Placebo: Análisis conceptual de un constructo en transición

RESUMEN

Los autores comienzan planteando que las opiniones vertidas en algunas revisiones acerca del constructo placebo son respuestas a la evolución actual hacia el empleo de conceptualizaciones más cognitivas en la psicoterapia. Seguidamente ofrecen un breve repaso histórico de esta noción, para centrarse en sus aspectos denotativos y connotativos. Respecto a los primeros, revisan las dos metáforas dominantes que pueden encontrarse en la literatura: (a) los placebos como ingredientes inertes en vez de activos y (b) como agentes no específicos en vez de específicos. En relación con los aspectos connotativos, examinan las cuatro fuentes de donde proceden y afirman que distinguiendo entre los verdaderos efectos placebo y los artefactos de medida las connotaciones negativas de este constructo son inmerecidas. Seguidamente abordan su utilidad en la evaluación de la eficacia de la psicoterapia y responden a la cuestión de si las terapias actuales son más eficaces que el tratamiento inespecífico. Este trabajo concluye que como el placebo ha de jugar un papel crucial en la evaluación científica de la psicoterapia, rechazarlo prematuramente constituiría una regresión conceptual y metodológica.     

The marriage checkup: increasing access to marital health care

Despite the ongoing prevalence of marital distress, very few couples seek therapy. Researchers and clinicians have increasingly been calling for innovative interventions that can reach a larger number of untreated couples. Based on a motivational marital health model, the Marriage Checkup (MC) was designed to attract couples who are unlikely to seek traditional tertiary therapy. The objective of the MC is to promote marital health for as broad a population of couples as possible, much like regular physical health checkups. This first paper from the largest MC study to date examines whether the MC engaged previously unreached couples who might benefit from intervention. Interview and survey data suggested that the MC attracted couples across the distress continuum and was perceived by couples as more accessible than traditional therapy. Notably, the MC attracted a substantial number of couples who had not previously participated in marital interventions. The motivational health checkup model appeared to encourage a broad range of couples who might not have otherwise sought relationship services to deliberately take care of their marital health. Clinical implications are discussed.     

Fidelity Failures in Brief Strategic Family Therapy for Adolescent Drug Abuse: A Clinical Analysis

As evidence‐based family treatments for adolescent substance use and conduct problems gain traction, cutting edge research moves beyond randomized efficacy trials to address questions such as how these treatments work and how best to disseminate them to community settings. A key factor in effective dissemination is treatment fidelity, which refers to implementing an intervention in a manner consistent with an established manual. While most fidelity research is quantitative, this study offers a qualitative clinical analysis of fidelity failures in a large, multisite effectiveness trial of Brief Strategic Family Therapy (BSFT) for adolescent drug abuse, where BSFT developers trained community therapists to administer this intervention in their own agencies. Using case notes and video recordings of therapy sessions, an independent expert panel first rated 103 cases on quantitative fidelity scales grounded in the BSFT manual and the broader structural‐strategic framework that informs BSFT intervention. Because fidelity was generally low, the panel reviewed all cases qualitatively to identify emergent types or categories of fidelity failure. Ten categories of failures emerged, characterized by therapist omissions (e.g., failure to engage key family members, failure to think in threes) and commissions (e.g., off‐model, nonsystemic formulations/interventions). Of these, “failure to think in threes” appeared basic and particularly problematic, reflecting the central place of this idea in structural theory and therapy. Although subject to possible bias, our observations highlight likely stumbling blocks in exporting a complex family treatment like BSFT to community settings. These findings also underscore the importance of treatment fidelity in family therapy research.     

Interventions for Family Members and Carers of Patients with Borderline Personality Disorder: A Systematic Review

Carers of patients with borderline personality disorder (BPD) experience high levels of distress. Several studies have been carried out on interventions designed to decrease their burden. However, the evidence from these studies has not been summarized. The objective of this work is to explore the clinical utility of interventions developed for family members of patients with BPD. A systematic review was conducted following the PRISMA guidelines (registration number CRD42018107318), including psychological interventions focused on relatives of patients with BPD. The following databases were used: PsycINFO, PubMed, EBSCOhost, and Web of Science. Two independent researchers reviewed the studies to determine whether the eligibility criteria were met. A total of 2,303 abstracts were identified. After duplicates had been removed, 1,746 studies were screened. Finally, 433 full‐text articles were reviewed, yielding 11 studies that satisfied the inclusion criteria. Results show that these interventions with different clinical formats and settings are effective. The quality of the included studies varies, and the empirical support for these programs is still preliminary. The results help to establish a general framework for interventions specifically developed for family members of patients with BPD, but additional efforts should be made to improve the methodological quality of this field of research and more solidly determine the utility of these interventions. Given the paucity of data so far, this information may open up new lines of research to improve the effectiveness of future programs for carers of patients with BPD and help to reduce their burden.     

Couple Therapy with Veterans: Early Improvements and Predictors of Early Dropout

Family services within Veterans Affairs Medical Centers fulfill an important role in addressing relationship distress among Veterans, which is highly prevalent and comorbid with psychopathology. However, even for evidence‐based couple therapies, effectiveness is weaker compared to controlled studies, maybe because many Veteran couples drop out early and do not reach the “active” treatment stage after the 3–4 session assessment. In order to improve outcomes, it is critical to identify couples at high risk for early dropout, and understand whether couples may benefit from the assessment as an intervention. The current study examined (a) demographics, treatment delivery mode, relationship satisfaction, and psychological symptoms as predictors of dropout during and immediately following the assessment phase, and (b) changes in relationship satisfaction during assessment. 174 couples completed questionnaires during routine intake procedures. The main analyses focused on 140 male Veterans and their female civilian partners; 36.43% dropped out during the assessment phase and 24.74% of the remaining couples immediately following the first treatment session. More severe depressive symptoms in non‐Veteran partners were associated with dropout during assessment. Relationship satisfaction improved significantly during the assessment phase for couples who did not drop out, with larger gains for non‐Veteran partners. No demographics or treatment delivery mode were associated with dropout. Although more research is needed on engaging couples at risk for early dropout and maximizing early benefits, the findings suggest that clinicians should attend to the civilian partner's and Veteran's depressive symptoms at intake and consider the assessment part of active treatment.     

We‐Language and Sustained Reductions in Drinking in Couple‐Based Treatment for Alcohol Use Disorders

Couple‐based treatments for alcohol use disorders (AUDs) produce higher rates of abstinence than individual‐based treatments and posit that active involvement of both identified patients (IPs) and significant others (SOs) is partly responsible for these improvements. Separate research on couples’ communication has suggested that pronoun usage can indicate a communal approach to coping with health‐related problems. The present study tested whether communal coping, indicated by use of more first‐person plural pronouns (“we” language), fewer second‐person pronouns (“you” language), and fewer first‐person singular pronouns (“I” language), predicted improvements in abstinence in couple‐based AUD treatment. Pronoun use was measured in first‐ and mid‐treatment sessions for 188 heterosexual couples in four clinical trials of alcohol behavioral couple therapy (ABCT). Percentages of days abstinent were assessed during treatment and over a 6‐month follow‐up period. Greater IP and SO “we” language during both sessions was correlated with greater improvement in abstinent days during treatment. Greater SO “we” language during first‐ and mid‐treatment sessions was correlated with greater improvement in abstinence at follow‐up. Greater use of IP and SO “you” and “I” language had mixed correlations with abstinence, typically being unrelated to or predicting less improvement in abstinence. When all pronoun variables were entered into regression models, only greater IP “we” langue and lower IP “you” language predicted improvements in abstinence during treatment, and only SO “we” language predicted improvements during follow‐up. Most pronoun categories had little or no association with baseline relationship distress. Results suggest that communal coping predicts better abstinence outcomes in couple‐based AUD treatment.     

COGNITIVE AND SOCIOEMOTIONAL FUNCTIONING AT 4½ YEARS IN CHILDREN BORN TO MOTHERS WHO HAVE RECEIVED TREATMENT FOR SUBSTANCE‐ABUSE PROBLEMS WHILE PREGNANT

Cognitive and socioemotional functioning at 4½ years of age were examined in children born to mothers with substance‐abuse problems (n = 22) recruited from residential treatment institutions while pregnant, and then compared to children born to mothers with mental health problems (n = 18) and children from a low‐risk group (n = 26). No significant group differences in cognitive functioning were found, but the children born to mothers with substance‐abuse problems showed more caregiver‐reported socioemotional problems than did the low‐risk children, like the children born to mothers with mental health problems. Birth weight had an effect on internalizing problems at 4½ years and mediated the relation between group and socioemotional problems, although not when controlling for caregiver education, single parenthood, and anxiety and depression. At 4½ years, 7 children born to mothers with substance‐abuse problems were placed in foster care. These children had lower birth weight and higher caregiver‐rated internalizing problems. In addition to emphasizing the importance of the quality of the prenatal environment, this study suggests that families with previous substance abuse are in need of long‐term follow‐up to address socioemotional problems and enhance further positive child cognitive development. The foster‐placed children may be in particular need of long‐term follow‐up.     

Evaluación de patrones de aprendizaje como cambio

Resumen

Como resumen de este artículo queremos manifestar que no son frecuentes las publicaciones que pretenden una armonización entre conceptualizaciones-reconceptualizaciones de contenidos de cambio, diseños de recogida de datos y métodos de tratamiento de datos. Menos frecuentes todavía son las publicaciones orientadas a conectar tipos y clases de diseños de recogida de datos con instrumentos de medida, a causa del hecho histórico de que, mientras que los diseños de recogida de datos han sido dominio casi exclusivo de los experimentalistas, los psicómetras se han centrado en los instrumentos de medida.

También queremos manifestar que el fin de este artículo es el de contribuir a esta armonización desde el contexto del método científico como marco de referencia de los distintos componentes que entran en juego.