Informed Outcomes: Self-rating measures and their use in psychodynamic therapy with adolescents

I am currently engaged in an A Space ¹ 1. A Space for Creative Learning and Support was set up as a research and development project in 1997 by The Glass-House Trust (a Sainsbury Family Charitable Trust), the Social Science Research Unit (Institute of Education, University of London) and Hackney Education. A core aim is to deliver psychodynamic therapies in the school setting, adapting and evolving current models of child and adolescent psychotherapy, where necessary, both in response to the educational context and to ensure that the needs of children and adolescents are best met. In 2010, A Space and The Centre for Psychoanalytic Studies, University of Essex, began a formal study into school-based therapy. Funded by The Glass-House Trust, this research will run through to 2013. A conference will be held in 2013, so that the findings can be more widely disseminated. /University of Essex research study looking at the ways in which psychodynamic counselling can best meet the needs of young people accessing therapy in the school setting. As part of the study, I have looked at the main outcome measures used in work with adolescents in clinics, the community and voluntary sector and in education settings. In this article, I look at the process of assessment, including the use of written self-rating outcome measures with young people. I critically review a selection of these and reflect on their application in practice. I go on to consider how collaborative written assessment procedures may be more appropriate for use by psychodynamic therapists working with school-based clients, given the challenges of delivering therapy in the education sector.     

Monitoring the effects of adult psychotherapy in routine practice in Switzerland: A feasibility trial

Background: Several studies have been published on the effects of psychotherapy in routine practice. Complementing traditional views summarised as ‘dose‐effect models’, Stiles et al. put forward data consistent with the responsive regulation model underlining the importance of the client's active participant role in defining length of treatment. One may ask what level of change reached by a patient is considered to be the ‘good enough level’ (GEL) and if it is related to the duration of psychotherapy. Aims: The main objective of the present feasibility trial was to monitor the patient's session‐by‐session evolution using a self‐report questionnaire in order to define the GEL, i.e. the number of sessions necessary for the patient to reach significant change. Method: A total of N=13 patients undergoing psychotherapy in routine practice participated in the study, completing the Outcome Questionnaire – 45.2 (OQ‐45), which assesses the symptom level, interpersonal relationships and social role after every psychotherapy session. The data was analysed using multi‐level analyses (HLMs). Results: High feasibility of fine‐grained assessment of effects of psychotherapy in routine practice in Switzerland was shown; response rates being acceptable; however, detailed analysis of the GEL was not feasible within the short study time‐frame. Conclusions: Reflections on the political context of monitoring in the specific case of routine psychiatric practice in Switzerland are discussed.     

Critical Success Factors of Rural and Urban Special Education Administration

Perceptions and opinions are reported of special education administrators in Indiana and Massachusetts. The data that are presented reflect administrators' ratings of factors that they consider critical to their personal success on-the-job and factors they see as essential to successful functioning of their organizational unit. Discussion occurs within the context of operation of special services programs in single district units and those found in cooperative or intermediate unit structures.     

Interoceptive Exposure Therapy Combined with Trauma‐related Exposure Therapy for Post‐traumatic Stress Disorder: a Case Report

Trauma‐related exposure therapy is a useful but not universally effective treatment for post‐traumatic stress disorder. Anxiety sensitivity may play an important role in this disorder, as it does in panic disorder. Studies have shown that interoceptive exposure therapy reduces anxiety sensitivity in panic disorder. The present case study was a preliminary investigation of the merits of including interoceptive exposure therapy in the treatment of post‐traumatic stress disorder, in order to improve treatment outcome for a patient who had no history of panic disorder or panic attacks. Interoceptive exposure therapy (4 sessions) was one component of treatment, combined with trauma‐related exposure therapy (4 sessions of imaginal exposure followed by 4 sessions of in vivo exposure). Treatment outcome was assessed with the Clinician‐Administered Post‐traumatic Stress Disorder Scale, a self‐report measure of post‐traumatic stress disorder symptoms, and measures of symptoms and cognitions commonly associated with post‐traumatic stress disorder. Scores on all outcome measures decreased over the course of treatment, with gains maintained at 1‐ and 3‐month follow‐up. Symptoms of anxiety sensitivity and post‐traumatic stress disorder decreased during interoceptive exposure therapy. The results indicate that interoceptive exposure therapy is a promising adjunctive intervention for post‐traumatic stress disorder. Further research is needed into the merits of combining interoceptive exposure therapy and trauma‐related exposure therapy as a means of boosting treatment efficacy.     

Perceived Health: A Test of Incremental Validity in Relation to Smoking Outcome Expectancies,Motivation to Smoke and Desire to Quit Smoking

This study examined the role of perceived health in predicting theoretically‐relevant aspects of smoking behavior among 161 young adult regular smokers (67 females; mean age = 21.9 years (SD = 7.2), cigarettes per day (M) = 12.2 (SD = 5.7)) recruited from the general community. Consistent with prediction, results indicated that relative to anxiety sensitivity, gender, number of cigarettes smoked per day and nicotine dependence, perceived physical health uniquely and significantly predicted expectancies for negative affect reduction and expectancies that smoking would lead to negative personal consequences. Additionally, perceived health incrementally predicted motivation to smoke to reduce negative affect. In contrast to expectation, perceived health was unrelated to motivation to quit smoking. Results are discussed in relation to the role of perceived health as a cognitive vulnerability factor for specific types of smoking patterns.     

Impact of Experimentally Induced Positive and Anxious Mood on Alcohol Expectancy Strength in Internally Motivated Drinkers

The effects of musically‐induced positive and anxious mood on explicit alcohol‐related cognitions (alcohol expectancy strength) in 47 undergraduate students who consume alcohol either to enhance positive mood states (for enhancement motives) or to cope with anxiety (for anxiety‐related coping motives) were investigated. Pre‐ and post‐mood induction, participants completed the emotional reward and emotional relief subscales of the Alcohol Craving Questionnaire – Now. The hypothesis that anxiety‐related coping motivated drinkers in the anxious mood condition (but not those in the positive mood condition) would exhibit increases in strength of explicit emotional relief alcohol expectancies after the mood induction was supported. An additional, unanticipated finding was that enhancement‐motivated drinkers in the anxious condition also showed significant increases in strength of explicit emotional relief (but not emotional reward) alcohol expectancies. The hypothesis that enhancement‐motivated (but not anxiety‐related coping motivated) participants would exhibit increases in explicit emotional reward expectancies following exposure to the positive mood induction procedure was not supported. Taken together with past research findings, the current results highlight the importance of distinguishing between subtypes of negative affect (i.e., anxious and depressed affect) in exploring the affective antecedents of explicit alcohol outcome expectancies.     

Is Acoustic Startle a Viable Exposure Protocol for Posttraumatic Stress Disorder? A Clinical Case Study

Exaggerated startle is a common symptom (based on Diagnostic and Statistical Manual of Mental Disorders [fourth edition] Criterion D) for many patients with posttraumatic stress disorder (PTSD). Findings from previous studies suggest that exaggerated startle may be due to trauma exposure or pretrauma vulnerability factors for PTSD development. The present clinical case study reports on a patient with PTSD characterized by a very prominent startle response and preference against standard trauma-related exposure strategies. On the basis of recent findings that interoceptive exposure exercises (e.g. shaking head side to side, hyperventilation) elicit trauma-related memories (Wald & Taylor, 2008), the authors sought to determine whether repeated application of an acoustic startle stimulus would serve to diminish the prominent startle response and facilitate exposure and overall symptom reduction by eliciting trauma-related memories. The protocol was successful in eliciting vivid and distressing trauma-related memories. Over the course of seven exposure trials, the patient demonstrated a decrease in distress elicited during the protocol, improved mood, and reduced general anxiety and trauma-related distress. He also reported significantly decreased startle response to loud noises encountered during activities of daily living. Although preliminary, these finding suggest that the acoustic startle protocol may be a viable (interoceptive) exposure strategy for individuals with PTSD, particularly those with exaggerated startle responses and those who are not amenable to standard trauma-related exposure strategies.     

Nature and Role of Change in Anxiety Sensitivity During NRT-Aided Cognitive-Behavioral Smoking Cessation Treatment

This study evaluated the associations between change in anxiety sensitivity (AS; fear of the negative consequences of anxiety and related sensations) and lapse and relapse during a 4-week group NRT-aided cognitive-behavioral Tobacco Intervention Program. Participants were 67 (44 women; M _age = 46.2 years, SD = 10.4) adult daily smokers. Results indicated that participants who maintained high levels of AS from pretreatment to 1 month posttreatment, compared to those who demonstrated a significant reduction in AS levels during this time period, showed a significantly increased risk for lapse and relapse. Further inspection indicated that higher continuous levels of AS physical and psychological concerns, specifically among those participants who maintained elevated levels of AS from pre- to posttreatment, predicted significantly greater risk for relapse. Findings are discussed with respect to better understanding change in AS, grounded in an emergent taxonic-dimensional factor mixture model of the construct, with respect to lapse and relapse during smoking cessation.     

A brief intervention to increase physical activity behavior among adolescents using mental simulations and action planning

This study evaluated the effectiveness of a brief integrated theory-based intervention to increase physical activity (PA) among adolescents over a three-month follow-up period. A 2 (mental simulation: present vs. absent) × 2 (action planning: present vs. absent) × 4 (time: baseline vs. one-month vs. two-month vs. three-month follow-up) mixed-model randomized controlled design was adopted. Adolescents aged 14–15 years (N = 267) completed baseline psychological measures and self-reported PA followed by the relevant intervention manipulation, if appropriate, with follow-up measures collected one, two, and three months later. Results revealed no significant effects for the mental simulation and action planning strategies nor the interaction of the two strategies. However, among participants with low levels of baseline PA, participants in both mental simulation alone and action planning alone groups reported significantly higher levels of PA at one-month follow up than other groups, suggesting that individual intervention components may be effective in low-active adolescents.     

The two sides of goal intentions: Intention self-concordance and intention strength as predictors of physical activity

Objective: The present research introduces an extended conceptualisation of self-concordance, which is considered an attribute not only of goals, but also of goal intentions. Based on a corresponding operationalisation, we investigate the interplay of both intention strength and intention self-concordance in the prediction of physical activity.

Design: Data were taken from a longitudinal study of 134 obese people who were asked to fill out a questionnaire three times every six months.

Main measures: Physical activity and intention self-concordance were measured by validated scales. Intentions strength was assessed by an item typically employed in the extant literature.

Results: Logistic regression analyses and path analyses showed both intention strength and self-concordance to be significant predictors of changes in physical activity over time. Additional analyses found self-efficacy to be a significant predictor of intention strength and self-concordance; for outcome expectations this was not the case.

Conclusions: Findings support the idea that intention strength and self-concordance are two critical facets of a goal intention that need to be considered in the prediction of physical activity participation. Whereas intention strength refers to the degree of determination with which a goal intention is adopted, self-concordance rather captures the quality of this intention.