Brief motivational interviewing as a clinical strategy to promote asthma medication adherence

Patient-centered approaches are associated with better patient retention and treatment outcomes, without increased time and cost. Motivational interviewing (MI) is a patient-centered counseling approach that can be briefly integrated into patient encounters and is specifically designed to enhance motivation to change among patients not ready to change. Existing asthma management approaches (eg, education and self-management) increase resistance among patients not ready or willing to follow medical recommendations. MI helps patients resolve their ambivalence about behavior change and builds their intrinsic motivation before providing education. Although MI overlaps with patient-centered communication, it additionally includes some concrete motivational strategies that can be briefly and easily implemented in medical settings (eg, setting an agenda, assessing motivation and confidence for change, helping the patient weigh the costs and benefits of change, and providing medical advice and health feedback). Reflective listening is used to help patients clarify their ambivalence and diffuse resistance. MI has been shown to be efficacious across a wide variety of health behavior change areas. This article will describe the method and spirit of MI as applied to asthma management by reviewing the principles of MI, brief MI strategies to motivate medication adherence, the evidence base for MI, and the costs and benefits of building MI into clinical practice.     

Encouraging acceptance of ambivalence using the expressive writing paradigm

Objectives. Ambivalence is regarded as a key target for psychotherapeutic change. This study aimed to examine the effectiveness of a brief expressive writing intervention for reducing distress about goal ambivalence. Design. A sample of 40 undergraduate students were randomly allocated to an experimental ‘expressive writing’ condition or a control condition. Method. Participants rated their ambivalence about the 10 most important goals they were currently pursuing and rated how distressing they found these feelings of ambivalence. Participants then completed three short expressive writing sessions on consecutive days. Participants in the experimental condition participants wrote about their deepest thoughts and feelings relating to their ambivalence, and participants in the control condition wrote about how they had spent their time that day or week. Results. When controlling for baseline distress about ambivalence, there was a significant effect of writing condition on distress about ambivalence at follow‐up; individuals who wrote about their ambivalence experienced a significant reduction in their level of distress about ambivalence. Conclusion. It was concluded that expressive writing might represent an analogue of therapeutic approaches to encourage acceptance of ambivalence.     

Ambivalence resolution in brief psychotherapy for depression

Ambivalence in the process of psychotherapeutic change should be addressed and resolved if we are to avoid psychotherapeutic failure and promote sustained change. In this context, ambivalence can be defined as the cyclical conflictual relation between two opposed positions of the self: one expressed as an innovation, and a subsequent one expressed in a trivialization or rejection of the innovation (problematic position). This conflict may be resolved in two different ways: (a) the dominance of the innovative position and the consequent inhibition of the problematic one and (b) the negotiation between the innovative and the problematic positions. In this study, we sought to study the evolution of the dominance and the negotiation processes in recovered and unchanged cases; to analyse if different therapeutic models produce different results on the evolution of the dominance and negotiation processes, and finally, to study if these processes are predictive of ambivalence resolution. The complete sessions of 22 clinical cases of depression (6 cognitive‐behavioural therapy, 10 narrative therapy, and 6 emotion‐focused therapy cases) were independently coded for innovative moments, ambivalence, and ambivalence resolution. Results revealed that recovered cases had a progressively higher proportion of negotiation along treatment, whereas in unchanged cases, negotiation was virtually absent throughout treatment. Both dominance and negotiation were significant predictors of ambivalence reduction, however, negotiation had a higher impact than dominance. Overall, these results did not significantly differ for the 3 therapeutic models. The theoretical implications of these findings are discussed, and theoretical derived suggestions for clinicians are presented.     

Perceived costs and benefits of behavioral change: reconsidering the value of ambivalence for psychotherapy outcomes

This study examined the measurement of ambivalence toward change, and the predictive utility of ambivalence in terms of psychotherapy outcomes. Ambivalent individuals were defined as those acknowledging both costs and benefits to change. Two competing hypotheses were tested. The first, based on the transtheoretical model (C. C. DiClemente & J. O. Prochaska, 1998), predicted that ambivalent individuals would experience less symptom change than those who predominantly acknowledge benefits to change. The second, based on evidence that acknowledging the costs of change is associated with better outcomes, predicted that ambivalence would be associated with more change. Patients (n = 173) with anxiety and affective disorders completed unitary and multidimensional measures of perceived costs and benefits to change, with a subset (n = 115) completing a course of cognitive-behavioral therapy. Results suggested that ambivalence was best measured within a multidimensional framework. Patients who acknowledged both costs and benefits to change (i.e., ambivalent) achieved better outcomes than those acknowledging predominantly benefits, or few costs and benefits, to change.     

Conflict-related activity in the caudal anterior cingulate cortex in the absence of awareness

The caudal anterior cingulate cortex (cACC) is thought to be involved in performance monitoring, as conflict and error-related activity frequently co-localize in this area. Recent results suggest that these effects may be differentially modulated by awareness. To clarify the role of awareness in performance monitoring by the cACC, we used rapid event-related fMRI to examine the cACC activity while subjects performed a dual task: a delayed recognition task and a serial response task (SRT) with an implicit probabilistic learning rule (i.e. the stimulus location followed a probabilistic sequence of which the subjects were unaware). Task performance confirmed that the location sequence was learned implicitly. Even though we found no evidence of awareness for the presence of the sequence, imaging data revealed increased cACC activity during correct trials which violated the sequence (high-conflict), relative to trials when stimuli followed the sequence (low conflict). Errors made with awareness also activated the same brain region. These results suggest that the performance monitoring function of the cACC extends beyond detection of errors made with or without awareness, and involves detection of multiple responses even when they are outside of awareness.     

Ambivalence in Psychotherapy Questionnaire: Development and validation studies

Research emphasizes that individuals' engagement with change process is a significant predictor of therapeutic outcomes. Ambivalence is a natural phenomenon in change processes, but when individuals cannot overcome it, their problems may intensify. Ambivalence towards change, a client variable characterized by an intrapersonal conflict between two positions of the self, one in favour of change and another one in favour of the status quo, is shown to play a determinant role in psychotherapy. Despite its importance, few empirical studies have examined this process, and the considerable methodological differences among existing studies make it difficult to generalize results. Therefore, instruments measuring ambivalence in an effective way can help broaden the understanding of the process. First, we performed a content analysis of ambivalence events identified in psychotherapy sessions from previous studies using an observational coding system. The factor structure, reliability and validity of the measure were tested using 91 and confirmed with 223 psychotherapy clients at any time during the therapeutic process. A two‐factor structure was found, suggesting two components of Ambivalence—Demoralization and Wavering. The results indicated that the Ambivalence in Psychotherapy Questionnaire exhibits good psychometric properties, including good convergent and divergent validity. The implications are discussed.     

Emotion in psychotherapy: a practice-friendly research review

This article reviews the process and outcome research on emotion in psychotherapy. Four distinct types of emotion processes are identified in the literature as useful in therapy, depending on a client's presenting concerns: emotional awareness and arousal; emotional regulation, active reflection on emotion (meaning making), and emotional transformation. Research findings are summarized to highlight the practical implications of these different emotion processes to psychotherapy. A range of selected treatments from different therapeutic orientations are addressed collectively as different types of emotion-focused, experiential therapies and are compared on the basis of how they work with emotion in session.     

Financial conflict-of-interest policies in clinical research: issues for clinical investigators.

As industry sponsorship of clinical research grows, investigators' personal financial relationships with those sponsors are under increasing scrutiny. The federal government, some states, and many universities have enacted conflict-of-interest policies to monitor and regulate investigators' financial relationships. Little is known, however, about investigators' awareness of or support for these policies or their attitudes toward regulatory efforts. To explore the possible implications of conflict-of-interest policies for clinical researchers, the authors interviewed active clinical investigators at two institutions where the conflict-of-interest policies differ. The most striking feature of the interviews was the range of perceptions and attitudes expressed by clinical investigators and their implications for administrators, professional societies, and policymakers concerned with conflicts of interest. Fewer than half of the interviewed investigators could accurately describe their campus' conflict-of-interest policy. Many investigators felt that professional societies, the public, and individual investigators were appropriate monitors of conflicts of interest. Many investigators recognized the general risks associated with conflicts of interest, but felt that they personally were not at risk. A fundamental challenge facing administrators and policymakers is to demonstrate to all investigators, both clinical and nonclinical, that the potential for bias, pressure and conflict is relevant to all investigators with industry relationships.     

A cognitive perspective on resistance in psychotherapy.

The phenomena that comprise resistance in therapy are described and discussed from a cognitive viewpoint. The cases of Brian, Julie, and Victoria are reviewed to illustrate similar and contrasting manifestations of resistance, and suggestions for further individualized conceptualization and intervention are presented. Emphasis is placed on gaining an accurate, empathic understanding of the client's difficulties in changing. This is coupled with methods that allow the client some autonomy in charting the course of therapy, at the same time reinforcing the importance of the therapist's active involvement in educating and stimulating the client toward greater awareness and adaptability. In order to be maximally effective in encouraging such changes, therapists must be aware of their own tendencies to react adversely to client resistance. It is vital that therapists maintain their professionalism and confidence in persevering toward a better understanding of what will be helpful to their clients.     

Hospital to home: Improving internal medicine residents' understanding of the needs of older persons after a hospital stay.

Physicians-in-training discharge many older patients from the hospital, but few have any knowledge of what happens to the patients they send home, of how discharge plans are applied, or of the difficulties patients and their families face. The authors describe a pilot program, Hospital to Home, at the University of Rochester School of Medicine and Dentistry's internal medicine residency program, which uses home visits as an educational tool in geriatrics training. The program was begun in July 2001, and 23 residents have participated. Home visits expose residents in their first-year geriatrics rotation to the elements and outcomes of discharge planning and create a heightened awareness of the needs of older persons recently discharged from the hospital. The home visits are videotaped, and the residents present a videoconference based on the visits, which are attended by internal medicine residents, family medicine residents, and medical students. The authors describe the three-part Hospital to Home program, three vignettes that highlight learning experiences, and the residents' feedback about the experience and the use of audiovisual recording for education.     

MOTHER COURAGE: REFLECTIONS ON MATERNAL RESILIENCE

abstract    This paper attempts to develop a psychoanalytic perspective on maternal resilience. It argues that notions of resilience have been largely focused on the development of resilience in children, with the mother being viewed as a key figure in understanding its success or failure. However, the development of maternal resilience – the capacity for mothers to survive the vicissitudes of the parenting experience itself – has received less attention, occluding an important aspect of maternal subjectivity. Drawing on recent work on maternal ambivalence, this paper explores the relation between ambivalence and resilience, and provides clinical material from a two-year slow-open analytic group for mothers at the Maya Centre to illustrate our view that maternal resilience may usefully describe the aspect of ambivalence that entails bearing and accepting ourselves as mothers as well as our ambivalent feelings about our children.     

The present and future of appointment, tenure, and compensation policies for medical school clinical faculty.

The authors present data and information about appointment, tenure, and compensation policies to describe how medical schools are redefining the terms under which they relate to their full-time clinical faculties. First, the authors note the increasing differentiation of clinical faculty members into two groups, researchers and clinicians. The present-day competitive realities of both research and clinical enterprises have prompted this change and the principles of mission-based management are reinforcing it. Second, they document the long-term tendency of schools to appoint new clinical faculty members to contract-term (as opposed to tenure) appointments, as special non-tenure-eligible tracks for clinically oriented faculty proliferate. Third, they report on the policies of schools to limit the financial guarantees provided to clinical faculty members who are awarded tenure. For schools that have yet to address this issue, they discuss the various employment and pay arrangements that inform or confuse the question. Fourth, they describe historic problems with clinical faculty compensation arrangements and illustrate, with examples from ten schools, the characteristics of recently implemented performance- and risk-based compensation plans. While these trends in institutional policies and practices may initially concern faculty advocate groups, the authors argue that they may serve the long-term interests of those groups. The terms of relationships between medical schools and their clinical faculties are tied closely to the specifics of organizational structure, which are currently undergoing review and change. The challenge all schools face is to define these terms in ways that allow them to continue to attract high-quality clinical faculty while avoiding an insupportable financial liability.     

Mixed feelings: ambivalence as a predictor of relapse in ex-smokers

Objectives. Ambivalence can be viewed as a normal temporary psychological state in a decision process, for example, on quitting smoking. However, when ambivalence is still present after the decision has been made, it may undermine the motivation to stick to the decision. In smoking cessation, ambivalence can be expected to increase the risk for relapse. Design. In a cohort of 352 ex‐smokers, felt ambivalence measured at baseline was used to predict relapse after 1 month. Results. Firstly, felt ambivalence was a predictor of relapse. Secondly, felt ambivalence moderated the strength of the relation between a psychological determinant of behaviour and actual behaviour: anticipated negative self‐evaluative emotions only predicted relapse when felt ambivalence was low. Thirdly, the relation of felt ambivalence with relapse was partly mediated by ex‐smokers' evaluations of risk situations (situations in which they used to smoke in the past). Conclusion. Ambivalence is related to relapse in different ways and in ex‐smokers it may be conceptualized as a non‐optimal decision process. Although the role of felt ambivalence needs further study, the data suggest that ambivalence must be taken into account in the practice of relapse prevention.     

Religious beliefs and practices and Catholic couples' management of anger and conflict

Grounded theory techniques and Repertory Grids were used in a qualitative study to generate and analyse material from 20 Catholics each interviewed twice. Religious practices increased the amount of intrapersonal ‘space’ available by acting physiologically, cognitively and affectively to reduce the intensity of anger experienced and to support couples in taking responsibility for their own part in a conflict. Couples could also regulate the interpersonal space between them by detouring their anger to God, and by finding support for both the avoidance and confrontation of conflict through religious beliefs. The relationship with God had an interactive and compensatory role in relation to the marital relationship. Changes in religious beliefs or marital relationship dynamics were not always neatly integrated and ambivalence over anger and conflict sometimes resulted and manifested in discordance between the spousal and God relationships. Copyright © 2000 John Wiley & Sons, Ltd.     

The role of numeracy on client knowledge in BRCA genetic counseling

Objective

To assess the impact of numeracy and health literacy on client's ability to learn information orally communicated during a BRCA 1/2 genetic counseling session.

Methods

Fifty-nine videotaped simulated genetic counseling sessions were shown to 246 analogue clients (AC) recruited to imagine themselves as the client in the genetic counseling session. AC numeracy, genetic literacy, state and trait anxiety, and decisional conflict were assessed. The primary outcome was AC learning about BRCA 1/2.

Results

Health literacy and numeracy were moderately correlated, and each independently predicted learning. Higher numeracy was associated with higher knowledge scores only among ACs with adequate literacy. Decisional conflict was not related to literacy, numeracy, or knowledge acquisition. It was, however, inversely related to state anxiety so that the higher post-session state anxiety, the lower the AC's decisional conflict.

Conclusion

Numeracy and health literacy are associated with learning of orally communicated information during genetic counseling. It appears that numeracy can facilitate learning for literate subjects; it does not, however, make any difference in learning ability of clients with significant literacy deficits.

Practice implications

Numeracy plays an important role in client's ability to learn information communicated during medical sessions, especially among clients who are otherwise regarded as literate.     

Core processes of psychopathology and recovery: “Does the Dodo bird effect have wings?”

This editorial proposes that the task of identifying common processes across disorders and across psychotherapies will be the most fruitful way to develop efficient, easily trainable and coherent psychological interventions. The article adapts the concept of the ‘Dodo Bird Effect’ to argue for a mechanistic, testable account of functioning, akin to other unified approaches in science. The articles in the special issue complement this perspective in several ways: (1) three articles identify common processes across disorders within the domains of anger dysregulation, sleep disruption and perfectionism; (2) one article emphasises a case conceptualisation approach that is applied across different disorders and integrates theoretical approaches; (3) three articles focus on the utility of a control theory approach to understand the core processes of maintenance and change. Critically, there is a consensus that change involves facilitating the integration within the client's awareness of higher level, self-determined goals (e.g. insight; cognitive reappraisal) with their lower level regulation of present-moment experience (e.g. emotional openness; exposure). Taken together, these articles illustrate the benefits of a convergent rather than divergent approach to the science and practice of psychological therapy, and they strive to identify common ground across psychotherapies and across widely different presentations of psychopathology.     

IS EMPIRICAL RESEARCH COMPATIBLE WITH CLINICAL PRACTICE?

ABSTRACT This paper explores the provocative question in the title through the authors’experiences of working within a couple psychotherapy service. In it we hope to chart how it became possible to undertake empirical research in a clinical setting. Underlying the question we found a number of others. For example, when and how does empirical research threaten or enhance couples’therapies? Is empirical research a toxic introject, an idealized object and/or a real cultural, developmental experience for a clinical service? The process of change described in this paper involved conflict and took time to develop. We hope to demonstrate that what was achieved was done without detriment to the quality of the service offered and was not at the expense of those who used it. Our view is that the careful engagement we describe is most likely to have had a beneficial impact on both.     

Predicting change for individual psychotherapy clients on the basis of their nearest neighbors

This study extended client-focused research by using the nearest neighbor (NN) approach, a client-specific sampling and prediction strategy derived from research on alpine avalanches. Psychotherapy clients (N=203) seen in routine practice settings in the United Kingdom completed a battery of intake measures and then completed symptom intensity ratings before each session. Forecasts of each client's rate of change and session-by-session variability were computed on the basis of that client's NNs (n=10-50 in different comparisons). Alternative forecasts used linear or log-linear slopes and were compared with an alternative prediction strategy. Results showed that the NN approach was superior to the alternative model in predicting rate of change, though the advantage was less clear for predicting variability.