Directive Counseling Research Articles

Preconception care and genetic risk: ethical issues

Preconception care to address genetic risks in reproduction may be offered either individually to couples with a known or suspected increased risk of having a child with a genetic disorder, or systematically to couples or individuals of reproductive age. The identification of couples at risk of transmitting a (serious) genetic disorder allows those couples to refrain from having children or to adapt their reproductive plans (using prenatal or preimplantation diagnosis, donor gametes, or adoption). Ethical issues concern the possible objectives of providing these options through preconception genetic counseling or screening, objections to abortion and embryo-selection, concerns about eugenics and medicalization, and issues arising in the professional–client relationship and/or in the light of the normative framework for population screening. Although enhancing reproductive autonomy rather than prevention should be regarded as the primary aim of preconception care for genetic risks, directive counseling may well be acceptable in exceptional cases, and prevention in the sense of avoiding serious suffering may be an appropriate objective of specific community-based preconception screening programmes. The seemingly unavoidable prospect of comprehensive preconception screening raises further ethical issues.

Giving offspring a healthy start: parents' experiences of health promotion and lifestyle change during pregnancy and early parenthood

BackgroundThere are good opportunities in Sweden for health promotion targeting expectant parents and parents of young children, as almost all are reached by antenatal and child health care. In 2005, a multisectoral child health promotion programme (the Salut Programme) was launched to further strengthen such efforts.MethodsBetween June and December 2010 twenty-four in-depth interviews were conducted separately with first-time mothers and fathers when their child had reached 18 months of age. The aim was to explore their experiences of health promotion and lifestyle change during pregnancy and early parenthood. Qualitative manifest and latent content analysis was applied.ResultsParents reported undertaking lifestyle changes to secure the health of the fetus during pregnancy, and in early parenthood to create a health-promoting environment for the child. Both women and men portrayed themselves as highly receptive to health messages regarding the effect of their lifestyle on fetal health, and they frequently mentioned risks related to tobacco and alcohol, as well as toxins and infectious agents in specific foods. However, health promotion strategies in pregnancy and early parenthood did not seem to influence parents to make lifestyle change primarily to promote their own health; a healthy lifestyle was simply perceived as 'common knowledge'. Although trust in health care was generally high, both women and men described some resistance to what they saw as preaching, or very directive counselling about healthy living and the lack of a holistic approach from health care providers. They also reported insufficient engagement with fathers in antenatal care and child health care.ConclusionPerceptions about risks to the offspring's health appear to be the primary driving force for lifestyle change during pregnancy and early parenthood. However, as parents' motivation to prioritise their own health per se seems to be low during this period, future health promoting programmes need to take this into account. A more gender equal provision of health promotion to parents might increase men's involvement in lifestyle change. Furthermore, parents' ranking of major lifestyle risks to the fetus may not sufficiently reflect those that constitute greatest public health concern, an area for further study.

Treatment Fidelity of Motivational Interviewing Delivered by a School Nurse to Increase Girls' Physical Activity

Motivational interviewing, which involves the use of person-centered, directive counseling techniques, shows promise for changing adolescent behaviors. The purpose of this article was to describe the methodology and findings related to the treatment fidelity of three face-to-face motivational interviewing sessions involving middle school girls and a school nurse to help the girls increase their moderate-to-vigorous physical activity. The following four areas related to treatment fidelity were addressed: (a) study design, (b) training of interventionists, (c) intervention delivery, and (d) intervention receipt. Findings showed that 34 of 37 (91.9%) girls completed all three sessions. An initial motivational interviewing training workshop followed by evaluation of audiotaped sessions with constructive feedback can result in successful and consistent delivery by a school nurse.

Learning motivational interviewing in a real‐life setting: A randomised controlled trial in the Swedish Prison Service

Motivational interviewing (MI) is a client-centred, directive counselling style for helping people to explore and resolve ambivalence about behaviour change and shown to decrease drug and alcohol use. A five-session semi-structured MI intervention [Beteende, Samtal, Förändring (BSF; Behaviour, Counselling, Change)] was implemented in Swedish prisons. To examine whether, in a real-life implementation of semi-structured MI, staff receiving ongoing MI training, based on audio-recorded feedback in peer groups (BSF+), possess greater MI skill compared with staff receiving workshop-only MI training (BSF), and staff conducting usual prison planning interviews (UPI). Prisoners were randomised to one of the three interventions. The fi rst sessions between staff and prisoner with complete data were assessed with the Motivational Interviewing Treatment Integrity Code 3.0. Content analysis of 45 staff: prisoner sessions revealed that counsellors in the BSF+ group were significantly more competent in MI than those in the UPI group, but there was no difference in MI competency between the BSF and UPI groups. Overall, staff were rated as not having achieved beginning proficiency. Our findings suggest that staff delivering motivational interviewing programmes for substance-misusing prisoners in Sweden are not being given sufficient training for the task. Previous literature has suggested that staff need more than a basic 3- to 5-day workshop training, but our findings suggest that they may need longer-term continuing supervision and support than previously recognised.

Design and implementation of a dental caries prevention trial in remote Canadian Aboriginal communities

BackgroundThe goal of this cluster randomized trial is to test the effectiveness of a counseling approach, Motivational Interviewing, to control dental caries in young Aboriginal children. Motivational Interviewing, a client-centred, directive counseling style, has not yet been evaluated as an approach for promotion of behaviour change in indigenous communities in remote settings.Methods/designAboriginal women were hired from the 9 communities to recruit expectant and new mothers to the trial, administer questionnaires and deliver the counseling to mothers in the test communities. The goal is for mothers to receive the intervention during pregnancy and at their child's immunization visits. Data on children's dental health status and family dental health practices will be collected when children are 30-months of age.The communities were randomly allocated to test or control group by a random "draw" over community radio. Sample size and power were determined based on an anticipated 20% reduction in caries prevalence. Randomization checks were conducted between groups.DiscussionIn the 5 test and 4 control communities, 272 of the original target sample size of 309 mothers have been recruited over a two-and-a-half year period. A power calculation using the actual attained sample size showed power to be 79% to detect a treatment effect. If an attrition fraction of 4% per year is maintained, power will remain at 80%. Power will still be > 90% to detect a 25% reduction in caries prevalence. The distribution of most baseline variables was similar for the two randomized groups of mothers. However, despite the random assignment of communities to treatment conditions, group differences exist for stage of pregnancy and prior tooth extractions in the family. Because of the group imbalances on certain variables, control of baseline variables will be done in the analyses of treatment effects.This paper explains the challenges of conducting randomized trials in remote settings, the importance of thorough community collaboration, and also illustrates the likelihood that some baseline variables that may be clinically important will be unevenly split in group-randomized trials when the number of groups is small.Trial registrationThis trial is registered as ISRCTN41467632.

Tinnitus Retraining Therapy (TRT) for tinnitus.

Tinnitus is described as the perception of sound or noise in the absence of real acoustic stimulation. Although an outright cure for tinnitus remains elusive, various management strategies have been developed to help to lessen the impact of the symptom. Following the publication of a neurophysiological model of tinnitus, Tinnitus Retraining Therapy (TRT) was developed. Using a combination of directive counselling and sound therapy in a strict framework, this is one of the most commonly used treatment modalities for tinnitus. Many studies refer to the use of TRT where in fact a modified version of this therapy is actually being implemented. It is therefore important to confirm the use of authentic TRT when reviewing any study that reports its use. To assess the efficacy of TRT in the treatment of tinnitus. The search included the Cochrane ENT Group Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, EMBASE and reference lists of identified publications. The date of the most recent search was 26 August 2009. Randomised controlled trials of TRT versus no treatment, or other forms of treatment, in adult patients with tinnitus. Both authors critically appraised the retrieved studies for risk of bias and extracted data independently. Where necessary, we contacted the original study authors for further information. Only one trial (123 participants) was included in the review. Several excluded trials did not follow the strict protocol for TRT, evaluating instead a modified form of TRT. The included trial showed TRT to be more effective than a tinnitus masking (TM) approach. In this study outcome data for tinnitus severity were presented using three instruments (Tinnitus Handicap Inventory (THI), Tinnitus Handicap Questionnaire (THQ), Tinnitus Severity Index (TSI)) for patients in three groups (participants' tinnitus being a 'moderate problem', big problem' or 'very big problem').At 18 months, improvements for the three groups in the three scores (TRT versus TM) were respectively: 'moderate problem' - THI: 18.2 versus 4.6, THQ: 489 versus 178, TSI 7.5 versus 1.6; 'big problem' - THI: 29.2 versus 16.7, THQ: 799 versus 256, TSI: 12.1 versus 6.7; and 'very big problem' - THI: 50.4 versus 10.3, THQ; 1118 versus 300, TSI: 19.7 versus 4.8. A single, low-quality randomised controlled trial suggests that TRT is much more effective as a treatment for patients with tinnitus than tinnitus masking.

Resolution of hyperacusis associated with depression, following lithium administration and directive counselling

Hyperacusis may be described as a decreased threshold for discomfort from sound. It may have a serious impact on an individual's lifestyle, as a result of decreased sociability and inability to spend time with family and friends due to intolerance of sound. We present a case of hyperacusis associated with depression, with no other audiological abnormality. The patient reported greater difficulty during the depressive episode. Audiological investigation was undertaken, followed by counselling and medication for depression. The pathophysiological mechanism of hyperacusis in depression is discussed. Outcomes following treatment with directive counselling and lithium (an antidepressant) are described. Research indicates that both hyperacusis and depression can be caused by hypoactivity of 5-hydroxytryptamine (also known as serotonin) in the brain. The patient reported improvement which cannot be explained solely on the basis of counselling. Enhancement of serotonin activity due to lithium, prescribed for depression, may also play a role in alleviation of hyperacusis.

Tinnitus Retraining Therapy: Our Experience

Background and Aim: Tinnitus Retraining Therapy (TRT), a combination of directive counseling and low-level broadband noise exposure, attempts to induce and facilitate habituation to the tinnitus signal. The aim of this study is to present our experience on the efficacy of TRT for tinnitus relief in patients with clinically significant tinnitus.

Association between tinnitus retraining therapy and a tinnitus control instrument

Objective Tinnitus retraining therapy (TRT), which is an adaptation therapy for tinnitus based on the neurophysiological model proposed by Jastreboff in 1990,consists of directive counseling and acoustic therapy with a tinnitus control instrument (TCI) or other devices. For the past 5 years, our hospital has administered TRT characterized by the use of a TCI. Method In this study, we reviewed the clinical course of patients with tinnitus who presented to our outpatient clinic for tinnitus and hearing loss during the 3-year period from April 2004 to March 2007 and underwent TRT with a TCI. Among 188 patients with tinnitus (105 males and 83 females), 88 patients (51 males and 37 females, excluding dropouts) who purchased a TCI and continued therapy were included in the study. Results Significant improvement in Tinnitus Handicap Inventory (THI) and Visual Analogue Scale (VAS) scores was found as early as 1 month of treatment and later compared with those on initial examination, suggesting that TRT with a TCI may be an effective treatment for tinnitus. Among the noises generated by the TCI, the sound pressure output from the TCI was set at just below tinnitus loudness level both of the first adjustment and the second adjustment. Speech noise and white noise were frequently selected, whereas high-frequency noise and pink noise were infrequently selected. Speech noise was most frequently selected at the first adjustment, and the number of patients selecting white noise increased at the second adjustment. The results that we compared the two also revealed that the mean hearing level and tinnitus loudness levels were higher in the white noise group than in the speech noise group, which suggested that the inner ear disorder was more harder in the white noise group. Both the THI score and VAS grade improved after 1 month of treatment in the speech noise group, whereas improvement in these parameters was observed in the white noise group after 6 months of treatment. These results suggest that it took much longer the patients in the white noise group to improve. Conclusion : Significant improvement in THI and VAS scores was found as early as 1 month of treatment and later compared with those on initial examination, suggesting that TRT with a TCI may be an effective treatment for tinnitus. It resulted that many patients chose the speech noise or the white noise. And also it was indicated that noise generators set at just below mixing point with tinnitus are more effective. In this study, however, speech noise was often selected probably because of the reduced output at high frequencies and the level of comfort. As white noise produces greater sound volume, patients tended to switch from other therapeutic sound to white noise at the second adjustment. These findings may help administer acoustic therapy in the future.

Child Risk and Parental Resistance: Can Motivational Interviewing Improve the Practice of Child and Family Social Workers in Working with Parental Alcohol Misuse?

Motivational Interviewing (MI) is a client-centred, directive counselling method. This study evaluates the effectiveness of a two-day workshop in MI for forty social workers in changing self-reported practice over a three-month period, the levels of skills achieved, and factors associated with acquired skills, including the impact of post-workshop supervision. The focus of training was alcohol misuse but participants were encouraged to explore the use of MI with other issues. A multi-method pre and post-design was used, utilizing both quantitative and qualitative data and employing an embedded randomized controlled trial of the impact of supervision. The two-day workshop had a modest positive impact on evaluations of simulated practice, on some measures of attitudes to working with problem drinkers and in qualitative accounts of practice. Despite this, three months post-workshop, workers generally had not reached a skilful level of MI practice as measured in ratings of an interview with a simulated client. Offer of post-workshop supervision had little impact on skill, with take-up being low. There was a significant difference between participants in the two workshops, despite identical programmes and trainers. Qualitative data suggested that participants had found the training useful and many reported a positive impact on their practice.

Start Talking About Risks: development of a Motivational Interviewing-based safer sex program for people living with HIV.

The epidemiology of HIV infection in the US in general, and in the southeast, in particular, has shifted dramatically over the past two decades, increasingly affecting women and minorities. The site for our intervention was an infectious diseases clinic based at a university hospital serving over 1,300 HIV-infected patients in North Carolina. Our patient population is diverse and reflects the trends seen more broadly in the epidemic in the southeast and in North Carolina. Practicing safer sex is a complex behavior with multiple determinants that vary by individual and social context. A comprehensive intervention that is client-centered and can be tailored to each individual's circumstances is more likely to be effective at reducing risky behaviors among clients such as ours than are more confrontational or standardized prevention messages. One potential approach to improving safer sex practices among people living with HIV/AIDS (PLWHA) is Motivational Interviewing (MI), a non-judgmental, client-centered but directive counseling style. Below, we describe: (1) the development of the Start Talking About Risks (STAR) MI-based safer sex counseling program for PLWHA at our clinic site; (2) the intervention itself; and (3) lessons learned from implementing the intervention.

Kommunikative Fertigkeiten bei der pränatalen Beratung schwangerer Frauen

Prenatal counselling is characterized by specific characteristics: A):The communication is about the values of the pregnant woman and her relationship with the child to be. B) The communication deals with patient's images and emotions. C) It is a communication about risks, numbers and statistics. D) Physician and patient deal with important ethical issues. In this specific setting of prenatal diagnosis and care physicians should therefore learn to apply basic principles of patient-centred communication with elements of non directive counselling, patient education and shared decision making. These elements are integrated into a process which comprises the following "steps": 1. Clarification of the patient's objectives and the obstetrician's mandate. 2. The providing of individualized information and education about prenatal tests and investigations. 3. Shared decision making regarding tests and investigations 4. Eventually Breaking (bad, ambivalent) news. 5. Caring for patients with an affected child.

Using mediators and moderators to test assumptions underlying culturally sensitive therapies: An exploratory example.

Factors hypothesized to impact Asian American responses to counseling were tested as mediators and moderators of perceived counselor credibility and working alliance. Asian and European American college students (N = 182) were assigned randomly to view simulated directive or nondirective therapy approaches. Mediation analyses examined whether ethnic group differences in initial perceptions were accounted for by therapist understandability and previous therapy experiences. Moderation analyses examined whether expectations for directive therapy, ambiguity tolerance, and resistance influenced initial perceptions across directive and nondirective counseling. Asian Americans rated the counseling approaches significantly less favorably than Europeans Americans. A significant mediation effect was found for therapist understandability, whereas a significant moderation effect was found for expectation for directive therapy on initial perceptions of counselor credibility.

Communicating genetic information in families – a review of guidelines and position papers

This article aims to review ethical and clinical guidelines and policies addressing the communication of genetic information in families. Websites of national and regional bioethics committees, national human genetics societies, international health organisations, genetic interest groups and legal recommendations committees were searched for guidelines and policies. The databases Medline, Web of Science and Google Scholar were also utilised to search for additional guidelines relating to the communication of genetic information in families. The guidelines and policies included in this review are limited to those available in English. The search resulted in guidelines from 18 international, regional and national organisations from six countries pertaining to family communication of genetic information. The following ideals were common in their guidelines: (1) individuals have a moral obligation to communicate genetic information to their family members; (2) genetic health professionals should encourage individuals to communicate this information to their family members; and (3) genetic health professionals should support individuals throughout the communication process. The difference between the organisations' guidelines was the inclusion of information about the role of the health professional in supporting clients during the process of communicating genetic information to their family members. Only two recommendations suggested that the health professional should support their clients by identifying at-risk family members, but more guidelines recommended that directive counselling should be undertaken to encourage clients to communicate genetic information to their family members. In conclusion, the guidelines provide an overview of the role that genetic health professionals may undertake; however, there are gaps that need to be addressed.

Evaluation of a Faith-Based Culturally Relevant Program for African American Substance Users at Risk for HIV in the Southern United States

Objective: This article provides an evaluation of a federally funded faith-based program that serves African Americans who use heroin and cocaine and are at risk for HIV/AIDS in Nashville, Tennessee. Methods: Data were collected from 163 individuals at baseline and 6- and 12-month follow-up interviews. A subset of participants (n = 51) completed all three interviews. Results: Results suggested that this culturally relevant set of interventions was successful in reducing substance use and HIV/AIDS risk behaviors. The program was able to show data that supported the efficacy of a faith-based approach emphasizing spirituality rather than directive, aggressive, authoritarian, or coercive counseling techniques. Discussion: The model is important to the continued development of culturally relevant interventions that are vital to decreasing the disproportionate rates of HIV/AIDS within the African American community.

A Modified Version of Tinnitus Retraining Therapy: Observing Long-Term Outcome and Predictors

Tinnitusretraining therapy (TRT) in Germany includes not only directive counseling and sound therapy but also stress management and facultative psychotherapeutic treatment. The aim of the present study was to investigate the impact of this modified version of TRT on certain tinnitus-related aspects of distress and variables that may predict treatment outcome. Clinical data from 92 patients undergoing outpatient TRT in the Charité Tinnitus Centre were evaluated retrospectively over 1 year. Treatment outcome was defined by changes in specific areas of tinnitus-related distress and assessed by the Tinnitus Questionnaire. Changes in audiometric frequency and loudness of tinnitus were examined by regular audiometric testing. The overall Tinnitus Questionnaire score was significantly reduced after 1 year. Severely affected tinnitus sufferers (decompensated tinnitus) profited more than less affected patients (compensated tinnitus). In cases of indicated psychotherapy, improvement was significant for the patients who took advantage of psychotherapeutic treatment during TRT but was not significant for those who interrupted or dismissed an indicated psychotherapy. Changes in tinnitus-specific areas of distress were most pronounced in the scales for emotional and cognitive distress and intrusiveness. Significant changes in sleep disturbances, auditory perceptual difficulties and somatic complaints were observed in patients with decompensated tinnitus. In patients with chronic tinnitus, modified TRT may lead to significant subjective improvement in certain tinnitus-related symptoms like emotional and cognitive distress and intrusiveness. Particularly patients suffering from severe tinnitus distress take advantage of therapy. Careful psychotherapeutic diagnostics and therapies and, if necessary, motivation to make use of psychotherapy seem to be essential preconditions for therapeutic success in patients with severe psychosomatic comorbidity.

Preventive ethics for including women of childbearing potential in clinical trials

We present a preventive ethics approach for including women of childbearing potential in clinical trials. We explain the concept of preventive ethics and identify its implications for study design, the informed consent process, and study management. We identify and address ethically significant questions for investigators and institutional review boards to address, to responsibly enroll women of childbearing potential in clinical trials. These questions concern preventive ethics for study design, for the informed consent process, and for study management. Distinctive components of this preventive ethics approach include the distinction between directive and nondirective counseling, the recognition of the concept of moral risk for women as research subjects, and the distinction between professional and individual conscience. We identify ethical considerations for physicians considering referral of their patients to clinical trials. A comprehensive, preventive ethics approach to the ethical challenges in clinical trials related to the prevention and occurrence of pregnancy is essential for responsibly enrolling women of childbearing potential.

Evaluation of the Mixing Point in Tinnitus Sound Therapy by a Psychoacoustic Matching Protocol with a Digital Tinnitus Evaluation System

Directive counseling and sound therapy have been reported to effectively alleviate tinnitus suffering. Without objective evaluation, researchers doubt the real effect of sound therapy. This study was designed to evaluate the frequency and intensity of the theoretical ‘mixing point’ (MP) in sound therapy and to investigate its relationship with the minimal masking level (MML) of tinnitus. The tinnitus tones of 133 patients were successfully matched in frequency (dominant in 4–10 kHz) and loudness (83.09 ± 12.04 dB) using a psychoacoustic matching protocol and a newly designed tinnitus evaluation system. The matching rate was 83%. The relationship between the MP and MML is described by a linear regression equation: MP = 0.90 × MML + 1.98 (r² = 0.82, p < 0.0001). The results of matching and correlation analysis confirmed the consistency of the MP in sound therapy. The psychoacoustic characteristics of tinnitus can be objectively evaluated with our matching protocol and evaluation system.

An Exploration of the Usefulness of Motivational Interviewing in Facilitating Secondary Prevention Gains in Cardiac Rehabilitation

Motivational interviewing is a client-centered, directive counseling approach aimed at promoting motivation in clients to change certain behaviors. Its effect is to reduce defensiveness and promote disclosure, engagement, and participation, thereby motivating the client to make behavioral changes. Motivational interviewing marries well with the principles of cardiac rehabilitation (CR) in terms of increasing motivation among CR clients, promoting a client-centered approach and in the cost- and time-effective practices of CR. Very little research has been conducted examining the effectiveness of motivational interviewing in enhancing CR outcomes. This article discusses research that has been conducted in motivational interviewing that relates to the components of CR, provides examples of how motivational interviewing can be applied to CR, and recommends further exploration, development, and investigation of the usefulness of motivational interviewing in the field of CR.

Motivational Interviewing and Rehabilitation Counseling Practice

This article explores commonalities between rehabilitation counseling and the counseling approach known as motivational interviewing. Motivational interviewing is an empirically supported, client-centered, directive counseling approach designed to promote client motivation and reduce motivational conflicts and barriers to change. The underpinnings of motivational interviewing are related to several principles that drive rehabilitation counseling practice. Motivational interviewing focuses on issues that have been emphasized in the rehabilitation literature: clients' sense of the importance of potential changes, their confidence that change can be successful, and their readiness to make changes. Current and potential uses of motivational interviewing in rehabilitation counseling practice are outlined, and additional research directions are recommended.