Unsolvable Fear, Trauma, and Psychopathology: Theory, Research, and Clinical Considerations Related to Disorganized Attachment Across the Life Span

This article features a selective review of attachment theory and research that have contributed knowledge about dynamics underlying early trauma, mechanisms by which maladaptive responses to trauma may be transmitted between generations, and trauma-related risk factors for psychopathology in children, adolescents, and adults. First, we focus on the foundations of attachment theory and discuss ways in which the attachment, exploratory, and fear behavioral systems interact to promote infants' survival. The second section of the paper examines the connection between frightening experiences and disorganized attachment. Infants who are regularly and seriously frightened by aspects of their caregiving environment are believed to be at risk for "unsolvable fear" in which organized attachment responses to fear are impossible. We describe the behaviors and representations characteristic of disorganized children and their parents. Next, we review recent research about relations among attachment, trauma, and psychopathology across the lifespan. Finally, we discuss implications of these findings for clinical practice.     

Intrapersonal, Interpersonal, and Contextual Factors in Engaging in and Responding to Extramarital Involvement

Extramarital involvement (EMI) occurs with high prevalence among couples in clinical and community settings, frequently resulting in considerable distress both to participants and their spouses. The field lacks a synthesized review of this literature. Without such a synthesis, it has been difficult for researchers and clinicians to have an understanding of what is and is not known about EMI. This article reviews the large and scattered EMI literature using a framework that encompasses multiple source domains across the temporal process of engaging in and responding to EMI. In addition, this review delineates conceptual and methodological limitations to previous work in this area and articulates directions for further research.     

Older men's knowledge about osteoporosis and educational interventions to increase osteoporosis knowledge in older men: a systematic review

Objective

The prevalence of osteoporosis and low bone density in men over the age of 65 is approximately 45%. The public health response to a disease affecting almost half of a given population includes assessment of knowledge and design of educational interventions in order to improve screening and prevention. The aim of this systematic review is two fold. We aim to describe older men's knowledge about the osteoporosis disease process, risk factors, and prevention. Second, we examine educational interventions designed to increase older men's knowledge about osteoporosis.

Methods

Computerized literature searches were performed with multiple databases including Academic Search Premier, CINAHL, MEDLINE, SocINDEX, and Psychology and Behavioral Sciences Collection. Studies were considered if they included men aged 50 years or older, included a measure of osteoporosis knowledge and/or had an intervention designed to change osteoporosis knowledge and/or lifestyle risk factors for osteoporosis.

Results

Thirteen studies were included in the review. Nine of the studies were cross-sectional studies on men's knowledge of osteoporosis. All of the studies found that men have minimal knowledge of the osteoporosis disease process, risk factors, and prevention. Four studies focused on education about osteoporosis. Educational interventions were found to increase initiation of calcium supplementation and knowledge about osteoporosis prevention.

Conclusion

Older men know remarkably little about the osteoporosis disease process, risk factors for the disease, or prevention. Education has the potential to improve this situation. Unfortunately, so few clinical trials have occurred that the best method for improving men's knowledge cannot be stated. Future studies examining knowledge and education of osteoporosis for men need to use validated instruments with a focus on risk factors pertinent to men.     

Planning for,implementing and assessing the impact of health promotion and behaviour change interventions: a way forward for health psychologists

Researchers in the field of health psychology have increasingly been involved in translating a body of knowledge about psychological factors associated with health-relevant behaviours, into the development and evaluation of interventions that seek to apply that knowledge. In this paper we argue that a changing economic and political climate, and the strong behavioural contribution to disease morbidity and mortality in developed nations, requires health psychologists to plan more rigorously for, and communicate more effectively, about how health promotion, social cognition and behaviour change interventions will have impact and be increasingly embedded into health services or health promotion activity. We explain academic and wider socio-economic uses of ‘impact’ in health services research. We describe the relationship between impact and dissemination, and impact as distinct from, but often used interchangeably with the terms ‘implementation’, ‘knowledge transfer’ and ‘knowledge translation’ (KT). The evidence for establishing impact is emergent. We therefore draw on a number of impact planning and KT frameworks, with reference to two self- management interventions, to describe a framework that we hope will support health psychologists in embedding impact planning and execution in research. We illustrate this further in an on-line annexe with reference to one of our own interventions, Mums-and-MS (see Supplemental Material).     

Knowledge, attitudes and beliefs of women about the importance of prostate cancer screening

OBJECTIVES: To understand women's knowledge, attitudes and beliefs about prostate cancer. METHODS: A survey was self-administered to 324 women age >18 years. It contained 42 questions that assessed women's knowledge about prostate cancer, possible risk factors, and opinions regarding screening and early detection. Women were grouped as married or unmarried for convenient comparisons. Chi-squared and F statistics were performed. RESULTS: Ninety-seven percent of married women reported having some influence over the healthcare decisions of their spouse. Married women's worst fear about their spouse or family member's diagnosis of prostate cancer was death. The most important benefit of prostate cancer screening was the possibility of cure, while the main hindrance was fear of the digital rectal exam. Marital status, age, educational level and income were all significantly associated with women's knowledge about prostate cancer (p<0.001). CONCLUSIONS: Women play an important role in health-related matters in the home. Educating women on prostate cancer may improve early detection efforts and reduce the devastating impact of this disease on their family.     

Participant experiences and perceptions of physical activity-enhancing interventions for people with physical impairments and mobility limitations: a meta-synthesis of qualitative research evidence

Disabled people face multiple personal, environmental and social barriers that interfere with leading a physically active lifestyle. Thus, there is an urgent need for behaviour change interventions to increase physical activity (PA) by specifically addressing the situations of disabled people, and barriers to participation. This original meta-synthesis of qualitative research was undertaken to explore participants’ experiences and perceptions of PA-enhancing interventions for adults with physical impairments resulting in mobility limitations. Published articles were identified through a rigorous systematic search. Based on the inclusion/exclusion criteria, 10 articles were included for review. Following a critical appraisal of the articles, methods of thematic synthesis were drawn upon to generate overarching concepts through interpretation and conceptual synthesis. Seven interrelated concepts were constructed representing both components and outcomes of the interventions. These were (i) Diversity of interventions; (ii) Importance of communication; (iii) Need for social support; (iv) Behavioural strategies; (v) Gaining knowledge; (vi) Re-framing thoughts about exercise and the self and (vii) Health and well-being. The results revealed that a combination of informational, social and behavioural interventions is perceived as crucial for PA initiation and maintenance. Furthermore, key elements of effective intervention design and implications for policies and practices to increase PA participation are proposed.     

A systematic review of therapeutic alliance,group cohesion,empathy, and goal consensus/collaboration in psychotherapeutic interventions in cancer: Uncommon factors?

The effects of four empirically supported therapeutic relationship factors (therapeutic alliance, empathy, goal consensus/collaboration, and group cohesion) on the outcome of psychotherapeutic interventions conducted with individuals living with cancer were systematically reviewed. PubMed, PsycINFO, and CINAHL were searched from their inception through November 13, 2008. Studies of psychotherapeutic interventions targeted to individuals living with cancer, which also empirically assessed the association between any of these therapeutic relationship factors and psychotherapy outcome were included in the review (8 of 742 papers initially reviewed). Information on study methodology and results were abstracted independently by the authors using a standardized form. Results indicated that therapist-rated rapport and group cohesion were significantly related to positive psychotherapeutic outcomes. No studies examined empathy. The literature on collaboration was mixed, but showed some support for increased collaboration being related to positive therapeutic outcomes. Overall the current literature on the role of therapeutic relationship factors in the context of individuals living with cancer is scant, and much more research is needed to determine the overall contribution of these four relationship elements to the outcomes of psychotherapeutic interventions for individuals living with cancer. Results of such studies could have important clinical and research implications.     

Psychological interventions in the treatment of childhood obesity: what we know and need to find out

This review aims to assess the effectiveness of psychological interventions for treating childhood obesity. Firm conclusions about the effectiveness of psychological interventions to treat childhood obesity remain unclear. Based on current knowledge, the review suggests that a number of interventions may be effective including: multi-component family-based behavioural interventions, interventions aimed at reducing sedentary behaviour and/or increasing physical activity levels as a component of family-based behavioural treatments, in addition to population-based school-wide treatment for girls. Further investment is needed to improve current research and find new, more imaginative ways to research childhood obesity.     

Tailored information about cancer risk and screening: A systematic review

Objective

To study interventions that provide people with information about cancer risk and about screening that is tailored to their personal characteristics. We assess the tailoring characteristics, theory base and effects on risk perception, knowledge and screening behavior of these interventions.

Methods

A systematic literature review in this field was performed. PubMed, EMBASE, PsychINFO, CINAHL and Cochrane databases were searched. Forty studies fulfilled all inclusion criteria. Methodological quality was assessed and a best evidence synthesis conducted for the 28 randomized controlled trials without co-intervention or with similar co-intervention in intervention and control group.

Results

Most included studies evaluated an intervention aiming to promote cancer screening. The majority of articles (30) evaluated information that was tailored based on variables related to behavior change, sometimes combined with cancer risk factors. Ten other articles described an intervention that tailored information based on risk factors only.

Conclusion

Information that was tailored based on behavior change variables increased realistic perception of cancer risks and knowledge of cancer compared to generic information. Also, information tailored to individuals’ risk factors increased realistic risk perception compared to generic information.

Practice implications

To improve cancer risk perception and knowledge health providers could better give patients information about cancer risk and screening that is tailored to their personal characteristics than generic information.     

The Prevention of Extramarital Involvement: Steps Toward "Affair Proofing" Marriage

In this paper I provide comments on the Allen et al. paper (this issue). I note that it provides the first critical, comprehensive, and integrative review of extramarital involvement (EMI) to appear in the literature, and I summarize some of its major contributions to the field. I then focus on how the review stimulated my thinking about current and future best practices in marriage education for the prevention of EMI. I conclude by suggesting several directions for future research and practice. Key words: affair prevention, infidelity, couples.     

Psychosocial factors influencing the eating behaviours of older adults: A systematic review

Our understanding of how eating behaviours change in later life have been dominated by the studies of physiological and biological influences on malnutrition. Insights from these studies were consequently used to develop interventions, which are predominantly aimed at rectifying nutritional deficiencies, as opposed to interventions that may enable older adults to eat well and enjoy their food-related life well into older age. The objective of the present review is to summarise the existing knowledge base on psychosocial influences on eating behaviours in later life. Following comprehensive searches, review, and appraisal, 53 articles were included (22 qualitative and 31 quantitative) to provide a greater understanding of the mechanisms underpinning the psychosocial factors influencing eating behaviours. Our analysis identified eight underpinning psychosocial factors that influences eating behaviours in later life; (1) health awareness & attitudes, (2) food decision making, (3) perceived dietary control, (4) mental health & mood, (5) food emotions & enjoyment, (6) eating arrangements, (7) social facilitation, and (8) social support. The importance and lasting influence of early food experiences were also identified as contributing to eating behaviours in later life. The review concludes with the call for further investigation into specific psychosocial factors that influence eating behaviour, calls for improvements in methodologies, and a summary of psychosocial barriers and enablers to eating well in later life.     

Gender differences in reasons patients delay in seeking treatment for acute myocardial infarction symptoms

Patients (n = 194) with confirmed acute myocardial infarction (AMI) were interviewed to determine sociodemographic, clinical, social, behavioral, cognitive and emotional factors that contribute to delay in seeking treatment for their symptoms. Initial symptom experience was similar for men and women: both were most commonly at home when symptoms began; both were most commonly in the presence of their spouse or other family member; few patients (<10%) called the emergency medical system as their first reaction. Several factors contributed similarly to delay in men and women. Factors that exerted a differential effect on delay between men and women were age, history of AMI, type of AMI (Q-wave and non-Q-wave), concerns about not wanting to trouble others, and prior knowledge of thrombolytics. There was no difference in delay between men and women (median 3.08 versus 3.10 h), but there are important gender differences in the reasons patients delay and in their patterns of decision-making that may assist clinicians trying to tailor interventions.     

Smoking cessation: progress,priorities, and prospectus

The authors review developments in understanding smoking cessation interventions over the past decade. Noteworthy is the unprecedented growth of research and knowledge that has left a deeper understanding of how best to use new and existing behavioral and pharmacologic tools and strategies to help smokers quit. The status of public-health-level interventions is evaluated, questions are raised concerning their efficacy, and suggestions are offered for further refinement of these intervention strategies. Development of cessation guidelines is reviewed, and the state of knowledge concerning behavioral and pharmacologic interventions is summarized. The authors also present agendas for behavioral and pharmacologic research related to smoking cessation and discuss individual difference factors among smokers that may prove to be important in designing new and refining existing treatments.     

Promoting men’s knowledge of cancer risk reduction: A systematic review of interventions

Objective

To critically appraise and discuss evidence from interventions designed to increase men's knowledge about cancer risk reduction.

Distinctive Features of Short-Term Psychodynamic-Interpersonal Psychotherapy: A Review of the Comparative Psychotherapy Process Literature

The present article is a review of the comparative psychotherapy process literature. It is an effort to delineate techniques and processes that distinguish two prominent forms of treatment. Seven interventions stood out as distinguishing psychodynamic-interpersonal therapy from cognitive-behavioral treatment: (1) a focus on affect and the expression of patients' emotions; (2) an exploration of patients' attempts to avoid topics or engage in activities that hinder the progress of therapy; (3) the identification of patterns in patients' actions, thoughts, feelings, experiences, and relationships; (4) an emphasis on past experiences; (5) a focus on a patients' interpersonal experiences; (6) an emphasis on the therapeutic relationship; and (7) an exploration of patients' wishes, dreams, or fantasies. A better understanding of the specific techniques and processes that distinguish psychodynamic-interpersonal from cognitive-behavioral therapy can facilitate process-outcome research, aid in the training and teaching of psychodynamic-interpersonal psychotherapy, and provide psychodynamic-interpersonal therapists with a guide for session activity.     

Individualized interventions for rare genetic conditions and the research-treatment spectrum: Stakeholder perspectives

PurposeAdvances in the study of ultrarare genetic conditions are leading to the development of targeted interventions developed for single or very small numbers of patients. Owing to the experimental but also highly individualized nature of these interventions, they are difficult to classify cleanly as either research or clinical care. Our goal was to understand how parents, institutional review board members, and clinical geneticists familiar with individualized genetic interventions conceptualize these activities and their implications for the relationship between research and clinical care.MethodsWe conducted qualitative, semi-structured interviews with 28 parents, institutional review board members, and clinical geneticists and derived themes from those interviews through content analysis.ResultsIndividuals described individualized interventions as blurring the lines between research and clinical care and focused on hopes for therapeutic benefit and expectations for generalizability of knowledge and benefit to future patients.ConclusionIndividualized interventions aimed at one or few patients reveal the limitations of a binary framing of research and clinical care. As a hybrid set of activities, individualized interventions suggest the need for flexibility and new frameworks that acknowledge these activities across the spectrum of research and clinical care.     

Mental health in marriage: the roles of need for affiliation, sensitivity to rejection, and other factors

This study reports on the associations between a number of personality factors and spouse mental health, happiness, and communication (N = 78). Lower Affiliative Drive and higher Sensitivity to Rejection emerge in this sample as being associated in wives (but not husbands) with increased psychological morbidity. Wives had higher levels of both Need for Affiliation and Sensitivity to Rejection than husbands, which possibly may lead to higher internal conflict for them. Although causality cannot necessarily be assumed, these results are consistent with the hypothesis that wives' mental health is more "relationship related" than that of husbands.     

Systematic Review of Interventions to Prevent Spread of Sexually Transmitted Infections,Including HIV,Among Young People in Europe

Aim

To examine the effectiveness of interventions seeking to prevent the spread of sexually transmitted infections (STI), including HIV, among young people in the European Union.

Methods

For this systematic review, we examined interventions that aimed at STI risk reduction and health promotion conducted in schools, clinics, and in the community for reported effectiveness (in changing sexual behavior and/or knowledge) between 1995 and 2005. We also reviewed study design and intervention methodology to discover how these factors affected the results, and we compiled a list of characteristics associated with successful and unsuccessful programs. Studies were eligible if they employed a randomized control design or intervention-only design that examined change over time and measured behavioral, biologic, or certain psychosocial outcomes.

Results

Of the 19 studies that satisfied our review criteria, 11 reported improvements in the sexual health knowledge and/or attitudes of young people. Ten of the 19 studies aimed to change sexual risk behavior and 3 studies reported a significant reduction in a specific aspect of sexual risk behavior. Two of the interventions that led to behavioral change were peer-led and the other was teacher-led. Only 1 of the 8 randomized controlled trials reported any statistically significant change in sexual behavior, and then only for young females.

Conclusion

The young people studied were more accepting of peer-led than teacher-led interventions. Peer-led interventions were also more successful in improving sexual knowledge, though there was no clear difference in their effectiveness in changing behavior. The improvement in sexual health knowledge does not necessarily lead to behavioral change. While knowledge may help improve health-seeking behavior, additional interventions are needed to reduce STIs among young people.It is estimated that nearly 1 million people contract a sexually transmitted infection (STI) every day worldwide (1). In Western Europe, 17 million new cases of curable STIs occur annually (2). In the European Union (EU), the most common STIs are chlamydial genital infections, gonorrhea, hepatitis, and syphilis (3). Addressing more than 30 other bacterial, viral, and parasitic pathogens causing STIs has re-emerged as a major public health issue in Europe, starting in 1999 and building on the 2003 global health sector strategy that focused on HIV/AIDS (4-6). At the 59th World Health Assembly, in May 2006, the World Health Organization approved the Global Strategy for the Prevention and Control of Sexually Transmitted Infections: 2006-2015. This strategy makes strong arguments for why preventing STIs is important not only for maintaining general health, but also for ensuring safe pregnancies and preventing HIV transmission.STIs are transmitted through sexual contact, including vaginal, oral, and anal sex. Some STIs can also be transmitted through childbirth or breastfeeding, as well as through sharing needles during injecting drug use. Transmission patterns have changed over time and often differ greatly among and within EU member states. In some settings, HIV coinfection with other STIs is common, while in others, they appear independently.In Europe, the populations most at risk for HIV and for other STIs are often – but not always – the same: men who have sex with men (MSM), injecting drug users and their sexual partners, and heterosexual migrants from outside of the EU. Some STIs, like Chlamydia, are more prevalent among young people (7), and interventions frequently target this group to prevent the spread of STIs, both in and out of school. Various theories, including the health belief model, the theory of reasoned action, the trans-theoretical model and social cognitive theory, have been employed to promote behavior change (8). They are utilized in various ways in concrete interventions to reach young people and reduce their risk of contracting STIs. Unfortunately, the lack of age-disaggregated data on sexual and reproductive health and varying definitions of “young” make it difficult to assess the situation and provide a common evidence base for designing these interventions (9).Inspired by an EU call to action (10), we undertook this systematic review to examine the effectiveness of STI interventions for young people in the EU in the decade after the International Conference on Population and Development, held in Cairo in 1994, which put a focus on them. In doing so, it gathers a variety of approaches, such as the major implementation models – being peer-, teacher- and health professional-led – for reaching young people with sexual and reproductive health information and services, to inform and advance future policy development.     

Refugees' and asylum seekers' experiences of individual psychological therapy: A qualitative meta-synthesis

Purpose

The current review aimed to synthesise qualitative literature exploring adult refugees' and asylum seekers' experiences of individual psychological therapy.

Methods

A comprehensive systematic search of the following databases led to the identification of eight studies for inclusion in this review: PsycINFO, PsycARTICLES, MEDLINE, EMBASE, CINAHL and Academic Search Ultimate. All selected studies used qualitative methodology to explore refugees' and asylum seekers' experiences of individual psychological therapy. Studies were appraised using an adapted version of the Critical Appraisal Skills Programme (CASP) Tool. The data from these selected studies were then synthesised using a meta-ethnographic approach.

Results

The synthesis of selected studies resulted in the development of five themes; (i) the importance of recognition and validation within therapy, (ii) building a human connection within the therapeutic relationship and the importance of cultural competency, (iii) revisiting trauma, managing difficult emotions from therapy and regaining hope, (iv) the value of practical interventions, (v) ‘one should not wake up the djinns (demons)’—cultural stigma and accessing therapy. These themes illustrated the complexities of working therapeutically with asylum seekers and refugees and the vital role of building trust and safety within the therapeutic relationship prior to engagement in therapeutic work. The results also highlighted varied responses to engaging in trauma work ranging from participants finding the experience transformative to others finding it unhelpful, some participants preferred more practical interventions. Participants' cultural backgrounds and pre-conceptions around therapy impacted on engagement and the therapist's cultural competency was a significant factor in therapeutic engagement.

Conclusions

Working therapeutically with asylum seekers and refugees involves a number of factors for consideration. Forced migrants' socio-political context was seen as central to their experiences of distress and recognition of these factors was imperative for positive therapeutic engagement. This review highlights a number of clinical implications to guide practitioners working therapeutically with this community.