A Psychoeducational Approach to Stress Management...The World Health Organization (WHO) proposed in...

ONDERZOEKSGROEP VOOR GEZONDHEIDSPSYCHOLOGIE

FACULTEIT PSYCHOLOGIE ENPEDAGOGISCHE WETENSCHAPPEN

A Psychoeducational Approach to Stress Management. An Implementation and Effectiveness Study

Tom Van Daele

van de graad van Doctor in de Psychologie

Prof. dr. Omer Van den Bergh, promotorProf. dr. Dirk Hermans, copromotor

Prof. dr. Chantal Van Audenhove, copromotor

2013

Summary

There is a growing emphasis in high-income countries on the importance of mental

health. However, the majority of people in need lack access to professional care and a

significant number of those who do get professional attention, ironically receive

overtreatment. A number of barriers need to be addressed in order to overcome these

issues. These barriers are situated within the general public and the patients

themselves, within the health professionals and within the policy makers. Addressing

them successfully would allow mental healthcare to shift from an instance that

primarily focuses on curing, to one that also pays attention to educating, coaching and

promoting mental health. A first step in achieving this goal is to set up stepped care,

which particularly requires extending the number of primary care interventions (e.g.

psychoeducational group interventions).

In this doctoral dissertation we focused on three policy oriented research topics. A

first topic is effectiveness, as we set out to evaluate the effectiveness of a local

adaptation of a psychoeducational intervention for stress. A matched control design

showed that people participating in the intervention showed a steady linear decline of

stress and symptoms of depression. This improvement could be noticed up until 18

months follow-up and almost 30 percent of all participants experienced a clinically

significant and reliable change. Furthermore, we wanted to gain additional insight in

the overall evidence base for psychoeducational interventions that focus on stress

reduction and we also wanted to chart possible moderators of effectiveness. A

systematic review and meta-analysis was therefore conducted, which reported small

but consistently positive effects of short-term effectiveness. For long-term

effectiveness, results were less pronounced. As for the moderators, brief interventions

for women appeared to be most effective.

A second research topic is implementation, of which the importance became

apparent during the previously mentioned intervention study. A recurring topic for

researchers and partners who collaborate in the field is the dealing with issues of

fidelity and adaptation of interventions. We set out to help address this issue and our

personal experiences combined with a search in literature resulted in the construction

of ‘empowerment implementation’, a framework for implementation research. The

applicability of this framework was demonstrated using the psychoeducational

intervention study mentioned earlier.

A third and final research topic is prediction. We also wanted to investigate whether

we could predict to what extent participants could benefit from our psychoeducational

group intervention. We therefore considered the use of overgeneral memory as such a

predictor. In a first study, we found that the more specific responses participants

provided on the Autobiographical Memory Task (AMT, which has the capacity to

measure overgeneral memory), the more their problem solving strategies increased

during the intervention. Because of these encouraging results, we set out to investigate

whether the AMT could also be used to predict the evolution of a non-treated

population, using the large convenience sample of control subjects from the

effectiveness study. Results showed that, when controlling for baseline symptoms,

overgeneral memory could predict long-term changes for both depression and anxiety

after one year and 18 months.

After detailed reporting on each of these topics, the dissertation concludes with a

general discussion in which a synthesis of the three topics is made. Furthermore,

limitations and future perspectives are highlighted and we also reflect on the

characteristics of a PhD focusing on policy oriented research. Finally, a number of

general and specific policy recommendations are also made.

Samenvatting

In hoge inkomenslanden is er in toenemende mate aandacht voor geestelijke

gezondheid. De meerderheid van de bevolking die met psychische klachten kampt en

die nood heeft aan professionele zorg heeft hier echter geen toegang tot. Van zij die er

wel beroep op kunnen doen, worden er ironisch genoeg een aanzienlijk aantal

overbehandeld. Om deze problemen op te lossen moeten er op verschillende niveaus

barrières worden aangepakt: bij de publieke opinie en de patiënten zelf, bij de

zorgprofessionals en bij de beleidsmakers. Dit kan de geestelijke gezondheidszorg

toelaten om te evolueren van een instantie met als hoofdfocus zorgen en genezen, naar

een die ook aandacht besteedt aan gezondheidspromotie en preventie. Een eerste

belangrijke stap is het implementeren van eerstelijnsinterventies – zoals psycho-

educatieve groepsinterventies – in het kader van de uitbreiding van getrapte zorg.

Dit doctoraat behandelt drie beleidsgerelateerde onderwerpen. Een eerste is

effectiviteit, waarbij we als doel hadden om de effectiviteit van een lokale aanpassing

van een psycho-educatieve groepsinterventie voor stress te evalueren. Een matched

control design toonde aan dat deelnemers een geleidelijke, lineaire daling van stress en

depressieve symptomen vertoonden. Deze verbetering was merkbaar tot anderhalf jaar

na de interventie en in die periode realiseerde zowat dertig procent van de deelnemers

een klinisch significante en betrouwbare verandering. Daarnaast waren we ook

geïnteresseerd in de algemene onderzoeksevidentie van psycho-educatieve

groepsinterventies voor stress en of er moderatoren waren die een invloed hadden op

hun effectiviteit. Een systematische review en meta-analyse vonden kleine, consistent

positieve effecten op korte termijn, maar op langere termijn waren de effecten minder

duidelijk. Wat de moderatoren betreft, leken kortdurende interventies voor vrouwen

het meest effectief.

Een tweede onderwerp is implementatie, een topic waarvan het belang ons

duidelijk werd tijdens het evalueren van de interventie die we eerder vermeldden. Een

terugkerend aspect in de samenwerking tussen onderzoekers en lokale partners bleek

namelijk de ogenschijnlijke tegenstelling tussen (het bewaren van) betrouwbaarheid en

(het toestaan van) flexibiliteit bij het implementeren van interventies. Onze

persoonlijke ervaringen en een literatuurstudie lieten toe om een mogelijke oplossing

voor dit probleem te formuleren: empowerment implementation, een

wetenschappelijk kader voor implementatieonderzoek. De praktische toepasbaarheid

van dit kader werd vervolgens geïllustreerd aan de hand van de psycho-educatieve

groepsinterventie.

Een derde een laatste onderwerp is predictie. We wilden namelijk ook onderzoeken

of het mogelijk was om te voorspellen in welke mate individuele deelnemers baat

hebben van de psycho-educatieve groepsinterventie. We maakten hiervoor gebruik van

overalgemeen geheugen als predictor. In een eerste studie vonden we dat hoe

specifieker deelnemers hun antwoorden konden formuleren op de Autobiografische

Geheugen Taak (AGT, een instrument dat ondermeer overalgemeen geheugen kan

meten), hoe meer hun probleemoplossende strategieën toenamen tijdens de

interventie. Omwille van deze bemoedigende resultaten onderzochten we verder of de

AGT ook een rol kon spelen in het voorspelen van de klachtenevolutie bij personen die

geen behandeling volgden. We konden hiervoor gebruik maken van de aanzienlijke

hoeveelheid data van de participanten die deel uitmaakten van de controlegroep van

de effectiviteitsstudie. Overalgemeen geheugen bleek de langetermijnsevolutie van de

depressieve en angstgerelateerde klachten van deze deelnemers te voorspellen,

wanneer we controleerden voor hun klachten bij aanvang.

Na een gedetailleerd overzicht van elk van deze onderwerpen wordt de

doctoraatsverhandeling afgerond met een algemene discussie waarin we tot een

synthese komen van deze drie onderwerpen. Vervolgens worden de beperkingen van

de huidige studies opgelijst, samen met suggesties voor toekomstig onderzoek. We

staan daarna nog even stil bij de karakteristieken van een doctoraat met als focus

beleidsrelevant onderzoek om uiteindelijk ook een aantal algemene en specifieke

beleidsaanbevelingen te formuleren.

vii

Contents

1 General introduction ........................................................................... 1

1 Mental health in high income countries ............................................ 1

2 The current challenges for successful mental healthcare .................. 4

3 A paradigm shift from curing to educating, coaching and

promoting ......................................................................................... 11

4 The aim of this PhD ........................................................................... 29

Research Topic 1 : Effectiveness

2 Stress Reduction through psychoeducation: a meta-analytic review.. 33

1 Introduction ...................................................................................... 34

2 Method ............................................................................................. 40

3 Results .............................................................................................. 43

4 Discussion ......................................................................................... 49

5 Limitations and directions for future research ................................. 50

3 Effectiveness of a six session stress reduction program for groups ...... 53

1 Introduction ...................................................................................... 54

2 Method ............................................................................................. 56

3 Results .............................................................................................. 61

4 Discussion ......................................................................................... 66

Research Topic 2 : Implementation

4 Empowerment implementation: enhancing fidelity and adaptation in a

psychoeducational intervention ......................................................... 73

1 Introduction ...................................................................................... 74

2 Empowerment implementation ....................................................... 78

Contents

viii

3 Example: implementation of a psychoeducational group

intervention ...................................................................................... 83

4 Discussion ......................................................................................... 90

5 Conclusion ........................................................................................ 91

Research Topic 3 : Prediction

5 Reduced memory specificity predicts the acquisition of problem solving

skills in psychoeducation.................................................................... 95

1 Introduction ...................................................................................... 96

2 Method ........................................................................................... 100

3 Results ............................................................................................ 104

4 Discussion ....................................................................................... 107

6 Overgeneral autobiographical memory predicts changes in depression

and anxiety in a community sample ................................................ 111

1 Introduction .................................................................................... 112

2 Method ........................................................................................... 117

3 Results ............................................................................................ 120

4 Discussion ....................................................................................... 121

7 General discussion ........................................................................... 125

1 Research topics and main results ................................................... 126

2 Limitations and future perspectives ............................................... 133

3 Characteristics of the research in this PhD ..................................... 142

4 Specific implications and general policy recommendations .......... 145

ix

List of Tables

Table 1 Operationalization and descriptive statistics for moderators ......... 37

Table 2 Summary of studies included in the review .................................... 42

Table 3 Moderator values and effect sizes for psychoeducational and stress

reduction programs ...................................................................................... 45

Table 4 Effects for moderators ..................................................................... 47

Table 5 Sociodemographics for intervention group and matched control

group in percent ........................................................................................... 62

Tabel 6 Evolution of intervention group and matched control group ........ 63

Tabel 7 Changes in self-reported complaints after course participation ... 105

Tabel 8 Means and standard deviations on the different categories of the

autobiographical memory test ................................................................... 106

Table 9 Hierachical Linear Model and results of DASS-21-subscales of

depression and anxiety as the dependent variables. ................................. 119

Table 10 Descriptive statistics for the DASS-21-subscales of depression and

anxiety. ....................................................................................................... 120

xi

List of Figures

Figure 1. The mental health intervention spectrum (National Research

Council & Institute for Medical Research, 2009). ......................................... 13

Figure 2. Flow chart of the search strategy .................................................. 43

Figure 3. Overall effects of the interventions on stress at posttest ............. 48

Figure 4. Overall effect of the interventions on stress at follow-up ............ 48

Figure 5. Comparison of DASS-scores between participants with a low- and

high-level baseline of complaints. ................................................................ 65

Figure 6. Relationship between the AMT percentage of specific memories

and the SAD-MEPS change score for number of means. ........................... 107

Figure 7. Relationship between policy, research and practice. .................. 143

1

Chapter 1

General introduction

1 Mental health in high income countries

The World Health Organization (WHO) proposed in 2005 that “there is no

health without mental health” (WHO, 2005, p.11). This statement illustrates the

growing emphasis in high-income countries on the importance of not only a

healthy body, but also a healthy mind. But what is mental health exactly?

Among the many definitions available, Maercker and Zoellner (2004, p.42)

consider mental health a broadly termed construct “... defined as a processing

function not only to feel good about oneself, but also to develop good social

relationships; engage in productive, creative work; and combat subsequent

stress effectively”. The WHO (2001, p. 1) seems to concur with this point of

view and defines mental health “as a state of well-being in which every

individual realizes his or her own potential, can cope with the normal stresses of

life, can work productively and fruitfully, and is able to make a contribution to

her or his community”. When one or more of these conditions are not met,

people face mental illness.

If such symptoms arise, the Diagnostic and Statistical Manual of Mental

Disorders (DSM-IV-TR, American Psychiatric Association, 2000) and the

International Classification of Diseases (ICD-10, World Health Organization,

2008) are classification systems that can be used to diagnose common mental

disorders like depression and anxiety. Approximately 50% of the US-population

meets criteria for one or more of these mental disorders in their lifetime,

whereas about 25% of the population meets criteria in any given year (Kessler

& Wang, 2008). However, prevalence rates have high variability among

countries. Because recent WHO studies showed that the highest prevalence

estimates were documented in the United States of America (Kessler et al.,


2

2009), these numbers should therefore be interpreted with caution. European

data are available both from population studies and from primary care settings.

In ESEMeD, a European population study, Alonso et al. (2007) found a more

modest number compared to that of the United States, with a lifetime

prevalence of around 26% and a prevalence rate in the past year of almost

12%. Among all disorders, the most common mental disorders in the past year

were anxiety disorders (6%) and mood disorders (4%). Although it may seem

sensible to think that the actual prevalence rates are somewhere in-between

the American and European ones, there are several reasons to assume that

these still gravely underestimate the total rate of psychological dysfunction in

the population.

A first reason is that several specific criteria are required in order to be

officially diagnosed with a mental disorder. When failing to meet only one

criterion, the person’s state would not be considered a mental disorder, but

would still be associated with dysfunction or impairment. For depression, for

example, there is a vast amount of evidence indicating that a dimensional

approach is more valid than a categorical approach (Blatt, 1974; Haslam, 2003,

Kendler & Gardner, 1998; Ruscio & Ruscio, 2000; Solom et al., 2001, cited in

Luyten & Blatt, 2007). Several authors have therefore already suggested that,

at least for this disorder, arbitrary consensus-based cut-off criteria should be

open to re-evaluation (Brown & Barlow, 2005; First, 2005; Luyten & Blatt,

2007). A second point is made by Moffit et al. (2010), who remark that

prevalence rates are often, if not always, determined using retrospective

studies. However, such studies may undercount lifetime prevalence rates due

to recall failure. In order to test this hypothesis, a prospective longitudinal

study was conducted that determined the prevalence of lifetime disorder up to

the age of 32 for anxiety and depression. Results showed that the prevalence

rates were approximately doubled in prospective as compared to retrospective

data for both disorder types. In general, there are strong indications that a vast

Chapter 1

3

part of the population is at least once in their lifetime confronted with some

form of mental illness. Such a confrontation should not be taken lightly as

mental disorders have a substantial contribution to disease. Their impact can

be measured in terms of disability-adjusted-life years (DALYs), which is an

integrative measure of overall disease burden (Murray & Lopez, 1996).

Worldwide, depression currently accounts for one tenth of all DALYs, which is

similar to the 11% DALYs attributed to cancer (Prince et al., 2007). Projections

of global mortality and burden of disease expect depressive disorders to be one

of the three leading causes by 2030, together with HIV/AIDS and ischemic heart

disease (Mathers & Loncar, 2006).

When primary care settings are considered in particular, screening is

sometimes done here using the Diagnostic Manual of Mental Disorders Primary

Care Version (DSM-IV PC; American Psychiatric Association, 1995), but as

Williams, Noël, Cordes, Ramirez, and Pignone (2002) point out, more often

short instruments are used like the Beck Depression Inventory (BDI; Beck,

Ward, Mock, & Erbaugh, 1961), the Centre for Epidemiologic Studies

Depression Scale (CES-D; Radloff, 1977) or the Patient Health Questionnaire

(PHQ-9; Spitzer, Kroenke, & Williams, 1999). Although these instruments

strictly cannot be used to diagnose mental disorders, these are often used as

provisional ways of detecting them. Similar prevalence rates can also be found

here, with depression in the past year for example between 1% and 10%

(Bartholomeeusen, Kim, & Mertens, 2005; Lamberts, Oskam, & Hofman-Okkes,

1994). The reason why these numbers appear lower compared to the larger

epidemiological studies might be twofold. On the one hand general

practitioners (GPs) can use slightly different criteria to determine specific

mental disorders, which do not always correspond to those of manuals like the

DSM-IV-TR. Furthermore, GPs have to be vigilant for a very wide range of

(mental) disorders, some of which have low prevalence and incidence rates in

the population and therefore might go undetected (Buntinx et al., 2004). On


4

the other hand, on average 69% of patients with depression and 76% of

patients with mood or anxiety symptoms only report physical problems (De

Lepeleire, 2011). During a consult, time is often limited and both patients and

GPs have to prioritize which issues to address. When such competing demands

are present, physical complaints receive more attention compared to

psychological complaints (Klinkman, 1997), which reduces the number of

detections of mental disorders.

In conclusion, mental disorders have a significant impact on the general

population, and these are only expected to increase in the following decades.

This outlook is especially relevant for healthcare in high-income countries.

Although prevalence rates are also similar in low-income countries, the main

priority there remains to address communicable diseases, whose share and

impact is a much larger compared to high-income countries (WHO, 2010). For

these high-income countries, mental healthcare (MHC) may already make up a

larger portion of the healthcare system, but an additional increase in the

number of people affected and seeking help should still be anticipated.

2 The current challenges for successful mental healthcare

Even when more conservative numbers are considered it appears that the

majority of people with mental disorders lack access to professional care.

Currently, less than one in three receives treatment (Bebbington et al., 2000a;

Bebbington et al., 2000b, Kessler et al., 2005). In addition, a number of people

who are currently receiving treatment might not even need professional help.

Lauber, Nordt, and Rössler (2005) presented mental health professionals with a

vignette depicting either a person with schizophrenia, major depression or

without any psychiatric symptoms (a ‘non-case’). For this non-case, over 50%

proposed medical help, i.e. additional consults with psychologists and GPs.

Although a vignette study implies a hypothetical scenario and is therefore not

completely similar to real-life situations, it does provide an indication that in a

Chapter 1

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number of cases there might be a potential overtreatment in the absence of

relevant symptomatology. A study by Tiemeier et al. (2002) that specifically

aimed at the treatment of depression, showed more positive results, with only

around 10% overtreatment. Such studies highlight the importance of reducing

overtreatment, which implies – for one – a more accurate detection of mental

disorders. However, the number of people who actually need help, but are

lacking treatment is an even larger problem. Addressing this issue proves to be

complex, as there are some barriers that need to be overcome. These barriers

are situated at several levels: within the general public and the patients

themselves, within the health professionals at the primary care level and within

the policy makers. Each of these levels will be briefly discussed.

2.1 The general public and the patients

At the level of the general public, there are two main reasons as to why people

are not receiving the necessary treatment: The first reason is a lack of

knowledge. A relevant concept in this context is ‘mental health literacy’, which

is defined as “the knowledge and beliefs about mental disorders which aid their

recognition, management or prevention” (Jorm et al., 1997, p. 182). More

specifically, mental health literacy consists of several components including

knowledge and beliefs about risk factors and causes, available interventions,

the possibility to recognize specific disorders, attitudes towards help seeking,

and knowledge of how to seek information. One example of an intervention

used to address this issue is the Australian ‘beyondblue’ campaign. In order to

increase mental health literacy, public awareness activities were set up in a

number of states, including the distribution of posters, pamphlets and

postcards, a website with information, television advertising, advertisements in

print media, and educational videos (Morgan & Jorm, 2007). When initiatives

like ‘beyondblue’ are undertaken, the main idea is that this will lead to

increased help seeking (Goldney & Fisher, 2008). The evidence for this claim is


6

mixed. Overall, such campaigns are successful, as different studies show that in

recent years the public has gained more knowledge about causes and available

interventions (Angermeyer & Matschinger, 2005; Jorm, Christensen, & Griffiths,

2005a), that they have become better at recognizing mental disorders

(Goldney, Fisher, Dal Grande, & Taylor, 2005; Jorm, Chirstensen, & Griffiths,

2005b) and that willingness to seek professional help has also increased

(Angermeyer & Matschinger, 2005; Mojtabai, 2007). However, it seems

questionable that these changes also had an impact on the general attitude

towards people with mental illness. A study by Angermeyer, Holzinger, and

Matschinger (2009) showed that in recent years the desire for social distance

from people with depression even somewhat increased.

Knowledge alone seems insufficient, and therefore, there is also a second

main reason why people are not receiving the necessary treatment: negative

attitude. A large study by Lasalvia et al. (2012) conducted in 35 countries

showed that nearly eighty percent of people with MDD reported some

experiences of discrimination and almost one third stopped themselves from

doing something important in their life because of stigma or discrimination.

Stigma can therefore be considered a serious barrier to social participation and

to help seeking (Corrigan, Larson, & Rusch, 2009; Fuller, Edwards, Procter, &

Moss, 2000). There are nevertheless ways to reduce the reticence of the

general public to participate in preventive group interventions, for example

through awareness campaigns and mass social contact interventions that aim

to reduce (self-) stigma. One example is ‘Time to Change’, the largest anti-

stigma campaign in the UK ever (Henderson & Thornicroft, 2009). It did not

have a strong focus on educating, but rather aimed at mass level social contact

events through which members of the public with and without mental health

problems engage with each other in order to reduce discrimination and stigma.

There is already preliminary evidence that such interventions can work on a

mass level (Evans-Lacko et al., 2012). Combined with mental health literacy

Chapter 1

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programs, such an approach may help to overcome barriers at the level of the

general public.

2.2 The health professionals

Health professionals at the primary care level, like GPs, pharmacists and

community facilitators can all play a role in the early detection, referral and

care of people with mental disorders. However, these tasks require knowledge

or skills, which sometimes appear to be lacking. Some studies have already

shown that about half of patients with depression in primary care are not

detected (Cepoiu et al., 2008) and that professionals in primary care require

guidance to address the social needs of depressed patients (Barley, Murray,

Walters, & Tylee, 2011). The rate of success varies according to the background

of the health professional. GPs can for example adequately detect depression

in most of their patients, with around 10% missed and 15% false positives

(Mitchell, Vaze, & Rao, 2009). On the other hand, 73% of pharmacists in a

Belgian study by Scheerder, De Coster, and Van Audenhove (2008) indicated

their lack of education in mental health issues being a barrier for providing

depression care. Finally, mental health issues are rarely a part of the education

of most community facilitators like clergy, police officers and teachers. For

them, there is a clear need for training in mental health issues (Farrell &

Goebert, 2008; McCrae et al. 2005; Vermette, Pinals, & Appelbaum, 2005;

Walter, Gouze, & Lim, 2006), just as there is for nurses (Ayalon, Area &

Bornfeld, 2008). However, like for the general public, providing knowledge is

not sufficient. Attention also has to be paid to the attitude of professionals. A

number of studies have already shown that GPs – despite their above average

knowledge of mental health – do not hold fewer stereotypes compared to the

general public (Lauber, Nordt, & Rössler, 2006) and seem less optimistic about

prognosis and long-term outcomes (Caldwell & Jorm, 2001). Similar results

have been found for pharmacists (Scheerder et al., 2009). Finally, the opinion


8

of nurses seemed overall in line with those of GPs, although they are generally

more favourable towards the use of psychotherapy (Lauber et al., 2005).

As for addressing these issues, different interventions exist that incorporate

both knowledge and attitude change, like a Dutch GP training program by van

Os et al. (2002), which showed – among others – increased knowledge, a

limited (non significant) increase in the recognition of mental disorders and

significantly more patients receiving treatment according to clinical guidelines.

Similar other interventions seemed to be successful in supporting GPs (Hodges,

Inch, & Silver, 2001), nurses (Eisses et al., 2005), pharmacists (Bell, Whitehead,

Aslani, Sacker, & Chen, 2006) and the police (Watson, Corrigan, & Ottati, 2004)

in their role as gatekeepers for mental health.

2.3 Policy

One way to reduce the incidence of mental disorders, or to at least reduce their

impact, is through prevention and mental health promotion. There is strong

research evidence for the benefits of prevention, especially when physical

conditions are considered. This is partially reflected in the policies of the high-

income countries. Initiatives that require little effort and/or are mandatory

have high compliance rates. By means of vaccination, for example, over 90% of

parents take action to protect their children from infectious diseases like

diphtheria, tetanus and pertussis (WHO, 2011). Preventive interventions that

require more complex behaviour, like systematic screening in the case of breast

cancer prevention, or making lifestyle changes to avoid metabolic syndrome,

are far more difficult to achieve (Ahlin & Billhult, 2012). Furthermore,

evaluating the merits of such interventions is difficult, and substantial time may

be required before effects are noticed and interventions ‘pay off’. These are

just some of the reasons that can account for why the budget for the

prevention of non-communicable diseases is rather small, compared to that of

sick care. The Organisation for Economic Co-operation and Development

Chapter 1

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(OECD), comprising twenty high-income economies, estimates that on average

3% of the total health expenditure goes towards prevention, while the most is

spend on sick care (OECD, 2010).

When the MHC budget of any European country is considered, it is dwarfed

by the total healthcare budget. More specifically, around 6% is on average

spent on mental health. Within these constrained conditions, mental health

promotion and the prevention of mental disorders have to operate. Drawing

parallels with the prevention of physical conditions, not surprisingly, the

available budget is minuscule: about or below 1% of the total MHC budget

(Regional Office for Europe of the World Health Organization, 2010). It goes

without saying that such limited funding hampers the development of

preventive interventions and is certainly one of the main reasons for the

lagging of preventive interventions in the field of mental health. However,

these data can also be interpreted in a positive way, as a significant part of the

strong focus on sick care can actually be tackled at a policy making level. For

example, if for any European country efforts lead to a shift or reallocation of

0.06% of the total healthcare budget to the field of the prevention of mental

disorders, this would instantly double the available means. Such actions could

certainly have a strong impact on the field of prevention and the development

or improvement of preventive initiatives.

2.4 Conclusion

There are a number of barriers, outlined above, that hamper the access for

people with mental disorders to professional care. A lack of knowledge and

attitude in the general population, patients and professionals can be overcome

through targeted interventions. Furthermore, at a policy level, more attention

should be paid to the limited resources an important sector like MHC has to

deal with. More resources could for example be used to increase the number

of healthcare providers that – even with the small number of people actually


10

seeking treatment – are already actually overwhelmed by requests for help.

However, solely increasing the number of healthcare providers does not

seem to be a valid solution. In most areas of primary care, short appointments

are offered to a large number of patients. This is often referred to as ‘low

contact, high volume’. Psychological therapies, on the other hand, offer one-to-

one interventions of substantial duration to relatively few patients. These are

‘high contact, low volume’ interventions (France, 1995, cited in Brown,

Boardman, Whittinger, & Ashworth, 2010). For both types of intervention, the

number of people in need greatly outrank the number of MHC professionals, in

the USA even at 107 to one (Hoge et al., 2007). This makes it impossible to

reach all of those in need. Even doubling the work force might have little

impact (Kazdin & Blase, 2011). One of the major topics in the current mental

health policy therefore remains to create easily accessible facilities for people

with mental health problems (WHO International Consortium in Psychiatric

Epidemiology, 2000).

One way to improve the access to and efficiency of MHC is through a

stepped-care approach. This represents an attempt to maximize the efficiency

of resource allocation in therapy. Low threshold and low cost interventions are

offered first, and more intensive and costly interventions are reserved for those

who are not sufficiently helped by the initial intervention (Everaert, Scheerder,

De Coster, Van Audenhove, 2007; Haaga, 2000). Studies that compared the

effectiveness of a stepped care approach with care as usual (CAU) have shown

that stepped care is more effective in reducing the risk of onset of mental

disorders (van‘t Veer-Tazelaar et al., 2009) and is equally effective as CAU in

treating mental disorders (van Straten, Tiemens, Hakkaart, Nolen, & Donker,

2006). Intensive and costly interventions are already well established (Andrews,

Issakidis, Sanderson, Corry, & Lapsley, 2004), but a further extension of the

portfolio of models of delivery for primary MHC is needed. When extending the

portfolio, attention should be paid not only to effectiveness of interventions,

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but also to the aspects of their dissemination and implementation. Most of all

however, such an extension can only be successful if it is embedded in a

broader paradigm shift. The MHC system currently has a strong focus on

curating and although this is helpful for a substantial number of people, the

sector will need to move out of its comfort zone in order to better reach all of

those in need. This requires – at least partially – moving from curing to

educating, coaching and promoting mental health which will be highlighted in

the next chapter.

3 A paradigm shift from curing to educating, coaching and

promoting

The suggested paradigm shift for MHC in which the sector moves from curing

to educating, coaching and promoting mental health is not only reasonable

from a practical point of view, but can also be supported from theory. We will

first take a look at some theoretical background. Subsequently, a number of

aspects that are characteristic for the new paradigm will be highlighted,

followed by some methodological implications when studying interventions

within this new paradigm.

3.1 The theoretical background

The main rationale for implementing a new paradigm actually lies in how

mental disorders are classified. Throughout the years, there has been

increasing support for a shift from a categorical to a dimensional view on

mental disorders. Unfortunately, there is only some support for this view in the

new, fifth edition of the Diagnostic and Statistical Manual of Mental Disorder

(DSM-V). However a consensus has appeared in the discussions concerning its

controversial conceptualization (Uher, 2012), which Brown and Barlow (2005)

formulate as follows: “current psychosocial treatments have become overly


12

specialized because they focus on disorder-specific features … neglecting

broader dimensions that are more germane to favourable long-term

outcomes”. In their opinion, higher order dimensions could be incorporated in

the DSM, representing general vulnerabilities, which would make the

instrument become highly relevant to the primary and secondary prevention of

mental disorders. Stein et al. (2010) continue on this line of thought and

indicate that the distinction already has eroded between psychopathology and

normal psychological phenomena (e.g. sadness after a major stressful event).

Such a dimensional view on mental disorders therefore implies an extended

focus beyond sick care, with an increase in the share of prevention and early

intervention in MHC.

If the mental health intervention spectrum is considered however (Figure

1), most of our efforts are still in the ‘treatment’ category, whereas the

categories ‘promotion’ and ‘prevention’ have previously received only limited

attention (Muñoz, Cuijpers, Smit, Barrera, & Leykin, 2010). There is however

substantial evidence that mentally healthy adults – individuals who were free

of a mental disorder in the past year and were flourishing – miss less days of

work, have the healthiest psychosocial functioning, the lowest risk of

cardiovascular disease, the lowest number of chronic physical diseases with

age, the fewest health limitation of activities of daily living and lower

healthcare utilization. The prevalence of flourishing is only twenty percent in

the adult population, though (Keyes, 2007). Making the efforts to create a

more accessible and extended primary care is therefore a logical step, but

should not be noncommittal, as more is involved than merely increasing the

existing portfolio of services. In view of the paradigm shift, the position of MHC

organizations in society actually evolves from instances that primarily treat, to

services that (also) provide guidance and education. By changing MHC and

offering an increased number of primary care services, MHC can convey a

strong and positive message: mental health is more than the absence of mental

Chapter 1

13

illness and everyone can learn how to maintain or improve his or her mental

health. However, for those who struggle and who need additional help or

guidance, individual ambulatory consultation or even residential treatment is

still available.

Figure 1. The mental health intervention spectrum (National Research Council

& Institute for Medical Research, 2009).

3.2 A paradigm shift: characteristics of a new approach

Shifting from one paradigm to another is not something that can happen

overnight, it is rather a gradual effortful process, as the new paradigm has to

build on existing systems and structures. In order to successfully extend

primary care services and give them a clear focus, there are a few

characteristics of the current paradigm that impede such a shift and therefore


14

require to be changed. These are highlighted below and some suggestions are

also made as how to successfully overcome each of them.

3.2.1 From referral to self-referral

In general, when people experience mental health problems and seek

professional help, the first person they turn to is their GP. Not surprisingly, a

large proportion of a GPs’ daily workload consists of ‘common’ mental health

problems like depression and anxiety (Goldberg & Huxley, 1992). A significant

part of their primary care function in MHC involves prescribing medication

(Metaforum, 2010) and referring to psychological therapies (National Institute

for Clinical Excellence, 2009; cited in Brown, Boardman, Whittinger, &

Ashworth, 2010). However, only less than half of the GPs actually refer to such

therapies, a study of elderly GPs in the UK has shown (Collins, Katona, & Orrell,

1997). One of the main reasons for this limited referring is a lack of knowledge

about the different psychological therapies that are available. Furthermore,

GPs face daily challenges of urgent and competing demands for their limited

attention and resources (Lin, Simon, Katzelnick, & Pearson, 2001). In such

circumstances, prescribing medication takes only little effort and often also

meets the demands of the patient, who is looking for a ‘quick solution’ and

might not be interested in (costly) time consuming psychological therapies.

However, taking depression as an example, antidepressants are not that

effective in treating mild to moderate depression (van der Lem, van der Wee,

van Veen, & Zitman, 2012). So, in the long run, complaints may aggravate,

patients return to their GPs. More intensive (psychological) treatments are

required and also preferred by the patient at that point (Raue, Schulberg,

Moonseong, Klimstra, & Bruce, 2009; Steidtmann et al., 2012).

For the reasons mentioned above, targeted referral to interventions in the

field of primary MHC has not yet reached its full potential. An alternative way

for people to participate in such interventions is therefore often through self-

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referral: an intervention is promoted to the general public and attracts self-

registering community dwellers. This approach has some advantages: people

are for example not required to disclose their issues to their GP or anyone else

in order to participate, which otherwise might create an additional threshold

(Mischoulon et al., 2001). The people who are attracted by these interventions

and make use of self-registration can nonetheless have very different profiles.

If they already have elevated levels of complaints and decide to self-refer to a

low-intensity primary care intervention, the intervention might not fully meet

their needs. This furthermore also creates high heterogeneity in the participant

population, which is not beneficial for the group of participants as a whole.

Still, the benefits of self-referral do not seem to outweigh those of

professional referral. Therefore, it would still be preferred to further stimulate

specific referral of potential participants. One way is by informing (mental)

health professionals like GPs on the effectiveness of preventive interventions

and how to detect patients who are eligible for participation (Lin et al., 2001).

3.2.2 From individual to collective approaches

Individual psychotherapy is currently the dominant model of treatment

delivery (Kazdin & Blase, 2011). In a confidential setting, a therapeutic alliance

is created between a therapist and a patient in which they jointly try to

overcome the issues the patient presents him- or herself with. As mentioned

earlier, however, this is a very time consuming approach that is not really

suitable for preventive interventions, which need to reach a vast amount of

people. An alternative is therefore a collective approach, which allows one

professional to simultaneously reach a large group of individuals. Well-known

examples are stress management courses (Van Daele, Hermans, Van

Audenhove, & Van den Bergh, 2012) and (childhood) depression prevention

programs (Stice, Shaw, Bohon, Marti, & Rohde, 2009), where the professional is

considered the teacher and the participants are students. Such approaches


16

may entail certain benefits, aside from the more effective use of the limited

means available. Validation and social comparison offer the opportunity for

participants to see that they are not struggling alone. They may also learn

additional tips and tricks from other participants, and when in need of

assistance, they can also reach out to fellow participants for social support

(Burlingame, 2010). Not only have such interventions proven to be effective,

but because of the efficient use of resources, they also offer good value for

money (Mihalopoulos, Vos, Pirkis, & Carter, 2012; Van Daele et al., 2012).

Despite these advantages, the attractiveness of group preventive

interventions remains limited. There are a number of aspects that may account

for this, and an important one highlighted earlier is the stigma related to

mental health issues. As previously mentioned, there are nevertheless ways to

reduce the reticence of the general public to participate in preventive group

interventions. One way to do this is through awareness campaigns and mass

social contact interventions that aim to reduce (self)-stigma (Evans-Lacko et al.,

2012).

3.2.3 From traditional psychological treatment to education and skill

training

‘Traditional’ psychological treatments start with patients seeking help for

specific problems. These initial problems give treatments a clear focus: the

target for patients is to learn how to deal with them or how to overcome them.

When they manage to do so, in a second phase, they can use the acquired

knowledge or skills to further optimize and improve their quality of life.

Guidance by a professional is at this point not really necessary, but rather

optional and a matter of personal choice. Preventive (group) interventions

work the other way around. The initial focus of such interventions is quite large

and not specific: participants do not necessarily have specific complaints or

symptoms, and even when they do, these are (preferably) still subclinical.

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Contrary to traditional psychological treatment, people who participate in

group preventive interventions are not required to share their deepest

thoughts or feelings in group or with anyone in particular. During the

intervention they are rather considered students, who are educated and who

receive general information, for example on stress or depression. Furthermore,

they are taught skills to deal with both future and current problems. Although

these techniques can also be highly specific, teachers do not explicitly

determine which techniques should be used in which situations and leave this

up to the participants. When participants actually have to face their problems,

no professional is present to provide guidance. With their background

information and the techniques they have learned, participants are at that

point expected be able to manage their issues themselves.

Preventive (group) interventions therefore require a substantial amount of

initiative from individuals. A theoretical model like Prochaska and Diclemente’s

(1985) ‘Stages of Change’ can be used to illustrate this. In the first phase, which

is coined ‘precontemplation’, individuals are unaware of the fact that their

mental well-being is at risk and are not motivated to deal with their problems.

In a second phase, which is known as the ‘contemplation’ phase, participants

have to acknowledge they are lacking skills or information to adequately deal

with their everyday problems and that their problems might get out of hand if

no action is undertaken. In a third phase, ‘preparation stage’, individuals take

some limited action. Because this action is not systematic or coordinated,

success is varying. At this point, individuals are susceptible for initiatives like

preventive (group) interventions. If information on the intervention reaches

them and there are no additional barriers to enrolling, they can become

participants. Specific obstacles can for example be attitudes, norms, perceived

control, self-efficacy, habits, etc. (Reasoned Action Approach, Fishbein & Ajzen,

2010). The next phase, ‘action’, comprises the actual intervention. Individuals

need to participate and invest a significant amount of time and energy in


18

learning how to deal with these (future) problems. In the fifth and final phase,

‘maintenance’, what was taught and learned during the intervention should be

kept in mind and trained, in order to prevent relapse.

It goes without saying that undertaking an endeavour as described above

without additional encouragement and support from peers or professionals,

requires substantial self-insight, problem solving skills, and courage. Ironically,

these are just the qualities that the people who are most in need of such

interventions are lacking and that the interventions are intended to help foster.

A relevant concept in this context is ‘empowerment’. Empowerment can be

defined as "… an intentional, ongoing process through which people lacking an

equal share of valued resources gain greater access to and control over those

resources". It offers individuals the opportunity to gain control over their lives

and over democratic participation in the life of their community (Berger &

Neuhaus, 1977, cited in Zimmerman & Rappaport, 1988). Empowerment

recognizes the vulnerabilities and limitations of individuals, but primarily

focuses on their potential and strengths. Empowering in MHC implies 1) a

positive basic attitude and 2) suitable participation. A positive basic attitude

implies that all people have an inherent capacity to learn, grow, and change.

Professionals should be open, available and respectful towards their patients. A

hierarchical relationship is not imposed, because the goal is to establish a true

partnership. Suitable participation means that deciding on treatment or help is

a collaborative effort which is established through an intensive dialogue

between professionals and help seekers (Van Regenmortel, 2009). Yet again,

the importance of competent referrers, preferably (mental) health

professionals like GPs, is therefore emphasized. Together with peers and family

and by listening to people who seek help, they can stimulate and motivate

potential participants by giving them the necessary information and courage to

deal with their problems.

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3.2.4 Illustrations of primary care interventions in line with this new

paradigm

There are a number of primary care interventions that fit well within this new

paradigm. Two categories will be discussed and for both categories one

example will be highlighted.

Group interventions. A first category of primary care interventions are group

psychoeducational interventions, whose goal is twofold: transfer of knowledge

and the acquisition of skills. Both goals are aimed at in group sessions and

through homework assignments. Groups can be drawn from school classes,

associations, companies, primary healthcare units, or neighbourhood

organizations. In some cases, groups are even self-registered through media

advertisements. Psychoeducation can be considered an independent

intervention within the framework of a cognitive-behavioural approach.

According to Bäuml, Froböse, Kraemer, Rentrop, and Pitschel Walz (2006) a

‘proper’ group psychoeducational approach has the following characteristics:

teaching should be key, while other techniques – as relaxation, for example –

only serve to support these teaching activities. The teaching is provided

through standardized, non-individualized formats for each participant. During

the course, participants first receive information about the topic and how to

cope with it. In a second phase, they independently need to process and

implement this information. Although they are empowered to apply the

information to their personal lives and to develop skills that can help to

improve their situation, it is the responsibility of each participant to put into

practice what has been learned in the psychoeducational course.

One example is a psychoeducational intervention for stress called ‘Stress

Control’, a local adaptation of a program developed by White (2000; adaptation

by ISW-Limits, 2006). Psychoeducational interventions for stress are aimed at

reducing (perceived) stress, rather than preventing it. Nevertheless, these can


20

still be considered as preventive interventions, for instance, given the link

between high levels of stress and the subsequent onset of mental disorders like

depression (van Praag, 2004). This specific intervention comprises six weekly

lessons of two hours. In these lessons participants are offered general

information on stress and related psychopathology, and are learned basic self-

help tips and techniques for short-term stress reduction. Examples are

controlling bodily sensations through progressive relaxation and breathing

exercises, cognitive techniques like challenging dysfunctional thoughts, and

also some practical techniques on problem-solving and ending safety

behaviours. Through homework assignments participants learn to apply the

general information to their own personal situation, and to create a

personalized frame of reference for the course content.

Online self-help interventions. Online self-help interventions fall under e-

mental health, which can be seen as “… a generic term to describe the use of

information and communication technology – in particular the many

technologies related to the internet – when these technologies are used to

support and improve mental health conditions and mental healthcare” (Riper et

al., 2010). E-mental health interventions have proven to be effective, efficient

and cost-effective for depression, anxiety, posttraumatic stress, eating

disorders and a wide variety of other forms of psychopathology (Griffiths,

Farrer, & Christensen, 2010). Most of the time, interventions are based on

cognitive-behavioural therapy (CBT; Andrews, Cuijpers, Craske, McEvoy, &

Titov, 2010), although recently the first studies based on psychodynamic

therapy have also been conducted, which show similar positive results for

depression and anxiety (Andersson, et al. 2012; Johansson et al., 2012). In

addition to treatment, e-mental health interventions can also be used for

prevention and in primary care, in which they have a large potential to reduce

disease burden primarily because they permit a low-cost, widespread

dissemination (Christensen & Hickie, 2010). Their delivery can occur through a

Chapter 1

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partnership within existing primary care structures (Hickie et al., 2010) or

through a virtual clinic environment supervised by health professionals

(Andrews & Titov, 2010). The first option has the advantage of being a part of

the regular mental health services and can also offer a first step towards access

to more traditional person-based services for those who might not otherwise

seek care (Ruggiero et al., 2006). The latter has the advantage of anonymity

and easy access for people who experience stigma concerning their mental

health problems. Both options are not mutually exclusive as an intervention

can be tailored for both delivery methods.

One example is the ‘Kleur je Leven’ (Colour your Life) intervention.

Originally developed by the Trimbos Institute and based on the

psychoeducational ‘Coping with Depression’ course (Cuijpers, Muñoz, Clarke, &

Lewinsohn, 2009), a Flemish version has been adapted by ISW-Limits (2009).

Participants can enrol independently on http://www.kleurjeleven.be or can be

targeted towards the intervention by their GP. This online cognitive

behavioural self-help intervention helps them cope with mild to moderate

depressive feelings. In eight weekly lessons (and one booster session)

participants are taught insights and skills to deal with depressive feelings. The

website makes use of streaming video material of ‘models’ (actors playing

participants), voice-overs, interactive exercises, a mood diary, homework and a

workbook. Each lesson has a fixed structure in which 1) the topic of the lesson

is introduced, 2) the participant completes a questionnaire on the homework

from the previous lesson, and 3) the curriculum with some assignments is run

through. Afterwards 4) instructions are delivered for the new homework

assignment and 5) the lesson is evaluated. The specific knowledge and skills

consist of: 1) information concerning the origin of depressive complaints and

the relationships between, thinking, acting and feeling, 2) techniques to

improve relaxation, 3) techniques to plan and undertake more fun activities, 4)

techniques to reduce worrying, 5) skills in constructive thinking, through


22

detecting mood deteriorating thoughts and challenging these in order to

improve participant’s mood, 6) skills in coping with problems experienced with

(significant) others, and 7) increased assertiveness by expressing feelings and

thoughts and standing up for themselves (ISW Limits, 2009).

3.3 The methodological implications when studying primary care

interventions like group interventions

There are roughly two different ways of conducting research to determine the

effects of interventions similar to the ones described above: in carefully

controlled clinical trials or in a more applied context. The first, focusing on

efficacy is known for its high internal validity, but results are more difficult to

generalize. The latter, paying attention to effectiveness is high on external

validity, but is not as carefully controlled. Efficacy has primarily been favoured

by the research community, whereas the practice community prefers

effectiveness (Stricker, 2000). Because research is often conducted in highly

controlled academic settings, the efficacy of most interventions is well

documented. There is however a sharp contrast with the limited knowledge as

to how effective they are in everyday practice. Over the years, there has been

an increasing demand for research that bridges this gap (Glasgow, Lichtenstein,

& Marcus, 2003) and that evaluates the effectiveness of interventions (Jane-

Llopis, Hosman, & Saxena, 2004). This requires additional implementation in

real-life circumstances. When primary care interventions are evaluated

however, a number of issues that hamper the research process can be

encountered: not only for the actual implementation of the intervention, but

also for the interpretation of results. A number of these issues, both from

literature and own experience, are highlighted below.

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3.3.1 The participant profile

People who are attracted by a preventive group intervention can have very

different profiles. Without systematic screening, a group may for example

include participants who are simply interested in learning about a specific

mental health problem, but also those who already have elevated symptoms

and are hoping for quick symptom reduction. The variety of participants’

interests matches the variety of goals of these interventions, because their

main focus is not on curing, but rather on educating and giving people the

necessary support and tools to self manage and safeguard their mental health.

Because such interventions are often set-up in the local community with local

partners, this provides a low threshold for participation. Participants can

therefore easily commence such a course, but when the intervention does not

meet their expectations, they can also as easily cease to participate and drop

out.

Furthermore, within the group of participants, mixed results are often

obtained. Some participants can show strong declines in symptoms and

experience great benefits, whereas the symptoms of others remain stable or

even deteriorate (Van Daele et al., 2012). Because an intervention can also

attract a large number of participants who choose to follow the course out of

curiosity, this translates in few cases with quite low symptom profiles at

baseline, possibly causing floor effects. An intervention might therefore have

seemingly little effect, both in the short and in the long term. In such case, it

would nevertheless be premature to conclude that the intervention is

ineffective, because also for this particular subgroup of participants, there may

be long-term advantages. When they are facing life events or aversive

conditions in the future, they may be able to rely on knowledge from the

intervention to better cope with them. Because of the low frequency of such

events, it is however difficult to measure such effects. In conclusion, the

participant profile for effectiveness studies has two main challenges for


24

researchers: 1) to have a clear idea of which participants are attracted by a

specific intervention and 2) to try to accurately predict the effectiveness for an

intervention not as a whole, but for the individual participant.

3.3.2 Determining intervention effects

Because of this divergent participant profile, there may also be some unclarity

as to when an intervention is considered successful. Without a doubt, the most

suitable outcome for a preventive intervention should be the long-term

reduction of the probability of (the targeted) mental disorder for intervention

participants. This requires follow-up of sufficiently long duration. Because

means are typically limited, follow-up periods are often insufficiently long to

fully measure the effects of a preventive intervention. Therefore, the short-

term reduction of (secondary) symptoms like stress, worrying, or ruminating

are also considered, as high levels of these symptoms are known to precede

more serious forms of psychopathology. A combination of both short-term (not

necessarily lasting) and long-term effects being measured and documented is

to be preferred (Stice et al., 2009).

3.3.3 A suitable research design

The randomised controlled trial (RCT) is often referred to as the ‘gold standard’

of research designs, the most convincing form of evidence to show that an

intervention is truly effective (Oxford Centre for Evidence-Based Medicine,

2011). The concept behind RCTs is simple: study participants are randomly

assigned to an intervention or a (waiting list or placebo or non-intervention)

control group. Subsequently, one or multiple changes are applied to the

intervention group (for example participating in a stress management course),

whereas all other factors are held constant for the control group. Comparing

measures before and after a period of intervention administration

subsequently allows for causal inferences of intervention effectiveness. The

Chapter 1

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methodology of an RCT basically mimics the methodology of laboratory

experiments, implying full control of the environment of the participant and

truly random (and blinded) allocation of participants to the experimental

conditions.

There is no reason to contest the use of an RCT, if the context allows it. In

the context of applied knowledge of primary care interventions, however, an

RCT is sometimes not preferable or possible. However, valuable alternatives

exist. Examples are the matched control design, the interrupted time-series

(ITS) design or the multiple baseline design. In a matched control design

participants from the intervention group are matched with controls based on a

number of variables believed to be confounders (Rothman & Greenland, 1998).

An important step in this design is the selection of confounding variables to use

as matching variables, as a wrong match may result in a loss of efficiency (Rose

& van der Laan, 2008). Time-series design makes use of a string of consecutive

observations which are interrupted by the introduction of an intervention to

see whether the slope or level of the series changes following the intervention

(Shadish, Cook, & Campbell, 2002). This design is especially appropriate when it

is known at what specific point an intervention will occur in prospective

studies, or when it occurred in retrospective studies (Mercer, DeVinney, Fine,

Green, & Dougherty, 2007). Finally, a multiple baseline design is a form of ITS

design, most often used during the development of interventions, when

combinations of components within effective interventions are being tested

(Biglan, Ary, & Wagenaar, 2000). For a multiple baseline design it is crucial to

have instruments that are suitable for repeated measurements and to have a

clear idea what a stable baseline, is and how far apart intervention should be

staggered (Mercer et al., 2007). As highlighted above, just like with the RCT,

these designs have their strengths and merits in specific situations, but they

also require a number of conditions to be met in order to produce valid results.

These designs can therefore be revalued for intervention studies in the field of


26

prevention by giving more and explicit attention to the design aspects, for

example by using tools like the ‘TREND Statement’ (Des Jarlais, Lyles, Crepaz, &

the Trend Group, 2004). This checklist is designed for intervention evaluation

studies using nonrandomised designs and emphasizes 1) describing of the

intervention, 2) including the theoretical base, 3) describing of the comparison

condition, 4) full reporting of outcomes and 5) inclusion of information related

to the design needed to assess possible biases in outcome data. The ultimate

goal is to improve the quality of data reporting in peer-reviewed publications

so that the conduct and findings of studies are transparent. This in turn could

lead to an increased appreciation of non-randomised intervention studies as a

valid source for evidence-based practice and also allows for comparable

information across studies to be more easily consolidated and translated into

general knowledge and practice.

3.3.4 The implementation considerations

When pre-developed interventions are implemented in real-life contexts, there

is a strong tension between the principles of fidelity and adaptation. The

concept of ‘implementation fidelity’ refers to “the degree to which an

intervention or program is delivered as intended” (Carroll, 2007). Specifically, a

successful implementation is one that abides four components of fidelity:

adherence, exposure, quality of program delivery, and participant

responsiveness (Dane & Schneider, 1998). Mihalic (2002) describes each of

these components as follows: 1) ‘adherence’ refers to whether interventions

are delivered as intended, 2) ‘exposure’ refers to the number of sessions

implemented, session length, frequency of implementation of program

techniques, 3) ‘quality of program delivery’ refers to the manner in which staff

delivers a program, and 4) ‘participant responsiveness’ refers to the extent to

which participants are involved in program content. Hasson (2010) has

suggested two additional factors that moderate implementation fidelity,

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notably ‘recruitment’ and ‘context’. The concept of 5) ‘recruitment’ refers to

procedures that are used to attract potential program participants, whereas 6)

‘context’ refers to surrounding social systems, such as structures and cultures

of groups, inter-organizational linkages, and historical as well as concurrent

events. All these factors should be evaluated when conducting a process

evaluation. On the other hand, focusing on fidelity has also been criticized for

being rigid, as it assumes full compliance with the program as prescribed by the

program developer (Gresham et al., 2003). The fact that any change to the

program made by implementers is considered a bias and a threat to

implementation quality is at odds with the value placed on stakeholder

involvement and participation in health promotion (World Health Organization,

1986; Levy, Baldyga, & Jurkowski, 2003). An alternative approach to program

implementation is therefore to encourage adaptation rather than limit it. When

an intervention is implemented in the field, this therefore requires careful

balancing both principles. It is even more important when the implementation

of an intervention is also combined with evaluating its effectiveness. In such a

context, any unwanted or undocumented change to the intervention could

inadvertently lead to the invalid conclusion that an intervention is less effective

than it really is.

3.3.5 The importance of process evaluation

When an intervention is adapted, it is subjected to subtle changes. Therefore,

an important part of intervention research is the process evaluation. This is

necessary to understand the intervention results and enables program

management and accountability, which are essential to effective

implementation (Bartholomew, Parcel, Kok, & Gottlieb, 2011). This is especially

relevant when an intervention is evaluated in the field, because the research

component, which is necessary during the evaluation, is not always present

during standard implementation. There will therefore often be a slight


28

difference between an intervention which is being investigated and the one

that is afterwards broadly disseminated. This points at the importance of

carefully considering factors that might influence outcomes and otherwise

could lead to faulty conclusions. A process evaluation of a study can help to

overcome these issues and bring some clarity.

As an illustration, one important aspect to consider in the research on

primary care interventions is the determinants of non-participatory behaviour.

The rationale for such analysis was found in a study by Brouwer et al. (2009),

who evaluated the motivation for people to use an online cognitive-

behavioural intervention. According to them – and in line with McGuire’s

(1985) ‘Persuasion Communication Matrix’ and Rogers’ (2003) ‘Diffusion of

Innovation theory’ – the following determinants for participating were

applicable: 1) user characteristics, 2) intervention characteristics, and 3)

characteristics of the source. Azjen (1988) found that user characteristics

comprise personal characteristics (like age and gender), individual cognitions

(like attitudes, perceived control and the intention to participate) and

motivation. Characteristics of the intervention are complexity, first impressions

and advantages for participating and finally, characteristics of the source are

credibility and reliability. Aside from typical barriers for primary care

interventions, which were highlighted in the previous chapter, performing

research on these interventions adds additional barriers. As for user

characteristics, some potential patients might for example have a negative

attitude towards research. Although these attitudes are generally positive,

some people do not prefer to participate in research, primarily because of a

fear of the unknown and resentments towards randomisations (Madsen et al.,

2002). These randomisations, a typical characteristic of intervention research,

might also be one of the most radical differences between an intervention with

and without a research component. As this implies the possibility of a waitlist

control, an alternative (placebo) treatment or a non-intervention control, this

Chapter 1

29

can create a threshold for people who might initially be interested, but are

reluctant to participate in the prospect of ‘possibly ending up in the wrong

condition’. Finally, as for the characteristics of the source: when conducting an

intervention with a research component, a research centre is often involved,

which might not be well known to the public, or might appear to be less

reliable or credible as opposed to other primary care services. This may scare

away potential participants. This is one of the easiest barriers to remedy, as a

strong involvement of partners in the field, also in the promotion and

communication concerning the study, may help overcome this issue.

4 The aim of this PhD

As highlighted earlier, the choice for an increase in primary care interventions

is a bare necessity, as it may help to address to continuing lack of professional

care for a significant amount of people with mental health issues. Furthermore,

it also helps to facilitate a paradigm shift, in which a more positive view of

mental health is portrayed and people learn how to rely on their own strengths

and skills in order to safeguard their mental health.

A main goal of this PhD was to evaluate the effectiveness of a local adaptation

of a psychoeducational intervention for stress. As such primary care

interventions are still a rare commodity in Flanders, this effectiveness trial

could provide policy makers with relevant, local information as to how such

interventions perform in their local contexts. However, the goal of the PhD

extended beyond this. Aside from the evaluation of the Stress Control course,

we also wanted to gain additional insight in the overall evidence base for

psychoeducational interventions that focus on stress reduction. Therefore we

decide to conduct a systematic review of the literature, followed by a meta-


30

analysis. The results of both endeavours are a first part of the publications,

labelled ‘effectiveness’.

During the evaluation, we were also confronted with several implementation

issues. These made us reconsider how researchers and their partners in the

field collaborate. We thought about how their (sometimes conflicting) views

could be reconciled, while still maintaining the high standards of scientific

research. This tension between adaptation and fidelity during intervention

implementation, and how to resolve it, is discussed in the second part of the

publications, labelled ‘implementation’.

As a third point of attention, an attempt was made to predict individual success

for intervention participants. The autobiographical memory task, a measure for

autobiographical memory specificity, was used to predict individual changes in

problem solving skills for intervention participants. Furthermore, this measure

was also explored as a possible tool to predict the evolution of mental health in

a natural context, for individuals from the general population. Both attempts

are discussed in greater detail in the third part of the publications, labelled

‘prediction’.

31

Research topic 1

Effectiveness

Van Daele, T., Hermans, D., Van Audenhove, C., & Van den Bergh, O. (2012). Stress

reduction through psychoeducation: a meta-analytic review. Health Education &

Behavior, 39, 474-485. doi: 10.1177/1090198111419202

Van Daele, T., Van Audenhove, C., Vansteenwegen, D., Hermans, D., & Van den Bergh,

O. (2013). Effectiveness of a Six Session Stress Reduction Program for Groups.

Manuscript submitted for publication

33

Chapter 2

Stress reduction through psychoeducation: a meta-

analytic review

The aim of this meta-analysis was to evaluate the effectiveness of psychoeducational

interventions in reducing stress and to gain more insight in determining features

moderating the magnitude of effects. Relevant studies were selected from 1990 to

2010 and were included according to predetermined criteria. For each study, the

standardized mean difference was calculated for the outcome measure primarily

related to stress. Nineteen studies met the inclusion criteria; for 16 studies,a

standardized mean difference could be calculated. The average effect size was .27 (95%

confidence interval = *.14, .40+) at posttest and .20 (95% confidence interval = *−.04,

.43]) at follow-up. To determine possible moderators of intervention effects, all 19

studies were included. Only interventions that were shorter in duration provided better

results. When a model with multiple moderators was considered, a model combining

both intervention duration and the number of women in an intervention was significant

and accounted for 42% of the variability found in the data set. Specifically, interventions

with more women that were shorter in duration obtained better results.

Keywords

meta-analysis, psychoeducation, reduction, review, stress

Stress reduction through psychoeducation

34

1 Introduction

Worldwide, people of different ages and backgrounds are facing stress.

Researchers found a vast increase of stress for adults as well as teenagers and

children in the past decade. As an example, nearly a quarter of the respondents

who were interviewed by the American Psychological Association (APA) for

their annual national stress report indicated they were experiencing a high

level (8, 9, or 10 on a 10-point scale) of stress (APA, 2009). In 2010, about 44%

of the Americans said they had experienced an increase in stress over the past

5 years (APA, 2010). Although a certain amount of life stress is inevitable and

can be beneficial for an individual, it is now widely acknowledged that chronic

stress is a major health burden, both physically and mentally. High levels of

self-perceived stress are, for example, closely related to the metabolic

syndrome (Chandola, Brunner, & Marmot, 2006), to coronary heart disease

(Rosengren et al., 2004), and to ischemic stroke (Jood, Redfors, Rosengren,

Blomstrand, & Jern, 2009). There is also a clear link between high levels of

stress and the subsequent onset of mental health disorders such as depression

(van Praag, 2004; Wang, 2004). One way to improve the efficiency and access

to MHC is through stepped care, in order to use healthcare resources at an

optimal level. Low-cost interventions are offered first, and more intensive and

costly interventions are reserved for those who are not sufficiently helped by

the initial intervention (Haaga, 2000). Because intensive and costly

interventions are already well established (Andrews, Issakidis, Sanderson,

Corry, & Lapsley, 2004), further extension of primary MHC through

interventions with low financial and accessibility thresholds are needed

(Bebbington, Brugha, et al.,2000; Bebbington, Meltzer, et al., 2000). A

technique often used to manage stress is psychoeducation. The goal of

psychoeducation is to help people acquire competencies to manage stress and

Chapter 2

35

preserve their mental health. The transfer of knowledge and the acquisition of

skills are reached in individual encounters, in group sessions, and/or through

homework assignments. Preventive psychoeducation is primarily offered to

groups. Oftentimes healthcare providers make use of group sessions, but the

Internet or self-help groups are also valid options. Groups can be drawn from

school classes, associations, companies, primary healthcare units, or

neighborhood organizations. In some cases, groups are self-registered through

media advertisements.

Psycheducation can be considered an independent intervention within the

framework of a cognitive–behavioural approach (Bäuml, Froböse, Kraemer,

Rentrop, & Pitschel-Walz, 2006). In line with these authors, we adopted the

following criteria for what should constitute a ‘proper’ group

psychoeducational intervention: Teaching should be key, whereas other

techniques — such as relaxation, for example — only serve to support these

teaching activities. The teaching is provided through standardized, non-

individualized formats for each participant. During the course, participants first

receive information about stress and how to cope with it. In a second phase,

they independently need to process and implement this information. Although

they are empowered to apply the information to their personal lives and

develop skills that can help improve their situation, it is the responsibility of

each participant to put into practice what has been learned in the

psychoeducational course. Psychoeducational interventions for stress are

aimed at reducing (perceived) stress rather than preventing it. Nevertheless,

these can still be considered as preventive interventions, given, for example,

the link between high levels of stress and the subsequent onset of a mental

health disorder such as depression (van Praag, 2004). Preventive

psychoeducation, in general, has been the subject of a large number of

reviews, but the main focus has mostly been the prevention of depression in

specific populations, such as children and adolescents (Andrews & Wilkinson,


36

2002; Gladstone & Beardslee, 2009; Merry, 2007; Merry, McDowell, Hetrick,

Bir, & Muller, 2004; Merry & Spence, 2007; Neil & Christensen, 2009).

Sometimes adults are targeted (Barrera, Torres, & Muñoz, 2007), even though

reviews on the effects of psychoeducation on stress have typically focused on

occupational stress (van der Klink, Blonk, Schene, & van Dijk, 2001). The

present meta-analysis will focus on psychoeducation for the reduction of stress

in the general population (i.e., participants with no predetermined or specific

[risk for] pathology). Both overall effects and specific moderators of effects will

be analyzed. For the latter, the study of Stice, Shaw, Bohon, Marti, and Rohde

(2009) has been used as a source of inspiration. In their review, a broad array

of features that may influence the effectiveness of interventions to prevent

depression were listed. Given their relevance for our purpose, most of these

moderators were retained and few new moderators were added. All

moderators, their descriptions, and coding are listed in Table 1. They can be

classified in three categories: 1) participant features: gender (percentage of

females), ethnicity (percentage of Whites), age (in years); 2) intervention

features: relaxation, intervention duration (in hours), whether the intervention

makes use of homework, group size (N in each group), whether there is room

for interaction between teacher and students and among students; and 3)

design features: randomization (whether participants were randomly assigned

to intervention and control conditions) and follow-up duration.

1.1 Gender

It is hypothesised that interventions including a high number of women will

produce larger effects. Women typically report more stress than men (Matud,

2004). It seems plausible that their high levels of initial stress and the stronger

need for stress relief would make it easier to find improvements in stress

responses, not only because of the effect of regression on the mean but also in

terms of actual improvements.

Chapter 2

37

Table 1 Operationalization and descriptive statistics for moderators

1.2 Ethnicity

There is a clear connection between ethnicity and (work) stress, independent

of work characteristics and sociodemographic, socioeconomic, and

occupational factors (Smith et al., 2005). As with gender, it is hypothesised that

groups with higher number of non-Whites will produce larger effects, because

of the higher initial level of stress.

1.3 Age

The targeted interventions cover a large age span. It is well known that there is

a steady increase in cognitive abilities from adolescence into adulthood.


38

Studies have furthermore shown that older adults are also more effective in

solving everyday problems (Blanchard-Fields, Mienaltowski, & Seay, 2007).

Because knowledge and skill transference require well-developed cognitive

abilities, a linear relationship between age and intervention is expected, right

up until early old age.

1.4 Relaxation

Various psychoeducational interventions include a relaxation component. Very

early on, the relevance of relaxation for stress reduction was already illustrated

by Carrington et al. (1980). Further research consolidated these finding, for

example, Esch, Fricchione, and Stefano (2003). Based on the evidence in the

literature, we hypothesize that interventions including this component will be

more effective.

1.5 Intervention Duration

The more time spent working on and learning about stress and stress-related

problems, the more knowledge transfer and skill development is expected to

ensue. We therefore expect a linear relationship between duration and

effectiveness.

1.6 Homework

We hypothesize that homework assignment will add beneficial effects,

especially for longer lasting interventions. This may enhance consolidation of

acquired knowledge, induce skill training, and bridge the gap between the

learning context and real life.

Chapter 2

39

1.7 Group Size

We hypothesize that students in smaller groups will be less distracted, more

involved, and have more possibilities to ask questions and receive additional,

personally relevant information. Therefore, interventions that make use of

small group sizes are expected to generate larger effects compared with

interventions with large groups, similar to effects found in classroom situations

(Ehrenberg, Brewer, Gamoran, & Willms, 2001).

1.8 Interactive

In some types of interventions there is room for interaction during the sessions

among group members. This aspect may work both ways: either it may

enhance social support mechanisms, create modeling effects, and so on, or it

may create an environment in which the participant feels pressure to open up

to fellow participants and/or the teacher. The latter may create tension that

subsequently interferes with the learning process. In general, it nevertheless

appears that interaction is beneficial during the learning process (King, 1990).

Therefore, we hypothesize that interventions in which interaction is present

will produce larger effects than interventions in which interaction is absent.

1.9 Randomization

We hypothesize that studies in which participants were randomly assigned to

the intervention and control conditions will produce smaller effect sizes. The

adequate and equal distributions of participants to the different conditions

provide perfect control for evolutions in the intervention group. This is a

superior alternative to research designs with nonrandomised controls and


40

minimizes allocation bias and possible confounding factors, both known and

unknown (Moher et al., 2010).

1.10 Follow-Up Duration

Similar programs typically produce the strongest effect sizes at posttest,

followed by a gradual decrease at each follow-up assessment (Stice, Shaw, &

Marti, 2007). We therefore hypothesize that the later on the follow-up is

conducted, the smaller the reported effect sizes will be.

In sum, the goal of this review is to provide an overview of the short- and long-

term effectiveness of psychoeducation for stress and their possible

moderators.

2 Method

2.1 Search Strategy

A comprehensive search on the literature was set up. First, major database

search engines were used, including MEDLINE, Web of Knowledge, Wiley

Interscience Journals, PubMed, Cochrane Library, Ovid, and Embase, to search

with predefined keywords. A detailed table with the keywords can be found in

the appendix. Second, relevant journals were searched by hand. These included

the International Journal of Stress Management, Work and Stress, and Anxiety,

Stress and Coping. Additionally, references of the studies included were

searched by hand, together with available reviews. If necessary elements for

data analysis were missing, authors were contacted for additional information.

Chapter 2

41

2.2 Inclusion Criteria

To identify relevant studies on the effectiveness of psychoeducation, that is,

having a focus on transmitting information on stress in a teaching format,

seven search criteria were determined. To be eligible a study had to be

published in the past 20 years (January 1990 to January 2010), had to be

published in an international (English language) journal, and needed to have a

preventive aim with a main focus on stress. Furthermore, each study had to

include a valid outcome measure of stress. Finally, it had to use methodology

that included quantitative longitudinal measurement and a quasi-experimental

or experimental design with a control condition. No participant age–related

exclusion criterion was used for any of the interventions.

2.3 Statistical Methods

2.3.1 Overall effect size estimation

As a primary outcome measure, the scores on different scales all measuring

(perceived) stress were used and were evaluated in a similar way to earlier

work by Martin, Sanderson, Cocker, and Hons (2009). Treatment effect sizes

were calculated using Hedge’s g, later on referred to as standardized mean

difference (SMD). This is the difference between posttreatment means, divided

by the pooled standard deviation, with adjustment for small sample bias. Each

study was coded so that a positive SMD indicated a superiority of the

intervention Group over the comparison group. Overall effect size was

calculated using the RevMan program (The Cochrane Center, The Cochrane

Collaboration, Copenhagen, Denmark). A random effects model was preferred

to a fixed effects model for the meta-analysis. Because not all the interventions

and outcome measures were exactly the same, this was the most suitable

method for evaluating the overall effect size (Higgins & Green, 2008).


42

Table 2 Summary of studies included in the review

2.3.2 Moderator analysis

Moderators were analyzed for the following: 1) participant features: gender

(percentage of females), ethnicity (percentage of whites), age (in years); 2)

intervention features: intervention content (knowledge transition, skill

transition, relaxation), intervention duration (in hours), whether the

intervention makes use of homework, group size (N in each group), whether

there are booster sessions, whether there is room for interaction between

Chapter 2

43

teacher and students; and 3) design features: follow-up duration. All data

concerning the moderators were entered into SAS software (version 9.1, SAS

Institute, Cary, NC). Because moderators are possibly confounded, analyses

were not only undertaken for each moderator separately but also for the group

of moderators as a whole using a sample size weighted regression model. If the

effect size was not reported, it was generated from the available data using

ClinTools (version 4.1; Devilly, 2005).

3 Results

3.1 Search Results

The search strategy generated 221 studies that met the inclusion criteria. The

inclusion and exclusion processes are summarized in Figure 2. Due to the large

scope of the search strategy, many of the initially retrieved studies were not

retained. Sixty-one articles appeared relevant after an initial screening, of

Figure 2. Flow chart of the search strategy


44

which 44 were excluded after closer inspection for not meeting one or more of

the predefined inclusion criteria. Finally, 17 articles – accounting for 19

studies – were accepted. Sixteen were used in the effect size estimation,

whereas all 19 studies could be included for the moderator analysis, which

required less stringent preconditions. Table 2 presents a brief summary of all

the studies included with a description of the sample and the intervention, the

intervention group size, the relevant outcome measure, and general findings.

3.2 Effect Size Estimation

The SMDs at posttest for each of the 16 studies included are presented in

Figure 2. These varied from a small negative effect of −.03 to a large effect of

.89. An overall positive effect was found. The inverse variance weighted SMD

was small, but significant with an SMD of .27 (95% confidence interval [CI] =

[.14, .40], p < .0001). Alternatively, effect sizes were also weighted using their

sample size (N). This produced similar results, with an SMD of .21 (95% CI =

[.12, .30]). Statistical heterogeneity is assessed using I2, a common method for

measuring the magnitude of between-study heterogeneity. Higher

heterogeneity makes it more difficult to interpret results. Generally,

percentages of around 25%, 50%, and 75% are considered, respectively, as low,

medium, and high heterogeneity (Huedo-Medina, Sanchez-Meca, Marin-

Martinez, & Botella, 2006). In this case, with 35%, medium statistical

heterogeneity is present. The study by Kirby, Williams, Hocking, Lane, and

Williams (2006) compared multiple interventions with the same control group.

Because this could introduce bias in the results, a sensitivity analysis was

undertaken. In this analysis, only the intervention with the most

comprehensive treatment group was included. This produced a similar overall

result with an SMD of .27 (95% CI = [.13, - .41]), indicating that including all

three Kirby et al. (2006) studies does not bias the results.

Chapter 2

45

Tab

le 3

Mo

de

rato

r va

lue

s an

d e

ffe

ct s

ize

s fo

r p

sych

oe

du

cati

on

al a

nd

str

ess

re

du

ctio

n p

rogr

ams


46

Another form of bias is publication bias. To take this into account, a weighted

‘fail-safe N’ statistic was calculated using Fail-Safe Number Calculator, a

software program based on the methods described in Rosenberg (2005).

Rosenberg’s fail-safe number using a random effects model was 22.8,

indicating at least 23 unpublished studies finding no effect would be needed to

produce an overall noneffect. Not all the aforementioned studies included a

follow-up measurement. The overall effect size estimation for relevant studies

can be found in Figure 3. Effect sizes varied from −.10 to .78. Contrary to the

results at posttest, the effect was not overall positive. Only a small effect was

found, and the results had a high amount of statistical heterogeneity (I² = 73%),

which makes them difficult to interpret. In general, the conclusion is that there

is mixed evidence when it comes to the long-term effects of psychoeducational

interventions for stress.

3.3 Moderator Analysis

When the results for the effect size estimation are taken into consideration,

there is little difference between weighing according to inverse variance and

weighing according to sample size. Therefore, we opted to weigh according to

sample size for the moderator analysis, taking benefit of the fact that all 19

studies – of which the sample size was known, but not always the variance –

could be included in the analysis. A schematic overview of the moderator

values and effect sizes for each study can be found in Table 3. Results of the

regression analysis are presented in Table 4.

Chapter 2

47

Table 4 Effects for moderators

3.3.1 At posttest

One moderator reached significance at posttest: ‘Intervention duration’.

Contrary to what could be expected, studies that evaluated interventions that

were short in duration found significantly better effects. When a model with

multiple moderators was considered, a model combining both intervention

duration and the number of women in an intervention was significant and

accounted for 42% of the variability found in the data set. Specifically,

interventions with more women that were shorter in duration obtained better

results. Other (combinations of) moderators did not produce significant effects.

3.3.2 At follow-up

A moderator that has a certain amount of variance and therefore still can be of

particular interest is ‘Time of follow-up since course end’. Apparently there is a

negative relationship between the follow-up effect found and the duration of

the follow-up (p < .0001). This could mean that psychoeducation does not

stand the test of time and beneficial effects tend to fade out. Moderator

effects found for follow-up results should be interpreted with caution though,

due to the small number of studies and the limited variance across the studies.

For the latter reason, no conclusions can be drawn for the – significant –


48

moderators ‘Participant Ethnicity’, ‘Participant Age’, and ‘Follow-up Duration’.

As with the effect size estimation, a sensitivity analysis was conducted for the

Kirby et al. (2006) studies. Again, all reported estimates were within the

confidence intervals reported in Table 4. As such, it could be concluded that

inclusion of the three Kirby et al. studies did not create bias.

Figure 3. Overall effects of the reviewed interventions on stress at posttest

Figure 4. Overall effect of the reviewed interventions on stress at follow-up

Chapter 2

49

4 Discussion

The first question was whether psychoeducational interventions are effective

in reducing stress. The effect sizes reported in this review are small, but

consistently positive, indicating effectiveness for this type of psychoeducation.

The overall effect (SMD = .27) is larger than in similar meta-analyses, for

example, the study by Martin et al. (2009) on the effects of health promotion

interventions for depression and anxiety symptoms (SMD = .05) or the study by

Stice et al. (2009) on depression prevention programs for children and

adolescents (r = .15). Learning about stress and extending techniques to cope

with it seems to contribute positively to mental health.

Despite a large variety in intervention formats, it appears that

psychoeducation is effective for people of varying ages, from different

backgrounds, and with different interests to follow a psychoeducational course.

Some remarks do have to be made, though. First, the results at follow-up are

relatively weak (SMD = .20) and – on average after 6 months – the confidence

interval of the overall SMD even reaches a negative effect size. This is contrary

to the idea that psychoeducational interventions provide people with skills to

continuously improve their mental health. On the other hand, because only

half of the reported studies record follow-up data, the evidence base for this

conclusion is in itself much weaker.

The second question was whether there were characteristics of a

psychoeducational intervention that would make it less or more effective. Only

intervention duration appeared as a significant moderator. A model including

intervention duration and participant gender explained 42% of the variance in

effects. Apparently, short lasting psychoeducational interventions for women

are most effective. These results are correlational. Therefore, we refrain from

making firm causal interpretations and advancing specific suggestions for

interventions. Several findings require further research: 1) Women appear to

benefit more than men from this type of intervention. This suggests that these


50

interventions should therefore primarily target women and that seeking an

alternative approach for men would be premature. This should be further

investigated, preferably in an RCT, dividing men and women at random over an

intervention group and a waiting list control/placebo/alternative approach

group. 2) Shorter interventions obtain better effects, which is contradictory to

what was hypothesised originally. Future research could focus on two

alternative hypotheses: that a shorter intervention is more effective in

transferring a set of knowledge and skills than a longer lasting intervention and

that people who opt to participate in shorter interventions generally benefit

more from this type of intervention because of specific characteristics. With

the worldwide expansion of primary care, preventive interventions for groups

that are short lasting and easily accessible are quickly emerging. Although

mostly focusing on depression, stress-related interventions are also on the rise.

Together with this rise, a clear need emerges for evaluating the effectiveness of

these interventions. The goal of this review was to provide some insight in the

nature of these interventions and their target groups, as well as to map what is

currently subject to research. Last, but not least, some additional, more general

recommendations for future research are provided.

5 Limitations and directions for future research

The major limitation is that this article made use of published articles only. This

may have made the review prone to bias, as interventions finding no effect

probably are not easily reported. Still, some nuance can be made. Although

sometimes controversial, the failsafe N statistics does provide a certain ground

to account for publication bias. The reported results are considered relatively

solid, given the large number of studies reporting no effect needed, to

generate an overall non effect.

Another limitation is the design used in (some of) the reported studies.

Chapter 2

51

Follow-up measurements are paramount when trying to assess long-lasting

(behavioral) changes. Without them, there is no way to know whether

interventions do add something substantial to the lives of participants or

whether they only scratch the surface. As such, this review is also a plea to

include at least one follow-up measurement in any design that intends to

evaluate an intervention with the potential for realizing long-lasting change.

The initial setup required including only RCTs. Therefore, most of the

control groups are waitlist controls or no treatment controls. Although

sometimes an alternative program was set up as a pastime, the current

evaluation cannot compare psychoeducation with other means of intervention

and conclude psychoeducation is to be preferred. We can only state that it is

more effective in reducing stress than undertaking no action at all.

Our recommendation concerning the information reported in articles is

especially interesting in light of moderator analyses. It would be considered a

big advantage for meta-analyses if these would move beyond reporting

standard information such as average age of participants and their gender and

also start including other characteristics that are not commonly reported, such

as group sizes. We are still unaware of what the exact factors are that

contribute to the effectiveness of psychoeducational interventions. Therefore,

as many intervention characteristics as possible should be taken into account

when setting up an intervention and these characteristics should subsequently

be documented in publications. In the long run these data will have the

potential to provide us with valuable information for adjusting and redirecting

future interventions.


52

53

Chapter 3

Effectiveness of a six session stress reduction

program for groups

Objectives. The goal of the present study was to determine the effectiveness of six-

week cognitive-behavioural stress reduction course for large groups (two hours per

week). Methods. Two groups (intervention group N=47; matched control group N=47)

completed self-report questionnaires on stress, depression, anxiety, worrying, and

stress management skills at pre- and post-intervention and at six months and one year

follow-up. Results. Linear declines for the intervention group were found for all

symptoms from pre-intervention to post-intervention and further on through follow-up

(linear trends ps < .05), whereas stress management skills remained stable. Clinically

significant and reliable change (in almost 30% of participants) confirmed these findings.

No such change was found for the control group. The strongest effect occurred for

those participants who presented themselves with higher levels of initial symptoms.

Conclusions. Overall, the data showed small but reliable and long-lasting effects on self-

reported stress, worrying and symptoms of depression and anxiety.

Keywords

stress reduction, psychoeducation, cognitive-behavioural, intervention, matched control

design

Effectiveness of a stress reduction program

54

1 Introduction

In 1984, Lazarus and Folkman (1984, p. 19) defined psychological stress as “... a

particular relationship between the person and the environment that is

appraised by the person as taxing or exceeding his or her resources and

endangering his or her well-being.“ Almost three decades later, chronic stress is

considered a major burden in modern society, compromising both physical and

mental health (American Psychological Association, 2010). High levels of self-

perceived stress are, for example, closely related to several adverse health

conditions like metabolic syndrome (Chandola, Brunner, & Marmot, 2006) and

coronary heart disease (Jood, Redfors, Rosengren, Blomstrand, & Jern, 2009;

Rosengren et al., 2004; Xu, Zhao, Guo, Guo, & Gao, 2009). There is also a clear

link between high levels of stress and the subsequent onset of mental disorders

such as depression (van Praag, 2004; Wang, 2004).

Considering the scope of the burden of stress, no health service will ever be

able to provide adequate treatment for all, even in more affluent countries

(van ‘t Veer-Tazelaar et al., 2009). This emphasizes the need for large scale

prevention, for example by reducing stress in the general population. In MHC,

prevention can be situated within a stepped-care approach. This represents an

attempt to maximize the efficiency of resource allocation in therapy: low

threshold and low cost interventions are offered first, and more intensive and

costly interventions are reserved for those who are not sufficiently helped by

the initial intervention (Haaga, 2000). A recent meta-analysis including a variety

of programs confirmed that the average participant of a stress reduction

program obtains a significant reduction of perceived stress. When long-term

changes are considered, however, results are less clear. The limited number of

studies that include follow-up for up to six months or less find mixed results

(Van Daele, Hermans, Van Audenhove, & Van den Bergh, 2012).

The current study therefore aims at consolidating the evidence base for

Chapter 3

55

stress reduction programs, both in the short and long term. In the present case,

we are interested in how the intervention performs in the real-life context of

communities, resembling common practice. This provides a more accurate view

of intervention effectiveness in everyday life. The intervention itself is a stress

reduction program, developed within the CBT tradition as an adaptation of a

program by White (2000) that was originally developed to reduce anxiety. It is

being offered to large groups of self-registering community dwellers. Since they

self-register, participants may have various initial complaints and motivations

constituting a heterogeneous group of participants with ‘typical’ elevated

stress symptoms, but also participants with low levels of stress whose main

interest is to learn more about stress and how it may affect them. Whereas

White’s course was more focused on curing participants with elevated

complaint levels, the current course has therefore more characteristics of a

selective preventive intervention.

The goal of the program is to reduce stress by altering the relationship

between the person and the environment. More specifically, stress reduction is

intended to occur through two main routes. One focuses on strengthening the

participants’ resources through developing social and self-management skills.

The other attempts to change cognitive representations through targeting

negative appraisals and unhelpful perseverative thinking, such as worrying and

ruminating which may mediate the relationship between stressors and

psychopathology (Brosschot, Gerin, & Thayer, 2006). Because the program

aims to initiate a learning process, the reduction of stress-related symptoms is

expected to occur gradually and to continue in the months following the

intervention.

Changes were assessed through self-report questionnaires. Stress scores

were considered as the primary outcome measure, depression and anxiety as

secondary outcome measures, and reduction in worrying and increase in stress

management skills as the means for stress reduction. We used a pre-post


56

matched control design with two follow-up moments, one after six and one

after 12 months. Because participants needed time to process all the

information and practice the skills taught during the course, it was

hypothesised that in the months following the intervention, a steady, gradual

decline in worrying and a gradual increase in stress management skills would

be accompanied by a decline in stress and depression and anxiety. The

strongest effect is expected to occur for those participants who present

themselves with higher levels of initial symptoms.

2 Method

2.1 Recruitment and screening

In order to participate, respondents had to reside in one of three regions in

Flanders (Belgium). In each region, local organizations were contacted to help

distribute information leaflets through their own networks and communication

channels, including GPs, (sports) clubs, libraries and local press. Exclusion

criteria were defined and potential participants who met at least one of these

were informed that the current intervention might not completely suit their

needs and that additional professional help might be necessary. Subsequently,

they could decide to continue following the course or not, but they were

always advised to contact the local centre for ambulatory MHC. The centres

were informed about these potential contacts and agreed to give these

requests priority. If participants continued to follow the course, they were

removed from the study sample. The exclusion criteria were the answers on 1)

question 15 of the Web Screening Questionnaire (WSQ; Donker, van Straten,

Marks, Cuijpers, 2009) indicating suicidal tendencies (Answering ‘I would do it

given the opportunity’ on the question whether the idea of harming yourself or

taking your life, recently came into their mind), 2) the General Anxiety Disorder

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Questionnaire-7 (GAD-7; Spitzer Kroenke, Williams, & Lowe, 2003) showing

they suffered from a severe generalized anxiety disorder (15+ on a 21 point

scale), 3) three questions of the Alcohol Use Disorders Screening Test (AUDIT;

Saunders, Aasland, Babor, de la Puente, & Grant, 1993) pointing to problematic

substance abuse (which could lead to alcohol induced violence, endangering

fellow participants). During the course, participants could also be excluded if

the teacher-therapist noticed signs of psychotic disorders or severe deviant

behaviour.

To study long-term effects, the original goal was to randomly allocate

participants to a stress management course or to a one-year non-intervention

control group. This, however, raised practical and ethical concerns in local

partners endangering course implementation: local partners were reluctant to

advertise the study when half of the participants would be denied treatment

for twelve months or would receive some kind of placebo treatment. A

matching procedure was therefore used to collect control data instead of using

randomized non- or pseudo-intervention controls. In the matching procedure,

a large sample was recruited from the general population through local

newspapers, answering an advertisement to participate in a questionnaire

study concerning their general well-being. Subsequently, a selected number of

them were matched one-on-one to the course participants according to

predetermined criteria: stress scores, depression and anxiety, as well as age,

socioeconomic status and gender. Participants in this control group were not

aware of the intervention and had not expressed an explicit desire to

participate in the stress course. This design proved to be acceptable for local

partners. It was subsequently also approved by the ethics committee of the

Faculty of Psychology and Educational Studies of the KU Leuven. Controls

received € 10 per data collection wave for participating.


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2.2 Intervention

The intervention was an adaptation of a program called ‘Stress Control’

(White, 2000; adaptation by ISW-Limits, 2006). Teachers were trained

psychologists from local centres for ambulatory MHC. They led this course,

which comprised six weekly lessons of two hours during which participants

mostly listen and are not required to interact. In lesson 1, participants were

offered general information on stress; it served as a general course

introduction, followed by two homework assignments. For the first homework

assignment participants needed to evaluate their own stress level, reaction

patterns, and general well-being. This was followed by determining concrete

goals they wanted to reach during the time of the course. A second homework

assignment implied reading an overview of basic self-help tips and techniques

that could help them with short–term stress reduction, including distraction,

practicing sports, breathing exercises, and a proper diet. The goals of these

homework assignments were to familiarize participants with the course, to

help them apply the general information to their own personal situation, and

to create a personalized frame of reference for the course content. This

allowed course participants to select specific, relevant techniques presented in

the following lessons. During lesson 2 they focused on the effects of stress on

the body and controlling bodily sensations. After some theoretical background,

participants learned the techniques of progressive relaxation and breathing

exercises. Furthermore, the importance of active recreation was emphasized.

In lesson 3 cognitive techniques were demonstrated and participants focused

on becoming aware of fallacies and challenging dysfunctional thoughts. In

lesson 4 techniques were taught from problem-solving and participants learned

how to confront their fears, end safety behaviours, and increase their

assertiveness. In lesson 5 and the first part of lesson 6 the knowledge from

Lesson 1 and the techniques learned in the previous lessons were rehearsed.

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These were subsequently applied to problems of anxiety, panic, sleeping

disorders and feelings of depression, and tension and burn-out. In the second

part of lesson 6, guidance was provided on how to control future stress.

2.3 Measures

The Depression Anxiety Stress Scales-21 (DASS-21; Lovibond & Lovibond, 1995;

Dutch version by de Beurs, Van Dyck, Marquenie, Lange, & Blonk, 2001) is a 21-

item self-report questionnaire measuring stress (7 items, α = .89) in the past

week. Symptoms of depression (7 items, α = .94), and symptoms of anxiety (7

items, α = .91) are also considered as secondary outcome measures.

The Penn State Worry Questionnaire (PSWQ; Meyer, Miller, Metzger, &

Borkovec, 1990; Dutch version by van Rijsoort, Vervaeke, & Emmelkamp, 1997)

is a 16-item self-report questionnaire used to measure worrying on a five point

Likert scale ranging from 1 ‘Not at all typical for me’ to 5 ‘Very typical of me’.

The questionnaire has a high internal consistency both for normal (α = .90) and

clinical (α = .86) populations.

The Coping Strategies Indicator (CSI; Amirkhan, 1990, Dutch version by

Bijttebier & Vertommen, 1997) is a 33-item self-report questionnaire that

measures three coping styles: problem-solving (11 items, α = .87), social

support seeking (11 items, α = .90), and avoidance (11 items, α = .73). Because

the course supports problem-solving and social support seeking and tries to

diminish avoidance when faced with stress, this questionnaire is therefore

suited to evaluate the change in stress management skills. The questionnaire

uses a three point Likert scale (3 ‘a lot’, 2 ‘a little’, 1 ‘not at all’). The higher the

scores, the more commonly a strategy is used. High scores are therefore

considered positive for problem-solving and social support seeking, and

negative for avoidance.


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2.4 Course implementation

The intervention was implemented using a framework called empowerment

implementation. This strategy offers interventions room to be flexible to local

needs, while still maintaining adherence to strict implementation guidelines.

More details on the actual implementation and the underlying framework can

be found in Van Daele, Van Audenhove, Hermans, Van den Bergh, & Van den

Broucke, 2012.

2.5 Statistical analysis

All data were analyzed using SPSS (SPSS 16.0, IBM). Group by time interaction

was evaluated using a generalized linear model (GLM) and compared self-

reported symptoms and skills at each measurement point of the design.

Furthermore, when group by time interactions were at least marginally

significant (p < .10), group by trend-over-time interactions were also

conducted, testing for linear and quadratic trends in the time variable.

Reliable and clinically significant changes were used as secondary measures

for course effectiveness. According to Jacobson and Truax (1991), the optimal

way to determine clinically significant change is according to ‘criterion C’. This

method assumes that both the normal and the clinical population are normally

distributed. In order to achieve clinically significant change (CSC), symptoms

severity of participants should be closer to the mean score of the normal

population than to those of the clinical population. Therefore, a cut-off score is

determined. Because such a cut-off score is arbitrary and small changes may

also lead to a change from one side of the cut-off score to the other, reliable

change (RC) is used as an additional criterion. RC indicates that the change

reported is larger than expected by chance. Both types of change are

independent of one another, but the change aimed for is one that is both

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reliable and clinically significant. For this analysis, DASS stress scores were used

to determine treatment effects, because for this questionnaire Dutch

normative data were available both for the normal (M = 8.5, SD = 8.0) and

clinical population (M = 15.8, SD = 9.8; de Beurs, personal communication,

October 28, 2007).

3 Results

3.1 Participants

Questionnaires were administered pre-intervention, post-intervention, after six

months, and one year after course completion. A total of 77 participants

completed the first questionnaire. Two participants who had completed the

first questionnaire dropped out after the first session, one due to lack of

interest, the other due to unexpected surgery. Furthermore, based on the

exclusion criteria, one participant with a suicide risk was informed that the

intervention might not suit her needs and she was referred to a local centre for

ambulatory MHC. This participant nevertheless decided to continue following

the course, but was removed from the study sample. Overall, 75 participants

from three different locations (N = 28, N = 34 and N = 13) completed the

course, of which 47 participants (63% of the completers) filled in the

questionnaires at all four times. Their mean age was 44. 1 years (SD = 10.1,

range 21-63).

From a total of 158 controls that completed the questionnaire at pre-

intervention, 139 (88%) completed the questionnaires at all four times. From

these 139 controls, 47 were matched with the intervention participants within

one standard deviation on depressive, anxiety and stress scores, as well as for

age, socioeconomic status and gender. The mean age was 39.15 years (SD =

13.4, range 20-69). Other socio-demographics for both groups can be found in

Table 5.


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Table 5 Sociodemographics for intervention group (N = 47) and matched control

group (N = 47) in percent

3.2 Missing data

By the end of the study 28 (37%) of the 75 completers had not returned one or

more questionnaires and were therefore left out of the final analyses. These

non-responders were compared to responders on pre-intervention scores for

the DASS, PSWQ, and CSI. Only for stress management skills, a significant

difference was found with non-responders having higher problem-solving

scores, CSI-problem-solving: F(1,73) = 4.20, p = .04. Other measures did not

show a difference between both groups. Overall, these analyses showed little

difference between both groups, which makes the results outlined below

relevant for the group of participants as a whole.

3.3 Course effectiveness

An overview of the data for all measurements can be found in Table 6. The

analyses apply to all four repeated measures, which were done over the course

of one year.

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Tabel 6 Evolution of intervention group (N = 47) and matched control group

(N = 47)

3.3.1 Stress, depression and anxiety

When the group by time interaction was evaluated using GLM, no significant

effect on stress scores was found F(3, 276) = 2.07, p = .10. For the secondary

outcome measures, a significant effect was found for depressive symptoms,

F(3,276) = 2.72, p = .05, but not for anxiety, F(3,276) < 1. Additionally, the

group by trend-over-time interactions did show a clear trend for stress scores,

F(1,92) = 5.26, p = .02, with a linear decline in the intervention group F(1,46) =

7.60, p =.01, which was absent in the control group F(1,46) < 1. This was also


64

the case for depressive symptoms, F(1,92) = 5.39, p = .02, with a linear decline

in the intervention group F(1,46) = 7.08, p = .01, whereas the control group

remained stable F(1,46) < 1. No such changes were found for anxiety, F(1,92) <

1.

Furthermore, the intervention group could be split into two: one group with

higher and one group with lower initial symptoms. For each measure, the split

value is determined as the value of the intersection point between the

distributions of the normal and clinical population (Figure 5). When low (N =

12) and high (N = 35) stressed participants were compared using GLM, there

was a strong group by time interaction, F(3, 135) = 4.24, p = .007. Similar results

were found for low (N = 22) and high (N = 25) depressed participants, F(3,135)

= 4.70, p = .004, and for low (N = 25) and high (N = 22) anxious individuals, F(3,

135) = 6.05, p = .001. Additional analyses on the group by trend-over-time

interaction showed clear linear trends for stress F(1, 45) = 9.61, p = .003,

depression, F(1. 45) = 11.39, p = .002, and anxiety, F(1, 45) = 6.76, p = .013, with

participants with high levels of initial symptoms showing a decline, whereas

patients with low initial levels remained stable or showed a limited increase.

3.3.2 Worrying

An analysis of the group by time interaction with GLM showed a strong effect

on worrying, F(3,276) = 5.60, p < .001. This was confirmed with an analysis on

the group by trend-over-time interaction, F(1,92) = 13.20, p < .001, which

showed a clear decline for the intervention group F(1,46) = 21.12, p < .001,

whereas the control group remained stable F(1,46) < 1.

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Figure 5. Comparison of DASS-scores between participants with a low- and

high-level baseline of complaints.

3.3.3 Stress management skills

When the group by time interaction was evaluated using GLM, a significant

effect was found for problem-solving, F(3,264) = 2.95, p = .03, in which scores

for the intervention group increased from pre to post followed by a limited

decline at follow-up whereas those of the control group remained relatively

stable. No such differences were found for social support, F(3,264) < 1, or

avoidance, F(3,264) = 2.26, p = .08. Analyses on the group by trend-over-time

interaction for stress management however, were not significant for problem

solving, F(1,88) < 1, social support seeking F(1,88) = 1.23, p = .27, nor for

avoidance, F(1,88) = 3.06, p = .08.


66

3.4 Clinical significance

Clinical significance was evaluated using reliable and clinically significant

change. DASS-stress-scores were used to determine treatment effects. The cut-

off score for clinically significant change was determined at 11.7, which

indicated that anyone above this score was considered within the range of the

clinical population and anyone below this score was within the range of the

normal population. Furthermore, in order for a change to be considered

reliable – not attributable to chance – it had to be larger than 6.3. Initially, 85%

of all participants reported stress symptoms within the range of the clinical

population. At post intervention, 13% of these participants showed both a

reliable and clinically significant change. After six months this number had

increased to 23% and by the one year follow-up, 28% of the participants had

undergone a reliable and clinically significant change. Because clinically

significant change implied that participants had to be within the range of the

clinical population, it is not surprising that 92% of the participants that

underwent a clinically significant and reliable change were part of the group

with higher initial symptoms mentioned earlier.

4 Discussion

This study aimed to investigate whether a six-week CBT stress reduction course

for groups was effective in the long term in reducing stress and depression and

anxiety, in decreasing worrying, and in increasing stress management skills. The

results of the trend analyses indicated a linear decline of stress and depression

in the intervention group from pre-intervention to post-intervention and

further on through follow-up. These effects were not observed in the non-

intervention group. There was also a strong linear decline in worrying, but only

little change in stress management skills. Furthermore, measures of clinical

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67

significance showed that almost 30 percent of all course participants

experienced a clinically significant and reliable change in the year following the

course. Finally, the strongest effect occurred for those participants who

presented themselves with higher levels of initial symptoms.

The overall modest mean effects seem to be due to the high amount of

variation on all measures between participants. Evidence for this explanation

can be found in the comparison of stress, anxiety and depression between

participants with low and high initial symptoms, in which participants with high

initial levels show a much stronger continuous and gradual decline of

symptoms, whereas participants with low initial symptoms remained stable.

This is in line with other stress management programs that intend to realize

long-term changes and which find effects up to four years after the

intervention (Rowe, 2000, 2006). The course therefore appears to initiate a

long-term process characterized by gradual declines in self-reported symptoms.

However, these declines were not strong enough to find significant effects for

all symptoms at all times using a GLM.

There was nevertheless a strong decline in worrying, one of the two

mechanisms targeted by the intervention. The other mechanism focused on

the improvement in stress management techniques of participants, which

showed little difference. The absence of an effect could be because the CSI

might not be that well suited as a questionnaire to measure general changes in

stress management skills. Since participants were asked to report how they

managed a specific problem they encountered in the month preceding the time

of completing the questionnaire, it might be that stress management in highly

specific situations was reported, as opposed to the more general stress

management skills that were intended. An alternative explanation is that the

primary focus of the intervention was on psychoeducation and less on the

actual skill training: participants were expected to practice at home in real life

situations. Since this was not a controlled environment, feedback could not be


68

delivered immediately and teachers had little control over whether course

participants actively used the acquired stress management techniques in their

home situations. This would imply that it might be the reduction in worrying

that is primarily responsible for the decline in symptoms. Because the current

design does not allow making causal inferences, a focus for future research

would therefore be to determine the mechanisms through which the symptom

reduction is accomplished and potentially improve the skill training component

in order to make it (more) effective.

Finally, the present study did not make use of random allocation of

participants, because looking into the long-term effectiveness of the

intervention would have required withholding (wait list) control participants

from following the course for over a year, which was not acceptable for the

organizations promoting the course locally. In addition, random allocation to an

intervention or control group is difficult for any study planning to do a long-

term follow-up. A matched control design therefore turned out to be the most

practical and ethical solution. While in an RCT initial conditions in both groups

are equalized, including the motivation to participate in a course, the latter

aspect was not present in our control group. Neither did they receive some

kind of bogus or placebo treatment. However, we used a matched control

design in which we tried to control for a wide range of variables related to

participant’s initial level of symptoms, as well as their socio-demographics.

Balancing both the need for long term follow-up and randomized allocation of

participants to non-intervention conditions may prove to be a difficult task.

Overall, the main conclusion of this study is that there are substantial

indications that the intervention has long-term effects on participants’ stress,

anxiety and depression, especially for those who have higher initial symptoms

and as far as up to one year after the intervention. It furthermore also shows

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69

that the effectiveness of ‘interventions in the field’ that focus on self-

registering community dwellers should be interpreted carefully. The

heterogeneous groups they attract might not only include people who

participate in order to obtain an immediate reduction of high symptoms, but

also those who have low level symptoms and follow the course in order to

prevent future symptoms. Especially the latter group could be responsible for

an underestimation of intervention effectiveness if they are not specifically

taken into consideration, as this might cause floor effects.

71

Research topic 2

Implementation

Van Daele, T., Van Audenhove, C., Hermans, D., Van den Bergh, O., & Van den Broucke,

S. (2012). Empowerment implementation: Enhancing fidelity and adaptation in a

psychoeducational intervention. Health Promotion International. Advance online

publication. doi: 10.1093/heapro/das070

73

Chapter 4

Empowerment implementation: enhancing fidelity

and adaptation in a psychoeducational intervention

Implementation is an emerging research topic in the fieldof health promotion. Most of

the implementation research adheres to one of two paradigms: implementing

interventions with maximum fidelity or designing interventions that are responsive to

the needs of a local community. While fidelity and adaptation are often considered as

contradictory, they are both essential elements of preventive interventions. An

innovative program design strategy is therefore to develop hybrid programs that ‘build

in’ adaptation to enhance program fit, while also maximizing the implementation

fidelity.

The present article presents guidelines for this hybrid approach to program

implementation and illustrates them with a concrete psychoeducational group

intervention. The approach, which is referred to as ‘empowerment implementation’ on

the analogy of empowerment evaluation, builds on theory of implementation fidelity

and community-based participatory research. To demonstrate the use of these

guidelines, a psychoeducational course aimed at stress reduction and the prevention of

depression and anxiety was implemented according to these guidelines. The main focus

lies on how an intervention can benefit from adaptations guided by local expertise,

while maintaining the core program components and still respecting the

implementation fidelity.

Keywords

implementation science, effectiveness, empowerment, mental health promotion

Empowerment implementation

74

1 Introduction

Implementation is an emerging research topic in the field of public health. This

growing interest reflects a changing view on what counts as evidence. For a

long time, ‘evidence’ was a synonym for empirical data supporting either the

scale or cause of a health problem, or the causal relations between

interventions and outcomes. For both kinds, the level of evidence provided is a

key quality feature, with an RCT traditionally regarded as the ‘golden’ – but

often unachievable – standard for evaluation. However, over the last decade it

has become clear that public health needs other types of research evidence as

well (Aro et al., 2005; Rychetnik et al., 2002). It is not sufficient to know the

magnitude, severity and causes of public health problems and the relative

effectiveness of specific interventions to inform public health policy and

practice. It is also necessary to know how a specific intervention should be

implemented and under which circumstances it can be successful. Accordingly,

Rychetnik et al. (2004) distinguish between three types of evidence in public

health: evidence pointing to the fact that ‘something should be done’, to

determine ‘what should be done’ and informing on ‘how it should be done’.

The attention for the latter kind of evidence has given rise to a research

investigating the quality and the processes of implementation (Breitenstein et

al., 2010; Glasgow, Lichtenstein & Marcus, 2003; Palinkas et al., 2011; Rabin et

al., 2010). Although there is no consensus with regard to the conceptual and

methodological frameworks to be used to study implementation, various

strategies have been proposed to enhance the quality of implementation.

These strategies often draw upon the literature on the diffusion of innovation

from the 1970s and 1980s (Dusenbury, Brannigan, Falco, &, Hansen, 2003). The

most influential strategy is to maximize the fidelity of intervention delivery

(Dumas, Lynch, Laughlin, Smith, & Prinz, 2001). The concept of implementation

fidelity refers to ‘the degree to which an intervention or program is delivered as

intended’ (Carroll et al., 2007). Specifically, a successful implementation is one

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75

that abides with four components of fidelity: adherence, exposure, quality of

program delivery and participant responsiveness (Dane and Schneider, 1998).

Mihalic (2002) describes each of these components as follows: 1) ‘adherence’

refers to whether interventions are delivered as intended; 2) ‘exposure’ refers

to the number of sessions implemented, session length, frequency of

implementation of program techniques; 3) ‘quality of program delivery’ refers

to the manner in which staff deliver a program; and 4) ‘participant

responsiveness’ refers to the extent to which participants are involved in

program content. Hasson (2010) has suggested two additional factors that

moderate implementation fidelity, notably ‘recruitment’ and ‘context’. The

concept of 5) ‘recruitment’ refers to procedures that are used to attract

potential program participants, whereas 6) ‘context’ refers to surrounding

social systems, such as structures and cultures of groups, inter-organizational

linkages and historical as well as concurrent events. All these factors should be

evaluated when conducting a process evaluation.

Multiple methodologies have already been developed to measure the

implementation fidelity (Blakely et al., 1987). Their main goal is to identify the

factors that lead to (the lack of) intervention success. In addition, they also

focus on the mechanism and processes that must be taken into consideration

when implementing complex interventions (Breitenstein et al., 2010; Campbell

et al., 2000; Oakley et al., 2004; Toroyan et al., 2004). Several attempts have

also been made to increase the implementation fidelity (Basen-Engquist et al.,

1994; Burns, Peters, & Noell, 2008; Macaulay, Gronewold, Griffin, Williams, &

Samuolis, 2005; Vitale & Romance, 2005).

On the other hand, focusing on fidelity has also been criticized for being

rigid, as it assumes full compliance with the program as prescribed by the

program developer (Gresham et al., 1993). The fact that any change to the

program made by implementers is considered as bias and as a threat to

implementation quality is at odds with the value placed on stakeholder


76

involvement and participation in health promotion (WHO, 1986; Levy, Baldyga,

& Jurkowski, 2003). An alternative approach to program implementation is

therefore to encourage adaptation, rather than limit it. Drawing on the

principles of community-based health promotion—which emphasizes the

participation of the community in program planning, implementation,

evaluation and dissemination—the program adoption approach holds that

users or local adopters should be allowed to reinvent or change programs to

meet their own needs and derive a sense of ownership.

The tension between the fidelity and adaptation approach is a recurrent

theme in the implementation literature (Blakely et al., 1987; Dusenbury et al.,

2003). Berman (1981) proposed a contingency model of implementation, in

which choosing between the strategies of fidelity and adaptation should

depend on the nature of the intervention. The fidelity approach would be most

suited for highly structured interventions, whereas the adaptation approach

would work better in less structured interventions. Yet, the dominant view

remains that both approaches have competing objectives: implementing

interventions with maximum fidelity, versus designing interventions that are

responsive to the cultural needs of a local community. However, these two

objectives are not necessarily contradictory (Castro et al., 2004; Weissberg,

1990). In fact, fidelity and adaptation are both essential elements of preventive

interventions. Moreover, both of them are best addressed by a planned,

organized and structured approach (Shen, Yang, Cao, & Warfield, 2008).

An interesting attempt to unite both approaches has been proposed by

Backer (2001). Based on a literature review, this author formulated six

recommendations for implementers. For a successful intervention

implementation one should 1) identify and understand the theory behind the

program; 2) locate or conduct a core components analysis of the program; 3)

assess fidelity/adaptation concerns for the implementation site; 4) consult with

the program developer; 5) consult with the organization and/or community in

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77

which the implementation will take place; and 6) develop an overall

implementation plan based on these inputs. Adding to this discourse, Castro et

al. (2004) suggest that an innovative program design strategy would be to

develop hybrid programs that ‘build in’ adaptation to enhance program fit,

while also maximizing the fidelity of implementation and program

effectiveness. Unfortunately, however, the authors do not provide any

guidelines as to how exactly such programs should be developed and validated,

only stating that it would require 'rigorous science-based evaluation and

testing’. The basis for such guidelines may, however, be found in similar,

related theoretical frameworks like empowerment evaluation.

Empowerment evaluation is grounded in empowerment theory

(Zimmerman, 1995). Empowerment can be defined as “... an intentional,

ongoing process through which people lacking an equal share of valued

resources gain greater access to and control over those resources”. It can exist

at community, organizational and individual level and can be viewed both as a

process and as an outcome, reflecting the achieved level of empowerment.

This process offers individuals the opportunity to gain control over their lives

and over democratic participation in the life of their community (Berger &

Neuhaus, 1977, cited in Zimmerman & Rappaport, 1988). Zimmerman’s view of

an empowerment approach to intervention design, implementation and

evaluation redefines the professional’s role as that of a collaborator and

facilitator, rather than an expert and counselor (Zimmerman, 2000). Fetterman

(1996) applied these principles to the evaluation of interventions, referring to

this as the empowerment evaluation. It is defined as “... an evaluation

approach that aims to increase the probability of achieving program success by

providing program stakeholders with tools for assessing the planning,

implementation and selfevaluation of their program, and mainstreaming

evaluation as a part of the planning and management of the program”

(Wandersman et al., 2005, p. 28). In this sense, empowerment evaluation is


78

closely linked to capacity building. According to Fetterman, building the

capacities of others to evaluate their own programs involves several steps: 1)

determining where the program stands, including strengths and weaknesses; 2)

focusing on establishing goals with an explicit emphasis on program

improvement; 3) helping participants determine their own strategies to

accomplish program goals and objectives; and 4) helping program participants

determine the type of evidence required to document progress credibly toward

their goals.

The present article aims to extend these guidelines to program

implementation. In the next section, this theoretical framework will be

introduced, followed by the presentation of the guidelines. Finally, a

psychoeducational course aimed at reducing stress and at preventing

depression and anxiety will serve as an example of how these guidelines can be

put into practice.

2 Empowerment implementation

While empowerment evaluation is mainly concerned with the evaluation of a

program, the same principles can also be applied to implementation. Such an

‘empowerment implementation’ could well reconcile the opposing fidelity and

adaptation approaches to implementation. Indeed, involving the community in

program implementation as an equal partner does not have to be at the cost of

fidelity. It only requires providing the community with the concepts, tools and

skills to identify the core components of the intervention, to adapt the

intervention to their context and culture, and to assess, monitor and maintain

the implementation quality.

The steps of an empowerment implementation approach would be as

follows: 1) developing a core component; 2) selecting partners; 3) assessing the

fidelity/adaptation concerns with partners; and 4) developing an overall

implementation plan. The way in which these steps are executed is inspired by

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community-based participatory research (CBPR), a collaborative approach to

research, involving all partners equitably in the research process, recognizing

the unique strengths that each brings (Minkler & Wallerstein, 2003, p. 4;

Minkler, Vásquez, Warner, Stuessey, & Facente, 2006) and empowerment

evaluation. The content of each step is defined by the key elements of high

fidelity implementation, and by research concerning the balancing of program

fidelity and adaptation. The consecutive steps will now be explained in detail.

2.1 Developing a core component

Prior to implementation, an intervention program is developed based on a

sound theoretical framework. One example is Intervention Mapping (IM), a tool

for the planning and development of health promotion interventions. It maps

the path from the recognition of a need or problem to the identification of a

solution (Kok, Schaalma, Ruiter, & Van Empelen, 2004). The first four steps of

IM could be run through as follows: 1) needs assessment; 2) preparing matrices

of change objectives; 3) selecting theory-informed intervention methods and

practical strategies; and 4) producing program components and materials. The

resulting intervention is tested in a controlled setting and empirically adapted

until researchers end up with an effective intervention. Subsequently,

researchers empirically) define which aspects of the intervention are especially

important for its efficacy and label these as the core components of the

intervention.

2.2 Selecting partners who will implement the intervention

Implementing an intervention requires the participation of partners in the field

in order to guarantee its success. Given that the main goal is to adapt a

previously developed intervention to the unique conditions of the real-life

context in which it is implemented, the notion of participation in this context


80

does not refer to the involvement of the end users, but to that of the

implementers. In terms of Fetterman’s (1996) framework, implementers can

indeed be considered as primary stakeholders, whose role is not that of an

expert or professional, but of a facilitator and enabler (Laverack & Wallerstein,

2001). As such, the focus of the participation of this study is more placed on the

participation of the active ‘can affect’-stakeholders than of the ‘affected’

parties (Freeman, 1984, cited in Achterkamp & Vos, 2008). These partners

preferably dispose of existing networks related to the intervention topic. For

example, an interesting partner for interventions related to cancer in the USA

would be the Cancer Information Service, a network of health education offices

(Glasgow, Marcus, Bull, and Wilson, 2004). However, if potential partners

show limited interest in the program, their participation is of little use. Even if

they can be persuaded to implement the program, they will be unlikely to

strive for quality, and this will probably lead to poor results, i.e. inadequate

implementation, weak fidelity and limited evidence-based actions ... In order to

avoid this, it is important to carefully select the partners who will implement

the intervention. A first step is therefore to make an overview of local partners

who are available. Subsequently, these potential partners must be consulted to

ascertain if they are interested to participate and whether they subscribe to

the scientific basis of the intervention to be implemented. The most suitable

partners for the intervention can then be selected through an evaluation of

their strengths and weaknesses in the function of the intervention.

2.3 Assessing the fidelity/adaptation concerns with partners

The next step is to assess the concerns with regard to fidelity and adaptation

together with the partners. This implies two aspects.

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2.3.1 Deciding on practical intervention aspects

To implement an intervention, a large number of practical aspects need to be

taken into consideration. Although not all of these are crucial for the

intervention to be effective, they play a large role in how the intervention can

be perceived and received by the target population. Aspects that are not

included in the core components of the program as defined in step 1 should

therefore certainly be open for discussion, as they can have a significant impact

on intervention dissemination. In the discussion about these non-core

components, local partners should take the lead, as they know the situation

and the target population best. Researchers should acknowledge their

expertise, but remain available as resource persons. Together, researchers and

implementers can tailor the intervention to suit present needs. Examples of

more ‘practical’ aspects that – depending on the particular program and

situation – might be open to discussion are: the recruitment of participants, the

intervention location and context, the number/length/frequency of sessions …

2.3.2 Deciding on content-related intervention aspects

It is very important that partner participation is not limited to practical aspects

only and that partners are also offered the possibility to give advice on content,

as the impetus for partners wanting to participate depends on the

opportunities that are presented by a project (van der Velde, Williamson, &

Ogilvie, 2009). In this regard, researchers and local partners are considered as

equal, each with their unique expertise. Both often have a substantial

theoretical background, experience and personal affinity for the intervention,

although these may vary in amount and in specific content. For intervention

implementation, researchers can mainly rely on their theoretical background,

whereas local partners most of the time have a better understanding of the

specific implementation setting. Letting local partners change content may be a


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sensitive matter for researchers, but if this is done through an open and

respectful dialogue, the intervention can benefit greatly from this collaborative

action.

The starting point should be that local partners have the possibility to

change everything of the intervention, as long as the core components remain

untouched. Examples of more ‘content-related’ aspects are participant

responsiveness, means of program delivery, cultural sensitivities or

preference ... Only some examples of aspects that are open to change were

highlighted above. This list is therefore not exhaustive: there may be additional

aspects to be taken into account, depending on the target group or context of

the intervention. These can easily be chosen in collaboration between

researchers and partners.

2.4 Developing an overall implementation plan

To ensure a successful implementation of the intervention, it is necessary to

develop an implementation plan. This plan should specify the role of all

partners involved and provide a clear timeline with an overview of what actions

need to be undertaken when. One way to assure such quality management and

avoid unintended effects at the phase of intervention realization is for

researchers to actively monitor intervention implementation by the partners in

the field, document potential deviations and subsequently go through these

together with them to avoid future mistakes at later stages of the

implementation process. Given the commensurability between efficacy and

effectiveness (Stricker, 2000), this framework increases the chances for an

effective intervention when implemented in practice. Furthermore, it helps to

avoid certain problems that are common to CBPR, such as the lack of skills in

research methods of community members, differences in the appraisal of

intervention criteria between the community and funding agencies, and

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shifting levels of community involvement throughout the research process

(Levy, Baldyga, & Jurkowski, 2003; Wallerstein & Duran, 2006).

In the following sections, empowerment implementation will be illustrated

by describing the implementation process of a psychoeducational group

intervention aimed at reducing stress and preventing depression and anxiety.

This will show how each step of empowerment implementation can be put into

practice. First, the context is described, followed by the method and the

intervention. These descriptions are followed by an overview of the

implementation process. During this overview, attention is directed to specific

points of interest to illustrate main aspects of the framework.

3 Example: implementation of a psychoeducational group

intervention

3.1 Context

The project on the implementation of a psychoeducational group intervention

was commissioned by the Flemish government in 2007 to the Policy Research

Centre Welfare Health and Family (SWVG), a consortium of Flemish research

and expertise centers on health and well-being whose task is to support the

Flemish minister in pursuing an effective evidence-based policy. Its aim was to

determine whether a psychoeducational group intervention to reduce stress

and prevent depression could support the organizations in primary MHC to

reduce the growing burden of mental health problems. The primary MHC

sector in Flanders consists of a large number of organizations, each with their

own goals and ways of working. Because of this diversity, a concern of the

Flemish government was not only to evaluate the effectiveness of the

intervention, but also whether such a course could be organized through ad

hoc partnerships. The feasibility of such an implementation would offer

perspectives for large-scale implementations in the future. Local organizations


84

would be at liberty to select partners they consider most appropriate in order

to achieve their (mutual) goals.

Three Flemish cities and their communities were selected as intervention

sites: one larger (Antwerp) and two smaller ones (Ypres, Genk). All

organizations participated voluntarily and by means of their own funding.

Although there were some differences between regions, key partners were

provinces, local organizations for health consultation (LOGO), local

governments and local centres for ambulatory mental healthcare (CGG). The

location for the course was either provided by the provinces or by the local

governments. Teachers were psychologists from local centres for ambulatory

mental healthcare. Although all partners were involved in course promotion,

the local organizations for health consultation had the most suitable and

extended network at their disposal to promote the intervention and took the

lead by, e.g. distributing the majority of flyers.

3.2 Method

Questionnaires were administered to the participants before and after the

intervention. These included socio-demographic variables, depression, anxiety

and stress scores (DASS-42; Lovibond & Lovibond, 1995; Dutch version by de

Beurs, Van Dyck, Marquenie, Lange, & Blonk, 2001) and course evaluation at

the level of participant reactions (Kirkpatrick, 1975, Dutch version by Baert,

De Witte, & Sterck, 2001). This course evaluation was also used as a semi

structured interview conducted with the course teachers after course

completion.

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3.3 Intervention

3.3.1 Background

The psychoeducational course used for the intervention is a Flemish adaptation

of a Scottish program called ‘Stress Control’. It was first described by White

(White, 2000, p. 57) as “... a six-session didactic cognitive behavioural ‘evening

class’. It aims to: [1] teach students about anxiety and associated problem s-

depression, panic and insomnia; [2] teach self-assessment skills to allow

individuals to learn how these problems affect them [3] teach a range of

techniques designed to enable individuals to tailor their own treatment with

minimal therapist contact” and has been developed within the CBT approach

close to Beck (1981) and Meichenbaum (1985). The Flemish version is not an

exact replica of the original course. The goal of the Flemish version is more to

preserve mental health than to restore it. Therefore, it focuses primarily on the

phenomenon of stress than on anxiety. Since 2003 this intervention is being

offered to the Flemish population, primarily by one of the major public health

insurance companies. After paying an entry fee, both their members and non-

members have the ability to attend the course.

3.3.2 Core component

The core component of the intervention is the course material containing a

relaxation CD and various booklets. Each of the six weekly lessons has its own

separate booklet with all (and even more) of the information presented during

the evening course. One additional booklet contains all homework

assignments. Teachers received course material from SWVG and were

instructed to distribute this to course participants in their original format,

without any changes.


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3.4 Implementation

3.4.1 Developing a core component

In this particular case, the stress control course was developed within a CBT

approach, tested in a setting with college students, and found efficacious in this

controlled environment. For the subsequent larger intervention with multiple

partners in different regions, the course material was defined as the core

component of the intervention which had to guarantee a qualitative

intervention.

3.4.2 Selecting partners who will implement the intervention

The psychoeducational course was implemented in three Flemish regions,

selected from the regions in which the Policy Research Centre Welfare Health

and Family is active (KU Leuven, UGent, VUG, & KHK, 2007). To assure an

optimal reception of the intervention by all partners, concept mapping was

used. This research method is based on Gray’s (1989) collaboration model. A

selection of potential partners for each region was brought together in focus

groups. Through prioritizing their goals and interests, the three regions that

were most suited for the implementation of this intervention were determined.

The partners in these regions showed positive attitudes toward

psychoeducation and prevention. For each region, researchers and partners

together determined the strengths and weaknesses of all involved. After this

evaluation, four main tasks were determined and distributed among each

other: 1) organizing administration and data collection; 2) providing the

teacher; 3) providing the location; and 4) promoting the intervention. One

example of the strengths and weaknesses analysis is that in each region it was

agreed upon by all involved that the centres for ambulatory mental healthcare

were best placed to provide teachers for the course. Researchers, partners and

the centres themselves did not consider it wise to also involve them in

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promoting the intervention, though. Because of the stigma that is often still

associated with MHC (providers) in Flanders (Reynders, Scheerder,

Molenberghs, & Van Audenhove, 2011), it was decided to look for alternative

channels.

3.4.3 Assessing the fidelity/adaptation concerns with partners

In each of the three regions researchers and partners gathered to address both

practical and content-related intervention aspects. The researchers already had

suggestions for different aspects that were open for discussion, but some also

emerged during the meetings. Partners were hereby considered as the experts,

the researchers only took the role of facilitators to moderate discussions

between them. The goal was hereby not to create homogeneous

implementation conditions across regions, but rather to determine and adapt

specific and relevant aspects for each region. Because the three regions each

had their unique context, this resulted – as expected – in some level of

heterogeneity across regions.

3.4.4 Deciding on practical intervention aspects

These aspects were 1) the time of course commencement. The course was set

up as an evening course, but partners decided themselves which day and at

which exact time they preferred the course to start, taking into account the

habits and possibilities of the target population in their region. All regions

opted for Tuesday, with the time of commencement at 6 p.m., 7 p.m. and 8

p.m. 2) The course location. Both researchers and partners quickly agreed that

the location should be neutral, not providing a threshold for people with any

specific background to participate. Governmental buildings (respectively, a

cultural centre, a lecture hall and even a city hall) were chosen as the most

suitable locations. 3) Which channels would be used to promote the course and


88

by which means. In each region, partners had specific ideas and opportunities

to promote the course: distributing flyers in public locations like libraries and to

their personnel, posting advertisements on their websites, publishing

announcements in official city papers, contacting specific organizations which

aim at the target population, and setting up meetings between the researchers

and local stakeholders. 4) Which of their staff members would be most suited

to teach the course. The researchers left this completely open to the partners.

They all chose psychologists with considerable professional experience, both on

psychopathology and in teaching (psychoeducational) courses. Finally, 5)

manner of distribution of the course material. The course material could be

distributed to the participants in parts, one for each lesson, or given as a whole

at the commencement of the course. For didactic purposes, two regions

decided to distribute the course material in parts, whereas in one region the

course material was distributed as a whole, mainly for practical concerns.

3.4.5 Deciding on content-related intervention aspects

To support teachers during the course, default PowerPoint presentations were

made available by the researchers. However, if preferred; 1) teachers could

change the presentations to suit their own needs and the particular condition.

Other content-related aspects also apply to teachers, since they could exert

most influence on the intervention content; 2) they could decide whether they

wanted to read the relaxation exercise aloud themselves or play it from the CD;

3) they had the possibility to introduce interaction in the course, provided they

felt like the course participants needed this; and finally 4) they could also add

their own additional examples during the course in order to make them more

relevant for the group.

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3.4.6 Developing an overall implementation plan

Together with partners, researchers wrote down all arrangements, decisions

and agreements in an overall implementation plan. The researchers took the

final responsibility and assured in each region and for each lesson that

everything was implemented as decided upon. If – for one reason or another –

there were deviations from the original plan, these were carefully documented

and subsequently communicated to the partners. When the course would be

evaluated, these could then be taken into consideration.

3.4.7 Actual implementation

The course was subsequently implemented in the three regions, for two groups

of 34 and one group of 18 participants. The total number of participants was

not that high, but partners indicated that it was still larger than when they set

up similar courses in the past.

The average age of participants was 43.0 years (SD = 10.3) and the majority

was currently employed (85%). Close to 80% of participants were women,

which is a high number, but not uncommon for this type of intervention (Van

Daele, Hermans, Van Audenhove, & Van den Bergh, 2012). Participants’

depression, anxiety and stress measures were high, approaching the clinical

threshold (normative data provided by E. de Beurs, personal communication,

28 October 2007).

In general, both course participants and course trainers were pleased with

the outcome. In a written questionnaire, 70% of course participants agreed

that the course was useful and a total of 91% of participants indicated they

would recommend the course to a friend. The three trainers were interviewed

and were also favourable to the intervention. Based on their experiences, they

did have some remarks, both concerning practical aspects and content. All


90

these remarks were discussed during the interview, carefully written down and

will certainly be taken into consideration for future implementations.

4 Discussion

In this paper, we have introduced a framework to program implementation

which reconciles the competing paradigms of maximizing implementation

fidelity versus adapting programs to the needs of the local stakeholders.

Starting from the premise that fidelity and adaptation are both essential

elements of implementation ideally addressed in a planned, organized and

structured way, we have proposed a four-step framework to implement

prevention programs, balancing program fidelity with adaptation. The

framework is based on CBPR and on empowerment evaluation, which we have

extended to program implementation.

This ‘empowerment implementation’ was illustrated by applying the

framework to the implementation of a psychoeducational Group intervention

in Flanders. The example showed that empowerment implementation offers

the possibility of implementing the core components of an intervention with

high fidelity, while allowing for the adaptation of the intervention to local

needs, thus enhancing ownership by local stakeholders. It was seen that local

partners not only prefer this flexibility, but consider it as necessary for any

intervention which they are offered or required to implement. Whereas

previously the adaptations made by local stakeholders to existing ‘standard’

intervention programs were mostly considered as ‘flaws’ in the implementation

process, empowerment implementation provides an opportunity to redefine

these adaptations as useful additions with a high ecological validity and

relevance, which do not interfere with the core elements of the intervention.

The aim of the psychoeducational course was to strengthen the resilience of

participants to deal with daily stressors, and to empower them to take charge

of their own mental health. Whether or not this aim was achieved was not

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addressed in this study. However, what this study did show is that the

participatory approach to implementation that was followed for this program

led to a better understanding of the intervention, its goals and its core

elements by the local health workers who implemented it, and stimulated

them to develop, adapt and implement future interventions. As such, the

effects may extend beyond the stated outcomes of the program, despite the

fact that it was essentially conceived as a top-down intervention. In that way,

the approach can be considered as truly empowering.

The fact that empowerment implementation is characterized by a high level

of collaboration, mutual respect and program flexibility does not mean that

anything goes. It remains important for researchers and stakeholders to control

the outcome to assure that the intervention is implemented according to plan,

maybe even more compared with ‘traditional’ frameworks for implementation.

The main difference is that implementation fidelity is not determined by the

strict implementation of the entire intervention, but of its core components.

Deviating from the original intervention is allowed, even required and

stimulated, as long as the core components remain untouched.

Such an implementation is ideally followed by empowerment evaluation. In

the current study this was not possible, because clear research objectives were

already formulated by policy makers prior to the start of the project. However,

even in that situation it remains important to involve partners in the evaluation

process. Taking time to consider the strengths and weaknesses of the actual

implementation in comparison with the ideal scenario can serve as leverage for

improvement. It also creates a strong intrinsic motivation for change among

the partners and may offer opportunities for further collaboration.

5 Conclusion

Empowerment implementation provides a new look at the concept of

implementation fidelity and intervention effectiveness. In this framework an


92

intervention consists of two parts: a core component and less important

intervention aspects. The core component is proved effective in clinical trials

and remains untouched throughout the implementation process. Less

important intervention aspects are decided upon through an intensive

collaboration between researchers and local partners. The framework

therefore consists of three main phases: partner selection, deciding upon

practical aspects and deciding upon content-related aspects. As such, it

addresses and overcomes the apparent contradiction between implementation

fidelity and adaptation.

Current research concerning implementation fidelity often considers

partner input and variability as bias. The strength of the current framework is

that it offers the possibility to take this disadvantage and turn it into an

advantage. All those who are involved in the program benefit from increased

stakeholder participation: researchers can evaluate an intervention

implementation in more realistic circumstances, whereas local partners have

the ability to control and to adapt an intervention (as much as possible) to their

needs, to enhance their ownership of the intervention, and to increase their

capacities to develop, adapt and implement interventions in the future.

93

Research topic 3

Prediction

Van Daele, T., Van den Bergh, O., Van Audenhove, C., Raes, F., & Hermans, D. (2013).

Reduced Memory Specificity Predicts the Acquisition of Problem Solving Skills in

Psychoeducation. Journal of Behavior Therapy and Experimental Psychiatry, 44, 135-

140. doi: 10.1016/j.jbtep.2011.12.005

Van Daele, T., Griffith, J., Van den Bergh, O., Hermans, D. (2013). Overgeneral

autobiographical memory predicts changes in depression and anxiety in a community

sample. Manuscript submitted for publication

95

Chapter 5

Reduced memory specificity predicts the acquisition

of problem solving skills in psychoeducation

Background and objectives. Research has shown that overgeneral autobiographical

memory (OGM) is a valid predictor for the course of depression. It is not known,

however, whether OGM also moderates information uptake and consolidation in a

psychoeducation program to prevent stress, anxiety and depression. The present study

was designed to investigate whether the Autobiographical Memory Test (AMT;

Williams, & Broadbent, 1986) is a valid predictor for the actual unfolding of skills

learned through psychoeducation. Methods. The questionnaire included primarily the

AMT and the Stress Anxiety Depression Means-Ends Problem Solving Questionnaire

(SAD-MEPS). It was filled in prior to and after the psychoeducational course by 23

participants. Results. Correlations were calculated for the AMT at baseline and the

differences between the pre and post measurements on the SAD-MEPS. Significant

correlations were observed between the number of specific responses and the changes

in the number of relevant means (r = .49, p < .01). Limitations. The sample size was

rather small, but several checks were able to reduce the chance of spurious findings.

Conclusions: These findings may have important implications for the guidance to and

the setup of psychoeducational interventions. Suggestions include screening and

memory specificity training prior to course commencement.

Keywords

autobiographical memory, psychoeducation, prevention, depression

Autobiographical memory and problem solving

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1 Introduction

In the past twenty years a large amount of research has focused on the

predictive validity of overgeneral autobiographic memory (OGM) for the course

of depression. OGM is the difficulty to recall specific memories from one’s past

life. Instead of reporting memories that refer to a specific context and last less

than a day, overgeneral memories are reported. These last longer than a day or

are recurring events (Gibbs & Rude, 2004). Within the population, there is

some variance in the level of specificity between individuals, but people who

suffer from depression or posttraumatic stress disorder (PTSD) generally have a

less specific autobiographic memory (Harvey, Bryant, & Dang, 1998; Williams et

al., 2007). Reduced memory specificity has been found to be a predictor for a

worse course of depressive and trauma-related anxiety disorders. An early

study by Brittlebank, Scott, Williams, and Ferrier (1993) with patients meeting

the criteria of major depressive disorder (MDD) reported that overgenerality

was highly correlated with failure to recover from depression (also see: Raes et

al., 2006). Gibbs and Rude (2004) found that students with high frequencies of

stressful life events and high OGM demonstrated higher levels of depressive

symptoms four to six weeks later. In a study by Raes et al. (2008) OGM

predicted an unfavourable course of depression in an electroconvulsive

therapy, with patients high in OGM having increased depression scores at

follow-up. Furthermore, for patients with PTSD, poor recall of specific

memories of their trauma accounted for 25% of the variance of PTSD severity 6

months post trauma (Harvey et al., 1998).

Memory specificity also appears to be a valid predictor for the clinical status

at follow-up for patients with MDD. According to Hermans et al. (2008), for

these patients, high levels of OGM increased the probability of still being

diagnosed with MDD three to four weeks later. In a recent meta-analysis,

Sumner, Griffith, and Mineka (2010) evaluated the available data for a total of

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15 studies. They concluded that OGM is predictive of more elevated depressive

symptoms at follow-up.

Several explanations can be offered for why reduced memory

specificity is associated with a worse prognosis in a variety of mental health

disorders (see Raes, Williams, & Hermans, 2009). First, reduced memory

specificity is known to block efficient social problem solving strategies. As

mentioned by Baddeley (1988), when referring to non-clinical samples, specific

memories of past situations are used as a frame of reference to guide problem

solving in the present. So when people face a problem, they tend to think back

to comparable situations and use their knowledge of what worked earlier on

for such a problem. Overgeneralization, i.e. not being able to access these

specific memories, leads to poor problem solving, both in non-clinical and

clinical samples (Evans, Williams, O’Loughlin, & Howells, 1992; Goddart,

Dritschel, & Burton, 1996; Pollock & Williams, 2001; Raes et al., 2005). For

depressed individuals, not being able to solve social problems can contribute to

the continuation of depressive feelings and, in turn, lead to more persistent

depression.

Second, individuals who are overgeneral about the past also appear to be

overgeneral about their future. Williams, Ellis, Tyers and Healy (1996) reported

that the degree of difficulty in generating specific images of the future was

found to correlate with the extent to which subjects failed to retrieve specific

autobiographical memories from their past. Such an aspecific, blurred

perspective on the future might engender feelings of indifference and

hopelessness.

Third, reduced memory specificity might lead to poor emotional processing.

After being faced with a negative event, thinking and talking in a specific

manner about such an experience is an easy way to reexpose oneself, allowing

the individual to emotionally process the negative emotional experience

(Littrell, 1998). Not being able to access specific memories of past situations


98

may lead to a much lower level of natural exposure.

A fourth pathway suggested by Raes et al. (2006) is a reciprocal interplay of

OGM with rumination. Both may represent two different aspects of a common

underlying process. This process would be discrepancy-driven and attempts to

use analytical thinking (rumination) and overly general self-referent knowledge

(OGM) to solve personal problems. Two aspects of this process are key: 1)

verbal-abstract analytic reasoning e.g. questions, ‘Where did it all go wrong?’

combined with 2) self-relevant material in the form of categoric statements

(‘Always alone’, ‘Feeling unhappy’, ‘Never relaxed’). Both of them interact and

fuel each other, creating a spiral interaction, producing fruitless attempts

resolving problems, thus enhancing depressive feelings and feelings of

hopelessness (Williams et al., 2007).

The issue of how reduced memory specificity impacts the course of

disorders like depression is both theoretically and clinically relevant. In addition

to the four aforementioned pathways, we believe that there might be an

additional process involved. More specifically, we argue that reduced memory

specificity might impact the extent to which patients can benefit from

psychotherapy. Most therapies include components of psychoeducation or

include other elements of knowledge transfer or information that needs to be

stored in memory (e.g. new insights, agreements and homework assignments).

Many of these elements play a crucial role in the effectiveness of interventions

(Stice, Shaw, Bohon, Marti, & Rohde, 2009). From our own experience, we

know that patients can strongly differ in the extent to which they recall

elements of previous therapeutic sessions. Some clients have very vivid and

specific memories (e.g. ‘Last session, you mentioned how I make things more

difficult by avoiding my sister. This has kept me busy. Observing myself last

week, I think I must agree.’), whereas other patients are left with a mere

general sense of what happened in the last session (e.g. ‘It was a good session’,

we talked about stress.’). The extent to which specific memories can be

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retrieved with respect to therapy sessions may codetermine the efficacy of

treatment. Patients who are more specific may benefit more, as they have

better access to new perspectives and interpretations, suggested problem

solving strategies, and will be able to implement these elements in between

sessions (e.g. behavior change). Asa result, not being able to retrieve specific

memories of therapy sessions might be an additional mechanism through

which reduced memory specificity impacts the course of emotional disorders.

Some prospective studies have already focused on this the relationship

between autobiographical memory specificity and treatment for depression

(Brittlebank et al., 1993; Peeters, Wessel, Merckelbach, & Boon-Vermeeren,

2002; Raes et al., 2006), finding some evidence that treatment effectiveness

could be predicted by autobiographical memory specificity. Nevertheless, these

have mainly focused on the predictability of memory specificity for complaints

at a future time, whereas the current study focuses on whether memory

specificity is predictive for the extent to which problem solving skills are

acquired through a psychoeducational course.

In line with our hypothesis, the present study was therefore primarily

designed to investigate whether differences in memory specificity are

associated with the extent to which persons can benefit from a

psychoeducational intervention for stress, anxiety and depression.

Psychoeducational interventions may be particularly sensitive to differences in

memory specificity as they mainly rely on the transfer of information to impact

behaviour outside the session. Because the psychoeducational program under

investigation primarily focused on the acquisition of new problem solving skills,

the dependent variable in this study concerned changes in problem solving

skills from pre- to post-treatment. Rather than measuring problem solving

through self-report, we employed a behavioural task (Mean Ends Problem

Solving task; MEPS, Platt & Spivack, 1975). The main advantage of using this

behavioural task is that participants are not simply asked to report on how they


100

solve problems in general, but actually have to solve presented problems. This

test has been shown to provide more valid and accurate measures of

participants’ problem solving capabilities. It was predicted that memory

specificity would be associated with changes in problem solving skills, such that

the more specific the participant (as measured at the start of the training), the

more benefit in terms of problem solving skills acquisition. In addition, we also

investigated changes in self-reported complaints, but these were considered as

less relevant for the present research question given that such changes might

be short-term effects that are unrelated to the process of acquiring long lasting

problem solving skills (e.g. remoralization, hope, relief, social comparison). Two

secondary short-term relationships were nevertheless expected. A first

relationship was between changes in problem solving and selfreported

complaints, with a higher increase in problem solving strategies being related

to a larger decline in self-reported complaints. A second relationship was

between memory specificity and self-reported complaints, such that the more

specific the participant, the greater the decrease in self-reported complaints.

2 Method

2.1 Participants

Twenty-three students (17 women, 6 men) from two stress prevention courses

organized in the spring of 2007, agreed to participate in this study. The average

age was 21.7 years (SD = 1.9; range 19-26) and all participants were Dutch-

speaking. The courses were organized by the Psychotherapeutic Centre of the

KU Leuven and students were informed of these courses through the

university’s website and/or by a general mailing to all Dutch-speaking students

in the university. As an incentive for participation in the research, cinema

tickets were raffled.

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2.2 Materials

2.2.1 AMT

Memory specificity was measured using the AMT. Based on the extended

version of the Dutch AMT (Raes et al., 2008) two parallel versions were created

containing 20 cue words each. The words were matched for familiarity,

imageability and emotional intensity. In this version of the AMT, participants

were asked to write down a specific memory in response to 20 cue words of

alternating valence, with ten positive and ten negative words. Parallel version A

contained the following words: pleasurable, angry, attentive, emotionally hurt,

proud, angry, social, clumsy, enthusiastic, disappointed, self-confident, alone,

competent, desperate, succeeded, jealous, surprised, ashamed, satisfied, and

failed. Parallel version B consisted of: active, furious, interested, guilty, brave,

powerless, safe, sorry, carefree, anxious, happy, scared, relaxed, lonely,

successful, hopeless, brave, sad, helpful, and unhappy. These are all translations

of the original Dutch words. Reported memories can be roughly divided in two

groups. Specific memories are personal memories that refer to one particular

event, localized moment in time, lasting less than one day (e.g. ‘The moment I

heard I got the job at the pet shop’). Non-specific memories are subdivided in

categoric and extended memories, omissions, same events and no memories.

Generalized categoric memories are memories that may have occurred more

than once (e.g. ‘Every time I went to my friends’). Generalized extended

memories on the other hand refer to an event that may have happened only

once, but that lasted longer than one day (e.g. ‘During my vacation in Spain last

year’). When memories were coded, this scoring procedure produced a good

inter-rater reliability (K = .79).


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2.2.2 SAD-MEPS

The SAD-MEPS is an adapted version of the Means-Ends Problem Solving

Questionnaire (MEPS) developed by Platt and Spivack (1975). Like the original

MEPS the SAD-MEPS is used as assessment of problem solving skills. It consists

of a series of short stories with interpersonal problem situations faced by a

hypothetical protagonist. In each story, this protagonist is presented with a

problem, which is immediately followed by the successful resolution.

Respondents have to provide the middle of the story with the means and

strategies to reach its resolution. In the adapted version, stories are related to

situations of stress, anxiety or depression (Hermans et al., 2008). Three parallel

versions of the adapted format were used. In each version, three stories were

presented: one concerning stress, one concerning anxiety and one concerning

depression. Each story was scored for relevant means according to the manual

of Platt and Spivack (1975). A relevant mean is defined as being a discrete

sequential step enabling the protagonist to reach the goal described in the

story. Furthermore, also the overall effectiveness of the stories was calculated

on a 7- point Likert scale ranging from not at all effective to extremely effective

following a method provided by Fischler, Kendall, and Vye (1982). For both

scales, the average of all three stories was calculated. The inter-rater reliability

was good for number of means (ICC = .74) and acceptable for effectiveness (ICC

= .62).

2.2.3 DASS-42

To assess levels of depression, anxiety and stress, the Dutch version of the

Depression Anxiety Stress Scales-42 (DASS-42; Lovibond & Lovibond, 1995;

Dutch version by de Beurs, Van Dyck, Marquenie, Lange and Blonk (2001)) was

used. The internal consistency for the three subscales in this study was high

(.92 > α > .95).

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2.2.4 PSWQ

The Penn State Worry Questionnaire (PSWQ; Meyer, Miller, Metzger, &

Borkovec, 1990; Dutch version by van Rijsoort, Vervaeke, and Emmelkamp,

1997) was included in the study to measure beyond typical symptoms.

Worrying was therefore considered as an additional symptom and as an

underlying process of psychopathology (Raes et al., 2005). The questionnaire

showed an acceptable internal consistency (α = .78) in this study.

2.3 Procedure

2.3.1 Intervention

The psychoeducational course ‘Stress Control’ is based on the work of Jim

White (Borkovec & Whisman, 1996; White & Keenan, 1990; White, Keenan, &

Brooks, 1992). It is aimed at groups and delivered by a trained clinical

psychologist. For six sessions of two hour, twelve steps are run through. The

first step corresponds with the first session and consists of general information

concerning stress. This provides a framework for the session to follow. Steps 2

and 3 are linked to the first session and are homework assignments. The idea

behind this is that participants learn to apply the general information to their

own personal situation and create a personal frame of reference. In this way

they will have less effort to select the information that is being presented in the

subsequent sessions which can be relevant for them. Steps 4 to 12 are used to

examine a few contents in a more detailed way. Step 4 (Session 2) takes a

closer look to body control combined with breathing exercises; Step 5 discusses

(Session 3) cognitive techniques in combination with relaxation; and Step 6

(Session 4) teaches new skills in combination with relaxation. Step 7 to Step 10

(Session 5 and 6) used the knowledge from the first session and the learned

techniques from Session 2 and 3 and apply them to anxiety, panic, sleeping

problems and depressive feelings, and burnout. Finally, Steps 11 and 12


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(Session 6) provide an overview as guidance for future stress control. Both

courses were administered by the same clinical psychologist, who had received

prior training by the organization that adapted the original course to the

Flemish situation.

2.3.2 Assessment

Questionnaires were provided using the online survey site SurveyMonkey.com

(SurveyMonkey.com, Portland, Oregon, USA). First the AMT was presented

(only before the intervention), followed by the DASS, PSWQ and MEPS

(administered before and after the intervention). These were made available

one week before course commencement and one week after course

completion. To monitor each individual’s evolution, participants had to enter a

personal code before commencing with the questionnaire. After agreeing to an

informed consent form, they were able to fill out the questionnaires.

3 Results

3.1 Participant characteristics

DASS scores before the intervention were 11.48 (SD = 7.80) for depression,

12.48 (SD = 9.05) for anxiety and 18.61 (SD = 10.72) for stress. For worrying, a

mean PSWQ-score of 48.74 (SD = 8.42) was obtained. Overall, compared to

Dutch normative data (de Beurs, personal communication, 28 October 2007),

DASS scores were closer to those of a clinical sample than to scores of the

normal population. Worrying, furthermore, was slightly higher compared to the

normal Dutch population (van Rijsoort et al., 1997).

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Tabel 7 Changes in self-reported complaints (N = 23) after course

participation

3.2 Changes in self-reported complaints

DASS scores show a significant decline of complaints on all subscales, especially

for depressive complaints (Table 7). Worrying, as measured by the PSWQ,

shows a borderline statistically significant decline.

3.3 Autobiographical memory and changes in problem solving skills

Correlations were calculated for the AMT categories at baseline and the

differences between the pre and post measurements on the two SAD-MEPS

scores. Significant correlations were observed between the number of specific

responses and the changes in the number of relevant means. This was true for

the overall level of specific memories (r = .49, p < .01). Memory specificity went

hand in hand with positive changes in the number of suggested problem

solving strategies throughout the psychoeducational program (Figure 6). In

addition to the associations with memory specificity, a correlation was

observed between changes in ‘number of means’ on the SAD-MEPS and the

number of general extended responses (r = -.39, p < .05). Finally, a borderline

statistical significant correlation was found for changes in overall effectiveness

and the no memory category, (r = -.35, p = .06).


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Tabel 8 Means (percentages) and standard deviations on the different

categories of the autobiographical memory test (AMT) (N = 23)

3.4 SAD-MEPS Performance & relationship to complaints

For all participants, the average number of means reported in the SAD-MEPS

was 3.04 (SD = 1.03) before the course and 3.09 (SD = .98) after course

completion. The quality of the reported meanswas 4.03 (SD = 1.00) before

course commencement and 3.87 (SD = .82) afterward. Neither the change in

means nor the change in effectiveness of the SAD-MEPS responses were

significant, both Fs < 1. Furthermore, correlations were calculated for the DASS

and the PSWQ change scores and the two SAD-MEPS subscales. No statistically

significant correlations were found (rs < .33, ps < .13).

3.5 AMT Performance and relationship to complaints

Approximately 45% of the responses on the AMT were specific (Table 8).

Furthermore, 12% of the memories were general categoric and 30% were

general extended. Change scores were computed by subtracting pre

intervention scores from post intervention scores. Subsequently, correlations

were calculated for the DASS and the PSWQ change scores, and the AMT

baseline scores. Significant correlations were retrieved for the DASS-Anxiety

change scores, with the number of specific memories provided (r = .49, p =

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.009) and general extended memories (r = -.48, p = .01). As such, the more

specific memories and the less general extended memories a participant

provided prior to course commencement, the larger the decrease of the score

on the DASS Anxiety scale at post intervention.

Figure 6. Relationship between the AMT percentage of specific memories and

the SAD-MEPS change score for number of means.

4 Discussion

The goal of this study was to determine whether differences in memory

specificity are associated with the extent to which persons can benefit from a

psychoeducational intervention for stress, anxiety and depression. Although

there is already evidence for the overall effectiveness for psychoeducational

group interventions for stress, anxiety, and depression (Cuijpers, Muñoz,

Clarke, & Lewinsohn, 2009; Neil & Christensen, 2009; Van Daele, Van

Audenhove, Hermans, Van den Bergh, 2011), little is known about participant

characteristics that may influence course outcome at the individual level.


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For autobiographical memory, on average almost half of the answers were

specific in nature, but there was a certain amount of variability between

participants. No overall significant changes were reported when looking at the

effects of the psychoeducational intervention on problem solving strategies.

When the relationship between the AMT and the change scores for the SAD-

MEPS was considered however, some significant relationships were observed.

More specifically, a high number of specific memories and/or a low level of

general extended memories as measured by the AMT was found to predict an

increase in the number of relevant means used in SAD-MEPS’ problem solving

tasks. One could assume that this relationship might be accounted for by

changes in a communal third, for example executive functioning. In a study

with depressed patients Raes et al. (2005) already found that when SAD-MEPS

effectiveness was regressed on rumination, memory specificity, and working

memory functioning, memory specificity was the only significant predictor of

MEPS effectiveness. Whether this also applies to the acquisition of problem

solving skills is not yet known and will require further research.

Looking at in self-reported complaints, a significant decline was found on all

subscales of the DASS, indicating a short-term beneficial effect of the

psychoeducational course. Although these changes are positive, they are

considered to be only temporary and unrelated to the process of acquiring long

lasting problem solving skills, which in turn would lead to an actual, more

permanent reduction of complaints. This is in line with findings of previous

studies e.g. by White and Keenan (1990) and White et al. (1992) and also with

the current study not finding any correlations between changes in problem

solving as measured by the SAD-MEPS and these short-term changes in

complaints. Furthermore, there were only a limited number of significant

correlations between the AMT baseline scores and the DASS- and PSWQ

change scores. The absence of this relationship might seem surprising given the

research evidence on the predictive validity of the AMT for the course of

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depression, which was presented in the introduction. It is nevertheless

plausible that the time between pre and post measurement is not sufficiently

long enough to detect actual, long lasting changes at the symptom level. This

could explain the absence of these correlations.

As for other limitations: a first limitation the present study is its small

sample size (N = 23), which limited the power of the statistical tests. A second

limitation is that no follow-up data could be provided. It is expected that

individuals would continue to apply the problem solving skills taught during

psychoeducation to their own situations and therefore these would improve

over time. Because this assumption is dependent on further skill acquisition,

consolidation and continued practice, it is uncertain which correlations could

be expected when measured at a later point in time (e.g., six months after

course completion). A third limitation is that no information was gathered on

whether participants made clinical criteria for depression or if they were

undergoing any treatment during the time of the intervention. A final limitation

is the predominantly female composition of the study. Psychoeducational

interventions nevertheless primarily attract women and a relatively higher

proportion of women is associated with overall better results (Van Daele et al.,

2012). Therefore, having a primarily female composition does not make these

findings less relevant for the target group.

Nonetheless, if subjected to replication, these findings may have important

implications for the guidance and the setup of (psychoeducational)

interventions that intend to transfer knowledge and skills to targeted groups. A

first suggested step could be to setup an initial (self) screening of course

participants by means of the AMT, in order to determine whether their

memory specificity is sufficient to benefit from a psychoeducational

intervention. This will of course require further research on the predictive

capacities of the AMT, in order to determine what exactly corresponds with

insufficient memory specificity (e.g. determine a cut-off score). A second, and


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even more important step, would be to subsequently provide memory

specificity training to people with low memory specificity. This would enable

them to maximize their potential and to benefit fully from a psychoeduational

course.

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Chapter 6

Overgeneral autobiographical memory predicts

changes in depression and anxiety in a community

sample

This study investigated whether overgeneral autobiographical memory (OGM) predicts

the course of symptoms of depression and anxiety in a community sample, after 3, 4, 6,

12 and 18 months. Participants (N = 156) completed the Autobiographical Memory Test

and the Depression Anxiety Stress Scales-21 (DASS-21) at baseline and were

subsequently reassessed using the DASS-21 at four time points over a period of 18-

months. Using hierarchical linear modelling, we found that OGM predicted long-term

changes at 12 months, B31= 22.4, p = .005, and at 18 months, B41 = 13.1, p = .025, from

baseline for depression. OGM furthermore predicted long-term changes for anxiety at

12 months, B31 = 16.3, p = .026. Similar to other studies, no short-term predictive

effects were found. The results from the current study provide additional support for

the hypothesis of OGM as trait-like characteristics, as it also appears to predict the

evolution of symptoms of depression and anxiety in a community sample.

Keywords

autobiographical memory, depression, anxiety, prediction, community sample

OGM predicts evolution of anxiety and depression

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1 Introduction

Overgeneral autobiographical memory (OGM) is defined as a difficulty in

recalling specific memories from one’s life. It was first investigated by Williams

and Broadbent (1986) in a sample of suicidal patients. The most common

assessment tool for OGM is the Autobiographical Memory Task (AMT; Williams

& Broadbent, 1986), which exists in several different versions. Generally,

participants are asked to provide specific memories in response to a set of cue

words. The instructions state that a specific memory is a personal memory of

one particular event that is localized in time lasting less than one day (e.g., ‘The

moment I found out that I got the job’; Williams et al., 2007). The valence of

the cue words is usually alternated between positive (e.g. ‘happy’) and negative

(e.g. ‘sad’). Although the goal is to retrieve specific memories, participants

often generate various types of non-specific memories. Some of these non-

specific memories are ‘categoric’, which are events that have occurred more

than once (e.g. ‘Every time I go to my favourite pub’). Other non-specific

memories include ‘extended’ memories (lasting longer than one day, e.g.

‘During my vacation in Spain last year’) or are ‘non-memories’ (a.k.a. semantic

associates). People suffering from clinical depression generally report fewer

specific and more categoric memories (van Vreeswijk & de Wilde, 2004;

Williams et al., 2007). These are considered to be the best indications for OGM.

1.1 OGM and depression

There is evidence that OGM also predicts increases in depression following

stressful life events, as shown by Mackinger, Loschin, and Leibetseder (2000) in

a sample of pregnant women and by Gibbs and Rude (2004) in students

experiencing high frequencies of stressful life events. Rawal and Rice (2012)

showed similar findings in a sample of 277 adolescents who were at familial

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risk for depression. These participants were initially free from a depressive

disorder, but OGM predicted the onset of MDD.

In depressed participants, however, OGM does not seem to be related to

the level of symptoms, as it actually appears to predict the course of their

depression (Brittlebank, Scott, Williams, & Ferrier, 1993). In a sample of 22

patients with MDD they found that OGM was highly correlated with the failure

to recover from depression and accounted for 33% of the variance in the

Hamilton Rating Scale for Depression (HRSD; Hamilton, 1960) at seven months

follow-up. Since this first study, similar results have been observed, for

example in 25 patients with MDD in a study by Peeters, Wessel, Merckelbach,

and Boon-Vermeeren (2002) and in a study by Raes et al. (2006) for 28 MDD

patients, both after seven months of follow-up. In conclusion, OGM seems to

predict the course of depression in specific populations including students and

clinical populations (Sumner et al., 2011).

1.2 OGM and anxiety

Since mood and anxiety disorders are often comorbid (e.g, Mineka, Watson, &

Clark, 1998; Kessler et al., 2005), it is possible that OGM is related to anxiety

and depression alike. A number of studies have already found evidence for an

immediate relationship between OGM and PTSD. Studies by McNally Lasko,

Macklin, and Pitman (1995) and McNally, Litz, Prassas, Shin, and Weathers

(1994) reported that Vietnam combat veterans with PTSD exhibited more

difficulty in recalling specific memories compared to those without PTSD.

Schönefeld, Ehlers, Böllinghaus, and Rief (2007) expanded upon these findings

in a study with 42 assault survivors. They reported that participants with PTSD

retrieved fewer specific memories and more overgeneral memories compared

to assault survivors without PTSD, but only when they were explicitly instructed

to suppress assault memories. For other anxiety disorders, the relationship

between OGM and anxiety is less clear. For example, Wilhelm, McNally, Baer,


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and Florin (1997) found that patients with obsessive compulsive disorder do

not exhibit OGM, unless they suffer from concurrent MDD. Furthermore, OGM

also does not seem to be associated with general anxiety disorder, social

anxiety disorder or blood and spider fearful individuals (Williams et al., 2007).

There are some indications, however, that OGM might be related to

changes in anxiety. Until now, the majority of these studies focused on OGM

predicting anxiety in the context of trauma or stressful life events (Williams et

al., 2007). Harvey, Bryant, and Dang (1998) found that participants who

developed acute stress disorder (ASD) following motor vehicle accidents

reported fewer specific memories in response to positive cue words, compared

to those who did not develop ASD. van Minnen et al. (2005) reported that for

women who failed an in vitro fertilization treatment, the number of reported

specific memories at baseline was negatively related to depressive and anxiety

symptoms after the treatment. Furthermore, Bryant, Sutherland, and Guthrie

(2007) conducted a study with fire fighters over a period of four years. They

found that impaired retrieval of specific memories in response to positive cues

prior to trauma exposure significantly predicted posttraumatic stress severity

after exposure to trauma. Finally, a study by Kleim and Ehlers (2008) showed

that for participants who were measured two weeks after an assault, OGM

predicted PTSD six months later over and above what could be predicted from

symptom severity and initial diagnoses of MDD, acute stress disorder, or

assault-related specific phobia. As of yet, no studies have focused on the

relationship between OGM and the occurrence of anxiety outside of trauma

research. Thus, there is little evidence that OGM is related to current

symptoms of anxiety. The current study sought to expand this area of research

by examining the relationship between OGM and anxiety as well as depression.

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1.3 OGM and the evolution of depression and anxiety

When studies focus on OGM and its relationship with the evolution of

emotional disorders, symptoms are often considered at one specific follow-up

point. Examples are the study by Anderson, Goddard, and Powell (2010) in

students with one follow-up after three months, the study by Dalgleish, Spinks,

Yiend, and Kuyken (2001) in patients with seasonal affective disorder with one

follow-up after seven months and the study by Raes et al. (2006) in depressed

inpatients which also included one follow-up after seven months. Although

these studies provide insight into the relationship between OGM and

psychopathology, they give little information on the trajectory of change over

time. Studies that include multiple discrete time points have the advantage

that they assess the form of the relationship over time. At present, few studies

have included multiple follow-up moments. Two of them focused on depressed

patients. A first was the study by Brittlebank et al. (1993) in which OGM in

response to positive words showed stable correlations to depression measured

at three months and seven months follow-up. A weaker relationship was found

for negative cue words. A second study was conducted by Peeters et al. (2002)

in 25 patients with MDD. In this study, the strongest effect was found for OGM

in response to negative cue words, which predicted depression at three

months. Borderline significant results were reported at seven months.

Furthermore, a study by Hipwell, Reynolds, and Pitts Crick (2004) with healthy

pregnant women found that OGM did not predict post-partum depressive

symptoms after two weeks. After eight weeks, however, OGM did significantly

predict depression. Hermans et al. (2008) focused on students who failed their

first exams at the university. No significant correlation was found between

OGM and change scores for depression at baseline and at a first follow-up after

two weeks. However, after nine weeks, a significant correlation for OGM and

change scores was found.


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In summary, there is evidence for a relationship between OGM and changes

in symptoms of depression and anxiety, but the available studies are difficult to

compare and few of them include long-term follow-up at more than one time

point.

1.4 Current study

It is clear that OGM can predict the course of depression in some populations,

and that OGM also predicts changes in anxiety. However, little is known on

whether OGM can successfully predict symptoms of anxiety and depression

outside the specific contexts of stressors and traumas. To redress these gaps in

the literature, we recruited a community sample and set out to examine the

potential of OGM to predict symptoms of depression and anxiety alike. Our

sample received questionnaires at five different time points (3 months, 4

months, 6 months, 12 months and 18 months) to accurately determine the

trajectory of this relationship. This follow-up is the longest known in literature

for a community sample. It is also one of the longest follow-up studies on OGM

in general, together with those by Spinhoven et al. (2006) and Bryant,

Sutherland, and Guthrie (2007), which included follow-up periods for 49 and 24

months respectively.

We hypothesised that OGM at baseline would predict the trajectory of

anxiety and depression. Specifically, we hypothesised that a higher proportion

of categoric memories and/or a lower proportion of specific memories at

baseline would be associated with an increase in symptoms of depression and

anxiety over time.

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2 Method

2.1 Participants

Our sample included 156 participants (53 men and 103 women; mean age 38.8

years, SD = 14.1, range = 18.9 – 68.8) from Flanders, the northern, Dutch-

speaking region of Belgium. Potential participants responded to advertisements

in local newspapers to participate in a questionnaire study concerning their

general well-being. Participants received € 10 per data collection wave for

participating. They were recruited as a convenience sample in a matched

control study evaluating the effectiveness of a psychoeducational intervention.

In this context a number of them would be matched with intervention

participants. For the current study, we only considered this control group, as

we were interested in the natural course of depression and anxiety and

whether OGM predicts this course.

2.2 Materials

2.2.1 Autobiographical Memory Task

Memory specificity was measured using the AMT. Participants were presented

with ten cue words and asked to provide a different, specific memory in

response to each of them. The words were of positive and negative valence

and presented in alternating order. Translated from Dutch, the positive cues

were: pleasurable, attentive, proud, social and enthusiastic; negative cues

were: angry, emotionally hurt, angry, clumsy, and disappointed. Responses

were scored as falling into one of six categories: specific memories, categoric

memories, extended memories, no memory (a.k.a. semantic associates),

repeated events, and omissions. Extended memories refer to an event that

may have happened only once, but that lasted longer than one day. A memory

is labeled as ‘same event’, when participants violate instructions and an event


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is repeated at least once in response to different cue words. The ‘no memories’

category mostly concerns semantic associations and irrelevant answers.

Omissions are non-responses. Inter-rater reliability was determined for the

responses of 30 participants. The level of agreement between raters was high

(K = .84; Viera & Garrett, 2005). In addition, multiple studies support good

psychometric properties of the AMT (Heron et al., 2012; Griffith et al., 2009;

Griffith, Kleim, Sumner, & Ehlers, 2012, Griffith, et al., 2012).

2.2.2 Depression Anxiety Stress Scales

Participants completed the DASS-21, including the depression (DASS-21-D) and

anxiety (DASS-21-A) subscales. Each subscale contains 7 items and sum scores

range from 0 to 42. Although symptoms of depression and anxiety are often

highly correlated, the DASS has adequate discriminant validity (Crawford &

Henry, 2003). Internal consistency for both the depression and anxiety subscale

is excellent with αs of .95 and .90 respectively.

2.3 Procedure

Participants completed the AMT and DASS-21 at Time 1, which were

subsequently sent back by mail to the investigators. During the follow-ups, the

DASS-21 was the only measure as participants no longer received the AMT.

Time 2 was five months after Time 1; Time 3 was six months after Time 1; Time

4 was one year after Time 1; Time 5 was 18 months after Time 1. Drop-out was

limited, with a maximum of 9 percent at any time point: 156 participants

completed the questionnaire at Time 1, 153 at Time 2, 144 at Time 3, 145 at

Time 4, and 145 at Time 5. As a part of the larger treatment effectiveness

study, participants also completed additional measures, which were unrelated

to the current study.

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Table 9 Hierachical Linear Model and results of DASS-21-subscales of depression and

anxiety as the dependent variables.

2.4 Analyses

For both DASS subscales, if fewer than 20% of the items were missing (i.e. not

more than one item), we prorated the scores by assigning the missing item the

average value of the other items of the subscale. We used hierarchical linear

modelling (Raudenbush & Bryk, 2002) to examine the effect of overgeneral

memory on the trajectory of complaints of depression and anxiety. Because

OGM, anxiety and depression were not normally distributed in this sample, we

used robust standard errors for significance testing. Participants had to

complete at least the baseline and one additional time point in order to be

included in the analyses. Full maximum likelihood estimation, which is robust in

the presence of missing data, was used in the estimation of model parameters.

Table 9 presents both models.


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Table 10 Descriptive statistics for the DASS-21-subscales of depression and anxiety.

The level-1 models for depression and anxiety, respectively, contained the

within-subject relationship between time point and the DASS-21. Time point

was dummy coded such that one variable measured the change from baseline

to T2 and from baseline to respectively T3, T4, and T5. Level 2 of the model

contained the regression of the level-1 parameters on baseline AMT. At level 2,

error terms were included for the four level-1 slopes to capture participant-to-

participant differences that might exist for the relationship between time point

and depression or anxiety.

3 Results

3.1 Descriptive statistics

Table 10 presents means and standard deviations for DASS-21-subscales of

depression and anxiety. At each time point, there was, on average, five percent

of data missing (after scores were prorated). We furthermore calculated AMT

proportions by dividing the number of responses for each category by the total

number of actual responses minus the number omissions (i.e., the

denominator of each proportion was the total number of responses possible

with the number of non-responses subtracted).

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Participants reported 64% (SD = 27) specific memories, 5 % (SD = 10) categoric

memories, 17% (SD = 16) extended memories, 14 % (SD = 19) no memories,

and 1 % (SD = 0) repeated events. In 2% (SD = 8) of the cases, no response was

given.

3.2 OGM and symptom changes

To test our hypothesis on the relationship between OGM and the change in

depression, we used DASS-21-D as the dependent variable in the regression

analysis. For the relationship between OGM and changes in anxiety, the DASS-

21-A was used as the dependent variable in the regression using robust

standard errors. When OGM was operationalized as the proportion of specific

memories, no significant results were found. However, when OGM was

operationalized as the proportion of categoric memories we found it did not

significantly predict depression at Times 1, 2, or 3, but did predict it at Times 4

and 5 (Table 9). Prediction of anxiety was significant at Time 4, and approached

significance at Time 5. In terms of the size of the effects, the coefficients that

indicate the effect of baseline categoric memories for depression were largest

at Time 4, B31 = 22.4, p = .005, and decreased at Time 5, B41 = 13.1, p = .025.

For anxiety, the coefficients were also significant at Time 4, B31 = 16.3, p =

.026, but the effect only approached significance at Time 5, B41 = 12.5, p =

.063.

4 Discussion

We studied a large community sample at five time points, with the last time

point 18 months after baseline. OGM predicted changes in symptoms of

depression and anxiety in this community sample. The large number of time

points allowed for a precise assessment of the form of the relationship.

Inspection of the size of the regression coefficients for each of these time


122

points (Table 9) showed that the effects were small at first, increased gradually,

and were strongest after one year. After one year, the effect sizes diminished.

Overall, effects are slightly stronger for depression compared to anxiety. A

limitation of this study is that we did not assess life stress or trauma, which

may also be related to anxiety and depression. Contrary to our hypothesis, we

did not find significant correlations at six months, which has been reported in

other OGM studies (Sumner, Griffith, & Mineka, 2010). A possible explanation

is that OGM has less influence on non-clinical samples, which has been

hypothesised by Raes, Hermans, Williams, and Eelen (2007). This would explain

why a longer follow-up period is required for our community sample before

significant (negative) effects of OGM on symptoms of depression and anxiety

are found. The increasing influence of confounding factors (e.g. environmental

or personal changes) in turn might be the reason why the strength of the

effects diminishes after peaking at one year follow-up and are no longer

significant at 18 months.

Most studies up until now have focused on the relationship between OGM

and changes in depression, so it is important to extend this research into

anxiety. Furthermore, previous studies on OGM and anxiety have always

considered the effects of OGM for a select number of people who faced highly

stressful or traumatic situations, whereas the current study broadens its

applicability to a more general community sample. A final merit is that we were

able to map changes across several time points.

In our sample, we did not find significant correlations between OGM and

symptoms of anxiety and depression at baseline, but hierarchical linear

modeling allowed us to examine changes in anxiety and depression from

baseline; these findings were consistent with our hypotheses. OGM may be an

underlying process involved in the exaggeration of symptoms, which is

consistent with the hypothesis of Williams et al. (2007) – that OGM may be a

trait-like characteristic that serves as a vulnerability factor for depression. As

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pointed out by Sumner, Griffith, & Mineka (2010) there was already evidence

that OGM was associated with the later increase of depressive symptoms in

non-clinical samples, but only mixed evidence for OGM predicting the course of

depression. This study adds additional support to the hypothesis of OGM as a

trait-like characteristic, as it also appears to predict the evolution of symptoms

of depression and anxiety in a community sample.

More research is needed on OGM across several time points. This could

provide a better view on changes in the strength of the relationship between

OGM and depression and anxiety. If our hypotheses are correct, a gradual

incline in the relationship between OGM and symptoms of anxiety and

depression, followed by a slight decline could be found in clinical samples in the

short-term (e.g. six months to one year) and in non-clinical samples in the

long(er) term (e.g. one year to one year and a half, or even longer). Finally,

further replication of these results in non-clinical samples could confirm the

potential of the AMT as a screening measure for internalizing psychopathology

in the general population. If similar results can also be found in clinical samples

(for example in patients with MDD), this would provide additional evidence for

OGM as a trait-like characteristics that can act as a significant vulnerability

factor for depression.

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Chapter 7

General discussion

Mental health is becoming increasingly important in high income countries

(World Health Organization, 2005; World Health Organization, 2012). However,

these countries also face more people with mental disorders (Mathers &

Loncar, 2006). Furthermore, even when conservative numbers are considered,

it appears that the majority of these people lack access to professional care.

Currently, less than one in three receives treatment (Kessler et al., 2005).

Ironically, we simultaneously also face the issue of overtreatment, due to

significant numbers of false positive detections of mental disorders in primary

care setting (Mitchell, Vaze, & Rao, 2009). If MHC ever wants to be able to

meet the demands and provide sufficient, efficient and adequate care for all, a

paradigm shift is required. In this paradigm shift, the position of MHC

organizations in society has to evolve from instances that primarily treat

disorder to services that also provide education, coaching and prevention. A

practical implication of this paradigm is the creation of a more accessible and

extended primary care, a goal to which this doctoral dissertation hopes to

contribute on a number of levels.

In this general discussion, we will offer a synthesis of the three main

research topics and their results. Next, we will discuss some limitations of the

research in this doctoral dissertation, together with future perspectives based

on these specific studies as well as on available literature. We will conclude this

general discussion with some considerations on the characteristics of

policy oriented research and a number of general and specific policy

recommendations.

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1 Research topics and main results

The research topics of this doctoral dissertation might seem diverse, but are all

united under the goal of policy oriented research. The first topic was

‘effectiveness’, which set out to gain additional insight in the overall evidence

base for psychoeducational group interventions that focus on stress reduction.

We furthermore evaluated the effectiveness of a local adaptation of a

psychoeducational group intervention. The second research topic was

‘implementation’ and focused on means to increase both fidelity and

adaptation when researchers and their partners in the field collaborate in

evaluating intervention effectiveness. A third and final research topic

considered the possibilities for ‘prediction’. Within this research topic, the

potential of autobiographical memory was investigated in predicting

intervention success for individual participants and in predicting the evolution

of mental health in a community sample.

1.1 Effectiveness

A first focus was to evaluate the effectiveness of psychoeducational

interventions for stress reduction in general. The goal was twofold: to provide

an overview of the short- and long-term effectiveness of psychoeducational

group interventions for stress and to chart possible moderators of intervention

effectiveness. The systematic review and meta-analysis reported small, but

consistently positive effect sizes for 16 studies at post-treatment (Cohen’s d =

.27). This provided a clear indication for the short-term effectiveness for this

type of interventions, with a larger overall effect compared to similar meta-

analyses (Martin, Sanderson, Cocker & Hons, 2009; Stice, Shaw, Bogon, &

Marti, 2009). Long-term effectiveness, measured for nine studies after on

average six months, was less pronounced (Cohen’s d = .20). Furthermore, as for

the moderators, a model including intervention duration and participant

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gender was found to explain 42% of the variance in effects. Apparently, short

lasting psychoeducational interventions for women were most effective. These

results are of course correlational and we therefore had to refrain from making

firm causal interpretations.

The finding that shorter interventions were more effective could be

considered surprising. One could have expected that the more time spent

working on and learning about stress and stress-related problems, the more

knowledge transfer and skill development would occur. However, in the

literature, this relationship is also not consistently reported. Richardson and

Rothstein (2008) for example reported similar results as they found that

shorter interventions produced better results. They even reported a distinct

pattern in which interventions that relied solely on relaxation techniques

benefit from longer duration, whereas interventions that were multimodal (a

description that fits almost all of the interventions in our meta-analysis) appear

to lose effect as their length increases. Aside from their (slightly) larger

effectiveness, shorter programs are also likely to be more cost effective and

practical to implement. Therefore, we tend to agree with the authors when

they state that short-term interventions just might be sufficient – and perhaps

even better – than programs of longer duration. As surprising as the results on

intervention duration might have been, as unsurprising is the finding that

interventions with larger numbers of women appear to accomplish better

results. Several explanations can be found; a first is that women typically report

more stress than men (Matud, 2004). The higher their initial level of symptoms,

the more change there can occur and the less chance there is for floor effects.

A second reason is that they have a more positive attitude concerning

psychological openness and they have more favourable intentions to seek help

from mental health professionals, compared to men. As Bertakis, Azari, Helms,

Callahan, and Robbins (2000) state, these might be just some of the reasons

why they also make more frequent use of (mental) healthcare services. This is

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also in line with findings by Pyne et al. (2003) who reported that their primary

care intervention for depression was cost-effective for women, but not for

men.

A second focus was to evaluate the effectiveness of ‘Stress Control’ (White,

2000, adaptation by ISW Limits, 2006). A total of 47 people participating in the

intervention were first matched with an equal number of controls on socio-

demographic variables and baseline levels of symptoms. Results of trend

analyses showed a steady linear decline of stress and depression in the

intervention group from pre-intervention to post-intervention and further on

through follow-up. These effects were not observed in the non-intervention

group. There also was a strong decline in worrying, but only little change in

stress management skills. Furthermore, measures of clinical significance

showed that almost 30 percent of all participants experienced a clinically

significant and reliable change in the year following the course. Finally, the

strongest effect occurred for those participants who presented themselves

with higher levels of initial symptoms. Within the intervention group, there was

a considerable amount of variation, which is why solely presenting the study

outcomes for the group as a whole might be misleading. When we compared

participants with low and high initials symptoms, participants with high initial

levels showed a much stronger continuous and gradual decline of symptoms

whereas most participants with low initial symptoms remained stable. Similar

results have already been found in other interventions (Rowe, 2000, 2006).

Some might consider this heterogeneity as a design flaw: if we would have had

a stricter participant recruitment policy, the participant group as a whole could

have been more homogenous. However, we wanted to implement the

intervention in real life circumstances in the field and measure how effective it

is in these conditions. Therefore, we only controlled a limited number of

parameters (i.e. the explicit exclusion criteria for potential high risk

participants). Because of that, we ended up with large differences between

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participants, but we believe this represents a more accurate and better

reflection of this stress management course when it is implemented in the

field.

1.2 Implementation

The second research topic was a direct consequence of (struggles with) the

evaluation of the effectiveness study. Personal experiences combined with a

search in literature resulted in the construction of a framework for

implementation research. Empowerment implementation provides a new look

at the concept of implementation fidelity and intervention effectiveness, as it

reconciles the apparent contradiction between adaptation and fidelity (Castro,

Barrera, & Martinez, 2004). More specifically, when implementing

interventions in the field, researchers have always struggled keeping their

interventions as pristine as possible, in order to safeguard their effectiveness

(Burns, Peters, & Noell, 2005). These well-meant attempts often had an

adverse effect though, as local partners were not fully convinced of the

proposed approach or decided to change vital intervention features anyway

(Levy, Baldyga, & Jurkowski, 2003). When commencing the effectiveness study

in three regions in Flanders, we became aware of these issues, as we noticed

that small changes were required to the initial implementation plan in order to

accommodate to local needs, suggestions or demands. In small scale

interventions that are tied to one particular setting it might be easy to make

such changes: deviations are documented and reported as ‘condiciones sine

quibus non’. This subsequently raises little issues for the gathering of data,

reporting of results and the final evaluation. However, because our

intervention had to be implemented in three different regions, it quickly

became clear that small deviations from the initial plan in each region could

possibly results in large differences between implementation settings. In the

end, this could hamper comparability across regions. Not accommodating to

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the needs and suggestions of local partners was out of the question, as the goal

of the Policy Research Centre Welfare, Health and Family, is to obtain results

that are highly relevant for both policy and practice (KU Leuven, UGent, VUB, &

KHK, 2007). Active involvement of partners in the field is considered key in this

context.

We therefore developed empowerment implementation, which tries to

overcome this issue. In this framework, an intervention consists of two parts: a

core component and less important intervention aspects. The core component

is proven effective in clinical trials and remains untouched throughout the

implementation process. Less important intervention aspects are decided upon

through an intensive collaboration between researchers and local partners. The

framework therefore consists of three main phases: partner selection, deciding

upon practical aspects and deciding upon content-related-aspects. As such, it

addresses and overcomes the issues of implementation fidelity and adaptation.

Because this framework has a broad applicability, it is interesting for all

researchers wishing to evaluate an intervention implementation in more

realistic circumstances, while also using partner input to their advantage. In the

end, all of those involved in the program benefit from increased stakeholder

participation, including the local partners (World Health Organization, 1986).

Because of their involvement, they have the ability to control and to adapt an

intervention to their needs, to enhance their ownership of the intervention,

and to increase their capacities to develop, adapt and implement future

interventions. This framework proved to be particularly useful for our

effectiveness study and because we wanted to spread this knowledge, we

decided to consolidate our findings in a publication in which we used the

effectiveness study as an illustration of how to put this framework into

practice.

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1.3 Prediction

Group psychoeducational interventions target large amounts of people and

often make little distinction between different participant profiles. This can be

considered an inherent strength of this intervention type, as it offers

anonymity and does not force people to interact with other participants and

professionals or to disclose personal information, which may lower the

threshold for participation (Mischoulon et al., 2001). However, it also has a

downside, as not all participants may benefit equally. Therefore, an important

improvement would be to predict the success for each individual in advance

and make use of targeted referral for this type of interventions. Because

determining this chance of success should require little time and should also

not be intrusive, the Autobiographical Memory Task (AMT; Williams &

Broadbent, 1986) was considered. This instrument is often used to determine

both memory specificity and overgeneral memory, concepts that have

previously shown their merits in predicting the course of mental health

disorders in a clinical context (e.g. Raes, Williams, & Hermans, 2009). In a first

study, evidence was found for memory specificity as a predictor for the

acquisition of problem-solving skills during a group psychoeducational

intervention ‘Stressbeheersing’ (ISW Limits, 2006), a local adaptation of the

intervention ‘Stress Control’ (White, 2000). More specifically, questionnaires

including the AMT and the Stress Anxiety Depression Means-Ends Problem

Solving Questionnaire (SAD-MEPS; Hermans et al., 2008) were administered.

This SAD-MEPS is used as assessment of problem solving skills. It consists of a

series of short stories with interpersonal problem situations faced by a

hypothetical protagonist. In each story, this protagonist is presented with a

problem, which is immediately followed by the successful resolution.

Respondents have to provide the middle of the story which contains the means

and strategies to reach its resolution. A total of 23 participants filled in these

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questionnaires prior to and after the psychoeducational course. Subsequently

correlations were calculated for the AMT at baseline and the difference

between the pre and post measurements on the SAD-MEPS. Significant

correlations were observed between the number of specific responses and the

changes in the number of relevant means.

Because of the encouraging results in the psychoeducational group

intervention, the AMT was also considered as a predictor for the course of

depression and anxiety in a nontreated convenience sample, i.e. the larger

community sample (N = 157) from which the matched control group in the

effectiveness study was sampled. Using hierarchical linear modelling

(Raudenbush & Bryk, 2002) OGM managed to predict changes in the long-term

for depression and anxiety. No effects were found after three, four and six

months. However, categoric memories did appear to predict depression and

anxiety after one year. After 18 months, only the significant relationship

between categoric memories and depression remained.

Before both these studies were conducted, OGM had already successfully

been applied in different situations. In clinical contexts it can serve as a

predictor for the course of depression (e.g. Brittlebank, Scott, Williams, &

Ferrier, 1993) and for the clinical status at follow-up for patients with MDD

(e.g. Hermans et al., 2008). Furthermore, OGM can also tell us something about

whether people are capable to have specific expectations and hopes about

their future (Williams, Ellis, Tyers, & Healy, 1996) or if people can successfully

manage negative emotional experiences (Littrell, 1998). These studies now add

additional applications to the use of OGM as it might also tell us something

about whether overgeneral patients can benefit from psychoeducation (or

maybe even psychotherapy in general) and if people from a community sample

might be vulnerable for developing (symptoms of) anxiety and depression.

However, questions still remain. For our study on the acquisition of

problem-solving skills, it is for example not quite clear whether these changes

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are actually caused by OGM or if a communal third like executive functioning

might also play a role. A study by Raes et al. (2005) already found that when

the effectiveness of problem-solving skills was regressed on rumination,

memory specificity and working memory functioning, memory specify was the

only significant predictor of the effectiveness of problem-solving skills.

Whether this also applies to the acquisition of problem-solving skills, is

nevertheless not yet clear. For our study with the community sample,

alternative explanations for the observed effects also exist, as there might be a

reciprocal interplay between OGM and rumination, both of which could

represent different aspects of a common underlying process (Raes et al., 2006).

Such a process would combine continuous worrying with overgeneral thinking

about one’s particular situation, as such creating a negative spiral interaction

leading to emotional problems.

2 Limitations and future perspectives

Within this PhD, we have focused on three different research topics. For each

of them, there are of course some methodological limitations, which will be

discussed below. These limitations also draw our attention to opportunities.

Therefore, we will also make recommendations for future research.

Furthermore, this research will also be framed within the larger context of

policy related research and the challenges this upholds.

2.1 Effectiveness

2.1.1 Limitations

The meta-analysis only used published articles, which made our study – just like

any other meta-analysis – prone to publication bias. We tried to avoid this by

using failsafe N-statistics (Rosenberg, 2005), but it remains highly likely that a

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number of interventions finding no effects probably never have been published

and therefore went undetected. Furthermore, in order to successfully conduct

the meta-analysis only randomized controlled trials could be considered in

which most studies made use of waitlist controls and no treatment controls.

We can therefore not conclude that psychoeducational group interventions for

stress are better than other specific interventions. Furthermore, we can also

not compare these interventions to treatment or care as usual, which could

have been achieved by (including) non-inferiority trials (Chevalier, 2009),

although such results are far more difficult if not impossible to include in a

meta-analysis. We can therefore only conclude that these interventions are

more effective in dealing with stress than undertaking no action at all.

As a first remark concerning the effectiveness study, we did not make use of

random allocation of participants, which seems rather inherent of research in

the field making use of long-term follow-up. Withholding (wait list) control

participants from following an intervention – even a psychoeducational stress

course – seemed deontologically incorrect. We found the matched control

design to be the most practical and ethical solution. Using this design, we could

have long-term follow-up because our control group did not require denying

people treatment. However, the main limitation of the study is that the

matching procedure was far from perfect. Although we managed to recruit a

large number of participants for the control group and could successfully match

people on socio-demographics like age, gender and socio-economic status, the

level of complaints at baseline turned out to be far higher for in the

intervention group compared to the control group. It therefore proved to be a

difficult task to find enough people with sufficiently high complaints in the

control group, which led to unequal baseline levels of complaints in the two

groups.

A second remark concerns the fact that this primary care intervention was

initially also presented as a primary preventive intervention. This is one of the

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three types of prevention, according to Caplan (1964, cited in Van den Broucke,

2001), together with secondary and tertiary prevention. Primary prevention

tries to reduce the incidence of new cases of a specific mental disorder.

Secondary prevention aims at reducing the prevalence by means of early

detection and treatment, whereas tertiary prevention aims at reducing the rate

of residual disability of chronic ill patients and also attends to them. The goal of

a psychoeducational group intervention with a focus on primary prevention is

therefore primarily to teach people who are mentally healthy how to safeguard

their mental health. A number of participants of the intervention actually

belonged to that target group and could be considered – according to the

definition of Keyes (2007) – as flourishing. However, the majority of

participants were facing at least mild to moderate symptoms. The course could

therefore not be considered as a primary preventive intervention. However,

because complaints were often still subclinical and the course could help

people to avoid crossing the ‘clinical threshold’, it may still be considered as a

preventive intervention, although ‘only’ focussing on secondary prevention.

A third remark concerns the participant profile. As often, the people

attracted by the intervention were on average middle-aged highly educated

women. It goes without saying that this makes the results hard to generalise to

other subpopulations. On the other hand, our meta-analysis had already shown

that other psychoeducational interventions for stress were evaluated with

similar participant groups, because in general (highly educated, employed)

women make most use of these services.

2.1.2 Suggestions for future research

Both studies also have their merits: aside from their findings, they also offer

suggestions for future research. The meta-analysis points out two major issues

in current research. A first is that still too little studies make use of (sufficient)

follow-up and effects are only considered in the period immediately following

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an intervention. Even when follow-up is included, six months is often

considered as strong evidence for long-term effects. More and longer follow-up

is however required to truly determine long-term effects. Furthermore, a lot of

studies report too little information on intervention characteristics. When

conducting moderator analyses we often encountered unclarities or

unspecified aspects of interventions. Since we are still unaware of what the

exact factors are that contribute to the (lack of) effectiveness of

psychoeducational interventions, documenting and reporting intervention

characteristics as detailed as possible is paramount. Only if we move beyond

reporting standard information like average age and gender, and also start

including characteristics that are not commonly reported like group sizes,

ethnicity, and presence of interaction, we will obtain a better view of factors

influencing effectiveness.

The main conclusion of the effectiveness study is in line with that of the

meta-analysis, but also offers some nuance. Our theoretical reflection remains

correct that effectiveness research with longer follow-up is necessary. When

implementing in the field however, methodology like the ‘gold standard’ RCT,

seems to reach its limits. Withholding treatment from people for long periods

in real life contexts not only seems, but actually is unethical. Alternatives like

matched control designs have their merits, but their validity is highly

dependent on the matching process and the pool of subjects from which they

can be recruited. Because this premise is partially violated in our own study,

conclusions had to be cautious. Future research studies will therefore have to

find a balance between producing studies of high internal validity, like RCTs,

and setting up studies of high ecological validity that make use of sufficiently

long follow-up. Balancing both contradictory needs may prove to be a difficult

task.

Furthermore, the general search throughout the literature that was a part

of this doctoral dissertation also pointed out to the need for a more extensive

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way of conducting research. When reading articles on intervention studies, the

strong emphasis on statistical significance of obtained effects cannot be

ignored. In general it seems that for a large part of the scientific community it is

even the major – if not the only – means to confirm effectiveness. However,

the goal for almost any intervention should be to obtain improvements for

participants or patients that truly matter for them. Realising a mere statistically

significant change on a number of highly specific preselected symptoms might

be insufficient. Making sure that change is not only reliable but also meaningful

should be an important consideration. Paying more attention to clinical

significance – in case of severe initial symptoms – might be one way to obtain

this goal. This can be done by systematically monitoring the evolution of

participants during interventions using validated questionnaires of which

normative data is available for large population groups. On the one hand, this is

advantageous for participants because it allows for detailed and personal

feedback on their progress. On the other hand, the advantage for researchers is

that this approach not only offers insight in whether any change is occurring for

participants, but also whether that change is meaningful from a clinical

perspective. Other monitoring efforts could also focus on paying more

attention to changes concerning the perception of mental disorders by patients

and to their general quality of life. These suggestions are without a doubt not

only relevant to research; ideally they could also be incorporated in everyday

practice.

Finally, in recent years there has been on a strong increase in the number of

economic analyses of (preventive) interventions. These compare the estimates

of economic burden to the costs of the program designed to reduce that

burden and compared to the outcomes achieved by the intervention (Corso &

Lutzker, 2006). An optimal cost effectiveness analysis ideally targets an

intervention that is well-defined, short-term and with a measurable outcome.

When Sefton (2000) considered social welfare interventions, he however found

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most interventions had multiple, long-term outcomes, which were often

qualitative in nature. The programs were also heterogeneous and often local

variations existed. The overall interventions effects were rather small and user

involvement appeared to be a determining factor for intervention

effectiveness. Taking these considerations into account, the importance, the

need and the possible merits of such analyses for preventive interventions in

the field of mental health should be acknowledged. However, when

considering the cost-effectiveness of interventions, results should always be

interpreted with caution and within the larger contextual framework.

2.2 Implementation

2.2.1 Limitations

For true empowerment of stakeholders, involvement is ideally present

throughout the whole research project (Levy et al., 2003; Wallerstein & Duran,

2006). Empowerment implementation should therefore be followed by

empowerment evaluation (Fetterman, 1996). This implies that partners would

be closely involved with the evaluation of the project. However, because clear

research objectives were determined in advance by policy makers, this was

unfortunately not possible in our study. Furthermore, although we made every

effort to involve partners in the field as much as possible during the

implementation, the explicit and detailed construction of the systematic

framework was only done after the actual implementation. If we could have

constructed this prior to the implementation, we might have obtained even

more relevant information and could have used this to optimize the framework

even further. Although we consider the current framework to be coherent and

well constructed, it certainly should not be considered a final version, as there

will always be room to add more detail and perfect it further.

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We especially hope that this framework will be used by other researchers when

conducting research with partners in the field. Not only to actively apply

empowerment implementation in numerous similar contexts, but also to

specifically adapt and improve it. One suggestion for such an improvement

could concern the way in which interventions are presented towards

participants during their implementation. Motivational research has already

shown that there is a difference in how people perceive the pursuit of

promotion versus the pursuit of prevention. Pursuing health promotion implies

striving towards positive outcomes (gains) or trying to avoid the absence of

positive outcomes (non-gains). Pursuing prevention, however, implies striving

towards the absence of negative outcomes (non-losses) or trying to avoid

negative outcomes (losses) (Molden, Lee, & Higgins, 2007). A common

misconception is that prevention is all about avoiding undesired outcomes and

promotion focuses solely on achieving desired outcomes. However, whereas

both approaches are quite different, their outcome can be the same (Carver,

2004). For example, two individuals can strive to obtain the same positive goal,

reducing their stress level. For one person, this might be in order to avoid

becoming depressed (prevention concern), whereas for another it may well be

a way to achieve more calmness (promotion concern).

Although the focus on prevention or promotion may shift within an

individual depending on the circumstances or context, there is evidence for the

fact that some people are chronically promotion- or prevention-focused (Lee et

al., 2000). For now, this motivation research has mainly focused on individuals,

but it may also have opportunities in the field of intervention implementation.

Our intervention was mainly presented as prevention: dealing with stress, in

order to avoid depression and anxiety. This approach may appeal far less to

people who have a health promotion-focused mindset. Could the reach or even

the effectiveness of the intervention be influenced by changing the way an

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intervention is portrayed, depending on the target group or even depending on

each individual participant?

An intervention that better matches the motivational goals of individuals

could perhaps improve their intervention adherence, their retaining of

information, and the time and effort they invest in the intervention. Achieving

such an improved match between intervention and individual would only

require minor adaptations to the original intervention: the actual content does

not require change, but only the way it is portrayed. Such adaptation might of

course be difficult to achieve for group interventions as the intervention cannot

be tailored to fit each and every individual. However, there are certainly

interventions in which the way content is portrayed can be tailored more easily

(e.g. e-mental health interventions). It does not seem unlikely that this may

have substantial effects. This could therefore be an interesting next step in

improving the implementation strategy of preventive interventions.

2.3 Prediction

2.3.1 Limitations

The first study found that memory specificity could act as a predictor for the

acquisition of problem-solving skills during a group psychoeducational

intervention. There were several limitations to this study. As a first, its sample

size was rather small. Furthermore, the participants were predominantly

female. This limitation was however not a major drawback, given that we

previously found in the meta-analysis that psychoeducational interventions

actually attract mostly women and the results are therefore still relevant for

the participant group as a whole. Furthermore, only post measurements were

available. Given our strong emphasis on the need for follow-up in intervention

studies, it is unfortunate that for this specific study, we do not dispose of long-

term follow-up data. A limitation of the second study is that it made use of a

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convenience sample, which is not the same as a non-clinical sample, as we

could not determine whether individual participants suffered from a DSM-IV

disorder. Furthermore, we also were not aware of the occurrence of possible

stressors, like aversive (life) events that may have influenced symptoms of

participants.


Because of the small sample size, a next step would be to replicate the findings

from the first study. If replicated, these findings may have important

implications. When guiding people towards this particular or other similar

interventions, a first step could be an initial (self) screening during which

potential participants can determine whether they might benefit from the

intervention or not. A second and possibly even more important step is that

memory specificity training (MeST; Raes, Williams, & Hermans, 2009) could be

offered to people with low memory specificity prior to the psychoeducational

intervention. This would enable them to maximize their potential and to

benefit fully from the intervention. Such a training program consists of four

weekly one hour sessions, offered to small groups of three to eight

participants. The first session mainly concerns psychoeducation about memory

functioning in relation to depression, after which participants are offered

homework exercises that require them to generate specific memories for ten

cues, in preparation of the second session. The second session starts with

discussing the homework, after which participants are asked to recall detailed

specific memories for four cues (two positive and two negative) and they again

receive ten cues to prepare for the next session. Session three and four are

similar to session two, but focus more on negative cues. In the end, a brief

summary of the whole program is offered and participants can evaluate the

course and share their personal experiences with the training with the other

group members and the trainer. A study by Raes et al. (2009) showed that the

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retrieval style of participants became significantly more specific following the

training. Neshat-Doost et al. (2012) found similar results and also reported that

lower levels of depression at two month follow-up compared to a control

group. Finally, Raes, Schoofs, Griffith and Hermans (submitted) replicated these

findings in a non-randomised controlled trial and furthermore also found that

for MeST participants, increases in memory specificity were maintained at one-

year follow-up.

The second study provides preliminary indications that the concepts of

memory specificity and OGM could be relevant for predicting the increase of

symptoms of depression and anxiety. This offers opportunities for the AMT as a

screening measure for internalizing psychopathology in the general population.

Because we furthermore know that memory specificity can also be trained, it

may also be relevant to incorporate MeST as a component in more general

preventive interventions in primary care.

Aside from these suggestions that focus on more applied research, both

studies also highlight opportunities for basic research, as a number of

theoretical questions remain. For each study, we like to highlight one. As for

OGM and the acquisition of problem solving skills, an interesting question is

whether a communal third like executive functioning also play a role in the

acquisition of problem solving skills. For the relationship between OGM and

symptoms of anxiety and depression in a community sample, a hypothesis

worth investigating is whether a reciprocal interplay between OGM and

rumination could be the explanation for a negative spiral, leading to depression

or anxiety. In both cases, future research is required.

3 Characteristics of the research in this PhD

The topics in this doctoral dissertation might seem quite diverse. This is a

consequence of the focus of this PhD which was not solely to conduct in-depth

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research, but especially to advance general knowledge and my personal

expertise across the domains of research, policy and practice. These three

domains interact closely and decisions in one domain almost always influence

the others. The interaction between these domains is visualised in Figure 7 and

will be discussed in detail below.

For this PhD, Policy is represented by the Policy Research Centre Welfare,

Health and Family. It has the specific goal to support policy makers in pursuing

an effective and innovative policy, and to do so with scientific results (KU

Leuven et al., 2007). Closely involved in the Research component are the

Research Group on Health Psychology, the Centre for Excellence:

Generalization in Ill Health and Psychopathology and LUCAS, the centre for

Care Research and Consultancy, all units of the KU Leuven. Last but certainly

not least is Practice, which is embedded in the complex context of MHC in

Flanders (one of the regions of Belgium).

Figure 7. Relationship between policy, research and practice.

General discussion

144

Policy interacts with research (1) as time and means are often limited and

interests and opportunities have to be balanced. Research is done on a per

project basis, of which both the duration and focus do not always correspond

with the typical trajectory for obtaining a doctoral degree. Research on the

other hand also interacts with policy (2), as results obtained in research are

translated into policy recommendations which can subsequently for example

be incorporated in national guidelines or action plans. The results on the

effectiveness study can for example be framed within the larger context of

Flemish action plan on prevention of suicide (Coppens, Scheerder, & Van

Audenhove, 2011). Research furthermore also influences practice (3), as

concepts that are found in basic research are translated to relevant tools and

interventions which can be applied by partners in the field. Both articles on the

AMT have the literature on OGM and memory specificity as a basis. We used

this evidence from basic research and translated it to the field, in a search for

highly specific applications, like predicting the capability of stress course

participants to acquire problem-solving strategies or for predicting the

evolutions of symptoms of anxiety and depression in a community sample. The

other way around, feedback and concerns from practice are also conveyed to

research (4). These concerns help shape both content and implementation of

tools and interventions, for which empowerment implementation is an

example. Finally, practice and policy also interact closely (5+6) and in this

interaction they often rely on information from research to find suitable

compromises between what is preferred by practitioners and with is possible

for (government) administrators.

In conclusion, applied research may be broader and therefore less in depth,

but it also has several merits. Because it is conducted in more realistic

circumstances, obtained research evidence is more relevant for everyday

practice and also for policy makers. This makes further translation and

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145

subsequent dissemination of findings easier and improves its chances for

success.

4 Specific implications and general policy recommendations

4.1 Specific implications

The results from this doctoral dissertation have a number of specific

implications for practitioners and for policy makers. First, it provides good

prospects for the use of group (psychoeducational) interventions as a means of

primary and/or secondary prevention. Although there is still some level of

uncertainty concerning the effectiveness, we have found that different

organisations in the field of primary (mental) healthcare are capable of

successfully setting up primary care interventions through means of ad hoc

partnerships. Second, throughout the dissertation it became clear that primary

care interventions may provide an opportunity for MHC to redefine its services.

These interventions may not only reach a greater number of people in need of

care, in some cases they may even be used to prevent (the deterioration of)

subclinical mental disorders. As they are set up within the local community and

with well known partners from outside of medical contexts, or virtually through

means of the internet, this makes the threshold for participation lower in both

cases. A key advantage is furthermore that they may be less associated with

stigma, which still remains an important issue.

The main challenge for these primary care interventions seems to be in the

actual reaching of the people in need or even the people not (yet) in need. The

slogan we would like to propose in this context is: ‘reach out to where the

people are’, an adage which can also be found in the context of neighbourhood

work (Henderson & Thomas, 2013). Currently, MHC acts mostly as a service

provider which attracts a limited number of people who struggle and reach out

General discussion

146

themselves with a request for help. Healthcare professional subsequently try to

accommodate their needs, alleviate their distress, or reduce their symptoms.

This concerns however a limited number of people, who professionals often

only see when much harm has already been done. If MHC however wants to

make optimal use of primary care interventions, it has to quit being a mere

service provider and also be more proactive by promoting such services. This

implies that mental health professionals should actively try to reach people

who have increased risks for mental disorders.

At a structural level, two main components are required to evolve to a

better MHC: 1) integration of mental health services into primary care and 2)

an intense integrated and collaborative care between service providers (Collins,

Hewson, Munger, & Wade, 2010). Taken together, this doctoral dissertation

portrays a positive and hopeful message, as it shows that both aspects are well

within our reach and that these can already be realised successfully in small

scale studies.

4.2 General policy recommendations

If we transcend our research further, some general policy recommendations

and long term proposals can also be made. In a post-financial crisis period,

means are scarce and everyone – including the MHC sector – has to be

economical. It may therefore seem sensible to invest most (or maybe even all)

of these limited means in those who currently require them most: the patients

in need of (urgent) psychological care. However, although this group may

certainly not be forgotten and their funding and support should not be

interrupted, there is also a need for a future-oriented policy that extends

beyond maintaining the status-quo. The current situation is far from ideal, with

a significant number of people suffering from mental disorders because they

are lacking professional care (Bebbington et al., 2000; Kessler & Wang, 2008).

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147

Without additional efforts, we should not expect any drastic change in the near

future, if any even deterioration (Mathers & Loncar, 2006).

4.2.1 Beyond the healthcare sector

In order to address this issue, we first need to extend our scope beyond the

healthcare sector. Unemployment, adverse neighbourhood characteristics, low

income, education, socio-economic status (SES) and income inequality are all

associated with mental disorders, as described in a meta-analysis by Lund et al.

(2010). It might therefore seem like a good idea to set up primary care

interventions targeted at people from a lower SES aimed at teaching them how

to cope with stress. However, as their stress may likely be caused by

unemployment or by other factors related to their current standard of living,

such initiatives might just be a bit perverse. Although there is ‘no health

without mental health’, a first prerequisite for everyone still remains to

safeguard more basic needs, labelled as ‘physiological’ and other ‘safety needs’

by Maslow (1954) already a long time ago. The primary goal for every policy

maker should therefore still be to first address such issues. It seems however

unrealistic to expect that such societal problems will be easily addressed or

quickly resolved. Furthermore, not every mental disorder or all symptoms of

depression, anxiety ... can be traced back to e.g. poor standards of living or to

income inequality.

4.2.2 Innovations within MHC

MHC therefore still needs to evolve further. For people with severe mental

disorders, an increased attention to outreaching is required and for the general

population the attention should shift, preferably from curing to educating,

coaching and promoting mental health.

Without a doubt, advanced care for people with severe symptoms and

mental disorders will always remain an aspect of MHC. When such care is

General discussion

148

organised, it is preferably done in a context of integral care, in which the needs,

questions and goals of people who require care are taken into account in order

to pursue good quality of life for each patient (SARWGG, 2012). Similar to these

changes is the choice for more outreaching of care, in which patients are no

longer always treated in specialised hospitals, but in their own living

environment. Assertive community treatment (ACT) is such an intervention

type in which care providers first focus on gaining patients’ trust in order to

make them voluntarily engage in treatment (Mulder & Kroon, 2009).

As previously discussed in the introduction, there are furthermore some

essential changes required in order to provide a better fit of MHC with the

general population as a whole (Werkgroep Eerstelijnsgezondheidszorg, 2010).

At the level of the general public and patients, it is important to increase

mental health literacy, but also to improve the general attitude, as stigma

remains an important issue (Lasalvia et al., 2012). Also for health professionals,

there should be increased attention to knowledge and attitudes towards

mental health. One particularly promising initiative is the introduction of

primary care psychologists. Primary care psychologists offer generalist, short-

term support in primary care in close collaboration with other professionals like

GPs. This initiative has already proven its merits in The Netherlands (Emmen,

Meijer, & Verhaak, 2008) and may also offer opportunities to promote and

disseminate primary care interventions further to the broad general public. Last

but certainly not least is the policy level: all of the realisations mentioned

above required substantial funding, something MHC – and especially

prevention in MHC – is lacking. Aside from the important role policy makers can

play in providing additional funding, they can also help practitioners guide this

transition. For this they can rely on both basic and applied research can help

them to take the leap. Because any policy should rely on the best available

information, an important goal remains therefore to continue investing in

policy research. This can help policy makers gather insights in the current state

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149

of MHC, how particular interventions work, for whom these are most effective

and how they should be implemented. This knowledge has high practical value,

as it can be used to shape current and future MHC and as it also helps to make

optimal use of all resources currently available. Research evidence on the

effectiveness of stepped care (e.g. van Straten, Tiemens, Hakkaart, Nolen, &

Donker, 2006; van‘t Veer-Tazelaar et al., 2009) and the use of primary care

interventions like group psychoeducational interventions (e.g. Van Daele et al.,

2012), and e-mental health (e.g. Griffiths, Farrer, & Christensen, 2010) all has to

be taken into account when shaping the MHC system of the future.

If we can manage to realize these prerequisites, MHC might be able to

successfully restructure itself. During this restructuring, MHC has the

opportunity to convey a strong and positive message: mental health is more

than the absence of mental illness and everyone can learn how to maintain or

improve his or her mental health. However, for those who struggle and who

need additional help or guidance, individual ambulatory consultation and

residential treatment is still available. Translating this stepped-care approach to

any local situation will require a great deal of effort, but should preferably start

today, rather than tomorrow.

151

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Dankwoord

Ziezo, je bent er geraakt: het einde van dit doctoraat, meerbepaald het

dankwoord! Een woordje van dank op het einde plaatsen leek me iets logischer

dan in het begin, want alleen al het feit dat je tot hier bent geraakt verdient

een welgemeende dankjewel. Tenzij je al mijn harde werk gewoon genegeerd

hebt en uit nieuwsgierigheid meteen tot hier hebt gebladerd. Ik neem het je

niet kwalijk, maar ik kan je wel aanraden om toch eens terug te kijken naar de

voorgaande hoofdstukken: interessant onderzoek, relevante resultaten en toch

ook wel een groot deel van mijn tijdsinvestering de afgelopen vier jaar.

Maar, genoeg gezeverd en nu even serieus. Ik mag dan wel degene zijn die

‘het proefschrift heeft aangeboden’, het is zeker niet enkel en alleen mijn

verdienste. Doorheen de jaren heb ik met heel veel mensen contact gehad die

elk op hun eigen manier hebben bijgedragen aan dit doctoraat. Ze allemaal

bedanken is een huzarenstukje en je loopt natuurlijk altijd het risico om iemand

te vergeten, maar ik zou toch graag een poging wagen.

Ten eerste natuurlijk mijn promotor, Omer. Vier jaar geleden introduceerde

je me bij het steunpunt, gaf je me de mogelijkheid om te doctoreren en nam je

daarbij ook de rol op van promotor. We waren beiden misschien enigszins naïef

om na het relatieve succes van mijn masterproef de stresscursus nu eens te

gaan implementeren en valideren in de wijde wereld (of althans toch in

Vlaanderen). Het bleek uiteindelijk een hele beproeving, met onverwachte

ontwikkelingen en veel bijsturen. Ik kon er echter altijd op rekenen dat je me

met de nodige rust en kalmte hierdoor zou leiden. Bij het schrijven van

verschillende artikels en het doctoraat stond je verder ook altijd klaar met

nuttige en constructieve feedback. Al zal ik vooral de bemerking “opvallend

goed geschreven qua taal, beter dan gewoonlijk :)”, niet snel vergeten. Voor dit

Dankwoord

180

alles wil ik je heel oprecht van harte bedanken!

Ik kon verder ook nog rekenen op twee copromotoren die me elk vanuit

hun eigen expertise met raad en daad hebben bijgestaan. Dirk, bijna zes jaar

geleden werd mijn eerste keuze voor een masterproefonderwerp door puur

toeval, tot twee maal toe uitgeloot. Al na onze eerste contacten bleek dat ik

niet alleen het geluk had om een masterproef te mogen schrijven op een

onderwerp dat me echt aansprak, maar dat het ook wel heel goed klikte met

de promotor daarvan. Doorheen de jaren heb ik altijd op je kunnen rekenen

voor snelle commentaren, je oprechte interesse en een grenzeloos en

aanstekelijk enthousiasme. Ook aan jou daarom: bedankt! Chantal, LUCAS was

in eerste instantie onbekend terrein: niet alleen was het een eindje verwijderd

van het vertrouwde PSI, ook beleidsrelevant onderzoek was mij nog vrij

onbekend. Doorheen de jaren heb je me stap voor stap geïntroduceerd in deze

wereld en was je er steeds om me op de do’s en don’ts te wijzen. Jouw

ervaring, bijsturingen en tips hebben een essentiële rol gespeeld in het tot

stand komen van dit doctoraat.

Naast met mijn promotorenteam was er ook veel ondersteuning uit diverse

andere hoeken. Ten eerste zijn er de co-auteurs van onze publicaties en de

leden van mijn begeleidingscommissie. Bedankt Filip, om altijd vol

enthousiasme en ongelofelijk snel te reageren op mijn vragen en om geregeld

te polsen hoe het met de vooruitgang van mijn doctoraat stond. Jamie, al

beperkt onze samenwerking zich slechts tot het afgelopen jaar, ik heb in die

periode je analytische skills en je input bij het schrijven heel erg geapprecieerd.

Deb, bedankt voor de verschillende keren dat we hebben samengezeten rond

het opzetten van de interventies, het waren telkens heel verrijkende

ervaringen. Een dankjewel is zeker ook gepast voor de je hulp die je hebt

geboden in het bijsturen van het onderzoek, toen dat wat moeilijker liep.

Stephan, ik kwam destijds naar jou met een idee om een artikel over onze

implementatieperikelen te schrijven. Ik ben er nog altijd van onder de indruk

Dankwoord

181

hoe we onder jouw impuls erin geslaagd zijn om op basis daarvan een volledig

theoretisch framework te construeren. Hoewel onze contacten meestal via

mail verliepen, vond ik de bezoekjes aan Louvain-La-Neuve ook heel verrijkend.

Daarnaast kon ik ook beroep doen op de nationale en internationale expertise

van mijn juryleden. Jim, I would like to thank you sincerely. You might not be

fully aware of it, but you have been a major influence on me for the past six

years. Ever since I heard about the Stress Control course and your vision on

mental health(care) I was really fascinated by its potential and I wanted to get

involved. In the end, both my master’s thesis and my doctoral dissertation are

largely inspired by your work. Furthermore, I really enjoyed our contacts so far

and I hope we can keep in touch! Heleen, ook jou wil ik bedanken om opnieuw

een tekst van mij door te nemen en hier kritisch over te reflecteren. Daarnaast

zal ik zeker ook onthouden hoe je me geïntroduceerd hebt in de wondere

wereld van e-mental health en de groep Europese onderzoekers die hiermee

bezig is. Professor Claes wil ik ten slotte bedanken om ook de rol als jurylid van

mijn doctoraat te willen opnemen.

De volgende groep mensen die ik wil bedanken, is een meer omvangrijke:

mijn collega’s. Het Steunpunt Welzijn, Volksgezondheid en Gezin was officieel

mijn werkgever. Valérie, als coördinator stond je heel dicht bij het dagelijks

reilen en zeilen van mijn onderzoek. Ik wil je bedanken voor het luisterend oor,

de talloze keren dat ik je bureau ben binnengestormd met de een of andere

bezorgdheid. Je zorgde voor het nodige overzicht, maar ook voor een

ontspannende babbel bij een kop koffie of tijdens een lunch in de Timory en in

diverse andere etablissementen. LUCAS was de onderzoeksgroep waar ik

meestal mijn dagen spendeerde. Jullie zijn ondertussen met een hele bende en

de laatste tijd zijn er ook heel wat nieuwe gezichten, maar ik wil jullie allemaal

bedanken om af en toe te polsen hoe het onderzoek of het doctoraat gaat en

de vele ontspannende momenten. Sophie, Evelien, Johanna, Anja, Iris, Veerle,

Jasper, Eva, Kirsten, Koen, Jeroen, Evy, Inge, Jessie, Aline, Nele, Stephanie, Joke,

Dankwoord

182

Liza, Dirk, Marieke, Monia, Kevin, Manuela en Lut: allemaal hartelijk bedankt!

Ook bedankt aan de collega’s die er voor een groot deel van mijn traject bij

waren, maar ondertussen elders vertoeven: Alexandre, Ann, Else, Kristien,

Maartje, Nele en Bert. Ten slotte, een specifieke dankjewel aan mijn huidig

bureaugenoot Annelies voor haar steun. Aan jou wil ik ook mijn oprechte

excuses aanbieden voor mijn vele ostentatieve gezucht de afgelopen maanden

tijdens het finaliseren van dit doctoraat. Zeker ook bedankt aan mijn oud

bureaugenoot Bram, voor de jaren die we samen al doorgesparteld hebben en

waarbij ping pong tijdens de middagpauze werd afgewisseld met hitte- en

koudegolven, met het maken van constructies met duplo en met het bezoek

van wespen, een ‘inbreker’ en een verdwaalde koolmees. Natuurlijk was er ook

nog de Onderzoekseenheid voor Gezondheidspsychologie. De meeste onder

jullie kennen me daar vooral als de persoon die pas opduikt tijdens retraites,

recepties of etentjes. Verder was de jaarlijkse International Dinner Party

telkens een schot in de roos, waarvoor dank, Angela! Jullie hielpen me met de

nodige ontspanning, maar het was voor mij ook iedere keer weer een

verrijkende confrontatie met basisonderzoek en het reilen en zeilen van de

academische wereld. Ook jullie allemaal bedankt: Kai, Katleen, Erik, Elena,

Marleen, Rena, Hassan, Ali, Joanna, Meike, Sibylle, Martien, Elke, Stéphanie,

Marta, Katja en Ruth. Een extra dankjewel aan Thomas, Steven en Ann: al van

bij het hele begin, op de eerste retraite in de Ardennen, hebben jullie visie en

de ervaringen die jullie deelden mij een beeld helpen vormen van wat de

mogelijkheden zijn als onderzoeker en hoe je die zo optimaal mogelijk kan

benutten.

Omdat mijn onderzoek in nauwe samenwerking werd opgezet met de

praktijk, kan ik ook de verschillende lokale partners niet dankbaar genoeg zijn.

Velen van jullie hebben je vrijwillig geëngageerd en bijkomend ingezet voor het

project. Sommige onder jullie gingen zelfs zo ver om deelnemers aan te manen

de vragenlijsten in te dienen ‘want het is toch wel voor Tom zijn doctoraat,

Dankwoord

183

hoor!’. Een welgemeende dankjewel daarom aan CGG Vagga, Provincie

Antwerpen, het toenmalig LOGO Antwerpen, Stad Antwerpen, CGG LITP,

OCMW Genk, de gemeentebesturen van As, Zutendaal, Opglabbeek en

Diepenbeek, de werkgroep Genk Preventief Gezond, CGG Largo, het toenmalig

LOGO OIVD, de Provincie West-Vlaanderen, het Cultuurcentrum Ieper en alle

andere personen en organisaties die zich op de een of andere manier voor het

STAP-project hebben ingezet.

Onderzoek is natuurlijk niet alles. Daarom ook bedankt aan iedereen uit

mijn omgeving en de mensen bij het VVKP en het LAPP, in het bijzonder Jana,

voor de nodige afwisseling en ontspanning. Verder wil ik ook Sigrid bedanken

voor de wekelijkse broodjes in de Kruidtuin, een ideaal moment om even te

ventileren over de problemen met publicaties, maar ook om stil te staan bij hoe

leuk doctoreren soms wel niet kon zijn. Daarnaast zijn er natuurlijk ook nog

Steven, Pieter en Ben. De middagslunches aan ‘de tempel’, onze

mannenweekends, de after work drinks en zo veel meer, het zijn telkens

hoogtepunten.

Daarnaast is er natuurlijk ook mijn familie. Een speciaal woordje van dank

voor tante Karien en nonkel Martin die al sinds mijn eerste jaren hier aan de

universiteit er een gewoonte van hebben gemaakt om af en toe uit Zuienkerke

langs te komen, vooral in de examens, om me even uit de studiesfeer te halen

en voor wat broodnodige ontspanning te bezorgen. Ook bedankt aan mijn

broer Dries, voor de avonden hier in Leuven, maar ook voor de gezellige tijd die

we samen geregeld hebben in Varsenare. Mama en papa ik heb zoveel aan

jullie te danken: doorheen de jaren hebben jullie me steeds alle kansen

gegeven en hebben jullie me steeds op alle mogelijke manieren ondersteund.

Zonder jullie was dit nooit gelukt. Het mag dan misschien wel ‘mijn’ doctoraat

zijn, maar jullie verdienste hierin is niet te onderschatten.

Als allerlaatste wil ik ook nog Ann-Sofie bedanken. Mijn verloofde op het

moment dat ik dit schrijf, mijn vrouw wanneer ik dit doctoraat verdedig. Na al

Dankwoord

184

die tijd zijn we zo op elkaar ingespeeld dat ik mijn leven zonder jou eigenlijk

niet kan voorstellen. Je hebt samen met mij het hele traject meegemaakt,

zowel de frequente ups als de occasionele downs. Je bent er altijd voor mij

geweest. Samen met jou tijd doorbrengen is pure ontspanning en brengt me

altijd tot rust. Laat ons eerlijk zijn: had iedereen iemand zoals jou, kreeg ik

‘mijn’ stresscursussen zelfs aan de straatstenen niet kwijt. Ik hart je hard!

185

Curriculum vitae

Tom Van Daele obtained a Master of Science in Clinical and Health Psychology,

with a specialization in children and adolescents at the KU Leuven. During that

time he took an internship in a local organization for health consultation

(LOGO) and completed a master thesis on the effectiveness of a stress control

intervention. These experiences sparked his interest for research in primary

mental healthcare and in the field of (mental) health prevention and

promotion. More information can be found on www.vandaeletom.be.

Publication List

Articles in internationally reviewed scientific journals

Van Daele, T., Van Audenhove, C., Hermans, D., Van den Bergh, O., & Van

den Broucke, S. (2012). Empowerment implementation: Enhancing

fidelity and adaptation in a psychoeducational intervention. Health

Promotion International. Advance online publication.

doi: 10.1093/heapro/das070

Van Daele, T., Van den Bergh, O., Van Audenhove, C., Raes, F., & Hermans,

D. (2013). Reduced Memory Specificity Predicts the Acquisition of

Problem Solving Skills in Psychoeducation. Journal of Behavior Therapy

and Experimental Psychiatry, 44, 135-140.

doi: 10.1016/j.jbtep.2011.12.005

Van Daele, T., Hermans, D., Van Audenhove, C., & Van den Bergh, O.

(2012). Stress reduction through psychoeducation: a meta-analytic

review. Health Education & Behavior, 39, 474-485.

doi: 10.1177/1090198111419202

http://www.vandaeletom.be

Curriculum vitae

186

Van Daele, T., Hermans, D., Vansteenwegen, D., Van Audenhove, C., & Van

den Bergh, O. (2010). Preventie van stress, angst en depressie door

psycho-educatie: een overzicht van interventies. Psychologie &

Gezondheid, 38, 224-235. doi: 10.1007/s12483-010-0390-5

Articles in other scientific journals

Van Daele, T. (2012). Computergestuurde zelfhulp een meerwaarde voor

hulpzoekende adolescenten met depressieve symptomen? [Does

computerized self help over advantages for help seeking adolescents with

depressive symptoms?]. Minerva: Tijdschrift voor Evidence-based Medicine,

11(10), 121-122.

Meeting abstracts, presented at international conferences and

symposia, published or not published in proceedings or journals

Van Daele, T., Van Audenhove, C., Vansteenwegen, D., Hermans, D., Van den

Bergh, O. (2013). Detecting depression in chronic ill patients by home nurses:

Effects of a minimal intervention. Paper presented at the 27th Annual

Conference of the European Health Psychology Society. Bordeaux, France,

16-20 July 2013.

Van Daele, T., Hermans, D., Vansteenwegen, D., Van Audenhove, C., & Van

den Bergh, O. (2012). Effectiveness of a Six Session Stress Reduction

Program for Groups. Poster presented at the 120th Annual Convention of

the American Psychological Association. Orlando, FL, USA, 2-5 August 2012.

Van Daele, T., Van Audenhove, C., Hermans, D., Van den Bergh, O., & Van den

Broucke, S. (2012). Towards a Participatory Approach To Implement a

Psychoeducational Intervention. Poster presented at the 120th Annual

Convention of the American Psychological Association. Orlando, FL, USA, 2-5

August 2012.

Curriculum vitae

187

Van Daele, T., Vansteenwegen, D., Luts, A., Hermans, D., & Van den Bergh, O.

(2012). Online intervention for depressive symptoms in chronic illness. Work

in progress. Poster presented at the First Meeting of the European Society

for Research on Internet Interventions. Lüneburg, Germany, 30-31 May

2012.

Van Daele, T., Van den Bergh, O., & Vansteenwegen, D. (2012). Happiness

coach: Preliminary results of an online intervention to increase mental

fitness. Poster presented at the First Meeting of the European Society for

Research on Internet Interventions. Lüneburg, Germany, 30-31 May 2012.

Van Daele, T., Hermans, D., Van Audenhove, C., & Van den Bergh, O. (2011).

Stress prevention through psychoeducation: a meta-analytic review. Paper

presented at the 25th European Health Psychology Conference. Crete,

Greece, 20-24 September 2011.


Impact research of a psychoeducational course for stress management.

Poster presented at the 25th European Health Psychology Conference.

Crete, Greece, 20-24 September 2011.

Van Daele, T., Hermans, D., Van Audenhove, C., Van den Bergh, O. (2011).

Stress prevention through psychoeducation: A meta-analytic review.

International Conference of the European Network of Mental Health

Services. Ulm, Germany, June 2011.

Hermans, D., Vuerstaeck, S., Van Daele, T., & Raes, F. (2008).

Autobiographical memory specifity and the effects of a psycho-

educational programme for stress and anxiety. Paper presented at the 6th

Special Interest Meeting on Autobiographical Memory and

Psychopathology. Amsterdam, The Netherlands, January 2008.

Hermans, D., Ruys, K., Vuerstaeck, S., Van Daele, T., & Raes, F. (2007).

Autobiographical memory specificity and the effects of a psycho-educational

programme for stress and anxiety. Annual Convention of the Association for

Curriculum vitae

188

Advancement of Behavioral and Cognitive Therapies (AABCT). Philadelphia,

PA, USA, November 2007.

Meeting abstracts, presented at local conferences and symposia,

published or not published in proceedings or journals

Van Daele, T., Vansteenwegen, D., Hermans, D., Van Audenhove, C., & Van

den Bergh, O. (2012). Effectiviteit van een stressreductieprogramma in

groepsverband. Paper presented at the Zesde Vlaams Geestelijk

Gezondheidscongres ‘Macht en kracht. Zorgrelaties in verandering’.

Antwerpen, Belgium, 18-19 September 2012.

Van Daele, T., Van den Bergh, O., Hermans, D., & Van Audenhove, C. (2011).

Stress in Vlaanderen: perspectieven van psycho-educatie als

eerstelijnsinterventie. Paper presented at the Steunpunt WVG studiedag

‘Wel en Wee in Vlaanderen’. Leuven, Belgium, 28 October 2011.


What is the participant profile in psychoeducational group interventions for

stress?. Poster presented at the Steunpunt WVG studiedag ‘Wel en Wee in

Vlaanderen’. Leuven, Belgium, 28 October 2011.


STAP, Stress AanPakken. Poster presented at the Steunpunt WVG studiedag

‘Wel en Wee in Vlaanderen’. Leuven, Belgium, 28 October 2011.

Van Daele, T., Van den Bergh, O., Hermans, D., & Van Audenhove, C. (2010).

Proces-evaluatie van een proefimplementatie. STAP als praktijkvoorbeeld.

Paper presented at the Steunpunt WVG Studiedag ‘In-zicht’. Leuven,

Belgium, 2 December 2010.


STAP, STress AanPakken. Een systematische meta-analytische review van

preventieve psycho-educatie bij stress. Poster presented at the Steunpunt

WVG Studiedag ‘In-zicht’. Leuven, Belgium, 2 December 2010.

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