A Systematic Review of Group Social Skills Interventions, and Meta-analysis of Outcomes, for Children with High Functioning ASD

Group social skills interventions (GSSIs) are a commonly offered treatment for children with high functioning ASD. We critically evaluated GSSI randomised controlled trials for those aged 6–25 years. Our meta-analysis of outcomes emphasised internal validity, thus was restricted to trials that used the parent-report social responsiveness scale (SRS) or the social skills rating system (SSRS). Large positive effect sizes were found for the SRS total score, plus the social communication and restricted interests and repetitive behaviours subscales. The SSRS social skills subscale improved with moderate effect size. Moderator analysis of the SRS showed that GSSIs that include parent-groups, and are of greater duration or intensity, obtained larger effect sizes. We recommend future trials distinguish gains in children’s social knowledge from social performance.

The enriched environment ameliorates chronic unpredictable mild stress-induced depressive-like behaviors and cognitive impairment by activating the SIRT1/miR-134 signaling pathway in hippocampus

BACKGROUND

Chronic unpredictable mild stress (CUMS) is an important risk factor for depression and cognitive deficits in humans. Enriched environment (EE) showed a beneficial effect on depression and cognition by enhancing brain derived neurotrophic factor (BDNF) expression and synaptic plasticity. However, it is still not clearly understood whether an epigenetic mechanism is involved in the BDNF modulation and synaptic plasticity that occurs after EE treatment for the depressive-like behaviors and cognitive deficits elicited by CUMS. In this study, we investigated the possible mechanism of the neuroprotective effect of EE.

METHODS

All rats were exposed to the 5-week CUMS procedure except the control group. After CUMS procedure, some rats were stereotaxically injected with SIRT1 pharmacologic inhibitor EX527 or SIRT1 knocking down lentivirus (sh-SIRT1) in the hippocampus followed by EE treatment for 3 weeks. Other rats were directly subjected to EE treatment without stereotaxic injection. Behavioral tests were used to appraise depression and cognition after EE treatment. Then epigenetic molecules, synaptic proteins, dendritic spine density and branches, and synaptic morphology of the dorsal hippocampus were determined.

RESULTS

We found that CUMS induced depressive-like behaviors including decreased sucrose preference ratio, prolonged immobility and reduced locomotor and exploratory activity; cognitive deficits including spatial learning and memory impairment; reduced dendritic spine density and number of branches; thinned postsynaptic density; downregulated SIRT1/microRNA-134 pathway, decreased BDNF and synaptic proteins including synaptophysin (SYN) and postsynaptic density protein 95 (PSD95) expression in the hippocampus. However, the CUMS-induced depressive-like behaviors, cognitive deficits, dendritic spine density and branch number reduction, postsynaptic density thinning, SIRT1/microRNA-134 pathway downregulation, BDNF and synaptic proteins reduction, including synaptophysin (SYN) and postsynaptic density protein 95 (PSD95), were reversed by EE treatment. However, depressive-like behaviors and cognitive deficits were observed again in rats subjected to stereotaxic injection with EX527 or sh-SIRT1. Furthermore, this study also found that SIRT1/microRNA-134 regulates the downstream molecules BDNF, and the synaptic proteins SYN and PSD95 in primary cultured hippocampal neurons.

CONCLUSIONS

This study provides evidence for the neuroprotective role of EE on depression and cognitive deficits by activating the SIRT1/microRNA-134 pathway, which accounts for the regulation of synaptic proteins, including BDNF, PSD95 and SYN, dendritic remodeling and ultrastructure changes of synapses in the hippocampus.

Enhancing social functioning in young people at Ultra High Risk (UHR) for psychosis: A pilot study of a novel strengths and mindfulness-based online social therapy

BACKGROUND

Psychological and pharmacological treatments have been shown to reduce rates of transition to psychosis in Ultra High Risk (UHR) young people. However, social functioning deficits have been unresponsive to current treatments.

AIMS

The study aims were to: i) describe the theoretical basis and therapeutic targets of a novel intervention targeting social functioning in UHR young people; and ii) examine its acceptability, safety and preliminary effect on social functioning.

METHODS

An international, multidisciplinary team developed a new intervention (MOMENTUM) to improve social functioning in UHR young people. MOMENTUM blends two novel approaches to social recovery: strengths and mindfulness-based intervention embedded within a social media environment, and application of the self-determination theory of motivation. The acceptability and safety of MOMENTUM were tested through a 2-month pilot study with 14 UHR participants.

RESULTS

System usage was high, with over 70% of users being actively engaged over the trial. All participants reported a positive experience using MOMENTUM, considered it safe and would recommend it to others. 93% reported it to be helpful. There were large, reliable improvements in social functioning (d = 1.83, p < 0.001) and subjective wellbeing (d = 0.75, p = 0.03) at follow-up. There were significant increases in the mechanisms targeted by the intervention including strengths usage (d = 0.70, p = 0.03), mindfulness skills (d = 0.66, p = 0.04) and components of social support. Social functioning improvement was significantly correlated with indicators of system usage.

CONCLUSION

MOMENTUM is engaging and safe. MOMENTUM appeared to engage the hypothesized mechanisms and showed promise as a new avenue to improve social functioning in UHR young people.

Treating Aggression in Forensic Psychiatric Settings

Forensic psychiatric units are high-risk environments for aggressive behavior. Many elements are necessary for the successful reduction or elimination of aggression in the process of creating a safe treatment environment. Many specific interventions have been attempted over the years with various degrees of, usually limited, success. Tolisano et al. present an integrated behavioral approach with solid theoretical underpinnings and opportunities to support significant safety improvements for select patients, albeit with several caveats.

Recovery from schizophrenia and the role of evidence-based psychosocial interventions

Recovery is the new vision for mental health services, in which two definitions of recovery dominate. Firstly, recovery is an outcome; research suggests that many people with serious mental illness learn to cope with their disabilities so they can achieve major life goals related to independent living. Secondly, recovery is a process; it reintroduces such important values as hope, empowerment and goal orientation into the service system. Both definitions have data that support its assertions, suggesting that an integration of the two offers the most complete and effective picture of recovery. Psychosocial interventions integrated with psychopharmacological strategies have been shown to most effectively help individuals recover. Effective interventions are those that are evidence based and include, illness management, supported employment, assertive community treatment, services to families and dually diagnosed services.

[Characteristics of psychotherapeutic support for patients with traumatic encephalopathy]

As a result of psychological research on 127 patients with traumatic encephalopathy and complex treatment methods with the inclusion of psychotherapy marked positive dynamics of the psychological status, and found three main syndromes (asthenic, hypochondriac, hysterical) and concluded the most effective methods of psychotherapy.

[The newest therapeutic directions in the rehabilitation of patients with mental disorders]

In this paper, the authors attempted to present the comprehensive literature review on the newest therapeutic interventions such as cognitive remediation therapy (CRT), mindfulness-based cognitive therapy (MBCT), social cognition and interaction training (SCIT), and acceptance and commitment therapy (ACT) which appeared promising whilst their implementing among schizophrenic patients, patients with anxiety disorders, eating disorders, and affective disorders. In the presented work particular attention was focused on two kinds of psychotherapeutic interventions: social cognitive trainings and cognitive remediation therapy (CRT) and their effectiveness in the rehabilitation process of schizophrenic patients. The growing body of research based on application of the above mentioned techniques in psychiatric population gives remarkable hope to improve quality of cognitive and psychosocial therapeutic interventions and to set up both complex and comprehensive therapeutic programme for patients with mental disorders.

Counseling and behavior change in pediatric obesity

To effectively intervene with the overweight and obese youth, it is imperative that primary care providers and behavioral interventionists work in concert to help families implement healthy behaviors across socioenvironmental domains. In this article, the authors review current office-based counseling practices and provide evidence-based recommendations for addressing weight status and strategies for encouraging behavior change with children and families, primarily by increasing social support. By providing such collaborative targeted efforts, consistent health messages and support are delivered across children's everyday contexts, thereby helping the youth to achieve successful implementation of eating and activity behaviors and sustainable weight loss outcomes.

[The mystery of schizophrenia. The role of a preventive approach in the treatment of mental illness]

Despite decades of research, there is still a disquieting amount of unanswered questions concerning the genesis as well as the efficient therapy of schizophrenia. The classic approaches emphasizing genetic and family influences were followed by more comprehensive ones that focus on the interplay between the cognitive and the emotional social symptoms of the illness. The demand-access-matching model and, perhaps even more clearly, the cognitive appraisal model seek to integrate biological and early childhood experience factors and show their impact on cognitive as well as emotional functioning. The health-psychosis-continuum model, on the other hand, offers a possible answer to the quantity-quality dilemma of psychotic symptoms. Following a review of the different approaches as well as recent findings in research, the present study outlines a possible route to the development of mental illness starting from a genetically determined more general vulnerability leading to non-specific cognitive dysfunct on in early childhood on to an impaired synchronicity finally leading to a distancing from external reality in the form of overt psychotic symptoms. The second part of the study focuses on the advantages and difficulties of the different therapeutic approaches to mental illness. Based on these approaches, the study outlines an alternative preventive model that, rather than focusing on the former dichotomies lays the emphasis on the early identification and detection of non-specific childhood cognitive dysfunction and early intervention to correct these. These interventions certainly require the close cooperation between psychologists, psychiatrists and special education experts.

An asset-based approach to facilitating positive youth development and adoption

The present study examined outcomes for youth in foster care who participated in an asset-based camp designed to build youth assets and facilitate adoption. The study addresses youth perceptions of their assets and the relationship between assets and adoption status. Youth perceived that their assets increased over time and adopted youth reported having more assets than youth who were not adopted. An asset-based approach may lead to positive outcomes for youth in foster care.

Psychosocial treatment malls for people with intellectual disabilities

The provision of active treatment for people with intellectual disabilities has been seminal in the literature and in practice for a number of years. Active treatment has programmatic, financial, and legal ramifications for agencies and should be at the center of all appropriate treatment plans. The current work examines the use of psychosocial rehabilitation treatment malls to deliver active treatment to people with intellectual disabilities. The history, development, and implementation of these methods are discussed, with emphasis on services that are functional, meaningful, and portable. The importance of the therapeutic milieu is considered in context and discussed as the primary pathway to increased community integration. Finally, future directions of the treatment malls are considered.

Psychosocial treatment of depression and suicidality in adolescents

Depression is a common disorder among adolescents and is associated with a high risk of suicide. Suicide is the third leading cause of death among adolescents in the United States. Currently, there are only two evidence-based psychotherapies for adolescence depression: cognitive-behavioral therapy and interpersonal psychotherapy. Furthermore, psychosocial interventions that specifically target suicidal behavior in adolescents are even fewer in number than treatments for depression. This article will review the psychosocial interventions for depression and suicidality in adolescents and will describe a recently developed treatment that is under study for depressed suicidal adolescents.

Morita therapy for schizophrenia

BACKGROUND

Morita therapy was founded in 1919 by Shoma Morita (1874-1938). The therapy involves a behavioural structured programme to encourage an outward perspective on life and hence an increased social functioning.

OBJECTIVES

To evaluate the effects of Morita therapy for schizophrenia and schizophrenia-like psychoses.

SEARCH STRATEGY

We searched the Cochrane Schizophrenia Groups Trials Register, the Chongqing VIP Database, the Wanfang Database (August 2006), all relevant references and contacted the first author of each included study.

SELECTION CRITERIA

We included all randomised clinical trials comparing Morita therapy with any other treatment.

DATA COLLECTION AND ANALYSIS

We reliably selected studies and extracted data. For homogenous dichotomous data we calculated random effects, relative risk (RR), 95% confidence intervals (CI) and, where appropriate, numbers needed to treat (NNT) on an intention-to-treat basis. For continuous data, we calculated weighted mean differences (WMD).

MAIN RESULTS

We found 11 small, studies of medium-poor quality (total n=1041). The standard care versus Morita therapy comparison (total n=679 people) had very low attrition (<2%, 9 RCTs, RR 1.02 CI 0.3 to 3.1). Mental state did tend to improve with Morita therapy (n=76, 1 RCT, RR no >25-30% decline in BPRS RR 0.36 CI 0.1 to 0.9, NNT 5 CI 4 to 25). For negative symptoms data were inconsistent, with data from three trials favouring Morita therapy (n=243, RR -10.87 CI -20.5 to -1.2), but heterogeneity was considerable (I(2) =92%). Morita therapy plus standard treatment did significantly improve the ability of daily living compared with standard treatment alone (n=104, 1 RCT, WMD -4.1 CI -7.7 to -0.6). Compared with a rehabilitation programme Morita therapy did not promote attrition (n=302, 2 RCTs, RR 1.00 CI 0.5 to 2.1). In two very similar studies Morita therapy showed better effect on mental state with lower BPRS score (n=278, 2 RCTs, WMD -6.95 CI 9.3 to 4.6, I(2) =0%) insight (n=278, 2 RCTs, WMD -1.11 CI -1.3 to -0.9, I(2) = 0%) and social functioning (n=278, WMD average IPROS score -18.14 CI -21.3 to -15.0, I(2) =0%).

AUTHORS' CONCLUSIONS

Currently trial based data on Morita therapy is inconclusive. Morita therapy for schizophrenia remains an experimental intervention, new trials are justified and specific outlines for design of future studies are outlined in additional tables.

The biopsychosocial approach to adolescents with somatoform disorders

Somatoform disorders are presented in the first article in this issue of Adolescent Medicine Clinics because the physical symptoms that cause the adolescent to present for diagnosis and treatment reflect the interaction of the psyche and the soma in ways that are poorly understood. Because of dualistic conceptualizations that are encouraged by technology such as MRI, CT scans and other technologically advanced tools, patients who have these conditions often suffer. As noted by Cassell [35], "suffering is experienced by persons, not merely by bodies, and has its source in challenges that threaten the intactness of the person as a complex social and psychological entity." Clinicians who care for adolescents who have somatic complaints also suffer when they are unable to provide relief of an adolescent's suffering. Cassell [36] noted that "physicians are less skilled at what were once thought to be the basic skills of doctors-discovering the history of an illness though questioning and physical examination, and working toward healing the whole person." The biopsychosocial approach offers a means of working toward healing the whole person, and the focus of this article is on practical solutions to difficult challenges that are presented by adolescents and their families.

Effectiveness of cognitive-behavioural, person-centred and psychodynamic therapies as practised in UK National Health Service settings

BACKGROUND

Psychotherapy's equivalence paradox is that treatments have equivalently positive outcomes despite non-equivalent theories and techniques. We compared the outcomes of contrasting approaches practised in routine care.

METHOD

Patients (n = 1309) who received cognitive-behavioural therapy (CBT), person-centred therapy (PCT) and psychodynamic therapy (PDT) at one of 58 National Health Service (NHS) primary and secondary care sites in the UK during a 3-year period completed the Clinical Outcomes in Routine Evaluation-Outcome Measure (CORE-OM) at the beginning and end of their treatment. Therapists indicated which treatment approaches were used on an End of Therapy form. We compared outcomes of six groups: three treated with CBT, PCT or PDT only, and three treated with one of these plus one additional approach (e.g. integrative, supportive, art), designated CBT+1, PCT+1 or PDT+1 respectively.

RESULTS

All six groups averaged marked improvement (pre-post effect size = 1.36). Treatment approach and degree of purity ('only' vs. '+1') each accounted for statistically significant but comparatively tiny proportions of the variance in CORE-OM scores (respectively 1% and 0.5% as much as pre-post change). Distributions of change scores were largely overlapping.

CONCLUSIONS

Results for these three treatment approaches as practised routinely across a range of NHS settings were generally consistent with previous findings that theoretically different approaches tend to have equivalent outcomes. Caution is warranted because of limited treatment specification, non-random assignment, lack of a control group, missing data and other issues.

Narrative as an outcome domain in psychosis

A recent renewed interest in psychosocial treatments for psychosis has only minimally included considerations of narrative therapy and other interventions based in post-modernism. This lack of attention is curious given the profound narrative disruptions often seen in psychotic illness. In this review article we describe several studies in which narratives and narrative dimensions have been utilized to assess outcomes in psychosis. Valid and reliable measures of narrative change in psychosis are possible and can coexist with and complement traditional outcome measures. Perhaps more significantly, considerations of narrative changes may offer unique insights into the process of recovery from psychosis as well as leading to beneficial psychosocial treatments for the same.

Recognition and optimal management of schizophrenia and related psychoses

Schizophrenia continues to remain one of the major unsolved conditions of our time, contributing significantly to causes of disability worldwide. Advances in neuroimaging have demonstrated that schizophrenia appears to be primarily a neurodevelopmental disorder. The dopamine theory of schizophrenia continues to hold sway but interest is growing in the role of other neurotransmitters. Genetic linkage studies continue to suggest that specific chromosomes have a role in the aetiology of the condition but the findings are, as yet, inconsistent. A new generation of drug therapies and reforms of the mental health system have meant that it is now possible to treat the majority of those with this condition in the community albeit, in some instances, against their will. The medical complications of both the disorder, the lifestyle changes resulting from the disorder and the new and older medications have come to prominence in recent years. The development of guidelines for treatment has the potential to reduce the variability in clinical practice that currently exists in the management of the condition.

[Resource-oriented child therapy]

In relation to current American approaches on the development of a positive psychology, positive psychological assessment and positive therapy different strategies of a resource-oriented child therapy are introduced, which are based on multimodal resource assessment, and which shall effectively complement treatments of disorders. It is distinguished between a therapeutical focussing on personal or environmental client resources, although these forms of treatment are often combined in practice. By examples from child therapeutic practice different possible applications of resource-centered treatments are presented.

A jeep trip with young adult cancer survivors: lessons to be learned

The paper describes major areas of concern and preferred coping mechanisms among 17 young survivors of childhood cancer who participated in an 8-day adventure jeep trip in Greece. The paper also deals with various aspects of "adventure therapeutic activity." The participants were videotaped and interviewed during and after the trip. The data gathered were studied through a process of content analysis. Survivors' main areas of concern included: coping with uncertainty, dependency versus autonomy, social exclusion, separation processes, body image, intimacy, sexuality and fertility, and occupation. Preferred coping styles included use of humor, religious beliefs, cognitive reframing, and use of imagination. The trip provided the young adults with an opportunity for physical challenges, and they reported improvements in self-confidence, independence, and social contacts. The trip served as a catalyst for further group activities and group support. An adventure trip seems to be a suitable therapeutic milieu for young adult cancer survivors, where they can profit from a nurturing setting in which rehabilitation-promoting resources are available. It still remains to be seen which components of such an activity are more health promoting, what contraindications there could be, if any, for participation in such a trip, and what role health professionals should play in this kind of activity.

Treatment of acute psychosis without neuroleptics: two-year outcomes from the Soteria project

The Soteria project (1971-1983) compared residential treatment in the community and minimal use of antipsychotic medication with "usual" hospital treatment for patients with early episode schizophrenia spectrum psychosis. Newly diagnosed DSM-II schizophrenia subjects were assigned consecutively (1971 to 1976, N = 79) or randomly (1976 to 1979, N = 100) to the hospital or Soteria and followed for 2 years. Admission diagnoses were subsequently converted to DSM-IV schizophrenia and schizophreniform disorder. Multivariate analyses evaluated hypotheses of equal or better outcomes in Soteria on eight individual outcome measures and a composite outcome scale in three ways: for endpoint subjects (N = 160), for completing subjects (N = 129), and for completing subjects corrected for differential attrition (N = 129). Endpoint subjects exhibited small to medium effect size trends favoring experimental treatment. Completing subjects had significantly better composite outcomes of a medium effect size at Soteria (+.47 SD, p =.03). Completing subjects with schizophrenia exhibited a large effect size benefit with Soteria treatment (+.81 SD, p =.02), particularly in domains of psychopathology, work, and social functioning. Soteria treatment resulted in better 2-year outcomes for patients with newly diagnosed schizophrenia spectrum psychoses, particularly for completing subjects and for those with schizophrenia. In addition, only 58% of Soteria subjects received antipsychotic medications during the follow-up period, and only 19% were continuously maintained on antipsychotic medications.

Attachment and affect regulation: a framework for family treatment of conduct disorder

Conduct disorder (CD), a pervasive adolescent disorder with clinically significant antisocial behaviors, has been a difficult syndrome to treat successfully. Recently, research on affect regulation and attachment has suggested that attachment and affect regulation strategies may underlie the development of conduct disorder in adolescents, implying that attention to these factors might improve family treatment for CD. In this review of the research literature, I discuss the role of attachment and affect regulation in the development and treatment of CD. In addition, I present information about the framework, intervention protocol, and preliminary evidence of effectiveness of an attachment- and affect regulation-based intervention that has been developed and implemented with multiple-family groups of parents and incarcerated adolescents.

Use of antecedent control to improve the outcome of rehabilitation for a client with frontal lobe injury and intolerance for auditory and tactile stimuli

KM, a single 23-year-old male, sustained a severe traumatic brain injury in a motor vehicle accident. Aggressive and uncooperative behaviour, resulting from the client's cognitive deficits and hypersensitivity to stimuli, made him unmanageable in a subacute rehabilitation setting. Minimizing sources of agitation reduced the client's outbursts and facilitated the completion of functional tasks, such as bathing and dressing. Modifying his environment also increased the client's participation in social and leisure activities. These changes improved the outcome of the client's rehabilitation.

Aichhorn revisited

August Aichhorn first published Wayward Youth in German in 1925. His willingness to approach a problem as difficult as delinquency in terms of psychoanalytic theory and to then test his theories with groups of delinquents in a reformatory setting were truly pioneering. Perhaps his greatest success as an educator was in attracting other psychoanalytic leaders, most notably Sigmund Freud and Kurt Eissler, to extol and extend his early efforts. The turn of the century seems a fitting time to revisit Aichhorn's views, to assess his impact on colleagues, and to place his contribution in the perspective of current research and practices.

Family treatment and medication dosage reduction in schizophrenia: effects on patient social functioning, family attitudes, and burden

The effects of 2 family intervention programs (supportive family management [SFM], including monthly support groups for 2 years; or applied family management [AFM], including 1 year of behavioral family therapy plus support groups for 2 years), and 3 different neuroleptic dosage strategies (standard, low, targeted) on social functioning of patients with schizophrenia. their relatives' attitudes, and family burden were examined. AFM was associated with lower rejecting attitudes by relatives toward patients and less friction in the family perceived by patients. Patients in both AFM and SFM improved in social functioning but did not differ, whereas family burden was unchanged. Medication strategy had few effects, nor did it interact with family intervention. The addition of time-limited behavioral family therapy to monthly support groups improved family atmosphere, but did not influence patient social functioning or family burden.

Integrating harm reduction therapy and traditional substance abuse treatment

One-size-fits-all therapy has not worked well for a majority of substance users seeking help. New approaches to substance abuse treatment are desperately needed. Traditional models of service delivery offer little, if any, help to people who may not choose abstinence as a goal. To address this concern, the Bridging the Gap Conference was sponsored by the San Francisco Department of Public Health. The overall goals of the conference were to improve standards of care, develop best practice principles for integrating harm reduction approaches into traditional substance abuse services, and increase the accessibility of quality services to people in need of alcohol and drug treatment. G. Alan Marlatt gave a keynote address on the integration of harm reduction therapy into traditional treatment services, an expanded version of which is presented in this article. Such integration would broaden the scope of services available to a larger group of consumers of substance abuse treatment. Furthermore, harm reduction therapy would infuse traditional treatment practices with scientifically-based pragmatism that pays close attention to individual and community public health needs. Because of its tolerance of treatment goals other than abstinence, harm reduction therapy offers the greatest hope to expand the availability of substance abuse services to people who have not benefited from traditional abstinence-based treatment models.

Pragmatic randomized trial of antenatal intervention to prevent post-natal depression by reducing psychosocial risk factors

BACKGROUND

Social support theory and observational risk factor studies suggest that increased antenatal psychosocial support could prevent post-natal depression. We used empirical knowledge of risk and protective factors for post-natal depression not employed previously in order to develop and evaluate an antenatal preventive intervention.

METHODS

We conducted a pragmatic randomized controlled trial in antenatal clinics. We screened 1300 primiparous women and 400 screened positive, 69 screen-positive women were untraceable or not eligible. Of 292 women who completed baseline assessment, 209 consented to randomization, of these 190 provided outcome data 3 months post-natally. 'Preparing for Parenthood', a structured antenatal risk factor reducing intervention designed to increase social support and problem-solving skills, was compared with routine antenatal care only. We compared the percentage depressed at 3 months after childbirth using the self-completion General Health Questionnaire Depression scale and Edinburgh Post-natal Depression Scale (EPDS), and the Schedules for Clinical Assessment in Neuropsychiatry a systematic clinical interview.

RESULTS

Assignment to the intervention group did not significantly impact on post-natal depression (odds ratio for GHQ-Depression 1.22 (95% CI 0.63-2.39), P = 0.55) or on risk factors for depression. Forty-five per cent of the intervention group women attended sufficient sessions to be likely to benefit from intervention if effective. Attenders benefited no more than non-attenders.

CONCLUSIONS

Prevention services targeting post-natal depression should not implement antenatal support programmes on these lines until further research has demonstrated the feasibility and effectiveness of such methods. The development of novel, low cost interventions effective in reducing risk factors should be completed before further trial evaluation.

Prevention research in eating disorders: theory and new directions

BACKGROUND

Over the past two decades, scores of articles and several books have been published calling for more attention to the prevention of eating disorders, but less than two dozen prevention intervention studies have been conducted to date.

METHODS

This paper reports the results of a systematic review of 20 empirical intervention studies on eating disorders prevention, discussing the data accumulated on what has and has not been effective. Beyond a description of study design and findings, this paper devotes special attention to the theoretical orientations of the studies and their implied assumptions about preventive strategies.

RESULTS

Though there has been a compelling interest in social, political and economic factors influencing the incidence of disordered eating, little of this interest has been carried over into the prevention end of eating disorders research. Most studies reported thus far have been designed to target and measure change principally on the individual level, to the exclusion of considering leverage points for intervention in the larger social environment.

CONCLUSIONS

This paper concludes with a recommendation for new attention to a model of proactive primary prevention targeted at environmental change and cross-disciplinary collaboration to achieve a reduction in the incidence of eating disorders.

Abstinent-contingent housing and treatment retention among crack-cocaine-dependent homeless persons

This study investigated Behavioral Day Treatment attendance in relation to treatment outcome among homeless persons dependent on crack-cocaine. Participants (N = 141) were 72.3% male and 82.7% African American. Days attended, activities attended, and follow-up rates over a 12-month period were positively affected by the more attractive treatment of providing immediate, rent-free, abstinent-contingent housing during a 2-month Behavioral Day Treatment program. Results replicated previous findings that abstinence is a function of treatment attendance and more treatment is associated with greater abstinence. The loss of predictive power at long-term follow-up, limitations of a retrospective design, need to identify most predictive therapeutic activity types, and potential influence of mental disorders were discussed. Analytical techniques used in this study allows for the planning, predictability, and measurement of drug abuse treatment success as a function of service utilization.

Characteristics of women in jail and treatment orientations. A review

Women who have been incarcerated are a high-risk group for criminal recidivism, and criminal justice statistics indicate that females are increasing in numbers more rapidly than the male detainee population. According to data from epidemiologic studies, incarcerated women are often young, single, mothers from ethnic minority backgrounds who have little education and poor work histories. Mental illness, drug abuse, and risky behaviors relating to contracting HIV/AIDS are common problems among female detainees. In this report, research into characteristics of women in jail and literature relating to treatment programs for incarcerated women are reviewed. Implications relating to treatment needs, program development, and further research are discussed. A case example and treatment intervention are presented based on this review.

Mechanisms of change in multisystemic therapy: reducing delinquent behavior through therapist adherence and improved family and peer functioning

The mechanisms through which multisystemic therapy (MST) decreased delinquent behavior were assessed in 2 samples of juvenile offenders. Sample 1 included serious offenders who were predominantly rural, male, and African American. Sample 2 included substance-abusing offenders who were predominantly urban, male, and Caucasian. Therapist adherence to the MST protocol (based on multiple respondents) was associated with improved family relations (family cohesion, family functioning, and parent monitoring) and decreased delinquent peer affiliation, which, in turn, were associated with decreased delinquent behavior. Furthermore, changes in family relations and delinquent peer affiliation mediated the relationship between caregiver-rated adherence and reductions in delinquent behavior. The findings highlight the importance of identifying central change mechanisms in determining how complex treatments such as MST contribute to ultimate outcomes.

Phase-specific psychosocial interventions for first-episode schizophrenia

Phase-specific psychosocial interventions for first-episode schizophrenia are outlined and described using examples from clinical practice with 68 patients. These interventions are based on the unique aspects of the first episode and patients' clinical states. Although schizophrenia may run an uneven and often unpredictable course, most patients experience three distinct phases: (1) the acute phase, (2) the healing phase, and (3) the maintenance phase. The timeliness of phase-specific interventions is crucial in helping both patients and families understand the illness, evaluate options, accept treatment, and adjust to changes in functioning and expectations.

Community reinforcement approach for combined opioid and cocaine dependence. Patterns of engagement in alternate activities

We compared outcomes for agonist-maintained patients with combined opioid and cocaine dependence who were treated in an earlier clinical trial with group drug counseling (DC; n = 57) or in a current trial with the Community Reinforcement Approach (CRA; n = 60). The association between engagement in nondrug-related activities and abstinence was also evaluated. There were no significant differences between the treatments in retention or drug use. The total number of hours and average hours per week engaged in nondrug-related activities was significantly higher for CRA-treated patients who achieved abstinence from opioids, cocaine, or both combined than for those who never achieved abstinence. Although CRA was not more effective overall than DC, the finding that engagement in reinforcing community activities unrelated to drug use (e.g., planned pleasurable events or parenting activities) was associated with abstinence suggests that the planning and reinforcement of specific nondrug-related social, vocational, and recreational activities is a crucial component of CRA.

Sensory and movement-led approach to design for elderly severely mentally ill units

The evolution of a design embodying the alliance of movement to sensory stimulus for confused and Alzheimer sufferers. The paper is an account of the design concept of an Elderly Severely Mentally Ill (ESMI) unit under the Government Private Finance Initiative (PFI) rules. Previous papers by the author recorded the development of elderly care nursing units that sought to use the planning of circulation as a means to provide stimulation for patients. The results demonstrated a therapeutic value for this approach. In the latest version for ESMI, the concept has been taken further with the creation of a "Memory Trail" that provides a choice of routes with organised points of interest containing stimulus for the senses in order to trigger memory. This is seen as beneficial not only for patient but also provides a positive role for relatives in escorting and planning the "journey". The paper records how the design amended the original brief by the participation of user groups re-evaluating the requirements in discussion and visits to earlier versions of this approach.

Facilitating adjustment to inflammatory bowel disease: a model of psychosocial intervention in non-psychiatric patients

BACKGROUND

There is no consensus about the most appropriate psychosocial interventions for people with inflammatory bowel disease (IBD) or the most appropriate criteria by which to select which patients might benefit from the available interventions. Nonetheless the perception that stress and other subjective factors contribute to suffering in IBD is persistent and professionals are often called upon to offer appropriate support. A model of normal psychosocial adjustment to IBD and the interventions which can improve difficulties with adjustment will facilitate rational therapeutic intervention and needed research in this area.

METHODS

A model of normal adjustment to IBD is developed from a synthesis of the empirical literature and clinical experience in a tertiary care medical/surgical IBD centre and is used to identify potential points of psychosocial intervention.

RESULTS

Normal adjustment to IBD can be understood as a process involving the interaction of a triad of adaptive challenges: illness uncertainty, loss and change, and suffering. Each of these challenges requires different criteria of psychosocial assessment and may lead to different interventions.

CONCLUSIONS

Although the interventions available for improving adjustment to IBD have not been exhaustively investigated, the existing data support the value of further study. The model of psychosocial adjustment presented here provides a synthesis of the existing data and a starting point for further research.

[Investigation of personal niche as basis of supportive psychotherapy]

According to the ecological theory of Willi 1996, people create and maintain their psychic wellbeing through constant shaping of their environment, i.e. setting up a personal niche. The personal niche in turn responds to, guides and challenges further personal development. This study explores what kind of solutions single patients with psychiatric invalidity can find in order to form their environment as a niche in which they may develop effectiveness and use it for their psychic regulation. 30 people were questioned with a semi-structured interview: they were patients of a psychiatric out-patient's clinic, living alone and psychiatrically invalidated (2/3 with schizophrenia of the residual type). The results were ranked after their increasing demands in a relational and in an activity inventory. The more relationship is based on mutuality expectations of others, personal disclosure and binding the more the subjects feel overstrained. The investigation of these inventories serve as a technical aid in supportive psychotherapy.

Description and immediate impacts of a preventive intervention for conduct problems

A population-based randomized intervention trial for the prevention of conduct problems (i.e., oppositional defiant disorder and conduct disorder) is described. The LIFT (Linking the Interests of Families and Teachers) intervention was designed for all first- and fifth-grade elementary school boys and girls and their families living in at-risk neighborhoods characterized by high rates of juvenile delinquency. The 10-week intervention strategy was carefully targeted at proximal and malleable antecedents in three social domains that were identified by a developmental model of conduct problems. From 12 elementary schools, 671 first and fifth graders and their families participated either in the theory-based universal preventive intervention or in a control condition. The intervention consisted of parent training, a classroom-based social skills program, a playground behavioral program, and systematic communication between teachers and parents. A multiple measure assessment strategy was used to evaluate participant satisfaction and participation, fidelity of implementation, and the immediate impacts of the program on targeted antecedents.

Retrospective analyses of additional services for methadone maintenance patients

We report on the 6-month outcome of a retrospective analysis of additional treatment services for patients entering a methadone maintenance program who transferred from community methadone treatment programs (n = 83) or entered off the street (n = 83) not currently on methadone. Patients were participating in a clinical treatment trial examining the effectiveness of Community Reinforcement Approach and Relapse Prevention. Patients in the methadone transfer group were using less heroin at intake than patients newly initiated onto methadone and both groups improved from additional treatment services in the following problem areas specifically: drug, alcohol, legal, employment, social, and in some measures of psychiatric distress. Therefore, both groups of patients in this study benefited from additional treatment services.

Addictive disorders in adolescents

Physicians should recognize the importance of individual differences in the etiologic pathway to drug abuse. Drug use in most adolescents subsides or stops by adulthood; however, adolescents with behavioral or affective dysregulation, poor social skills, a limited social network, and substance abuse during late adolescence are at increased risk for substance dependence in adulthood. Research is needed, however, to clarify the developmental emergence and interaction between individual and contextual risk factors. Understanding person-environment processes within a developmental perspective not only yields a better understanding of the causes but also informs about taxonomy, prevention, and readiness to change and compliance in treatment and after-care. Treatment outcome research suggests that (1) relapse is likely to occur within the first 3 months after treatment completion and, to a lesser extent, over the year following treatment completion; (2) relapse is more likely in adolescents who have comorbid psychiatric disorders and other problems, such as high stress, low social skills, lack of involvement in productive activities or active leisure, and no follow-up intervention; (3) continued after-care treatment may maintain treatment gains; (4) the effectiveness of treatment and aftercare is likely to vary by the amount, mode, and the consistency with which it is delivered; (5) gender differences might have an impact on treatment outcome; and (6) adolescents presenting for treatment are likely to respond well to interventions based on family therapy and CBT approaches.

Coping and social skills training for alcohol and cocaine dependence

Coping and Social Skills Training (CSST) has been in the forefront of the addictions literature for over two decades. In this review, we provide an outline of empirically validated CSST assessment measures and treatment protocols for alcohol dependence and cocaine dependence. Key elements covered in CSST include communication skills training, cue exposure treatment with urge coping skills, and cocaine-specific coping skills training. We conclude with a summary of the research to date in support of CSSt and future directions for the treatment of addictive behaviors.

[Psychiatric vocational therapy--concepts, practice and scientifically-based results]

Work therapy is a widespread form of socio-therapy. In contrast to pharmacological and somatic forms of treatment, proof of efficacy is difficult to produce in multimodal therapy of psychiatric patients. Within the framework of an extensive study on vocational rehabilitation of mentally ill patients, we carried out a naturalistic follow-up study of 112 mostly schizophrenic patients attending outpatient work therapy programmes. The courses of illness and rehabilitation were documented prospectively over a three-year period. At the end of the study 23% of the patients were integrated into the open labour market, 25% were working in sheltered employment, 25% remained in work therapy, and 27% were unemployed. Controlled studies with schizophrenic patients show, that work therapy contributes to improved vocational integration, a reduction of rehospitalizations and a stabilisation of the psychopathological status.

The therapeutic use of ritual and ceremony in the treatment of post-traumatic stress disorder

The therapeutic purposes and effects of specially designed ceremonies in the treatment of persons with post-traumatic stress disorder are described. Ceremonies compartmentalize the review of the trauma, provide symbolic enactments of transformation of previously shattered relationships, and reestablish connections among family and with society in general. Four ceremonies used with Vietnam combat veterans are described which focus on the themes of separation from and return to the family, forgiveness of the living, and releasing the dead. Ritual and ceremony are highly efficient vehicles for accessing and containing intense emotions evoked by traumatic experience. Evaluation by family and veterans judge these ceremonies to be the most effective components of treatment.

The treatment of avoidant personality disorder by social skills training in the clinic or in real-life settings

Twenty-eight outpatients who met DSM-III diagnostic criteria for avoidant personality disorder completed 14 one and a half hour sessions of social skills training in the clinic only or a combination of four sessions in the clinic, four sessions in real-life and six follow-up sessions in the clinic. Subjects were assessed before treatment began, after four sessions, at the end of treatment and at three month follow-up points. Training in real-life did not enhance social skills training; no significant difference between the groups at any assessment points was found. In both groups improvement in time was significant and clinically worthwhile. The treatment effects were maintained up to the three month follow-up, where available. Social skills training appears to be a useful and promising intervention for avoidant personality disorder but its long term impact remains to be investigated.

Conduct disorder: long-term outcomes and intervention effectiveness

OBJECTIVE

To review the literature on conduct disorder in two areas: long-term outcome and the effects of interventions.

METHOD

The sources of the articles for review were computer searches, but the articles were selected for this review to illustrate key findings in the long-term outcome area and to review critically four intervention strategies to prevent or treat conduct disorder, namely, parent- and family-targeted programs, social-cognitive programs, peer and school-based programs, and community programs.

RESULTS

Conduct problems in childhood predict the same increased rates of psychiatric disorder overall in men and women but the patterns are different: for externalizing disorders, the prediction is stronger in men and for internalizing disorders, the prediction is stronger in women. In the intervention domain, the literature provides limited evidence of the effectiveness of either primary or secondary prevention.

CONCLUSIONS

Prospective studies of community samples of children provide the best opportunity to understand more thoroughly the adult outcomes of conduct disorder. Because of the heavy burden of suffering of conduct disorder, and the limited effectiveness of clinical interventions, there is a compelling argument in favor of an increased emphasis on primary prevention efforts.

A multicomponent behavioral treatment for social phobia: social effectiveness therapy

The development of a new, comprehensive and multicomponent treatment for social phobia is described. Initial results of a pilot study with the new treatment also are reported. The treatment was found to be effective with severe (generalized) social phobics, most of whom had co-occurring Axis I and/or II conditions. In addition to significant change on a host of outcome variables, a normative-based endstate functioning index was used to determine treatment efficacy. The results are discussed with respect to the implementation of the treatment and in terms of the need for a comprehensive approach to treating social phobia.

Psychosocial interventions in the management of recurrent headache disorders. 1: Overview and effectiveness

This is the first in a series of three articles addressing nonpharmacologic therapies for management of recurrent migraine and tension-type headache. It provides an overview of the commonly employed nonpharmacologic therapies for recurrent headache, reviews scientific evidence of their efficacy, and identifies the psychosocial interventions that have the greatest potential to enhance the management of recurrent migraine and tension-type headache in primary care settings internationally. In the second article, the authors offer practical guidelines for the administration of recommended nonpharmacologic interventions. The third article explores healthcare policy implications involved in a decision to incorporate psychosocial interventions into primary care practice.