Occupational therapists' experiences of photo-supported conversations - An intervention in primary health care.

BACKGROUND: The health-promoting intervention BeWell™, which includes photo-supported conversations, is intended for people with stress-related illnesses. Its focus is on improving the individual's health and well-being by addressing what contributes to well-being from the patient's own perspective. There is no current knowledge of the experiences of occupational therapists of using BeWell™ in primary health care. It is thus important to gain knowledge of their experiences of using this intervention as part of investigating its feasibility. AIM: To describe the occupational therapists' experiences of photo-supported conversations about well-being (BeWell™) with patients diagnosed with stress-related illnesses. MATERIAL AND METHODS: Six occupational therapists, working in primary health care, who had conducted the photo-supported conversations about well-being (BeWell™), were interviewed individually, and one focus group discussion was also conducted. Systematic text condensation was used as the analysis method. RESULTS: Three main themes with two to three subgroups in each were identified; Discovering well-being through images, Enhancing patient's own efforts towards well-being, and Contributing to one's own well-being. CONCLUSIONS AND SIGNIFICANCE: The results provide important knowledge for the continued research work with BeWell™ by investigating how the users of the intervention experienced it.

The Impact of Mental Imagery Instructions on Patients' and Therapists' Positive Affect and Strength-Based Behaviours Within Psychotherapy Sessions: A Randomized Controlled Process Study.

OBJECTIVE: Increased attention has recently been paid to the well-being and flourishing of patients in psychotherapy. This study investigated the occurrence of positive affect (PA) and strength-based behaviours within psychotherapy sessions contrasting positive versus neutral imagery instructions. METHODS: This is a secondary analysis of a randomized controlled trial. Seventy-eight sessions of cognitive behavioural therapy involving 26 patients (69.23% female; Mage = 40.31) treated by 13 therapists were selected. PA and strength-based behaviours of patients and therapists were coded on a minute-by-minute basis with the Resource-Oriented Microprocess Analysis. Each session started with a brief mental imagery instruction. Data were analysed using multilevel modelling. RESULTS: Mild levels of PA were very common, whereas stronger expressions were occasional, especially at the beginning and end of sessions. Strength-based behaviours were employed in one-fifth of the videos analysed. Therapists in the positive imagery instruction showed more strength-based behaviours in the beginning phase of sessions, p < 0.05. The two imagery instructions significantly differed in the session trajectories of PA, p < 0.05. A quadratic trend with higher initial values and a sharper decline in PA were found in the positive instruction, whereas the neutral instruction showed a flatter trend. CONCLUSION: Patients and therapists experience PA and discuss strengths in psychotherapy sessions despite patients' distress. The positive imagery instructions potentially induced a positive focus at baseline for therapists but had a negligible effect on the subsequent session progression. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT03767101 (registered December 6, 2018).

Cortisol Synchrony in Psychotherapy for Major Depressive Disorder.

INTRODUCTION: Accumulating research emphasizes the role of interpersonal coordination in arousal levels, which may manifest as cortisol synchrony, in interpersonal interactions. While the role of cortisol has been investigated in psychotherapy, cortisol synchrony and its characteristics and effect on treatment progress remain a relatively unexplored area. This study aims to explore the existence of distinct patterns of cortisol coordination throughout psychotherapy and test the associations of different coordination patterns with patients' pre-treatment characteristics and treatment progress measures. METHODS: Fifty patient-therapist dyads participated in 16 weeks of psychodynamic treatment for major depressive disorder. Salivary cortisol samples were collected before and after each session at four time points. Self-report questionnaires and treatment session video-coding were used to characterize and differentiate between patterns of cortisol coordination. RESULTS: Three patterns of cortisol coordination were identified: synchronized, unsynchronized and stable-therapist. These patterns differed in patient characteristics and treatment progress measures in that patients exhibiting a synchronized pattern tended to be more anxious and dominant in their relationships and were more prone to withdrawal ruptures. CONCLUSIONS: Results provide novel evidence regarding variability in patient-therapist cortisol patterns and its putative associations with treatment progress.

Exploring the experience of working relationships for support workers of adults with intellectual disabilities.

BACKGROUND: Research suggests that a better awareness of how staff who directly support people with intellectual disabilities experience their working relationships, will contribute to understanding staff wellbeing and the quality of care they offer. This study aimed to gain insights into the lived experiences of support workers in supported living services in England. METHOD: Six support workers participated in semi-structured interviews, about their working relationships with service-users and colleagues. Data was analysed using interpretative phenomenological analysis. RESULTS: Six interconnected themes emerged: The essence of good relationships; a trusting relationship as the vehicle for meeting service-users' needs; belonging to the support team; the organisational context of relationships; the social context of relationships; 'a fine balancing act'. CONCLUSIONS: The findings provide insights into staff wellbeing, indicating that developing supportive, trusting relationships with both service-users and colleagues, plays an important role in delivering effective care. Potential implications for service providers are discussed.

The Impact Message Inventory-Circumplex (IMI-C): Exploring the Aversiveness Component of Therapists' Covert Reactions to Patients' Interpersonal Communications.

The Impact Message Inventory-Circumplex (IMI-C) is a two-dimensional measure of patient-induced countertransference. Surprisingly, in a replication study of its circumplex structure, Hafkenscheid and Timmerman could retrieve a third dimension, in addition to the basic dimensions of Affiliation and Control. They tentatively interpreted this preliminary third dimension as representing 'reactance' (oppositional and uncooperative patient behaviours), with 'active' and 'passive' as polarities. This provisional interpretation was no more than plausible and was partly speculative. Therefore, a more systematic empirical approach to the meaning embedded in the third dimension is required. The present empirical study tests the hypothesis that the preliminary third dimension might represent aversiveness rather than reactance. A panel of IMI-C users (N = 100) independently judged all 56 items of the instrument in terms of the general (i.e., without taking a specific patient in mind) emotional undertone enclosed in the item formulations using a forced choice three point scale format: 'positive emotional undertone' (+), 'neutral' (o) and negative (aversive) undertone (-). Overall, IMI-C users appeared to evaluate the formulations of items constituting the preliminary third dimension as intrinsically more aversive (negative emotional connotation), compared to the group of IMI-C items not included in this preliminary third dimension. However, the original octants of the IMI-C could be discriminated in terms of aversiveness as well. Anyhow, clinical interpretations of IMI-C profiles may benefit from an examination of the aversiveness component, enclosed within the items and octants themselves, irrespective of the specific patients judged with the instrument.

Experiencing pregnancy in the context of lupus and antiphospholipid syndrome: a grounded theory.

OBJECTIVE: To understand the meanings attributed to pregnancy in the context of Lupus and antiphospholipid syndrome by women and healthcare professionals. METHOD: Qualitative research, using Symbolic Interactionism as a theoretical framework and Grounded Theory, a constructivist perspective. Data were collected between January and August 2022, through online interviews with 27 women with Lupus located on the social network Facebook and in-person or remote interviews with 12 healthcare professionals. RESULTS: The theoretical model constructed has two categories: "Equal conditions, distinct experiences: experiencing the gestational process" shows that obstetric complications and lack of connection with healthcare professionals trigger negative meanings to the experience; and "Therapeutic management interfering in the attribution of meanings to the experience", demonstrates that the way women interact with healthcare professionals and how they manage treatment favors a positive reframing. FINAL CONSIDERATIONS: The meanings attributed to pregnancy are elaborated and modified according to the interpretation of previous and current experiences, healthcare trajectory and interactions with healthcare professionals. Previous guidance, planning, bonding and trust in healthcare professionals enable positive meanings, while obstetric complications, unqualified assistance and lack of bonding with professionals provide negative meanings.

Impacts of Clinical Decision Support Systems on the Relationship, Communication, and Shared Decision-Making Between Health Care Professionals and Patients: Multistakeholder Interview Study.

BACKGROUND: Clinical decision support systems (CDSSs) are increasingly being introduced into various domains of health care. Little is known so far about the impact of such systems on the health care professional-patient relationship, and there is a lack of agreement about whether and how patients should be informed about the use of CDSSs. OBJECTIVE: This study aims to explore, in an empirically informed manner, the potential implications for the health care professional-patient relationship and to underline the importance of this relationship when using CDSSs for both patients and future professionals. METHODS: Using a methodological triangulation, 15 medical students and 12 trainee nurses were interviewed in semistructured interviews and 18 patients were involved in focus groups between April 2021 and April 2022. All participants came from Germany. Three examples of CDSSs covering different areas of health care (ie, surgery, nephrology, and intensive home care) were used as stimuli in the study to identify similarities and differences regarding the use of CDSSs in different fields of application. The interview and focus group transcripts were analyzed using a structured qualitative content analysis. RESULTS: From the interviews and focus groups analyzed, three topics were identified that interdependently address the interactions between patients and health care professionals: (1) CDSSs and their impact on the roles of and requirements for health care professionals, (2) CDSSs and their impact on the relationship between health care professionals and patients (including communication requirements for shared decision-making), and (3) stakeholders' expectations for patient education and information about CDSSs and their use. CONCLUSIONS: The results indicate that using CDSSs could restructure established power and decision-making relationships between (future) health care professionals and patients. In addition, respondents expected that the use of CDSSs would involve more communication, so they anticipated an increased time commitment. The results shed new light on the existing discourse by demonstrating that the anticipated impact of CDSSs on the health care professional-patient relationship appears to stem less from the function of a CDSS and more from its integration in the relationship. Therefore, the anticipated effects on the relationship between health care professionals and patients could be specifically addressed in patient information about the use of CDSSs.

Sexual Orientation Microaggression Rating Scale (SOMRS): Development and association with alliance ruptures.

Sexual minority clients report experiencing frequent microaggressions during therapy, however, therapists may not recognize those microaggressions or may be reluctant to self-report them. The main aim of the present study was thus to develop an observational measure of in-session therapist-committed microaggressions related to the sexual orientation of sexual minority individuals (e.g., those who identify as lesbian, gay, bisexual, or queer). The present study further examined the association between therapist-committed sexual orientation microaggressions and ruptures in the therapeutic alliance. We hypothesized that clinically significant microaggressions would be positively associated with withdrawal ruptures in the alliance. The sample consisted of 44 gay and bisexual men who participated in a cognitive behavioral treatment designed to reduce depression, anxiety, human immunodeficiency virus-transmission-risk behaviors, and substance use. An observer-based coding measure designed for this study, the Sexual Orientation Microaggression Rating Scale (SOMRS), was utilized to capture sexual minority microaggressions in the initial sessions of treatment. Good interrater reliability was achieved for the SOMRS. Microaggressions were coded in 34% of the sessions. Within the subset of sessions with coded microaggressions, a significant association was found between withdrawal ruptures and microaggression significance ratings. The SOMRS holds potential for supporting research on microaggression as well as future efforts to help clinicians recognize and repair in-session behaviors that negatively impact sexual minority clients. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Psychoanalysis and the Experience of Homelessness.

Psychoanalysis is often viewed as a practice relevant only to educated people of means. This article describes a project that matches psychoanalytically trained clinicians with unhoused and formerly unhoused adults in a large urban community. D. W. Winnicott's ideas about impingement, the holding environment, fear of breakdown, and careful monitoring of the analyst's interiority have proven to be most valuable theoretical and clinical tools. A decade-long case example demonstrates the challenges and healing potentials of the work.

Wondering and Wandering: In Defense of Free Association and the Fundamental Rule.

"Free association" and the "fundamental rule" are bedrock for psychoanalytic therapy and apply to what both patient and analyst should experience in the process. The article traces Sigmund Freud's revolutionary recognition of the importance of free association that began with his tribute to the works of Ludwig Börne and Friedrich Schiller. The author invokes other proposals akin to free association made by artists and scientists, including John Keats, Charles Dickens, Robert Frost, Thomas S. Kuhn, Arthur Koestler, and Albert Einstein. While emphasizing the importance and the liberatory potential of free association as it relates to effective treatment and discovery, the author contends that there is a "moral press" for both the patient and the analyst to permit free associative thoughts, particularly to question assumptions about how things are supposed to be.

Impact of racial microaggressions in psychotherapy vignettes with african american clients: An experimental analogue design.

Mental health researchers have focused on promoting culturally sensitive clinical care (Herman et al., 2007; Whaley & Davis, 2007), emphasizing the need to understand how biases may impact client well-being. Clients report that their therapists commit racial microaggressions-subtle, sometimes unintentional, racial slights-during treatment (Owen et al., 2014). Yet, existing studies often rely on retrospective evaluations of clients and cannot establish the causal impact of varying ambiguity of microaggressions on clients. This study uses an experimental analogue design to examine offensiveness, emotional reactions, and evaluations of the interaction across three distinct levels of microaggression statements: subtle, moderate, and overt. We recruited 158 adult African American participants and randomly assigned them to watch a brief counseling vignette. We found significant differences between the control and three microaggression statements on all outcome variables. We did not find significant differences between the microaggression conditions. This study, in conjunction with previous correlational research, highlights the detrimental impact of microaggressions within psychotherapy, regardless of racially explicit content. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

The interplay between patients and healthcare professionals in a cross-sectoral setting in connection with the treatment and care of patients with diabetic foot ulcers: a realistic evaluation.

BACKGROUND: Diabetes-related lower extremity complications such as diabetic foot ulcer (DFU) are a global disability burden. Treatment and care for patients with DFU call for a multisectoral approach that incorporates interdisciplinary care pathways. We aimed to explore the interplay between patients with DFU and healthcare professionals in cross-sectoral settings that address treatment and care and to determine "what works, for whom, and under what circumstances". METHOD: The study was designed as a realistic evaluation. The data were generated from September 2022 to March 2023 and drew upon approximately 60 h of participant observation of 14 patients during the treatment and care of DFUs in their homes (primary care) and/or at outpatient clinics (wound specialist clinics in a hospital setting) in a Danish cross-sectoral setting. The Standards for Reporting Qualitative Research (SRQR) were applied in this study. RESULTS: We identified three illuminating themes that described the interplay between patients with DFU and related healthcare professionals representing both primary and secondary health care systems: (1) humour is a relationship-enhancing element between nurses and patients; (2) support from patients' coping strategies promotes patient-centeredness and collaboration; and (3) patients and professionals occupy unnegotiated identity roles. CONCLUSION: Our study led to a refined programme theory developed through the realistic evaluation process that allows us to propose an answer to the problem of "what works, for whom, and under what circumstances". The interplay between patients with DFU and healthcare professionals in a cross-sectoral setting for treatment and care is characterised by the use of humour as a relation-enhancing element and by improving support for patient coping strategies, which encourages healthcare professionals to promote health literacy. Future research should examine strategies for negotiating identity roles between patients with DFU and healthcare professionals to enhance collaboration, patient health literacy, and health promotion in cross-sectoral healthcare settings.

Perspectives of healthcare professionals and people living with HIV in dialogue: on information sharing to improve communication at the consultation.

We report on a qualitative Group Survey study involving four healthcare professionals (HCPs) and eight people living with HIV who were recipients of care in the United Kingdom (UK). The survey aimed to bring participants' perspectives into dialogue and establish consensus about how communication between HCPs delivering HIV care and their patients could be improved in the context of the routine care consultation. Responses from both parties were anonymously collated, thematically analysed, and shared back with participants in two subsequent survey rounds to support consensus-building on matters of concern and identify thematic insights. In this paper, we report three themes for informing future designs of tools and services to support communication between patients and HCPs: Patient-clinician relationship for trusted sharing; Self-reporting psychosocial information to support Whole-person care; and Perceived barriers for online trusted sharing with HCPs. Our findings highlight key areas of concern and further investigation is needed to understand how self-reported information may be meaningfully captured, interpreted and processed by HCPs in ways that are trusted by patients who voice privacy and security concerns.

Healthcare professionals' perceptions of challenges in vaccine communication and training needs: a qualitative study.

BACKGROUND: Healthcare professionals (HCPs) can play an important role in encouraging patients and their caregivers to be vaccinated. The objective of this qualitative study was to investigate HCPs' perspectives on challenges in vaccine communication and unmet training needs in this domain. METHODS: Semi-structured interviews were conducted with 41 HCPs (mainly nurses and physicians) with vaccination roles (23 in England; 18 in France), gathering information on: (1) HCPs' approach to vaccine conversations with patients; (2) Challenges of communicating about vaccines; (3) Vaccine-related training and learning resources available to HCPs, and; (4) HCPs' training needs around vaccine communication. RESULTS: HCPs described a range of communication experiences that indicated insufficient time, information, and skills to confidently navigate difficult conversations with vaccine-hesitant patients. Communication skills were especially important to avoid conflict that could potentially damage the patient-provider relationship. Some HCPs interviewed had received communication training, but for most, this training was not specific to vaccination. Although general communication skills were transferable to vaccine conversations, most HCPs welcomed specific training and informational resources to support countering patients' misconceptions or misinformation about vaccines. CONCLUSIONS: HCPs would benefit from training tailored to address vaccine communication with patients, and this should be part of a systemic approach that also provides time and space to have effective vaccine conversations.

Playing, Paradox, and Analytic Activity Between Knowing and Being.

The author explores some ways that we help patients to hold paradoxical realities intrinsic to transference and play in analytic work. He suggests that Winnicott's guardianship of the setting for the emergence of playing raises questions about the role of neutrality in an ontological analysis. The author tries to demonstrate some ways that the work of helping patients to hold paradox in play overlaps with a concept that he has earlier referred to as an activity of neutrality. He explores how in the analytic process, understanding and being are two dimensions of the analytic process that work in concert with each other. Often the analyst works quietly in spaces between epistemological and ontological approaches in the holding of paradox.

Perceptions of patient-provider communications with healthcare providers among sexual and gender minority individuals in the United States.

OBJECTIVES: To identify perceived differences in the key domains of patient-provider communications between sexual and gender minority (SGM) and non-SGM patients. METHODS: We reviewed data from the Health Information National Trends Survey (HINTS) to assess patient perspectives on different domains of patient-provider communications in the ideological framework by Epstein and Street (2007) [1]. Between SGM-identified (N = 491) and cisgender, heterosexual respondents (N = 7426), we assessed the proportions of responses to survey questions about the six domains of patient-provider communications and calculated odds ratios (OR) with 95 % confidence intervals (CI) (N = 7917). RESULTS: Overall, compared to cisgender, heterosexual individuals, fewer SGM individuals reported always experiencing optimal patient-provider communications across all domains, most notably in areas of emotional support (OR=0.70, 95 % CI: (0.51, 0.97)), patient self-management (OR=0.73, 95 % CI: (0.54, 0.99)), and managing uncertainty (OR=0.68, 95 % CI: (0.49, 0.94)). CONCLUSION: Further research on detailed SGM patient perceptions of their relationships with healthcare providers is needed to understand why such differences in communication exist and provide practical recommendations to improve care delivery. PRACTICE IMPLICATIONS: SGM patients perceive their current provider communications to be suboptimal, so we must improve emotional management training in future provider-based SGM competency trainings and encourage patient self-management during individual provider encounters.

Good-enough Care? How Patients' Perceptions of Counselors' Professional Skills Relate to Everyday Life in Forensic Long-stay Units.

The overall goal of long-term forensic care is to strive toward acceptable levels of adaptation and quality of life (QoL) of the forensic patient in the institutional context. While the bulk of the literature has focused on the deleterious consequences of personality pathology in this regard, research investigating the contribution of the quality of the therapeutic relationship has remained rather scant. Assuming that the perceived competence of the direct counselor, as perceived by patients, forms an important aspect in this regard, the central aim of this study was to investigate the relationship between patients' perceptions of their therapist's professional skills, their self-reported maladaptive behavior on the ward, and their experienced QoL. To this end, we recruited patients (N = 60) in long-stay forensic units and investigated their perceptions of 10 specific skills displayed by their therapist, along a "too little-too much" rating scale. The results revealed that patients who had the overall impression that their counselor was equipped with an adequate set of professional skills showed less maladaptive behavior and perceived a higher QoL on the ward. Conversely, at a more specific competence level, only a positive relationship between a counselor's predictability and self-reported QoL was found. Taken together, these results highlight that an overall professional skill evaluation matters in the context of forensic patients' adaptation and QoL in their long-stay units, with the counselor's predictability serving as a crucial aspect in obtaining the most favorable outcomes.

Healthcare Providers' Resilience Communication: A New Type of Patient-Centered Communication.

Patient-centered communication (PCC) is considered a key component of quality healthcare, with reported levels of PCC rising over the last decade. However, engagement with patient emotions and uncertainty have been slower to rise, and healthcare providers at times use PCC behaviors to manipulate patients. Healthcare providers' use of the communication theory of resilience's (CTR) processes could benefit patients. A cross-sectional survey in the United States (N = 486) tested associations between CTR processes and patient satisfaction and perceived physical and mental health. All five core CTR processes were positively correlated with patient outcomes. When controlling for traditional PCC behaviors: (a) crafting normalcy, identity anchors, and alternative logics were positively related to patient satisfaction, (b) no processes were related to perceived mental health, and (c) communication networks, alternative logics, and productive action were positively related to perceived physical health. Condition severity moderated three associations. At moderate-high severity, crafting normalcy and communication networks were positively related to perceived mental health, and crafting normalcy was positively related to perceived physical health. Findings extend CTR into the patient-provider relationship and demonstrate the practical potential of CTR processes for improving patient outcomes. The study also forwards a measure of healthcare provider resilience communication (HPRC).

Integrating the Principles of Academic Freedom and Patient-Centered Care to Promote Tolerant Listening Skills in Health Care Providers.

ABSTRACT: Collaboration is a vital skill that needs to be developed in health professions students. Developing tolerance for differing viewpoints and valuing an understanding of others' lived experiences are instrumental skills in learning to provide patient-centered care. Fostering the expression of diverse viewpoints and working through uncomfortable and distressful situations are a part of the experience in acquiring these skills. It is the educator's duty to facilitate these encounters in a way that upholds the tenants of academic freedom and civility to create optimal educational outcomes. Doing so creates opportunities for transformative learning and the facilitation of higher cognitive development when compared with the avoidance of exposing students to divergent viewpoints. It is through freedom of discussion that one must teach students that ultimately the pursuit of truth, even when it may be unwelcome, disagreeable, or deeply offensive, greatly outweighs the discomfort the process of discovering it may bring.

A relational approach to youth healthcare: Examining young people's, parents' and clinicians' experiences in the context of variations in sex characteristics.

According to popular understandings, children grow from a state of dependence to eventually become independent adults. Interdependence helps to disrupt the in/dependence binary and is a useful concept for making sense of the experiences young people with variations in sex characteristics in relation to healthcare. This study used semi-structured interviews with 32 health professionals, 33 caregivers and 12 young people recruited in the UK and Sweden. The analysis is guided by the questions: (1) how do young people, carers and health professionals position themselves in the adult/young person relationship in the context of healthcare? (2) how is the (in/ter)dependence of young people imagined when young people, carers and health professionals talk about healthcare? Our analysis shows how carers and health professionals might support dominant understandings about young people growing towards independence while providing little opportunity for young people's agency and voice. Interviews with young people gave clear examples of their negotiating relational ways of being, seeking agency in the context of healthcare and not simply becoming independent of adults. This analysis also draws attention to the ways young people might be silenced within healthcare contexts. The present paper is based on secondary analysis of data from the SENS. It works with concepts of relationality and interdependence to draw out the possibilities of voice and agency for young people with variations in sex characteristics in healthcare contexts.