Therapist Instruction Research Articles

Combining one-session treatment with a homework program including app-based technology to enhance the treatment of childhood specific phobias: A study protocol of a multicenter pragmatic randomized controlled trial

IntroductionChildhood specific phobias are among the most common and earliest onset mental disorders with a lifetime prevalence of more than ten percent. Brief intensive cognitive behavioral therapy (CBT) programs such as the One-Session Treatment (OST) are found to be effective in the remission of the specific phobias following treatment, but there is still room for improvement. The goal of the current study is to examine whether the long-term efficacy of OST increases by using a homework program supported by an app specifically designed for children; the Kids Beat Anxiety (KibA) homework program. MethodsChildren aged between 7 and 14 years with a specific phobia receive OST preceded by a three-week baseline phase to control for time-effects. Directly following OST, children are randomized to either a four-week homework period supported by an app (OST + app), or standard One-Session Treatment with a four-week homework period that is only supported by therapist instructions (OST-only). Primary outcome variables are diagnosis and severity of the specific phobia. Secondary outcomes include behavioral avoidance, self-reported fear, and functional impairment. Data will be analyzed based on intention-to-treat and per protocol samples using mixed-effects multilevel linear models. Ethics and disseminationThe current study was approved by the METC of the Academic Medical Center, Amsterdam, The Netherlands (number: NL72697.018.20) and the Ethical Committee of the Ruhr University, Bochum, Germany (number: 663). Results of this trial will be published in peer-reviewed journals. Trial registrationThe study was pre-registered at the Dutch Trial Register, number: NL 9216.

Addressing the intensity of rehabilitation evidence-practice gap: rapid review, stakeholder perspectives and recommendations for upper limb rehabilitation after acquired brain injury

Background/Aims For people living with acquired brain injury from stroke or trauma, clinical practice guidelines recommend high-intensity physical rehabilitation to optimise motor outcomes. There is an acknowledged evidence–practice gap between routine clinical practice and the amount, intensity and type of active upper limb rehabilitation recommended in research-informed guidelines. The aims of this study were to identify methods used to facilitate high doses of upper limb practice in published trials, understand stakeholder perspectives of the barriers and enablers to these methods in hospital settings, and to synthesise findings to form an evidence-based action plan for rehabilitation professionals, service providers and adults living with an acquired brain injury. Methods A rapid systematic literature review and a series of qualitative interviews with service users and rehabilitation clinicians explored the evidence on intensity and the experience of high intensity rehabilitation following brain injury and stroke. Triangulating this mixed method evidence, recommendations were generated on how to increase upper limb rehabilitation intensity during inpatient therapy. Results There was consensus in the literature that high-dose motor training improves a person's ability to move their hand and arm after brain injury and stroke. Trials mostly delivered therapy programmes as a replacement to usual care; however, it was unclear how high-intensity therapy was integrated into usual rehabilitation. Methods employed to increase the intensity of upper limb rehabilitation included strategies to optimise engagement (eg encourage independent practice and more practice); clinician-related processes (eg self-auditing, use of groups); environmental factors (eg equipment, dedicated space); and organisational influences (eg professional development, dedicated research positions and mentoring). Qualitative data showed that barriers and facilitators stem from service user factors (eg cognitive ability, advanced age, cultural mores) as well as clinician factors (eg quality of the therapeutic relationship, type and quality of therapist instructions). Organisational factors such as a strong research culture and a commitment to evidence-based practice positively influenced outcomes. Conclusions There is capacity to increase the intensity of upper limb rehabilitation by optimising organisational support and systems, as well as greater service user engagement in therapy processes. Implications for practice Rehabilitation clinicians have long understood that dose is a critical component of motor training. Findings may assist with structuring upper limb rehabilitation programs and addressing clinician factors to increase the intensity of therapy.

Interaction between multisensory information and emotional activation in video‐facilitated psychotherapy

AbstractBackgroundEmotional activation is regarded as central in psychotherapy. We have developed a method called VideoTalk, in which patients video themselves at home according to the therapist's instructions, and the videos are watched together in the therapy session. The aim of the study was to find out whether watching and listening to a video in psychotherapy readily activates the patient's emotions.MethodsThe video material was analysed by theory‐based content analysis using the interacting cognitive subsystems (ICS) theory. The ICS theory suggests a link between sensory information and emotions and describes two levels of meaning: propositional and implicational. The implicational level gains information from the propositional level and directly from perceptions and is central to the activation of emotions. Five patients participated in our schema therapy‐based intervention. Our material included videos of 10 therapy sessions, in which the patient and the therapist watched a video made by the patient at home in a state of helplessness. Watching the video in the session was performed in parts, and between watching periods, there were observation phases consisting of discussion about what the patient had seen and heard on the video and how it affected them. Our data included 38 observation phases, and in 35 of these, the patient verbalised an emotion after watching the video. The implicational level was involved in almost all observation phases in which the patient verbalised emotions.ResultsOur findings are in line with the hypothesis that added multisensory information via video enhances input to the implicational level and therefore emotional activation in psychotherapy. This is a possible mechanism by which the use of VideoTalk could facilitate the psychotherapy process.

Acupuncture in chemotherapy-induced dysgeusia (AcuDysg): study protocol of a randomised controlled trial

IntroductionDysgeusia is a common side effect of chemotherapy in patients with cancer, but to date, there is no effective treatment. Many patients with cancer request complementary medicine treatment in addition...

Using Arousal Suppression Exercises to Decrease Inappropriate Sexual Arousal in Detained Adolescent Males: Three Clinical Demonstrations

Reyes, Vollmer, and Hall (2011) found that 2 arousal suppression strategies, 1 of which involved counting backward from 100 to 0, decreased sexual arousal for 2 male sex offenders with intellectual disabilities. In the current clinical study, we taught 3 adolescent males who had been adjudicated for illegal sexual behavior to self-report arousal when they were presented with sexually arousing visual stimuli. Based on the procedures in the Reyes et al. (2011) study, we taught participants to count backward from 100 to 0 when they verbally reported a criterion level of sexual arousal in the presence of visual media. Subsequently, we gradually faded therapists' instructions for 2 participants until they independently used the arousal suppression exercise. Results showed that each participant's self-reported sexual arousal decreased upon implementation of treatment relative to baseline. Decreased sexual arousal continued even under conditions of faded therapist instructions for 2 participants. The relative merits of using self-report measures are discussed.

Comparison of Proprioception, Lower Limb stability, Blood Pressure and rOM after Proprioceptive Exercise by Ar exercise and therapist Instruction

The purpose of this study was to compare the changes and determine the effect of AR program and therapist instructions on exercise according to proprioception, stability, blood pressure and ROM. This study consisted of a total of 42 subjects; 22 healthy men and 20 healthy women with no orthopedic cardiovascular disease. The subjects performed proprioceptive exercise in various postures, and the Paired T-test was used to confirm the difference in change between the AR program group and the group trained under the therapist instruction. Independent T-test method was used to confirm the difference between the two groups. There were no ROM changes in both groups and the overall proprioception. The balance of the lower limb significantly increased but contrarily, the blood pressure significantly decreased. There were no significant differences between the two groups. The use of AR program and therapist's instructions has a positive effect on proprioception, balance and affects blood pressure. There were no significant differences between them. Therefore, it is thought that the AR program can be a good alternative as a therapeutic tool in clinical practice.

Is It Possible to Enhance Intensity in Guided Imagery Exercises? An Experimental Study.

Guided imagery exercises can have a powerful impact on distressing mental images. Clinically, it is usually recommended to experience these exercises as intensely as possible. However, patients sometimes object to the related instructions. In this study, we tested whether typical clinical instructions aiming at increasing intensity led to a stronger effect of the exercise. Sixty-four healthy participants watched a trauma movie clip. Then they were pseudo-randomized into one of two strategies (intense, less intense) or a waiting control condition. Dependent variables were self-reported emotional intensity and psychophysiology measures. Participants in the intense ImRS strategy did not experience the exercise as more intense than those in the less intense ImRS strategy on any outcome measure. Both ImRS strategies showed increased sympathetic activation compared to a decrease of activation in the waiting control group. Our results suggest that emotional intensity in guided imagery exercises may not depend very much on the therapist's instructions.

Learning classifier to evaluate movement quality in unassisted pick-and-place exercises for post-stroke patients: A preliminary study.

The use of service robots is gaining increasing interest in stroke rehabilitation research. In autonomous robot therapy sessions, it is important to monitor the qualitative motor performance of the patient and to evaluate if therapeutically desirable movements are reinforced as per the therapist's instructions. Research on computational means to address this issue has received little attention, despite the acknowledged importance thereof. This paper poses the question of whether the subjective evaluation of the therapist on the qualitative motor performance of the individual patient can be modelled. In an attempt to answer this question, we frame it as a supervised machine learning problem and investigate if kinematic sensor readings to the subjective evaluation of the therapist can be correlated. We further examine if the personalized classifier trained with the data of the individual patient should be favored over the general classifier. Our preliminary results suggest that, given kinematic observation, trained classifiers may be able to imitate the evaluation of the therapist for the movement quality of the post-stroke patient. In our experiments, the general classifier outperformed the personalized classifiers, however, further investigation is necessary to generalize this finding.

A Real Time Biofeedback System Using Visual User Interface for Physical Rehabilitation

This study was undertaken to investigate the effectiveness of biofeedback training when compared to conventional physical rehabilitation. Real time biofeedback plays an important role for patients and therapists to assess the success and performance of the training process. Visual user interface allows new forms of therapy simplifying the process and increasing patients’ motivation. An experimental investigation was conducted to study the effect of using a visual interface as an add-on therapy to standard exercises for Range of Motion (ROM) measurements in glenohumeral movements. Human movement was collected by a Kinect sensor and the ROM measurements were computed using spatial coordinates provided by the official Microsoft Kinect SDK. The design allows patients to train therapeutic exercises, while receiving different types of real time feedback indicating measures of performance evaluation through the course of the training. Moreover, both the environment and the training task are customizable to the patient needs. In order to evaluate the biofeedback effectiveness, subjects that participated in the study were required to do a therapeutic exercise twice: firstly following the instructions of the therapist and secondly adding the visual biofeedback to the therapist instructions. The results obtained suggest that the proposed visual interface was an effective tool to achieve a significant improvement in the performance of the exercise. The exercises correctness when performed with visual feedback was significantly higher than the same exercises performed without this visual stimulus. In trials where subjects received visual feedback, it was observed a greater effort to achieve the proposed objective and superior movement control. Given the potential benefits of biofeedback, the proposed interface can become a helpful tool to patients that can confirm the correctness of their exercises and therapists that can adapt the prescribed exercises considering patients’ evolution and performance.

Early response markers from video games for rehabilitation strategies

Stroke commonly leads to partial or complete paralysis of one side of the body and there is limited availability of therapists to provide rehabilitation. It is a priority therefore to identify the most effective rehabilitation strategies and/or pharmacotherapies. Motor learning, the essential process underpinning rehabilitation, can be assessed more quickly and robustly than outcomes from rehabilitation. In this paper we describe a proof of concept system utilising a commodity input device to play a bespoke video game to measure the critical components of motor learning. We demonstrate that we can detect how simple changes in therapist instruction significantly change motor performance and learning. Although video games have been shown to aid in rehabilitation, this is the first time video games have been used to derive early response markers, based on the measurement of performance and motor learning, for use in the evaluation of the efficacy of a rehabilitation strategy.

The aged and the Test of folding a rhombus Psychometric and chronopsychological aspects

This study highlights the incongruence of geriatric institutions to set up activities for elderly people without taking into account the circadian fluctuations of cognitive processes related to circadian rhythms. By example, rehabilitation for falls is based on the indication given by the therapist (instruction), its integration and assimilation by the patient (comprehension), and the resulting action (execution). However, the recorded information and the execution may present a shift of phase and even an opposition of phase. The Test of Folding a Rhombus (TFR) was conceived to assess the fluctuation and articulation of these processes. It was proposed to 60 elderly individuals divided into 2 groups (30 subjects with cognitive disorders - case group - and 30 subjects without cognitive disturbance - control group -), and was applied at different time schedules of the day (8:00, 11:00, 15:00 and 18:00 h) once a week during 4 weeks. Its purpose was to quantify the relationship between automatic and controlled processes. Statistical analysis indicates significant circadian differences during the evolution of the two processes between the case and control groups. Simple, fast and easy to use, the TFR can also help professionals to choose the best automatic or controlled processes activity according to the need of patients.

La importancia de las instrucciones del psicólogo para favorecer la adhesión terapéutica

This paper presents a first descriptive approach to the study of instructions in therapy as a previous step to a more comprehensive research about the influence of instructions on therapeutic adherence. Two cases treated by two behavioral therapists were analyzed throughout the treatment –one of them was an experienced therapist and the other was inexperienced one. The sessions were observed and registered with a specific coding system and The Observer XT software. Data highlight the differences in frequency and type of instructions depending on the tasks carried out by the therapists, as well as on their experience. Results provide some first hypotheses (to be proved) about the existence of different patterns of therapist instructions during the psychological treatment and allow us to establish some bases for the study of the influence of instructions on therapeutic adherence which may improve the effectiveness of psychological interventions.

La importancia de las instrucciones del psicólogo para favorecer la adhesión terapéutica

This paper presents a first descriptive approach to the study of instructions in therapy as a previous step to a more comprehensive research about the influence of instructions on therapeutic adherence. Two cases treated by two behavioral therapists were analyzed throughout the treatment –one of them was an experienced therapist and the other was inexperienced one. The sessions were observed and registered with a specific coding system and The Observer XT software. Data highlight the differences in frequency and type of instructions depending on the tasks carried out by the therapists, as well as on their experience. Results provide some first hypotheses (to be proved) about the existence of different patterns of therapist instructions during the psychological treatment and allow us to establish some bases for the study of the influence of instructions on therapeutic adherence which may improve the effectiveness of psychological interventions.

FURTHER EVALUATION OF ANTECEDENT INTERVENTIONS ON COMPLIANCE: THE EFFECTS OF RATIONALES TO INCREASE COMPLIANCE AMONG PRESCHOOLERS

Functional analyses were conducted to identify reinforcers for noncompliance exhibited by 6 young children. Next, the effects of rationales (statements that describe why a child should comply with a caregiver-delivered instruction) were evaluated. In Experiment 1, 3 participants received the rationales immediately after the therapist's instruction. In Experiment 2, 3 additional participants received more practical rationales immediately before the therapist's instruction. The results indicate that rationales were ineffective for all 6 children. A guided compliance procedure increased compliance for 1 child; contingent access to preferred items with or without response cost increased compliance for the other participants. Although levels of problem behavior varied within and across participants, they were often higher in the rationale and guided compliance conditions.

Crucial Processes in EMDRMore Than Imaginal Exposure

The processes that underlie the effectiveness of eye movement desensitization and reprocessing (EMDR) are examined by evaluating the procedural differences between it and exposure therapy. Major factors include the degree of emphasis placed on reliving versus distancing in the therapies and the degree to which clients are encouraged to focus on direct trauma experiences versus experiences associated with the trauma. Research results indicate that, unlike traditional imaginal exposure, reliving responses in EMDR did not correlate with symptom improvement. Instead, consistent with an information processing model, the degree of distancing in EMDR was significantly associated with improvement. A case study is described to highlight these methodological divergences in the respective therapies relating to reliving. Finally, the research regarding the possible sources of the distancing response within EMDR was examined. The results indicate that the distancing process was more likely to be an effect produced by eye movements than by any therapist instructions. Theoretical and research evaluations indicate that the mechanisms underlying EMDR and traditional exposure therapy are different.

Single-case experimental studies of a self-help manual for traumatic stress in earthquake survivors

Studies showed that earthquake-related posttraumatic stress disorder could be reduced by a single session of therapist instructions for self-exposure to fear cues. Eight single-case experimental studies examined whether such instructions were as effective when delivered through a self-help manual after an initial assessment. After two baseline assessments conducted at the participants homes, the manual was delivered to the participants, who were then assessed at week 10 (post-treatment) and at 1-, 3-, and 6-month post-treatment. After minimal improvement during the baseline, treatment achieved marked improvement in seven survivors, leading to effect sizes comparable to those obtained by therapist-delivered treatment. Self-help appears to be a promising approach in cost-effective survivor care.

Effects of eye movement versus therapist instructions on the processing of distressing memories

The effectiveness of components of eye movement desensitization and reprocessing (EMDR) was tested by randomly assigning 48 participants to either an eye movement or an eye stationary condition and to one of two types of therapist instructions (reliving or distancing). Participants were university students (mean age 23) who were asked to recall a personal distressing memory with measures of distress and vividness taken before and after treatment, and at follow-up. There was no significant effect of therapist's instruction on the outcome measures. There was a significant reduction in distress for eye movement at post-treatment and at follow-up but overall no significant reduction in vividness. Post hoc analysis revealed a significant reduction in vividness only for the eye movement and distancing instruction condition. The results were consistent with other evidence that the mechanism of change in EMDR is not the same as traditional exposure.

Anomalies in Covert Conditioning

The covert conditioning approach has received much empirical support. Despite the utility of this approach, a number of anomalies (or methodological problems) have been considered in the past. This study describes three anomalies in covert conditioning which have received little attention: (1) the difficulty in assessing the application of the covert conditioning technique by the client, (2) the difficulty in explaining client's failures during use of the technique in terms of either problems with the therapist's instructions regarding the use of the technique or problems with the client's inability to imagine the scene, and (3) the use of single-case experimental designs in the evaluation of the effectiveness of covert conditioning techniques seems to violate the experimental format of such designs.

Treatment integrity of relaxation training for tension headaches

Treatment integrity procedures, generally lacking in previous research, were employed for evaluation of relaxation training for tension headaches. Treatment integrity is the extent to which the therapist implements the relaxation procedure as describe, and the degree to which the patients comply with the therapist's instructions. Objective compliance with the home practice of relaxation training was assessed using a microcomputer-based method which required the patient to squeeze a hand control when instructed to tense a muscle. A single-case replication design with three tension headache patients was used. The dependent variables were taken from patients' self-reported daily headache data. Results indicate that: (a) the therapist accurately adhered to the relaxation training protocol; (b) headache frequency decreased in all patients from baseline to 1-year follow-up (improvements ranged from 72.7% to 98.2%); and (c) improvement was greater with higher compliance.

How effective is oral hygiene instruction? Results after 6 and 24 weeks.

We studied the clinical effectiveness of oral hygiene instruction given to 71 "high" plaque patients in 19 Washington State dental practices to determine the extent of plaque reduction. Patients were examined prior to instruction and prophylaxis. Therapist instructions were tape-recorded and content analyzed, and therapists' expectations were scored. Patients were surveyed as to oral health behaviors and general health habit characteristics. Only 20 of 71 (28%) initially "high" plaque patients had reduced mean plaque scores to 1.0 or less at six weeks. An additional 13 percent had deteriorated plaque levels at 24 weeks. We concluded that therapists did not consistently follow principles of effective instruction and often overestimated their effectiveness. Determinants of relapse involve the educational process, the patients' oral status, and patients' life situations.