Prevention opportunities in health care settings

Psychologists have an opportunity to offer their expertise at a time when health care settings are beginning to recognize the importance of behaviorally based interventions for improving health and health care. The authors review the changing patterns of health and illness that have led to an increased interest in the role of patient and provider behavior and discuss the many advantages of using health care settings as prevention sites. Examples of successful behaviorally based prevention programs are presented, along with the evidence supporting the cost-effectiveness of such programs. Challenges presented by working in health care settings are described. Throughout, the authors emphasize the multiple opportunities for psychologists' involvement across a wide variety of health care delivery sites.     

Examining Factors Associated with Primary Care and Continuity of Care Among Adults with Severe Mental Illness

A number of studies have consistently reported that there is a greater prevalence of mental illness among the most socioeconomically disadvantaged. At the same time, there is evidence that services are not optimally accessed by the most socioeconomically disadvantaged; the most in need of care are also the most likely to have unmet healthcare needs. Of people with mental illnesses, those with severe mental illnesses (SMI) are the most at risk of poverty and the least likely to have optimal care. In the past, specialized community mental health services have been identified as the primary provider for people with SMI. However, there is growing interest in using the primary care setting as the main source of mental health care where both medical treatment and psychotherapy can be accessed. In this paper, we examine factors related to primary care use (and in turn, pharmacologic and psychotherapies) for people who are socioeconomically disadvantaged and who have a SMI.     

Treatment for anxiety disorders: Efficacy to effectiveness to implementation

Anxiety disorders are common, costly and debilitating, and yet often unrecognized or inadequately treated in real world, primary care settings. Our group has been researching ways of delivering evidence-based treatment for anxiety in primary care settings, with special interest to preserving the fidelity of the treatment while at the same time promoting its sustainability once the research is over. In this paper, we describe the programs we have developed and our directions for future research. Our first study evaluated the efficacy of CBT and expert pharmacotherapy recommendations for panic disorder in primary care, using a collaborative care model of service delivery (CCAP). Symptom, disability and mental health functioning measures were superior for the intervention group compared to treatment as usual both in the short term and the long term, although also more costly. In our ongoing CALM study, we have extended our population to include panic disorder, social anxiety disorder, generalized anxiety disorder and posttraumatic disorder, while at the same time utilizing clinicians with limited mental health care experience. In addition to pharmacotherapy management, we developed a computer-assisted CBT that guides both novice clinician and patient, thereby contributing to sustainability once the research is over. We have also incorporated a measurement based approach to treatment planning, using a web-based tracking system of patient status. To date, the computer-assisted CBT program has been shown to be acceptable to clinicians and patients. Clinicians rated the program highly, and patients engaged in the program. Future directions for our research include dissemination and implementation of the CALM program, testing potential alternations to the CALM program, and distance delivery of CALM.     

Chronic illness: not-so-passive injustice?

Why is our system, which is so biased toward the provision of acute care, underserving the chronically ill?...I think the main reason...has to do with the difficulty of providing for the needs of the chronically ill through a system of largely employment-based private insurance. People who are chronically ill are likely to drop out of employment: they are not a group that employment-based insurance is intended to serve or that employers have an interest in serving....I do not believe we can shift the focus of organization of services for the chronically ill to home or family, as Douard suggests, without reforming the insurance system....     

„Da wirst du ja auch bekloppt bei“

Given a growing demand of psychotherapeutic care the interest of students in a psychotherapeutic occupation is gaining relevance. At the same time psychoanalytic training institutions and societies have been confronted with a continuous decrease of candidates over the last decades. Psychology students, medical students and students of educational sciences (the latter only in the child and adolescent treatment sector) are admitted for a psychotherapeutic training approved by the health care insurances in Germany and have the possibility to choose between a behavioral or a psychodynamic oriented training. In the present multimethodological cross-sectional study those student groups (N?=?679) were questioned about their interest in a psychotherapeutic training in general and, if they proved to be interested, about their specific choice of training. Amongst psychology students the largest group of those interested in a psychotherapeutic training would opt for a behavioral education. Amongst medical students and students of pedagogy and social pedagogy a psychotherapeutic training is less frequently an option for their future career plans. Amongst the students of educational sciences, for those interested in training, psychodynamic methods are more often of interest. Possible reasons for the students' decisions in the context of the specific German legal situation are discussed.     

A model of short-term counselling in primary care

Counselling in prima y care settings has received much interest throughout Britain. Many surgeries employ counsellors or psychologists as part of the primay health care team. This paper describes a model of primary care counselling using an example of a case encountered in general practice. It emphasizes the advantages of offering on-site counselling services, such as better possibilities of liaison with the referring doctor and coordination of patient care. Progress was made in seven sessions of short-term cognitive-behavioural treatment and a more stigmatizing referral (for example, to psychiatric services) was avoided. The case can be seen as an appropriate referral in the context of primay care counselling and illustrates the benefit of this approach to the treatment of psychological and social problems in general practice. Names and details have been changed to preserve confidentiality.     

Hearing a Voice: Results of a Participatory Action Research Study

Interest in participatory action research (PAR) is rising among academics, researchers, families, and youth themselves who are involved in the system of care. PAR combines systematic research and professional guidance with the development of a practical intervention tailored to the user population in collaboration with the user population. We designed our research to sample and assess the level of interest in PAR for adolescents, gathering qualitative data about the level of understanding of, and expectations for, youth participatory action research. We present the results of a pilot study and then a survey, administered to two different conference populations during 2008. Our data offers insight into the world of service providers, beneficiaries, and advocates for children with mental health disorders. Based on the responses to our questionnaire, we identify four major themes and their underlying issues concerning the benefits and drawbacks of PAR for a young population. We also examine the concerns of each of the self-identified group to determine whether there were dominant characteristics for each group. We conclude that stakeholders do have reasonable expectations of participatory action research as a process and of the youth who could be empowered to bring about change in their system of care. Finally, we make recommendations for future research.     

Top Ten Questions Male Sexual Abuse Survivors Want to Know from Health Care Research

Sexual abuse is an often overlooked public health issue for boys and men. Given its prevalence and well-documented connection to mental and physical health disorders, the relevance of male survivor input and engagement in health care research is profound. Using a community-based participatory research design, an in-person focus group with male survivors of sexual abuse and researchers was conducted. This paper describes the top ten research questions male sexual abuse survivors would like to have answered. Survivors were most interested in knowing how sexual abuse and assault impact men’s emotional and sexual functioning, what factors are involved in preventing and treating sexual assault-related emotional distress, and what can be done to prevent sexual abuse of boys and men. The fact that some of the questions survivors expressed an interest in knowing about have actually previously been investigated by researchers suggests a disconnect in translating evidence-based findings. Clinical and research implications include designing outreach interventions and gender-specific psychoeducation to increase engagement and access to care for men.     

Disponibilité à la psychothérapie et à l’engagement dans les soins chez les patientes boulimiques : contribution du Rorschach

The instability of involvement in the care process and psychotherapy is frequent among bulimic women. The preliminary evaluation of the capacity of involvement helps to make the decision to begin specific care with these patients. We thus make the assumption that involvement in the care process can express itself in indexes of Rorschach when this test is part of a prior examination of orientation at the beginning of the care. These indexes concern the relationship dependence and the capacity of development of subjective expression. They appear in several analysis registers of the Rorschach protocol, which are: the scale of oral dependence (ROD); the index of expressive capacity (EX); the recurring object (ORec); contents in connection with the representation of dependence among bulimic women. A group of 34 bulimic women involved in multifocal care process, especially including a psychoanalytical-inspired psychotherapy (ES) is compared with a group of 34 bulimic women who precociously stopped this care or didn’t get involved in it (NES). The subjects of the ES group received care during at least 1 year. The comparison between the two groups shows significant differences in the pretherapeutic indexes (ROD, ORec). The interest and the limits of this type of analysis are debated.     

Factors Influencing Experienced Distress and Attitude Toward Trauma by Emergency Medicine Practitioners

Authors explored whether the dose-response relationship evident in PTSD also applied to cases of vicarious trauma and, if so, which variables serve to moderate such reactions. This study examined the surveyed responses of emergency care workers in a group geographically near the September 11, 2001 New York terrorist site, comparing the results to a group of emergency care workers geographically distant from the terrorist site. Study results lend support to the presence of a dose-response relationship within vicarious traumatization. Specific variables associated with higher distress levels for practitioners included the discipline of the practitioner, treating an injured victim, and personally knowing a victim of the New York terrorist attacks. Past training related to vicarious traumatization was not associated with lower distress levels for practitioners. In addition, practitioners' awareness and interest in psychological issues related to trauma appear to have been enhanced by geographic proximity to the New York terrorist attacks.     

The Berkeley Civic Courage and Heroism Experiment: The Group Dynamics of Individuals Acting in Concert to Advance Ethical Goals in the Public Interest

Many studies have investigated how to get individuals to obey external authority, as noted in the obedience experiments (Miller, 1986). But next to none have investigated how individuals obey their conscience as they act as members of a group committed to taking nonviolent courageous action in the defense of ethical principles and the public interest. The present study investigates the situational group context and group dynamics that allow individuals to act in concert with others to carry out ethical goals, even at personal cost to themselves.     

应激的缓冲器：人格坚韧性

过去30年来,关注身心保健和组织行为的心理学家都对人格心理学中的一个概念发生了兴趣,就是人格坚韧性（hardiness）,大量实证研究证明人格坚韧性可以有效地缓解生活应激给人们带来的身心不适,并有助于提高人们在各领域的工作表现。该文在回顾西方以往研究的基础上,介绍这一概念,以及这方面研究的不足之处,并提出在中国开展此项研究的思路。作为整体人格结构的一部分,人格坚韧性应该从人格“大五”或“大七”结构中探索。在中国已有研究发现,人格“大七”维度对身心健康有不同的影响,哪些维度构成人格坚韧性,这些问题有待进一步的研究     

Thoughts on how to regulate behaviours: an overview of the current debate

ABSTRACT

The article intends to present the debate on behaviour modification in the regulation studies literature, at a time of renewed interest among regulators for new ideas and strategies. As the financial crisis has led to the most public critique yet of the rational choice view of individuals that has informed regulation in the last few decades, other ideas that value realism more than simplicity and parsimony deserve some attention. Some of these – proposed by behavioural economics – have already raised considerable interest from regulators, especially in the UK and the USA, and have begun to impact various types of regulation. This article puts these various elements in perspective and as such provides tools to appraise and engage with past and future attempts to regulate social groups in health care and elsewhere.     

Examining Externalizing Behavior Trajectories of Youth in Group Homes: Is there Evidence for Peer Contagion?

Although concerns about peer contagion are often cited in critiques of group treatments for troubled youths, few studies have examined the effects of exposure to deviant peers in residential group care settings. This study used administrative data of youth served at Boys Town, a nationally-known group care provider. Using latent class growth analysis, this study identified the externalizing behavior trajectories of youth in group care as well as the behavior trajectory of the peers with whom they lived, assessed the relationship between youth trajectory classes and individual and peer group characteristics as well as the relationship between an individual youth’s behavior pattern and the behavior pattern of proximal peers. Several results suggested the presence of peer contagion in group care: a trajectory class of gradually increasing externalizing behavior problems, the strength of deviant peer density in predicting an individual youth’s externalizing behavior trajectories and significant associations between behavior patterns of youth and proximal peers. While there is some evidence that suggests an increase in problem behavior during care, results from this study indicated that over 90% of the youth did not have an increase in problem behaviors and that positive peer influences may also be protective and inhibit problem behaviors.     

FACTS, FANTASIES AND THE FUTURE OF CHILD CARE IN THE UNITED STATES

Psychologists in both family practice and developmental research may be puzzled about the scientific status of research on child care as it affects children, parents, and caregivers. What conclusions can be reached about mothers in the labor force, about the advisability of various child care arrangements, about their short and long-term consequences, and what advice do we as psychologists have to offer in the public interest to parents of infants and young children? In this article, we review research on child care, and discuss its implications for the nation and for psychology as a research enterprise and a helping profession.     

Survivors of Torture: Realities, Responsible Care, and Rehabilitation

This paper provides an overview of special issues and challenges for the psychiatrist providing care to a survivor of government sponsored torture. Case examples illustrate cultural concerns, issues of confidentiality, transference, dual loyalties, and provider responsibilities. The author hopes to stimulate interest in others to learn more about working with this challenging and rewarding group of patients.     

Interest in smoking cessation among emergency department patients.

The authors interviewed adult patients presenting to 4 Boston emergency departments (EDs) about their smoking, quit attempts, and interest in an outpatient referral. Of the 539 patients enrolled, 26% were current smokers. Of the current smokers, 72% had tried to quit in the past year, and 34% wanted an outpatient referral. Current smokers were younger than nonsmokers and were less likely to have a high school education, primary care provider, and private insurance. The findings of this study reinforce the potential benefit of routine screening for smoking and interest in quitting in the ED. Because many underinsured Americans use the ED as a source of regular health care, the public health implications of increasing screening, counseling, and referral for smokers are substantial.     

Prolonging life and delaying death: The role of physicians in the context of limited intensive care resources

Critical care is in an emerging crisis of conflict between what individuals expect and the economic burden society and government are prepared to provide. The goal of critical care support is to prevent suffering and premature death by intensive therapy of reversible illnesses within a reasonable timeframe. Recently, it has become apparent that early support in an intensive care environment can improve patient outcomes. However, life support technology has advanced, allowing physicians to prolong life (and postpone death) in circumstances that were not possible in the recent past. This has been recognized by not only the medical community, but also by society at large. One corollary may be that expectations for recovery from critical illness have also become extremely high. In addition, greater numbers of patients are dying in intensive care units after having receiving prolonged durations of life-sustaining therapy. Herein lies the emerging crisis – critical care therapy must be available in a timely fashion for those who require it urgently, yet its provision is largely dependent on a finite availability of both capital and human resources. Physicians are often placed in a troubling conflict of interest by pressures to use health resources prudently while also promoting the equitable and timely access to critical care therapy. In this commentary, these issues are broadly discussed from the perspective of the individual clinician as well as that of society as a whole. The intent is to generate dialogue on the dynamic between individual clinicians navigating the complexities of how and when to use critical care support in the context of end-of-life issues, the increasing demands placed on finite critical care capacity, and the reasonable expectations of society.     

Communication Differences Between Physicians and Their Patients in an Oncology Setting

The physician-patient relationship has critical importance in the quality of medical care, especially in the oncology setting. Of particular interest over the past two decades has been the communication between physicians and their patients. It is understood that communication is related to patient and physician satisfaction as well as other medical outcomes. However, despite this interest and attention, investigators have only recently begun to assess the communication between physicians and patients from the patient's point of view. Additionally, previous investigations have primarily relied upon retrospective reports of the interaction from patients or physicians. The current investigation assessed physician–patient communication in an oncology setting, both as it was occurring and following the interaction. The units of analysis included participant ratings as well as those of trained observers. Findings revealed that physicians and patients disagree as to the valence of the messages which transpired. Additionally, results suggest that it is the patients who distort the messages in the positive direction. Research and clinical implications of this disagreement and positivity bias are discussed.