Mediators and Moderators of Active Music Engagement to Reduce Traumatic Stress Symptoms and Improve Well-being in Parents of Young Children With Cancer.

OBJECTIVE: This trial examined the effects of proximal/distal mediators and moderators of an Active Music Engagement (AME) intervention on young child/parent distress, quality of life, and family function outcomes. METHODS: Child/parent dyads (n = 125) were randomized to AME or Audio-storybooks attention control condition. Each group received 3 sessions with a credentialed music therapist for 3 consecutive days with data collection at baseline, post-intervention (T2), and 30-days later (T3). Potential proximal mediators included within session child and parent engagement. Potential distal mediators included changes in perceived family normalcy, parent self-efficacy, and independent use of play materials. Potential moderators included parent/child distress with prior hospitalizations, parent traumatic stress screener (PCL-6), and child age. Outcomes included child emotional distress and quality of life; parent emotion, traumatic stress symptoms (IES-R), well-being; and family function. Mediation effects were estimated using ANCOVA, with indirect effects estimated using the percentile bootstrap approach. Moderation effects were tested by including appropriate interaction terms in models. RESULTS: No significant mediation effects were observed. Child distress with prior hospitalizations moderated AME effects for IES-R intrusion subscale scores at T2 (P = .01) and avoidance subscale scores at T3 (P = .007). Traumatic stress screener scores (PCL-6) moderated intervention effects for IES-R hyperarousal subscale scores at T2 (P = .01). There were no moderation effects for child age. CONCLUSIONS: AME is a promising intervention for mitigating traumatic stress symptoms and supporting well-being in parents of children with cancer, particularly for parents who screen high for traumatic stress and whose children are more highly distressed with hospitalization.

Barriers and facilitators to implementation of trauma support services at a large HIV treatment center in the Southern United States.

The high prevalence of trauma among people living with HIV underscore the need for tailored, integrated trauma management ("trauma-informed care" or TIC) to improve retention, adherence to care, and overall well-being. Although TIC has been identified as a priority area for HIV care, uptake has been limited. To investigate barriers and facilitators to integrating trauma support services within HIV primary care, surveys (n=94) and interviews (n=44) were administered to providers, staff, and patients at a large HIV treatment center. Results highlighted the availability of several trauma services, including psychotherapy and support groups, but also revealed the absence of provider training on how to respond to patient trauma needs. Identified gaps in TIC services included written safety and crisis prevention plans, patient education on traumatic stressors, and opportunities for creative expression. Providers and staff supported implementation of trauma support services and employee trainings, but expressed a number of concerns including resource and skill deficiencies. Patient-reported barriers to TIC services included lack of awareness of services and difficulties navigating the healthcare system. This assessment revealed support and methods for strengthening integration of trauma support services within HIV primary care, which future TIC implementation efforts should address.

Introduction to the special issue: Complementary medicine and integrative health approaches to trauma therapy and recovery.

The popularity of complementary and integrative health (also complementary integrated health; CIH) approaches has significantly increased in recent years. According to the National Center for Complementary and Integrative Health (NCCIH), part of the National Institutes of Health, about 1 in 3 adults and 1 in 9 children used CIH approaches to healing. Some reports estimate that the use of CIH approaches will continue to increase (Clarke et al., 2015) as these therapies are cost effective and also due to the difficulties in finding trained mental health professionals (Simon et al., 2020). For the purpose of this special issue, we use the NCCIH's definition of CIH as "a group of diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine" (Barnes et al., 2004, p. v). However, the integration of these therapies into the health system has not followed the same pattern despite the fact that patients report the need to discuss CIH therapies with their doctors or are actually using them (de Jonge et al., 2018; Jou & Johnson, 2016; Stapleton et al., 2015). This inability to keep up with the demand or patients' preference is possibly due to providers' lack of understanding and/or knowledge of these therapies, as well as scientific skepticism (Ali & Katz, 2015; Fletcher et al., 2017). Using data from the 2012 National Health Interview Survey, Jou & Johnson (2016) identified patterns of CIH use in the United States and reasons for patients' nondisclosure of the use of these therapies. Patients' fear of disclosure due to perceived skepticism or disapproval from their provider was frequently attributed as a cause of patients' nondisclosures to providers about the use of these therapies (Eisenberg et al., 2001; Jou & Johnson, 2016; Thomson et al., 2012). The arrival of patient-centered care models is beginning to shift the ways we understand the patient's role in treatment engagement. Patient-centered approaches often emphasize the use of preventative and holistic wellness models that go beyond the use of evidence-based treatments. This approach also seeks to be culturally responsive, which is a key factor in addressing health disparities in the United States (American Psychological Association [APA], 2019). The Institute of Medicine, in its report on CIH therapies, highlighted the importance of engaging patients in their own care, including having a decision about therapeutic options (Bondurant et al., 2005). Likewise, the Race and Ethnicity Guidelines in Psychology (APA, 2019) recommend psychologists engage the patient's cultural beliefs, or what Kleinman called the "explanatory belief model" (Kleinman, 1978)- for example, by "aim[ing] to understand and encourage indigenous/ ethnocultural sources of healing within professional practice" (APA, 2019, p. 24). (PsycInfo Database Record (c) 2020 APA, all rights reserved).

The effectiveness of trauma-informed wilderness therapy with adolescents: A pilot study.

Objective: Wilderness therapy (WT) is a complementary/integrative approach for treating struggling adolescents by using outdoor adventure activities to foster personal and interpersonal growth/well-being. Empirical support for the effectiveness of traditional WT is growing, but evidence supporting trauma-informed WT (TIWT) is lacking. This pilot study addresses that gap. Method: Between 2009 and 2019, 816 adolescents (Ages 13-17, Mage = 15.36, SD = 1.25; 41.1% female) completed the Youth-Outcome Questionnaire-SR 2.0 at intake and discharge (M = 75.02 days, SD = 28.77). Three-hundred seventy-eight adolescents also completed the Family Assessment Device-General Functioning (FAD-GF), and 253 adolescents completed two, 2.5-min segments of heart-rate-variability biofeedback (one while resting and one while using a coping skill). One-hundred eighty-nine caregivers completed the Youth-Outcome Questionnaire 2.01, and 181 caregivers completed the FAD-GF. Between 25 and 99 adolescents and caregivers also completed psychological and family measures at 6 months and 1 year postdischarge. Results: Adolescents reported experiencing improvements in psychological and family functioning. They also exhibited improvement in psychophysiological functioning (heart-rhythm coherence). Caregivers reported improvements in family functioning and their child's psychological functioning. Caregivers observed more persisting benefits in their child's psychological functioning, whereas adolescents reported more persisting benefits in family functioning. Changes in psychological and family functioning were related. There were very few differential effects on the basis of demographic factors, trauma exposure, or past and current treatment factors. Conclusion: Results of this pilot study suggest TIWT is a promising complementary/integrative intervention for improving the psychological, family, and psychophysiological functioning of struggling adolescents. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Augmentation of Extinction and Inhibitory Learning in Anxiety and Trauma-Related Disorders.

Although the fear response is an adaptive response to threatening situations, a number of psychiatric disorders feature prominent fear-related symptoms caused, in part, by failures of extinction and inhibitory learning. The translational nature of fear conditioning paradigms has enabled us to develop a nuanced understanding of extinction and inhibitory learning based on the molecular substrates to systems neural circuitry and psychological mechanisms. This knowledge has facilitated the development of novel interventions that may augment extinction and inhibitory learning. These interventions include nonpharmacological techniques, such as behavioral methods to implement during psychotherapy, as well as device-based stimulation techniques that enhance or reduce activity in different regions of the brain. There is also emerging support for a number of psychopharmacological interventions that may augment extinction and inhibitory learning specifically if administered in conjunction with exposure-based psychotherapy. This growing body of research may offer promising novel techniques to address debilitating transdiagnostic fear-related symptoms.

Harnessing Electroceuticals to Treat Disorders Arising From Traumatic Stress: Theoretical Considerations Using A Psychosensory Model.

Traumatically encoded memories can last a lifetime. These memories, either by purposeful or inadvertent re-activation, cause the release of stress hormones and generate a persistent and inescapable allostatic load on the body, brain and mind. This leads to a maladaptive response, as the ability to return to pre-event homeostasis is no longer possible. The consequence of this response is that it increases risk for further traumatization and other disorders. Remarkably, recent research has shown that these memories become labile and subject to disruption upon recall. In this paper we outline conditions needed for an event to be encoded as a trauma and describe a method that abrogates the release stress hormones when cued by these memories of the event. Critical to this process is the AMPA receptor (so named for its specific agonist, AMPA, α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid, a compound that acts as glutamate, its natural substrate). It is hypothesized that traumatic encoding requires increasing the number and permanence of AMPA receptors on the lateral nucleus of the amygdala by a process called synaptic potentiation. Depotentiation, that is removal of these AMPA receptors, is required for de-encoding. We speculate that the generation of oscillatory intracellular calcium waves is necessary for this to occur. Electromagnetic fields, acting as electroceuticals, interact with voltage-gated calcium channels on depolarized post-synaptic membranes to produce these intracellular calcium oscillations of varying frequency. These oscillatory calcium waves are decoded by intracellular calmodulin which, depending on the frequency, either act to potentiate or depotentiate AMPA receptors. This article describes the theory and practical application of a psychosensory approach called Event Havening that generates an electromagnetic field to synaptically depotentiate these encoded AMPA receptors and eliminate the effects of traumatic encoding.

Macrophage Migration Inhibitory Factor and microRNA-451a in Response to Mindfulness-based Therapy or Treatment as Usual in Patients with Depression, Anxiety, or Stress and Adjustment Disorders.

Background: Macrophage migration inhibitory factor is a proinflammatory cytokine that has been associated with various psychiatric disorders. MicroRNA-451a can directly target macrophage migration inhibitory factor and downregulate its expression in cells. However, the role of macrophage migration inhibitory factor and microRNA-451a in psychiatric patients treated with psychotherapeutic interventions is unknown. In this study, our aim was to investigate levels of macrophage migration inhibitory factor and its regulating microRNA-451a in patients with depression, anxiety, or stress and adjustment disorders who underwent mindfulness-based therapy or treatment as usual. Methods: A total of 168 patients with psychiatric disorders were included from a randomized controlled trial that compared mindfulness-based therapy with treatment as usual. Plasma levels of macrophage migration inhibitory factor and microRNA-451a were measured at baseline and after the 8-week follow-up using Luminex assay and qPCR. Results: Macrophage migration inhibitory factor levels decreased significantly in patients posttreatment, whereas microRNA-451a levels showed a nonsignificant change. Macrophage migration inhibitory factor levels were inversely associated with microRNA-451a expression levels at baseline (ß=-0.04, P=.008). The change in macrophage migration inhibitory factor levels (follow-up levels minus baseline levels) was associated with the change in microRNA-451a (follow-up levels minus baseline levels) (ß=-0.06, P < .0001). The change in either macrophage migration inhibitory factor or microRNA-451a was not associated with improvement in psychiatric symptoms. Conclusion: We demonstrate that the levels of macrophage migration inhibitory factor decreased after psychotherapeutic interventions in patients with psychiatric disorders. However, this reduction was not associated with an improvement in psychiatric symptoms in response to the treatment. We also found an association between macrophage migration inhibitory factor and its regulating microRNA. However, this association needs to be further examined in future studies.

[Mental treatment of refugees in Germany : Model for a stepped approach]. / Psychische Versorgung von Flüchtlingen in Deutschland : Modell für ein gestuftes Vorgehen.

The recent influx of refugees and asylum seekers into Germany poses a challenge for the national healthcare system. In compliance with the present Asylum Seekers Benefits Act, the national healthcare system can be expected to have 1.5 million new members by early 2017. Providing adequate care particularly for people with mental illnesses or disorders will represent an immense challenge for all actors in the system. The circumstances of the flight combined with the foreign linguistic and socio-cultural background increase the severity of the cases and the difficulties of treatment. No procedures or guidelines for treatment have yet been established to ensure a standardized, cost-efficient and therapeutically effective treatment of patients with this background. This article describes the components of a stepped treatment procedure and proposes a stepped and collaborative care model (SCCM) that could be evaluated in nationwide studies. This approach is based on national and international treatment guidelines and aims to provide target-group specific, culturally sensitive methods of diagnosis and treatment. The various steps of the model build on each other, with the first steps relying on technological aids (e.g. online or smartphone options) and support from lay helpers and the more expensive specialist psychiatric and psychotherapeutic therapy only being initiated in cases of more severe mental disorders.

Practical Steps to Integrate Family Voice in Organization, Policy, Planning, and Decision-Making for Socio-Emotional Trauma-Informed Integrated Pediatric Care.

This article explores barriers and strategies to achieving family-driven integrated child health care. Family involvement in health system design and reform has become a guiding principle in national and local efforts to improve children's mental health services. In practice, primary care clinicians, staff, and families continue to describe common barriers to integrating family voice. Drawing from the collective knowledge of the Pediatric Integrated Care Collaborative (PICC) and the National Alliance on Mental Illness (NAMI), we present strategies to overcome these barriers to successfully recruit, sustain, and expand family influence on health systems. Family advocates and clinical leaders from two clinic sites in Albuquerque, New Mexico and Santa Rosa, California share challenges and strategies for building family involvement in system design.

Integrating Mental and Physical Health Services Using a Socio-Emotional Trauma Lens.

This article provides a synthesis of the lessons learned from the Pediatric Integrated Care Collaborative (PICC), a SAMHSA-funded project that is part of the National Child Traumatic Stress Network. The high prevalence of trauma exposure in childhood and shortage of mental health services has informed efforts to integrate mental and behavioral health services in pediatric primary care. This article outlines strategies to integrate care following the six goals of the PICC change framework: create a trauma/mental health informed office; involve families in program development; collaborate and coordinate with mental health services; promote resilience and prevent mental health problems through a particular focus on trauma-related risks; assess trauma-related somatic and mental health issues; and address trauma-related somatic and mental heath issues. We conclude with a summary of key strategies that any practice or practitioner could employ to begin or continue the process of integration.

A Meta-Analysis of Hypnotherapeutic Techniques in the Treatment of PTSD Symptoms.

The efficacy of hypnotherapeutic techniques as treatment for symptoms of posttraumatic stress disorder (PTSD) was explored through meta-analytic methods. Studies were selected through a search of 29 databases. Altogether, 81 studies discussing hypnotherapy and PTSD were reviewed for inclusion criteria. The outcomes of 6 studies representing 391 participants were analyzed using meta-analysis. Evaluation of effect sizes related to avoidance and intrusion, in addition to overall PTSD symptoms after hypnotherapy treatment, revealed that all studies showed that hypnotherapy had a positive effect on PTSD symptoms. The overall Cohen's d was large (-1.18) and statistically significant (p < .001). Effect sizes varied based on study quality; however, they were large and statistically significant. Using the classic fail-safe N to assess for publication bias, it was determined it would take 290 nonsignificant studies to nullify these findings.

Mindfulness-Oriented Recovery Enhancement versus CBT for co-occurring substance dependence, traumatic stress, and psychiatric disorders: Proximal outcomes from a pragmatic randomized trial.

In many clinical settings, there is a high comorbidity between substance use disorders, psychiatric disorders, and traumatic stress. Novel therapies are needed to address these co-occurring issues efficiently. The aim of the present study was to conduct a pragmatic randomized controlled trial comparing Mindfulness-Oriented Recovery Enhancement (MORE) to group Cognitive-Behavioral Therapy (CBT) and treatment-as-usual (TAU) for previously homeless men residing in a therapeutic community. Men with co-occurring substance use and psychiatric disorders, as well as extensive trauma histories, were randomly assigned to 10 weeks of group treatment with MORE (n = 64), CBT (n = 64), or TAU (n = 52). Study findings indicated that from pre-to post-treatment MORE was associated with modest yet significantly greater improvements in substance craving, post-traumatic stress, and negative affect than CBT, and greater improvements in post-traumatic stress and positive affect than TAU. A significant indirect effect of MORE on decreasing craving and post-traumatic stress by increasing dispositional mindfulness was observed, suggesting that MORE may target these issues via enhancing mindful awareness in everyday life. This pragmatic trial represents the first head-to-head comparison of MORE against an empirically-supported treatment for co-occurring disorders. Results suggest that MORE, as an integrative therapy designed to bolster self-regulatory capacity, may hold promise as a treatment for intersecting clinical conditions.

Open Mind, Open Heart: An Anthropological Study of the Therapeutics of Meditation Practice in the US.

Based on ethnographic fieldwork and interviews collected with meditation teachers and students in the United States, this article will argue that active training in meditation-based practices occasions the opportunity for people with traumatic stress to develop a stronger mind-body connection through heightened somatic awareness and a focus on the present moment that they find to be therapeutic. Three important themes related to healing through meditation for trauma emerged from the data and centered around the ways our interlocutors attempted to realign their sense of self, mind and body, after a traumatic experience. The themes helped explain why US women perceive meditation as therapeutic for trauma, namely that the practice of meditation enables one to focus on the lived present rather than traumatic memories, to accept pain and "open" one's heart, and to make use of silence instead of speech as a healing modality. As meditation practices increasingly enter global popular culture, promoted for postulated health benefits, the driving question of this research--how meditation may perpetuate human resilience for women who have experienced trauma based on their own perspectives of meditation practices--is a critical addition to the literature.

Supporting the need for an integrated system of care for youth with co-occurring traumatic stress and substance abuse problems.

Adolescents are at high risk for violence exposure and initiation of drug use. Co-occurring substance use and trauma exposure are associated with increased risk of mental health disorders, school underachievement, and involvement with multiple systems of care. Coordination and integration of systems of care are of utmost importance for these vulnerable youth. This study delineates the negative sequelae and increased service utilization patterns of adolescents with a history of trauma, substance abuse, and co-occurring trauma and substance abuse to support the need for integrated mental health and substance abuse services for youth. Data from two national sources, the National Child Traumatic Stress Network and Center for Substance Abuse Treatment demonstrate the increased clinical severity (measured by reports of emotional and behavioral problems), dysfunction, and service utilization patterns for youth with co-occurring trauma exposure and substance abuse. We conclude with recommendations for an integrated system of care that includes trauma-informed mental health treatment and substance abuse services aimed at reducing the morbidity and relapse probability of this high-risk group.

Trauma and humanitarian translation in Liberia: the tale of open mole.

The focus of this paper is the intercultural process through which Open Mole and trauma-related mental illnesses are brought together in the postconflict mental health encounter. In this paper, I explore the historical dimension of this process by reviewing the history of Open Mole, and the ways in which it has been interpreted, acted on, and objectified by external observers over the last half-century. Moving into Liberia's recent war and postconflict period, I examine the process by which Open Mole is transformed from a culture-bound disorder into a local idiom of trauma, and how it has become a gateway diagnosis of PTSD-related mental illnesses, and consider how it is produced as an objectified experience of psychiatric disorder in clinical humanitarian contexts. By studying how Open Mole is transformed in the humanitarian encounter, I address the structure and teleology of the humanitarian encounter and challenge some of the foundational assumptions about cultural sensitivity and community-based mental health care in postconflict settings that are prevalent in scholarship and practice today.

Dissociative symptoms and reported trauma among patients with spirit possession and matched healthy controls in Uganda.

Spirit possession is a common, worldwide phenomenon with dissociative features. Studies in Europe and the United States have revealed associations among psychoform and somatoform dissociation and (reported) potential traumatic events. The aim of this study was to explore the relationships among spirit possession, dissociative symptoms and reported potentially traumatizing events in Uganda. One hundred nineteen persons with spirit possession, diagnosed by traditional healers, were compared to a matched control group of 71 nonpossessed persons. Assessments included demographic items and measures of dissociation and potentially traumatizing events. Compared to the nonpossessed group, the possessed group reported more severe psychoform dissociation and somatoform dissociation and more potentially traumatizing events. The associations between these events and both types of dissociation were significant. Yet, consistent with the cultural perception of dissociative symptoms, the participants subjectively did not associate dissociative symptoms with potentially traumatizing events. In conclusion, spirit possession deserves more interest as a possible idiom of distress and a culture-specific expression of dissociation related to potential traumatizing events.

Impact of a meaning-centered intervention on job satisfaction and on quality of life among palliative care nurses.

OBJECTIVE: Palliative care (PC) nurses experience several recurrent organizational, professional, and individual challenges. To address existential and emotional demands, the meaning-centered intervention was recently developed. The intervention applied didactic and process-oriented strategies, including guided reflections, experiential exercises, and education based on themes of Viktor Frankl's logotherapy. The objective of this study was to test its efficiency to improve job satisfaction and quality of life in PC nurses from three regional districts in Quebec Province, Canada. METHODS: A randomized waiting-list group design was conducted, intervention group (n=56) versus waiting-list group (n=53). Job satisfaction, perception of benefits of working in PC, and spiritual and emotional quality of life were measured at pre-, posttest, and 3-month follow-up. RESULTS: The PC nurses in the experimental group reported more perceived benefits of working in PC after the intervention and at follow-up. Spiritual and emotional quality of life remained, however, unaffected by the intervention. CONCLUSIONS: To explain null findings, theoretical and methodological challenges, related to existential interventions, such as choice of outcomes, and selection bias (participants recruited were healthy workers) are discussed. Future directions and strategies to deal with those issues are proposed.

Hypnotherapy in child psychiatry: the state of the art.

Children are more easily hypnotized than adults, and hypnotherapy as a method responds to the general developmental needs of children by addressing their ability for fantasy and imagination. Hypnotherapy and self-hypnosis are tools with which to assess and develop protective factors, and enhance positive adjustment. Meta-analyses and overviews have demonstrated the effect of hypnotherapy in paediatric disorders like asthma, chronic and acute pain, and in procedure-related distress in cancer patients. We wanted to examine the use and benefits of hypnotherapy when applied to child psychiatric disorders. A review of a literature search from PubMed, PsychINFO and the Cochrane databases revealed 60 publications, mostly case reports based on 2-60 cases, addressing the use of hypnotherapy in various child psychiatric conditions. Findings indicate that hypnotherapy may be useful for a wide range of disorders and problems, and may be particularly valuable in the treatment of anxiety disorders and trauma-related conditions. In conclusion, knowledge of hypnosis is useful in clinical practice and hypnotherapy may play an important role as an adjunctive therapy in cognitive-behavioural treatment and family therapy. Additional qualitative and quantitative studies are needed to assess the place for hypnosis/hypnotherapy in child psychiatry.