Readiness to change and therapy outcomes of an innovative psychotherapy program for surgical patients: results from a randomized controlled trial

Henning Krampe, Anna-Lena Salz, Léonie F Kerper, Alexander Krannich, Tatjana Schnell, Klaus-Dieter Wernecke, Claudia D Spies, Henning Krampe, Anna-Lena Salz, Léonie F Kerper, Alexander Krannich, Tatjana Schnell, Klaus-Dieter Wernecke, Claudia D Spies

Abstract

Background: Readiness to change is a pivotal construct for psychotherapy research and a major target of motivational interventions. Our primary objective was to examine whether pre-treatment readiness to change moderated therapy effects of Bridging Intervention in Anesthesiology (BRIA), an innovative psychotherapy approach for surgical patients. This stepped care program aims at motivating and supporting surgical patients with mental disorders to engage in psychosocial mental health care.

Methods: The major steps of BRIA are two motivational interventions with different intensity. The first step of the program consists of preoperative computer-assisted psychosocial self-assessment including screening for psychological distress and automatically composed computerized brief written advice (BWA). In the second step, patients participate in postoperative psychotherapy sessions combining motivational interviewing with cognitive behavioural therapy (BRIA psychotherapy sessions). We performed regression-based moderator analyses on data from a recent randomized controlled trial published by our research group. The sample comprised 220 surgical patients with diverse comorbid mental disorders according to ICD-10. The most frequent disorders were mood, anxiety, substance use and adjustment disorders. The patients had a mean age of 43.31 years, and 60.90% were women. In a regression model adjusted for pre-treatment psychological distress, we investigated whether readiness to change moderated outcome differences between (1) the BRIA psychotherapy sessions and (2) no psychotherapy / BWA only.

Results: Multiple regression analyses showed that readiness to change moderated treatment effects regarding the primary outcomes "Participation in psychosocial mental health care options at month 6" (p = 0.03) and "Having approached psychosocial mental health care options at month 6" (p = 0.048) but not regarding the secondary outcome "Change of general psychological distress between baseline assessment and month 6" (p = 0.329). Probing the moderation effect with the Johnson-Neyman technique revealed that BRIA psychotherapy sessions were superior to BWA in patients with low to moderate readiness, but not in those with high readiness.

Conclusions: Readiness to change may act as moderator of the efficacy of psychosocial therapy. Combinations of motivational interviewing and cognitive behavioural therapy may be effective particularly in patients with a variety of mental disorders and low readiness to change.

Trial registration: clinicaltrials.gov Identifier: NCT01357694.

Keywords: Bridging Intervention in Anesthesiology (BRIA); Cognitive behavioural therapy (CBT); Motivational interviewing (MI); Surgical patients; University of Rhode Island Change Assessment (URICA).

Conflict of interest statement

Ethics approval and consent to participate

This study was approved by the Ethics Committee of the Charité – Universitätsmedizin Berlin [EA1/014/11]. All patients provided written informed consent.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Unrelated to this work, CDS received grants AbbVie Deutschland GmbH & Co. KG; Aguettant Deutschland GmbH; AppAdventure; Aspect / Covidien; Arbeitsgemeinschaft industrieller Forschungsvereinigungen „Otto von Guericke “e. V. (AiF); Aridis Pharmaceutical Inc.; Baxter Deutschland GmbH, Berufsverband Deutscher Anästhesisten e. V. (BDA); Biotest AG; B. Braun Melsungen AG; Bundesministerium für Bildung und Forschung (BMBF); Carinopharm GmbH; Cytosorbents Europe GmbH; Delcath Systems, Inc.; Deutsche Forschungsgemeinschaft; Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ); Deutsches Zentrum für Luft- und Raumfahrt e. V. (DLR); Dr. F. Köhler Chemie GmbH; Drägerwerk AG & Co. KG; Dräger Medical Deutschland GmbH; Edwards Lifesciences Germany GmbH; Einstein Stiftung Berlin; European Commission Funding; European Society of Anaesthesiology; Fresenius Medical Care; Gemeinsamer Bundesausschuss (G-BA); Grünenthal GmbH; INC Research UK Ltd.; Infectopharm GmbH; Inner University Grants; J&P Medical Research Ltd.; La Jolla Pharmaceutical Company; Maquet Vertrieb und Service Deutschland GmbH; Masimo Europe Ltd.; Medtronic GmbH; Mundipharma; Novartis Pharma GmbH; Orion Pharma GmbH; Pfizer Pharma PFE GmbH; Pharmaceutical Research Associates GmbH; Philips Electronics Nederland B.V.; Pulsion Medical Systems SE; Sedana Medical Ltd.; Sintetica GmbH; Stifterverband / Non-Profit Society Promoting Science and Education; Westfälische Wilhelms-Universität Münster/DFG, WHOCC: In addition, Dr. Spies reports personal fees from B. Braun Melsungen AG; Fresenius Kabi; Georg Thieme Verlag, as well as a patent 10 2014 215,211.9 pending, a patent Application No. PCT/EP2015/067730 pending to Graft Gesellschaft von Architekten mbH, and a patent Application No. PCT/EP2015/067731 pending to Graft Gesellschaft von Architekten mbH.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Figures

Fig. 1
Fig. 1
Flow of participants through the trial. + Numbers in brackets refer to patients lost to follow-up and drop outs concerning the secondary outcome. Numbers of patients lost to follow-up differ between primary and secondary outcomes because the primary outcome was assessed via a telephone interview, and the secondary outcome as a postal questionnaire. Kerper et al., Effects of an innovative psychotherapy program for surgical patients - Bridging Intervention in Anesthesiology: A randomized controlled trial. Anesthesiology 2015;123:148-59 [6]
Fig. 2
Fig. 2
Johnson-Neyman plots of the interaction between treatment allocation (BRIA psychotherapy sessions vs. BWA, N = 220) and readiness to change. a Participation in psychosocial mental health care options at month 6; b Having approached psychosocial mental health care options at month 6. The black continuous lines show the conditional effects of BRIA psychotherapy sessions for all values of readiness to change, and the dotted lines above and below indicate the corresponding 95% confidence intervals (CI). The gray vertical dashed lines identify the regions of significance, reaching from the lowest score until the score of readiness to change at which the lower 95% CI of the slope crosses the zero point. For all readiness values below, the effect of BRIA psychotherapy sessions is statistically significant

References

    1. Prochaska JO, DiClemente CC. Stages and processes of self-change of smoking: toward an integrative model of change. J Consult Clin Psychol. 1983;51:390–395. doi: 10.1037/0022-006X.51.3.390.
    1. Prochaska JO, DiClemente CC, Norcross JC. In search of how people change. Am Psychol. 1992;47:1101–1114. doi: 10.1037/0003-066X.47.9.1102.
    1. Norcross J, Krebs P, Prochaska J. Stages of change. J Clin Psychol. 2011;67:143–154. doi: 10.1002/jclp.20758.
    1. DiClemente CC, Carbonari J, Zweben A, Morrel T, Lee R. Motivation hypothesis causal chain analysis. In: Longabaugh R, Wirtz P, editors. Project MATCH: hypotheses, results, and causal chain analyses. Bethesda, MD: National Institute on Alcohol Abuse and Alcoholism Project Match Monograph Series; 2001. pp. 206–222.
    1. Lange LF, Spies CD, Weiß-Gerlach E, Neumann T, Salz A-L, Tafelski S, Hein J, Seiferth N, Heinz A, Glaesmer H, Brähler E, Krampe H. Bridging intervention in Anaesthesiology: first results on treatment need, demand and utilization of an innovative psychotherapy program for surgical patients. Clin Health Promot. 2011;1:41–49.
    1. Kerper LF, Spies CD, Salz A-L, Weiß-Gerlach E, Balzer F, Neumann T, Tafelski S, Lau A, Neuner B, Romanczuk-Seiferth N, Glaesmer H, Wernecke K, Brähler E, Krampe H. Effects of an innovative psychotherapy program for surgical patients - bridging intervention in anesthesiology: a randomized controlled trial. Anesthesiology. 2015;123:148–159. doi: 10.1097/ALN.0000000000000685.
    1. Neumann T, Neuner B, Weiss-Gerlach E, Tønnesen H, Gentilello LM, Wernecke K-D, Schmidt K, Schroeder T, Wauer H, Heinz A, Mann K, Mueller JM, Haas N, Kox WJ, Spies CD. The effect of computerized tailored brief advice on at-risk drinking in subcritically injured trauma patients. J Trauma. 2006;61:805–814. doi: 10.1097/01.ta.0000196399.29893.52.
    1. Miller WR, Rollnick S. Motivational interviewing. Preparing people for change, 2nd edition. New York: The Guilford Press; 2002.
    1. Arkowitz H, Westra HA, Miller W, Rollnick S. Motivational interviewing in the treatment of psychological problems. New York: The Guilford Press; 2008.
    1. Moyers TB, Miller W. Is low therapist empathy toxic? Psychol Addict Behav. 2013;27:878–884. doi: 10.1037/a0030274.
    1. Aharonovich E, Stohl M, Ellis J, Amrhein P, Hasin D. Commitment strength, alcohol dependence and HealthCall participation: effects on drinking reduction in HIV patients. Drug Alcohol Depend. 2014;135:112–118. doi: 10.1016/j.drugalcdep.2013.11.015.
    1. Capone C, Wood M. Thinking about drinking: need for cognition and readiness to change moderate the effects of brief alcohol interventions. Psychol Addict Behav. 2009;23:684–688. doi: 10.1037/a0016235.
    1. Dray J, Wade T. Is the transtheoretical model and motivational interviewing approach applicable to the treatment of eating disorders? A review. Clin Psychol Rev. 2012;32:558–565. doi: 10.1016/j.cpr.2012.06.005.
    1. Gaume J, Bertholet N, Daeppen J-B. Readiness to change predicts drinking: findings from 12-month follow-up of alcohol use disorder outpatients. Alcohol Alcohol. 2017;52:65–71. doi: 10.1093/alcalc/agw047.
    1. Lewis CC, Simons AD, Silva SG, Rohde P, Small DM, Murakami JL, High RR, March JS. The role of readiness to change in response to treatment of adolescent depression. J Consult Clin Psychol. 2009;77:422–428. doi: 10.1037/a0014154.
    1. Mander J, Wittorf A, Teufel M, Schlarb A, Hautzinger M, Zipfel S, Sammet I. Patients with depression, somatoform disorders, and eating disorders on the stages of change: validation of a short version of the URICA. Psychotherapy. 2012;49:519–527. doi: 10.1037/a0029563.
    1. Pantalon MV, Nich C, Frankforter T, Carroll KM. The URICA as a measure of motivation to change among treatment-seeking individuals with concurrent alcohol and cocaine problems. Psychol Addict Behav. 2002;16:299–307. doi: 10.1037/0893-164X.16.4.299.
    1. Soler J, Trujols J, Pascual J, Portella M, Barrachina J, Campins J, Tejedor R, Alvarez E, Pérez V. Stages of change in dialectical behaviour therapy for borderline personality disorder. Br J Clin Psychol. 2008;47:417–426. doi: 10.1348/014466508X314882.
    1. Abd Elbaky GB, Hay PJ, le Grange D, Lacey H, Crosby RD, Touyz S. Pre-treatment predictors of attrition in a randomised controlled trial of psychological therapy for severe and enduring anorexia nervosa. BMC Psychiatry. 2014;14:69. doi: 10.1186/1471-244X-14-69.
    1. Arnaud N, Baldus C, Elgán TH, Tønnesen H, De Paepe N, Csemy L, Thomasius R. Moderators of outcome in a web-based substance use intervention for adolescents. Sucht. 2015;61:377–387. doi: 10.1024/0939-5911.a000397.
    1. Field C, Adinoff B, Harris T, Ball S, Carroll K. Construct, concurrent and predictive validity of the URICA: data from two multi-site clinical trials. Drug Alcohol Depend. 2009;101:115–123. doi: 10.1016/j.drugalcdep.2008.12.003.
    1. Myers B, van der Westhuizen C, Naledi T, Stein DJ, Sorsdahl K. Readiness to change is a predictor of reduced substance use involvement: findings from a randomized controlled trial of patients attending south African emergency departments. BMC Psychiatry. 2016;16:35. doi: 10.1186/s12888-016-0742-8.
    1. Nosyk B, Geller J, Guh DP, Oviedo-Joekes E, Brissette S, Marsh DC, Schechter MT, Anis AH. The effect of motivational status on treatment outcome in the north American opiate medication initiative (NAOMI) study. Drug Alcohol Depend. 2010;111:161–165. doi: 10.1016/j.drugalcdep.2010.03.019.
    1. Palfai TP, Tahaney K, Winter M, Saitz R. Readiness-to-change as a moderator of a web-based brief intervention for marijuana among students identified by health center screening. Drug Alcohol Depend. 2016;161:368–371. doi: 10.1016/j.drugalcdep.2016.01.027.
    1. Saitz R, Palfai TP, Cheng DM, Horton NJ, Dukes K, Kraemer KL, Roberts MS, Guerriero RT, Samet JH. Some medical inpatients with unhealthy alcohol use may benefit from brief intervention. J Stud Alcohol Drugs. 2009;70:426–435. doi: 10.15288/jsad.2009.70.426.
    1. Sherman BJ, Baker NL, McRae-Clark AL. Gender differences in cannabis use disorder treatment: change readiness and taking steps predict worse cannabis outcomes for women. Addict Behav. 2016;60:197–202. doi: 10.1016/j.addbeh.2016.04.014.
    1. Walton M, Goldstein A, Chermack S, McCammon R, Cunningham R, Barry K, Blow F. Brief alcohol intervention in the emergency department: moderators of effectiveness. J Stud Alcohol Drugs. 2008;69:550–560. doi: 10.15288/jsad.2008.69.550.
    1. McConnaughy E, Prochaska J, Velicer W. Stages of change in psychotherapy: measurement and sample profiles. Psychother Theor Res Pract. 1983;20:368–375. doi: 10.1037/h0090198.
    1. McConnaughy E, DiClemente C, Prochaska J, Velicer W. Stages of change in psychotherapy: a follow-up report. Psychother Theor Res Pract. 1989;26:494–503. doi: 10.1037/h0085468.
    1. Boswell J, Sauer S, Gallagher M, Delgado N, Barlow D. Readiness to change as a moderator of outcome in transdiagnostic treatment. Psychother Res. 2012;22:570–578. doi: 10.1080/10503307.2012.688884.
    1. Dozois DJA, Westra HA, Collins KA, Fung TS, Garry JKF. Stages of change in anxiety: psychometric properties of the University of Rhode Island Change Assessment (URICA) scale. Behav Res Ther. 2004;42:711–729. doi: 10.1016/S0005-7967(03)00193-1.
    1. Litt MD, Shafer DM, Kreutzer DL. Brief cognitive-behavioral treatment for TMD pain: long-term outcomes and moderators of treatment. Pain. 2010;151:110–116. doi: 10.1016/j.pain.2010.06.030.
    1. Barnett NP, Apodaca TR, Magill M, Colby SM, Gwaltney C, Rohsenow DJ, Monti PM. Moderators and mediators of two brief interventions for alcohol in the emergency department. Addiction. 2010;105:452–465. doi: 10.1111/j.1360-0443.2009.02814.x.
    1. Freyer-Adam J, Baumann S, Schnuerer I, Haberecht K, Bischof G, John U, Gaertner B. Does stage tailoring matter in brief alcohol interventions for job-seekers? A randomized controlled trial. Addiction. 2014;109:1845–1856. doi: 10.1111/add.12677.
    1. Grossbard J, Mastroleo N, Geisner I, Atkins D, Ray AE, Kilmer J, Mallett K, Larimer M, Turrisi R. Drinking norms, readiness to change, and gender as moderators of a combined alcohol intervention for first-year college students. Addict Behav. 2016;52:75–82. doi: 10.1016/j.addbeh.2015.07.028.
    1. Kelly A, Zuroff D, Foa C, Paul GP. Who benefits from training in self-compassionate self-regulation? A study of smoking reduction. J Soc Clin Psychol. 2010;29:727–755. doi: 10.1521/jscp.2010.29.7.727.
    1. Lynch K, Van Horn D, Drapkin M, Ivey M, Coviello D, McKay JR. Moderators of response to telephone continuing care for alcoholism. Am J Health Behav. 2010;34:788–800. doi: 10.5993/AJHB.34.6.13.
    1. Mastroleo NR, Murphy J, Colby SM, Monti PM, Barnett NP. Incident-specific and individual level moderators of brief intervention effects with mandated college students. Psychol Addict Behav. 2011;25:616–624. doi: 10.1037/a0024508.
    1. Ouimet M, Dongier M, Di Leo I, Legault L, Tremblay J, Chanut F, Brown T. A randomized controlled trial of brief motivational interviewing in impaired driving recidivists: a 5-year follow-up of traffic offenses and crashes. Alcohol Clin Exp Res. 2013;37:1979–1985. doi: 10.1111/acer.12180.
    1. Project MATCH Research Group Matching alcoholism treatments to client heterogeneity: project MATCH Posttreatment drinking outcomes. J Stud Alcohol. 1997;58:7–29. doi: 10.15288/jsa.1997.58.7.
    1. Stice E, Marti N, Shaw H, O’Neil K. General and program-specific moderators of two eating disorder prevention programs. Int J Eat Disord. 2008;41:611–617. doi: 10.1002/eat.20524.
    1. Derogatis LR. The brief symptom inventory (BSI): administration, scoring and procedures manual. 3. Minneapolis, MN: National Computer System; 1993.
    1. Franke GH. Brief symptom inventory (BSI) Göttingen: Beltz Test; 2000.
    1. Margraf J. MiniDIPS: Diagnostisches Kurz-Interview bei psychischen Störungen [MiniDIPS: Short diagnostic interview for mental disorders] Berlin: Springer; 1994.
    1. DiNardo PA, Barlow DH. Anxiety disorders interview schedule - revised (ADIS-R) Albany, NY: Graywind Publications; 1988.
    1. American Society of Anesthesiologists New classification of physical status. Anesthesiology. 1963;24:111.
    1. Wolters U, Wolf T, Stuetzer H, Schröder T. ASA classification and perioperative variables as predictors of postoperative outcome. Br J Anaesth. 1996;77:217–222. doi: 10.1093/bja/77.2.217.
    1. Charlson ME, Pompei P, Ales K, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987;40:373–383. doi: 10.1016/0021-9681(87)90171-8.
    1. Copeland GP, Jones D, Walters M. POSSUM: a scoring system for surgical audit. Br J Surg. 1991;78:356–360. doi: 10.1002/bjs.1800780327.
    1. Noordzij PG, Poldermans D, Schouten O, Bax JJ, Schreiner FAG, Boersma E. Postoperative mortality in the Netherlands: a population-based analysis of surgery-specific risk in adults. Anesthesiology. 2010;112:1105–1115. doi: 10.1097/ALN.0b013e3181d5f95c.
    1. World Health Organization . Info package: mastering depression in primary care, version 2.2. Copenhagen: WHO, Regional Office for Europe; 1998.
    1. Kroenke K, Spitzer RL, Williams JB, Monahan PO, Loewe B. An ultra-brief screening scale for anxiety and depression: the PHQ–4. Psychosomatics. 2009;50:613–621.
    1. Zigmond A, Snaith R. The hospital anxiety and depression scale. Acta Psychiatr Scand. 1983;67:361–370. doi: 10.1111/j.1600-0447.1983.tb09716.x.
    1. Reinert D, Allen J. The alcohol use disorders identification test: an update of research findings. Alcohol Clin Exp Res. 2007;31:185–199. doi: 10.1111/j.1530-0277.2006.00295.x.
    1. Hautzinger M. Kognitive Verhaltenstherapie bei Depressionen, 6. Auflage [cognitive behavioural therapy for depression, 6th edition] Weinheim: Beltz PVU; 2003.
    1. Margraf J, Schneider S. Panik: Angstanfälle und ihre Behandlung [panic disorders: anxiety attacks and their treatment] Berlin: Springer; 1990.
    1. Becker E, Hoyer J. Generalisierte Angststörung, Fortschritte der Psychotherapie, 25 [Generalized Anxiety Disorder, Progress in Psychotherapy, 25] Göttingen: Hogrefe; 2005.
    1. Stangier U, Heidenreich T, Peitz M. Soziale Phobien: ein kognitiv-verhaltenstherapeutisches Behandlungsmanual [social anxiety disorder: a cognitive behavioural therapy manual] Weinheim: Beltz PVU; 2003.
    1. Lindenmeyer J. Alkoholabhängigkeit, Fortschritte der Psychotherapie, 6 [Alcohol dependence, Progress in Psychotherapy, 6] Göttingen: Hogrefe; 2005.
    1. Graham HL. Cognitive-behavioural integrated treatment (C-BIT): a treatment manual for substance misuse in people with severe mental health problems. Chichester: John Wiley & Sons; 2004.
    1. Bundeszentrale für gesundheitliche Aufklärung [Federal Centre for Health Education] Leitfaden zur Kurzintervention bei Raucherinnen und Rauchern [Guideline for brief interventions for smokers] Köln: BZgA; 2006.
    1. Heidenreich T, Hoyer J, Fecht J. Veränderungsstadien-Skala (VSS) [University of Rhode Island Change Assesment, German version] In: Gloeckner-Rist A, Rist F, Kuefner H, editors. Elektronisches Handbuch zu Erhebungsinstrumenten im Suchtbereich (EHES) version 30 [electronic manual of assessment tools in the addiction field] Mannheim: Zentrum für Umfragen, Methoden und Analysen; 2003. pp. 1–3.
    1. Hoyer J, Heidenreich T, Fecht J, Lauterbach W, Schneider R. Stadien der Veränderung in der stationären Alkoholentwöhnungstherapie [stages of change in alcohol inpatient treatment] Verhaltenstherapie. 2003;13:31–38. doi: 10.1159/000070497.
    1. Derogatis LR, Melisaratos N. The brief symptom inventory (BSI): an introductory report. Psychol Med. 1983;13:595–605. doi: 10.1017/S0033291700048017.
    1. Linnen H, Krampe H, Neumann T, Weiss-Gerlach E, Heinz A, Wernecke K-D, Spies CD. Depression and essential health-risk factors in surgical patients in the preoperative anesthesiological assessment clinic. Eur J Anaesthesiol. 2011;28:733–741. doi: 10.1097/EJA.0b013e3283478361.
    1. Kerper LF, Spies CD, Lößner M, Salz A-L, Tafelski S, Balzer F, Weiß-Gerlach E, Neumann T, Lau A, Glaesmer H, Brähler E, Krampe H. Persistence of psychological distress in surgical patients with interest in psychotherapy: results of a 6-month follow-up. PLoS One. 2012;7:e51167. doi: 10.1371/journal.pone.0051167.
    1. Kerper LF, Spies CD, Buspavanich P, Balzer F, Salz A-L, Tafelski S, Lau A, Weiß-Gerlach E, Neumann T, Glaesmer H, Wernecke K, Brähler E, Krampe H. Preoperative depression and hospital length of stay in surgical patients. Minerva Anestesiol. 2014;80:984–991.
    1. Hayes AF. Introduction to mediation, moderation, and conditional process analysis: a regression-based approach. New York: Guilford Press; 2013.
    1. Hayes AF, Rockwood NJ. Regression-based statistical mediation and moderation analysis in clinical research: Observations, recommendations, and implementation. Behav Res Ther 2016;epub ahead of print: 10.1016/j.brat.2016.11.001.
    1. IBM Corp. Released 2015. IBM SPSS statistics for windows, version 23.0. Armonk, NY: IBM Corp.
    1. Bohart AC, Greaves WA. The client in psychotherapy. In: Lambert MJ, editor. Bergin and Garfield’s handbook of psychotherapy and behavior change. 6. New York, N.Y: John Wiley & Sons; 2013. pp. 219–257.
    1. Moyers TB, Miller WR, Hendrickson SM. How does motivational interviewing work? Therapist interpersonal skill predicts client involvement within motivational interviewing sessions. J Consult Clin Psychol. 2005;73:590–598. doi: 10.1037/0022-006X.73.4.590.
    1. Moyers TB, Rowell LN, Manuel JK, Ernst D, Houck JM. The motivational interviewing treatment integrity code (MITI 4): rationale, preliminary reliability and validity. J Subst Abus Treat. 2016;65:36–42. doi: 10.1016/j.jsat.2016.01.001.
    1. Young J, Beck A. Cognitive therapy scale: rating manual. Philadelphia, PA: Unpublished manuscript, Center for Cognitive Therapy; 1980.
    1. Keeley RD, Brody DS, Engel M, Burke BL, Nordstrom K, Moralez E, Dickinson LM, Emsermann C. Motivational interviewing improves depression outcome in primary care: a cluster randomized trial. J Consult Clin Psychol. 2016;84:993–1007. doi: 10.1037/ccp0000124.
    1. Romano M, Peters L. Evaluating the mechanisms of change in motivatinal interviewing in the treatment of mental health problems: a review and meta-analysis. Clin Psychol Rev. 2015;38:1–12. doi: 10.1016/j.cpr.2015.02.008.
    1. Westra HA, Constantino MJ, Antony MM. Integrating motivational interviewing with cognitive-behavioral therapy for severe generalized anxiety disorder: an allegiance-controlled randomized clinical trial. J Consult Clin Psychol. 2016;84:768–782. doi: 10.1037/ccp0000098.

Source: PubMed

Sponsorer og samarbeidspartnere

Medisinsk tilstand

Legemiddelintervensjoner

3
Abonnere