How important are the common factors in psychotherapy? An update

The common factors have a long history in the field of psychotherapy theory, research and practice. To understand the evidence supporting them as important therapeutic elements, the contextual model of psychotherapy is outlined. Then the evidence, primarily from meta‐analyses, is presented for particular common factors, including alliance, empathy, expectations, cultural adaptation, and therapist differences. Then the evidence for four factors related to specificity, including treatment differences, specific ingredients, adherence, and competence, is presented. The evidence supports the conclusion that the common factors are important for producing the benefits of psychotherapy.     

Biofeedback and the placebo effect

This article reviews the role of positive expectations, including those engendered by placebos, in symptom relief following medical and surgical procedures, and psychotherapy. Viewing biofeedback as instrument-aided psychotherapy, its procedures are considered in the light of their ability to mobilize the same healing forces as all forms of psychotherapy, with some implications for promising directions of biofeedback research.Slightly modified from an invited address to the Biofeedback Society on March 15, 1981 in Louisville, Kentucky.     

The alliance in mental health care: conceptualization,evidence and clinical applications

The concept of alliance reflects the collaborative relationship between a clinician and a patient, defined as consisting of three elements: a) the agreement on the goals of treatment; b) the agreement on a task or series of tasks; c) the development of a bond. Although much of the theory and research on the alliance comes from the domain of psychotherapy, the concept is applicable to any practice involving a person seeking help and a socially sanctioned healer. An extensive research evidence suggests that the alliance (typically measured at the third or fourth session) is a robust predictor of the outcomes of various forms of psychotherapy, even when prior symptom improvement and other factors are considered. Both the clinician and the patient bring to the therapy situation different capacities to form an alliance. Factors concerning the patient include, among others, the diagnosis, attachment history and style, motivation, and needs for affiliation. However, the benefits of the alliance have been found to be mostly due to the therapist's contribution, in particular his/her facilitative interpersonal skills, including verbal fluency, communication of hope and positive expectations, persuasiveness, emotional expression; warmth, acceptance and understanding; empathy, and alliance rupture-repair responsiveness. Placebo studies have allowed to experimentally manipulate aspects of the relationship between a therapist and a patient in non-psychotherapy contexts. In these settings, two components of the relationship have emerged: an emotional one (involving being cared for and understood by the clinician) and a cognitive one (including the belief in the competence of the therapist to select and administer an effective treatment). Here we propose a model that describes three pathways through which the alliance creates benefits, named CARE (caring, attentive, real and empathic), EXPECTANCY, and SPECIFIC. Although research and clinical attention have mostly focused on the alliance between a clinician and a patient in face-to-face interactions, there is preliminary evidence concerning the alliance between patients and other clinic staff, systems of care, or the program in Internet-mediated services. These new research areas clearly require further development.     

Identifying Elements of Patient-Centered Care in Underserved Populations: A Qualitative Study of Patient Perspectives

Patient-centered care is an important goal in the delivery of healthcare. However, many patients do not engage in preventive medical care. In this pilot study, we conducted twenty in depth, semi-structured qualitative interviews at the University of Illinois at Chicago Health Sciences campus in a four month time frame. Many patients were underserved and underinsured, and we wanted to understand their experiences in the healthcare system. Using content analysis, several themes emerged from the interview data. Participants discussed the need for empathy and rapport with their providers. They identified provider behaviors that fostered a positive clinical relationship, including step-by step explanations of procedures, attention to body language and clinic atmosphere, and appropriate time management. Participants identified cost as the most common barrier to engaging in preventive care and discussed children and social support as motivating factors. A long-term relationship with a provider was an important motivator for preventive care, suggesting that the therapeutic alliance was essential to many patients. Conversely, many participants discussed a sense of dehumanization in the healthcare system, reporting that their life circumstances were overlooked, or that they were judged based on insurance status or ethnicity. We discuss implications for provider training and healthcare delivery, including the importance of patient-centered medical homes.     

Real-time fMRI Biofeedback Targeting the Orbitofrontal Cortex for Contamination Anxiety

We present a method for training subjects to control activity in a region of their orbitofrontal cortex associated with contamination anxiety using biofeedback of real-time functional magnetic resonance imaging (rt-fMRI) data. Increased activity of this region is seen in relationship with contamination anxiety both in control subjects¹ and in individuals with obsessive-compulsive disorder (OCD),² a relatively common and often debilitating psychiatric disorder involving contamination anxiety. Although many brain regions have been implicated in OCD, abnormality in the orbitofrontal cortex (OFC) is one of the most consistent findings.^{3, 4} Furthermore, hyperactivity in the OFC has been found to correlate with OCD symptom severity⁵ and decreases in hyperactivity in this region have been reported to correlate with decreased symptom severity.⁶ Therefore, the ability to control this brain area may translate into clinical improvements in obsessive-compulsive symptoms including contamination anxiety. Biofeedback of rt-fMRI data is a new technique in which the temporal pattern of activity in a specific region (or associated with a specific distributed pattern of brain activity) in a subject''s brain is provided as a feedback signal to the subject. Recent reports indicate that people are able to develop control over the activity of specific brain areas when provided with rt-fMRI biofeedback.^7-12 In particular, several studies using this technique to target brain areas involved in emotion processing have reported success in training subjects to control these regions.^13-18 In several cases, rt-fMRI biofeedback training has been reported to induce cognitive, emotional, or clinical changes in subjects.^{8, 9, 13, 19} Here we illustrate this technique as applied to the treatment of contamination anxiety in healthy subjects. This biofeedback intervention will be a valuable basic research tool: it allows researchers to perturb brain function, measure the resulting changes in brain dynamics and relate those to changes in contamination anxiety or other behavioral measures. In addition, the establishment of this method serves as a first step towards the investigation of fMRI-based biofeedback as a therapeutic intervention for OCD. Given that approximately a quarter of patients with OCD receive little benefit from the currently available forms of treatment,^20-22 and that those who do benefit rarely recover completely, new approaches for treating this population are urgently needed.     

Outcome of Biofeedback-Assisted Relaxation for Pain in Adults with Cerebral Palsy: Preliminary Findings

Chronic pain is a common secondary problem associated with cerebral palsy (CP). This pain may be due to the musculoskeletal problems that often accompany CP, including spasticity, scoliosis, and bony deformity. The purpose of this study was to determine the effects of biofeedback-assisted relaxation training on self-reported pain and muscle tension in 3 adults with CP using a multiple baseline design across subjects. Two of 3 participants reported decreases in their pain experiences posttreatment. Their subjective reports, however, did not correspond with physiological changes. Complications in the use of progressive relaxation exercises and EMG biofeedback equipment are described and suggestions for future research provided.     

Carbamazepine and psychotherapy in the treatment of schizoaffective psychosis

The authors describe the interactions between and the differential effects of carbamazepine and individual psychotherapy in the treatment of a schizoaffective patient. Carbamazepine's impact on the patient's affective life facilitated the establishment of a working alliance in psychotherapy. As the patient began to understand and differentiate aspects of his affective, cognitive, bodily, and interpersonal experiences, his life situation stabilized and his carbamazepine dose requirements diminished.     

On clinical efficacy: why biofeedback does--and does not--work

Questions of clinical efficacy are becoming more prominent in this era of diminishing funds for research and clinical care, and new treatment procedures, in particular, are being rigorously scrutinized. This presents a challenge for the relatively recent field of biofeedback and applied psychophysiology. This field has a strong scientific orientation and a rapidly expanding research base, which includes many well-controlled clinical outcome studies. The point is raised, and illustrated with data from current clinical outcome studies, that it is time for a shift in emphasis away from simply piling study upon study and toward more thoughtful interpretation of experimental and clinical findings and the development of a clearer conceptual framework for biofeedback therapy and research.     

Economics of interstitial cystitis in clinical practice

Urologists may be concerned that treatment of patients with interstitial cystitis (IC) is not economically feasible, and the time spent on these patients could be used for more profitable urologic therapy. However, care of IC patients can provide urologic practices with increased revenue opportunities through a wide range of procedures, including IC evaluation and management, treatment planning, and diagnostic, therapeutic, and even surgical techniques. Current Procedural Terminology (CPT) and evaluation and management (E&M) charge codes are provided for many types, levels, and complexities of IC procedures. Some of these treatments may use physician extenders who generate profits without additional overhead costs. Further, IC therapy may involve the use of many in-office services, such as urodynamics, biofeedback, and peripheral nerve stimulation that can be economically profitable. Rather than being an economic drain, patients with IC can enhance the profitability of a urologic practice while they receive much needed care.     

Biofeedback in medicine: who,when, why and how?

Biofeedback is a mind-body technique in which individuals learn how to modify their physiology for the purpose of improving physical, mental, emotional and spiritual health. Much like physical therapy, biofeedback training requires active participation on the part of patients and often regular practice between training sessions. Clinical biofeedback may be used to manage disease symptoms as well as to improve overall health and wellness through stress management training. Research has shown that biofeedback interventions are efficacious in treating a variety of medical conditions, and many Americans are turning to biofeedback and other less traditional therapies for their routine healthcare.Clinical biofeedback training is growing increasingly popular in the USA, as many people are seeking out relatively new approaches to healthcare. This article provides an overview of clinical biofeedback training, outlines two models of training, details research which has established how effective biofeedback is in patients with a given disease, and describes who should be referred for biofeedback training.     

EMG biofeedback treatment of torticollis: a controlled outcome study.

Successful treatment of torticollis with electromyographic (EMG) biofeedback has been reported in a number of single case and single group studies. The present investigation represents the first controlled outcome study. Twelve torticollis patients were randomly assigned to EMG biofeedback or relaxation training and graded neck exercises (RGP). The procedure involved three sessions of baseline assessment, 15 sessions of EMG BF or RGP, 6 sessions of EMG BF or RGP plus home-management, 6 sessions of home-management alone, and follow-up 3 months after the end of treatment. A variety of outcome measures were used including physiological (EMG from the two sternocleidomastoid muscles, skin conductance level), behavioral (angle of head deviation, range of movement of the head), and self-report (depression, functional disability, body concept), therapist and "significant other" reports and independent observer assessment of videos. In both groups, neck muscle activity was reduced from pre- to posttreatment. This reduction was greater in the EMG biofeedback group. There was evidence of feedback-specific neck muscle relaxation in the EMG biofeedback group. Therefore, the outcome was not due to nonspecific factors and could be attributed to feedback-specific effects. Changes in skin conductance level showed that neck muscle relaxation was not simply mediated by a general reduction of "arousal." Significant improvements of extent of head deviation, and range of movement of the head, as well as reductions of depression were present, which were not different in the two groups. At the end of treatment, no patient was asymptomatic. Any therapeutic benefit was generally maintained at follow-up. The results and the procedural simplicity of RGP make the issue of cost-efficacy of EMG biofeedback a pertinent one. Further controlled outcome studies of EMG biofeedback treatment of torticollis with larger samples are required.     

Discourse on the development of EEG diagnostics and biofeedback for attention-deficit/hyperactivity disorders

This article presents a review of work that my colleagues and I have been doing during the past 15 years developing a rationale for the diagnosis of attention-deficit/hyperactivity disorder (ADHD) and treatment of ADHD employing EEG biofeedback techniques. The article first briefly reviews the history of research and theory for understanding ADHD and then deals with the development of EEG and event-related potential (ERP) assessment paradigms and treatment protocols for this disorder, including our work and that of others who have replicated our results. Illustrative material from our current research and child case studies is included. Suggestions for future experimental and clinical work in this area are presented and theoretical issues involving the understanding of the neurophysiological and neurological basis of ADHD are discussed.Over the years, many people have been involved both in my laboratory and at Southeastern Biofeedback Institute working with me in developing this area; I wish to acknowledge some of them. They are specifically Dr. Margaret Shouse and Dr. Chris Mann, who have been involved in the initial and recent stages of my research; Ms. Jennifer Samples, who has worked with us in the Institute for many years and has helped us in training many of the children that have benefited from EEG biofeedback. I would especially wish to acknowledge the skill and dedication of Judith O. Lubar, of Southeastern Biofeedback Institute, who has worked with me clinically in terms of developing treatment protocols for ADHD biofeedback and who has trained many of the children who have successfully completed EEG Biofeedback. I would like to acknowledge the generous help of the Lexicor Corporation of Boulder, Colorado who have provided support and instrumentation for recent studies in this area. Mr. Rod Bunn and Mr. Robert Muenchen, who have provided computer support, programming, and statistical assistance in evaluating data in various studies, are gratefully acknowledged. Some of this research was supported by a grant under the ESEA Title IV-C Program for the handicapped. I also gratefully acknowledge Children's Hospital of Knoxville, TN, who have provided essential contract support for our laboratory at the University of Tennessee.     

On clinical efficacy: Why biofeedback does—and does not—Work

Questions of clinical efficacy are becoming more prominent in this era of diminishing funds for research and clinical care, and new treatment procedures, in particular, are being rigorously scrutinized. This presents a challenge for the relatively recent field of biofeedback and applied psychophysiology. This field has a strong scientific orientation and a rapidly expanding research base, which includes many well-controlled clinical outcome studies. The point is raised, and illustrated with data from current clinical outcome studies, that it is time for a shift in emphasis away from simply piling study upon study and toward more thoughtful interpretation of experimental and clinical findings and the development of a clearer conceptual framework for biofeedback therapy and research.Preparation of this paper was supported in part by NIDRR grant No. H133G90085, Department of Education, DHEW.     

New migrant businesses and their workers: developing,but not transforming,the ethnic economy

ABSTRACT

Studies of businesses established by migrants to the UK traditionally stressed co-ethnic relationships as economic resources. More recent work identifies a new ethnic economy characterized by migrants’ common experiences, with ethnicity playing less of a role. The present study complements this newer perspective through investigation of the experiences of forty-nine business owners and sixty of their workers in the West Midlands. Economic relationships were central to the operation of migrant firms, and a minority of firms escaped from sectors traditionally dominated by migrant firms. Yet substantial continuity was also evident, including exclusion from the mainstream on ethnic lines and relations with workers characterized by informality. Migrant business is evolving but it retains many of its features; this pattern can be explained by combining the mixed embeddedness theory of the enterprise with labour process analysis.     

Autophagy and Angiogenesis Inhibition

Angiogenesis, the process by which new blood vessels are formed is critical for embryonic development and physiological functioning of normal tissues. Angiogenesis also plays a critical role in the pathology of many diseases including cancer, wherein the supply and demand for blood vessels determines the rate of cancer growth. A number of therapeutic strategies are being developed to inhibit pathological angiogenesis. Kringle domains of plasminogen such as kringle 5 (K5) and a proteolytic fragment of collagen type XVIII (endostatin) are well-characterized, potent angiogenesis inhibitors. These inhibitors activate different intracellular signaling pathways to induce apoptosis and inhibit cell proliferation. Recent studies from our group have shown that K5 and endostatin can also induce autophagy in addition to apoptosis in endothelial cells. A common feature of the two treatments was the upregulation of Beclin 1 levels leading to alterations in the Beclin 1-Bcl-2 complex. Angiogenesis inhibitor-induced autophagy in endothelial cells was independent of nutritional or hypoxic stress and initiated even in the presence of endothelial-specific survival factors such as vascular endothelial growth factor (VEGF). Interfering with the autophagic response by knocking down Beclin 1 levels dramatically increased apoptosis of endothelial cells. These findings identify the autophagic response as a novel target for enhancing the therapeutic efficacy of angiogenesis inhibitors.

Addendum to:

Kringle 5 of Human Plasminogen, an Angiogenesis Inhibitor, Induces Both Autophagy and Apoptotic Death in Endothelial Cells

T.M.B. Nguyen, I.V. Subramanian, A. Kelekar and S. Ramakrishnan

Blood 2007; 109:4793-802     

Ethical issues in research on sensitive topics: participants' experiences of distress and benefit

While many studies ask participants to disclose sensitive information or to participate in emotionally arousing tasks, little is known about participants' subjective experiences of discomfort and benefit. Ethics review committees, therefore, have little information about participant experiences to guide their informed decision-making. We asked undergraduate females about their experiences in a study that included an experimental session, interviews, and self-report measures on sensitive topics. We examined results overall, and compared the responses of individuals with and without childhood abuse experiences. Participants who had experienced child abuse were more likely to report distress due to remembering the past, but also more likely to report that participation was helpful. Implications for future research, and recommendations for review boards, are discussed.     

Personality development in psychotherapy: a synergetic model of state-trait dynamics

Theoretical models of psychotherapy not only try to predict outcome but also intend to explain patterns of change. Studies showed that psychotherapeutic change processes are characterized by nonlinearity, complexity, and discontinuous transitions. By this, theoretical models of psychotherapy should be able to reproduce these dynamic features. Using time series derived from daily measures through internet-based real-time monitoring as empirical reference, we earlier presented a model of psychotherapy which includes five state variables and four trait variables. In mathematical terms, the traits modulate the shape of the functions which define the nonlinear interactions between the variables (states) of the model. The functions are integrated into five coupled nonlinear difference equations. In the present paper, we model how traits (dispositions or competencies of a person) can continuously be altered by new experiences and states (cognition, emotion, behavior). Adding equations that link states to traits, this model not only describes how therapeutic interventions modulate short-term change and fluctuations of psychological states, but also how these can influence traits. Speaking in terms of Synergetics (theory of self-organization in complex systems), the states correspond to the order parameters and the traits to the control parameters of the system. In terms of psychology, trait dynamics is driven by the states—i.e., by the concrete experiences of a client—and creates a process of personality development at a slower time scale than that of the state dynamics (separation of time scales between control and order parameter dynamics).     

Study on public acceptance of nuclear power plants: Evidence from China

Abstract

This empirical study evaluated the public acceptance of nuclear-power plants in China. A conceptual framework was proposed to explain the factors affecting nuclear-power acceptance based on antecedent variables, including social-media-use frequency, social-media information trust, nuclear-power knowledge, nuclear-accident knowledge, and risk-and-benefit perception. An empirical study was operated based on the Haiyang nuclear-power plant by conducting a face-to-face survey among residents who use social-media platforms near the plant. The frequency of social-media-use and the trust on social-media information promote individuals’ knowledge about nuclear power and nuclear accidents, leading to risk and benefit perception. Finally, benefit perception results in nuclear-power acceptance among the individuals. Implications and suggestions for future research are discussed.     

Challenges and advice for MD/PhD applicants who are underrepresented in medicine

The importance of diversity is self-evident in medicine and medical research. Not only does diversity result in more impactful scientific work, but diverse teams of researchers and clinicians are necessary to address health disparities and improve the health of underserved communities. MD/PhD programs serve an important role in training physician-scientists, so it is critical to ensure that MD/PhD students represent diverse backgrounds and experiences. Groups who are underrepresented in medicine and the biomedical sciences include individuals from certain racial and ethnic backgrounds, individuals with disabilities, individuals from disadvantaged backgrounds, and women. However, underrepresented students are routinely discouraged from applying to MD/PhD programs due to a range of factors. These factors include the significant cost of applying, which can be prohibitive for many students, the paucity of diverse mentors who share common experiences, as well as applicants’ perceptions that there is inadequate support and inclusion from within MD/PhD programs. By providing advice to students who are underrepresented in medicine and describing steps programs can take to recruit and support minority applicants, we hope to encourage more students to consider the MD/PhD career path that will yield a more productive and equitable scientific and medical community.     

The Potential Influence of a Companion-Animal's Presence on Aspects of the Therapeutic Alliance

ABSTRACT

Seventy-one college students participated in an experiment exploring the impact of a companion-animal's presence (viz., a dog) on several aspects of the participants' experience during an interview. Specifically, the study examined how the presence of a companion animal impacts participants' perception of the interviewer, including perceived levels of empathy and participants' willingness to self-disclose. Participants were prescreened with questions regarding past experience with animals. The researcher then conducted interviews with each participant, simulating a process comparable to that of an abridged initial psychotherapy intake session. Participants completed measures on their experience at the completion of the interview. Primary findings of the study determined that the presence of a companion animal did not influence participants' overall perceptions of the interviewer, willingness to self-disclose to the interviewer, and perceptions of the interviewer's level of empathic understanding. Participants' level of exposure to animals (current and past) also had no impact on these dependent measures. When participants' attitudes toward pets were examined, negative attitudes toward pets were associated with a diminished willingness to self-disclose in this study. This study represents an initial attempt at using more rigorous methodical controls to study the effect of companion animals in therapy-like situations. Contrary to previous research, the results imply that the presence of a companion animal during an interview analogous to the initial psychotherapy intake session may not influence aspects of the therapeutic alliance examined in this study. Future research is needed to determine if the same findings will be found with actual psychotherapy cases.