Barriers and facilitators for dental care among patients with severe or long-term mental illness.

BACKGROUND: Persons who struggle with severe or long-term mental illness (SMI) have a higher prevalence of oral health problems than the general population. Obtaining and continuing dental treatment is challenging for this patient group for many reasons, and many drop out of active treatment. Our study aimed to explore perceived barriers to obtaining optimal dental health care for patients with SMI. Further, we sought to identify possible ways to facilitate for providing true access to dental services for this population. METHODS: The study utilised a flexible qualitative design with data collected during ordinary clinical practice in a public dental clinic in Norway. We conducted semi-structured face-to-face interviews with 51 persons with SMI twice: an initial interview before dental treatment and a final one after dental treatment. We applied the thematic analysis method. RESULTS: Thematic analysis revealed two key themes in the participants' experiences of access to dental health services: practical conditions and relationship with the dentist. Patients reported barriers and facilitators for access to care as factors associated with patients (patient factors), with the dentist (dentist factors) and with healthcare services (system factors). CONCLUSIONS: Our study indicates that persons with SMI appreciate oral health and want to obtain needed oral care and dental treatment, but they encounter barriers on several fronts. The participants offered suggestions for how to facilitate attendance and adherence. Our findings suggest that dental healthcare services require reorganisation to meet the needs of patients with SMI.

Participant experiences of change in mindfulness-based stress reduction for anxiety disorders.

AIM: To explore experiences of change among participants in a randomized clinical trial of mindfulness-based stress reduction (MBSR) for anxiety disorders. METHOD: Semi-structured interviews were conducted to explore the subjective experiences of change for individuals with anxiety disorders after a course in MBSR. Interviews were analysed employing hermeneutic-phenomenological thematic analysis. RESULTS: Five main themes were identified: 1) Something useful to do when anxiety appears, 2) Feeling more at ease, 3) Doing things my anxiety wouldn't let me, 4) Meeting what is there, and 5) Better-but not there yet. Most participants used what they had learned for instrumental purposes, and described relief from anxiety and an increased sense of personal agency. A few reported more radical acceptance of anxiety, as well as increased self-compassion. CONCLUSION: Participants of MBSR both describe mindfulness as a tool to "fix" anxiety and as bringing about more fundamental change towards acceptance of their anxiety. The complexity of reported change corresponds with better handling of areas representing known transdiagnostic features of anxiety disorder, such as dysfunctional cognitive processes (including attentional biases), emotional dysregulation, avoidance behaviours, and maladaptive self-relatedness. This supports MBSR as a transdiagnostic approach to the treatment of anxiety disorders.

Does exposure to bullying behaviors at the workplace contribute to later suicidal ideation? A three-wave longitudinal study.

OBJECTIVE: This study aimed to determine the relative impact of person-related, work-related and physically intimidating bullying behaviors on suicidal ideation two and five years after the fact. METHODS: Logistic regression analyses were utilized to examine relationships between bullying behaviors and suicidal ideation in a random and representative cohort sample of 1775 (T1-T2)/1613 (T1-T3) Norwegian employees. The time lag between T1 and T2 was two years and five years between T1 and T3. Exposure to bullying behaviors was measured with the revised version of the Negative Acts Questionnaire. Suicidal ideation was measured with a single item asking respondents whether they had "Thoughts about ending your life" during the past seven days. RESULTS: Prevalence of suicidal ideation was 4% at T1, 5% at T2, and 4.2% at T3. At T1, 8.2% reported monthly exposure to person-related bullying, 19.1% to work-related bullying, and 1.8% to physically intimidating bullying behaviors. After adjusting for demographic characteristics, baseline suicidal ideation, and the shared variance of the bullying behavior categories, exposure to physical intimidation was the only form of bullying which significantly predicted suicidal ideation two [odds ratio (OR) 10.68, 95% confidence interval (95% CI) 4.13-27.58) and five (OR 6.41, 95% CI 1.85-22.14) years later. CONCLUSIONS: Exposure to workplace bullying behaviors in the form of physically intimidating behaviors is a risk factor for suicidal ideation. Although the prevalence of physical intimidation is low, this study shows that the consequences can be detrimental and organizations should therefore be especially aware of, and have available measures against, this type of bullying.

Workplace Bullying and Suicidal Ideation: A 3-Wave Longitudinal Norwegian Study.

OBJECTIVES: We examined whether victimization from bullying is related to an increased risk of suicidal ideation over time and whether suicidal ideation is related to subsequent bullying. METHODS: In a longitudinal study (2005-2010), we used well-established single-item measures to assess victimization from bullying and suicidal ideation. We used latent Markov models to determine forward and reverse relationships between variables at 3 time points with 2 or 3 years between the measurement points among a randomized nationwide sample of 1846 employees in Norway. RESULTS: Victimization from bullying was associated with subsequent suicidal ideation (odds ratio = 2.05; 95% confidence interval = 1.08, 3.89). Suicidal ideation at baseline was not related to subsequent victimization from workplace bullying. CONCLUSIONS: Workplace bullying may be a precursor to suicidal ideation, whereas suicidal ideation seems to have no impact on subsequent risk of being bullied. Regulations against bullying should be integrated into work-related legislation and public health policies.

Mindfulness- and acceptance-based interventions for anxiety disorders: a systematic review and meta-analysis.

PURPOSE: Mindfulness- and acceptance-based interventions (MABIs) are receiving increasing attention in the treatment of mental disorders. These interventions might be beneficial for patients with anxiety disorders, but no prior reviews have comprehensively investigated the effects of this family of interventions on clinical samples. The aim of this study was to review and synthesize extant research on MABIs for patients with diagnoses of anxiety disorders. METHODS: We conducted a systematic search of relevant databases according to pre-defined criteria. Studies were eligible for inclusion if they employed MABIs for patients diagnosed with anxiety disorders. RESULTS: Nineteen eligible studies were found. Meta-analysis of within-group pre- to post-treatment effects yielded overall Hedges'g effect sizes of 1.08 for anxiety symptoms and 0.85 for depression symptoms. For controlled studies, overall between-group Hedges'g was 0.83 for anxiety symptoms and 0.72 for depression symptoms. Moderator analyses examined whether intervention type, design, treatment dosage, or patient sample was associated with systematic variation in effect sizes. No significant moderating effects were found on the variables examined, apart from an observed superiority in effect size for clinical trials on samples of patients with mixed anxiety disorders. However, differential effect sizes indicated benefits of adding specific psychotherapeutic content to mindfulness training, as well as an advantage of individual over group treatment. CONCLUSIONS: MABIs are associated with robust and substantial reductions in symptoms of anxiety and comorbid depressive symptoms. More research is needed to determine the efficacy of MABIs relative to current treatments of choice, and to clarify the contribution of processes of mindfulness and acceptance to observed outcome.

The relationship between activating affects, inhibitory affects, and self-compassion in patients with Cluster C personality disorders.

In the short-term dynamic psychotherapy model termed "Affect Phobia Treatment," it is assumed that increase in patients' defense recognition, decrease in inhibitory affects (e.g., anxiety, shame, guilt), and increase in the experience of activating affects (e.g., sadness, anger, closeness) are related to enhanced self-compassion across therapeutic approaches. The present study aimed to test this assumption on the basis of data from a randomized controlled trial, which compared a 40-session short-term dynamic psychotherapy (N = 25) with 40-session cognitive treatment (N = 25) for outpatients with Cluster C personality disorders. Patients' defense recognition, inhibitory affects, activating affects, and self-compassion were rated with the Achievement of Therapeutic Objectives Scale (McCullough et al., 2003b) in Sessions 6 and 36. Results showed that increase in self-compassion from early to late in therapy significantly predicted pre- to post-decrease in psychiatric symptoms, interpersonal problems, and personality pathology. Decrease in levels of inhibitory affects and increase in levels of activating affects during therapy were significantly associated with higher self-compassion toward the end of treatment. Increased levels of defense recognition did not predict higher self-compassion when changes in inhibitory and activating affects were statistically controlled for. There were no significant interaction effects with type of treatment. These findings support self-compassion as an important goal of psychotherapy and indicate that increase in the experience of activating affects and decrease in inhibitory affects seem to be worthwhile therapeutic targets when working to enhance self-compassion in patients with Cluster C personality disorders.

Mindfulness-based stress reduction for patients with anxiety disorders: evaluation in a randomized controlled trial.

The aim of this study was to investigate the effect of mindfulness-based stress reduction (MBSR) for patients with heterogeneous anxiety disorders. Seventy-six self-referred patients were randomized to MBSR or a waiting-list control condition. Eight participants did not complete the eight-week MBSR intervention. Treatment completers improved significantly on all outcome measures compared to controls. The completer sample showed medium to large effect sizes on measures of anxiety (Cohen's d = 0.55-0.97), and a large effect size for symptoms of depression (Cohen's d = 0.97). Intention-to-treat analyses yielded effect sizes in the small to moderate range (Cohen's d = 0.32-0.76). Gains were maintained at six months follow-up. The percentage of participants reaching recovered status was highest for symptom measures of depression and anxiety, and lower for worry and trait anxiety. Mediation analyses indicated that mindfulness fully mediated changes in acute anxiety symptoms, and partially mediated changes in worry and trait anxiety. However, the present study did not find evidence of temporal precedence for the proposed mediator. In the absence of true mediation and an active control condition, it cannot be ruled out that results are due to non-specific aspects of treatment. Despite these and other limitations, we conclude that MBSR is an effective treatment for anxiety disorders and related symptomatology.

Commitment under pressure: experienced therapists' inner work during difficult therapeutic impasses.

Interviews were conducted to explore the recall of impasse experiences of 12 highly skilled and experienced therapists. Participants were interviewed in depth individually about a specific impasse from their experience that resolved successfully. The transcribed interviews were analysed using qualitative methodology. The authors found that participants understood their reported impasse experiences as important for their professional development. The category of "helpful subjective presence" describes the mode of being with patients that the participants found therapeutic. The categories of "losing hope" and "difficult feelings in the therapist in the here and now" are processes that threaten the helpful presence. The participants' inner work on the two latter categories is identified as a key to the successful resolution of impasses.

What is a "good outcome" in psychotherapy? A qualitative exploration of former patients' point of view.

The aim of this study was to explore how former psychotherapy patients characterize "good outcome" after having completed treatment that they described as successful, in the sense that therapy had changed their lives in ways that made a difference. Semistructured qualitative depth interviews were conducted with 10 former psychotherapy patients. A hermeneutical-phenomenological approach was used to analyse interview transcripts. The former patients' descriptions of good outcome clustered around four themes: establishing new ways of relating to others; less symptomatic distress, or changes in behavioural patterns contributing to suffering; better self-understanding and insight; and accepting and valuing oneself. Interrelationships between the four components of good outcome, along with limitations and implications of the study, are discussed.

Self-esteem and interpersonal functioning in psychiatric outpatients.

This study explored associations between self-esteem and interpersonal functioning in a one-year clinic cohort of psychiatric outpatients (n= 338). At intake, patients completed questionnaires measuring self-esteem, interpersonal problems, interpersonal style, and general symptomatic distress. They were also diagnosed according to the ICD-10. Interpersonal behaviour was measured along the agency and communion dimensions of the Inventory of Interpersonal Problems-Circumplex [IIP-C]. The results show that lower self-esteem was associated with higher levels of interpersonal problems in general. Further, lower self-esteem was first and foremost linked to frustrated agentic motives, as measured by the IIP-C. Hence, the study concludes that fostering patient agency should be considered as an important goal in psychotherapy. Furthermore, the analyses revealed an interaction effect of agency and communion on self-esteem, indicating a need for balancing the two motive dimensions. Finally, some questions are raised concerning the interpretation of the IIP-C subscales in general.

A comparison of actigraphy and polysomnography in older adults treated for chronic primary insomnia.

STUDY OBJECTIVES: The present study explores the accuracy and clinical utility of actigraphy compared with polysomnography in older adults treated for chronic primary insomnia. DESIGN: Polysomnographic and actigraphic data were collected before and after treatment. SETTING: A university-based outpatient clinic for adults and elderly. PARTICIPANTS: Thirty-four participants with chronic primary insomnia. Mean age was 60.5 years. INTERVENTIONS: Participants received either a manualized treatment package based on cognitive-behavior therapy and sleep management or hypnotic-drug treatment (7.5 mg zopiclone) for 6 weeks (these findings are reported elsewhere). MEASUREMENTS AND RESULTS: Although the sensitivity of actigraphy to detect sleep was very high (95.2%), actigraphy performed poorly in detecting wakefulness (specificity: 36.3%), yielding on an overall level of accuracy of 83.1%. However, the level of actigraphy accuracy was dependent upon polysomnography-registered sleep efficiency. Actigraphy underestimated total wake time and sleep-onset latency and consequently overestimated total sleep time and sleep efficiency. Compared with polysomnography, actigraphy captured only part of the treatment effects on total wake time and sleep-onset latency and failed to detect significant changes in sleep efficiency. CONCLUSIONS: The present findings suggest that the clinical utility of actigraphy is still suboptimal in older adults treated for chronic primary insomnia and should, hence, be used in this clinical setting with the concurrent use of supplementary assessment methods.

Affect consciousness or mentalization? A comparison of two concepts with regard to affect development and affect regulation.

Affect consciousness refers to the ability to adequately perceive, reflect upon and express affect. The concept is used in clinical work with adults, but lacks an equivalent for children's experience of affect. This paper examines the developmental prerequisites for affect consciousness, as well as the concept's applicability to work with children. The main focus is on the development of affect regulation throughout the first 6 years of life. Special emphasis is put on the role of attachment and the unfolding of mentalization ability in this development. The role of play as an organizing factor for affective experience is discussed. Observation of play is highlighted as a strong indicator of affect consciousness in children.

Cognitive behavioral therapy vs zopiclone for treatment of chronic primary insomnia in older adults: a randomized controlled trial.

CONTEXT: Insomnia is a common condition in older adults and is associated with a number of adverse medical, social, and psychological consequences. Previous research has suggested beneficial outcomes of both psychological and pharmacological treatments, but blinded placebo-controlled trials comparing the effects of these treatments are lacking. OBJECTIVE: To examine short- and long-term clinical efficacy of cognitive behavioral therapy (CBT) and pharmacological treatment in older adults experiencing chronic primary insomnia. DESIGN, SETTING, AND PARTICIPANTS: A randomized, double-blinded, placebo-controlled trial of 46 adults (mean age, 60.8 y; 22 women) with chronic primary insomnia conducted between January 2004 and December 2005 in a single Norwegian university-based outpatient clinic for adults and elderly patients. INTERVENTION: CBT (sleep hygiene, sleep restriction, stimulus control, cognitive therapy, and relaxation; n = 18), sleep medication (7.5-mg zopiclone each night; n = 16), or placebo medication (n = 12). All treatment duration was 6 weeks, and the 2 active treatments were followed up at 6 months. MAIN OUTCOME MEASURES: Ambulant clinical polysomnographic data and sleep diaries were used to determine total wake time, total sleep time, sleep efficiency, and slow-wave sleep (only assessed using polysomnography) on all 3 assessment points. RESULTS: CBT resulted in improved short- and long-term outcomes compared with zopiclone on 3 out of 4 outcome measures. For most outcomes, zopiclone did not differ from placebo. Participants receiving CBT improved their sleep efficiency from 81.4% at pretreatment to 90.1% at 6-month follow-up compared with a decrease from 82.3% to 81.9% in the zopiclone group. Participants in the CBT group spent much more time in slow-wave sleep (stages 3 and 4) compared with those in other groups, and spent less time awake during the night. Total sleep time was similar in all 3 groups; at 6 months, patients receiving CBT had better sleep efficiency using polysomnography than those taking zopiclone. CONCLUSION: These results suggest that interventions based on CBT are superior to zopiclone treatment both in short- and long-term management of insomnia in older adults. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00295386.

Balancing losses and growth: a relational perspective on identity formation in the second half of life.

Psychoanalysis has so far only to a limited extent examined specifically grown-up and mature organizations of the self. The Freudian contributions mainly examine the impact of losses on the second half of life. The Eriksonian approaches put greater emphasis of possible gains and adaptation, while less attention is paid to inner, subjective life. In contrast, the Jungian and transpersonal views emphasize possible increase in inner freedom and a more relativistic, holistic, and possibly spiritual or "worldcentric" view on existence. Within a relational psychoanalytic perspective on identity formation in the second half of life, these possible changes may be described as a mature widening of potential space, using Winnicott's terms. Relationships also may be more based on "being" than "doing." A perspective incorporating potentials for increased experiential depth and creativity must include attention to actual losses and suffering, conflicts involved in letting go of certain ambitions, and lifelong themes that may be actualized.

Psychological characteristics of elderly insomniacs.

Sixty insomniacs, aged 60 years or over, fulfilling the DSM-IV criteria for primary insomnia, completed a set of questionnaires measuring psychological distress. These included the Sleep Impairment Index (SIM), the Symptom Check List 90-Revised (SCL-90-R), the Penn State Worry Questionnaire (PSWQ), the Toronto Alexithymia Scale-20 (TAS-20) and the Elders Life Stress Inventory (ELSI). The insomniacs were compared on these measures with two contrast groups, one of elderly good sleepers and one an elderly community sample. As norms were developed for the SCL-90-R and PSWQ, insomniacs were also contrasted with the norm groups on these measures. In general, the results indicated a higher level of psychological distress among insomniacs than among the good sleepers, while there were negligible differences between insomniacs and the community sample on most measures. Overall, elderly insomniacs scored higher on measures of worry compared with the other groups, followed by measures of somatization, obsessive-compulsion and depression. It is concluded that excessive worrying was the most characteristic feature of elderly insomniacs.