Understanding drift in the treatment of eating disorders using a mixed-methods approach.

Despite strong empirical support for treatments of eating disorders, research has demonstrated a trend of clinicians deviating from protocols outlined in empirically supported manuals. The present study used a convergent mixed-methods design to understand clinicians' use of and drift from empirically supported treatments in a sample of 114 licensed clinicians in the US who had substantial experience (i.e. one-third of caseload) working with patients with eating disorders and training in cognitive-behavioral therapy (CBT), family-based therapy (FBT), and/or interpersonal therapy (IPT) for eating disorders. Results revealed that 63.7-76.3% of clinicians drift from empirically supported treatments and 71.8% were aware they deviated from empirically supported treatments. Qualitative analyses identified client differences (57.2%) to be the primary reason why clinicians drift, with less participants describing therapist factors (20.4%), treatment shortcomings (12.6%), treatment setting (11.7%), logistic constraints (4.9%) and family factors (4.9%) as reasons why they drift. These findings suggest that drift for most clinicians may be better explained under the umbrella of evidence-based practice. Clinicians also identified a number of ways in which treatment and access to treatment can be improved. This broadened understanding of the use of empirically supported treatments within evidence-based practice may serve to help bridge the gap between research and practice.

A Dyadic Investigation of Depressed Affect and Interspousal Behavior in Couples With Chronic Back Pain.

BACKGROUND: Depression and marital discord are characteristic not only of individuals with chronic low back pain (ICPs) but also of their spouses. PURPOSE: We examined actor-partner interdependence models to evaluate associations among depressed affect and criticism and support of partners at the same time point (concurrent effects) and 3 hr later (lagged effects). Fully dyadic models were used to account for both within-person and cross-spouse associations among depressed affect, criticism, and support for ICPs and spouses. We also examined the direction of the relationships (depressed affect predicting behavior and behavior predicting depressed affect) all while controlling for pain intensity, pain behavior, and the prior dependent variable. METHODS: ICPs (n = 105) and their spouses completed electronic diary measures of depressed affect and behavior (criticism and support) five times a day for 2 weeks. Hierarchical linear modeling with person-mean centering was used for data analysis. RESULTS: Within the same 3 hr epoch, more depressed affect was related to higher criticism and generally less support. Lagged analyses suggested bidirectional relationships between spouse's own depressed affect and spouse's own criticism of ICPs. Spouse depressed affect was also associated with decreased support received from ICPs. Pain behavior and pain intensity were also related to depressed affect, criticism, and support especially concurrently. CONCLUSIONS: Theories and interventions need to address not only ICP depressed affect but also spouse depressed affect, as spouse depressed affect may be a stress generating precursor to criticism and support.

Spouse and Patient Beliefs and Perceptions About Chronic Pain: Effects on Couple Interactions and Patient Pain Behavior.

Patient beliefs and perceptions about the causes and meaning of their chronic pain are related to their psychosocial functioning. Beliefs and perceptions about chronic pain held by spouses may also be related to patient functioning. We used a laboratory procedure to evaluate whether spouse beliefs about and perceptions of chronic pain were related to spouse negative responses toward patients with chronic low back pain during a conflictual discussion and to their attributions about patient pain behavior during a subsequent pain-induction task. Patients (n = 71) and their spouses (n = 71) participated in a 10-minute discussion followed by the patient undergoing a 10-minute structured pain behavior task. Findings were that a) spouse perceptions that patient's pain was a mystery were significantly related to greater patient perceived spouse critical/invalidating responses toward the patient during the discussion; and b) spouse perceptions that patient's pain was a mystery were related to internal and negative attributions spouses made while observing patients display pain behaviors during the structured pain behavior task. Inasmuch as both spouse critical/invalidating speech toward patients and negative attributions regarding the cause of patient behavior are related to poor patient functioning, spouse uncertainty about the source and potential legitimacy of their partner's pain may play crucial roles in affecting patient well-being. PERSPECTIVE: Spouse beliefs about and perceptions of patient chronic pain were related to spouse behavior toward patients during a discussion and to attributions explaining patient pain during physical activity. If spouse confusion and doubt about patient pain is related to negative behavior and attributions, then modifying these perceptions may be a fundamental intervention target.

Depressive Symptoms, Criticism, and Counter-Criticism in Marital Interactions.

Although people with depressive symptoms face criticism, hostility, and rejection in their close relationships, we do not know how they respond. Following interpersonal theories of depression, it might be expected that depressive symptoms would be associated with a tendency to receive and also to express criticism toward one's spouse, and that at least some of this criticism would be a contingent response to criticism received (i.e., "counter-criticism"). However, other research has determined that depressive symptoms/behaviors suppress partner criticism, suggesting that depressed people might respond to partner criticism similarly, by subsequently expressing less criticism. In a sample of 112 married couples, partial correlations, regressions, and Actor-Partner Interdependence Modeling indicated that lower criticism and counter-criticism expression during a laboratory marital interaction task was associated with higher depressive symptoms, especially when such individuals were clinically depressed. Furthermore, during a separate and private Five-Minute Speech Sample, lower criticism by partners was associated with higher depressive symptoms, especially when those who chose the interaction topic were also clinically depressed. All analyses controlled for relationship adjustment. These results suggest that spouses with higher depressive symptoms and clinical depression diagnoses may be suppressing otherwise ordinary criticism expression toward their nondepressed partners; furthermore, nondepressed partners of depressed people are especially likely to display less criticism toward their spouse in a private task.

Aunque las personas con síntomas depresivos enfrentan la crítica, la hostilidad y el rechazo en sus relacionones cercanas, no sabemos cómo responden. Siguiendo las teorías intepersonales de depresión, podría esperarse que los síntomas depresivos estuvieran asociados con una tendencia a recibir y también a expresar críticas hacia el cónyuge de uno, y que por lo menos parte de esta crítica fuera una respuesta condicionada por las críticas recibidas (p. ej.: "contracrítica"). Sin embargo, otras investigaciones han determinado que las conductas o los síntomas depresivos moderan la crítica de la pareja, lo cual sugiere que las personas deprimidas podrían responder a las críticas de la pareja de forma similiar, expresando posteriormente menos críticas. En una muestra de 112 parejas casadas, las correlaciones parciales, los análisis de la regresión y el modelo de interdependencia actor-pareja (APIM) indicaron que una menor expresión de crítica y contracrítica durante una tarea de interacción conyugal en laboratorio estuvo asociada con mayores síntomas depresivos, especialmente cuando dichas personas estaban clínicamente deprimidas. Además, durante una muestra independiente y en privado de un discurso de cinco minutos, una menor expresión de crítica por parte de las parejas estuvo asociada con mayores síntomas depresivos, especialmente cuando los que eligieron el tema de interacción también estaban clínicamente deprimidos. Todos los análisis controlaron la adaptación de la relación. Estos resultados sugieren que los cónyuges con mayores síntomas depresivos y con diagnósticos de depresión clínica pueden estar suprimiendo una expresión de crítica normal hacia sus parejas no deprimidas. Además, las parejas no deprimidas de las personas deprimidas son especialmente propensas a mostrar menos críticas hacia su cónyuge en una tarea a solas.

Spouse Criticism/Hostility Toward Partners With Chronic Pain: The Role of Spouse Attributions for Patient Control Over Pain Behaviors.

Spouse attributions regarding displays of pain behaviors by their partners with chronic pain may account for subsequent increases in spouse critical/hostile responses toward their partners. People with chronic low back pain (n = 105) and their pain-free spouses (n = 105) completed electronic diary measures 5 times per day for 14 consecutive days. Key items assessed spouse observations of patient pain behavior, attributions regarding these behaviors, and spouse critical/hostile responses toward patients. Results were 1) spouse observations of patient pain behavior at time 1 predicted high levels of spouse critical/hostile responses toward the patient at time 2. 2) "Internal" attributions (eg, the patient was attempting to influence spouse's feelings) at time 1 predicted high levels of spouse critical/hostile responses toward the patient at time 2. 3) Internal attributions mediated links between spouse-observed pain behaviors at time 1 and levels of spouse critical/hostile responses at time 2. Spouse observations of patient pain behavior was also related to an "external" attribution (ie, patient pain behavior was due to pain condition), but this attribution was not a significant mediator. A vital factor linking spouse scrutiny to spouse critical/hostile responses may be the spouse's ascribed reasons for the patient's grimacing, bracing, complaining, and so forth. Perspective: Results indicate that spouse internal and negative attributions for pain behaviors of their partners with chronic pain may influence subsequent spouse critical/hostile reactions to them. Findings suggest that replacing spouse internal and negative attributions with external, compassionate, and accepting explanations may be useful therapeutic targets for couples coping with chronic pain.

Spouse criticism and hostility during marital interaction: effects on pain intensity and behaviors among individuals with chronic low back pain.

Individuals with chronic pain may experience negative responses from spouse, family, and friends. Responses such as overt criticism and hostility may be associated with worsening pain and function for chronic pain sufferers. We used a laboratory procedure to evaluate whether variability in spouse criticism/hostility exhibited toward chronic low back pain (CLBP) patients during a conflictual discussion predicted variability in patient pain and function during a subsequent pain-induction task. Chronic low back pain patients (n = 71) and their spouses (n = 71) participated in a 10-minute discussion followed by the patient undergoing a 10-minute structured pain behavior task (SPBT). Spouse criticism/hostility perceived by patients and patient Beck Depression Inventory-II (BDI) scores correlated significantly and positively with pain intensity during the SPBT, whereas perceived spouse hostility, patient BDI scores, and spouse trait hostility correlated significantly and positively with observed pain behaviors during the SPBT. Spouse criticism/hostility coded by raters from video recordings interacted significantly with patient BDI scores, such that observed spouse criticism/hostility was related significantly and positively with pain behaviors only for patients with high BDI scores. Patient sex interacted significantly with observed spouse criticism/hostility, such that observed spouse criticism/hostility was related significantly and positively with pain behaviors only for female patients. Results support the hypothesis that spouse criticism and hostility-actually expressed or perceived-may worsen CLBP patient symptoms. Further, women patients and patients high in depressive symptoms appeared most vulnerable to spouse criticism/hostility. Thus, negative marital communication patterns may be appropriate targets for intervention, especially among these 2 at risk groups.

Variability in negative emotions among individuals with chronic low back pain: relationships with pain and function.

Chronic pain is associated with elevated negative emotions, and resources needed to adaptively regulate these emotions can be depleted during prolonged pain. Studies of links between pain, function, and negative emotions in people with chronic pain, however, have focused almost exclusively on relationships among mean levels of these factors. Indexes that may reflect aspects of emotion regulation have typically not been analyzed. We propose that 1 index of emotion regulation is variability in emotion over time as opposed to average emotion over time. The sample was 105 people with chronic low back pain and 105 of their pain-free spouses. They completed electronic diary measures 5x/d for 14 consecutive days, producing 70 observations per person from which we derived estimates of within-subject variance in negative emotions. Location-scale models were used to simultaneously model predictors of both mean level and variance in patient negative emotions over time. Patients reported significantly more variability in negative emotions compared to their spouses. Patients who reported higher average levels of pain, pain interference, and downtime reported significantly higher levels of variability in negative emotions. Spouse-observed pain and pain behaviors were also associated with greater variability in patients' negative emotions. Test of the inverse associations between negative emotion level and variability in pain and function were significant but weaker in magnitude. These findings support the notion that chronic pain may erode negative emotion regulation resources, to the potential detriment of intra- and inter-personal function.

Associations Between Participant Ratings of PREP for Strong Bonds and Marital Outcomes 1 Year Postintervention.

After completing a relationship education program, collecting participant evaluations of the program is common practice. These are generally used as an index of "consumer satisfaction" with the program, with implications for feasibility and quality. Rarely have these ratings been used as predictors of changes in marital quality, although such feedback may be the only data providers collect or have immediate access to when considering the success of their efforts. To better understand the utility of such ratings to predict outcomes, we evaluated links between participant ratings and changes in self-reported marital satisfaction and communication scores one year later for a sample of 191 Army couples who had participated in a relationship education program delivered by Army chaplains (PREP for Strong Bonds). Overall ratings of general satisfaction with the program and the leader did not predict changes in marital outcomes one year later, whereas higher ratings of how much was learned, program helpfulness, increased similarity in outlook regarding Army life, and helpfulness of communication skills training predicted greater change in communication skills one year later. Higher ratings of items reflecting intent to invest more time in the relationship, and increased confidence in constructive communication and working as a team with the spouse predicted greater increases in both marital satisfaction and communication skills one year later. The constructs of intention and confidence (akin to perceived behavioral control) suggest that the Theory of Planned Behavior may be particularly useful when considering which Army couples will show ongoing benefit after relationship education.

Changes in the Sexual Relationship and Relationship Adjustment Precede Extradyadic Sexual Involvement.

Extradyadic sexual involvement (ESI) is associated with negative consequences for individuals and threatens couple stability. Research on ESI in unmarried samples has been marked by methodological limitations, such as examining only mean levels of sexual satisfaction or frequency to predict later ESI as opposed to changes in various aspects of the sexual relationship over time. The current study compared linear trajectories of four aspects of the sexual relationship-sexual satisfaction, frequency of sex, comfort communicating about sex, and sexual closeness-between individuals in opposite-sex, unmarried relationships who subsequently engaged in ESI (ESI group; n = 183) compared to individuals who did not engage in ESI (non-ESI group; n = 603). Trajectories of relationship adjustment were also evaluated leading up to ESI as well as controlled for in models evaluating the sexual relationship. Results indicated that relationship adjustment declined for individuals preceding ESI, but did not change for the non-ESI group. When controlling for relationship adjustment, comfort communicating about sex decreased for ESI women but increased for ESI men. Some results became nonsignificant after controlling for relationship adjustment, including that sexual satisfaction declined more steeply in the ESI group compared to the non-ESI group, and ESI women significantly decreased in sexual closeness while ESI men demonstrated no significant change. Some mean level differences were also discovered directly before ESI. Conclusions include that changes in a couple's sexual relationship and relationship adjustment are associated with ESI behaviors, providing novel information regarding normative and risk trajectories.

Relationships Between Sleep Quality and Pain-Related Factors for People with Chronic Low Back Pain: Tests of Reciprocal and Time of Day Effects.

BACKGROUND: Poor sleep quality among people with chronic low back pain appears to be related to worse pain, affect, poor physical function, and pain catastrophizing. The causal direction between poor sleep and pain remains an open question, however, as does whether sleep quality exerts effects on low back pain differently across the course of the day. PURPOSE: This daily diary study examined lagged temporal associations between prior night sleep quality and subsequent day pain, affect, physical function and pain catastrophizing, the reverse lagged temporal associations between prior day pain-related factors and subsequent night sleep quality, and whether the time of day during which an assessment was made moderated these temporal associations. METHODS: Chronic low back pain patients (n = 105) completed structured electronic diary assessments five times per day for 14 days. Items included patient ratings of their pain, affect, physical function, and pain catastrophizing. RESULTS: Collapsed across all observations, poorer sleep quality was significantly related to higher pain ratings, higher negative affect, lower positive affect, poorer physical function, and higher pain catastrophizing. Lagged analyses averaged across the day revealed that poorer prior night sleep quality significantly predicted greater next day patient ratings of pain, and poorer physical function and higher pain catastrophizing. Prior poorer night sleep quality significantly predicted greater reports of pain, and poorer physical function, and higher pain catastrophizing, especially during the early part of the day. Sleep quality × time of day interactions showed that poor sleepers reported high pain, and negative mood and low function uniformly across the day, whereas good sleepers reported relatively good mornings, but showed pain, affect and function levels comparable to poor sleepers by the end of the day. Analyses of the reverse causal pathway were mostly nonsignificant. CONCLUSIONS: Sleep quality appears related not only to pain intensity but also to a wide range of patient mood and function factors. A good night's sleep also appears to offer only temporary respite, suggesting that comprehensive interventions for chronic low back pain not only should include attention to sleep problems but also focus on problems with pain appraisals and coping.

Anger arousal and behavioral anger regulation in everyday life among people with chronic low back pain: Relationships with spouse responses and negative affect.

OBJECTIVE: To determine the degree to which anger arousal and anger regulation (expression, inhibition) in the daily lives of people with chronic pain were related to spouse support, criticism, and hostility as perceived by patients and as reported by spouses. METHOD: Married couples (N = 105, 1 spouse with chronic low back pain) completed electronic daily diaries, with assessments 5 times/day for 14 days. On these diaries, patients completed items on their own anger arousal, anger expression, and inhibition, and on perceived spouse support, criticism, and hostility. Spouses reported on their responses toward patients and their negative affect. Hierarchical linear modeling tested concurrent and lagged relationships. RESULTS: Patient-reported increases in anger arousal and anger expression were predominantly related to concurrent decreases in patient-perceived and spouse-reported spouse support, concurrent increases in patient-perceived and spouse-reported spouse criticism and hostility, and increases in spouse-reported negative affect. Relationships for anger expression remained significant with anger arousal controlled. These effects were especially strong for male patients. Spouses reported greater negative affect when patients were present than when they were not. CONCLUSIONS: Social support may facilitate adjustment to chronic pain, with declining support and overt criticism and hostility possibly adversely impacting pain and function. Results suggest that patient anger arousal and expression may be related to a negative interpersonal environment for married couples coping with chronic low back pain.

The Communal Coping Model of Pain Catastrophizing in Daily Life: A Within-Couples Daily Diary Study.

UNLABELLED: The Communal Coping Model characterizes pain catastrophizing as a coping tactic whereby pain expression elicits assistance and empathic responses from others. Married couples (N = 105 couples; 1 spouse with chronic low back pain) completed electronic daily diary assessments 5 times/day for 14 days. In these diaries, patients reported pain catastrophizing, pain, and function, and perceived spouse support, perceived criticism, and perceived hostility. Non-patient spouses reported on their support, criticism, and hostility directed toward patients, as well as their observations of patient pain and pain behaviors. Hierarchical linear modeling tested concurrent and lagged (3 hours later) relationships. Principal findings included the following: a) within-person increases in pain catastrophizing were positively associated with spouse reports of patient pain behavior in concurrent and lagged analyses; b) within-person increases in pain catastrophizing were positively associated with patient perceptions of spouse support, criticism, and hostility in concurrent analyses; c) within-person increases in pain catastrophizing were negatively associated with spouse reports of criticism and hostility in lagged analyses. Spouses reported patient behaviors that were tied to elevated pain catastrophizing, and spouses changed their behavior during and after elevated pain catastrophizing episodes. Pain catastrophizing may affect the interpersonal environment of patients and spouses in ways consistent with the Communal Coping Model. PERSPECTIVE: Pain catastrophizing may represent a coping response by which individuals' pain expression leads to assistance or empathic responses from others. Results of the present study support this Communal Coping Model, which emphasizes interpersonal processes by which pain catastrophizing, pain, pain behavior, and responses of significant others are intertwined.

Perceived criticism and marital adjustment predict depressive symptoms in a community sample.

Depressive symptoms are related to a host of negative individual and family outcomes; therefore, it is important to establish risk factors for depressive symptoms to design prevention efforts. Following studies in the marital and psychiatric literatures regarding marital factors associated with depression, we tested two potential predictors of depressive symptoms: marital adjustment and perceived spousal criticism. We assessed 249 spouses from 132 married couples from the community during their first year of marriage and at three time points over the next 10 years. Initial marital adjustment significantly predicted depressive symptoms for husbands and wives at all follow-ups. Further, perceived criticism significantly predicted depressive symptoms at the 5- and 10-year follow-ups. However, at the 1-year follow-up, this association was significant for men but not for women. Finally, a model where the contributions of marital adjustment and perceived criticism were tested together suggested that both play independent roles in predicting future depressive symptoms. These findings highlight the potential importance of increasing marital adjustment and reducing perceived criticism at the outset of marriage as a way to reduce depressive symptoms during the course of marriage.