Throughout history, warriors have been confronted with moral and ethical challenges and modern unconventional and guerilla wars amplify these challenges. Potentially morally injurious events, such as ...perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations may be deleterious in the long-term, emotionally, psychologically, behaviorally, spiritually, and socially (what we label as
moral injury). Although there has been some research on the consequences of unnecessary acts of violence in war zones, the lasting impact of morally injurious experience in war remains chiefly unaddressed. To stimulate a critical examination of moral injury, we review the available literature, define terms, and offer a working conceptual framework and a set of intervention strategies designed to repair moral injury.
Self-Compassion in Clinical Practice Germer, Christopher K.; Neff, Kristin D.
Journal of clinical psychology,
August 2013, Volume:
69, Issue:
8
Journal Article
Peer reviewed
Self‐compassion is conceptualized as containing 3 core components: self‐kindness versus self‐judgment, common humanity versus isolation, and mindfulness versus overidentification, when relating to ...painful experiences. Research evidence demonstrates that self‐compassion is related to psychological flourishing and reduced psychopathology. Mindful Self‐Compassion (MSC) is an 8‐week training program, meeting 2.5 hours each week, designed to help participants cultivate self‐compassion. MSC contains a variety of meditations (e.g., loving‐kindness, affectionate breathing) as well as informal practices for use in daily life (e.g., soothing touch, self‐compassionate letter writing). A detailed clinical case illustrates the journey of a client through the 8 weeks of MSC training, describing the key features of each session and the client's response.
Family caregivers of patients with chronic critical illness experience significant psychological distress.
To determine whether family informational and emotional support meetings led by palliative ...care clinicians improve family anxiety and depression.
A multicenter randomized clinical trial conducted from October 2010 through November 2014 in 4 medical intensive care units (ICUs). Adult patients (aged ≥21 years) requiring 7 days of mechanical ventilation were randomized and their family surrogate decision makers were enrolled in the study. Observers were blinded to group allocation for the measurement of the primary outcomes.
At least 2 structured family meetings led by palliative care specialists and provision of an informational brochure (intervention) compared with provision of an informational brochure and routine family meetings conducted by ICU teams (control). There were 130 patients with 184 family surrogate decision makers in the intervention group and 126 patients with 181 family surrogate decision makers in the control group.
The primary outcome was Hospital Anxiety and Depression Scale symptom score (HADS; score range, 0 best to 42 worst; minimal clinically important difference, 1.5) obtained during 3-month follow-up interviews with the surrogate decision makers. Secondary outcomes included posttraumatic stress disorder experienced by the family and measured by the Impact of Events Scale-Revised (IES-R; total score range, 0 best to 88 worst), discussion of patient preferences, hospital length of stay, and 90-day survival.
Among 365 family surrogate decision makers (mean age, 51 years; 71% female), 312 completed the study. At 3 months, there was no significant difference in anxiety and depression symptoms between surrogate decision makers in the intervention group and the control group (adjusted mean HADS score, 12.2 vs 11.4, respectively; between-group difference, 0.8 95% CI, -0.9 to 2.6; P = .34). Posttraumatic stress disorder symptoms were higher in the intervention group (adjusted mean IES-R score, 25.9) compared with the control group (adjusted mean IES-R score, 21.3) (between-group difference, 4.60 95% CI, 0.01 to 9.10; P = .0495). There was no difference between groups regarding the discussion of patient preferences (intervention, 75%; control, 83%; odds ratio, 0.63 95% CI, 0.34 to 1.16; P = .14). The median number of hospital days for patients in the intervention vs the control group (19 days vs 23 days, respectively; between-group difference, -4 days 95% CI, -6 to 3 days; P = .51) and 90-day survival (hazard ratio, 0.95 95% CI, 0.65 to 1.38, P = .96) were not significantly different.
Among families of patients with chronic critical illness, the use of palliative care-led informational and emotional support meetings compared with usual care did not reduce anxiety or depression symptoms and may have increased posttraumatic stress disorder symptoms. These findings do not support routine or mandatory palliative care-led discussion of goals of care for all families of patients with chronic critical illness.
clinicaltrials.gov Identifier: NCT01230099.
Westra and Di Bartolomeo (2024) make a compelling case for integrating "process acuity" skills into routine clinical training. The authors have done the field a service by articulating the need for ...novel and process-science-informed psychotherapy training and practice. This brief commentary echoes the authors' observations about the status quo of clinical training and expands upon what else will need to be considered to fully realize the goals of their proposal. Specifically, research on negative process signals has outpaced research on the optimal responses to such process signals. Further, process-outcome associations and the relevance of other technical mechanisms vary by the therapist/trainee (and dyad), which will require enhanced training personalization and precision. Future work on implementation will require elucidating responsive clinical strategies based on the accumulation of more sophisticated and contextualized process-outcome and training research.
In recent years, there has been increasing interest in utilizing time-lagged panel models to study mechanisms of change in psychotherapy. These models offer valuable insights into the dynamic ...relationships between variables over time and offer stronger causal inference capabilities than cross-sectional analyses. Therefore, they are well-suited for modeling the intricate relationships between mechanisms of change and outcomes in psychotherapy studies, which are typically beyond experimental control. However, their complexity, coupled with the fact that detailed explanations are often embedded in dense statistical or econometric texts, poses challenges. This paper provides a background on cross-lagged panel models and delves deeper into explaining the issues of 1) dynamic panel bias, 2) long-run effects, and 3) testing whether different treatments work by different mechanisms. Using data from a psychotherapy study on treatment of adolescent depression, I demonstrate how these issues manifest in real data. In conclusion, I recommend using structural equation modeling to circumvent dynamic panel bias, reporting long-run effects to reveal the long-term impact of sustained therapeutic work on mechanisms of change, and carefully considering whether mediation, moderation, or a combination of both, best describes differential effects of mechanisms between treatments.
•Time-lagged panel models are increasingly utilized in psychotherapy research to study mechanisms of change•Understanding dynamic panel bias, long-run effects, and differential mechanisms is beneficial for psychotherapy researchers•To avoid dynamic panel bias, researchers should use structural equation modeling•Long-run effects should be calculated to determine the consequence of prolonged therapeutic focus on a mechanism of change•Researchers should theoretically evaluate the use of mediation, moderation, or a combination of both
There is a paucity of controlled treatment trials for the treatment of conversion disorder, seizures type, also known as psychogenic nonepileptic seizures (PNES). Psychogenic nonepileptic seizures, ...the most common conversion disorder, are as disabling as epilepsy and are not adequately addressed or treated by mental health clinicians.
To evaluate different PNES treatments compared with standard medical care (treatment as usual).
Pilot randomized clinical trial at 3 academic medical centers with mental health clinicians trained to administer psychotherapy or psychopharmacology to outpatients with PNES. Thirty-eight participants were randomized in a blocked schedule among 3 sites to 1 of 4 treatment arms and were followed up for 16 weeks between September 2008 and February 2012; 34 were included in the analysis.
Medication (flexible-dose sertraline hydrochloride) only, cognitive behavioral therapy informed psychotherapy (CBT-ip) only, CBT-ip with medication (sertraline), or treatment as usual.
Seizure frequency was the primary outcome; psychosocial and functioning measures, including psychiatric symptoms, social interactions, quality of life, and global functioning, were secondary outcomes. Data were collected prospectively, weekly, and with baseline, week 2, midpoint (week 8), and exit (week 16) batteries. Within-group analyses for each arm were performed on primary (seizure frequency) and secondary outcomes from treatment-blinded raters using an intention-to-treat analysis.
The psychotherapy (CBT-ip) arm showed a 51.4% seizure reduction (P = .01) and significant improvement from baseline in secondary measures including depression, anxiety, quality of life, and global functioning (P < .001). The combined arm (CBT-ip with sertraline) showed 59.3% seizure reduction (P = .008) and significant improvements in some secondary measures, including global functioning (P = .007). The sertraline-only arm did not show a reduction in seizures (P = .08). The treatment as usual group showed no significant seizure reduction or improvement in secondary outcome measures (P = .19).
This pilot randomized clinical trial for PNES revealed significant seizure reduction and improved comorbid symptoms and global functioning with CBT-ip for PNES without and with sertraline. There were no improvements in the sertraline-only or treatment-as-usual arms. This study supports the use of manualized psychotherapy for PNES and successful training of mental health clinicians in the treatment. Future studies could assess larger-scale intervention dissemination.
clinicaltrials.gov Identifier: NCT00835627.
Objective: Despite the heightened urgency of the current prescription opioid crisis, few psychotherapies have been evaluated for chronic pain patients receiving long-term opioid analgesics. Current ...psychological pain treatments focus primarily on ameliorating negative affective processes, yet basic science suggests that risk for opioid misuse is linked with a dearth of positive affect. Interventions that modulate positive psychological processes may produce therapeutic benefits among patients with opioid-treated chronic pain. The aim of this study was to conduct a theory-driven mechanistic analysis of proximal outcome data from a Stage 2 randomized controlled trial of Mindfulness-Oriented Recovery Enhancement (MORE), an integrative intervention designed to promote positive psychological health. Method: Patients with opioid-treated chronic pain (N = 95; age = 56.8 ± 11.7; 66% female) were randomized to 8 weeks of therapist-led MORE or support group (SG) interventions. A latent positive psychological health variable comprised of positive affect, meaning in life, and self-transcendence measures was examined as a mediator of the effect of MORE on changes in pain severity at posttreatment and opioid misuse risk by 3-month follow-up. Results: Participants in MORE reported significantly greater reductions in pain severity by posttreatment (p = .03) and opioid misuse risk by 3-month follow-up (p = .03) and significantly greater increases in positive psychological health (p < .001) than SG participants. Increases in positive psychological health mediated the effect of MORE on pain severity by posttreatment (p = .048), which in turn predicted decreases in opioid misuse risk by follow-up (p = .02). Conclusions: Targeting positive psychological mechanisms via MORE and other psychological interventions may reduce opioid misuse risk among chronic pain patients receiving long-term opioid therapy.
What is the public health significance of this article?
Current pharmacological and psychological pain treatments focus largely on reducing negative emotional reactions to pain. This study suggests that a new psychological treatment, Mindfulness-Oriented Recovery Enhancement, decreases risk for prescription opioid misuse among patients with chronic pain by increasing positive psychological factors like positive emotions and meaning in life.
Though the impact of the therapeutic alliance on therapy outcomes has been well-demonstrated, little research exists regarding the therapeutic alliance within a neuropsychological assessment setting. ...This brief report, therefore, explores the relevance and application of the concept of the therapeutic alliance within an assessment context. A self-report measure of clinician alliance ratings (Working Alliance Inventory–Neuropsychology WAI-NP) was adapted for use in an assessment setting and completed by 141 examiner participants in relation to the most recent patient they saw in an assessment. This study was the first to adapt an alliance measure for an assessment context and to consider the impact of the alliance on factors directly related to the assessment. However, internal consistency of the WAI-NP was α = .63, indicating the need for future research to clarify how to best capture the alliance in assessments. Additionally, though there was no significant relationship between time spent in assessment activities and the alliance, other variables emerged as significant predictors of the alliance, including how familiar examiners were with the concept of the alliance, which was also correlated with time spent in assessment. Though more research is needed to clarify relevant outcomes to measure to quantify the alliance’s impact on assessments, initial findings suggest that examiner familiarity with the alliance may impact assessments and that there may be points of intervention to enhance the alliance, and in turn, improve neuropsychological assessments. Implications for researchers, practicing neuropsychologists, and supervisors are discussed. (PsycInfo Database Record (c) 2024 APA, all rights reserved) (Source: journal abstract)
Internet‐delivered cognitive behavior therapy (ICBT) has been tested in many research trials, but to a lesser extent directly compared to face‐to‐face delivered cognitive behavior therapy (CBT). We ...conducted a systematic review and meta‐analysis of trials in which guided ICBT was directly compared to face‐to‐face CBT. Studies on psychiatric and somatic conditions were included. Systematic searches resulted in 13 studies (total N=1053) that met all criteria and were included in the review. There were three studies on social anxiety disorder, three on panic disorder, two on depressive symptoms, two on body dissatisfaction, one on tinnitus, one on male sexual dysfunction, and one on spider phobia. Face‐to‐face CBT was either in the individual format (n=6) or in the group format (n=7). We also assessed quality and risk of bias. Results showed a pooled effect size (Hedges' g) at post‐treatment of −0.01 (95% CI: −0.13 to 0.12), indicating that guided ICBT and face‐to‐face treatment produce equivalent overall effects. Study quality did not affect outcomes. While the overall results indicate equivalence, there are still few studies for each psychiatric and somatic condition and many conditions for which guided ICBT has not been compared to face‐to‐face treatment. Thus, more research is needed to establish equivalence of the two treatment formats.
Alliance in Individual Psychotherapy Horvath, Adam O; Del Re, A. C; Flückiger, Christoph ...
Psychotherapy (Chicago, Ill.),
03/2011, Volume:
48, Issue:
1
Journal Article
Peer reviewed
This article reports on a research synthesis of the relation between alliance and the outcomes of individual psychotherapy. Included were over 200 research reports based on 190 independent data ...sources, covering more than 14,000 treatments. Research involving 5 or more adult participants receiving genuine (as opposed to analogue) treatments, where the author(s) referred to one of the independent variables as "alliance," "therapeutic alliance," "helping alliance," or "working alliance" were the inclusion criteria. All analyses were done using the assumptions of a random model. The overall aggregate relation between the alliance and treatment outcome (adjusted for sample size and non independence of outcome measures) was
r
= .275 (
k
= 190); the 95% confidence interval for this value was .25-.30. The statistical probability associated with the aggregated relation between alliance and outcome is
p
< .0001. The data collected for this meta-analysis were quite variable (heterogeneous). Potential variables such as assessment perspectives (client, therapist, observer), publication source, types of assessment methods and time of assessment were explored.
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