Development of a Q-sort version of the Defense Mechanism Rating Scales (DMRS-Q) for clinical use.

This report focuses on the need to provide clinicians with a reliable and valid measure for detecting patient defense mechanisms "inside psychotherapy." To avoid the limitations of existing methods, we designed a Q-sort based on the theoretical definitions and criteria of the Defense Mechanisms Rating Scales (DMRS-Q), but one that does not require transcripts of clinical interviews or sessions and may be applied without specific training on defenses. The DMRS-Q is sensitive to changes in psychotherapy and its scores correlate significantly with various aspects of mental functioning, making it potentially available for the psychotherapy process and outcome research as well. We report the results of using the DMRS-Q on a systematic single case study with the aim of detecting changes in defense mechanisms during a long-term psychodynamic psychotherapy. The DMRS-Q reveals change both in quantitative scores and in the literary Defensive Profile Narrative.

Core cognitions related to health anxiety in self-reported medical and non-medical samples.

The cognitive-behavioural model of health anxiety hypothesizes that the degree of health threat experienced by an individual is a function of the perceived: (1) likelihood of illness; (2) awfulness of illness; (3) difficulty coping with illness; and (4) inadequacy of medical services. While research has examined cognitions in health anxiety, it is not known whether these cognitions predict health anxiety in individuals who do or do not report medical conditions and whether these cognitions are uniquely related to health anxiety. After developing the Health Cognitions Questionnaire to assess these specific cognitions, we examined the extent to which the cognitions predicted health anxiety and poor response to reassurance in a healthy community sample (n = 273) and a sample who self-reported various medical conditions (n = 208). Supporting the cognitive-behavioural model, these cognitions predicted health anxiety and poor response to reassurance in both samples, with some differences observed between those who did or did not report medical conditions. The cognitions were uniquely related to health anxiety even after controlling for depression and general anxiety. Clinical and theoretical implications are discussed. Overall, the Health Cognitions Questionnaire has potential to facilitate further research on the development, maintenance, and treatment of health anxiety.

The relation of pain and caregiver burden in informal older adult caregivers.

OBJECTIVE: Pain in older adults is highly prevalent and although informal caregiving is commonly provided by an older cohort, the relationship between pain and caregiving has seldom been examined. Our goal was to study the associations between caregiver pain, depression, and caregiver burden in a sample of older adult caregivers. DESIGN: Questionnaires were completed by 116 caregivers (mean age=73.34) to measure the caregivers' overall pain, chronic pain status, caregiver burden and its five dimensions, depression, and the care recipients' level of disability. Hierarchical linear regression analyses evaluated the extent to which care recipient and caregiver variables, including caregiver pain and depression, were related to high levels of caregiver burden. RESULTS: The overall level of pain reported by the caregiver was a significant predictor of overall caregiver burden and the emotional and physical dimensions of caregiver burden, whereas a number of care recipient variables (e.g., disability level) were significant predictors of the social, emotional, and time dependence dimensions of caregiver burden. CONCLUSIONS: This is the first study to investigate the relationships among caregiver pain and caregiver burden in informal older adult caregivers. We conclude that the role of caregiver pain has been greatly underestimated in the caregiver burden literature and suggest a need for interdisciplinary collaboration for effective management of caregiver burden in older adults.

Volunteer client attachment moderates the relationship between trainee therapist attachment and therapist interventions.

This study explored the association between attachment security of therapists (alone and in interaction with clients' attachment) and therapist interventions in early sessions of short-term psychotherapy. Trainee therapists and volunteer clients (N=24) in short-term therapy completed the Experiences in Close Relationship Scale (Brennan, Clark, & Shaver, 1998) as a measure of adult romantic attachment orientations. Therapist interventions were identified and related to client and therapist attachment orientation. Results indicated that in early therapy sessions client attachment moderated the relationship between therapist attachment and therapist interventions. Specifically, avoidantly attached therapists intervened with more directive interventions when clients were high in attachment avoidance.

Client relationship incidents in early therapy: doorways to collaborative engagement.

The purpose of this study was to elaborate how clients understand the development of the alliance and to highlight aspects of the process particular to depressed clients working with experienced therapists. Fifteen participants described critical incidents in early therapy that influenced how they understood their working relationships with therapists. All incidents involved clients appraising what their therapists were doing. Through interviewer probing, participants were able to identify the importance of their own activity (disclosing and working with therapist input) as their collaboration in the incidents. Positive emotional responses were woven through the descriptions of the incidents. The research underscores how client understanding of collaboration might be accessed by researchers or clinicians and the potential importance of the interaction of client active exploration with positive emotions in understanding alliance development.

Person-centered risk assessment framework: assessing and managing risk in older adults living with dementia.

AIM: This study pilot-tested the person-centered risk assessment framework (PCRAF), a framework for managing risk among persons living with dementia (PLWD) in primary care. METHODS: Healthcare providers (N = 7) piloting the PCRAF completed a survey, rating their satisfaction with the tool, and an interview to gather their perceptions of the PCRAF. PLWD and care partners (N = 12) completed a survey, rating their satisfaction with safety planning. RESULTS: Care providers were very satisfied with the tool; however, patient or care partner inability to perceive or understand safety risks was a challenge. Use of the PCRAF was perceived as an opportunity to empower self-management, gather PLWD and care partner perspectives, reduce burden for care partners and increase understanding of potential risks. Patients and care partners were very satisfied with the way in which they were included in the risk discussion. CONCLUSION: The PCRAF is a promising new tool to reduce risks associated with dementia.

The secure-base hypothesis: Global attachment, attachment to counselor, and session exploration in psychotherapy.

This study explored J. Bowlby's (1988) secure-base hypothesis, which predicts that a client's secure attachment to the therapist, as well as the client's and the therapist's global attachment security, will facilitate in-session exploration. Volunteer clients (N = 59) and trainee counselors (N = 59) in short-term therapy completed the Experiences in Close Relationship Scale (K. A. Brennan, C. L. Clark, & P. R. Shaver, 1998) as a measure of adult global romantic and peer attachment orientations; the Client Attachment to Therapist Scale (B. Mallinckrodt, D. L. Gantt, & H. M. Coble, 1995) as a measure of attachment to counselor; the Working Alliance Inventory (A. O. Horvath & L. Greenberg, 1989) as a measure of working alliance; and the Session Evaluation Questionnaire-Depth Subscale (W. B. Stiles & J. S. Snow, 1984) as a measure of session depth. In line with Bowlby's hypothesis, the findings suggest that session depth is related to the client's experience of attachment security with the counselor and that counselor global attachment moderates the relationship between client global attachment and session exploration. (PsycINFO Database Record (c) 2010 APA, all rights reserved).

Examination of negative affective responses to waiting for surgery.

Long surgical waiting times are associated with many negative consequences. Although depression and anxiety have been studied among patients waiting for surgery, fundamental anxieties, such as anxiety sensitivity and health anxiety, have not been examined. Furthermore, research into patients' perspectives on coping while waiting is limited. The purpose of this study was to examine the extent of anxiety sensitivity, health anxiety, depression, and anxiety and their influence on coping, concern about waiting, and anxiety about surgery in individuals waiting for surgery. Individuals waiting for surgery completed measures assessing these constructs. Results revealed a high degree of health anxiety and anxiety sensitivity. Regression analysis showed that health anxiety and depression are unique predictors of coping and together help to predict concern about waiting. Anxiety sensitivity and anxiety did not add to the prediction of these variables. Overall, the results suggest that further attention should be given to interventions that address psychological distress during the wait for surgery.

Processes involved in client-nominated relationship building incidents: Client attachment, attachment to therapist, and session impact.

Thirty volunteer clients of trainee therapists nominated an incident that was critical in the development of their therapeutic relationship. Clients completed the Client Attachment to Therapist Scale (CATS), the Experiences in Close Relationships Scale (ECRS), and the Session Impacts Scale (SIS). Clients reported an increase in attachment security with their therapists, along with perceptions of support and relief and increasing exploration following the relationship building incident. While clients' avoidant attachment was unrelated to attachment to the therapist prior to the incidents, in subsequent sessions avoidance was related to a change in secure attachment to therapist. Finally, client attachment to therapist but not general attachment was significantly related to in-session exploration. Findings are discussed in light of attachment theory and convergence with findings from the field of social psychology. (PsycINFO Database Record (c) 2010 APA, all rights reserved).

Addressing and interpreting defense mechanisms in psychotherapy: general considerations.

Defense interpretations are commonly used techniques that clinicians employ more frequently than transference interpretations. How and when clinicians interpret defenses, however, has received little empirical examination. In an effort to facilitate the empirical study of defense interpretation, we reviewed 15 works by noted authors who gave a prominent role to interpreting defenses in discussing clinical work in general patient populations. Our goal was to identify and systematize distinct themes from these authors that might be testable hypotheses. We identified 74 themes related to the interpretation of defenses in psychotherapy-for example, "interpreting too frequently diminishes the emotional impact of interpretation"-which we organized into 17 distinct categories (e.g., factors associated with positive outcome). We subsequently selected 19 themes that were readily operationalizable as hypotheses and examination of which would advance clinical practice. These hypotheses address issues such as when, in what order, and how to interpret defensive material and what successful outcomes would be. We then describe prototypes of research designs, employing naturalistic observation, randomized controlled trials, or experimental laboratory studies, which could investigate these important hypotheses. Overall, this report codifies current clinical maxims and then provides future research directions for determining how clinicians can most effectively address defenses in psychotherapy.

Patient perceptions of hospital discharge: reliability and validity of a Patient Continuity of Care Questionnaire.

BACKGROUND: Review of the literature reveals a need to develop a questionnaire that measures patient perceptions of factors impacting continuity of care following discharge from hospital. Such a measure has the potential to guide quality improvement initiatives related to continuity of care. OBJECTIVE: Our objective was to develop and examine the psychometric properties of a measure that would meet this need, the Patient Continuity of Care Questionnaire (PCCQ). METHOD: The PCCQ was administered to 204 inpatients 4 weeks after discharge. The questionnaire was assessed by item and principal components analysis. Factors derived from principal components analysis were assessed for internal consistency and construct validity. RESULTS: A principal components analysis resulted in six subscales including perceptions of: (1) relationships with providers in hospital, (2) information transfer to patients, (3) relationships with providers in community, (4) management of written forms, (5) management of follow-up and (6) management of communication among providers. These subscales were internally consistent in our sample and demonstrated construct validity through correlations with other related constructs. CONCLUSION: This initial study supports the reliability and validity of the PCCQ for measuring patient perceptions of factors central to continuity of care. The questionnaire subscales correspond to the theoretical components of continuity of care that have been proposed in the literature, namely informational, relational and management continuity. The subscales may be of value for identifying problems in continuity of care and for evaluating interventions aimed at improving continuity of care for patients after hospital discharge.

What is a health expectation? Developing a pragmatic conceptual model from psychological theory.

INTRODUCTION: Examination of the existing literature in respect of health expectations revealed both ambiguity in relation to terminology, and relatively little work in respect of how abstract theories of expectancy in the psychological literature might be used in empirical research into the influence of expectations on attitudes and behaviours in the real world. This paper presents a conceptual model for the development of health expectations with specific reference to Alzheimer's disease. METHOD: Literature review, synthesis and conceptual model development, illustrated by the case of a person with newly diagnosed, early-stage Alzheimer's disease, and her caregiver. OUTCOME: Our model envisages the development of a health expectation as incorporating several longitudinal phases (precipitating phenomenon, prior understanding, cognitive processing, expectation formulation, outcome, post-outcome cognitive processing). CONCLUSION: Expectations are a highly important but still relatively poorly understood phenomenon in relation to the experience of health and health care. We suggest a pragmatic conceptual model designed to clarify the process of expectation development, in order to inform future research into the measurement of health expectations and to enhance our understanding of the influence of expectations on health behaviours and attitudes.