THE IMPACT OF FUNCTIONAL ANALYSIS METHODOLOGY ON OUTPATIENT CLINIC SERVICES

The impact of the article by Iwata, Dorsey, Slifer, Bauman, and Richman (1982) on research in severe behavior disorders has been impressive. Equally impressive, however, but not as fully recognized, has been the impact of this methodology on the routine professional activities of those who employ functional analysis methods in their daily work. As one example of this impact, we describe the evolution of assessment procedures based on “brief functional analysis” methodology in our outpatient clinics. Less apparent have been the collateral effects that occur from using these procedures. Interactions with clients and colleagues have changed in ways that result in increased positive reinforcement. In this article, we briefly discuss the positive impact functional analysis has had on one specific work behavior—outpatient clinic assessment—and describe some of the generalized effects we have experienced in related aspects of our daily professional activities.     

Current Status of Psychosocial Intervention Research for Pediatric Outpatient Surgery

We reviewed 20 published studies of psychosocial interventions (i.e., preoperative preparation, parental presence) for children undergoing outpatient surgical procedures. The effectiveness of different intervention strategies on child and parent outcomes is summarized. Few positive effects were found for any of the psychosocial interventions. However, only a small number of randomized controlled trials were conducted and many of the studies using quasi-experimental designs had significant methodological problems that limited the interpretation of their findings. Research recommendations are described such as strengthening methodological rigor, making intervention strategies relevant to outpatient surgery, and using developmentally appropriate intervention strategies.     

A probabilistic model of intensive designs

Without internal validity, experimental data are uninterpretable. With intensive designs, most methods presented to quantify a design's internal validity have been subject to criticism. A probabilistic model of intensive designs is presented that demonstrates the high degree of internal validity of these designs without relying on adaptations from traditional inferential statistics. Where the experimenter is able to conform to the restrictions of the model, the equations provide an estimation of internal validity for either reversal or multiple-baseline designs. More importantly, the model provides mathematical bases for some of the common recommendations and design considerations in intensive research (such as the desirability of within-subject replications and of four or more multiple baselines).     

Personality disorders and psychosocial changes after intensive psychotherapy: A prospective follow-up study of an outpatient psychotherapy project, 5 years after end of treatment*

This report presents the results of a 7-year prospective outcome study designed to examine the psychosocial changes during and after therapy among 25 outpatients suffering from personality disorders and psychoses. The therapeutic approach was based mainly on object relations theory and psychodynamic self-psychology, and focused in particular on affect consciousness, parental images, self-image and interpersonal relations. Twenty patients completed the form which measured psychosocial changes during therapy, and 21 persons participated at follow-up. The data show statistically significant changes in the capacity to tolerate intimate relationships and actually establish such relationships, improved quality of contact in relationships with friends, a general raising of socioeconomic status and reduced use of ordinary health and social services. Both the global psychosocial outcome at follow-up as measured by HSRS and the general level of symptoms measured by SCL-90 suggest that 76% of the sample had reached a level of psychosocial functioning and adaptation that can be defined as “no-caseness”.     

Does participation in research lead to changes in attitudes among clinicians? Report on a survey of those involved in a French practice research network

Background/Objective: With increasing awareness of some of the limitations of randomised controlled trials as the ‘gold standard’ of psychotherapy evaluation, researchers at the start of the twenty‐first century have focused on a number of new priorities: developing studies in natural conditions; investigating the psychotherapeutic process to better understand the conditions, causes and mechanisms of change; and reducing the gap between clinicians and researchers. Can these three interrelated objectives be combined? Method: A French psychotherapy practice‐based research network (PRN) is used as a field of research for these issues. A survey was used to investigate the conditions that encouraged the clinicians to participate in the PRN study within the context of clinicians’ general opposition to research. Results: Several elements emerged as the key to clinicians’ positive involvement in research: the methodology implemented (intensive case studies during one year); the choice of measures; the constant attention to the practicalities and the potential contribution of studies to clinical practice; the organisation of work in peer groups; the training methods; the use of new information technologies and the sense of participation in a project that would support the profession. Implications: These elements are briefly discussed in relation to the question of how best to encourage clinicians to engage with research.     

The elephant tied up with string: a clinical case study showing the importance of NHS provision of intensive,time-limited psychoanalytic psychotherapy treatments

Prof. Richard Layard's influential advocacy for greater provision of ‘evidence-based’ psychological therapies, based in part on an economic rationale, has lead to greatly increased provision of cognitive behavioural therapy (CBT) and short-term therapies for depression, through the Increasing Access to Psychological Therapies (IAPT) initiative, whilst longer-term psychodynamic treatments are under threat, criticised as lacking an evidence base. This paper argues for the continuing provision of intensive thrice-weekly psychoanalytic psychotherapy treatments, time-limited to two years. It does so by describing such a treatment within an NHS psychotherapy department with a patient with a long history of severe personality pathology, including significant levels of perversity. The paper describes the patient's difficulties and his movement through the treatment, focussing on his difficulties making genuine emotional contact, his destructiveness of such contact, his acting out in the treatment, his perversity and the vital working through of the ending. The shifts the patient made are described, and follow-up information on the patient is given. The paper discusses the unique benefits of time-limited treatment and intensive psychoanalytic treatments for this ‘hard-to-help’ group of patients, and the economic rationale that can be made for such treatments.     

Treatment of Adolescent Panic Disorder: A Nonrandomized Comparison of Intensive Versus Weekly CBT

This study compared the relative efficacy of intensive versus weekly panic control treatment (PCT) for adolescent panic disorder with agoraphobia (PDA). Twenty-six adolescents participated in weekly sessions and 25 received intensive treatment involving daily sessions. Both groups demonstrated significant and comparable reductions in panic disorder severity and general anxiety symptoms, which maintained over time. Participants receiving weekly treatment showed significant decreases in depressive symptoms, whereas those in the intensive program reported no change. Findings support the efficacy of the intensive approach for adolescent PDA, but suggest that adolescents receiving intensive treatment may benefit from a brief course of additional weekly sessions.     

ICU成人患者镇痛药物的使用：阿片类及其他

ICU患者经历着各种各样的疼痛,镇痛治疗对于ICU患者至关重要.目前可用于ICU成年患者的镇痛药物很多,主要有阿片类镇痛药、解热镇痛抗炎药和对某些特殊疼痛状态有效的药物.阿片类药物仍是非神经性疼痛的一线用药,使用最多的是阿片受体激动药,包括吗啡、芬太尼、舒芬太尼、瑞芬太尼等,其中舒芬太尼、瑞芬太尼在国内ICU中使用经验不多;阿片受体部分激动药在国内ICU使用很少,包括喷他佐辛、地佐辛等;非甾体类镇痛药在国内ICU使用也很少,包括氟比洛芬酯、帕瑞昔布等.本文旨在简单介绍舒芬太尼、瑞芬太尼、部分阿片受体激动剂及非甾体类镇痛药在ICU的应用.     

对心血管病临床强化治疗的质疑

强化治疗是最近几年反复提到的话题。很多临床试验研究各种强化治疗对心血管疾病预后的影响,但结果显示强化治疗并未能带来更多的益处,甚至有害。因此我们必须理性地看待这些所谓的强化治疗。更应该倾向于个体化治疗、综合治疗,包括控制各种危险因素,改善生活的方式。把治疗的眼光放到疾病发生的早期,早治疗,以求更多获益。     

Controversies in Family Preservation Programs

Summary

This paper examines the controversies over the use of family preservation policies to prevent and treat child abuse and neglect. Policies that aim to preserve families in which child maltreatment has occurred are at least a century old. However, there is renewed interest in such policies, given the dramatic rise in child abuse and neglect reports and a large number of children who spend time in out-of-home placements. New intensive family preservation services were advanced as able to assure the safety of children while working toward a lasting preservation of the family unit. The paper summarizes the research on intensive family preservation services and reports that such programs do not reduce placements nor do they appear to enhance child safety. The paper concludes by proposing that risk assessments and assessments of readiness to change could improve decision-making regarding which families might be aided by family preservation and which children should be protected by terminating their parents' rights.