Motivatie voor psychotherapie : een empirische verkenning

In het voorstadium van dit onderzoek, nl. tijdens het genereren en het formuleren van de onderzoeksvraag, werd als onderwerp overwogen: indicatiestelling voor psychotherapie. Hoe komt een beslissing tot stand om voor een patiënt al dan niet psychotherapie te indiceren? Wij zijn echter van deze vraagstelling afgestapt, vooral doordat deze te weinig ingeperkt is. Wij hebben ons gericht op een onderwerp dat een of meer essentiële ingrediënten met betrekking tot indicatiestelling voor psychotherapie omvat. Dit bleek niet moeilijk te zijn, als men uitgaat van de stelling dat positieve motivatie van de patiënt voor therapie een belangrijke voorwaarde is voor een succesvolle behandeling (zie onder meer Appelbaum, 1972; Sifneos, 1972; Strupp, 1972; Meltzoff en Kornreich, 1970). Derhalve hebben wij patiënts motivatie voor psychotherapie als onderwerp van deze studie gekozen. Motivatie manifesteert zich in de interactie tussen therapeut en patiënt en de therapeut verdisconteert zijn oordeel over de motivatie van de patiënt in de indicatiestelling. In dit onderzoek gaan wij uit van de therapeut als informatiebron. Het onderzoek is erop gericht zicht te krijgen op het construct "motivatie" voor psychotherapie; daarbij worden de factoren opgespoord die een rol spelen in de oordeelsvorming van de therapeut betreffende de motivatie van de patiënt. Deze tweeledige doelstelling kan niet stringent worden aangehouden, omdat niet altijd vaststaat of een bepaalde variabele als een indicator fungeert of dient te worden beschouwd als een eperationalisatie van het construct "motivatie". Na de literatuur over motivatie voor psychotherapie te hebben verkend, is ons gebleken dat in empirisch-psychologisch opzicht het onderzoeksterrein relatief onbetreden is. Om dit terrein op systematische wijze te ontginnen, richten wij ons op·het opsporen van relevante factoren en het empirisch schatten van het gewicht van deze factoren met betrekking tot het oordeel van de therapeut over motivatie; inherent hieraan is de bepaling van de structuur c.q. complexiteit van desbetreffende factoren. In concrete termen geformuleerd: therapeut A vindt een bepaalde patiënt gemotiveerd voor therapie omdat deze denkt in termen van psychologische problemen, therapeut B vindt een patiënt gemotiveerd indien hij zich wil houden aan de voor hem noodzakelijke en gewenste voorwaarden voor therapie, therapeut C acht een patiënt gemotiveerd vanwege de (hoge) lijdensdruk. Enkele voorbeelden van een negatief oordeel over motivatie zouden kunnen zijn: patiënt X wil (eigenlijk) alleen een medicamenteuze behandeling terwijl hij bovendien moeite heeft om actief tijdens de behandeling mee te werken, patiënt Y heeft als zijn wens (impliciet of expliciet) te kennen gegeven dat de therapeut bepaalde moeilijke beslissingen fiatteert, terwijl hij bovendien weinig vertrouwen in de therapiemethode heeft. Het onderzoek is voornamelijk verkennend van karakter. Het leek daarom gewenst het onderzoek te doen plaatsvinden in een klein aantal psychotherapeutische instituten met het doel na te gaan hoe het er in de dagelijkse praktijk aan toegaat. Dit impliceert dat er geen hypothesen zullen worden getoetst. De kern van het onderzoek draait in feite om de beantwoording van de vraag: Kunnen er factoren worden aangewezen welke van belang zijn in het oordeel van de therapeut dat een bepaalde patiënt gemotiveerd dan wel ongemotiveerd voor psychotherapeutische behandeling is

Predictability of psychic outcome for exercise training and exercise training including relaxation therapy after myocardial infarction

Abstract Predictability of the psychic outcome for two cardiac rehabilitation programmes was investigated in 119 myocardial infarction patients. They were randomly assigned to either a five-week daily exercise training or to an identical training in combination with six sessions of relaxation therapy, individually. The psychic outcome was constructed as a composite measure of change on six psychological questionnaires. The aim was to determine the predictive qualities of base-line: (1) clinical data; (2) exercise testing; (3) psychosocial information derived from interview; and (4) validated psychological questionnaires and whether the kind of rehabilitation programme has any influence on the predictive qualities of the variables. The psychic outcome turned out to be highly predictable (multiple correlation of 0.72). Predictors of relatively high importance were age, work-status and job-level, followed by mild heart failure, diastolic blood pressure and heart rate, all of them dependent upon the kind of treatment. It implies that the type of rehabilitation programme modified the effect of the determinants of psychic outcome. This research strategy is promisi

Shortening the State-Trait Anxiety Inventory

Abstract Questionnaires that are used in studies with severely ill patients should be as short as possible. Abridged versions of existing inventories are very practical in these instances. The answers of 444 subjects in three samples (cancer patients, medical students, surgical patients) were used to investigate the possibility of constructing short and reliable versions of the scales of the State and Trait Anxiety Inventory. A stepwise regression procedure showed the possibility to reliably predict the total score of the unabridged versions by means of weighted sums of eight items for each scale. Omission of weights did not lead to substantial loss of information. Cronbach's α of the State-scale decreased from 0.93 to about 0.85 for different combinations of items and from 0.91 to about 0.82 for combinations of eight items of the Trait-scale. The relationship between both scales was only slightly modified by the shortening procedure

Construction of a parent satisfaction instrument: Perceptions of pediatric intensive care nurses and physicians

Purpose: The aims of the study were (1) to identify parental satisfaction items through the opinions of pediatric intensive care unit (PICU) nurses and physicians, (2) to reach consensus on the identified items, and (3) to apply factor analysis to evaluate the items and domains toward a PICU parental satisfaction instrument. Materials and Methods: Pediatric intensive care unit nurses and physicians working in 8 university hospitals in the Netherlands participated. A 2-round Delphi method was completed. Confirmatory factor analysis was performed on the satisfaction items and domains. Results: Three hundred two nurses and 62 physicians participated in the Delphi study, and 269 (76%) completed 2 questionnaire rounds. In Delphi round 2, 14 of the 78 items had a mean of less than 8.0 (range, 1 [low importance] to 10 [high importance]). The interquartile range of all domains decreased by almost half, and only 10 satisfaction items had a heterogeneity of less than 70%. Structure determination revealed that 4 satisfaction items needed to be excluded. Out of 74 satisfaction items, 72 showed factor loadings greater than 0.50. The reliability estimates, Cronbach α, for the 6 domains varied from 0.74 to 0.92. Conclusions: Priorities in parental satisfaction measures are identified. The findings are fundamental in the development of a PICU parental satisfaction instrument

Perceptions of parents, nurses, and physicians on neonatal intensive care practices

OBJECTIVE: To identify satisfaction with neonatal intensive care as viewed by parents and healthcare professionals and to explore similarities and differences between parents and healthcare professionals. STUDY DESIGN: A 3-round Delphi method to identify neonatal care issues (round 1) and to determine the importance of these issues (rounds 2 and 3) was conducted among nurses (n = 84) and physicians (n = 14), followed by an exploratory survey among parents (n = 259). Main outcome measures were 92 neonatal care-related items. RESULTS: Sixty-eight nurses and 13 physicians completed all 3 rounds. The first round yielded 419 neonatal care related statements, which were clustered into 92 items. The survey was completed by 148 (57%) parents. Parents rated 25 of 92 care items significantly higher than did the professionals (effect size of Cohen's d, 0.31 to 1.14, P <or= .02). Two items related to medication administration had the largest effect size. Professionals rated 7 items significantly higher than didparents (Cohen's d, -0.31 to -0.58, P <or= .04). One of these was assigning a physician and a nurse to the parents. Three were related to multicultural care. CONCLUSIONS: This study revealed disparities between parents and neonatal intensive care unit staff on a number of care issues reflecting incongruity in rec

A critical analysis of the utility and compatibility of motivation theories in psychiatric treatment

The TransTheoretical Model (TTM), Self-Determination Theory (SDT), and the Integral Model of Treatment Motivation (IM) provide distinct but not incompatible conceptualisations of motivation. We discuss the utility of these theories as a basis for the improvement of psychiatric treatment engagement and treatment outcomes in patients with severe mental illness. It appears that all three theories have gained support for their predictions of outcomes in patients with severe mental illness, but important questions remain unanswered, such as which of these theories provides the best prediction of treatment engagement and treatment outcomes. We explain how these three theories could complete each other, based on their strong and unique assets. It is imperative that the theories are empirically tested and compared to confirm their utility, and to this end we propose several important research questions that should be addressed in future research. Theory comparisons can advance what is currently known about intrapersonal changes and interpersonal differences in treatment engagement and outcomes in severely mentally ill patients

Assessing nonacceptance of the facial appearance in adult patients after complete treatment of their rare facial cleft

Background Treatment of patients with severe congenital facial disfigurements is aimed at restoring an aesthetic and functional balance. Besides an adequate level of satisfaction, an individual's acceptance of facial appearance is important to achieve because nonacceptance is thought to lead to daily psychological struggles. This study objectified the prevalence of nonacceptance among adult patients treated for their severe facial clefts, evaluated risk factors, and developed a screening tool. Methods The study included 59 adults with completed treatment for their severe facial cleft. All the patients underwent a semistructured in-depth interview and filled out the Body Cathexis Scale. Results Nonacceptance of facial appearance was experienced by 44 % of the patients. Of the nonaccepting patients, 72 % experienced difficulties in everyday activities related to their appearance versus 35 % of the accepting patients. Acceptance did not correlate with objective severity or bullying in the past. Risk factors for nonacceptance were high self-perceived visibility, a troublesome puberty period, and an emotion-focused coping strategy. Also, the presence of functional problems was shown to be highly associated. Conclusions The objective severity of the residual deformity did not correlate with the patients' acceptance of their facial appearance, but the self-perceived visibility did correlate. The process of nonacceptance resembles the process seen in patients with body dysmorphic disorders. Surgical treatment is no guarantee for an improvement in acceptance and is therefore discouraged for patients who match the risk factors for nonacceptance unless it solves a functional problem. The authors therefore recommend screening patients for nonacceptance and considering psychological treatment before surgery is performed. Level of Evidence III This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors at www.springer.com/00266

Clinical prediction model to identify vulnerable patients in ambulatory surgery: towards optimal medical decision-making

__Background:__ Ambulatory surgery patients are at risk of adverse psychological outcomes such as anxiety, aggression, fatigue, and depression. We developed and validated a clinical prediction model to identify patients who were vulnerable to these psychological outcome parameters. __Methods:__ We prospectively assessed 383 mixed ambulatory surgery patients for psychological vulnerability, defined as the presence of anxiety (state/trait), aggression (state/trait), fatigue, and depression seven days after surgery. Three psychological vulnerability categories were considered–i.e., none, one, or multiple poor scores, defined as a score exceeding one standard deviation above the mean for each single outcome according to normative data. The following determinants were assessed preoperatively: sociodemographic (age, sex, level of education, employment status, marital status, having children, religion, nationality), medical (heart rate and body mass index), and psychological variables (self-esteem and self-efficacy), in addition to anxiety, aggression, fatigue, and depression. A prediction model was constructed using ordinal polytomous logistic regression analysis, and bootstrapping was applied for internal validation. The ordinal c-index (ORC) quantified the discriminative ability of the model, in addition to measures for overall model performance (Nagelkerke’s R2). __Results:__ In this population, 137 (36%) patients were identified as being psychologically vulnerable after surgery for at least one of the psychological outcomes. The most parsimonious and optimal prediction model combined sociodemographic variables (level of education, having children, and nationality) with psychological variables (trait anxiety, state/trait aggression, fatigue, and depression). Model performance was promising: R2 = 30% and ORC = 0.76 after correction for optimism. __Conclusion:__ This study identified a substantial group of vulnerable patients in ambulatory surgery. The proposed clinical prediction model could allow healthcare professionals the opportunity to identify vulnerable patients in ambulatory surgery, although additional modification and validation are needed. (ClinicalTrials.gov number, NCT01441843)

Modulation of immune response to rDNA hepatitis B vaccination by psychological stress

In a previous study it was shown that antibody formation after vaccination with a low-dose recombinant DNA (rDNA) hepatitis B vaccine was negatively influenced by psychological stress. The present study was designed to assess whether the same inverse relation between HBs-antibody levels and psychological stress could be observed, while administering the standard, and thus higher, dose of vaccine. Volunteers (n = 68) scoring extremely low or high on a combination of questionnaires measuring daily problems and psychoneurotic symptoms were selected for participation. Antibody levels were determined 2, 6, and 7 months after the first vaccination. Questionnaires were completed before entering the study and at month 6. In contrast to the previous study, psychological stress was not found to be related to the antibody levels at any timepoint. These results suggest that, under certain conditions, stress-induced immunomodulation in vivo might be dependent on antigen dose