T. Michael Vallis

Therapist Competence Ratings in Relation to Clinical Outcome in Cognitive Therapy of Depression

This study reports on the relationship of therapist competence to the outcome of cognitive-behavioral treatment in the National Institute of Mental Health Treatment of Depression Collaborative Research Program. Outpatients suffering from major depressive disorder were treated by cognitive-behavioral therapists at each of 3 U.S. sites using a format of 20 sessions in 16 weeks. Findings provide some support for the relationship of therapist competence (as measured by the Cognitive Therapy Scale) to reduction of depressive symptomatology when controlling for therapist adherence and facilitative conditions. The results are, however, not as strong or consistent as expected. The component of competence that was most highly related to outcome is a factor that reflects the therapists ability to structure the treatment.

The Role of Psychological Factors in Bariatric Surgery for Morbid Obesity: Identification of Psychological Predictors of Success

This paper deals with two important questions in the outcome of surgical treatment for morbid obesity. First, what is the impact of bariatric surgery on psychological functioning or quality of life? Second, and perhaps more important, can pre-surgical factors be identified that predict the outcome of surgery? These questions are answered by a systematic review of the current literature in this area. Throughout this paper the need for methodological rigour is stressed, and conclusions are based only on empirically sound findings. It is concluded that surgery is generally associated with improved psychological functioning and quantity of life for most individuals. While a significant minority of morbidly obese individuals do not respond positively to surgery, there is no evidence to support the theory that obesity is a psychological defense mechanism, and therefore that bariatric surgery will produce widespread psychological problems. On a less positive note, while some studies identify pre-surgery psychological factors that predict weight loss following surgery, there has been no attempt to systematically replicate findings across studies, and no consistent findings have emerged from the literature. Due to the fact that the predictor variables examined have not been selected on theoretical grounds, the interpretation of isolated findings is difficult. On the basis of this review, however, distress over obesity appears to be a potentially important psychological predictor of the success of surgery. Unfortunately, there currently is no measure to specifically measure distress over obesity. What is needed at this time is a theoretically derived approach to the development of a scale to assess distress over obesity.

Assessing Patient Suitability for Short-Term Cognitive Therapy with an Interpersonal Focus

In the current study, the development and initial validation of the Suitability for Short-Term Cognitive Therapy (SSCT) interview procedure is reported. The SSCT is an interview and rating procedure designed to evaluate the potential appropriateness of patients for short-term cognitive therapy with an interpersonal focus. It consists of a 1-hour, semistructured interview, focused on eliciting information from the patient relevant to nine selection criteria. The procedures involved in the development of this scale are described in detail, and preliminary evidence suggesting that the selection criteria can be rated reliably is presented. In addition, data indicating that scores on the SSCT scale predict the outcome of short-term cognitive therapy on multiple dependent measures, including both therapist and patient perspectives, are reported. It is concluded that the SSCT is a potentially useful scale for identifying patients who may be suitable, or unsuitable, for the type of short-term cognitive therapy administered in the present study.

The consequences of anxious temperament for disease detection, self-management behavior, and quality of life in Type 2 diabetes mellitus

OBJECTIVE The purpose of this study is to examine the consequences of anxious temperament for disease detection, self-management behavior, and quality of life in Type 2 diabetes mellitus (T2DM). METHOD A sample of 204 individuals newly diagnosed with T2DM completed measures of anxious temperament, self-management behavior, and quality of life; participants also supplied a blood sample for glycated hemoglobin (A1C) analysis at initial diagnosis (baseline) and at 6-month follow-up (as indicators of disease progression at diagnosis and achieved glycemic control, respectively). RESULTS Anxious temperament was inversely associated with A1C at both baseline and at 6-month follow-up. However, the association between anxious temperament and A1C at follow-up was mostly accounted for by the association between anxious temperament and baseline A1C and not by the uptake of self-management behaviors after diagnosis. Higher levels of anxious temperament were also associated with an increased likelihood of having been diagnosed with a prediabetic condition but were associated with poorer quality of life at both time points. CONCLUSION Anxious temperament appears to be a double-edged sword that may facilitate early detection but not subsequent behavioral or emotional adjustment to T2DM.

Blame, Shame, and Lack of Support: A Multilevel Study on Obesity Management

In this research, we examined the experiences of individuals living with obesity, the perceptions of health care providers, and the role of social, institutional, and political structures in the management of obesity. We used feminist poststructuralism as the guiding methodology because it questions everyday practices that many of us take for granted. We identified three key themes across the three participant groups: blame as a devastating relation of power, tensions in obesity management and prevention, and the prevailing medical management discourse. Our findings add to a growing body of literature that challenges a number of widely held assumptions about obesity within a health care system that is currently unsupportive of individuals living with obesity. Our identification of these three themes is an important finding in obesity management given the diversity of perspectives across the three groups and the tensions arising among them.

A complete component analysis of Stress Inoculation for pain tolerance

This study involved a complete component analysis of Stress Inoculation Training (SIT) for the reduction of cold pressor pain. SIT consists of an Education, Skills Acquisition, and Application phase. Each of these three phases alone, all possible pairs of phases, the complete protocol, and a pseudotreatment control were presented to groups of university women. While the complete protocol increased pain tolerance relative to the control protocol, not all of the phases of SIT were found to be important to the package. Only the Skills Acquisition phase played an important role in the SIT package. That is, when the Skills Acquisition phase was dropped from the package, the efficacy of SIT was significantly lower. While the Education phases increased pain tolerance when presented alone, it did not appear to add to the efficacy of the total package. The Application phase was ineffective for increasing tolerance by itself and did not add to the efficacy of SIT. Further data suggested that the effects of the Skills Acquisition phase might be mediated by increased use of relaxation and/or by a decrease in catastrophizing. Self-instructions were not readily employed and may not be important in increasing tolerance in the analogue context. These findings question the multidimensional training approach to SIT for analogue pain, as well as the focus on the role of self-instructions within the SIT package.

Self-efficacy as a predictor of behavior change: Interaction with type of training for pain tolerance

The relationship between self-efficacy expectations and the training effects of skill-based and non-skill-based procedures for pain reduction was investigated. Both pretraining self-efficacy magnitude and strength measures, as well as changes in self-efficacy magnitude and strength, were employed to predict posttraining behavioral tolerance and subjective discomfort to a cold pressor pain stimulus. Eighty university women received brief training in either skill-based (relaxation, attention diversion, and self-instruction skills) or non-skill-based (rationale, exposure, and demands for change) procedures. Results indicated that pretraining magnitude, as well as change in magnitude scores, significantly predicted posttraining tolerance and discomfort for the nonskills group. Changes in self-efficacy magnitude and strength both predicted posttraining tolerance for the skills group. For the discomfort measure, the nonskills procedure produced significantly lower scores than the skills procedure for subjects who demonstrated relatively large increases in self-efficacy magnitude. All predictive relationships in this study were independent of pretraining performance levels. The implications of these data for the selection and treatment of subjects is considered.

Postpartum Flatal and Fecal Incontinence Quality-of-Life Scale: A Disease- and Population-Specific Measure

Using various recruiting methods, the authors identified 10 women who suffer from flatal and/or fecal incontinence subsequent to one or more previous vaginal deliveries. Each of these women participated in an individual in-depth 1-hour interview assessing symptom frequency, severity, and impact on quality of life. Participants also completed the Fecal Incontinence Quality-of-Life Scale and evaluated how well this scale captured their experiences. The authors used qualitative analyses to generate themes from the interviews and modified the existing scale, adding new items and themes to capture this populations particular symptom experience. This scale is being evaluated in the context of a surgical clinical trial comparing two techniques for repairing anal sphincter lacerations from delivery.

A Novel Approach to Cardiovascular Health By Optimizing Risk Management (ANCHOR): Behavioural Modification in Primary Care Effectively Reduces Global Risk

BACKGROUND Primary care is well positioned to facilitate cardiovascular risk improvement and reduce future cardiovascular disease (CVD) burden. METHODS The efficacy of risk factor screening, behavioural counselling, and pharmacological treatment to lower CVD risk was assessed via a prospective pre- and postintervention health risk assessment, individualized intervention with behaviour modification, risk factor treatment, and linkage to community programs, with 1-year follow-up and final health risk assessment. Primary outcome was the proportion of subjects with moderate and high baseline Framingham Risk Score (FRS) reducing their risk by 10% and 25%, respectively; the secondary end point was the proportion dropping ≥ 1 risk category. RESULTS Patients were enrolled (N = 1509) from March 2006 through October 2008 and 72% completed the study. This analysis focuses on 563 subjects with moderate or high baseline FRS, and excluded 325 low-risk patients and 205 with established CVD or diabetes mellitus. Median age was 56 years, 57.7% were female. The primary outcome was achieved in 31.8% (N = 112; 95% confidence interval [CI], 26.9%-36.6%) of moderate risk FRS participants and 47.9% (N = 101; 95% CI, 41.2%-54.6%) of high-risk participants. The secondary outcome was achieved by 37.2% (N = 210; 95% CI, 33.2%-41.2%). Prevalence of metabolic syndrome fell from 79.2% (N = 446; 95% CI, 75.9%-82.6%) at entry to 52.8% (N = 303; 95% CI, 48.7%-56.9%) at study end. Significant improvements in all modifiable risk factors occurred through lifestyle modification. CONCLUSIONS Global cardiovascular risk can be effectively decreased via lifestyle changes informed by readiness to change assessment and individualized counselling targeting specific behaviours. TRIAL REGISTRATION ClinicalTrials.gov number NCT01620996.

A Novel Approach to Cardiovascular Health by Optimizing Risk Management (ANCHOR): A Primary Prevention Initiative Examining the Impact of Health Risk Factor Assessment and Management on Cardiac Wellness

Cardiovascular disease (CVD) represents an increasing burden to health care systems. Modifiable risk factors figure prominently in the population-attributable risk for premature coronary artery disease. Primary care is well placed to facilitate CVD risk improvement. We plan to evaluate the ability of a novel primary care intervention providing systematic risk factor screening, risk-weighted behavioural counselling and pharmacological intervention to achieve 2 objectives: (1) optimized management of global CVD risk of patients and (2) increased patient adherence to lifestyle and pharmaceutical interventions aimed at decreasing global CVD risk. A pre-post longitudinal prospective design with a nonrandomized comparison group is being undertaken in 2 geographically diverse primary care practices in Nova Scotia with differing reimbursement models. Participants will complete a readiness to change and pre-post health risk assessment (HRA), that will trigger a 1-year intervention individualized around risk and readiness. The primary outcome will be the proportion of participants with Framingham moderate and high-risk strata that reduce their absolute risk by 10% and 25%, respectively. The secondary outcome will be the proportion of moderate and high-risk participants who reduce their risk category. The impact of the intervention on clinical and behavioural variables will also be examined. Low risk participants will be separately analyzed. Data from participants unable to change from the high risk category because of diabetes mellitus or established atherosclerotic disease will also be analyzed separately, with changes in clinical measures from baseline being assessed. A health economic analysis is planned.