Understanding,respecting and integrating difference in therapeutic practice

The purpose of this paper is to promote thought and discussion around how and why we treat patients in chosen ways. In the present climate practitioners are required to treat patients following NICE guidelines in which cognitive behavioural therapy (CBT) is the treatment of choice in the majority of diagnoses. This paper raises concerns that this may lead to an homogenization of treatment, loss of invaluable skills and understanding from other treatment approaches, and loss to the patient who may be best cared for by a combination of treatments and approaches, most notably patients presenting with complex pathology. This paper aims to present this as a general principle, and by way of example, will focus on coupling two specific treatment orientations, cognitive behavioural therapy with psychodynamic psychotherapy, with the specific diagnosis of obsessive compulsive disorder (OCD).

Methods: Clinical material is drawn from case studies from practice in secondary adult mental health care services within the NHS. All patients were referred to the psychological services for treatment for OCD and provided with 1:1 therapy with UKCP‐registered therapists. Details have been anonymized by describing fictitious cases re‐constructed from clinical material. A theoretical understanding is included which provides both an overview for integrating treatment for the specific example of OCD and is intended by extension to other diagnoses.

Results: Working with the commonalities of therapeutic approaches, and integrating specific skills of CBT and psychodynamic psychotherapy, appears to offer a viable mode of treatment for cases resistant to single‐orientation therapies.

Conclusions: Coupling the skills of different therapies can be effective in treating complex patients that are referred to the secondary mental health services. Conversely, restricting practice to single orientation therapies can lead to an impoverished care for patients and diminution of invaluable therapeutic skills which may become underused, undervalued and lost in the practice of mental health care within the NHS. Acknowledgement of the skills of others, valuing these and learning from each other can help to avoid the defensive reactions of practitioners, where each may defensively retreat to their corners of specialism. Respecting and sharing skills from different orientations, and acknowledging this in the NICE guidelines, is good for both mental health services and patient care and addresses the concerns raised by practitioners exemplified by Bateman (2000 Bateman, A. 2000. Integration in psychotherapy: An evolving reality in personality disorder.. British Journal of Psychotherapy, 17(2): 147–156.  [Google Scholar], p. 147) that ‘psychotherapy continues to be bedeviled by ideological schisms with practitioners apparently ignoring alternative conceptualizations and potentially superior interventions’.     

It's Not Just a Headache,Dear

No abstract available for this article.     

Optimal versus heuristic planning of object manipulations: A review and a computational model of the continuous end-state comfort effect

Human beings select actions that facilitate the execution of later actions. For example, humans tend to select grasps that ensure that forthcoming object manipulations end in a comfortable posture (“end-state comfort effect”). Basic experimental results and their explanation within the optimal control framework are reviewed. I conclude that the discrete grasp selection tasks, which are commonly used to study anticipatory planning, leave room for alternative explanations. Moreover, the results of seven experiments employing a continuous grasp selection task seem incompatible with the optimal control (of end-state comfort) account. I introduce the weighted integration of multiple biases (WIMB) model, which accounts for many aspects of the selection of human grasp orientations in continuous tasks. Additionally, it accounts for the precision effect and hysteresis effect. The model shows that the brain may rely on a simple heuristic and does not actually has to anticipate the end-state of a movement to select effective grasps for object manipulations.     

Vigilant Self‐regulation and Costly Punishment in Public Goods Situations

Applying regulatory focus theory to the context of social dilemma situations, the present research demonstrates that individual differences in vigilant, prevention‐focused self‐regulation predict the tendency to invest private resources to punish uncooperative interaction partners (costly punishment), a behaviour that typically has strong positive effects on the collective level of cooperation. Analyses further support the distinctiveness of the vigilance system proposed in regulatory focus theory (prevention focus) in comparison with general defensive inhibitory tendencies (measured with Carver and White's Behavioral Inhibition System scale). Results document that individual differences in prevention‐focused self‐regulation but not differences in general defensive inhibitory tendencies are positively related to costly punishment. In sum, the findings indicate that vigilant, prevention‐focused self‐regulation plays a crucial role in the context of sanctions that enforce cooperation. Copyright © 2013 John Wiley & Sons, Ltd.     

A Little Goes a Long Way: The Impact of Distal Social Support on Community Integration and Recovery of Individuals with Psychiatric Disabilities

Although an extensive body of literature highlights the important role of social support for individuals with psychiatric disabilities, definitions of support tend to be restricted—focusing on intimate relationships such as friend and family networks and ignoring the role of casual relationships existing naturally in the community. This mixed-methods study of 300 consumers of mental health services in the Southeastern US aims to better understand the impact of community supports, termed distal supports, on community integration and recovery from mental illness. Qualitative content analysis, tests of group mean differences, and hierarchical linear regression analyses revealed the following: (1) participants primarily reported receiving tangible support (e.g., free medication/discounted goods) from distal supports rather than emotional support (e.g., displays of warmth/affection) or informational support (e.g., provision of advice); (2) women and older participants reported more distal supports than men or younger participants; and (3) distal supports played a unique role in predicting community integration and recovery even after accounting for the influence of traditional support networks. Results highlight the importance of considering diverse types of social support in naturally occurring settings when designing treatment plans and interventions aimed at encouraging community participation and adaptive functioning for individuals with psychiatric disabilities.     

Examining direct and indirect pathways to health behaviour: The influence of cognitive and affective probability beliefs

This study aimed to extricate the influence of rational (e.g. ‘I think …’) and intuitive (e.g. ‘I feel …’) probability beliefs in the behavioural decision-making process regarding skin cancer prevention practices. Structural equation modelling was used in two longitudinal surveys (sun protection during winter sports [N?=?491]; sun protection during summer [N?=?277]) to examine direct and indirect behavioural effects of affective and cognitive likelihood (i.e. unmediated or mediated by intention), controlled for attitude, social influence and self-efficacy. Affective likelihood was directly related to sun protection in both studies, whereas no direct effects were found for cognitive likelihood. After accounting for past sun protective behaviour, affective likelihood was only directly related to sun protection in Study 1. No support was found for the indirect effects of affective and cognitive likelihood through intention. The findings underscore the importance of feelings of (cancer) risk in the decision-making process and should be acknowledged by health behaviour theories and risk communication practices. Suggestions for future research are discussed.     

Life events and psychological well-being in old age

Abstract

Although life event research has burgeoned in recent years, little attention has been paid to the prevalence of events among the elderly or their relationship to psychological well-being. This paper presents data from a three-wave longitudinal study of community elderly in Aberdeen. Negative life events were highly prevalent among both survivors [N=349) and non-survivors [N=108], but the relatively small differences between the groups indicate that attrition does not seriously affect longitudinal findings. Longitudinal analysis of survivors' data was performed using LISREL and yielded a model with a goodness of fit index of 0.918, demonstrating a close fit between the data and the model. The model parameters indicate that those in poor psychological state were more likely to report serious non-health events than health events, although the latter were more likely than the former to result in a decline in psychological well-being, even after prior psychological state was taken into account. While elderly people with low social integration experienced more severe reactions to life events in the short term than those with high social integration, there were no significant long term effects, even for those reporting highly stressful events. There was no evidence of a sub-group of elderly people lacked into a cycle of serious life events. However life events were not random occurrences; serious health events were more often reported by those with low education while women and those in lower social classes were more likely to report serious non-health events. Overall, long term disruption, directly attributable to life events, was minimal when viewed within the context of the community elderly's stable psychological state.     

A pilot evaluation of the efficacy of a couple-tailored print intervention on colorectal cancer screening practices among non-adherent couples

The objective of this study was to evaluate the efficacy of a couple-tailored print (CTP) intervention on colorectal cancer screening (CRCS), CRCS intentions, and on knowledge and attitudes among couples in which neither partner is on schedule with regard to CRCS. A total of 168 married couples with both members non-adherent with CRCS were randomly assigned to receive either a CTP pamphlet accompanied by a generic print (GP) pamphlet or a GP pamphlet only. Couples completed measures of CRCS, intentions, relational perspective on CRCS, discussions about CRCS, spouse support for CRCS, spouse influence strategies, CRC knowledge, perceived CRC risk, and CRCS benefits and barriers. Results indicated there was no significant benefit of CTP vs. GP on CRCS, but there was a significant increase in CRCS intentions in CTP compared with GP. There was also a significant increase in relationship perspective on CRCS, a significant increase in husbands’ support of their wives’ CRCS, and a significant increase in CRCS benefits in CTP. In summary, CTP did not increase CRCS practices but increased intentions and perceived benefits of CRCS as well as improving couples’ ability to view CRCS as having benefit for the marital relationship.     

Changes in illness-related cognitions rather than distress mediate improvements in irritable bowel syndrome (IBS) symptoms and disability following a brief cognitive behavioural therapy intervention

Objective

A previous randomised controlled trial demonstrated that a cognitive behavioural therapy (CBT) self-management intervention significantly improved irritable bowel syndrome (IBS) symptoms and disability compared to treatment as usual (TAU). The current study analysed additional data to establish whether; 1) cognitive, behavioural and emotional factors hypothesized to perpetuate IBS symptoms and disability changed following CBT and, 2) ascertain if changes in these factors over the intervention period mediated treatment effects 6-months later.

Method

IBS patients (CBT = 31, TAU = 33) completed measures pre-and-post intervention including: Brief Illness Perception Questionnaire, Hospital Anxiety & Depression Scale and Cognitive and Behavioural Responses to Symptoms Questionnaire. Path models were evaluated to determine whether changes in cognitive and behavioural factors over the treatment period mediated treatment effects.

Results

Compared to TAU, CBT patients showed significant positive changes on several cognitive variables but not anxiety and depression following intervention. Positive change in illness perceptions following intervention mediated the treatment effect on improved IBS symptom severity and social adjustment six months later. Changes in damaging beliefs mediated the effect on social adjustment.

Conclusions

Change in cognition rather than mood mediated treatment related improvements. Changing negative perceptions of IBS appears to be a particularly important treatment mechanism.     

Computerised Cognitive Behavioural Therapy in an Adult Mental Health Service: A Pilot Study of Outcomes and Alliance

This pilot study aimed to explore the clinical outcomes and therapeutic relationship for clients of an adult mental health service using Beating the Blues, a computerised cognitive behaviour therapy (CCBT) package. Sixteen participants completed the programme and reported a significant reduction in Beck Depression Inventory scores posttreatment. Participants' mean item ratings on the relationship measure were above the neutral midpoint, but no association was found between the therapeutic relationship and outcome. The results are discussed in terms of the utility of CCBT as part of a stepped-care model and how further research might usefully explore the nature of the relationship formed between clients and CCBT programmes.