Meta-analytic investigation of the effectiveness of self-regulatory components in the treatment of adult problem behaviors

Toward a synthesis of cognitive behaviour therapy via component analysis of self-regulation

The cognitive behavioural therapies (CBTs) are the choice psychotherapies for many clinicians treating a wide range of adult psychological disorders including various anxieties, mood, substance use, eating, schizophrenia and personality-related. Empirical research in the CBTs is ever increasing, and the accumulating evidence supporting efficacious treatments is substantial and well documented. However, with prolific research comes a seemingly accelerating and worrying trend of purportedly different therapies, and numerous hybrids and combinations of therapies and techniques. For many clinicians this is increasingly confusing and not helpful in clinical practice. This article is a critique of current trends and directions in clinical research, which show signs of limited effectiveness, fragmentation, and obfuscation. An alternative strategy is proposed-examining transdiagnostic therapeutic effects, which appear related to treating pervasive dysregulated emotions, with component analyses of four principal self-regulation components (viz., self-monitoring; functional analysis; identifying values, goals and treatment-plans; and feedback). Such a strategy is likely to lead to a more coherently synthesized and effective CBT.

Training Willpower: Reducing Costs and Valuing Effort

The integrative model of effortful control presented in a previous article aimed to specify the neurophysiological bases of mental effort. This model assumes that effort reflects three different inter-related aspects of the same adaptive function. First, a mechanism anchored in the salience network that makes decisions about the effort that should be engaged in the current task in view of costs and benefits associated with the achievement of the task goal. Second, a top-down control signal generated by the mechanism of effort that modulates neuronal activity in brain regions involved in the current task to filter pertinent information. Third, a feeling that emerges in awareness during effortful tasks and reflects the costs associated with goal-directed behavior. The aim of the present article is to complete this model by proposing that the capacity to exert effortful control can be improved through training programs. Two main questions relative to this possible strengthening of willpower are addressed in this paper. The first question concerns the existence of empirical evidence that supports gains in effortful control capacity through training. We conducted a review of 63 meta-analyses that shows training programs are effective in improving performance in effortful tasks tapping executive functions and/or self-control with a small to large effect size. Moreover, physical and mindfulness exercises could be two promising training methods that would deserve to be included in training programs aiming to strengthen willpower. The second question concerns the neural mechanisms that could explain these gains in effortful control capacity. Two plausible brain mechanisms are proposed: (1) a decrease in effort costs combined with a greater efficiency of brain regions involved in the task and (2) an increase in the value of effort through operant conditioning in the context of high effort and high reward. The first mechanism supports the hypothesis of a strengthening of the capacity to exert effortful control whereas the second mechanism supports the hypothesis of an increase in the motivation to exert this control. In the last part of the article, we made several recommendations to improve the effectiveness of interventional studies aiming to train this adaptive function."Keep the faculty of effort alive in you by a little gratuitous exercise every day."James (1918, p. 127).

Health Goal Attainment of Patients With Chronic Diseases in Web-Based Patient Communities: Content and Survival Analysis

Background

Activities directed at attaining health goals are a major part of the daily lives of those fighting chronic diseases. A proliferating population of patients with chronic diseases are participating in web-based patient communities, wherein they can exchange health information and pursue health goals with others virtually.

Objective

In this study, we aimed to understand the effect of participation in social media–enabled web-based patient communities on health goal attainment. In particular, we studied the antecedents of health goal attainment in terms of social support and self-reflection in web-based patient communities.

Methods

This data set consists of web-based health management activities of 392 patients across 13 health support groups, that is, groups with medical issues such as high blood pressure, diabetes, and breast cancer; the data of the activities were collected from a leading web-based patient community. Content analysis was used to code the social interactions among the patients on the web-based platform. Cox regression for survival analysis was used to model the hazard ratio of health goal attainment.

Results

Our analysis indicated that emotional support from web-based patient communities can increase patients’ probability of achieving their goals (hazard ratio 1.957, 95% CI 1.416-2.706; P<.001) while informational support does not appear to be effective (P=.06). In addition, health-related self-reflection increases the patients’ likelihood of goal attainment through web-based patient communities (hazard ratio 1.937, 95% CI 1.318-2.848; P<.001), but leisure-oriented self-reflection reduces this likelihood (hazard ratio 0.588, 95% CI 0.442-0.784; P<.001).

Conclusions

Social media–enabled web-based platforms assist health goal management via both social interaction and personal discipline. This study extends the understanding of web-based patient communities by investigating the effects of both social and cognitive factors on goal attainment. In particular, our study advocates that health goals relating to chronic conditions can be better managed when patients use the facilities of web-based health communities strategically.

The impact of an mHealth app on knowledge, skills and anxiety about dressing changes: A randomized controlled trial

AIMS

To evaluate the effectiveness of a mobile health (mHealth) application, based on self-regulation theory, on patients' knowledge of wound care, skills in changing dressings and anxiety.

DESIGN

A prospective randomized controlled trial.

METHODS

Seventy patients (or family members) at a 1,500-bed university hospital in Taiwan were randomized into an experimental (N = 35) or control group (N = 35) from March to December 2016. The experimental group used a mHealth application for wound care; the control group received verbal instructions and a booklet. Instruments to collect data were a wound care knowledge scale, wound care skills scale, State-Trait Anxiety Inventory, and a digital heart variability device. Data were collected at baseline, after three additional demonstrations and before discharge. The generalized estimating equation was used for statistical analysis.

RESULTS

The experimental group showed significantly higher levels of wound care knowledge, improved wound care skills, lower levels of state anxiety, and lower heart rate variability than the control group after baseline data collection.

CONCLUSIONS

Results support hat a mHealth application may be effective in health education. Clinicians can use the results to promote patients' wound care knowledge, enhance their wound care skills, and reduce anxiety related to dressing changes.

IMPACT

Lack of wound care knowledge and skills can affect the willingness and ability to perform effective wound dressing changes, producing anxiety and having an impact on a patient's self-care after hospital discharge. mHealth applications (apps) have the potential to deliver health information in targeted and tailored ways that strengthen the self-management of diseases. mHealth app can increase wound care knowledge, improve care skills, and reduce anxiety related to wound care. mHealth app effectively supports self-monitoring of the wound healing process, self-judgement of the wound condition, and self-reaction of wound care accuracy. mHealth app provides step-by-step visual tutorials on wound care that allow patients and family caregivers to take pictures of the wounds and monitor the wound healing process. mHealth app for wound care knowledge is an effective and individualized method for learning.

CLINICAL TRIAL

This study was registered by U.S. National Library of Medicine, ClinicalTrials.gov (ID: NCT03683303).

Hazardous Alcohol Consumption Moderates the Relationship Between Safer Sex Maintenance Strategies and Condomless Sex With Clients Among Female Sex Workers in Mexico

Understanding the relationship between cognitive and behavioral processes and long-term behavior change is critical to developing behavior change maintenance interventions. We examined the relationship between cognitive and behavioral safer sex maintenance strategies and condomless vaginal/anal sex with clients among female sex workers (FSWs) in Mexico. We hypothesized a moderating effect of hazardous alcohol use, such that the relationship between the use of safer sex maintenance strategies and condomless sex would be weaker among FSWs who meet criteria for hazardous alcohol consumption. Data were gathered from 602 FSWs enrolled in a sexual risk reduction intervention with a text messaging maintenance component. Seven cognitive and behavioral strategies purported to be critical in sustaining long-term behavior change were measured (e.g., maintenance self-efficacy). The relationship between FSWs’ use of safer sex maintenance strategies and condomless vaginal/anal sex with clients was moderated by hazardous alcohol consumption. The association was weaker among FSWs who met criteria for hazardous alcohol consumption. Among FSWs who met criteria for hazardous alcohol consumption, maintenance self-efficacy was associated with fewer condomless sex acts with clients ( b = −0.35, p < .001). Among FSWs who did not meet criteria for hazardous alcohol consumption, recovery self-efficacy ( b = −0.21, p < .05) and self-monitoring ( b = −0.34, p < .001) were associated with fewer acts of condomless sex. Results indicate the importance of examining the multidimensional nature of safer sex maintenance strategies and of exploring subgroup differences in their associations with behavioral outcomes. Interventions that address safer sex maintenance strategies in the context of alcohol treatment should be developed for this subgroup of FSWs.

A Comparison of Four Measures of Self-Control Skills

This study compares the psychometric characteristics of four questionnaires designed to assess self-control skills: the Self-Control Questionnaire, the Frequency of Self-Reinforcement Questionnaire, the Cognitive Self-Management Test, and the Lifestyle Approaches Inventory. Content validity was judged to be fairly comparable by three raters in Study 1. In Study 2, convergent and divergent validity support was obtained for all four questionnaires when administered to 369 multiethnic college students, but the relative degree of support varied across constructs. Hence, selection of a self-control instrument may be guided by the target behavior of interest.

The role of self-monitoring in the maintenance of weight loss success

INTRODUCTION

Self-monitoring has been shown to be a crucial part of initial weight loss success in behavioral interventions. However, little is known about the impact of self-monitoring during the period following initial treatment.

METHODS

The current study examined the role of self-monitoring on weight loss during an initial 6-month intervention period (Phase 1) and a 12-month extended care period (Phase 2) in a group of 167 obese women (M±SD: BMI=37.0±5.1kg/m(2), age=59.9±6.2years) enrolled in a behavioral weight loss program.

RESULTS

Cluster analysis identified three groups of participants with low, moderate, and high rates of weight loss success during Phase 1 and Phase 2. A one-way ANOVA revealed no significant differences in self-monitoring frequency between groups during Phase 1 (p=.645), but significant differences between all three groups during Phase 2 (p=.001). High success participants completed the most self-monitoring records, followed by the moderate group. The low success group completed the least number of records. Furthermore, self-monitoring during Phase 2 significantly mediated the relationship between extended-care session attendance and percent weight change during that time (95% CI [-.004, -.001], p<.001).

CONCLUSION

These results highlight the importance of continuing self-monitoring after the initial phase of treatment to maintain lost weight.

Social network correlates of participation in telephone continuing care for alcohol dependence

BACKGROUND AND OBJECTIVES

Research on face-to-face treatment for substance misuse suggests that patients' social networks may impact treatment entry and participation, but there has been no similar research on entry and participation in telephone-based continuing care. We examined whether alcohol-specific social support predicted engagement and participation in telephone continuing care for alcohol dependence, and whether treatment participation resulted in beneficial changes in participants' social networks.

METHODS

Participants were 252 adults (162 male) enrolled in a randomized clinical trial testing the effectiveness of telephone continuing care for alcohol dependence. Participants who completed 3 weeks of intensive outpatient treatment were randomly assigned to treatment as usual, telephone monitoring (TM; N = 83), or telephone monitoring and brief counseling (TMC; N = 83). TM and TMC included 18 months of telephone treatment. Alcohol-specific social support was measured with the Important People Inventory at baseline and 6, 12, 18, and 24-month follow-up.

RESULTS

Alcohol-specific social support did not predict entry into TM or TMC. Among those who entered telephone treatment (N = 127), participants with higher network percentage of daily drinkers, higher percentage of network members who accept drinking, and lower percentage of network members who do not accept drinking completed more continuing care calls. There was no effect of continuing care participation on alcohol-specific social support over 24 months of follow-up.

CONCLUSION

Participants with more problematic social networks may self-select additional support in the form of telephone continuing care. Telephone continuing care does not appear to result in social network change.

Who Uses Smoking Cessation Apps? A Feasibility Study Across Three Countries via Smartphones

Background

Smartphone use is growing worldwide. While hundreds of smoking cessation apps are currently available in the app stores, there is no information about who uses them. Smartphones also offer potential as a research tool, but this has not previously been explored.

Objective

This study aims to measure and compare the uptake of a smoking cessation app over one year in Australia, the United Kingdom, and the United States. It also assesses the feasibility of conducting research via an app, describing respondents’ characteristics (demographics, smoking status, and other health related app use), and examining differences across countries.

Methods

This is a cross-sectional exploratory study of adults 18 years and older, passively recruited over one year in 2012, who downloaded this study app (Quit Advisor) via the two largest app stores (Apple and Android).

Results

The total number of app downloads after one year was 1751, 72.98% (1278/1751) of them were Apple operation system users. Of these 1751 participants, 47.68% (835/1751) were from the United States, 29.18% (511/1751) were from the United Kingdom, and 16.68% (292/1751) were from Australia. There were 602 participants, 36.75% (602/1638) that completed a questionnaire within the app. Of these 602 participants, 58.8% (354/602) were female and the mean age was 32 years. There were no significant differences between countries in terms of age, operation system used, number of quitting attempts, and language spoken at home. However, there were significant differences between countries in terms of gender and stage of change. There were 77.2% (465/602) of the respondents that were ready to quit in the next 30 days and the majority of these had never sought professional help (eg, “Quitline”). More than half had downloaded smoking cessation apps in the past and of these, three-quarters had made quitting attempts (lasted at least 24 hours) using an app before. Respondents who had attempted to quit three times or more in the previous year were more likely to have tried smoking cessation apps (OR 3.3, 95% CI 2.1-5.2). There were 50.2% (302/602) of the respondents that had used other health related apps before. Of these, 89.4% (270/302) were using health related apps at least once a week, but 77.5% (234/302) never checked the credibility of the health app publishers before downloading.

Conclusions

A smartphone app was able to reach smokers across three countries that were not seeking professional help, but were ready to quit within the next 30 days. Respondents were relatively young and almost demographically similar across all three countries. They also frequently used other health related apps, mostly without checking the credibility of their publishers.

Home telehealth: facilitators, barriers, and impact of nurse support among high-risk dialysis patients

OBJECTIVE

The value of home telehealth self-monitoring with nurse oversight has been demonstrated; however, there is a dearth of objective documentation of patients' experiences with such a model. We used a mixed methods approach to examine the value of home telehealth monitoring with remote care nurse (RCN) support from the perspective of participants in our study.

MATERIALS AND METHODS

Thirty-three patients who used remote technology to self-monitor their health at home participated in a semistructured interview. The instrument was designed to help identify facilitators and barriers and to evaluate patient satisfaction with and effectiveness of home telehealth self-monitoring.

RESULTS

Overall, patients reported high levels of satisfaction with RCN support as they received efficient feedback, were better able to identify changes in their health status, and experienced enhanced accountability, self-efficacy, and motivation to make health behavior changes. The most frequently cited barriers related to malfunctioning equipment or trouble with Internet connections, forgetfulness, and feeling poorly.

CONCLUSIONS

The results suggest that home telehealth self-monitoring with RCN support is effective in empowering patients to take a more active role in their healthcare and indirectly improve quality of life for those living with chronic illness.

Intermittent exercise in response to cigarette cravings in the context of an Internet-based smoking cessation program

BACKGROUND

Interventions using sustained aerobic exercise programs to aid smoking cessation have resulted in modest, short-term cessation rates comparable to conventional cessation methods. No smoking cessation trial to date has prescribed intermittent bouts of exercise in response to nicotine cravings.

OBJECTIVES

This pilot randomized controlled trial examined the feasibility and efficacy of an Internet-based smoking cessation program alone (CON) vs. the same Internet-based program + intermittent exercise in response to cigarette cravings (EX).

STUDY POPULATION

Participants (N = 38; mean age = 43.6 [SD = 11.5]; 60.5% women) were generally healthy, inactive adult smokers who desired to quit.

RESULTS

The overall retention rate was 60.5% (n = 23), and no significant retention rate differences were found between groups (EX vs. CON). Although retained participants achieved a higher cessation rate (26.1%) than all enrolled participants (15.8%), adjusted intent-to-treat and per-protocol binary logistic regression analyses revealed no significant cessation rate differences between EX and CON groups. Linear regression results indicated that additional days of self-reported exercise on the study website during the intervention phase predicted significantly higher reduction rates among EX group participants, F(2, 16) = 31.08, p < .001.

CONCLUSIONS

Results were mixed with regard to the incremental benefit of exercise in the presence of the apparently valuable Internet-based smoking cessation program. The results support findings from related research and underscore the need for additional investigation into both the mechanisms underlying the effect of exercise on cigarette cravings and the challenges of poor adherence in the context of exercise-based smoking cessation interventions.

Self-help therapies for sexual dysfunction

Self-help approaches can be relevant for individuals with sexual difficulties who cannot visit a therapist yet have sufficient coping skills and motivation to adhere to the advice and prescriptions included in the self-help method. Self-help can facilitate the transfer of treatment gains to the unassisted situation at home and thus reduce generalization difficulties from therapist setting to the home setting. They may prevent the development of client's codependency on therapist support and can help boost the client's sense of self-efficacy. Several self-help approaches were found to be efficacious, both statistically and clinically, in the treatment of several types of sexual dysfunction. The outcome is qualified by problem type, client characteristics, and delivery format of the self-help. The methods that are offered vary from cookbook-like protocols, which need to be followed in a stepwise and strict fashion, to strategies requiring the user to self-adapt a general problem-solving method to his or her personal situation, thereby enabling the individual to become his or her own therapist.

The relationship of self-regulation and aggression: an empirical test of personality systems interaction theory

On the basis of personality systems interaction (PSI) theory, the authors examine self-regulation, conflict behaviour, behavioural resources, and personality disorders in a sample of 83 male offenders and explore the role self-regulatory variables play with respect to aggressive behaviour. Although substantial correlations between self-regulatory functions and aggressive behaviour were found, these variables did not predict aggression in a subsequent regression analysis with measures of self-regulation, conflict behaviour, and personality disorders as independent variables. Antisocial behaviour, behavioural self-control, and affect were among the strongest predictors of aggression. Specific predictions based on PSI theory could not be confirmed. Theoretical implications of the findings are discussed and put into relation with treatment issues of offenders.

Aggressive behavior in male offenders: preliminary analyses of self-regulatory functions in a sample of criminals

The functional role of self-regulation in aggressive and violent behavior continues to be an important problem in the forensic field. Theoretically, self-regulatory functions should influence other dimensions known to be related to aggressive behavior, but as of yet there is no empirical test of this assumption. Emotional self-regulation, conflict behavior, behavioral resources, and personality disorders were examined in a sample of 70 offenders with respect to the role that self-regulatory variables play in aggressive behavior. Although substantial correlations between self-regulator functions and aggressive behavior were found, these variables did not predict aggression in a subsequent regression analysis. Implications of the findings are discussed and put into relation with treatment issues of aggressive offenders.

A concept analysis of self-monitoring

AIM

This paper reports a concept analysis delineating and clarifying the concept of self-monitoring to facilitate development and evaluation of interventions to enhance self-monitoring.

BACKGROUND

The concepts of self-monitoring, self-management, self-care and symptom management are often used in similar or interchangeable ways. Clarification of the concept of self-monitoring is needed for research and theory development.

METHOD

Rodgers and Knafl's evolutionary concept analysis process was used to delineate and clarify the concept. The PubMed and CINAHL databases were searched using keywords 'self-monitoring', 'self-management' and 'self-care' (with and without the hyphen) for the years 1998-2005, to update a previous study (not published). Later, searching was refined and the keyword 'self-monitoring' was paired with 'awareness' and 'self-regulation' was added. Approximately half the papers were from nursing (n = 34) and half from other disciplines (n = 32). The sample from 1998 to 2005 was further stratified by chronic condition. Definition, exemplars, usage, attributes, antecedents/consequences and implications for further study were identified.

FINDINGS

Self-monitoring was composed of two complementary components (attributes): (1) awareness of bodily symptoms, sensations, daily activities, and cognitive processes and (2) measurements, recordings and observations that inform cognition or provide information for independent action or consultation with care providers.

CONCLUSION

Self-monitoring may be an important concept for understanding how people self-manage chronic conditions. This concept analysis may be useful for researchers who wish to measure this dimension and to develop nursing theory in this area.

Self-regulation in violent and non-violent offenders: a preliminary report

BACKGROUND

The functional role of self-regulation in violent behaviour is not yet fully understood.

AIM

To test the hypothesis that violent offenders have more deficits in self-regulation and self-control than non-violent offenders.

METHODS

Self-regulation and personality disorders were evaluated in a sample of 70 violent and non-violent incarcerated offenders using the Volitional Components Questionnaire (VCQ) and the SCID-II for DSM-IV.

RESULTS

The self-report data indicate that violent offenders were no different from non-violent offenders on either facilitatory or inhibitory modes of self-regulation and self-control. Compared with a sample of normal, healthy men, differences were found in all tested self-regulation variables but not in self-control. Except for antisocial personality, the groups were similar in personality features.

CONCLUSIONS

The proposed hypothesis was not sustained on this measure of self-regulation. With regard to self-regulation and self-control, violent and non-violent offenders were similar and treatment interventions to improve capacity in these respects are probably useful for both groups.

Is goal planning in rehabilitation effective? A systematic review

Objective: To determine the evidence regarding the effectiveness of goal planning in clinical rehabilitation.

Design: Systematic review.

Method: MEDLINE, EMBASE, PsycINFO, CINAHL, AMED, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, American College of Physicians (ACP) Journal Club, and the Database of Abstracts of Reviews of Effects (DARE) were searched for randomized controlled trials on the therapeutic effectiveness of goal planning in the rehabilitation of adults with acquired disability. Studies were categorized by patient population and the clinical context of the study. Data were analysed using best-research synthesis, based on methodological quality determined by Physiotherapy Evidence Database (PEDro) scale scores.

Results: Nineteen studies were included in this review. Study populations in these papers included patients with neurological disorders, psychiatric disorders, musculoskeletal disorders, cardiovascular disorders, respiratory disorders and dietary/endocrine disorders. Six studies investigated the immediate effects of goal planning on patient behaviour. Thirteen studies investigated the effects of goal planning in the context of a rehabilitation programme lasting more than one week. Some limited evidence was identified that goal planning can influence patient adherence to treatment regimes and strong evidence that prescribed, specific, challenging goals can improve immediate patient performance in some specific clinical contexts. However, evidence regarding how these effects translated to improved outcomes following rehabilitation programmes was inconsistent.

Conclusions: This review identified that while some studies demonstrated positive effects associated with goal planning in local contexts, the best available empirical evidence regarding the generalizable effectiveness of goal planning was inconsistent and compromised by methodological limitations.

Self-regulation and goal theories in brain injury rehabilitation

Goal planning is a central concept in the clinical practice of rehabilitation. Several disciplines within psychology and medicine have elaborated theories related to goal attainment and self-regulation, the process of managing one's own goal-directed behavior. These theories may be highly relevant to brain injury rehabilitation both to help address characteristic deficits in executive function and to teach clients how to manage life tasks outside of formal rehabilitation. In this article, we describe testable, theoretically motivated interventions at 2 levels: the goal level focused on attaining or enhancing performance on individual tasks and the self-regulation level of metacognitive processes involved in planning and managing one's own goal-directed behavior. We also discuss issues in experimental methodology that are important to adapting this area of research to brain injury rehabilitation, including consideration of cognitive status and other individual differences in selecting the participant sample, choice of between-subjects versus within-subjects experimental design, and selection of appropriate outcome measures.

Langzeiteffekte einer Planungs- und Handlungskontrollintervention auf die körperliche Aktivität von Herzpatienten nach der Rehabilitation

Zusammenfassung. Personen, die Intentionen haben, körperlich aktiver zu werden, scheitern oft an der Umsetzung dieser Intentionen in Verhalten. Zur Überwindung dieser “Intentions-Verhaltens-Lücke“ bieten sich die volitionalen Konstrukte Ausführungsplanung, Bewältigungsplanung und Handlungskontrolle an. Die vorliegende Studie untersuchte die Effektivität einer Intervention zur Verbesserung der Ausführungsplanung, der Bewältigungsplanung und der Handlungskontrolle auf die körperliche Aktivität ein Jahr später im Vergleich zu einer Kontrollgruppe. Weiterhin sollte anhand von Mediatoranalysen ermittelt werden, welche der drei volitionalen Konstrukte die Wirksamkeit der Intervention maßgeblich beeinflussten. Teilnehmer der Studie waren 199 Herzpatienten, die nach Entlassung aus der Rehabilitation einen körperlich aktiven Lebensstil aufnehmen und aufrechterhalten sollten und die auch über eine entsprechende Intention berichteten. Die Ergebnisse zeigen, dass die Intervention die körperliche Aktivität der Teilnehmer, verglichen mit einer Kontrollgruppe, ein Jahr später positiv beeinflusst hat. Die Handlungskontrolle mediierte den Interventionseffekt auf die körperliche Aktivität. Implikationen für die Übertragung der Ergebnisse in die Praxis sowie für die weitere Forschung werden diskutiert.

Is there a case for extended interventions for alcohol and drug use disorders?

AIMS

To determine whether there is evidence to support the implementation of extended interventions (i.e. longer than 6 months) for individuals with alcohol or other drug use disorders.

METHODS

Literature on extended behavioral and pharmacotherapy interventions was reviewed, along with findings from studies of extended monitoring and monitoring paired with adjunctive counseling. Studies were identified through database searches, citations in prior reviews and examinations of recent volumes of relevant journals. Key terms were defined, and a theoretical rationale was presented for extended treatment. Several adaptive treatment studies that made use of stepped care or continuation protocols were also described.

MEASUREMENTS

The primary outcomes that were considered were alcohol and drug use during the intervention and post-intervention follow-ups. Other outcomes were examined when they were included in the articles reviewed.

FINDINGS

Most of the studies in the review provided support for the effectiveness of extended interventions for alcohol and drug abusers, whether the extended care was delivered through face-to-face contact or via the telephone. These findings held across all types of interventions that were examined (e.g. behavioral treatment, pharmacotherapy and monitoring). However, only a few studies directly compared extended and standard length version of the same intervention. New developments in addiction treatment with implications for extended care models were also described and discussed.

CONCLUSIONS

The findings of the review indicate that maintaining therapeutic contact for extended periods of time with individuals with alcohol and other drug disorders appears to promote better long-term outcomes than 'treatment as usual', although more studies are needed that compare extended and standard versions of interventions. Achieving good compliance and successful disease management with extended interventions will probably require adaptive protocols in which the intensity of treatment can be adjusted up or down in response to changes in symptoms and functioning over time. Future directions in research on extended interventions were discussed.

Pharmacotherapy of anxiety

The pharmacological treatment of anxiety has a long and chequered history, and recent years have seen a rich development in the options available to prescribers. Most of the currently used anxiolytic agents act via monoaminergic (chiefly serotonin) or amino acid (GABA or glutamate) neurotransmitters, and this chapter describes the pharmacology of the major drug groups. Clinical applications are discussed with respect to the five major anxiety disorders, as well as simple phobia and depression with concomitant anxiety. Prospective future developments in the field are considered.

THE IMPACT OF LIFE COACHING ON GOAL ATTAINMENT, METACOGNITION AND MENTAL HEALTH

Despite its high media profile and growing popularity there have been no empirical investigations of the impact of life coaching on goal attainment, metacognition or mental health. This exploratory study used life coaching as a means of exploring key metacognitive factors involved as individuals move towards goal attainment. In a within-subjects design, twenty adults completed a life coaching program. Participation in the program was associated with enhanced mental health, quality of life and goal attainment. In terms of metacognition, levels of self-reflection decreased and levels of insight increased. Life coaching has promise as an effective approach to personal development and goal attainment, and may prove to be a useful platform for a positive psychology and the investigation of the psychological mechanisms involved in purposeful change in normal, nonclinical populations.

A three-component model for reengineering systems for the treatment of depression in primary care

Depression in primary care is a chronic disease. As with most chronic diseases, long-term adherence to treatment plans is problematic. Evidence-based systems of care address this problem, but persistence and dissemination of systems after testing is a new problem. The three-component model for the care of patients with depression is a system of widely applicable, easily transported strategies and materials to address dissemination. The three-component model provides a series of routines (processes for structured diagnostic and follow-up-care with a time line) and division of responsibility, including a role for a telephone care manager. In the three-component model, clinician and office education create a prepared practice that is predisposed to providing evidence-based depression management. Enabling elements include the telephone care managers, who are trained to promote adherence to a management plan, and a supervising psychiatrist. The key reinforcing element is care manager reports about patient response to treatment. The three-component model is bound together by a common depression diagnostic and severity measure that facilitates communication and treatment decisions.

Self-control skills and negative emotional state: a focus on hostility

The self-control theory of psychopathology has contributed to the understanding and treatment of unipolar depression. This paper explores the relationship between self-control skills as measured by the Frequency of Self-reinforcement Questionnaire and other negative emotional states, with a focus on hostility. In Study 1, scores on the Brief Symptom Inventory were inversely related to self-control skills among a sample of 53 college students, suggesting potential generalizability of the theory. In Study 2, self-control skills were inversely related to hostility, anger, and aggression among a sample of 68 college students. The role of self-control skills in the regulation of hostility deserves further investigation.