Academic literature on the topic 'Psychother. research'

Background Awareness of synchronicity may be an opening to more general spiritual awareness. Empirical research analyzing the process of increased synchronicity awareness and investigating shifts in personal spirituality and mental health is limited. Might synchronicity awareness be a porthole for a more general sense of personal spiritual awareness, namely the experience of directly lived daily events as spiritually meaningful? Purpose This study evaluated a six-week synchronicity discussion group, Synchronicity Awareness Intervention (SAI), delivered to emerging educators and human service professionals. Its aim was to increase awareness of synchronistic events and to support spiritual awareness. Participants Final enrollment consisted of 12 females and 1 male, with a mean age of 26.8 years (SD=5.29). Religious denominations were 38.5% Catholic, 30.8% Protestant, 15.4% Hindu, 7.7% Buddhist, and 7.7% Atheist. Research Design The study used a pretest-posttest within subject design. This report focuses on the postintervention qualitative data collected through semi-structured interviews. Findings Data suggested that SAI was associated with increased awareness of synchronicity and suggested beneficial effects of synchronicity awareness on personal spirituality and mental health. Results showed that the program was well received and highly rated by the participants, indicating that it was an acceptable form of a spiritually informed psychother-apeutic discussion group. Conclusions This preliminary study showed promising support for the feasibility, acceptability, level of engagement, and potential helpfulness of an SAI in a group setting. Synchronicity awareness may support spiritual awareness and improve mental health.

A content analysis of the representative Journals in the field of psychothera-py research has been performed. The analysis focused on the articles’ keywords. We ana-lyzed 7,086 works published in 17 Journals, in the period 2005-2011, using a two-step multidimensional procedure. Firstly, a cluster analysis led to the extrapolation of 4 groups of keywords, each of them interpreted as the marker of a topic active within the literature. Secondly, a factorial analysis was carried out in order to picture the thematic orientation of the most representative Journals, namely the main topics they focus on and how they differ from each other in this respect.

Background:The Ankylosing Spondylitis Association of Switzerland (SVMB) offers weekly group exercise therapy for people with axial Spondyloarthritis (axSpA) supervised by physiotherapists (PTs). Given the EULAR physical activity (PA) recommendations [1] and recent research [2, 3], the SVMB has implemented a new concept including assessments evaluating all fitness dimensions, daily PA and disease activity. Based on its results, individual exercise-coaching by the group PT is provided to support the adherence to exercising in correct mode and dose. PTs use the visual-tactile instrument PRISM (Pictorial Representation of Illness and Self Measure) [5] to explore patients’ perceived burden of disease (BD) and importance of PA as starting-point for the exercise-coaching.Objectives:To measure to what extent the perceived BD and importance of PA, measured with PRISM, change over time and to evaluate if the PRISM results are associated with established measures of disease activity and daily PA across four pilot groups including four PTs and 30 people with axSpA.Methods:Each participant had three exercise-coaching sessions within six months. Each session was started by applying the PRISM, which is a white A4 board with a yellow disk at the bottom right hand corner. The participant was asked to imagine that the board represented his/her life and the yellow disk represented his/her “Self”. Then, a red disk, representing axSpA, and later a blue disk, representing PA, were handed and the participant was asked to place the disks where they represented best their importance in the participant’s life. The distances between Self and the red and blue disk respectively were measured in centimeters to quantify BD/importance of PA, and correlated with the Bath Ankylosing Spondylitis Disease Activity Inventory, BASDAI (measuring disease activity) and weekly METs (measured with the International PA Questionnaire, IPAQ) by means of spearman rank correlation. The analysis was based on the first session at baseline (T0) and the third session after six months (T1) and paired t-test was applied, to identify changes between sessions.Results:Complete data were available for 23 participants. Neither BD (distance to Self at T0: 13.7±7.2cm; T1: 12.1±6.2cm; t=0.386, p=0.703) nor importance of PA (distance to Self at, T0: 7.3±5.3cm; T1: 7.0±4.5cm); t=0.246, p=0.808) changed within six months. The perceived importance of PA correlated with IPAQ measured METs at T1 (r=0.572, p=0.00), no correlation between BD and METs was found.Conclusion:The stable perceived BD could be explained by long disease duration of participants and established disease management. The stable importance of PA could be due to the sample, as for group exercise participants PA may already be important. The correlation between importance of PA and MET at T1 could indicate that people learned more about the meaning of PA leading to a better understanding of the importance of PA. Future research should evaluate factors influencing the perceived importance of PA as well as further explore the use of PRISM in the context of exercise-coaching.References:[1]Rausch AK, et al. Ann Rheum Dis 2018; 9(77):1251-1260. 45[2]Sveaas SH, et al. Br J Sports Med 2019;0:1-7.[3]Rausch AK, et al. RMD open, 2018; 4:e000713.[4]Garber CE, et al. Med Sci Sports Exerc 2011;43:1334–59.[5]Buchi S, et al. Psychother Psychosom 2002;71(6):333-341.Acknowledgments:We thank Beatrice Walker and René Braem from Swiss Ankylosing Spondylitis Association.Disclosure of Interests:None declared

ObjectivesThe purpose is to analyze existing studies related to the field of demoralization through bibliometrics.MethodologyRelevant literature on demoralization was searched from PubMed, Web of Science, the Cochrane Library, and CINAHL Complete. Bibliometric analysis was performed using GraphPad Prisma 8.2.1, VOSviewer 1.6.18 and R software. Research publication trends, author-country collaboration, research hotspots and future trends were explored by generating network relationship maps.ResultsA total of 1,035 publications related to the field of demoralization were identified. The earliest relevant studies have been published since 1974, and the studies have grown faster since 2000. Psyche-oncology and Psychother Psychosom had the highest number of publications (n = 25). The United States, Italy and Australia have made outstanding contributions to the field and there was an active collaboration among leading scholars. Major research hotspots include the multiple ways of assessing demoralization, the specificity of various demographics and psychological disorders in different disease contexts, and the association and distinction of diverse clinical psychological abnormalities. The impact of COVID-19 on demoralization and subsequent interventions and psychological care may become a future research direction.ConclusionThere has been a significant increase in research in the field of demoralization after 2000. The United States provided the most publications. There is overall active collaboration between authors, countries, and institutions. In future research, more attention will be paid to the effects of COVID-19 on demoralization and intervention care for this psychology.

Introduction: despite large and widely accepted research on effectiveness, most of psychotherapy research has been done with adults; few studies have been published on the process of adolescent psychotherapy, due to the complexity of the subject and the absence of instruments sensitive enough to empirically capture its nuances. Within psychoanalytic framework, a developmental approach is particu-larly helpful in the psychotherapy of adolescents. Objective: the purpose of this study was to investigate the typical features of Italian Adolescence Psychodynamic Psychotherapy and its similarities and differences with other adolescence psycho-therapeutic approaches; We also aimed at analyzing typical therapists’ responses to adolescent patients. Method: 50 italian adolescence psychotherapists filled a brief questionnaire about their clinical expertise, completed the Adolescent Psychothe-rapy Q – Set (APQ) and the Therapist Response Questionnaire (TRQ) in order to describe their “actual” practice with adolescents. Results: therapeutic process is characterized by a priority to helping adolescent make sense of his own experience, it focuses on present relationships and emotions rather than on past. Strong similar-ities with Mentalization Based Therapy, mild and no correlations with Cognitive-Behavioral Therapy and Classical Psychoanalysis respectively were found; towards adolescents therapists generaly display positive and protective countertransference responses. They less frequenlty show negative responses as overprotection, hostility or feeling of overwhelming. Conclusions: APQ and TRQ can provide meaningfull information about adolescent psychotherapy process. Instruments’ improvement (i.e. reviewd items for APQ) and future perspectives are also discussed.

Photo by National Cancer Institute on Unsplash ABSTRACT The COVID-19 pandemic has brought about the advent of many new telehealth technologies as providers have been forced to shift their practice from the clinic to the cloud. Perhaps, none of these fields has been as widely advertised and expanded as telemental health. While many have lauded this change, it is important to question whether this method of practice is truly beneficial for patients, and further whether it benefits all patients. This paper critically examines the current structure of telemental health interventions and compares them to more traditional in-person interactions, reflecting on the unique benefits and challenges of each method, and ultimately concluding that telemental health is the wrong modality for certain patients and modalities. INTRODUCTION As the e-health revolution rapidly progresses, scientists, healthcare professionals, and technology experts are attempting to determine which areas of medical practice will best adapt to changing dynamics. Two key professions that are ripe for this kind of disruption are psychiatry and psychology. The American Psychiatric Association, along with its partners in the American Telemedicine Association, states that “telemental health in the form of interactive videoconferencing has become a critical tool in the delivery of mental health care. It has demonstrated its ability to increase access and quality of care, and, in some settings, to do so more effectively than treatment delivered in-person.”[1] This claim, though appearing bombastic, is also reflected, though with more nuance, by the American Psychological Association. For its part, the American Psychological Association states that “the expanding role of technology and the continuous development of new technologies that may be useful in the practice of psychology present unique opportunities, considerations, and challenges to practice.”[2] Thus, the point of this paper will be to examine whether the rapidly expanding system of telemental health is ethical based on its adherence to accepted standards of care, privacy concerns, and concerns about the boundaries of the patient-provider relationship. l. Standard of Care Concerns One of the most considerable objections to the broader implementation of telemental health services is the speculation that it is less effective than in-person treatment. It would follow that a system that is broadly implemented would not only fail to be beneficent, but it would also fail to be non-maleficent. Providers would be knowingly providing an ineffective treatment. Some may argue that such a system would also violate the principle of justice. It would create an unequal system of care in which those patients who could afford to see their therapist in person would benefit more than those who could not. However, data from a wide variety of sources at first glance, would seem to contradict these fears.[3] A review of the literature regarding the implementation of telemental health in geriatric patients, for example, showed that telemental health was as good as in-patient psychiatric care in several areas, including the diagnosis of dementia, nursing home consultations, and in conducting psychotherapy for geriatric patients and their caregivers.[4] On the other end of the age spectrum, a review of nineteen randomized controlled trials and one clinical trial demonstrated high comparative effectiveness between telemental health interventions in children and adolescents.[5] Hailey et al. found that telemental health interventions were effective in over half of the 65 studies reviewed. These studies encompassed a diverse and wide-ranging number of psychiatric disciplines, including child psychiatry, post-traumatic stress disorder, dementia, cognitive decline, smoking cessation, and eating disorders. Methods included phone- and web-based interventions.[6] Indeed, the data is not just limited to outpatient settings. For example, Reinhardt et al. conducted a literature review of studies about telemental health visits for psychiatric emergencies and crises. They found that no studies reported a significant statistical difference in diagnosis or disposition among psychiatric patients who presented to the Emergency Department. In addition, their review demonstrated a reduction in length of stay, reduction in time to care, and decreased costs among these patients. The authors also reviewed literature pertaining to crisis response teams and patients with severe mental illness. Both studies demonstrated that telemental health visits for these patients were similar, if not better, than face-to-face visits. In addition, both patients and practitioners showed high satisfaction with these services.[7] Thus, the implementation of telemental health is limited to out-patient settings and could feasibly be implemented in the in-patient and emergency settings. There is, however, one particularly glaring gap in telemental health services: group therapy. Perhaps the most famous example of group therapy is Alcoholics Anonymous, but group therapy has expanded to include many different modalities. Group therapy is a common intervention for many mental illnesses and can be incredibly effective in treating diseases ranging from PTSD to borderline personality disorder.[8] In a pilot study comparing a video teleconference based Dialectical Behavioral Therapy (DBT) group to an in-person DBT group, Lopez et al. found that while patients had similar levels of cohesion with the facilitator, participants in the video teleconference group saw less group cohesion than their peers in the in-person group. Further, while many patients in the video teleconference group believed that the convenience offset the adverse effects, many also wished for an in-person group. Attendance was also significantly higher in the video teleconference group.[9] Thus, while the video teleconference group did report some positives, some significant differences raise ethical questions. How well does a group do without cohesion? For example, if a person needing to be consoled breaks down and cries in front of the group, the in-person response may be different from the video conference. In the in-person group, other group members may place a gentle hand on the shoulder of the grieving person or maybe even hug them. The group facilitator or group members in the video conference group could say the same words of consolation as those in the in-person group. However, there still seems to be some missing action. The idea of physical touch, in this way, can mean a lot more than just a small action. Van Wynsberghe and Gastmans argue that this kind of deprivation may lead to feelings of depersonalization.[10] And, to an extent, their supposition is supported by the data presented by Lopez et.al. The low level of group cohesion in the video conference group could suggest that other group members seem unimportant to the participants. They are simply things on a screen, not real people. Dr. Thomas Insel, former National Institute of Mental Health Director writes that while technology may hold the key to improving mental health on the population level, there is a human-sized piece of the puzzle missing from these interventions. The solution, he asserts, lies somewhere in the integration of these two types of experiences, one that he terms “high-tech and high-touch.”[11] The lack of touch and physical presence is an obstacle for both patients and providers. At best this may lead to a slightly poorer provider-patient relationship and at worst may result in poorer quality care. ll. Privacy & Confidentiality Concerns Privacy and confidentiality are among the most serious concerns for practitioners and patients, made more complex by the advent of e-health. Major news outlets provide plenty of examples of breaches of confidentiality of people’s electronic records. Even significant systems, often thought to be secure, used to facilitate direct contact between people in the wake of COVID-19, like Zoom, have been breached. Not too long ago, "Zoom Bombing” was a national phenomenon, appearing in online classrooms, often sharing explicit or politically motivated content. Psychiatric patients are susceptible to issues surrounding privacy and confidentiality, and they may even come from communities that ostracize and stigmatize mental illness. These concerns must be taken seriously. Of course, both the American Psychiatric Association and the American Psychological Association address privacy concerns. Both organizations note in their guidelines that relevant HIPAA regulations apply to telehealth and doctors must use apps and videoconferencing tools with the highest levels of security.[12] Interestingly, the American Psychiatric Association takes these instructions one step further. It requires providers to be in a private room during telehealth videoconferences or calls and that people seeking care also have a private space so that any conversations are not overheard. This not only prevents violations of privacy but reassures the therapeutic relationship between provider and patient.[13] While providers can take these steps to ensure their patients’ privacy, an internet connection may not guarantee privacy. Many privacy issues are more easily mitigated in a clinical space. For example, walls and doors can be soundproofed, or white noise can be played in the waiting room to ensure that therapeutic conversations are not overheard. And while the American Psychiatric Association asks providers to mitigate these risks as they would in their respective clinics, there is another layer to online privacy. Providers should be concerned about telecommunications providers, how they collect information, and what types of information they collect.[14] If, for example, the patient must navigate to the practitioner’s webpage to enter into the therapy portal, that information might be tracked and used to generate personalized ads for the patient. If a person suffering from severe paranoia started receiving ads for psychiatric medication, they may react negatively to the invasion of privacy. That type of targeted advertising could even exacerbate a mental health condition. The scandals surrounding the National Security Administration (NSA) in recent years have added another layer of complexity to the issue of privacy. Whistleblowers like Edward Snowden, revealed that the government was collecting metadata from text messages, videos, and social media. Government surveillance is an added risk of mental health videoconferencing.[15] The government would not be bound by the rules that require privacy with few exceptions like the Tarasoff law, which could require disclosure to stop a violent act as a clinical care provider. The government might judge someone a risk-based on ill-gotten surveillance data, wrongly add a person to a watch list, or engage in further surveillance of a patient whom non-clinicians working in government assess to be a potential danger. Protection from government surveillance is a fundamental ethical endeavor. Yet government as a collector of data without a warrant or with easily attained FISA and other warrants is problematic. Scenarios may seem far-fetched but are within the realm of possibility. Secondly, the provider must envision how this might hinder care. For example, patients aware of the possibility of government surveillance may be reluctant to show up to online meetings if they show up at all. Perhaps they are so sensitive to these issues that they stop checking with their therapist altogether. It is easy to see how a person who has schizophrenia and shows signs of paranoia may avoid telehealth for fear of being tracked. Of course, one could also have privacy concerns about a therapist’s office. Perhaps patients are nervous about being seen in the office or parking lot. They might worry about being overheard. These concerns, however, can be mitigated fairly simply, for example, patients could find anonymous means of transportation and practitioners can soundproof their offices. Thus, in both the office and the videoconference, concerns can be mitigated easily and tangibly, but not eliminated entirely. Mental health providers should use the highest quality communication services with end-to-end encryption to bolster online privacy. lll. Boundary Issues and Professionalism The boundaries here are philosophical, not physical. Both the American Psychiatric Association and the American Psychological Association work to ensure that the patient-professional boundaries are kept as close to normal as possible. Both organizations expect practitioners to maintain the highest levels of professionalism when dealing with patients using telemental health services.[16] Practitioners are responsible for enforcing boundaries through informing their patients about appropriate behavior so that patients are discouraged from calling at inappropriate times absent an emergency. Videoconferencing systems and multi-layered protections like passwords and gatekeeping would prevent patients from logging into another patient’s appointment. These boundaries exist for a good reason. A 2017 report demonstrated that there is an escalating shortage of psychiatrists.[17] Nearly 1 in 5 people in the US has a mental health condition.[18] Mental health providers are nearly overwhelmed, therefore inappropriate, frequent, and unnecessary contact adds another level of complexity to treating patients. Mental health providers need to be stewards of the resource they provide. They must concentrate on the patient they are with. They also must guard themselves against burnout, because dealing with patients too often, even though technology allows for it, will lead to them being less effective for the rest of their patients. While these professional boundaries must be policed carefully, practitioners should also be careful of having boundaries that are too high. Thus, providers must balance between too much intimacy and too little.[19] Presence and physical touch have symbolic meaning. Being with a person reaffirms their personhood, and both provider and patient can feel that. Humans are relational beings, and a physical relationship often comforts people. It may also legitimize and reinforce the patient through sensation and perception. There may be something inherently missing from the practice of telemental health, as exemplified by the group members’ inability to console others in group therapy sessions over teleconference.[20] The screen may also be an agent of depersonalization. It may make the patient’s complaints seem less real. Or perhaps the patient may feel as though they are not being heard. Although the evidence of telemedicine’s successes above may seem to contradict this, none of the studies that extoll the benefits of telemental health have follow-up periods greater than one year. And while many studies show that patients are highly satisfied with telemental health, measurements of satisfaction are not standardized. It remains unclear whether patients benefit enough from their telemental sessions or whether they require more regular sessions to stay as satisfied as they were with in-person mental health care. Perhaps as time goes on, patients become more frustrated with telemental health. The research must answer these questions, but currently, it does not sufficiently address metaphysical arguments against telemental health. CONCLUSION Privacy is a key practical issue that remains. Although providers try to combat issues of privacy by using high-level conferencing software, which has end-to-end encryption,[21] surveillance and breaches may occur. While not suitable for all kinds of patients, telemental health services prove to be effective for groups of people that otherwise may not have been able to receive care over the past two years. There are some settings, such as group therapies, that are best suited for in-person meetings. Although online sessions encourage individuals to show up regularly, their downsides are not yet known. There is incredible power in the idea of presence, and humans are inherently relational beings. For some, a lack of contact is unwelcomed and makes therapy less satisfying. Opportunities to use in-person clinical care remain a priority for some patients, and healthcare providers should further investigate prioritizing in-person care for those who want it. Telemental health could be beneficial for emergencies, natural disasters, vulnerable groups, or when patients cannot get to their provider's office. However, for now, telemental health should not take a leading role in providing mental health treatment. - [1] Chiauzzi E, Clayton A, Huh-Yoo J. Videoconferencing-Based Telemental Health: Important Questions for the COVID-19 Era from Clinical and Patient-Centered Perspectives. JMIR Ment Health, 2020. doi:10.2196/24021 [2] Joint Task Force for the Development of Telepsychology Guidelines for Psychologists. Guidelines for the practice of telepsychology. American Psychologist, 2020. 791–800. doi.org/10.1037/a0035001 [3] Gentry MT, Lapid MI, Rummans TA. Geriatric Telepsychiatry: Systematic Review and Policy Considerations. Am J Geriatr Psychiatry. 2019 doi: 10.1016/j.jagp.2018.10.009; Campbell R, O'Gorman J, Cernovsky ZZ. Reactions of Psychiatric Patients to Telepsychiatry. Ment Illn. 2015;7(2):6101, 2015. doi:10.4081/mi.2015.6101; Malhotra S, Chakrabarti S, Shah R. Telepsychiatry: Promise, potential, and challenges. Indian J Psychiatry, 2013. doi: 10.4103/0019-5545.105499; Reinhardt I, Gouzoulis-Mayfrank E, Zielasek J. Use of Telepsychiatry in Emergency and Crisis Intervention: Current Evidence. Curr Psychiatry Rep, 2019. doi: 10.1007/s11920-019-1054-8 [4] Gentry, Lapid, and Rummans, Geriatric Telepsychiatry [5] Abuwalla, Zach & Clark, Maureen & Burke, Brendan & Tannenbaum, Viktorya & Patel, Sarvanand & Mitacek, Ryan & Gladstone, Tracy & Voorhees, Benjamin. Long-term Telemental health prevention interventions for youth: A rapid review, 2017. Internet Interventions. Doi.11. 10.1016/j.invent.2017.11.006. [6]Hailey D, Roine R, Ohinmaa A. The effectiveness of telemental health applications: a review, 2008. Can J Psychiatry. doi:10.1177/070674370805301109. [7] Reinhardt, Gouzoulis-Mayfrank, and Zielasek, Use of Telepsychiatry in Emergency and Crisis Intervention [8] Kealy, David & Piper, William & Ogrodniczuk, John & Joyce, Anthony & Weideman, Rene. Individual goal achievement in group psychotherapy: The roles of psychological mindedness and group process in interpretive and supportive therapy for complicated grief, 2018. Clinical Psychology & Psychotherapy. doi:10.1002/cpp.2346. Schwartze D, Barkowski S, Strauss B, Knaevelsrud C, Rosendahl J. Efficacy of group psychotherapy for posttraumatic stress disorder: Systematic review and meta-analysis of randomized controlled trials. Psychother Res, 2019. doi: 10.1080/10503307.2017.1405168; Wetzelaer P, Farrell J, Evers SM, Jacob GA, Lee CW, Brand O, van Breukelen G, Fassbinder E, Fretwell H, Harper RP, Lavender A, Lockwood G, Malogiannis IA, Schweiger U, Startup H, Stevenson T, Zarbock G, Arntz A. Design of an international multicentre RCT on group schema therapy for borderline personality disorder. BMC Psychiatry, 2014. doi: 10.1186/s12888-014-0319-3 [9] Lopez, Amy et al. “Therapeutic groups via video teleconferencing and the impact on group cohesion.” mHealth, 2020. doi:10.21037/mhealth.2019.11.04 [10] Van Wynsberghe A, Gastmans C. Telepsychiatry and the meaning of in-person contact: a preliminary ethical appraisal. Med Health Care Philos, 2009. doi: 10.1007/s11019-009-9214-y. [11]Thomas Insel, “Tech Can Help Solve Our Mental Health Crisis. But We Can’t Forget The Human Element.,” Substack newsletter, Big Technology (blog), January 27, 2022, https://bigtechnology.substack.com/p/tech-can-help-solve-our-mental-health. [12] Armstrong, C. M., Ciulla, R. P., Edwards-Stewart, A., Hoyt, T., & Bush, N. Best practices of mobile health in clinical care: The development and evaluation of a competency-based provider training program, 2018. Professional Psychology: Research and Practice. doi.org/10.1037/pro0000194 [13] Armstrong, C. M., Ciulla, R. P., Edwards-Stewart, A., Hoyt, T., & Bush, N. Best practices of mobile health in clinical care: The development and evaluation of a competency-based provider training program [14] Sabin JE, Skimming K. A framework of ethics for telepsychiatry practice. Int Rev Psychiatry, 2015. doi:10.3109/09540261.2015.1094034 [15] Lustgarten, S. D., & Colbow, A. J. Ethical concerns for telemental health therapy amidst governmental surveillance, 2017. American Psychologist. doi.org/10.1037/a0040321 [16] Armstrong, C. M., Ciulla, R. P., Edwards-Stewart, A., Hoyt, T., & Bush, N. Best practices of mobile health in clinical care: The development and evaluation of a competency-based provider training program [17] Merritt Hawkins. An Overview of the Salaries, Bonuses, and Other Incentives Customarily Used to Recruit Physicians, Physician Assistants and Nurse Practitioners, 2018. http://physicianresourcecenter.com/wp-content/uploads/2018/09/Merritt-Hawkins-2018-Review-of-Physician-and-Advanced-Practitioner-Incentives.pdf [18] Bose, J., Hedden, S., Lipari, R., Park-Lee, E. Key Substance Use and Mental Health Indicators in the United States: Results from the 2015 National Survey on Drug Use and Health, 2015. https://www.samhsa.gov/data/sites/default/files/NSDUH-FFR1-2015/NSDUH-FFR1-2015/NSDUH-FFR1-2015.pdf [19] Sabin and Skimming. A Framework of Ethics for Telepsychiatry Practice [20] Van Wynsberghe and Gastmans, Telepsychiatry and the Meaning of In-Person Contact [21] Lustgarten and Colbow, Ethical Concerns for Telemental Health Therapy amidst Governmental Surveillance

La Dialectical Behavior Therapy (DBT) è un programma di trattamento cognitivo-comportamentale strutturato, complesso e ricco, messo a punto per pazienti con Disturbo Borderline di Personalità (BPD) e gravi comportamenti disfunzionali (tentativi suicidari, autolesività, instabilità relazionale, comportamenti impulsivi). DBT ha dimostrato la sua efficacia in numerosi studi: i tentativi suicidari e i comportamenti disfunzionali si sono ridotti, mentre la regolazione emotiva e il funzionamento generale dei pazienti sono migliorati. La ricerca presentata i prefigge di valutare l’efficacia e i meccanismi d’azione di DBT, esaminando sia la dimensione di outcome, sia la dimensione di processo. La prima parte dell’elaborato è dedicata alla presentazione del modello DBT. Se ne discutono i fondamenti teorici, gli accordi alla base del trattamento, le modalità del programma terapeutico e le strategie di intervento. La seconda parte dell’elaborato è una valutazione dell’efficacia di DBT, rispetto alle variabili target. Lo studio è di tipo longitudinale ed è stato condotto seguendo le linee guida internazionali. DBT è stata messa a confronto con un programma di trattamento comparabile per tipologia di pazienti, obiettivi e complessità. Il campione è composto da 95 pazienti ambulatoriali, valutati ogni tre mesi. Poiché ci si attendeva che il contributo della variabilità individuale fosse rilevante, sono stati utilizzati modelli lineari gerarchici con effetti casuali. I risultati hanno mostrato che i tentativi suicidari, i comportamenti autolesivi, la disregolazione emotiva e comportamentale sono diminuiti in entrambi i gruppi dopo un anno; i modelli hanno mostrato come i soggetti differissero nella quota di cambiamento. Inoltre, i risultati sul campione dei completer hanno suggerito che il setting di gruppo e l’intensità del trattamento potrebbero agire quali specifici meccanismi terapeutici. La terza parte dell’elaborato si compone di una serie di studi di processo con un disegno single case, inseriti nel filone della ricerca process-outcome: si tratta della valutazione di due coppie terapeutiche, una con esito favorevole ed una con esito parziale. Le pazienti erano due giovani donne con diagnosi di BPD, differenti per profilo di personalità e comportamenti disfunzionali; hanno seguito un programma DBT standard con il medesimo terapeuta, un clinico esperto. Sono state esaminate le sedute durante il primo anno di trattamento. Si sono considerate tanto la dimensione tecnica quanto quella relazionale del processo terapeutico, esaminando entrambe da una prospettiva macroanalitica e microanalitica. I risultati hanno mostrato come alcuni aspetti siano riscontrabili in ambedue le coppie terapeutiche: l’aderenza al modello di trattamento e l’atteggiamento del terapeuta orientato alla collaborazione. D’altra parte, sono emerse specificità relative alle coppie terapeutiche. Nel trattamento della paziente con esito positivo, è presente un clima relazionale globalmente positivo, terapeuta e paziente riescono ad affrontare in modo proficuo anche le incomprensioni. Invece, nel trattamento della paziente con esito parziale, terapeuta e paziente faticano a trovare una sintonizzazione e a lavorare in modo sinergico, rimanendo bloccati in dinamiche problematiche e senza riuscire a conseguire pienamente gli obiettivi prefissati. Nel loro insieme, i risultati hanno confermato l’efficacia e la complessità di DBT. Più precisamente, hanno messo in luce le sovrapposizioni e le differenze tra DBT e altri modelli teorici, in particolare con gli interventi che promuovono il funzionamento riflessivo. Inoltre, i risultati hanno confermato l’importanza di una relazione collaborativa tra terapeuta e paziente. In sintesi, è possibile concludere che i meccanismi dell’azione terapeutica in DBT possono essere compresi solo alla luce delle dinamiche del processo terapeutico entro cui si verificano.
Dialectical Behavior Therapy (DBT; Linehan, 1993, 2014) is a structured, complex and comprehensive cognitive-behavioral treatment program for patients with Borderline Personality Disorder (BPD) and severe dysfunctional behaviors (repeated suicidal attempts, self-harm behaviors, relational instability, other impulsive behaviors). Up to now, DBT proved its effectiveness in several studies: suicide attempts and dysfunctional behaviors decreased, while emotional regulation and general functioning improved. The present research aimed at assessing the effectiveness of DBT and its mechanisms of action, evaluating both outcome and process dimensions. The first part of the thesis is dedicated to the presentation of the DBT model, examining its theoretical foundations, the agreements underlying the treatment, the modalities of therapeutic program, and the strategies of intervention. The second part of the thesis is an evaluation of the effectiveness of DBT, examining the course over time of the target variables. The study is longitudinal, single-blind, with a two-arm parallel design, conducted following the international guidelines for the outcome studies on intention-to-treat samples. DBT was compared with another treatment program comparable by patient type, objectives, and complexity of interventions. The sample was comprised by 95 outpatients, assigned to groups with the minimisation procedure and assessed every three months. Since the individual variability was expected to be consistent, Hierarchical Linear Models with random effects were used. Results showed that suicidality, self-harm, emotional and behavioral dysregulation decreased in both groups after one year; unconditional growth models indicated that subjects differed in the elevation and in the rate of change. Moreover, results on the completers’ subsample suggested that the group setting and the intensity of treatment could represent specific therapeutic mechanisms. The third part of the thesis is composed by process studies with a single-case design, in the strand of the process-outcome research: the empirical evaluation of two therapeutic couples, one with a favorable outcome and one with a partial outcome, was conducted. The patients were two young women with a diagnosis of Borderline Personality Disorder, different for personality profile and dysfunctional behaviors at the beginning of treatment; they followed a DBT standard program with the same therapist, a male experienced clinician. Sessions over the first year of treatment were examined (N1 = 38; N2 = 37). The technical and the relational dimensions of the therapeutic process were assessed and examined through a macroanalytic and microanalytic perspective. Results showed that some aspects are present in both couples: namely, the adherence to the treatment model and the attitude of the therapist oriented towards collaboration. On the other hand, specificities relating to each therapeutic couple emerged. In the treatment of the patient with positive outcomes, there was a globally positive relational climate; furthermore, therapist and patient can deal even with episodes of misunderstanding. Instead, in the treatment of the patient with partial outcomes, therapist and patient struggled to find an attunement and to work in synergy, remaining trapped in problematic relational patterns and without fully achieving the therapeutic objectives previously agreed. Taken together, results confirmed the effectiveness and the complexity of DBT. More specifically, they shed light on overlaps and differences between DBT and other theoretical models, in particular interventions promoting reflective functioning. Furthermore, the importance of a collaborative relationship between therapist and patient was confirmed. Overall, results suggested that mechanisms of action in DBT can be understood only in light of the dynamics of the therapeutic process in which they occur.