Expectancies, working alliance, and outcome in transdiagnostic and single diagnosis treatment for anxiety disorders: an investigation of mediation

Patients’ outcome expectancies and the working alliance are two psychotherapy process variables that researchers have found to be associated with treatment outcome, irrespective of treatment approach and problem area. Despite this, little is known about the mechanisms accounting for this association, and whether contextual factors (e.g., psychotherapy type) impact the strength of these relationships. The primary aim of this study was to examine whether patient-rated working alliance quality mediates the relationship between outcome expectancies and pre- to post-treatment change in anxiety symptoms using data from a recent randomized clinical trial comparing a transdiagnostic treatment (the Unified Protocol [UP]; Barlow et al., Unified protocol for transdiagnostic treatment of emotional disorders: Client workbook, Oxford University Press, New York, 2011a; Barlow et al., Unified protocol for transdiagnostic treatment of emotional disorders: Patient workbook. New York: Oxford University Press, 2017b) to single diagnosis protocols (SDPs) for patients with a principal heterogeneous anxiety disorder (n = 179). The second aim was to explore whether cognitive-behavioral treatment condition (UP vs. SDP) moderated this indirect relationship. Results from mediation and moderated mediation models indicated that, when collapsing across the two treatment conditions, the relationship between expectancies and outcome was partially mediated by the working alliance [B = 0.037, SE = 0.05, 95% CI (.005, 0.096)]. Interestingly, within-condition analyses showed that this conditional indirect effect was only present for SDP patients, whereas in the UP condition, working alliance did not account for the association between expectancies and outcome. These findings suggest that outcome expectancies and working alliance quality may interact to influence treatment outcomes, and that the nature and strength of the relationships among these constructs may differ as a function of the specific cognitive-behavioral treatment approach utilized.This study was funded by grant R01 MH090053 from the National Institutes of Health. (R01 MH090053 - National Institutes of Health)First author draf

Transparency in Complex Computational Systems

Scientists depend on complex computational systems that are often ineliminably opaque, to the detriment of our ability to give scientific explanations and detect artifacts. Some philosophers have s..

Deliberate clinical inertia: Using meta-cognition to improve decision-making

Deliberate clinical inertia is the art of doing nothing as a positive response. To be able to apply this concept, individual clinicians need to specifically focus on their clinical decision-making. The skill of solving problems and making optimal clinical decisions requires more attention in medical training and should play a more prominent part of the medical curriculum. This paper provides suggestions on how this may be achieved. Strategies to mitigate common biases are outlined, with an emphasis on reversing a 'more is better' culture towards more temperate, critical thinking. To incorporate such an approach in medical curricula and in clinical practice, institutional endorsement and support is required

Factors Associated With Perceived Burden, Resourcefulness, and Quality of Life in Female Family Members of Adults With Serious Mental Illness

BACKGROUND: Each year, 54 million American adults are affected by serious mental illness. Most of these persons depend on female family members for support or assistance, and unless these women are resourceful, they may experience considerable burden, stigma by association, depressive thoughts, and poor quality of life. OBJECTIVE:In this study, we examined the associations between characteristics of female family members (age, race, education), adults with serious mental illness (age, diagnosis), and the family situation (relationship, living arrangements, care provided) and caregivers\u27 burden, stigma, depressive cognitions, resourcefulness, and quality of life.STUDY DESIGN:In this descriptive, cross-sectional study, a convenience sample of 60 female relatives of adults with serious mental illness provided demographic information and completed established measures of the study variables.RESULTS:We discuss associations between contextual variables and process regulators, resourcefulness, and quality of life.CONCLUSIONS:The results highlight the importance of targeting interventions for caregivers of adults with serious mental illness who are parents, caregivers of younger seriously mentally ill persons in earlier stages of diagnosis, and caregivers of persons who have bipolar disorde

ADHD and College Students: Experiencing an Illness Career

This study examines one particular example of an illness career in a sociologically important yet understudied population: university students who have been diagnosed with Attention Deficit Hyperactivity Disorder (ADHD) and certified as eligible for support services by a university clinic. Most adults in America have visited a physician at least once in their lifetime. In our culture this is a regular, taken-for-granted activity for those who feel sick. But how does someone arrive at the decision to seek expert medical help? Sociological researchers have demonstrated that this process is actually quite complex, involving a series of decision-making steps that together can be analyzed as stages in an "illness career." Using qualitative interviews, I examined the experiences and processes that ADHD students pass through. I use the ideas of the sick role, illness career and gatekeeper to inform my results. Through my analysis, I have created a model for the illness career that contrasts with the traditional linear stages by viewing the different aspects of the career as intertwined. Regarding ADHD, I discovered that this disorder shifts from being other-diagnosed to self-diagnosed as a student progresses through the educational system. I also add insight to structural responses, and to the living experience of the ADHD diagnosed individual

The Assessment of Clinical Reasoning in Preceptors Across the Athletic Training Profession

Clinical reasoning (CR) is defined as a complex multi-factorial metacognitive process for diagnosis formulation. Clinical reasoning begins as a student and develops over a career. Students are typically taught an analytical approach defined as hypothetico-deductive reasoning (HDR). Expert clinicians use a non-analytical approach defined as the Knowledge Based Model (KBM) of CR. It is accepted that clinicians use the KBM with cases that they have more experience to streamline the evaluation process. Unfortunately, because of the nuance of CR there have been limited investigations within athletic training to evaluate CR outside of the student population. The overarching purpose of this dissertation was to investigate CR in athletic training preceptors. To achieve this purpose, three interrelated projects were conducted. The first project involved a systematic review to investigate the use of the Diagnostic Thinking Inventory (DTI). The second project assessed clinical reasoning using the Diagnostic Thinking Inventory for Athletic Trainers (DTI-AT) in athletic training preceptors. The second project was guided by the Longitudinal Framework for Fostering Critical Thinking and Diagnostic Reasoning to establish appropriate demographic questions associated with CR development. The final project explored preceptors’ perceptions of CR in athletic training. The systematic review confirmed that the DTI was a valid, reliable, and widely used instrument to assess CR in healthcare professions. The instrument was used in medicine, physiotherapy, and athletic training. Project II indicated that the athletic training preceptors studied scored higher on the DTI than the averages of all other professions assessed in the literature, however, all other professions included both students and professionals. Professional sociability was found to be the only demographic factor related to higher scores on the DTI-AT. This finding contrasted with the Longitudinal Framework for Fostering Critical Thinking and Diagnostic Reasoning. Project III identified that CR processes in athletic training are highly variable between individual clinicians based on their experiences, confidence, patients, and external factors. Findings from these three projects indicate the importance of continued CR assessment of athletic training professionals, inclusion of soft skills in athletic training education, and encouraging professional sociability both inter- and intraprofessionally