Using the Therapist's Inner Conversation in Teamwork with Novice Therapists

Peter Rober's work (2005a) on the therapist’s inner conversation (TIC) has been a significant contribution to understanding the therapist's 'here and now' experience that focuses on the emergence of different voices responding to what is said in the therapy session. Frediani and Rober (2016) conducted an investigation into the experience and TIC of novice therapists concerning emotions aroused and how they deal with them during family therapy. Their research prompted us to ask how this methodology could work with recent graduates and those in the last year of their undergraduate training. This was addressed in the adolescent psychotherapy team that is part of the Equipo de Trabajo y Asesoría Sistémica (Systemic Counselling and Teamwork) (eQtasis) of the Psychology Department of the University of Chile. An important characteristic has been developing an ethics for clinical practice and generating a collaborative reflexive approach as a central aspect of the clinical training. The paper aims to promote the legitimacy of the experience of novice therapists who despite limited professional experience have many stories that connect with what is said in therapy.     

Every Minute Counts: Using Process Improvement and Performance Feedback to Improve Patient Flow in an Emergency Department

Prolonged emergency department (ED) visits are associated with a number of adverse outcomes for patients as well as lower patient satisfaction scores and increased costs. Several factors that influence the length of ED visits are out of the control of hospital employees, but some opportunities exist to improve performance. For this study, the ED department of a 150-bed hospital in the southeastern United States wanted to improve door-to-discharge time. To do so, a subprocess of door-to-discharge time was targeted, door-to-order. After analyzing the process, the team created standard orders for the 10 most common presenting conditions in the ER with preapproval, allowing nurses to submit the orders without the provider first visiting the patient. Following the process change, daily feedback was added to increase utilization of the preapproved orders. Reductions in door-to-order times and door-to-discharge were observed and patient satisfaction remained stable. Implications for future research in this area are discussed.     

Blinded continuous monitoring in clinical trials with recurrent event endpoints

In studies with recurrent event endpoints, misspecified assumptions of event rates or dispersion can lead to underpowered trials or overexposure of patients. Specification of overdispersion is often a particular problem as it is usually not reported in clinical trial publications. Changing event rates over the years have been described for some diseases, adding to the uncertainty in planning. To mitigate the risks of inadequate sample sizes, internal pilot study designs have been proposed with a preference for blinded sample size reestimation procedures, as they generally do not affect the type I error rate and maintain trial integrity. Blinded sample size reestimation procedures are available for trials with recurrent events as endpoints. However, the variance in the reestimated sample size can be considerable in particular with early sample size reviews. Motivated by a randomized controlled trial in paediatric multiple sclerosis, a rare neurological condition in children, we apply the concept of blinded continuous monitoring of information, which is known to reduce the variance in the resulting sample size. Assuming negative binomial distributions for the counts of recurrent relapses, we derive information criteria and propose blinded continuous monitoring procedures. The operating characteristics of these are assessed in Monte Carlo trial simulations demonstrating favourable properties with regard to type I error rate, power, and stopping time, ie, sample size.     

Bayesian sample size determination for phase IIA clinical trials using historical data and semi‐parametric prior's elicitation

The Simon's two‐stage design is the most commonly applied among multi‐stage designs in phase IIA clinical trials. It combines the sample sizes at the two stages in order to minimize either the expected or the maximum sample size. When the uncertainty about pre‐trial beliefs on the expected or desired response rate is high, a Bayesian alternative should be considered since it allows to deal with the entire distribution of the parameter of interest in a more natural way. In this setting, a crucial issue is how to construct a distribution from the available summaries to use as a clinical prior in a Bayesian design. In this work, we explore the Bayesian counterparts of the Simon's two‐stage design based on the predictive version of the single threshold design. This design requires specifying two prior distributions: the analysis prior, which is used to compute the posterior probabilities, and the design prior, which is employed to obtain the prior predictive distribution. While the usual approach is to build beta priors for carrying out a conjugate analysis, we derived both the analysis and the design distributions through linear combinations of B‐splines. The motivating example is the planning of the phase IIA two‐stage trial on anti‐HER2 DNA vaccine in breast cancer, where initial beliefs formed from elicited experts' opinions and historical data showed a high level of uncertainty. In a sample size determination problem, the impact of different priors is evaluated.     

Interview schedule development for a Sequential explanatory mixed method design: complementary-alternative medicine (CAM) study among Indonesian psychologists

Sequential explanatory mixed method design is the most frequently applied in both health and social sciences literature. It is denoted by ‘QUAN → qual’ which represents the quantitative study occurs first and has greater weight in addressing the study’s aims, and the qualitative study follows to explain quantitative results. Despite the extensive use of sequential explanatory design, there are limited references to this design. Therefore, this methodological paper attempts to fill the gap by providing an illustration in developing a sequential explanatory interview schedule based on complementary-alternative medicine (CAM) study among clinical psychologists in Indonesia. The most important step to develop sequential explanatory interview schedule was the construction of aspects and questions that were immensely grounded on the most notable quantitative results. In this study, eight aspects of interview schedule were constructed after analyses of the nationwide survey. The interview schedule then piloted among participants with fairly similar characteristics to the participants in the main interviews. This process enhanced the quality of questions through feedback from participants and improved the interviewer’s skills through familiarization with questions. It is expected that this reflection report could be adopted as a practical guideline in developing interview schedule for sequential explanatory mixed method design, particularly in the field of psychology.     

Enacting reflective and deliberative practices in action research

ABSTRACT

We consider action research as a form of deliberative policy analysis. This analysis explores a “reconstruction clinic” in which stakeholders and public officials engaged memories, hopes and obligations as they sought to resolve controversies over details of policy implementation. We ask how institutional design shaped participants’ reflective and deliberative progress. Reflection in action can prompt not only changes in cognitive frames, but new behavioural capacities for action. Deliberative practices can shape new relationships between parties through the work of apology, recognition, appreciation, and emergent collaboration.     

A Study of Clinical Change in Individual Career Counseling

This study examined the clinical significance of career counseling effects. Participants were 111 university students (83% women) who participated in individual career counseling sessions at their university. All participants completed the French version of the Outcome Questionnaire–30.2 (OQ‐30.2; Lambert, Finch, Okiishi, & Burlingame, 2005) immediately before the 1st session (pretest) and at the beginning of the last session (posttest). The OQ‐30.2 assesses 3 client life domains: subjective discomfort, problems in interpersonal relationships, and problems in social role satisfaction. Using Jacobson and Truax’s (1991) statistical approach to assessing clinical change, the authors compared clients’ pretest OQ‐30.2 scores with their posttest scores. Among clients with a “dysfunctional” score (n = 59) at the study’s inception, 34% recovered and 14% improved, whereas 41% of clients with functional scores (n = 52) at the study’s inception improved. The results suggest that individual career counseling can make a difference in the lives of many clients; they also highlight the importance of further outcome research that accounts for possible variability in clients’ responses to career counseling.     

Social work and pastoral counseling: Empowering each other

ABSTRACT

This article addresses the divergent outcomes which can result from counseling services offered pastorally versus clinically. As faith leaders often have greater direct access than social workers to supporting religious populations, it is important to explore the intersection between religious pastoral support and clinical social work. Presenting six scenarios from the author’s own experiences as both a rabbi and social worker, this article processes each scenario first through the pastoral lens of an Orthodox rabbi, followed by the clinical lens of a social worker or other mental health professional. The client outcomes which are produced from each modality are radically different. This contrast demonstrates the distinction between the goals, values, and training of each profession, and highlights importance for future work to be done in linking religious and pastoral training to mental health services, as well as broadening the scope of cultural competence for social workers and therapists who may engage with tight-knit religious populations.     

Response‐adaptive designs for binary responses: How to offer patient benefit while being robust to time trends?

Response‐adaptive randomisation (RAR) can considerably improve the chances of a successful treatment outcome for patients in a clinical trial by skewing the allocation probability towards better performing treatments as data accumulates. There is considerable interest in using RAR designs in drug development for rare diseases, where traditional designs are not either feasible or ethically questionable. In this paper, we discuss and address a major criticism levelled at RAR: namely, type I error inflation due to an unknown time trend over the course of the trial. The most common cause of this phenomenon is changes in the characteristics of recruited patients—referred to as patient drift. This is a realistic concern for clinical trials in rare diseases due to their lengthly accrual rate. We compute the type I error inflation as a function of the time trend magnitude to determine in which contexts the problem is most exacerbated. We then assess the ability of different correction methods to preserve type I error in these contexts and their performance in terms of other operating characteristics, including patient benefit and power. We make recommendations as to which correction methods are most suitable in the rare disease context for several RAR rules, differentiating between the 2‐armed and the multi‐armed case. We further propose a RAR design for multi‐armed clinical trials, which is computationally efficient and robust to several time trends considered.