Stephen M. Auerbach

Integrating measurement of control and affiliation in studies of physician-patient interaction: the interpersonal circumplex

Following a brief overview and commentary on the physician-patient communication literature, this article summarizes and evaluates research on the relationship between physician-patient control (dominant-submissive) and affiliation (friendly hostile) behaviors as they relate to medical outcomes. Findings for both verbal and nonverbal control and affiliation measures are included. The interpersonal circumplex (together with the important interactional principles that it incorporates) is then introduced as an heuristic guide for future medical interaction research. The circumplex was constructed as a conceptual and empirical model to integrate the numerous studies that have established control and affiliation as universal dimensions of human interpersonal behavior and relationships. Next, the small group of studies that have applied circumplex inventories to analyses of practitioner-patient transactions are reviewed with emphasis on their strengths and unique aspects of their findings. The concluding section enumerates advantages and innovations that the interpersonal circumplex and its measures can provide to facilitate more heuristic studies of physician-patient interactions.

Cognitive, Affective, and Behavioral Effects of Reminiscence Group Therapy on Demented Elderly:

Twenty-seven demented elderly nursing home residents were given either reminiscence group therapy or supportive group therapy or were assigned to a no-treatment control group. The self-reported level of depression in participants given reminiscence therapy was positively affected compared to participants in the supportive therapy and control groups, but no significant effects were found for cognitive or behavioral functioning. Results are discussed in terms of the issue of the applicability of reminiscence therapy for cognitively impaired persons, the appropriateness of the measures used in this study to assess depression, cognitive ability and behavioral functioning, and in conjunction with clinical observations made during the process of therapy.

Crisis Intervention: A Review of Outcome Research

Crisis intervention studies conducted in suicide prevention/crisis intervention programs, in psychiatric settings, and with surgical patients are critically evaluated. In the first area the impracticality of suicide as an outcome measure and the need for shifting evaluation emphasis from crisis worker performance to client behavior change measures is stressed. Also, the virtual impossibility of demonstrating overall program impact on the community and the need for developing internal program evaluation procedures is noted. Studies in psychiatric settings suffer from considerable methodological shortcomings that prohibit definitive conclusions; studies operationally specifying treatment components are greatly needed here. Studies with surgery patients indicate the necessity for developing intervention techniques most appropriate for individuals differing in their typical manner of dealing with stress. In all settings, outcome measures should be appropriate to the situation and logically related to the goals of intervention. In the two decades following Eysencks (1952) classic survey calling into question the effectiveness of the traditional psychotherapies, the growth in output of research studies of therapeutic process and outcome has been phenomenal (Bergin, 1971; Marsden, 1971). However, crisis intervention, a therapeutic technique that is receiving increasing use, as indicated by the recent proliferation of suicide prevention/crisis intervention centers and telephone hot lines, has gone largely uninvestigated until recent years. This is probably due to the fact that as a clinical technique it does not fall under the rubric of traditional psychotherapy, and since initial attempts at formulations of crisis theory and delineation of technique have not been developed until recently (Aguilera & Messick, 1974; Caplan, 1964; Lieb, Lipsitch, & Slaby, 1973; McGee, 1974; Schulberg & Sheldon, 1968; Taplin, 1971).

Stress management and coping research in the health care setting: an overview and methodological commentary.

I argue that stress management and coping studies in the health care setting have not been sufficiently theoretically grounded. In particular, in formulating and evaluating intervention strategies, researchers have not adequately taken into account the nature of the stressor under study in terms of the degree to which it poses emotion-focused versus problem-focused coping demands for the individual. This theme is explored in examination of research in five essential areas: (a) effectiveness of problem- versus emotion-focused coping strategies, (b) effectiveness of interventions, (c) the role of individual difference variables, (d) timing of interventions, and (e) evaluation of treatment impact.

Adjustment to the stress of simulated captivity: effects of emotion-focused versus problem-focused preparation on hostages differing in locus of control.

We instructed 57 subjects about to be exposed to a simulated abduction and 4 days of captivity in either problem- or emotion-focused coping techniques, or we gave them a control orientation presentation. Retrospective self-report data obtained on the Ways of Coping Checklist indicated that subjects tended to use coping processes consistent with the type of prestress preparation they had received. Dramatic fluctuations in State Anxiety scores over the course of captivity indicated that the simulation was perceived to be highly stressful. Subjects given emotion-focused preparation reported the lowest anxiety and emotional distress levels and were rated as exhibiting the lowest levels of behavioral disturbance during captivity. Externals engaged in more emotion-focused coping than internals, but externals given problem-focused preparation responded the most poorly of all subgroups on all response measures. Overall, locus of control differences were of secondary impact (vs. situational variables) in influencing anxiety and adjustment. We discuss the characteristics of the stressor that may have accounted for the major findings and the stressful circumstances under which emotion-focused versus problem-focused coping may be of differential utility.

Effects of a Single Session of Large-Group Meditation and Progressive Muscle Relaxation Training on Stress Reduction, Reactivity, and Recovery

Three hundred eighty-seven undergraduate students in a large-group setting were exposed to 20 min of either meditation, progressive muscle relaxation (PMR), or a control condition, followed by 1 min of stress induction and another 10 min of each intervention. Participants in the meditation and PMR groups decreased more in cognitive, somatic, and general state anxiety than controls. The PMR group had the greatest decline in somatic anxiety, lending some support to the cognitive/somatic specificity hypothesis. After exposure to a visual stressor, those in the relaxation conditions had higher levels of anxiety and recovered more quickly than controls. Findings demonstrated the effectiveness of brief group training in meditation or PMR in reducing state anxiety after exposure to a transitory stressor.

Do Patients Want Control over their Own Health Care? A Review of Measures, Findings, and Research Issues

Across a wide variety of medical settings, patients report that they want detailed information about their condition and their treatment whereas stated desire for input into decision making is skewed more in the direction of physician-only or at least collaborative decision-making. These results, along with the contextual and individual difference factors associated with increased willingness to relinquish control (lower educational level, more serious illness, increasing age), indicate that patients want to assume control if they feel it will be beneficial to them to do so. The findings, however, are based largely on the relationship of patients’ mean scores to arbitrarily determined scale midpoints on measures with little or no criterion-related validity. These measures also show insufficient overlap with better validated measures of desire for health care control, which indicate more normally distributed scores and a broader range of individual differences among respondents. Findings are discussed in terms of the need for further research on the structure (dimensionality) and stability of the construct desire for health care control and issues involved in conducting needed criterion-related validational work.

Should patients have control over their own health care?: Empirical evidence and research issues

Available research indicates that purported patient insufficiences in ability to process information and make rational and reliable decisions have likely been overestimated. Furthermore, data indicate that nonscientific factors often play a role in physician decision-making and that physicians may not value different health outcomes in the same way as patients. Though the data on patient cognitive functioning are limited because of heavy reliance on patient responses in hypothetical versus actual decision-making situations, these findings lend credence to arguments that patients should have increased control over their own health care. Research on the effects of interventions designed to enhance patient control indicates that: (a) patients generally respond positively to increased information, but few studies have evaluated the effects of information as a precursor to decision-making; (b) the few studies using simple behavioral control interventions have shown generally positive effects on a range of patient outcomes; and (c) studies of decisional control (with breast cancer patients) have had experimental confounds which prohibit conclusions regarding effectiveness. Areas in greatest need of research includes: (a) further exploration of the utility of noninvasive behavioral control interventions in different settings; (b) measuring the impact of control manipulations on patient perception of control as well as patient control-related behaviors; (c) matching patient differences in desire for control to experimental conditions and to physician differences in receptiveness to patient control; and (d) clinical trials in which patients facing critical decisions in trade-off situations are actually given a choice.

Psychological factors in recurrent genital herpes infection: Stress, coping style, social support, emotional dysfunction, and symptom recurrence

The relationship among stress, coping style, emotional dysfunction, social support, and severity of symptoms (frequency of recurrence, and pain, duration, and bother of recurrences) was investigated in 35 females and 32 males suffering from severe cases of genital herpes infection. Level of emotional dysfunction as measured by the SCL-90 approached two standard deviations above the mean as compared with non-patient normals, and frequency, pain, and bother of recurrences were associated with level of emotional dysfunction. Negative life stress (as measured by the Life Experiences Survey) was unrelated to psychopathology, and was associated only with duration among the symptom measures. Regression analyses indicated that higher frequencies of recurrence and greater discomfort associated with symptoms were associated with an external locus of control orientation and with a tendency to use emotion-focused wishful thinking and to avoid using cognitive strategies to cope with the stress associated with herpes. It was suggested that stress management procedures involving teaching of problem-focused coping strategies and provision of social support would be most effective for this population.

Psychological factors in adjustment to orthognathic surgery

The psychological adjustment of 30 orthognathic surgery patients was evaluated before and on three occasions after surgery. Results of preoperative testing showed the group to be well adjusted, and there were no major changes in psychological functioning as a result of surgery. Motivation for surgery included both functional and esthetic goals, and the majority of patients were satisfied with the results of surgery. The patients perception of the surgeon was significantly related to pre- and postoperative adjustment. Two of the measures used, the Health Opinion Survey and the Impact Message Inventory, have potential as brief early screening devices to identify patients who may experience problems in psychological adjustment to orthognathic surgery.