Therapeutic alliance and change in psychiatric symptoms in adolescents and young adults receiving drug treatment

Background: Despite a significant literature examining the processes and outcomes of formal psychotherapeutic interventions, helping relationships outside of traditional psychotherapy settings have received less empirical attention. This study examined the effect of therapeutic alliance on client outcomes within two community‐based case management services for young drug users.

Methods: The impact of therapeutic alliance on substance use and mental health outcomes was assessed over two occasions in 100 young people (aged 16–22 years) receiving case management within two youth drug and alcohol services.

Results: At baseline, those clients with non‐substance‐related mental health disorders, especially PTSD, reported a significantly worse therapeutic alliance with their case manager. Clients who rated the therapeutic alliance more positively at the beginning of intervention were more likely to evidence improvement in depressive symptoms over the follow‐up period. Conversely, higher depressive symptoms at baseline predicted deterioration in therapist‐rated alliance over the follow‐up period. No significant associations were reported between substance use ratings and the therapeutic alliance.

Conclusions: These findings with young help‐seeking substance users suggest that therapeutic alliance has a significant impact on symptom change during drug treatment, but that it interacts more strongly with depressive than substance use symptomatology.     

Differences in client and therapist views of the working alliance in drug treatment

Background: There is growing evidence that the therapeutic alliance is one of the most consistent predictors of retention and outcomes in drug treatment. Recent psychotherapy research has indicated that there is a lack of agreement between client, therapist and observer ratings of the therapeutic alliance; however, the clinical implications of this lack of consensus have not been explored.

Aims: The aims of the study are to (1) explore the extent to which, in drug treatment, clients and counsellors agree in their perceptions of their alliance, and (2) investigate whether the degree of disagreement between clients and counsellors is related to retention in treatment.

Methods: The study recruited 187 clients starting residential rehabilitation treatment for drug misuse in three UK services. Client and counsellor ratings of the therapeutic alliance (using the WAI‐S) were obtained during weeks 1–12. Retention was in this study defined as remaining in treatment for at least 12 weeks.

Results: Client and counsellor ratings of the alliance were only weakly related (correlations ranging from r = 0.07 to 0.42) and tended to become more dissimilar over the first 12 weeks in treatment. However, whether or not clients and counsellors agreed on the quality of their relationship did not influence whether clients were retained in treatment.

Conclusions: The low consensus between client and counsellor views of the alliance found in this and other studies highlights the need for drug counsellors to attend closely to their clients' perceptions of the alliance and to seek regular feedback from clients regarding their feelings about their therapeutic relationship.     

Interprofessional communication in healthcare: An integrative review

The link between miscommunication and poor patient outcomes has been well documented. To understand the current state of knowledge regarding interprofessional communication, an integrative review was performed. The review suggested that nurses and physicians are trained differently and they exhibit differences in communication styles. The distinct frustrations that nurses and physicians expressed with each other were discussed. Egos, lack of confidence, lack of organization and structural hierarchies hindered relationships and communications. Research suggested that training programs with the use of standardized tools and simulation are effective in improving interprofessional communication skills. Recommendations include education beyond communication techniques to address the broader related constructs of patient safety, valuing diversity, team science, and cultural humility. Future directions in education are to add courses in patient safety to the curriculum, use handover tools that are interprofessional in nature, practice in simulation hospitals for training, and use virtual simulation to unite the professions.     

Reluctance to disclose difficult diagnoses: a narrative review comparing communication by psychiatrists and oncologists

Introduction National guidance in most medical specialties supports the full and open disclosure of diagnoses to patients. Results Surveys show that most patients want to know their diagnosis, whether it is medical or psychiatric, and a substantial proportion want to know detailed prognostic information. In the past, oncologists have been criticised for failing to reveal a diagnosis of cancer to patients in a sensitive and timely manner. Over the last 30 years, there is evidence that this practice has improved. Yet, clinicians still have difficulty when the diagnosis is not certain, when the prognosis is unfavourable, and when relatives request “not to tell.” All of these influences are present in mental health settings. Discussion Psychiatrists and general practitioners may be equally reluctant to reveal difficult diagnoses and prognoses of conditions such as schizophrenia and dementia. The reluctance to reveal a difficult diagnosis may be a routine, but little acknowledged the aspect of medical care that should be incorporated into undergraduate and postgraduate education and openly discussed during peer group supervision.     

Hope and schizophrenia: an integrative review

The purpose of this article is to describe the current status of research on hope and schizophrenia. The CINAHL database was used to identify the articles that met the criteria. The searches were conducted using the terms 'hope', 'hope instillation (IOWA NIC)', 'hope (IOWA NOC)', 'schizophrenia' and their combinations. The findings were limited to research articles. In addition, Pub Medical database was used by searching the words 'hope' and 'schizophrenia' from the fields 'title' or 'abstract'. Four new articles were found. The data consist of 17 articles on hope and schizophrenia published in peer-reviewed journals, which were analysed using content analysis. Existing research has focused on people with schizophrenia (n = 8), significant others (n = 4), staff (n = 2), hope-engendering interventions (n = 2) and treatment evaluation related to hope (n = 2) in the care of people with schizophrenia. Different data collection methods have been used in these studies. The most common method was interview (n = 9), followed by questionnaires (n = 8) and observation (n = 1). Most studies used quantitative methods (n = 9). Hope is considered a positive factor in the life of a person living with schizophrenia, in significant others as well as in staff members. Existing research provides evidence of the following themes: factors associated with hope and factors contributing to hope in people with schizophrenia; hope from the perspective of significant others of people with schizophrenia; staff hopefulness and factors contributing to their hope, hope-engendering interventions and treatment evaluation in regard to hope. Based on this review, research evidence of hope in the context of schizophrenia is quite scant and limited, even though the importance of hope in schizophrenia has been underlined in research reports and the literature. It is clear that hope is important to people with schizophrenia, their significant others and the healthcare personnel caring for them. It is therefore also important to study hope among these people.     

Intercultural communication in health care: challenges and solutions in work rehabilitation practices and training: a comprehensive review

Purpose: The purpose of this comprehensive literature review it to explore cross-cultural issues in occupational rehabilitation and work disability prevention. Method: A literature review on cross-cultural issues was performed in medicine, health sciences, and social sciences databases (PubMed, Ingenta, Canadian Centre for Occupational Health and Safety, Ergonomics Abstract, Google Scholar, OSH Update and the Quebec Workers’ Compensation Board data base). A total of 27 documents published until 2010 in English or French were selected and analyzed. Results: Cross-cultural issues in occupational rehabilitation show that representations of pain, communication and therapist–patient relationship and intercultural competence could be presented as the major topics covered in the selected literature. As for the general topic of immigrant workers and OSH, barriers were identified revealing personal, relational, contextual and structural levels that put immigrant and minority workers in situation of vulnerability (ex. linguistic and cultural barriers, lack of knowledge of the system, precarious work or exposition to higher risk hazards, etc.). Cultural issues in occupational rehabilitation put less attention to work-related contextual factors but emphasized on attitude and pain behaviours, perceptions of illness and appropriate treatment, therapist–patient relationship and cultural competences among OT professionals. Conclusions: The growth of immigration in countries such as Canada poses a real challenge to the delivery of health care and rehabilitation services. Despite growing concerns in providing culturally appropriate heath cares, intervention models, tools and training tools are still lacking in occupational rehabilitation and disability management. Nevertheless, cultural competence seems to be a promising concept to be implemented in work rehabilitation and disability management.

Implications for Rehabilitation

• Cultural differences may result in diverging and conflicting representations of health, illness and therapy, and this may hinder the healing process or even cause its failure.

• Assessing health and illness representations (perception and definition of the problem and its solution) may help clinicians facilitate cross-personal communication and develop therapeutic alliance.

• Cultural competence in health care is multi-faceted (individual, organization, health policies) and is becoming an unavoidable aspect of developing culturally adapted interventions.

     

Parent-adolescent communication and diabetes: an integrative review

Title. Parent–adolescent communication and diabetes: an integrative review. Aim. This paper presents a synthesis of findings from empirical studies about communication and interaction between parents and their adolescents with diabetes. Background. Communication between parent and adolescent is essential in transitioning the adolescent to increased responsibility for diabetes self‐management. Nurses are in a pivotal position to enhance the type of parent–adolescent communication that facilitates this transition. Data sources. A search of published studies from 1985 to 2006 featuring communication or interaction between parents and adolescents with type 1 diabetes was implemented through a computerized search. Review methods. Papers were organized by type of evidence and were analysed sequentially. Sources were described based on data elements which were extracted. Findings in the areas of productive and problematic parent–adolescent communications were included. Data elements were compared and critiqued, noting consistencies, and findings were summarized and evaluated. Results. Studies across several countries indicate that maternal support, conflict, control, involvement and emotional expression are important communication concepts that are linked to diabetes outcomes in adolescents. The influences of different family structures and cultural and socioeconomic circumstances, as well as developmental status and gender of adolescents on these types of communication, have not been systematically studied. Conclusion. Nurses caring for adolescents with type 1 diabetes need to consider family relationships and communication patterns in achieving health outcomes. Studies of communication, including perspectives of mothers and fathers, and the influence of family structure, economics and culture are needed to build a framework of parent–adolescent interaction and health outcomes for adolescents with type 1 diabetes.     

Lifestyle risk communication by general practice nurses: An integrative literature review

Background

The growth of the general practice nursing workforce, has created opportunities to enhance activities aimed at lifestyle change to optimise health and reduce risk. While health status and risk levels are amenable to behaviour change, a number of complex interrelated factors influence the general practice nurses’ (GPN) role, often resulting in the underutilisation of nurses. This can limit their capacity to respond to patients’ needs, including communication regarding lifestyle risk factors and their chronic health conditions. Understanding GPNs’ views on lifestyle risk communication and factors influencing this can inform improvement in chronic disease management and effectiveness of lifestyle risk communication by GPNs.

血清神经功能相关指标及体液免疫指标与精神分裂症的关系研究

目的研究分析血清神经功能相关指标及体液免疫指标与精神分裂症的关系。方法选取2012年1月至2014年3月诊治的61例精神分裂症患者作为观察组,并以同期的61名健康人员作为对照组,将两组患者的血清神经功能相关指标及体液免疫指标水平进行检测与比较,同时比较不同分类及分期患者的上述指标,并采用Logistic分析其与精神分裂症的关系。结果观察组的血清神经元特异性烯醇化酶(NSE)、S100B及补体C4均高于对照组,而血清脑源性神经营养因子(BDNF)、IgA、IgG及补体C3水平则低于对照组,且不同分期者上述指标存在显著差异(P均0.05),但不同分类者之间无显著差异(P均0.05)。经Logistic分析处理显示,上述指标均与精神分裂症有密切的关系。结论精神分裂症患者的血清神经功能相关指标及体液免疫指标呈现异常的状态,上述指标与疾病有着密切的关系,可作为疾病诊断及治疗效果监测的重要依据。     

Enhancing patient adherence: outcomes of medication alliance training on therapeutic alliance, insight, adherence, and psychopathology with mental health patients

The results of interventions to enhance patient adherence to medication have been inconsistent. This research investigated the utility of an enhanced adherence training programme to ascertain its effectiveness and the possible mechanisms of that effect. Forty-six clinicians were trained in 'medication alliance', and data were collected from 51 patients matched to the clinician. Data on clinician changes in skills, knowledge, and attitudes, in relation to enhancing patient adherence and patient changes in adherence, insight, and psychopathology were collected at baseline and at 6 and 12 months. The quality of the therapeutic relationship between the clinician and the patient was also assessed. The results indicated significant improvements in both clinician and patient measures, the majority of which were maintained over time. The quality of the therapeutic relationship was also enhanced. A hypothesized explanatory model accounting for the data was supported. It was concluded that clinician training to support improved patient adherence should include strategies that also enhance the therapeutic alliance.     

The relationship between perceived injustice and the working alliance: a cross-sectional study of patients with persistent pain attending multidisciplinary rehabilitation

Purpose: Accumulating research suggests that perceived injustice is a risk factor for adverse recovery following painful injury. Presently, however, little is known about the processes by which perceived injustice influences rehabilitation outcomes. It is plausible that perceived injustice and associated anger impact rehabilitation outcomes by compromising the quality of the therapeutic working alliance; however, research has not previously examined the relationship between perceived injustice and the working alliance. Therefore, the present study investigated the association between perceived injustice, anger, and the working alliance.

Methods: Sixty-six patients with persistent pain following musculoskeletal injury participated in this study. All participants were enrolled in a standardized multidisciplinary rehabilitation programme. Participants completed self-report measures of perceived injustice, pain intensity, disability, anger intensity and regulation style, depressive symptoms, and a measure of the working alliance with their principal rehabilitation clinician. Each participant’s principal clinician also completed the working alliance measure.

Results: Greater perceptions of injustice were associated with poorer client ratings of the working alliance. Results also showed that anger expression mediated the association between perceived injustice and the working alliance.

Conclusion: Strategies to enhance the working alliance between rehabilitation professionals and clients with elevated levels of perceived injustice are needed.

• Implications for Rehabilitation

• Perceived injustice is associated with poor progress in rehabilitation programmes for people with musculoskeletal pain following injury.

• Perceived injustice is negatively associated with the quality of the therapeutic working alliance.

• Strategies to enhance the working alliance between rehabilitation professionals and clients with elevated levels of perceived injustice are needed.

     

An integrative review of nurse practitioner practice and its relationship to the core competencies

BackgroundCompetency based education (CBE) has been suggested for nurse practitioner (NP) education reform. For this to occur, competencies should reflect the knowledge, skills, and attitudes that NPs need for independent practice.PurposeThis integrative review examined the general practice activities of NPs across all population foci to determine the extent to which these activities are reflected in current NP competencies.MethodUsing the Whittemore and Knafl (2005) integrative review method, 17 studies that focused on NP practice between 2008 and 2018 were retrieved from three electronic databases. These studies were evaluated, analyzed and synthesized for themes. Afterwards the themes were compared with seven sets of current NP core competencies.ResultsThe themes for NP practice activities were direct and indirect patient care activities with a majority of NP time spent performing direct patient care activities. However, only 14% of the NP core competencies reflected these direct care activities.ConclusionIn order to successfully implement CBE, a need exists for the NP core competencies to reflect current NP practice.