evidence. The main objective of this trial was to compare the efficacy of a behavioral and a nonbehavioral guided self-help program for parents. Families of children (aged 4–11 years) diagnosed with attention-deficit/hyperactivity disorder (ADHD) or oppositional defiant disorder (ODD) were randomized to either a behavioral or a nonbehavioral guided self-help program including 8 parenting booklets and 10 counseling telephone calls. The analyses considered the ratings of 5 informants: blinded clinician, therapist, participant, (her or his) partner, and teacher. Of the 149 families randomized to treatment (intention-to-treat sample [ITT]), 110 parents completed the intervention (per-protocol sample [PP]). For the 4 primary outcome measures (blinded clinician- and participant-rated ADHD and ODD) at post-assessment, the analysis revealed a treatment advantage for the behavioral group in blinded clinician-rated ODD symptoms (ITT: d = 0.37; PP: d = 0.35). Further treatment differences, all in favor of the behavioral group (ITT and PP), were detected in therapist ratings (i.e., ODD) and participant ratings (e.g., parental self-efficacy [only PP], negative parenting behavior, parental stress). In both samples, no differences were found at post-assessment for ratings of the partner and the teacher, or at the 12-month follow-up (only participant ratings available). Behavioral guided self-help shows some treatment advantage in the short term. No superiority over nonbehavioral therapy was detected 12 months after treatment termination.     

An Examination of the Effects of Stress Management Training for Japanese College Students of Social Work

The purpose of the present study was to examine the effects of a stress-management program for college students of social work on their perception of mental stress and stress-coping strategies. Students in a stress-management group received progressive muscle training, cognitive-behavioral skills training, and assertion training for 14 weeks. Their life events, stress symptoms, and stress-coping skills (active and passive coping skills), evaluated on the first and last days of program, were compared with those of a control group. The effect of the participants' trait anxiety on those variables was also examined. Because the stress-management program in the present study focused on coping strategies, it was expected that the students' coping skills would change. The results showed that passive coping skills of students in the stress-management group had decreased after the program.     

Family Themes: Transmission and Transformation

This article describes a method for doing therapy that uses multisystemic themes that combine meaning and action to facilitate therapeutic change. By identifying central themes that operate at the individual, dyadic, triadic, whole family, inter-generational, and sociocultural levels, the therapist is able to develop effective interview questions and design useful interventions. In this method, behavioral symptoms are framed as a current manifestation of an overarching theme. This orientation enables family and therapist to de-pathologize symptoms and work collaboratively toward change. Case examples from a wide variety of families with differing presenting problems, interactional patterns, three-generational histories, and cultural backgrounds, illustrate the efficacy of the method.     

A Model of Therapist Competencies for the Empirically Supported Cognitive Behavioral Treatment of Child and Adolescent Anxiety and Depressive Disorders

While a plethora of cognitive behavioral empirically supported treatments (ESTs) are available for treating child and adolescent anxiety and depressive disorders, research has shown that these are not as effective when implemented in routine practice settings. Research is now indicating that is partly due to ineffective EST training methods, resulting in a lack of therapist competence. However, at present, the specific competencies that are required for the effective implementation of ESTs for this population are unknown, making the development of more effective EST training difficult. This study therefore aimed to develop a model of therapist competencies for the empirically supported cognitive behavioral treatment of child and adolescent anxiety and depressive disorders using a version of the well-established Delphi technique. In doing so, the authors: (1) identified and reviewed cognitive behavioral ESTs for child and adolescent anxiety and depressive disorders, (2) extracted therapist competencies required to implement each treatment effectively, (3) validated these competency lists with EST authors, (4) consulted with a panel of relevant local experts to generate an overall model of therapist competence for the empirically supported cognitive behavioral treatment of child and adolescent anxiety and depressive disorders, and (5) validated the overall model with EST manual authors and relevant international experts. The resultant model offers an empirically derived set of competencies necessary for effectively treating children and adolescents with anxiety and depressive disorders and has wide implications for the development of therapist training, competence assessment measures, and evidence-based practice guidelines for working with this population. This model thus brings us one step closer to bridging the gap between science and practice when treating child and adolescent anxiety and depression.     

TRAINING FAMILY THERAPISTS: AN EXPERIMENTAL ANALYSIS

This study implemented and evaluated a training program (a written manual, videotaped models, rehearsal, role plays, and performance feedback) designed to teach five subjects the skills to become effective family therapists. The study examined the therapists' use of three target behaviors: instructing, informing, and praising. The therapists, each paired with a parent and a preschool-aged child (2 1/2–4 1/2 yr old), were trained in the clinic to use, and to teach to the parents, several behavioral skills (e.g., praising, planned ignoring, and time-out) relevant to teaching children compliance to parental instructions. A multiple-baseline design across triads (therapist/parent/child) demonstrated that after the training program was instituted, the therapists increased their rates of instructing, praising, and informing the parents; all parents increased attention to compliance, decreased attention to noncompliance, and increased rates of praise to their children; and all children increased their compliance and decreased their noncompliance.     

Usability and Utility of a Computerized Cognitive-Behavioral Self-Help Program for Public Speaking Anxiety

This study describes the use of a cognitive-behavioral computer-administered self-help program with minimal therapist contact for public speaking anxiety. Participants (N = 10) with social phobia, as measured by a structured clinical interview, completed the self-help program in an open clinical trial. The program was delivered via a CD-ROM during individual sessions at an outpatient clinic, including 4 sessions of psychoeducation/cognitive therapy and 4 sessions of exposure therapy using a virtual audience presented on a computer screen. A therapist was available in another room to answer questions and to debrief for up to 10 minutes after each session. Participants completed standardized self-report questionnaires assessing social anxiety at pretreatment, posttreatment, and 3-month follow-up. Participants also completed measures of computer usability. Results showed decreases on all self-report measures of social anxiety from pre- to posttreatment, which were maintained at follow-up (n = 8). Participants also reported that they were satisfied with treatment, that they felt improved after treatment, and that the computer program was user-friendly. This study provides preliminary evidence that a computer-administered cognitive-behavioral-based program that includes minimal therapist contact may reduce public speaking anxiety and suggests that further research with a controlled design is needed.     

Efficacy of cognitive training programs based on new software technologies in patients with Alzheimer-type dementia

The study aims to assess the efficacy of the Big Brain Academy (BBA), a computerized cognitive training program (CT) based on video games, compared to the Integrated Psychostimulation Program (IPP), a classical CT tool for patients with Alzheimer's disease (AD). A total of 45 patients with AD at the mild stage were randomly assigned to three experimental conditions. Two treatment groups were established, in which patients received either a stimulation program with BBA (EABB) or a traditional stimulation program (EAPI), based on paper-and-pencil tasks, for twelve weeks. A third group, the control group (EANT), did not receive any treatment during this period. The differential effectiveness of the programs was evaluated through pre-post design, considering neuropsychological, behavioral, and functional standard measures as outcome variables. The EABB group showed significantly slower rates of cognitive decline compared to the EAPI and EANT groups. Furthermore, the EABB group reported significantly greater decrease in depressive symptoms in comparison with the EAPI and EANT groups. The BBA program was more effective than IPP to reduce cognitive decline and depressive symptoms in patients with AD.     

Differential Associations Between Perceived and Objective Measurement of Distress Tolerance in Relation to Antiretroviral Treatment Adherence and Response Among HIV-Positive Individuals

The present study sought to extend prior work, showing an association between self-reported distress tolerance and self-reported antiretroviral treatment (ART) adherence, by conducting a multimethod test of the association between distress tolerance and objective measures of ART adherence among a sample of 140 individuals (23.6% female) with human immunodeficiency virus (HIV). Findings indicated that, after accounting for negative affectivity and ART side-effect severity, distress tolerance was significantly associated with pill count adherence as well as viral load. Specifically, a differential association was observed whereby self-reported distress tolerance was associated with pill count adherence, whereas behavioral distress tolerance was associated with viral load. Importantly, no associations were observed between either measure of distress tolerance and CD4 count. Findings are discussed in terms of the importance of both behavioral and perceived distress tolerance assessment among patients with HIV as well as potential clinical implications related to the integration of distress tolerance-focused treatments into existing interventions for individuals with HIV.     

Randomized Controlled Trial of Cognitive–Behavioral Group Therapy for Irritable Bowel Syndrome in a Medical Setting

Standard medical treatments have not been effective for irritable bowel syndrome (IBS) patients. Though individualized cognitive–behavior therapy is an empirically supported treatment option, cognitive–behavioral group therapy (CBGT) has yet to be established as an effective alternative in a randomized controlled trial. This study compared the efficacy of a 10-session CBGT with a home-based symptom monitoring with weekly telephone contact (SMTC) treatment for IBS, extending previous quasi-experimental research in this area. Twenty-eight refractory IBS patients, evaluated and referred by gastroenterologists using the Rome criteria, participated in the study. IBS symptoms, psychological functioning, and health-related quality of life were assessed pre- and posttreatment, and at 3-month follow-up. CBGT patients reported significantly more gastrointestinal (GI) symptom improvement than SMTC patients on posttreatment global measures and had significantly reduced daily diary pain scores at 3-month follow-up. Based on MANOVA, there was significant improvement in psychological distress and health-related quality of life for the CBGT patients in comparison to the SMTC patients. These improvements were also maintained at the 3-month follow-up. Reductions in GI symptoms, psychological distress, and improved health related quality of life may contribute to less behavioral avoidance, disability, and health care utilization in refractory IBS patients.     

Effectiveness of virtual reality distraction during a painful medical procedure in pediatric oncology patients

The effectiveness of virtual reality (VR) as a behavioral intervention designed to decrease distress during port access procedure was examined in 20 7- to 14-year-old pediatric oncology patients. Children were randomized to either engage in an immersive VR environment during the procedure or to a no VR control condition. Children's distress was assessed through subjective self-ratings and objective physiological and behavioral ratings. Narrative accounts of the experience were used as a measure of how well the child coped with the procedure. VR was effective in reducing children's distress on all measures. Implications of these findings for intervention are discussed.     

The Interaction of Motivation and Therapist Adherence Predicts Outcome in Cognitive Behavioral Therapy for Panic Disorder: Preliminary Findings

This report is a post-hoc, exploratory examination of the relationships among patient motivation, therapist protocol adherence, and panic disorder outcome in patients treated with cognitive behavioral therapy within the context of a randomized clinical trial for the treatment of panic disorder (Barlow, Gorman, Shear, & Woods, 2000). Results suggested that motivation and adherence interacted to predict change in panic severity. Among patients rated as less motivated, greater therapist protocol adherence was associated with poorer outcome. Among patients rated as more motivated, adherence was not significantly associated with outcome. Further process research is needed to confirm these preliminary results and to understand the interactions of patient and therapist factors and how they are related to outcome in standardized protocols such as cognitive behavioral therapy for panic disorder.     

Helping Yourself before Helping Others: How Sense of Control Promotes Charitable Behaviors

This research elucidates the conditions under which distress appeals can evoke the instinct to help without turning recipients away from uncomfortable situations. Five experiments demonstrated with behavioral evidence that evoking a sense of control by irrelevant causes prior to appeal exposure can increase the likelihood of registering as a volunteer (Studies 1 and 3) and the tendency to donate (Studies 2, 4, and 5) in a subsequent unrelated situation. The authors found that this effect was not evident in the absence of distress and for participants with enhanced distress tolerance. The results further showed that enhanced control increased distress tolerance, which mediated the observed effect on charitable acts but had no impact on self‐efficacy in contributing as a helper. The findings have both theoretical and managerial implications for promoting charitable behaviors.     

The Efficacy of Behavioral Couples Therapy and Emotionally Focused Therapy for Couple Distress

Twenty treatment outcome studies, 13 of which evaluated behavioral couples therapy (BCT) and seven of which evaluated emotionally focused therapy (EFT) were reviewed, leading to the following conclusions. BCT leads to short and long-term gains for moderate to severe couple distress. In the long term BCT probably leads to no better outcomes than its constituent components—behavioral exchange training and communication and problem solving skills training. Addition of a cognitive therapy component to BCT or the use of a variety of treatment formats does not improve the efficacy of BCT. Integrative couples therapy and insight-oriented marital therapy may be more effective than BCT, but studies supporting this conclusion require replication. EFT leads to short and long-term gains for mild to moderate couple distress. Addition of a cognitive therapy component to EFT does not enhance its efficacy. EFT may be more effective than problem solving therapy and less effective than integrated systemic therapy, but the two studies supporting this conclusion require replication.Michael Byrne, PhD, is a Clinical Psychologist, Midland Health Board, Ireland; Alan Carr, PhD, is Director of the Clinical Psychology Training Programme, Department of Psychology, Arts Building, University College Dublin, Belfield, Dublin 4, Ireland (alan.carr@ucd.ie). Marie Clark, PhD, is Lecturer, Department of Psychology, University of Surrey, United Kingdom.     

A randomized clinical trial of a population- and transtheoretical model-based stress-management intervention.

Stress has been associated with a variety of chronic and acute conditions and with higher use of health care services. This research reports on 18-month outcomes of a randomized clinical trial of a stress-management program based on the transtheoretical model (TTM; J. O. Prochaska & C. C. DiClemente, 1986). A national sample of 1,085 individuals participated (age range = 18-91 years, M = 55.33; 68.9% female, 31.1% male; 84.8% Caucasian; 15.2% non-Caucasian). Both the treatment and control groups received assessments at 0, 6, 12, and 18 months. In addition to the assessments, the treatment group received 3 individualized reports (0, 3, 6 months) and a manual. The 18-month assessment was completed by 778 individuals (72%). A random effects model indicated that participants completing the study in the treatment group had significantly more individuals reporting effective stress management at follow-up time points than did completers in the control group. Results also indicate that the intervention had significant effects on stress, depression, and specific stress-management behaviors. Results provide evidence for the effectiveness of this TTM population-based stress-management intervention.     

The role of optimism in the process of schema-focused cognitive therapy of personality problems

The aim of this study was to examine the determinants and effects of optimism in the process of schema-focused cognitive therapy of personality problems. The sample consisted of 35 patients with panic disorder and/or agoraphobia and DSM-IV Cluster C personality traits who participated in an 11-week residential program with one symptom-focused and one personality-focused phase. This study examines the role played by optimism during the individual sessions of the second phase, using a time series approach. Decreased patient's belief in his/her primary Early Maladaptive Schema and increased patient-experienced empathy from the therapist in a session predicted increased patient-rated optimism before the subsequent session. Increased patient-rated optimism in turn predicted decreased schema belief and distress and increased insight, empathy, and therapist-rated optimism. The slope of optimism across sessions was related to change in most of the overall outcome measures. There appears to be a positive feedback in the process of schema-focused cognitive therapy between decreased schema belief and increased optimism. In addition, optimism appears to mediate the effects of schema belief and therapist empathy on overall improvement, and to serve as an antecedent to decreased distress and to increased empathy, insight, and therapist's optimism.     

Building Resiliency in Dyads of Patients Admitted to the Neuroscience Intensive Care Unit and Their Family Caregivers: Lessons Learned From William and Laura

Sustaining a stroke, regardless of its severity, is a life-changing and often traumatizing event that can lead to chronic depression, anxiety, and posttraumatic stress in both survivors and their family caregivers. Psychosocial interventions for emotional distress after stroke are limited, have emphasized psychoeducation rather than skills, treatment of chronic emotional distress rather than prevention, and have targeted either the patient or their caregiver without accounting for the context of their interpersonal relationship. Here we discuss “Recovering Together,” a novel program for dyads of patients with stroke and their family caregivers aimed at preventing chronic emotional distress by using cognitive behavioral principles to teach resiliency and interpersonal communication skills beginning during hospitalization in a neuroscience intensive care unit and continuing after discharge via telehealth. We illustrate the case of a pilot dyad enrolled in the Recovering Together program, to showcase how patients and caregivers can engage with and benefit from it. This dyad’s experience suggests that Recovering Together is credible, feasible, and useful. The potential dyadic benefit of this intervention lies not only in providing the opportunity to optimize recovery and prevent long-term emotional distress, but also in creating the space to come together as a pair and make meaning from critical illness.     

A standardized behavioral group treatment program for obsessive-compulsive disorder: preliminary outcomes

This paper provides outcome data about the efficacy of a behavioral group therapy program for obsessive-compulsive disorder (OCD). Thirty-six patients completed a 7-week outpatient treatment program which provides: (1) education about OCD and its treatment, (2) instruction in a cognitive and behavioral approach to the self-treatment of OCD and (3) guided behavioral treatment. Significant improvement in obsession, compulsion, and depression scores were observed at completion of the group and at 3 month follow-up. Significant improvement in obsessions and compulsions was observed for both patients taking anti-obsessional medications and those who did not.     

Impact of Co-Therapy Teams on Client Outcomes and Therapist Training in Marriage and Family Therapy

This study of 33 student therapists, 402 client systems, and three supervisors tested the efficacy of using student co-therapy teams as an aspect of clinical training in a marriage and family therapy program. This study utilizes both quantitative and qualitative methodology. Two research questions were addressed: “Do different pairings of co-therapists affect client outcomes?” and “Is co-therapy a viable option for a training program?” The results indicate that client outcomes using co-therapy are at least as effective as treatment using one therapist and in some circumstances produce more positive outcomes for both clients and student therapists.     

An investigation of cognitive-behavior therapy combined with oral valium for children undergoing painful medical procedures

In previous research, a cognitive-behavioral therapy (CBT) package was found to be effective in reducing children's distress associated with the painful medical procedures of bone marrow aspirations (BMAs) and lumbar punctures (LPs). Orally administered Valium demonstrated less effectiveness but was helpful in reducing behavioral distress before the medical procedure. In the present study, we investigated whether the combination of oral Valium and CBT would result in increased efficacy of the CBT. Eighty-three subjects were randomly assigned to receive either CBT or CBT plus Valium while undergoing either a BMA or an LP. Dependent variables included observed behavioral distress, self-reported fear and pain, and pulse rate. Results failed to support the value of such a combination but did provide additional evidence in regard to the effectiveness of the CBT. The need for more potent medical interventions for some children is discussed.