Early maladaptive schemas impact on long-term outcome in patients treated with group behavioral therapy for obsessive-compulsive disorder.

BACKGROUND: Some studies have previously found that certain elevated early maladaptive schemas (EMSs) are negative predictors for outcome for patients with obsessive-compulsive disorder (OCD) treated with Cognitive-Behavioral Therapy (CBT) or Exposure and Response Prevention (ERP). The current study explores whether EMS were related to reductions in OCD symptom severity at long-term follow-up (Mean = 8 years) after group ERP for patients with OCD. The central hypothesis was that patients with no response to treatment or patients who relapsed during the follow-up period were more likely to have elevated pre-treatment EMSs compared to those who responded to initial treatment and maintained gains over time. We also investigated whether there were any differences in change over time of overall EMS between patients who were recovered versus patients who were not recovered at extended follow-up. METHODS: Young Schema Questionnaire -Short Form (YSQ-SF), Yale-Brown Obsessive-Compulsive Scale (Y-BOCS), Beck Depression Inventory (BDI) were measured in 40 OCD patients in a general outpatient clinic before and after group ERP, after 12-months and at extended follow-up. To analyze the predictors, a multiple regression analyses was conducted. Changes in overall EMS was analyzed by mixed models procedures. RESULTS: The major finding is that patients with high pre-treatment YSQ-SF total scores were less likely to respond to initial treatment or were more likely to relapse between post-treatment and the extended follow-up. The YSQ-SF total score at pre-treatment explained 10.5% of the variance of extended long-term follow-up outcome. The entire sample experienced a significant reduction in overall EMS over time with largest reduction from pre- to post-test. There were no statistically significant differences in total EMS change trajectories between the patients who were recovered at the extended follow-up compared to those who were not. CONCLUSION: The results from the present study suggest that patients with higher pre-treatment EMSs score are less likely to recover in the long-term after receiving group ERP for OCD. A combined treatment that also targets early maladaptive schemas may be a more effective approach for OCD patients with elevated EMS who don't respond to standard ERP.

Patients' experiences with lifestyle counselling in general practice: a qualitative study.

OBJECTIVE. (1) To elucidate the relevance of Habermas's theory as a practical deliberation procedure in lifestyle counselling in general practice, using a patient perspective. (2) To search for topics which patients consider of significance in such consultations. DESIGN. Qualitative observation and interview study. SETTING. General practice. Subjects. A total of 12 patients were interviewed after lifestyle consultations with their GPs. MAIN OUTCOME MEASURES. How the patients perceived the counselling, how it affected them, and what they wanted from their GP in follow-up consultations. RESULTS. The GP should be a source of medical knowledge and a caretaker, but also actively discuss contextual reasons for lifestyle choices, and be a reflective partner exploring values and norms. The patients wanted their GP to acknowledge emotions and to direct the dialogue towards common ground where advice was adjusted to the concrete life situation. A good, personal doctor-patient relationship created motivation and obligation to change, and allowed counselling to be interpreted as care. CONCLUSION. The findings underscore the necessity of a patient-centred approach in lifestyle counselling and support the relevance of Habermas's theory as practical guidance for deliberation. IMPLICATIONS. The findings suggest that GPs should trust the long-term effects of investing in a good relationship and personalized care in lifestyle consultations. The study should incite the GP to act as an encouraging informer, an explorer of everyday life and reasons for behaviour, a reflective partner, and a caretaker, adjusting medical advice to patients' identity, context, and values.

Effecting change through dialogue: Habermas' theory of communicative action as a tool in medical lifestyle interventions.

Adjustments of everyday life in order to prevent disease or treat illness afflict partly unconscious preferences and cultural expectations that are often difficult to change. How should one, in medical contexts, talk with patients about everyday life in ways that might penetrate this blurred complexity, and help people find goals and make decisions that are both compatible with a good life and possible to accomplish? In this article we pursue the question by discussing how Habermas' theory of communicative action can be implemented in decision-making processes in general practice. The theory of deliberative decision-making offers practical guidelines for what to talk about and how to do it. For a decision to be rooted in patients' everyday life it has to take into consideration the patient's practical circumstances, emotions and preferences, and what he or she perceives as ethically right behaviour towards other people. The aim is a balanced conversation, demonstrating respect, consistency and sincerity, as well as offering information and clarifying reasons. Verbalising reasons for one's preferences may increase awareness of values and norms, which can then be reflected upon, producing decisions rooted in what the patient perceives as good and right behaviour. The asymmetry of medical encounters is both a resource and a challenge, demanding patient-centred medical leadership, characterised by empathy and ability to take the patient's perspective. The implementation and adjustments of Habermas' theory in general practice is illustrated by a case story. Finally, applications of the theory are discussed.

Power and powerlessness: GPs' narratives about lifestyle counselling.

BACKGROUND: Power in doctor-patient relationships is asymmetrically distributed. The doctor holds resources the patient needs and has a mandate to promote healthy living. Power may benefit or harm the patients' health, and the doctor-patient relationship. AIM: To identify aspects of power and powerlessness in GPs' narratives about lifestyle counselling. DESIGN AND SETTING: A qualitative study using focus groups from peer-group meetings of Norwegian GPs attending continuing medical education. METHOD: GPs discussed case stories about lifestyle counselling in focus groups. The discussions were transcribed and the text analysed using systematic text condensation. RESULTS: Aspects of power concerning the framework of the consultation and the GPs' professional role were found. Also identified were: power expressed by opportunistic approaches to change patients' lifestyle; rhetoric communication; paternalism; and disclosure. GPs reported powerlessness in complex communication, when there were difficulties reaching goals, and when patients resisted or ignored their proposals. CONCLUSION: Case-study discussions in peer groups disclose several aspects of power and powerlessness that occur in consultations. Consciousness about aspects of power may facilitate counselling that benefits the patient and the doctor-patient relationship.

Lifestyle, health and the ethics of good living. Health behaviour counselling in general practice.

OBJECTIVE: To present theory that illustrates the relevance of ethics for lifestyle counselling in patient-centred general practice, and to illustrate the theory by a qualitative study exploring how doctors may obstruct or enhance the possibilities for ethical dialogue. METHODS: The theoretical part is based on theory of common morality and Habermas' communication theory. The empirical study consists of 12 consultations concerning lifestyle changes, followed by interviews of doctors and patients. ANALYSIS: Identification of two contrasting consultations holding much and little ethical dialogue, "translation" into speech acts, and interpretation of speech acts and interviews guided by theory. RESULTS: General advice obstructed possibilities for ethical clarification and patient-centredness. Ethical clarification was asked for, and was enhanced by the doctor using communication techniques such as interpretation, summarization, and exploration of the objective, subjective and social dimensions of the patients' lifeworlds. However, to produce concrete good decisions an additional reflection over possibilities and obstacles in the patient's lifeworld is necessary. CONCLUSION: Consultations concerning lifestyle changes hold opportunities for ethical clarification and reflection which may create decisions rooted in the patient's everyday life. PRACTICE IMPLICATIONS: The study suggests that GPs should encourage active reflection and deliberation on values and norms in consultations concerning lifestyle changes.