A systematic review of therapeutic alliance, group cohesion, empathy, and goal consensus/collaboration in psychotherapeutic interventions in cancer: Uncommon factors?

Meaning-centered psychotherapy training program for cancer care clinicians: Efficacy and impact of the first 5 years

Meaning-Centered Psychotherapy (MCP) is a manualized, evidence-based intervention designed to help cancer patients to find meaning and alleviate distress. Meaning-Centered Psychotherapy Training (MCPT) is a multicomponent program for cancer care clinicians that consists of didactics, group experiential learning, and role-plays with simulated patients to learn MCP and acquire skills to deliver it in real-world oncology settings. The efficacy and impact of MCPT for multidisciplinary cancer care clinicians to learn and disseminate MCP is described and evaluated. A multilevel evaluation based on the RE-AIM framework was utilized to assess the efficacy of the MCPT program over the initial 5 years of the program. The outcomes of the evaluation supported MCPT goals. Three hundred forty-two participants attended MCPT. Overall satisfaction measured in the post-training assessment was high. Significant increases in MCP skills were demonstrated by participants over the course of the role-play sessions, and participants showed significant improvements in pre/post-training MCP knowledge assessment scores, as well as significant increases in self-reported overall MCP skills and core competencies. Follow-up survey responses indicate that MCP trainees were utilizing MCP, had made changes to their clinical practice, and progressed on individual implementation goals. During the first 5 years, the MCPT program was successfully developed, established, implemented, and shown to be effective in the dissemination of MCP across the RE-AIM domains. Future directions for training and implementation research include increasing diversity of providers and investigating the impact of the program on patient outcomes.

Group engagement in parent-focused telehealth interventions for families of children with type 1 diabetes

INTRODUCTION

Group engagement is an important component of video-based telehealth interventions, yet this construct remains understudied. In the present study, we applied a multidimensional conceptualization of group engagement in two video-based telehealth interventions that either aimed to reduce fear of hypoglycemia or diabetes distress in parents of children with type 1 diabetes. We examined variability in group engagement across parents and assessed the relationship between parents' level of group engagement and their treatment outcomes.

METHODS

Twenty-nine parents participated in one of two manualized, closed-group, telehealth interventions and completed outcome measures pre- and post-treatment. We behaviorally coded telehealth sessions based on six dimensions of group engagement using the Group Engagement Measure (inter-rater reliability = 0.94). We examined correlations between group engagement dimensions, parent psychosocial well-being, and child hemoglobin A1c. Further, we examined independent sample t-tests to assess differences between treatment groups.

RESULTS

Mean parent age was 37.69  ±  6.83 years, mean child age was 7.69  ±  3.76 years, and mean child hemoglobin A1c was 8.06  ±  1.27% (41.4% had a hemoglobin A1c <7.5%). Parents who spent more time attending to other group member's issues, reported lower hypoglycemia fear at post-treatment, and parents who showed more active support of the group leader's purpose/goals during the session also reported fewer depressive symptoms at post-treatment.

DISCUSSION

We identify several dimensions of group engagement that are associate with improved parent psychosocial and child hemoglobin A1c outcomes. Intervention designs that use group engagement to guide treatment planning or inform treatment-related decisions in video-based telehealth interventions could help families achieve more optimal treatment outcomes.

Development and preliminary validation of the Group Cognitive Therapy Scale

Aim

The aim of this research was to create a scale to assess the competency of therapists who conduct group cognitive behavioral therapy (G-CBT). The scale is intended to serve as a tool to aid the training of therapists.

Methods

Three stepped studies were conducted. Process 1: Through literature review and experts' consensus process, essential skills for G-CBT were articulated and categorized according to the criteria of the Cognitive Therapy Scale, a well-established rating scale for evaluating clinicians' skills in individual cognitive behavioral therapy. The list of those skills was organized into a rating scale. Process 2: Behavioral anchors were added to each skill and were classified by the levels of difficulty (beginner, intermediate, and advanced levels), based on the rating by G-CBT experts. Process 3: Inter-rater reliability and validity of the rating scale were examined in a sample of 41 videotaped G-CBT sessions of actual clinical sessions and educational role-plays.

Results

The 12-item Group Cognitive Therapy Scale (G-CTS) was developed. It consists of 11 items that are adapted from the original Cognitive Therapy Scale, and a new 12th item called "Intervention using relationships with other participants," which describes therapists' skills to address group dynamics. The G-CTS showed excellent internal consistency (Cronbach's α: 0.95), satisfactory inter-rater reliability (interclass correlation coefficients: 0.65-0.88), and high predictive validity.

Conclusion

A novel rating scale to evaluate therapists' competency in G-CBT was developed and successfully validated. The G-CTS behavioral checklist created in this study provides concrete guidelines that can be used by therapists to hone their skills in G-CBT.

Aqua polo: Preliminary feasibility and efficacy study of a programme of adapted, supervised water polo to reduce fatigue and improve women's psychological and social recovery after breast cancer treatment: A mixed-methods design

Physical activity has been shown to have many benefits, including reducing cancer-related fatigue (CRF) and improving psychological and physical recovery from breast cancer. Some authors have shown the benefits of aquatic practice, while others have detailed the benefits of group and supervised practice. We hypothesize that an innovative sports coaching proposal could allow a significant adherence of patients and contribute to their health improvement. The main objective is to study the feasibility of an adapted water polo programme (aqua polo) for women after breast cancer. Secondarily we will analyse the effect of such a practice on patients' recovery and study the relationship between coaches and participants. The use of mixed methods will allow us to question the underlying processes precisely. This is a prospective, non-randomized, monocentric study with a sample of 24 breast cancer patients after treatment. The intervention is a 20 week programme (1 session per week) of aqua polo in a swim club facility, supervised by professional water-polo coaches. The variables measured are patient participation, quality of life (QLQ BR23), CRF (R-PFS) and post-traumatic growth (PTG-I) as well as different variables to observe physical capacity (strength with dynamometer, step-test and arm amplitude). The quality of the coach-patient relationship will be evaluated (CART-Q) to explore its dynamics. Participatory observations and interviews will be carried out to report on the interactions between the coach and the participants during the sessions.

Registration number and name of trial registry

No. EudraCT or ID-RCB: 2019-A03003-54 and NCT: NCT04235946.

The Relationship between Therapeutic Alliance and Quality of Care in Patients with Advanced Cancer in Spain

The therapeutic alliance is an important factor in successful cancer treatment, particularly for those with advanced cancer. This study aims to determine how the therapeutic alliance relates to prognostic preferences and satisfaction with the physician and medical care among patients with advanced cancer. We conducted a cross-sectional study to explore the therapeutic relationship, trust, satisfaction with healthcare, and prognostic preferences among 946 patients with advanced cancer at 15 tertiary hospitals in Spain. Participants completed questionnaires with self-reported measures. Most were male, aged > 65 years, with bronchopulmonary (29%) or colorectal (16%) tumors and metastatic disease at diagnosis. Results revealed that 84% of patients had a good therapeutic alliance. Collaborative and affective bond was positively associated with a preference to know the prognosis and satisfaction with care and decision. There was no difference in a therapeutic alliance based on clinical or sociodemographic factors. The therapeutic alliance between patient and physician is essential for successful treatment outcomes and better overall satisfaction. Therefore, it is vital for healthcare providers to focus on establishing and maintaining a strong relationship with their patients. To achieve this, transparency and care should be prioritized, as well as respect for the preferences of patients regarding the prognosis of their illness.

Therapeutic alliance impact on analgesic outcomes in a real-world clinical setting: An observational study

A good therapeutic alliance is relevant for healthcare providers exposed to patients' suffering, especially since patients and physicians may understand the painful experience differently. Our aim was to explore the impact of therapeutic alliance on analgesic outcomes in a real-world interdisciplinary pain unit (PU). A cross-sectional observational study was conducted on outpatients (n = 69) using opioids on a long-term basis for the treatment of chronic non-cancer pain, where clinical pharmacologists and pharmacists advised patients about their opioid treatment. Responses to the patient-doctor relationship questionnaire (PDRQ), sociodemographic and clinical information (pain level, quality of life and hospital use) were collected, whereas pharmacology data (analgesic prescription, adverse events, and compliance) were obtained from electronic health records. Patients were predominantly middle-aged (75 % women, 72 % retired), experiencing moderate pain (VAS 40-70 mm) on average, and under a high morphine equianalgesic dosage (95 ± 88 mg per day, mainly tapentadol or fentanyl). Patients with better PDRQ outcomes, and therefore better therapeutic alliance, showed lower pain intensity than patients with worse PDRQ outcomes (pain intensity: high scores 60 ± 47 mm and medium scores 60 ± 45 mm vs. low scores 80 ± 75 mm, p < 0.01). Along with this, pain intensity was lower when patients affirmed that, thanks to the health-care providers, they "gained new insight", "felt better", or "felt content with their doctor's treatment". What´s more, patients who affirmed "I benefit from the treatment" experienced increased pain relief (benefit 40 ± 30 vs. non-benefit 19 ± 26 mm, p = 0.010) and improved quality of life (benefit 33 ± 25 vs. non-benefit 18 ± 16 mm, p = 0.031). However, there was a percentage of patients who did not fully understand the provided information, which is something to be taken into account to improve in clinical routine. Therapeutic alliance supported by pharmacist experts on pain management can be an effective strategy to improve analgesic outcomes. Further efforts are needed to improve communication strategies for pain management. Future directions of research should include the analysis of the role of the pharmacist in poly-professional consultations as related to the advice of patients about their medication, and the mutual trust with the patients.

Does the Broaden-and-Build Theory Explain Reduction in Social Disruption After a Brief Relaxation Intervention for Women With Breast Cancer Undergoing Treatment?

Women with breast cancer experience social disruption during and after treatment. Brief cognitive-behavioral (CBT) and relaxation (RT) interventions may improve social disruption by increasing positive affect. Using the Broaden-and-Build Theory as a framework, this study examined whether short-term CBT- and RT-related increases in positive affect mediate long-term reductions in social disruption in women with breast cancer undergoing treatment (N = 183). This secondary analysis used latent change score and growth models to test 6- and 12-month intervention effects on positive affect and social disruption, respectively; a parallel-process model assessed mediation. RT demonstrated larger reductions in social disruption across 12 months compared to CBT and a health education control. Six-month latent change in positive affect was significant but not driven by condition. There was a significant direct effect linking the latent slopes of positive affect and social disruption but meditation was not observed. These preliminary findings hint at the value of promoting positive affect and inform the development of brief behavioral interventions that aim to augment social functioning among women surviving breast cancer.

Reflecting on meaning in an existential-reorientation group psychotherapy approach for cancer patients: A qualitative thematic analysis

OBJECTIVE

The objectives of this study were to evaluate, in the Italian cultural context, breast cancer patients' main meaning themes related to the experience of the disease, on the one side, and to be part of an existentially oriented group intervention, on the other.

METHOD

A short reorientation-existential (RET) group intervention, structured by using some tools and background from cognitive analytic therapy (CAT) and based on the meaning-centered psychotherapy (MCP) existential framework, was delivered to 29 breast cancer patients. The sessions were audio-recorded and transcribed verbatim, with the narratives from reflective exercises (meaning of the journey cancer, meaning of the journey of intervention) uploaded to computer software NVivo 11. Analysis of the transcripts emerged from reflective exercises on the personal meaning of cancer and the letters of meaning (goodbye letter) written by the patients to express the meaning of their experience in the group was conducted through the interpretative phenomenological analysis (IPA) framework.

RESULTS

Four superordinate themes were identified in the exercise meaning of the experience of cancer, namely "sense of stigma and loneliness (the foreigner)," "guilt (unjust guilt and anticipatory guilt)," "reconsidering one's own life and nostalgia," and "rebirth (a new life, life after life)." Three superordinate themes were found in the meaning of the group experience in the letters, namely "togetherness and gratitude," "legacy," and "acceptance."

SIGNIFICANCE OF RESULTS

The study confirmed that a short group intervention, based on the existentially oriented framework and delivered in a public clinical healthcare setting, was enriched by focusing on the personal meaning of cancer. Some themes, such as loneliness, nostalgia, and rebirth, emerged during reflection giving, in written letters to participants, the sense of the group therapeutic experience.

Keeping young people connected during COVID-19: the role of online groups

The COVID-19 pandemic has had a profound impact on young people, disrupting education, routines, hobbies and peer interactions and there is concern for longer term effects on physical and mental health outcomes. Young people living with chronic health conditions face additional challenges including reduced or no face-to-face contact with medical teams, shielding and the increased stressors of being in 'at-risk' groups and social isolation. In a climate of social isolation and disconnectedness, online groups could provide a method of delivering healthcare and support that strengthens social connectedness and reduces isolation. Despite the technology being available, uptake and evidence for online groups is limited. This article shares learnings from a paediatric and adolescent psychology service delivering online groups for young people with chronic health conditions and their healthcare teams. Ideas for how to transfer group process to online platforms are considered, with examples and tips. With sufficient staffing, preparation, thought, creativity and innovation, it is possible for face-to-face groups to successfully be offered online. Caution should be exercised trying to run online groups without these provisions in place, as the safety, comfort and experience of young people could be jeopardised. Further research is needed to better understand group processes online and to consider what is lost and what is gained when comparing online to face-to-face groups.

Measuring Perceptions of the Therapeutic Alliance in Individual, Family, and Group Therapy from a Systemic Perspective: Structural Validity of the SOFTA-s

This study examined the multidimensional structure of the client and therapist versions of the self-report measure, System for Observing Family Therapy Alliances (SOFTA-s; Friedlander, Escudero, & Heatherington, Therapeutic alliances in couple and family therapy: An empirically informed guide to practice. Washington, DC: American Psychological Association, 2006) across three distinct therapeutic modalities (individual, family, group). Specifically, we investigated whether the originally theorized model of four first-order factors (Engagement in the Therapeutic Process, Emotional Connection with the Therapist, Safety within the Therapeutic System, and Shared Sense of Purpose within the Family) would be reflected in a second-order factor (Therapeutic Alliance). The sample included 105 therapists who worked with 858 clients (165 individuals, 233 families, and 43 groups) in several Spanish community agencies. To control for dependent data, we used multilevel modeling. Results of the multilevel confirmatory factor analyses showed adequate reliabilities, fit indices, and factor loadings across the three therapy contexts for both versions of the measure (client and therapist). Adequate measurement invariance was also found across respondents and therapy modalities. Taken together, these results support the structural validity of the SOFTA-s, a brief and flexible self-report alliance measure that can be used reliably in clinical practice as well as in studies of individual, family, and group therapy.

Psychedelic Communitas: Intersubjective Experience During Psychedelic Group Sessions Predicts Enduring Changes in Psychological Wellbeing and Social Connectedness

Background: Recent years have seen a resurgence of research on the potential of psychedelic substances to treat addictive and mood disorders. Historically and contemporarily, psychedelic studies have emphasized the importance of contextual elements ('set and setting') in modulating acute drug effects, and ultimately, influencing long-term outcomes. Nevertheless, current small-scale clinical and laboratory studies have tended to bypass a ubiquitous contextual feature of naturalistic psychedelic use: its social dimension. This study introduces and psychometrically validates an adapted Communitas Scale, assessing acute relational experiences of perceived togetherness and shared humanity, in order to investigate psychosocial mechanisms pertinent to psychedelic ceremonies and retreats. Methods: In this observational, web-based survey study, participants (N = 886) were measured across five successive time-points: 2 weeks before, hours before, and the day after a psychedelic ceremony; as well as the day after, and 4 weeks after leaving the ceremony location. Demographics, psychological traits and state variables were assessed pre-ceremony, in addition to changes in psychological wellbeing and social connectedness from before to after the retreat, as primary outcomes. Using correlational and multiple regression (path) analyses, predictive relationships between psychosocial 'set and setting' variables, communitas, and long-term outcomes were explored. Results: The adapted Communitas Scale demonstrated substantial internal consistency (Cronbach's alpha = 0.92) and construct validity in comparison with validated measures of intra-subjective (visual, mystical, challenging experiences questionnaires) and inter-subjective (perceived emotional synchrony, identity fusion) experiences. Furthermore, communitas during ceremony was significantly correlated with increases in psychological wellbeing (r = 0.22), social connectedness (r = 0.25), and other salient mental health outcomes. Path analyses revealed that the effect of ceremony-communitas on long-term outcomes was fully mediated by communitas experienced in reference to the retreat overall, and that the extent of personal sharing or 'self-disclosure' contributed to this process. A positive relationship between participants and facilitators, and the perceived impact of emotional support, facilitated the emergence of communitas. Conclusion: Highlighting the importance of intersubjective experience, rapport, and emotional support for long-term outcomes of psychedelic use, this first quantitative examination of psychosocial factors in guided psychedelic settings is a significant step toward evidence-based benefit-maximization guidelines for collective psychedelic use.

Meditating in Virtual Reality 3: 360° Video of Perceptual Presence of Instructor

Objectives

The need for remote delivery of mental health interventions including instruction in meditation has become paramount in the wake of the current global pandemic. However, the support one may usually feel within the physical presence of an instructor may be weakened when interventions are delivered remotely, potentially impacting one's meditative experiences. Use of head-mounted displays (HMD) to display video-recorded instruction may increase one's sense of psychological presence with the instructor as compared to presentation via regular flatscreen (e.g., laptop) monitor. This research therefore evaluated a didactic, trauma-informed care approach to instruction in mindfulness meditation by comparing meditative responses to an instructor-guided meditation when delivered face-to-face vs. by pre-recorded 360° videos viewed either on a standard flatscreen monitor (2D format) or via HMD (i.e., virtual reality [VR] headset; 3D format).

Methods

Young adults (n = 82) were recruited from a university introductory course and experienced a 360° video-guided meditation via HMD (VR condition, 3D format). They were also randomly assigned to practice the same meditation either via scripted face-to-face instruction (in vivo [IV] format) or when viewed on a standard laptop display (non-VR condition, 2D format). Positive and negative affect and meditative experience ratings were self-reported and participants' maintenance of focused attention to breathing (i.e., meditation breath attention scores [MBAS]) were recorded during each meditation.

Results

Meditating in VR (3D format) was associated with a heightened experience of awe overall. When compared to face-to-face instruction (IV format), VR meditation was rated as less embarrassing but also less enjoyable and more tiring. When compared to 2D format, VR meditations were associated with greater experiences of relaxation, less distractibility from the process of breathing, and less fatigue. No differences were found between VR and non-VR meditation in concentration (MBAS). Baseline posttraumatic stress symptoms were risk factors for experiencing distress while meditating in either (VR and non-VR) instructional format. Of those who reported a preference for one format, approximately half preferred the VR format and approximately half preferred the IV format.

Conclusions

Recorded 360° video instruction in meditation viewed with a HMD (i.e., VR/3D format) appears to offer some experiential advantage over instructions given in 2D format and may offer a safe-and for some even preferred-alternative to teaching meditation face-to-face.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12671-021-01612-w.

Expectations and Concerns of Older Adults With Cognitive Impairment About Their Relationship With Medical Providers: A Call for Therapeutic Alliances

We sought to understand the expectations and concerns of older adults with cognitive impairment with regard to their relationship with medical providers. In particular, we observed whether study participants were involved in therapeutic alliances. Medical providers and patients create therapeutic alliances when they agree on the goals of the treatment and share a personal bond. Whereas such alliances have been studied in cancer research, little is known about therapeutic alliances in dementia research. Data were gathered in a qualitative study of 27 older adults with cognitive impairment and analyzed with narrative analysis. We introduce four case studies that illustrate the effects of having or missing a therapeutic alliance. Whereas the participant in the first case benefited from a therapeutic alliance, the other cases are marked by different experiences of abandonment. Findings suggest that interventions should concentrate on ways to enhance the relationship between medical providers and patients with cognitive impairment.

How short is too short? A randomised controlled trial evaluating short-term existential behavioural therapy for informal caregivers of palliative patients

BACKGROUND

Informal caregivers of palliative patients show higher levels of depression and distress compared with the general population. Fegg's (2013) existential behavioural therapy was shortened to two individual 1-h sessions (short-term existential behavioural therapy).

AIM

Testing the effectiveness of sEBT on psychological symptoms of informal caregivers in comparison with active control.

DESIGN

Randomised controlled trial.

SETTING/PARTICIPANTS

Informal caregivers of palliative in-patients.

METHODS

The primary outcome was depression; secondary outcomes were anxiety, subjective distress and minor mental disorders, positive and negative affect, satisfaction with life, quality of life and direct health care costs. General linear mixed models allow several measurements per participant and change over time. Reasons for declining the intervention were investigated by Rosenstock's Health Belief Model.

RESULTS

Overall inclusion rate was 41.0%. Data of 157 caregivers were available (63.1% females; mean age: 54.6 years, standard deviation (SD): 14.1); 127 participants were included in the main analysis. Participation in sEBT or active control was not significantly associated with post-treatment depression. Outcomes showed prevailingly significant association with time of investigation. Self-efficacy, scepticism of benefit of the intervention, belief of better coping alone and support by family and friends were significant factors in declining participation in the randomised controlled trial.

CONCLUSION

Inclusion rate was tripled compared with a previously evaluated longer EBT group intervention. By shortening the intervention, inclusion rate was traded for effectiveness and the intervention could not impact caregivers' psychological state. Early integration of sEBT and combination of individual and group setting and further study of the optimal length for caregiver interventions are suggested.

Empathy assessment in healthcare students is highly heterogeneous: A systematic review and meta-analysis (2012-2016)

BACKGROUND

Clinical empathy leads to improved patient satisfaction and better clinical outcomes. Currently, there are multiple empathy scales with minimal or no efforts to produce an integrated definition of clinical empathy which can be assessed sufficiently by only a few scales. Moreover, there is an unclear overall reliability of these empathy scales, hence limiting comparative evaluation.

AIM

To examine which empathy scales have been used in healthcare students and to estimate their overall internal consistency.

METHODS

A systematic review was performed with inclusion criteria any empirical study with quantitative data examining empathy of healthcare students toward patients between 2012 and 2016. A random effects model was used to produce a pooled estimate of the Cronbach’s alphas. The Hakstian-Whalen transformation was used for analyses based on the Rodriguez-Maeda method. Heterogeneity was quantified using the I² statistic and further investigated with subgroup analysis and meta-regression. Publication bias was assessed using funnel plots, Egger’s test, Begg’s test, and the trim and fill analysis.

RESULTS

Thirteen scales have been used to assess clinical empathy in healthcare students from forty nine studies with total sample size 49384 students. The most frequently used scale is the Jefferson Scale of Physician Empathy followed by Davis’ Interpersonal Reactivity Index. The overall reliability was 0.805 (95%CI 0.786-0.823), which is acceptable, but there was heterogeneity and publication bias. Some heterogeneity was explained by the different countries of the studies under investigation and student types but most heterogeneity remained unexplained.

CONCLUSION

The results indicate that scales have satisfactory internal consistency but there are a multitude of scales, definitions and empathy components. Future research should focus on standardizing scales and creating consensus statements regarding the definition of empathy and use of appropriate scales.

Barriers to empathy-based care: oncology nurses' perceptions

Purpose The purpose of this paper is to explore oncology nurses' barriers to empathy-based care perceptions. Design/methodology/approach The authors used a descriptive qualitative method. In total, 18 oncology nurses were selected via purposive sampling. Data were collected through in-depth interviews and qualitative content analysis using an inductive approach. Findings Three main categories emerged from the data analysis: barriers related to nursing including: lacking compassion; disinterest in oncology nursing and self-criticism; psychological distress; barriers related to healthcare: job strain; task-centeredness; no formal training; poor manager support; nurse-patient gender imbalance; and barriers related to cancer care including: difficulty maintaining empathy with cancer patients; and inappropriate cancer patient Practical implications Oncology nurses provided insights into barriers to empathy-based care and the challenges they encountered while caring for cancer patients. Understanding these barriers is the first step to overcoming obstacles and creating an open and caring environment to provide an empathic care culture. Originality/value Given that oncology nurses experience several emotions, positive coping strategies for these distresses should be adopted. Healthcare systems should change cancer-caring culture from task-centered to patient-centered care. Compassion and empathy should become patient care values.

The perceptions of nurses, patients and family members regarding nurses' empathetic behaviours towards patients suffering from cancer: a descriptive qualitative study

Background

Although evidence suggests that empathic behaviour is an essential component in nursing care that affects the psychological distress experienced by cancer patients, it remains a neglected issue in nursing in Iran.

Methods

This study was conducted on 33 participants selected through purposive sampling. Data were collected using in-depth interviews and were then analysed using qualitative content analysis with an inductive approach.

Findings

Three categories of data thus emerged, comprising: (a) empathetic attention; (b) empathetic presence; and (c) the facilitators of empathetic behaviour.

Conclusions

The findings can help oncology nurses provide more empathetic care to patients and their family members.

Psychotherapy in the Oncology Setting

A person who faces the diagnosis of cancer is subjected to changes within his body, but also with regard to his view of himself and his social relationships. Cancer related psychological distress occurs frequently and has a different prevalence according to-among other factors-cancer type and stage of disease. The main psychiatric disturbances observed in patients with cancer are adjustment disorders and affective disorders (anxiety and depression), which in the majority of patients are due to stressors related to the occurrence and threat of the disease and pre-existing psychological vulnerabilities; however, they might also be a direct consequence of biological causes either resulting from bodily modifications induced by the cancer or from treatment side effects. This chapter provides theoretical and practical information on the main psychotherapeutic approaches for cancer patients, complemented by some reflections on their clinical and scientific evidence.

Therapeutic Alliance and Group Cohesion in an Online Support Program for Adolescent and Young Adult Cancer Survivors: Lessons from "Recapture Life"

Psychological support services for adolescent and young adults (AYAs) with cancer are moving online and are increasingly peer based. It is unclear whether online service delivery impacts critical therapeutic elements such as collaborative patient-therapist rapport and group cohesion. AYA cancer survivors (N = 39) participating in a six-week online cognitive-behavioral therapy group program-"Recapture Life"-rated their perception of therapeutic alliance and group cohesion. Participant-rated alliance and group cohesion were high throughout the program, and therapist-rated participant openness, trust, and motivation strengthened over time. The findings provide further support for the expansion of AYA cancer support services to the online domain.

The physician-patient working alliance: Theory, research, and future possibilities

OBJECTIVE

This article discusses the physician-patient working alliance and reviews the empirical research that has been generated on the working alliance to date.

METHODS

The paper presents a brief history of the study of the physician-patient relationship, and discusses constructs that have examined aspects of the relationship, such as empathy, trust, and shared decision-making. Lastly, a meta-analysis was conducted based on the seven empirical studies (a total N of 1023 patients) that have examined the physician-patient working alliance.

RESULTS

Results of the meta-analysis found medium to large effect sizes between the working alliance and various behavioral care indices. The working alliance is positively associated with patient adherence, satisfaction, and improved patient outcomes.

CONCLUSION

Overall, the physician-patient working alliance provides researchers and medical-care providers with a unified construct that combines cognitive and affective dimensions inherent in the relationship in medical care. Furthermore, the PPWAI provides an efficient and inexpensive way to assess the physician-patient relationship in medical treatment.

PRACTICE IMPLICATIONS

The present findings warrant the development of an intervention focused on working alliance training that could be offered to healthcare providers.

Understanding the importance of therapeutic relationships in the development of self-management behaviours during cancer rehabilitation: a qualitative research protocol

INTRODUCTION

Cancer is a growing health, social and economic problem. 1 in 3 people in the UK will develop cancer in their lifetime. With survival rates rising to over 50%, the long-term needs of cancer survivors are of growing importance. Cancer rehabilitation is tailored to address the physical or psychosocial decline in ability to engage in daily activities. Its use is supported by high-quality international, multicentre research. Incorporating strategies for self-management behaviour development into rehabilitation can prepare individuals for cancer survivorship. However, healthcare professionals will need to adjust their therapeutic interactions accordingly. Research is yet to clarify the impact of the therapeutic relationship on rehabilitation outcomes in cancer. This study aims to explore the impact of therapeutic relationships on self-management behaviours after cancer.

METHODS AND ANALYSIS

This qualitative study aims to understand cancer rehabilitation participants' beliefs regarding the importance of therapeutic relationships in developing self-management behaviours. A sample representative of a local cancer rehabilitation cohort will be asked to complete a semistructured interview to identify their perspectives on the importance of therapeutic relationships in cancer rehabilitation. Data obtained from the interviews will be analysed, coded and entered into a Delphi questionnaire for circulation to a local cancer rehabilitation population to determine if the views expressed by the interviewees are supported by group consensus.

ETHICS AND DISSEMINATION

This study was approved by Wales Research Ethics Committee 6 (15/WA/0331) in April 2016. Findings will be disseminated through the first author's doctoral thesis; peer-reviewed journals; local, national and international conference presentations; and public events involving research participants and the general public.

Harnessing group composition-related effects in pain management programs: a review and recommendations

Cognitive-behavioral therapy, an effective management strategy for chronic pain, is frequently conducted in groups. Although clinicians often report 'knowing when a group will go well or badly', investigations of the effect that group composition might have on outcomes is lacking. Conceptual models, explanatory theories and experiments have been developed in fields of psychotherapy, organizational, social and educational psychology, but there has been no attempt to take on this issue in our field. The current hypothesis-generating review synthesizes these substantial bodies of literature to identify common themes across fields and integrate them with current concepts of cognitive-behavioral therapy-based pain management. We present a putative conceptual model with testable hypotheses relating to features of each group as a whole, the individuals in that group and the group's leader.

The Tree Theme Method® (TTM), an occupational therapy intervention for treating depression and anxiety: study protocol of a randomized controlled trial

Background

Depression and anxiety disorders are increasing among the general population in the Western world. Individuals may need several kinds of treatment in order to maintain health, such as cognitive behavioural therapy (CBT) and drug treatment. However, having an everyday life that “works” is also important, suggesting a need for interventions based on activities that facilitate a satisfying everyday life. There is still lack of such evidence-based interventions. The Tree Theme Method^® (TTM) is an occupational therapy intervention designed for a client-centred context in which an individual develops strategies to become an actor in his or her everyday life. Previous studies of the TTM have focused on process evaluation; therefore, further studies are needed to evaluate the method’s effects. The aim of this paper is to outline an intervention that can evaluate the effects of the TTM in terms of psychological symptoms, as well as everyday occupations and well-being, in patients suffering from depression and anxiety.

Methods/Design

This randomized clinical trial includes patients from three Swedish counties randomized to either intervention or treatment as usual. Men and women aged 18–65 years who have been diagnosed with either depression or anxiety are eligible for inclusion. Data collection is carried out at baseline, and outcomes are assessed at the end of intervention, as well as at 3 months and 12 months after intervention ends. The outcomes measured are psychological symptoms, everyday activities, and health-related factors.

Discussion

Depression and anxiety may create difficulties for individuals in the activities of their everyday lives to the extent that they require diagnosis and intervention. Despite this reality, evidence-based interventions that focus on everyday activities are lacking. Therefore, it would be useful to design a specific method for occupational therapy intervention that does precisely that. This study provides insight into the effects of the TTM, comparing it to occupational therapy treatment as usual.

Trial registration

ClinicalTrials.gov: NCT01980381; registered November 2013.

Group cohesion and between session homework activities predict self-reported cognitive-behavioral skill use amongst participants of SMART Recovery groups

SMART Recovery groups are cognitive-behaviorally oriented mutual support groups for individuals with addictions. The aim of the study was to assess the extent to which the quality of group facilitation, group cohesion and the use of between session homework activities contribute to self-rated use of cognitive-behavioral skills amongst group participants. Participants attending SMART Recovery groups in Australia completed a cross sectional survey (N=124). The survey included measures of cognitive and behavioral skill utilization, group cohesion, quality of group facilitation and a rating of how frequently participants leave group meetings with an achievable between session homework plan. On average, participants had been attending SMART Recovery meetings for 9 months. Participants were most likely to attend SMART Recovery for problematic alcohol use. Regression analyses indicated that group cohesion significantly predicted use of cognitive restructuring, but that only provision of homework at the end of each group session predicted self-reported behavioral activation. Both group cohesion and leaving a group with an achievable homework plan predicted participant use of cognitive behavioral skills. The concrete actions associated with homework activities may facilitate behavioral activation. There is a need for longitudinal research to examine the relationship between the utilization of cognitive and behavioral skills and participant outcomes (e.g. substance use, mental health) for people attending SMART Recovery groups.

Greater professional empathy leads to higher agreement about decisions made in the consultation

OBJECTIVE

To examine the relationship between professional expression of empathy and agreement about decisions made in the consultation.

METHODS

Consultations between 86 individuals with diabetes and four dieticians were audio-recorded. Immediately following consultations patients and dieticians independently reported decisions made in a booklet. Audio-recordings were coded directly for empathy using an amended version of the empathic communication coding system (ECCS).

RESULTS

Empathy correlated significantly with patient and professional agreement about decisions made in the consultation (τ=.283, p=.0005). Multiple regression analysis indicates that for each dietician the greater the empathy the higher the level of agreement about decisions (p<.0005). Professional empathic response to patients statements of challenge was a significant factor in increasing agreement about decisions (p=.008).

CONCLUSION

Results support the hypothesis that greater professional empathy will result in greater agreement about decisions made in consultations.

PRACTICE IMPLICATIONS

Findings have implications for empathy training and provide guidance on the communication skills needed to support expression of empathy. Patient and professional agreement about decisions made provides a simple marker of effectiveness and highlights the importance of empathy as a seminal component of professional communication skills during a patient consultation.

Trust and safe spaces: mental health consumers' and carers' relationships with community pharmacy staff

BACKGROUND

Trusting relationships between mental health consumers and health care providers are critical in the management and recovery process. Although community pharmacy staff are well placed to form relationships with mental health consumers and carers, little is known about the existence, nature or significance of consumer-staff relationships.

OBJECTIVES

The aim of this study was to explore mental health consumers' and carers' perceptions of community pharmacy services, and describe the nature of their relationships with pharmacy staff.

METHODS

Focus groups and semi-structured interviews were conducted with a convenience sample of 74 mental health consumers or carers who self-selected into the study. Thematic analysis was undertaken to explore participants' perspectives.

RESULTS

Positive experiences of pharmacy services were perceived to encourage consumers' and carers' trust in pharmacists and promote relationship development. This was enhanced when participants felt that elements of patient-centred care were part of the pharmacy services provided. Although some participants perceived community pharmacy to have a limited role in mental health, those who had established relationships highlighted the current role of pharmacists in their care, and appeared to welcome further extensions of pharmacists' role in mental health.

CONCLUSIONS

Trusting relationships between consumers and carers and community pharmacy staff were deemed to be important in mental health care and contributed to consumers' and carers' views of pharmacy as a safe health care space. Community pharmacy services that included core elements of patient-centred care appeared to facilitate relationship formation and associated benefits. Education and training is needed for community pharmacy staff to improve mental health knowledge and promote positive engagement with consumers and carers.

Parole officer-parolee relationships and HIV risk behaviors during community supervision

We tested if good parole officer (PO)-parolee relationships reduce HIV risk behaviors during parole, as they do for risk of rearrest. Analyses used data from 374 parolees enrolled in a randomized clinical trial. Past month HIV risk behaviors were assessed by interview at baseline, 3- and 9-months after parole initiation. The Working Alliance Inventory and the Dual-Role Relationships Inventory measured PO relationship. Gender-stratified multivariate regressions tested associations of PO-parolee relationship with sex with multiple partners, unprotected sex with risky partner(s), and drug injection. Women parolees (n = 65) who reported better PO relationship characteristics were less likely to report having multiple sex partners [adjusted odds ratio: 0.82 (0.69, 0.98) at 3-months, 0.89 (0.80, 0.99) at 9-months], and, among those reporting multiple sex partners, had fewer partners on average [adjusted relative risk 0.98 (0.96, 0.99)]. These effects were not found among men. PO-parolee relationship quality can influence sexual risk behaviors among women parolees.

Managing Cancer and Living Meaningfully (CALM): a qualitative study of a brief individual psychotherapy for individuals with advanced cancer

BACKGROUND

Although psychosocial care has been regarded as central to palliative and supportive care, there have been few empirically tested approaches to individual intervention.

AIM

The subjective experience of advanced cancer patients receiving a new manualized brief individual psychotherapy, referred to as Managing Cancer and Living Meaningfully (CALM), was examined prior to the initiation of a randomized controlled trial testing the effectiveness of this intervention.

DESIGN

Semi-structured interviews were conducted with patients who had a diagnosis of advanced cancer, and who underwent the intervention.

SETTING/PARTICIPANTS

Patients were recruited from a large urban regional cancer center in Toronto, Canada. The 10 interviewees included seven women and three men. All had completed between three to six CALM sessions prior to the interview.

RESULTS

The CALM intervention was associated with profound and unique patient-identified benefits and no patient-identified risks or concerns. Five interrelated benefits of the intervention were identified: (1) a safe place to process the experience of advanced cancer; (2) permission to talk about death and dying; (3) assistance in managing the illness and navigating the healthcare system; (4) resolution of relational strain; and (5) an opportunity to 'be seen as a whole person' within the healthcare system. These benefits were regarded by participants as unique in their cancer journey.

CONCLUSIONS

Findings from a qualitative study suggest that the CALM intervention provides substantial benefits for patients with advanced cancer prior to the end of life. Findings informed the development of a randomized controlled trial to evaluate the effectiveness of this intervention.

Therapeutic alliance in telephone-administered cognitive-behavioral therapy for hematopoietic stem cell transplant survivors

OBJECTIVE

A strong therapeutic alliance has been found to predict psychotherapeutic treatment success across a variety of therapeutic modalities and patient populations. However, only a few studies have examined therapeutic alliance as a predictor of psychotherapy outcome among cancer survivors, and none have examined this relation in telephone-administered cognitive-behavioral therapy (T-CBT). This study evaluated the extent to which therapeutic alliance affected psychotherapy outcomes in survivors of hematopoietic stem cell transplantation (HSCT), a treatment for some cancers.

METHOD

Forty-six patients enrolled in a randomized clinical trial of T-CBT for posttraumatic stress disorder (PTSD) completed a baseline assessment (including self-report measures of PTSD symptoms, depression, and general distress), 10 individual T-CBT sessions, and follow-up assessments at 6, 9, and 12 months post-baseline. Therapeutic alliance was assessed after the 3rd T-CBT session with the Working Alliance Inventory, which yields overall and subscale (task, bond, and goal) scores.

RESULTS

Analyses revealed that higher total therapeutic alliance scores prospectively predicted decreased depressive symptomatology; higher task scores predicted decreased overall distress, depressive symptomatology, symptoms of re-experiencing, and avoidance; and higher bond scores predicted decreased depressive symptomatology and symptoms of re-experiencing.

CONCLUSIONS

These results suggest that assessments of therapeutic alliance should be incorporated into routine clinical care, and therapeutic alliance should be specifically cultivated in interventions to maximize psychotherapeutic benefits involving vulnerable populations such as cancer survivors.

Post-stroke fatigue: a treatment protocol that is being evaluated

This series of articles for rehabilitation in practice aims to cover a knowledge element of the rehabilitation medicine curriculum. Nevertheless they are intended to be of interest to a multidisciplinary audience. The competency addressed in this article is the neuropsychologist.

AbstractPurpose: Post-stroke fatigue is a common and debilitating complaint, which has only recently received attention in clinical rehabilitation. Until now, no evidence-based treatments have been available for the condition. Therefore, a new treatment was designed to reduce post-stroke fatigue complaints: Cognitive and Graded Activity Training (COGRAT).

Rationale: Following the premise that post-stroke fatigue is primarily caused by brain damage, the treatment aims to prevent fatigue and to manage existing fatigue symptoms. The purpose of the added graded activity programme is to reduce fatigue by changing cognitions and enhancing physical fitness.

Theory into practice: COGRAT consists of a cognitive treatment and graded activity programme in small groups over 12 weeks. In the cognitive treatment, patients receive education on post-stroke fatigue and register their activities and fatigue to gain insight into their daily agenda and fatigability. Patients are then taught several compensation strategies. Cognitive behavioural therapy is used to diminish anxiety, facilitate behavioural change and manage fatigue symptoms. The graded activity programme consists of walking on a treadmill, strength training and home work assignments. Maximum heart rate and strength are increased from 40% at the beginning of the training to a maximum of 70%.

Considerations for future improvements: COGRAT is currently being evaluated in outpatients with severe post-stroke fatigue in a multicentre randomized controlled trial. Preliminary data suggest both positive short- and long-term effects. Adaptations for other neurological patient groups suffering from fatigue are suggested.