Determining differences between therapists using an extended version of the facilitative interpersonal skills performance test.

OBJECTIVES: The therapist-facilitative interpersonal skills (FIS) has shown to predict therapy outcomes, demonstrating that high FIS therapists are more effective than low FIS therapists. There is a need for more insight into the variability in strengths and weaknesses in therapist skills. This study investigates whether a revised and extended FIS-scoring leads to more differentiation in measuring therapists' interpersonal skills. Furthermore, we explorative examine whether subgroups of therapists can be distinguished in terms of differences in their interpersonal responses. METHOD: Using secondary data analysis, 93 therapists were exposed to seven FIS-clips. Responses of therapists using the original and the extended FIS scoring were rated. RESULTS: Three factors were found on the extended FIS scoring distinguishing supportive, expressive, and persuasive interpersonal responses of therapists. A latent profile analysis enlightened the presence of six subgroups of therapists. CONCLUSION: Using the revised and extended FIS-scoring contributes to our understanding of the role of interpersonal skills in the therapeutic setting by unraveling the question what works for whom.

Dual harm: Violent behaviour to others and self-harm behaviour in adults compulsorily admitted to a Dutch psychiatric hospital.

BACKGROUND: Verbal and physical violence in psychiatric hospitals can have harmful consequences for staff members, such as physical injury, traumatisation, and sick leave, and they often accompany involuntary admission. Harm to others may co-occur with self-harm, i.e., dual harm. However, little is known about the association between dual-harm and violent behaviour towards staff members and its clinical outcomes, such as seclusion and rapid tranquilisation after involuntary admission to a psychiatric inpatient unit. METHOD: A convenience sample of patients admitted involuntarily (N = 384; mean age = 48.03, SD = 19.92) between January 2016 and December 2019 in Western Brabant, the Netherlands, was used to design a retrospective file audit. Distinct harm groups, marked by the presence/absence of self- and/or other-harm, were investigated using multivariate linear regression modelling on the seriousness of violent acts and the total length of admission. Logistic regression analyses were used to study the association between harm groups and the administration of rapid tranquilisation, seclusion, and extended involuntary admissions. RESULTS: Several harm groups were identified, including self-harm only, other-harm only, and dual-harm groups. Psychiatric patients admitted to the hospital because of (the risk of) violence towards others had a higher risk of violent incidents during admission and some restrictive measures. In a subgroup of patients with psychotic disorders, patients with dual harm committed the most serious violent incidents compared to those in the other harm groups. CONCLUSION: Distinct harm groups were identified in a sample of involuntarily admitted patients. In a general adult psychiatric setting, patients at risk for violent behaviour, especially dual-harm patients, should be identified and monitored as part of the risk assessment. Future research is needed to explore more clinical correlates in the proposed distinction between harmful groups and to assess long-term prognosis.

Pathways to antisocial behavior: a framework to improve diagnostics and tailor therapeutic interventions.

The Antisocial Personality Disorder (ASPD), and antisocial behavior (ASB) in general, is associated with significant impact on individuals themselves, their environment, and society. Although various interventions show promising results, no evidence-based treatments are available for individuals with ASPD. Therefore, making informed choices about which treatment can be applied to an individual patient is complicated. Furthermore, contradictory findings on therapy effectiveness and underlying factors of ASB, such as cognitive impairments and personality traits, fuel the debate whether the conceptualization of ASPD in the DSM-5 is accurate and whether this population can be seen as homogeneous. A conceptual framework, based on the reciprocal altruism theory, is presented in which we propose different pathways to ASB. These pathways suggest underlying dynamics of ASB and provide an explanation for previous contradictory research outcomes. This framework is intended to serve as a clinically relevant model that provides directions for improving diagnostics and matching treatments to underlying dynamics in the antisocial population.

A capability perspective on sustainable employability: A Dutch focus group study on organizational, work and personal conversion factors.

OBJECTIVE: In the field of work, there is a shift towards more value-based approaches to study the sustainable employability of the present-day worker. The capability approach offers a value based and innovative conceptualisation and framework of sustainable employability characterized by contextuality, normativity and diversity. The capabilities of Dutch employees have been established and validated, yet it is not known which conversion factors on a personal, work and organizational level enable employees to achieve value in work in different Dutch occupational sectors. METHODS: Our qualitative approach included seven focus groups in different occupational sectors including elderly care, higher education, insurance work, facility management and the oil-, car- and chemical industry. Each focus group included 5-11 participants and took approximately one and a half hour. A qualitative content analysis was used to analyse the data, by combining deductive and inductive coding respectively. Deductive coding involved assigning themes to the conversion of resources into capabilities at the organizational, work and personal level. RESULTS: On the organizational conversion level, important themes were cultural aspects, power relations, shortage of personnel and policies for self-management. On the work conversion level, social contacts, communication and workload, tasks and schedules were identified. Social contacts were described as a work value in itself, but also conditional for achieving other work values. On the personal conversion level, experienced work stress, motivation and the ability to achieve values informally within the company. CONCLUSION: From our findings it follows that focus groups are sensitive to identify conversion factors on all three levels of conversion. In addition, companies and their employees might effectively increase work capabilities by being sensitive to all three conversion levels simultaneously. Further research is necessary to study the effect of a capability-based intervention at the work floor.

[Alarming situation amongst mental health care employees; mental health issues with possible resignation as a consequence]. / Alarmerend beeld onder personeel ggz; uitputting, angst- en somberheidsklachten met mogelijk vertrek uit de ggz als gevolg: Wat kan de ggz doen?

While the COVID-19 pandemic integrates more and more into daily life and hospitalizations decrease, the consequence for mental health care personnel is becoming clearer. 50% of the employees in mental health care institutes experience stress and 30% have signs of depression. Simultaneously more patients present themselves at the mental health care institutes with complaints as a result of the COVID-19 pandemic. This increases workload even more while the waiting lists are already very long. To prevent sick leave and/or even resigning, social support in the working environment, prevention measures for mental complaints, and support have to be initiated by every level of the mental health care institutes.

Explaining the willingness of clinicians to work with patients with antisocial personality disorder using the theory of planned behaviour and emotional reactions.

Many clinicians seem to experience negative emotions towards patients with antisocial personality disorder (ASPD), resulting in the exclusion of patients in many treatment programmes. The behaviour of individuals with ASPD has a significant impact on society, which affects ASPD patients and their environment, and therefore, the exclusion from programmes is a serious concern. Relatively, little is known about why some clinicians are willing to work with ASPD patients and others are not and what factors contribute to an increase in the motivation to do so. In this study, clinicians (n = 130) working in a regular and forensic mental health service in the Netherlands completed a questionnaire based on the theory of planned behaviour (TPB) and the Feeling Word Checklist and questions about the relevant experience gained and education received. The current study confirms the limited willingness to work with ASPD patients, especially in regular mental health care. Experience working with ASPD patients, education on cluster B personality disorders and having experienced verbal and/or physical violence in clinical practice did not fully explain whether or not clinicians were motivated to provide treatment to ASPD patients. TPB appeared to predict the intention to provide psychological therapy to ASPD patients adequately. The impact of positive emotions towards ASPD patients on providing treatment appeared to be stronger than negative emotions. This study provides more insight into why so few clinicians are willing to work with ASPD patients and what may increase motivation to include this group in treatment programmes.

Group Cognitive-Behavioral Therapy in a Sample of Dutch Intimate Partner Violence Perpetrators: Development of a Coding Manual for Therapist Interventions.

This qualitative study investigated which types of interventions are made by group therapists during group cognitive-behavioral therapy (GCBT) with individuals who have perpetrated intimate partner violence (IPV) in the "Not 'Losing It' Anymore"(NLIA) outpatient programs across the Netherlands. Audio recordings of group sessions (N = 60) facilitated by 13 co-therapist teams across 25 different groups were analyzed using the general inductive approach. Fifteen distinct therapist interventions were identified, categorized, and described using examples from the data. Two categories of interventions could be distinguished: CBT interventions and process-oriented interventions. In future research the coding manual can be tested for interrater reliability and might be used in research on the effectiveness of GCBT therapist interventions.

Psychometric analysis of the Dutch language Facilitative Interpersonal Skills (FIS) video clips.

With the motivation of investigating the replicability and transferability of the findings employing the Facilitative Interpersonal Skills (FIS) performance task beyond Anglophone countries, a set of Dutch FIS clips have been scripted and recorded. In this study the psychometric properties of the Dutch clips was tested. Furthermore, an additional set of FIS clips portraying a non-challenging client-therapist interaction was tested. 369 psychology students rated the interpersonal impact (IMI-C) and the affect (positive and negative affect schedule) displayed by the hypothetical client. Thirteen out of sixteen FIS clips were located in the same IMI-C quadrant as the US clips, indicating good content validity for all sets of FIS clips. Inter-rater reliability was reasonable for one set of Dutch language FIS clips (k=0.416). Visual inspection of quadrants showed the different character of the non-challenging set of FIS clips. The Dutch FIS clips are directly applicable for educational and research purposes.

How can wellbeing at work and sustainable employability of gifted workers be enhanced? A qualitative study from a capability approach perspective.

BACKGROUND: Being gifted with a very high IQ (> 98 percentile) can provide an advantage in the occupational context but can also come with its` own specific challenges. Where some studies found higher than average levels of wellbeing at work and successful careers amongst the gifted, other studies report boredom and less job satisfaction. This poses the question what gifted people value in work, and which factors are associated with the achievement of valued work related outcomes, wellbeing and sustainable employability. In this study these questions were explored using the value driven capability approach as a theoretical framework. METHOD: A qualitative approach was chosen and 16 in-depth semi-structured interviews with gifted workers (IQ > 130) were conducted. The transcripts were analysed using a reflexive thematic analysis aimed at identifying the work related outcomes participants aspired to achieve and the contextual and personal factors that affected the actualisation of these outcomes. RESULTS: Participants placed great value on the opportunity to learn, to use their knowledge and skills, and tended to have high ethical standards. If realized, these values contributed to wellbeing whereas if not fulfilled, this often resulted in frustration and sadness. The most important personal factors associated with wellbeing at work and sustainable employability were the level of organizational awareness, self-knowledge, a willingness to compromise, and fear of stigmatisation. Contextually a facilitating leadership style of managers was important, allowing the worker autonomy and decision latitude. Socially, participants enjoyed others as sparring partners but often had an aversion to small talk which could lead to social avoidance and loneliness. CONCLUSIONS: If gifted workers managed (to get) what they valued in work, this was associated with wellbeing and sustainable employment Coaching aimed at improving organizational awareness, specific social skills (e.g. small talk, adaptability) and understanding their own cognitive processes could be valuable. The application of an autonomy supporting facilitative leadership style by supervisors would be beneficial. Further research should try to confirm the findings using quantitative methods and needs to examine more closely the impact of stigmatisation and leadership styles.

Internet-Based Cognitive Behavioral Therapy for Chronic Fatigue Syndrome Integrated in Routine Clinical Care: Implementation Study.

BACKGROUND: In a clinical trial, internet-based cognitive behavioral therapy (I-CBT) embedded in stepped care was established as noninferior to face-to-face cognitive behavioral therapy (CBT) for chronic fatigue syndrome (CFS). However, treatment effects observed in clinical trials may not necessarily be retained after implementation. OBJECTIVE: This study aimed to investigate whether stepped care for CFS starting with I-CBT, followed by face-to-face CBT, if needed, was also effective in routine clinical care. Another objective was to explore the role of therapists' attitudes toward electronic health (eHealth) and manualized treatment on treatment outcome. METHODS: I-CBT was implemented in five mental health care centers (MHCs) with nine treatment sites throughout the Netherlands. All patients with CFS were offered I-CBT, followed by face-to-face CBT if still severely fatigued or disabled after I-CBT. Outcomes were the Checklist Individual Strength, physical and social functioning (Short-Form 36), and limitations in daily functioning according to the Work and Social Adjustment Scale. The change scores (pre to post stepped care) were compared with a benchmark: stepped care from a randomized controlled trial (RCT) testing this treatment format. We calculated correlations of therapists' attitudes toward manualized treatment and eHealth with reduction of fatigue severity. RESULTS: Overall, 100 CFS patients were referred to the centers. Of them, 79 started with I-CBT, 20 commenced directly with face-to-face CBT, and one did not start at all. After I-CBT, 48 patients met step-up criteria; of them, 11 stepped up to face-to-face CBT. Increase in physical functioning (score of 13.4), social functioning (20.4), and reduction of limitations (10.3) after stepped care delivered in routine clinical care fell within the benchmarks of the RCT (95% CIs: 12.8-17.6; 25.2-7.8; and 7.4-9.8, respectively). Reduction of fatigue severity in the MHCs was smaller (12.6) than in the RCT (95% CI 13.2-16.5). After I-CBT only, reduction of fatigue severity (13.2) fell within the benchmark of I-CBT alone (95% CI 11.1-14.2). Twenty therapists treated between one and 18 patients. Therapists were divided into two groups: one with the largest median reduction of fatigue and one with the smallest. Patients treated by the first group had a significantly larger reduction of fatigue severity (15.7 vs 9.0; t=2.42; P=.02). There were no (statistically significant) correlations between therapists' attitudes and reduction in fatigue. CONCLUSIONS: This study is one of the first to evaluate stepped care with I-CBT as a first step in routine clinical care. Although fatigue severity and disabilities were reduced, reduction of fatigue severity appeared smaller than in the clinical trial. Further development of the treatment should aim at avoiding dropout and encouraging stepping up after I-CBT with limited results. Median reduction of fatigue severity varied largely between therapists. Further research will help understand the role of therapists' attitudes in treatment outcome.

Implementation of stepped care for patients with chronic fatigue syndrome in community-based mental health care: outcomes at post-treatment and long-term follow-up.

BACKGROUND: Cognitive behavioural therapy (CBT) is an evidence-based treatment for chronic fatigue syndrome (CFS). Stepped care for CFS, consisting of a minimal intervention followed by face-to-face CBT, was found efficacious when tested in a CFS specialist centre. Stepped care implemented in a community-based mental health centre (MHC) has not yet been evaluated. AIMS: (1) To test the effectiveness of stepped care for CFS implemented in a MHC at post-treatment and at long-term follow-up; and (2) compare post-treatment outcomes of implemented stepped care with treatment outcomes of a CFS specialist centre. METHOD: An uncontrolled study was used to test effectiveness of stepped care implemented in a MHC (n = 123). The outcomes of implemented care were compared with the outcomes of specialist care reported in previous studies (n = 583). Data on outcomes from implemented stepped care were gathered at post-treatment and at long-term follow-up. Mixed models were used as method of analysis. RESULTS: Fatigue decreased and physical functioning increased significantly following implemented stepped care (both p < .001). The follow-up was completed by 94 patients (78%) within 1-6 years after treatment. Treatment effects were sustained to follow-up. Patients in the MHC showed less improvement directly following stepped care compared with patients in a CFS specialist centre (p < .01). CONCLUSION: Implemented stepped care for CFS is effective with sustained treatment gains at long-term follow-up. There is room for improvement when compared with outcomes of a CFS specialist centre. Some suggestions are made on how to improve stepped care.

Internet-Based Cognitive Behavioral Therapy in Stepped Care for Chronic Fatigue Syndrome: Randomized Noninferiority Trial.

BACKGROUND: Internet-based cognitive behavioral therapy (I-CBT) leads to a reduction of fatigue severity and disability in adults with chronic fatigue syndrome (CFS). However, not all patients profit and it remains unclear how I-CBT is best embedded in the care of CFS patients. OBJECTIVE: This study aimed to compare the efficacy of stepped care, using therapist-assisted I-CBT, followed by face-to-face (f2f) cognitive behavioral therapy (CBT) when needed, with f2f CBT (treatment as usual [TAU]) on fatigue severity. The secondary aim was to investigate treatment efficiency. METHODS: A total of 363 CFS patients were randomized to 1 of the 3 treatment arms (n=121). There were 2 stepped care conditions that differed in the therapists' feedback during I-CBT: prescheduled or on-demand. When still severely fatigued or disabled after I-CBT, the patients were offered f2f CBT. Noninferiority of both stepped care conditions to TAU was tested using analysis of covariance. The primary outcome was fatigue severity (Checklist Individual Strength). Disabilities (Sickness Impact Profile -8), physical functioning (Medical Outcomes Survey Short Form-36), psychological distress (Symptom Checklist-90), and proportion of patients with clinically significant improvement in fatigue were the secondary outcomes. The amount of invested therapist time was compared between stepped care and TAU. Exploratory comparisons were made between the stepped care conditions of invested therapist time and proportion of patients who continued with f2f CBT. RESULTS: Noninferiority was indicated, as the upper boundary of the one-sided 98.75% CI of the difference in the change in fatigue severity between both forms of stepped care and TAU were below the noninferiority margin of 5.2 (4.25 and 3.81, respectively). The between-group differences on the secondary outcomes were also not significant (P=.11 to P=.79). Both stepped care formats required less therapist time than TAU (median 8 hours, 9 minutes and 7 hours, 25 minutes in stepped care vs 12 hours in TAU; P<.001). The difference in therapist time between both stepped care formats was not significant. Approximately half of the patients meeting step-up criteria for f2f CBT after I-CBT did not continue. CONCLUSIONS: Stepped care, including I-CBT followed by f2f CBT when indicated, is noninferior to TAU of f2f CBT and requires less therapist time. I-CBT for CFS can be used as a first step in stepped care. TRIAL REGISTRATION: Nederlands Trial Register NTR4809; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=4809 (Archived by WebCite at http://www.webcitation.org/74SWkw1V5).

Becoming an eCoach: Training therapists in online cognitive-behavioral therapy for chronic pain.

OBJECTIVE: Online cognitive-behavioral therapy (iCBT) is effective in supporting patients' self-management. Since iCBT differs from face-to-face CBT on several levels, proper training of therapists is essential. This paper describes the development and evaluation of a therapist training based on theoretical domains that are known to influence implementation behavior, for an iCBT for chronic pain. METHODS: The training consists of 1.5 days and covers the implementation domains "knowledge", "skills", "motivation", and "organization", by focusing on the therapy's rationale, iCBT skills, and implementation strategies. Using an evaluation questionnaire, implementation determinants (therapist characteristics, e-health attitude, and implementation domains) and iCBT acceptance were assessed among participants after training. RESULTS: Twenty-two therapists participated, who generally showed positive e-health attitudes, positive implementation expectations, and high iCBT acceptance. Organizational aspects (e.g., policy regarding iCBT implementation) were rated neutrally. CONCLUSIONS: An iCBT therapist training was developed and initial evaluations among participants showed favorable implementation intentions. PRACTICE IMPLICATIONS: Therapists' positive training evaluations are promising regarding the dissemination of iCBT in daily practice. Organizational support is vital and needs to be attended to when selecting organizations for iCBT implementation.

Spousal Assaulters in Outpatient Mental Health Care: The Relevance of Structured Risk Assessment.

This study examined whether a typology of perpetrators of intimate partner violence (IPV) could be replicated in a Dutch sample ( N = 154) of self-referred IPV perpetrators using a structured risk assessment tool for relational violence (Brief Spousal Assault Form for the Evaluation of Risk [B-SAFER]). Our findings support the previous IPV perpetrator subtypes: low-level antisocial (LLA), family only (FO), psychopathology (PP), and generally violent/antisocial (GVA). The subtypes differed on the descriptive dimensions general criminality, substance use, and mental health problems. The prevalence rates for each subtype were roughly comparable with those in previous studies. Contrary to expectation, the prevalence of the GVA subtype was relatively high in our self-referred sample compared with court-referred samples. Our findings suggest that structured risk assessment should be an integral part of the intake procedure for IPV perpetrators entering treatment, to assess their level of risk and to arrive at a tailored risk management strategy, regardless of setting or referral source.

Motivation, treatment engagement and psychosocial outcomes in outpatients with severe mental illness: a test of Self-Determination Theory.

Currently, it is unclear whether Self-Determination Theory (SDT) applies to the mental health care of patients with severe mental illness (SMI). Therefore, the current study tested the process model of SDT in a sample of outpatients with SMI. Participants were 294 adult outpatients with a primary diagnosis of a psychotic disorder or a personality disorder and their clinicians (n = 57). Structural equation modelling was used to test the hypothesized relationships between autonomy support, perceived competence, types of motivation, treatment engagement, psychosocial functioning and quality of life at two time points and across the two diagnostic groups. The expected relations among the SDT variables were found, but additional direct paths between perceived competence and clinical outcomes were needed to obtain good model fit. The obtained process model was found to be stable across time and different diagnostic patient groups, and was able to explain 18% to 36% of variance in treatment engagement, psychosocial functioning and quality of life. It is concluded that SDT can be a useful basis for interventions in the mental health care for outpatients with SMI. Additional experimental research is needed to confirm the causality of the relations between the SDT constructs and their ability to influence treatment outcomes.

Subgroup Analysis in Burnout: Relations Between Fatigue, Anxiety, and Depression.

Several authors have suggested that burned out patients do not form a homogeneous group and that subgroups should be considered. The identification of these subgroups may contribute to a better understanding of the burnout construct and lead to more specific therapeutic interventions. Subgroup analysis may also help clarify whether burnout is a distinct entity and whether subgroups of burnout overlap with other disorders such as depression and chronic fatigue syndrome. In a group of 113 clinically diagnosed burned out patients, levels of fatigue, depression, and anxiety were assessed. In order to identify possible subgroups, we performed a two-step cluster analysis. The analysis revealed two clusters that differed from one another in terms of symptom severity on the three aforementioned measures. Depression appeared to be the strongest predictor of group membership. These results are considered in the light of the scientific debate on whether burnout can be distinguished from depression and whether burnout subtyping is useful. Finally, implications for clinical practice and future research are discussed.

Different Perspectives of Clinicians and Patients with Severe Mental Illness on Motivation for Treatment.

The present study assessed motivation for engaging in treatment as rated by clinicians (n = 57) and patients with severe mental illness (SMI, n = 294) using measures based on three different motivation theories. Questionnaires were derived from self-determination theory, the transtheoretical model and the integral model of treatment motivation. It was investigated to which extent clinicians of patients with SMI were able to estimate their patient's perspective on motivation for engaging in treatment, to which extent they agreed on the patient's motivation and which factors were associated with estimation and agreement on treatment motivation. It was found that clinicians were poorly to moderately capable of estimating their patient's type of motivation and readiness for change. Further, agreement on the level of motivation between patients and clinicians was moderate. These findings were consistent across diagnostic groups (psychotic and personality disorders). A higher quality therapeutic relationship was generally associated with higher clinician-rated motivation. The patient's ethnicity and socially desirable responding were factors that differentiated between scales of different motivation theories. It is concluded that patients with SMI and their clinicians have different perceptions on the patient's motivation for engaging in psychiatric treatment, regardless of the theoretical framework that is used to measure motivation. The findings imply that a negotiated approach is needed where both perceptions of clinicians and patients on motivation for treatment are considered to ensure effective mental health interventions. Copyright © 2015 John Wiley & Sons, Ltd. KEY PRACTITIONER MESSAGE: Clinicians show poor to moderate capability in estimating how patients perceive their motivation for engaging in treatment, especially so when the patient's motives revolve around feelings of shame and guilt. Clinicians generally give higher motivation ratings for patients where they experience a higher quality therapeutic relationships with, whereas-depending on the scale that is used to measure motivation-they give lower ratings to patients who respond in socially desirable ways and to ethnic minority patients. As patients with SMI and their clinicians have different perceptions on the patient's motivation for engaging in psychiatric treatment (regardless of the theoretical framework that is used to assess motivation), this implies that a negotiated approach is needed where both perceptions of clinicians and patients on motivation for treatment are considered to ensure effective mental health interventions.

The effects of motivation feedback in patients with severe mental illness: a cluster randomized controlled trial.

OBJECTIVE: To evaluate the effectiveness of providing clinicians with regular feedback on the patient's motivation for treatment in increasing treatment engagement in patients with severe mental illness. DESIGN: cluster randomized controlled trial (Dutch Trials Registry NTR2968). PARTICIPANTS: adult outpatients with a primary diagnosis of a psychotic disorder or a personality disorder and their clinicians, treated in 12 community mental health teams (the clusters) of two mental health institutions in the Netherlands. INTERVENTIONS: monthly motivation feedback (MF) generated by clinicians additional to treatment as usual (TAU) and TAU by the community mental health teams. PRIMARY OUTCOME: treatment engagement at patient level, assessed at 12 months by clinicians. RANDOMIZATION: teams were allocated to MF or TAU by a computerized randomization program that randomized each team to a single treatment by blocks of varying size. All participants within these teams received similar treatment. Clinicians and patients were not blind to treatment allocation at the 12-month assessment. RESULTS: The 294 randomized patients (148 MF, 146 TAU) and 57 clinicians (29 MF, 28 TAU) of 12 teams (6 MF, 6 TAU) were analyzed according to the intention-to-treat principle. No statistically significant differences between treatment groups on treatment engagement were found (adjusted mean difference =0.1, 95% confidence interval =-2.2 to 2.3, P=0.96, d=0). Preplanned ancillary analyses showed statistically significant interaction effects between treatment group and primary diagnosis on treatment motivation and quality of life (secondary outcomes), which were beneficial for patients with a primary diagnosis of a personality disorder but not for those with a psychotic disorder. There were no reports of adverse events. CONCLUSION: The current findings imply that monitoring and discussing the patient's motivation is insufficient to improve motivation and treatment engagement, and suggests that more elaborate interventions for severe mental illness patients are needed.

Level and appraisal of fatigue are not specific in burnout.

Fatigue is a main feature of the burnout syndrome but also very common in other psychiatric disorders such as major depression and anxiety disorders. This raises the question of whether the level and appraisal of fatigue is experienced differently by individuals suffering from burnout than by those exhibiting anxiety disorders and major depression. If fatigue is experienced differently in burnout compared with other disorders, this may clarify why fatigue is the main feature of the burnout syndrome. This knowledge may lead to the application of specific therapeutic interventions aimed at the experience of fatigue in burnout. In the present study, we investigated whether fatigue is experienced differently in burnout patients than in patients suffering from anxiety disorders or major depression. We presented 73 burnout patients, 67 depressed patients, 57 patients with an anxiety disorder and 127 healthy participants with a rating scale containing statements about the fatigue-performance relationship, and we assessed the level of fatigue, depression and anxiety. The level of fatigue reported by burnout patients was high but did not differ from that of the other patient groups. The appraisal of fatigue also did not differ among the patient groups. The burnout patients did not appraise their fatigue as a result of unrewarding activities nor did they catastrophize fatigue in an exceptional way. Thus, the level of fatigue and the appraisal of fatigue may be less relevant to the understanding of the specific pathological processes associated with burnout than is often presumed.

Measures of motivation for psychiatric treatment based on self-determination theory: psychometric properties in Dutch psychiatric outpatients.

Self-determination theory is potentially useful for understanding reasons why individuals with mental illness do or do not engage in psychiatric treatment. The current study examined the psychometric properties of three questionnaires based on self-determination theory-The Treatment Entry Questionnaire (TEQ), Health Care Climate Questionnaire (HCCQ), and the Short Motivation Feedback List (SMFL)-in a sample of 348 Dutch adult outpatients with primary diagnoses of mood, anxiety, psychotic, and personality disorders. Structural equation modeling showed that the empirical factor structures of the TEQ and SMFL were adequately represented by a model with three intercorrelated factors. These were interpreted as identified, introjected, and external motivation. The reliabilities of the Dutch TEQ, HCCQ, and SMFL were found to be acceptable but can be improved on; congeneric estimates ranged from 0.66 to 0.94 depending on the measure and patient subsample. Preliminary support for the construct validities of the questionnaires was found in the form of theoretically expected associations with other scales, including therapist-rated motivation and treatment engagement and with legally mandated treatment. Additionally, the study provides insights into the relations between measures of motivation based on self-determination theory, the transtheoretical model and the integral model of treatment motivation in psychiatric outpatients with severe mental illness.