Internet-Delivered Cognitive Behavioral Therapy Tailored to Spouses and Significant Others of Public Safety Personnel: Formative Evaluation Study

BACKGROUND

Spouses and significant others (SSOs) of public safety personnel (PSP) are affected by the risks and requirements of these occupations. Internet-delivered cognitive behavioral therapy (ICBT) provides a convenient and accessible treatment format that can be tailored to the needs of SSOs of PSP.

OBJECTIVE

This study aimed to assess the initial use and client perceptions (eg, likes, helpfulness, and areas for improvement) of a self-guided, transdiagnostic ICBT course designed for Canadian SSOs of PSP and identify opportunities to further tailor ICBT for this group.

METHODS

SSOs were invited to complete a 5-lesson, self-guided, transdiagnostic ICBT course. Descriptive statistics were used to analyze the demographic and clinical characteristics of participants. Content analysis was used to analyze the data from open-ended survey responses and interviews to understand their experiences with ICBT.

RESULTS

Clients (N=118) endorsed various mental health concerns (eg, depression, anxiety, posttraumatic stress symptoms, and relationship concerns) with a range of severity levels. Most clients identified as White (110/116, 94.8%) and women (108/116, 91.5%), with a mean age of 42.03 (SD 9.36) years. Of the 26 clients who were interviewed, 89% (23/26) reported believing that ICBT is helpful and 92% (24/26) reported finding at least 1 skill helpful. Clients provided suggestions for course improvements. On the basis of this feedback and quantitative data, changes were made to areas such as the delivery of materials, content, case stories, and timelines. Overall, the results indicated that many SSOs of PSP had positive perceptions of ICBT tailored to their needs and found several aspects of the course helpful, supporting the continued delivery of tailored ICBT to this population. However, there remains a need for continued promotion of the course and outreach to diverse groups of SSOs of PSP.

CONCLUSIONS

Findings from this formative evaluation provide insight into the unique experiences and needs of SSOs of PSP and provide preliminary evidence for the use of tailored ICBT to support the mental health of this group in Canada.

Fetal health anxiety: development and psychometric properties of the fetal health anxiety inventory

Objective: To develop a measure to assess fetal health anxiety and examine its factor structure, convergent and divergent validity. Methods: In Study 1, the Short Health Anxiety Inventory-14 item version (SHAI) (Salkovskis et al., Psychol Med. 2002;32:843-853) was adapted for use with pregnant women to examine fetal health anxiety named the Fetal Health Anxiety Inventory (FHAI). Four pregnant women and three subject matter experts (SMEs) reviewed the FHAI. In Study 2, 100 pregnant women completed the FHAI and related self-report measures. Results: In Study 1, both reviewer groups provided feedback directing minor changes to the FHAI. In Study 2, a revised version was used. The revised FHAI demonstrated excellent internal consistency (α = 0.91). Results from an EFA suggested that the FHAI may be conceptualized as a one- or two-factor scale. Convergent (pregnancy-related anxiety [r = 0.56, p = .0001], parental health anxiety [r = 0.53, p = .0001], anxiety [r = 0.57, p = .0001], anxiety sensitivity [r = 0.28, p = .004] and intolerance of uncertainty [r = 0.29, p = .003]) and divergent (parental depression [r = 0.16, p = .12]) validity was evidenced with additional measures of interest. Conclusion: Preliminary findings suggest that the FHAI represents a psychometrically sound instrument to measure the construct of fetal health anxiety. Practical and theoretical implications of the present results are discussed.

Examining the relationships between childhood abuse history, attachment, and health anxiety

This study examined the relationship between childhood abuse experiences and health anxiety in adulthood and investigated the role of attachment in this relationship. In total, 181 university students (aged 18–29 years) completed a battery of measures that assessed childhood abuse, health anxiety, and attachment orientation. Health anxiety was associated with all categories of childhood abuse and overall childhood abuse severity. Anxious attachment partially mediated the relationship between overall childhood abuse and health anxiety in adulthood. The results further our understanding of the relationship between childhood abuse and health anxiety in adulthood and provide support for the interpersonal model of health anxiety.

Adverse childhood experiences and health anxiety in adulthood

Childhood experiences are thought to predispose a person to the development of health anxiety later in life. However, there is a lack of research investigating the influence of specific adverse experiences (e.g., childhood abuse, household dysfunction) on this condition. The current study examined the cumulative influence of multiple types of childhood adversities on health anxiety in adulthood. Adults 18-59 years of age (N=264) completed a battery of measures to assess adverse childhood experiences, health anxiety, and associated constructs (i.e., negative affect and trait anxiety). Significant associations were observed between adverse childhood experiences, health anxiety, and associated constructs. Hierarchical multiple regression analysis indicted that adverse childhood experiences were predictive of health anxiety in adulthood; however, the unique contribution of these experience were no longer significant following the inclusion of the other variables of interest. Subsequently, mediation analyses indicated that both negative affect and trait anxiety independently mediated the relationship between adverse childhood experiences and health anxiety in adulthood. Increased exposure to adverse childhood experiences is associated with higher levels of health anxiety in adulthood; this relationship is mediated through negative affect and trait anxiety. Findings support the long-term negative impact of cumulative adverse childhood experiences and emphasize the importance of addressing negative affect and trait anxiety in efforts to prevent and treat health anxiety.

The technologies of time measurement: implications at the bedside and the bench

This essay explores how chronologically linked indices of health and illness, such as variation in body temperature, achieved clinical and scientific significance. It shows why time has been a potent concept through which key associations among the data of medicine are ordered and revealed, and it examines the graphical and case reporting methods of organizing evidence that made such associations possible.

Linking excellence in teaching to departments' budgets

It is time for the research and clinical practice communities, which dominate medical schools, to realize that the enhanced support of teaching is essential not only for students and society but also because these communities' successes hinge on how well their investigators and clinicians were taught. The need to learn more about the evaluation of teaching should not be a barrier to the productive use of current knowledge about it, which is sufficient for schools to improve the standing and effectiveness of teaching. A greater focus on teaching is even more urgent now because the disbursement of medical school funding is changing, and fewer funds are being allowed for the use of education. Also, other pressures, such as greater demands on faculty time for research and patient care activities and the tendency for research and clinical care to evolve into autonomously governed activities, are distracting faculty from teaching. To establish a superior ethos for education, the author proposes a new approach to faculty compensation and advancement, in which half of the available resources would be distributed according to departmental merit, which would link compensation to the performance of the faculty group composing a department. Performance in both research and teaching in all venues of medical work would be weighed equally. The dean's office would be responsible for making departmental merit awards, using advice and information from faculty, students, and administrative staff, and all decisions would be reviewed with each department chair.(ABSTRACT TRUNCATED AT 250 WORDS)

The ethics of learning and teaching medicine

During the second half of the twentieth century, medicine turned its attention to the ethics of practice. A large and important literature has developed that clarifies the problems generated in the treatment of illness. The same focused attention now should be given to ethical issues and relationships connected with teaching and learning in medicine and to elaborating an ethics of education. Pedagogic relationships anticipate professional relationships. The associations that medical students form with teachers, patients, school, and each other, and the values that shape them have a great influence in determining the sort of physicians students will be. This article examines ethical principles and their application to the relationships and pedagogic problems encountered in studying and teaching medicine. It shows how the introduction of ethics into these areas can not only help students and teachers but also enhance the standing of teaching itself.

Misconduct and the development of ethics in the biological sciences

A variety of cases of scientific misconduct have been documented since the 1980s among biological scientists. These cases have focused the attention of the public and scientific community on this behavior and made it the centerpiece of the concern about ethics in the biological sciences. In contrast, the ethics movement in clinical medicine, which arose in the 1960s, was not basically directed at the problems of wrong-doing. Instead it concentrated on the difficult ethical choices that had to be made In the practice of medicine.

In this essay, I discuss the two movements. The attention given to misconduct In the biological sciences has become excessive and diverts its ethics movement from exploring and teaching about the difficult ethical decisions scientists must make in weighing obligations to self, science, and society. A more balanced and selective approach to developing an ethical framework in the biological sciences is needed.

Criteria for standard versus experimental therapy

This paper demarcates the boundaries between experimental and standard therapy and the influence of this division on policy, payment, and practice. It proposes a new category, crossover therapy, to deal with the many therapies that fall in between. It establishes four criteria to separate these categories: (1) the populations and conditions for which use is helpful; (2) the expected outcomes of care; (3) the skill, personnel, and site requirements and the economic, ethical, and legal understandings essential for use; and (4) the level of knowledge needed to certify that prospective users can apply it well. The paper then explores the use of experimental therapy in desperate situations and of standard therapies in new areas and gives policy recommendations to facilitate these actions.

Creating a course on ethics in the biological sciences

The authors examine the social and scientific context within which a course on the ethical dimensions of the biological sciences was created in the mid-1980s to instruct students at The University of Texas-Houston Health Science Center's Graduate School of Biomedical Sciences. They discuss how the basic purposes of such a course--to help students resolve ethical issues encountered in the scientific work, examine the values underlying science, and explore its relation and obligations to society--may be accomplished, and describe the salience to scientific work of two ethical values significant for science, truthfulness and benefit to others, to demonstrate the application of ethics to science. The present version of the course is described. Particular issues arising in the construction of a course on ethics and science are described, such as gaining faculty support, selecting instructors, constructing a syllabus of topics, using cases in instruction, creating examinations dealing with students from other cultures who may have difficulty with applying and using American values, and evaluating the educational effort.

Overlooking ethics in the search for objectivity and misconduct in science

The author investigates the relationship between the reliability of scientific data and the ethics of the scientist, demonstrates how attention given to misconduct in the biological sciences adversely affects the broader significance of ethics in this field, and extracts from the applications of ethics in medicine perspectives relevant to the biological sciences. As twentieth-century biological scientists applied increasingly powerful methods to diminish bias and to improve the objectivity of their work, including the replication of experimental findings to verify them, they came to believe that these methods would protect their studies from error and misleading conclusions. This assumption has been shown to be unwarranted because it cannot protect scientists from self-conscious or biased selection in reporting evidence. The canons of scientific objectivity must be grounded in something more fundamental--the canon of ethics. In the end, a commitment to the ethical standard of truthfulness, through an understanding of its meaning to science, is essential to enhance objectivity and diminish bias. Unfortunately, the ethos of concern for scientific misconduct continues to dominate the research-ethics movement. This focus is damaging because it turns the attention to seeking and finding wrong-doers and determining punishment rather than discussing generic issues of doing the right thing, preventing harms, seeking benefits, and understanding the right-making and wrong-making characteristics of actions. The focus on scientific misconduct makes ethical issues appear synonymous with legal issues and the search for ethical understanding synonymous with carrying out an investigation.(ABSTRACT TRUNCATED AT 250 WORDS)

Studying science in the context of ethics

The authors describe their experiences in developing and introducing a course on responsible conduct at the Graduate School of Biological Sciences at the University of Texas Health Science Center at Houston. The paper covers issues involved with course faculty, course content and format, and evaluation. At least half of the course time focused on general or case-study discussions of the students and faculty about ethical problems raised in course readings or the students' research experiences. An important issue for institutions trying to encourage students to recognize, reason about, and understand ethical concerns is how the institution itself becomes aware of the ethical implications of its own unconsciously or explicitly stated policies. Such reflection among institutional leaders is critical to fostering the public trust necessary for a profession to sustain its right to self-regulation and its claim of authenticity.

The era of the patient. Using the experience of illness in shaping the missions of health care

The emergence of an era that focuses on the experiences of individuals with illness to provide an alternative voice in health care is explored. Antecedent events that caused the eclipse of the patient and challenged the authenticity of personal experience in establishing medical facts--the introduction of the concept of diseases and the technologic revolution in medicine--are examined. Recent events that returned the patient's views to the center of medical attention--the medical ethics and outcomes movements--are analyzed and connected. Recommendations are presented to make the experience of individuals with illness significant features of health care practice, education, research, and policy, and to reverse the view of patients and subjects as individuals benefited by medicine, but unable to help it.

Consumer competence and the reform of American health care

This report examines the role of the expert in the American health care system, both as provider and administrative policymaker. It shows that the guiding assumption of American health care policy, ie, that the medical system can and should be managed by experts on behalf of consumers and patients, does not hold up to scrutiny. It also demonstrates that the important theme in American history of placing authority and responsibility for action in the hands of the individual has not been sufficiently influential in American health care. Drawing on this theme and creating consumer competence and responsibility in health care choices as the keys to health care reform in the United States are advocated.

The corporate organization of hospital work: balancing professional and administrative responsibilities

The development of the hospital into a corporation has influenced the care of patients and the work of the professional staff. As a corporate enterprise, the modern hospital has a private agenda aimed at increasing growth and efficiency with an emphasis on technical services, professionals as employees, and patients as customers. These changes have resulted in a decrease in trustee and professional authority and an increase in administrative control. This shift in the control structure has continued in response to the need for accounting and regulation of services and in response to demands for increased growth and efficiency made by an increasingly competitive market environment. Strategies for the reorganization of hospital staff aimed at improving both inpatient and outpatient care are reviewed. The reorganization of the institution and staff, using either a staff group-practice corporation or an administrative staff model, is proposed. Clinicians have new responsibilities for developing collective arrangements for institutional governance, for allocating institutional resources, for providing public accountability regarding the use of these resources, and for defining the missions of care.

The intensive care unit. The unfolding ambiguities of survival therapy

The intensive care unit (ICU), one of the great achievements of modern medicine, is both a set of technologies and a space with a special function. This essay traces the evolution of the ICU's crucial technologies, and how the space bearing this name was carved out in the hospital. Ethical, legal, and social developments, an important part of this story, are incorporated in it.

Medical ethics reflected in codes of ethics: the Hippocratic Oath and the 1980 AMA code compared

The Hippocratic Oath and 1980 Code of Ethics of the American Medical Association (AMA) are compared to evaluate the nature of the relationship between students and teachers of medicine and the ethical injunctions that guide practice and make up the essence of the Hippocratic Oath. Such injunctions include the need to take care that harm is not done, to maintain confidentiality, and to avoid acts leading to death. The AMA code is analyzed from the perspective of its injunctions to give competent and compassionate care, to follow the law, to be responsible for guarding patients against incompetent physicians, and to assure that patient care is based on principles of compassion and skill. The centrality of trust in the relationship between patient and doctor as a crucial value in defining a profession is emphasized.

A perspective on ethical issues in technology assessment

In doing technology assessments, it is essential to understand the ethical values used and encountered on the way to reaching judgments and making choices. Some of these values, and the context of their application are discussed. Considered are the application of the do-not-harm principle of medical action, the duty to maintain a scientific medicine, the ethical problems of introducing technologic innovations, and using technology assessments in the allocation of health care resources.

Ethical aspects of organ allocation in transplantation

Of the two major ethical issues surrounding organ allocation-determining criteria for expanding the size of the organ pool and determining criteria for allocation itself-I focus on the issue of allocation, and begin by assuming that there are five main criteria for use in deciding who gets a donor organ: age, medical benefit, merit, ability to pay, and geographical residence. I discuss each of these in turn, eliminating age because it fails to indicate the overall status of a patient's health; eliminating merit because physicians have neither the time nor the ability to act as judges; choosing medical benefit as the best criterion because it is fairest and does not call for such judgements; and leaving open considerations of ability to pay and geographical residence, for application in the event the issue cannot be decided on the ground of medical benefit alone. These criteria, I conclude, are best treated as guidelines, and not as rules.

Assessment and the technologic present

Do we have the will, the power of innovation, to lift ourselves above our own creations and control them? This is the central question of modern medicine, a question which for some time has dominated current discourse in health care and which gave rise in the early 1970s to the field of technology assessment. The technologic armory that has been developed over the past one and a half centuries is vast, formidable, and expanding. Its presence must be reckoned with, and to do this we must begin by understanding our relationship to it.

Codes of medical ethics

With one of the oldest codes of ethics in history, the medical profession continues to arouse controversy. This author examines the fifth major revision of the American Medical Association's code of ethics, published in 1957. Within this revision are the basic premises in establishing a medical code of ethics. Subsequent ethical dilemmas, involving technology, for example, can still be applied to the 1957 fundamental code.

Responsibility for personal health: a historical perspective

Reflections about the role of human choice in determining personal health occur in the writings of practitioners and laymen throughout history. THe Greek and Roman writers emphasized the effect of life's activities. During the Middle Ages and Renaissance, disease continued to be seen as a consequence of disorder of the bodily humors, which were under the individual's control. THe rise of the paternalistic national regimes in Europe produced the view that society had the responsibility to maintain health. Jacksonian egalitarianism led to a reaction against the aggressive therapies of established professional experts, a view furthered by the Thomsonian belief that people should wrist control of their health away from orthodox physicians. Among the twentieth century reactions was the movement to urge people to have doctors evaluate laypersons' health. By the 1970s a movement emerged emphasizing again personal responsibility, which, in turn, produced a concern that this was merely "victim-blaming". Views on the role of lay people in determining personal health are heavily influenced by prevailing social, political, and moral climates.

Technology, specialization, and the allied health professions

Medical specialization has been made possible through the evolution and dominance of the anatomic theory of disease and the growth of technology. Through the view offered by anatomy, the idea of dividing and studying portions of the body seemed natural and desirable. Through technology, diagnostic and therapeutic actions on these parts became possible. Specialization has affected all aspects of medicine, particularly the allied health professions. The narrow perspective on illness that specialization can produce in allied health professionals may be forestalled through systematic educational efforts to broaden their understanding of illness by delineating the ethical dimensions of their relationship to patients, creating a view of their place in the historical evolution of medicine, and examining how technology influences medicine and its role in shaping allied health careers.

Ethics rounds: a model for teaching ethics in the psychiatric setting

Despite growing interest in ethical matters in psychiatry, little attention has been paid to means of teaching ethics to mental health professionals. In a monthly "ethics rounds" developed in a community mental health center, the co-leaders of the rounds visited one of the center's clinical services during a regularly scheduled staff conference to lead a discussion of a case selected by the staff and the underlying ethical problems. The rounds were attended by personnel at all levels and from a variety of disciplines. A survey of participants showed that the program was generally well received. Two cases selected for discussion at the rounds--one concerned with confidentiality and the other with court-ordered treatment--are presented, along with the discussion that each case stimulated. The advantages and disadvantages of the model are discussed, and suggestions for implementing a similar program are offered.

Words as scalpels: transmitting evidence in the clinical dialogue

This paper examines rationales and policies developed by physicians through history about what to tell patients found to have serious illness. The widespread belief among doctors that the revelation of threatening news causes patients considerable anguish and seriously erodes the prospect of maintaining their hope encouraged a policy of concealment for many centuries. Arguments that encourage candor have been increasingly pressed during the last two centuries. Advocates point out that candor can be beneficial and is favored by many patients, and that a policy of concealment usually fails to work, tends to place stress on patients by constraining discussion of anxieties generated by vague or explicit knowledge of the true situation, and exerts a damaging effect on trust in the medical relationship. Not only the moral aspects of this problem but also its clinical dimensions, such as mastering the skill to discuss threatening news with patients, bear considerable scrutiny by physicians and medical educators.

Refusing treatment for mental illness: historical and ethical dimensions

The author summarizes the historical bases for overzealous intervention by physicians, noting the tensions among medical technology, nature as a healing force, and the physician's warrant to treat. He discusses John Mill's On Liberty and Gerald Dworkin's "Paternalism" and suggests that there are times when the intervention should be withheld, but never the care.