مداخله آموزش روانی مبتنی بر پذیرش برای کاهش ابراز احساسات در بستگان بیماران مبتلا به اختلال دوقطبی

Abstract Expressed emotion (EE) is a robust predictor of outcome in bipolar disorder. Despite decades of research, interventions to reduce EE levels have had only modest effects. This study used an expanded model of EE to develop an intervention. Research has demonstrated a strong link between attributions and EE in families of patients with psychiatric disorders. There is also substantial research to suggest that anger can drive blaming attributions. Combining these ideas, this study built on previous psychoeducation interventions through the addition of an acceptance component designed to decrease anger and blaming attributions among family members of those with bipolar disorder. Twenty-eight family members attended a 1-day or 2-evening multifamily group workshop and completed a follow-up assessment 1 week later. At follow-up, participants demonstrated more knowledge about bipolar disorder. Anger, blaming attributions, and number of criticisms remained unchanged. Results of this study are consistent with others in that it is difficult to change EE. Implications for future clinical research in this area are addressed.

Results Overview of Analyses Before conducting analyses of hypotheses, participant satisfaction and therapist adherence and competence were examined. Next, distributions were examined for normalcy and outliers. The primary goal of the current study was to determine whether participants demonstrated increased levels of knowledge about bipolar disorder, decreased anger, fewer blaming attributions, and fewer critical comments toward their relative with the illness. To do so, paired dependent t-tests were conducted to examine whether these variables changed from baseline to follow-up. Participant Satisfaction, Therapist Adherence and Competence Workshop participants reported a high degree of satisfaction with the program on the Client Satisfaction Questionnaire (M = 25.26, SD = 2.69, of a total possible score of 28, N = 42) and with the workshop facilitators on the Working Alliance Inventory (M = 75.27, SD = 6.95, of a total possible score of 77, N = 42). Eighty-four percent were very satisfied with the quality of service, 90% felt that the program met their needs, and 97% felt that they would be able to deal with their problem more effectively after the workshop. One participant expressed dissatisfaction that the workshop did not address the process of hospitalization. Some written comments by relatives who participated in the intervention included the following: “In 31 years, I've never discussed my [relative's] disorder and behavior with a group, so it was a great value for me to be open and honest about who he is and what he's done and how I've coped with it”; “It was a great experience for me and I would recommend it to anyone that needs help.” Therapists demonstrated a high degree of competency and strong adherence to the intervention. Across seventapes, the mean score on the Competency Rating Scale was 50.43 (SD = 2.37) out of a possible total of 56. Analyses The pattern of missing data suggested no systematic response bias. That is, missing values were not clustered for a particular variable or for any participant. Missing data were imputed for number of hours spent with relative and age of relative before the workshop using the expectation maximization (EM) method in SPSS Missing Value Analysis software (Little & Rubin, 1987). The percentage of missing data for these variables was 36% and 7%, respectively. This algorithm does not impute missing data for categorical variables. Before conducting tests of hypotheses, univariate distributions for all continuous variables were examined to determine if a transformation of a variable was required. Because distributions mirrored those expected for a relatively healthy community sample, distributions were not transformed. Means and standard deviations of all measures are reported in Table 3. Participants came into the workshop with high levels of knowledge as measured by the UMDQ and mild levels of anger as measured by the STAXI. For nonpsychiatric populations, the mean state anger score for females age 30 and over is 17.50 (SD = 4.52) and for males is 18.43 (SD = 5.63) ( Spielberger, 1988). The majority of families expressed no criticisms at baseline, which is consistent with other studies ( Rein et al., 2006). The number of criticisms was not related to the number of hours spent with the relative (r = .32, p > .10). Summarizing across measures, most people in the sample experienced relatively little anger and tended not to make many criticisms. Table 3. Means, Standard Deviations and Dependent Sample t-tests (N = 28) Measure Pre Means Post Means Mean Difference SE t (27) p Effect size Knowledge 30.12(4.86) 33.89(3.16) − 3.77 0.85 − 4.44 < .001 .79 Feeling Angry 10.57(3.96) 9.40(3.87) 1.17 0.88 1.33 .20 .21 Blaming Attributions 26.85(12.38) 26.07(12.42) 0.79 1.84 0.43 .67 .09 Number of criticisms 0.25(0.44) 0.14(0.45) 0.11 0.13 0.83 .42 .10 Table options Before conducting primary analyses, correlations between the measures administered before and after the workshop were examined (Table 4). Before the workshop, knowledge was negatively correlated with blaming attributions. Anger was positively correlated with blaming attributions. It is noteworthy that the correlation between blaming attributions and number of criticisms was unexpectedly low (r = .02) and not significant. Table 4. Correlations among Measures Before and After the Workshop PREWORKSHOP 1 2 3 4 5 6 7 8 1. Knowledge 1 − .19 − .39* − .20 .44* .06 - .32 − .08 2. Feeling Angry 1 .62** − .06 − .26 .29 .55** .16 3. Blaming Attributions 1 .02 − .16 .09 .69** .41* 4. Number of Criticisms 1 − .11 − .17 .02 − .19 POSTWORKSHOP 5. Knowledge 1 − .17 − .43* .14 6. Feeling Angry 1 .31 .07 7. Blaming Attributions 1 .27 8. Number of Criticisms 1 *p < .05; **p < .01; ***p < .001. Table options Next, the correlations between each measure before and after the workshop were examined. As would be expected, blaming attributions correlated positively. There were moderate correlations between pre- and postworkshop measures of knowledge. Pre- and postworkshop measures of anger and number of criticisms were not correlated. In an examination of the correlations among measures administered after the workshop, blaming attributions remained negatively correlated with knowledge. The relationship between anger and attributions was not significant. Number of criticisms after the workshop did not correlate with any other postworkshop variables. Tests of Hypotheses Using a within-subjects pre-post design, paired dependent t-tests were used to test the hypothesis that after the intervention relatives would demonstrate an increased knowledge of bipolar disorder, less anger about their ill relative, fewer blaming attributions, and fewer critical comments. Analyses demonstrated that knowledge increased significantly (t(27) = - 4.44, p < .001; effect size = .79), but no significant changes were observed in blaming attributions, anger, or in the number of criticisms ( Table 3). In examining the knowledge variable further, the area relatives improved most was knowledge about symptoms of the disorder, t(27) = 4.42, p < .001.