Sunday January 18th 2015 - NYBH Staff
Natural Weight Loss Recovery from Obesity
Even though many types of obesity treatment programs are ineffective, some individuals successfully resolve their weight problems without professional help (Garner & Wooley, 1991). Very little is known about the natural recovery process, including what motivates people to successfully lose weight, what deters help-seeking and what behavior change strategies are most effective. This information could be very helpful in improving obesity treatment interventions as well as reducing barriers to finding help.
For example, we know from the field of substance abuse and addictions (which are much better researched), that current treatments are often perceived as stigmatizing and ineffective (Cunningham, Sobell, Sobell, Agrawal, & Toneatto, 1993). Moreover, psychosocial variables can play a strong role in motivating or deterring one from seeking help (George & Tucker, 1996), and lasting behavior change often occurs over several years and can be supported by changing environmental conditions (Tucker, Vuchinich, & Pukish, 1995).
So, help seeking among substance users is more strongly linked to psychosocial problems than demographics or substance use patterns. Also, recovery is often associated with increased problems pre-treatment and improved functioning post-treatment, such as interpersonal relationship or physical and mental health (Tucker et al., 1995).
Weight Loss Study
The study that this blog post is referring to is a retrospective investigation of motivations for weight loss and behavior change strategies associated with natural recovery from obesity. The data was gathered from a group of previously obese but currently normal-weight individuals as well as an untreated group of obese individuals, who were serving as controls to identify what specifically helped recovery in the first group. Participants in both groups had a past or present weight problem of at least 4 years in duration. The recovered participants had maintained a normal weight (=-10% of ideal weight) for at least 1 year and a mean of 4.5 years.
Thus, recovered participants have maintained their weight loss results for a substantial amount of time. The two groups were similar in terms of the age of onset (early adulthood), problem duration, past weight loss attempts, weight-related health problems, and number of pregnancies for women. Both groups also had an original BMI of above 30, which exceeds the cutpoint for obesity; however, recovered participants had a somewhat lower BMI than controls. Participants were interviewed in person and were asked about three main topics – weight loss methods (15 weight loss methods including behavioral strategies, diets, use of drugs), motivations for and influences on weight loss (18 factors such as role of significant other and family members, changes in social activities, physical health), and treatment barriers (27 potential reasons why participants did not seek treatment). The researchers also interviewed participants’ family members and friends to verify participants’ claims.
Weight Loss Strategy Findings
Interestingly, the results on what methods successful participants used to lose weight are not surprising. Significantly greater exercise and increased intake of vegetables, fruits and fiber distinguished formed failed weight loss attempts and successful long-term ones. Furthermore, recovered participants were more likely to eat slowly and reduce snacking compared to the control group. Even though many control group participants used exercise previously as a weight-loss strategy, only successful participants continued to exercise at least at 50% of their original level after losing weight.
In terms of the motivational factors for losing weight, problems related to appearance (e.g.: problems with clothes) and negative emotional states (low self-esteem, unhappiness) scored the highest. These were followed by concerns about future health, wanting to be healthier now, and family histories of illness and obesity. Men were actually significantly more likely to report health problems or health concerns as motivation to lose weight. Also, many participants cited social problems and intimate relationships as motivating factors.
When it comes to weight loss maintenance, it seems that relationship difficulties and changes in living arrangements can hinder maintenance, although positive changes in these categories also help weight loss efforts both in the short- and long-run. Finally, the main reason why participants would not seek help is the belief that they could do just as well on their own as with treatment. Other barriers are treatment cost, negative attitudes toward treatment, embarrassment related to treatment procedures (being weighed and measured, disclosing food intake, exercising in front of others), and believing that one’s weight problem is not serious enough for treatment.
Obesity Treatment and Weight Loss Conclusions
According to current findings, weight loss can be achieved and maintained by following behavioral change strategies (Schachter, 1982). Obesity treatment programs need to understand what motivates people to want to lose weight for the long term and what contextual variables can help this, often lengthy, process. Further studies are necessary to understand what aids natural weight loss and how to incorporate those elements into treatment models.
Weight Loss References
Tinker, J.E. & Tucker, J.A. (1997). Motivations for weight loss and behavior change strategies associated with natural recovery from obesity. Psychology of Addictive Behaviors, 11, 98-106.
Garner, D. M., & Wooley, S. C. (1991). Confronting the failure of behavioral and dietary treatments for obesity. Clinical Psychology Review, 11, 729—780.
Cunningham, J. A., Sobell, L. C., Sobell, M. B., Agrawal, S., & Toneatto, T. (1993). Barriers to treatment: Why alcohol and drug abusers delay or never seek treatment. Addictive Behaviors, 18, 347-353.
Tucker, J. A., Vuchinich, R. E., & Pukish, M. M. (1995). Molar environmental contexts surrounding recovery from alcohol problems by treated and untreated problem drinkers. Experimental and Clinical Psychopharmacology, 3, 195-204.
Tucker, J. A. (1995). Predictors of help-seeking and the temporal relationship of help to recovery among treated and untreated recovered problem drinkers. Addiction, 90, 805-809.
Schachter, S. (1982). Recidivism and self-cure of smoking and obesity. American Psychologist, 37, 436-444.
Tuesday October 21st 2014 - NYBH Staff
Eating Disorders' Prevalence and Consequences
According to the National Eating Disorder Association
(2013), 20 million women and 10 million men suffer from a clinically
significant eating disorder including anorexia nervosa, bulimia nervosa, binge
eating disorder or eating disorder not otherwise specified (EDNOS) at a point
in their lifetime. Eating disorders can result in a wide range of physical and
psychological health problems. For women, eating disorders are among the top 10 causes of disability (Striegel-Moore & Bulik, 2007) and anorexia has the
highest lethality rate of any mental disorder (Crow et al., 2009). Individuals
with eating disorders also tend to experience strained interpersonal
relationships (Ringer & Crittenden, 2007), difficulty regulating emotions
(Whiteside et al, 2007), more frequent anxiety and depression (Doyle, le
Grange, Goldschmidt, & Wilfley, 2007) and lower levels of occupational
functioning (McElroy et al., 2011). The more frequently an individual engages
in disordered eating behaviors (restriction, bingeing/purging, or both), the
more health consequences they may to face. Some examples are bone density loss,
gastrointestinal complications, chronic pain, inflammation, tooth decay, high
blood pressure, cardiovascular impairment, heart disease, gallbladder disease,
high cholesterol, etc. (NEDA, 2014). Due to the chronic and often long-lasting
course of eating disorders, clients are also more prone to developing
co-occurring psychiatric disorders including anxiety disorders, obsessive
compulsive disorder (OCD), and depression. Depression is highly associated with
suicidal gestures and attempts (O’Brien & Vincent, 2003), therefore
reducing depression symptoms (and the potential for self-injurious and suicidal
behaviors) is important for successful treatment (Walsh et al., 2006).
DBT Model of Eating
DBT was originally developed by Marsha Linehan for the
treatment of borderline personality disorder but has been adopted to treat
various other disorders including eating disorders since then. The DBT model of
eating disorders conceptualizes eating disorder episodes as attempts by the
client to neutralize intense negative emotions as a result of feeling
emotionally vulnerable due to severely restricted food intake or bingeing
(Bankoff et al., 2012). When disordered eating fails to decrease the intensity
of negative emotional experiences, the client intensifies the behavior to try
to achieve a sense of balance, control and belonging. According to Linehan (1987)
an individual keeps using disordered eating and self-harming strategies because
they lack skills such as distress tolerance, inadequate coping resources, and
believe that the behavior is an effective problem-solving strategy. DBT aims to
help clients through developing a strong working alliance with the therapist,
accepting the client’s current level of functioning and desire for change while
learning more adaptive coping skills to increase well-being and healthy
functioning (Salsman & Linehan, 2006).
DBT Program for
A comprehensive Dialectical Behavior Therapy (DBT) program
for eating disorders includes four main targets: a) reducing life-threatening
behaviors (self-injury, suicide, severe food restriction), b) reducing
therapy-interfering behaviors (missing appointments, early termination), c)
reducing behaviors that interfere with the client’s quality of life
(unemployment, divorce, financial issues), and d) increasing behavioral skill
use (Linehan et al., 1991). Clients are expected to commit to a one-year
program that includes a weekly individual therapy session and a weekly DBT
skills group. DBT skills groups are a fundamental element of DBT and are
created to teach clients healthier ways to cope with painful emotions and difficult
life circumstances. Groups are 2.5 hours long and include four areas of skill
development – mindfulness, distress tolerance, interpersonal skills, and
emotion regulation (Bankoff et al., 2012).
A fundamental aspect of DBT is the concept of dialectics –
the understanding that multiple truths can exist in a given moment and one idea
or belief is not more true or right than another. DBT aims to decrease tension
by searching for a synthesis between two opposite points of view instead of
allowing one party to override another (Linehan, 1993a). This idea, however, is
not a feature of traditional eating disorder treatment. In general, DBT
advocates an approach that offers greater choice, collaboration, and autonomy
for clients than traditional treatment modalities (Geller, Brown, Zaitsoff,
Goodrich, & Hastings, 2003). Therapists and clients in DBT treatment
continually strive to balance acceptance and change, flexibility and stability,
nurturance and challenge, and focus on deficits while developing capabilities
(Linehan, 1993a). For example, if the client wants to stay underweight and the
treatment team wants her to gain 2lbs a week, the therapist would work to find
a synthesis by validating the client’s position and looking for common ground
such as gaining only 1lb a week instead of 2lbs.
Another dominant feature of DBT is its emphasis on enabling
clients to act as their own agents. DBT therapists do not solve problems for
clients but teach them to take responsibility for their own lives including
coordinating treatment with other providers, improving communication with
others, and problem-solving (Linehan, 1993a).
Eating Disorders Conclusion
Eating disorders are complex, often long-lasting, and
sometimes life-threatening illnesses. While some traditional treatment
approaches (CBT, Interpersonal Psychotherapy) have been shown to be effective,
DBT can certainly offer many additional benefits in this field and can be a
part of a well-rounded treatment program.
If you or someone you know suffers from an eating disorder
or disordered eating, please contact New York Behavioral Health or a qualified
treatment provider for help.
DBT and Eating Disorders References
Lenz, S.A., Taylor, R., Fleming, M., & Serman, N.
(2014). Effectiveness of dialectical behavior therapy for treating eating
disorders. Journal of Counseling &
Development, 92, 26-35.
Federici, A., Wisniewski, L., & Ben-Porath, D. (2012).
Description of an intensive dialectical behavior therapy program for
multidiagnostic clients with eating disorders. Journal of Counseling & Development, 90, 330-338.
Striegel-Moore, R., & Bulik, C. (2007). Risk factors for
eating disorders. American Psychologist,
Crow, S., Peterson, C., Swanson, S., Raymond, N., Specker,
S., Eckert, E. D., & Mitchell, J. (2009). Increased mortality in bulimia nervosa
and other eating disorders. American
Journal of Psychiatry, 166, 1342–1346.
Ringer, F., & Crittenden, P. M. (2007). Eating disorders
and attachment: The effects of hidden family processes on eating disorders. European Eating Disorders Review, 15, 119–130.
Whiteside, U., Chen, E., Neighbors, C., Hunter, D., Lo, T.,
& Larimer, M. (2007). Difficulties regulating emotions: Do binge eaters
have fewer strategies to modulate and tolerate negative affect? Eating Behaviors, 8, 162–169. doi:10.1016/j.eatbeh.2006.04.001
Doyle, A. C., le Grange, D., Goldschmidt, A., & Wilfley,
D. E. (2007). Psychosocial and physical impairment in overweight adolescents at
high risk for eating disorders. Obesity,
McElroy, S. L., Frye, M. A., Hellemann, G., Altshuler, L.,
Leverich, G. S., Suppes, T., & Post, R. (2011). Prevalence and correlates of
eating disorders in 875 patients with bipolar disorder. Journal of Affective Disorders, 128, 191–198.
O’Brien, K. M. O., & Vincent, N. K. (2003). Psychiatric
comorbidity in anorexia and bulimia nervosa: Nature, prevalence, and causal relationships.
Clinical Psychology Review, 23,
Walsh, B. T., Kaplan, A. S., Attia, E., Olmsted, M.,
Parides, M., Carter, J. C., Rockert, W. (2006). Fluoxetine after weight restoration
in anorexia nervosa: A randomized controlled trial. Journal of the American Medical Association, 295, 2605–2612.
Bankoff, S., Karpel, M., Forbes, H., & Pantalone, D.
(2012). A systematic review of dialectical behavioral therapy for eating disorders.
Eating Disorders, 20, 196–215.
Linehan, M. M. (1993a). Cognitive behavioral treatment of
borderline personality disorder. New York, NY: Guilford Press.
Linehan, M. M., Armstrong, H. E., Suarez, A., Allmon, D.,
& Heard, H. L. (1991). Cognitive-behavioral treatment of chronically
parasuicidal borderline patients. Archives
of General Psychiatry, 48, 1060–1064.
Geller, J., Brown, K. E., Zaitsoff, S. L., Goodrich, S.,
& Hastings, F. (2003). Collaborative versus directive interventions in the treatment
of eating disorders: Implications for care providers. Professional Psychology: Research and Practice, 34, 406–413.doi:10.1037/0735-7028.34.4.406
Monday October 13th 2014 - NYBH Staff
Dialectical Behavior Therapy Overview
Dialectical Behavior Therapy (DBT) was originally developed by Marsha Linehan for the treatment of individuals diagnosed with Borderline Personality Disorder (BPD). In recent years many new psychotherapies have been studied for the treatment of BPD; however, DBT has been the most studied and most widely practiced of all. According to Swenson (2000), some of the reasons for DBT’s popularity are strong empirical support for the treatment, integration of four domains (biological, environmental, spiritual, and behavioral) into a unique treatment approach that appeals to many people with different backgrounds, and the synthesis of acceptance and change strategies.
Friday October 3rd 2014 - NYBH Staff
Psychological Reactions to Pain
Pain is an essential biological function that signals damage in the body, prevents further damage by limiting mobility of the affected area and promotes healing. Pain can become chronic as a result of abnormal healing, additional damage or failed medical interventions. Once pain is chronic, it is no longer a useful biological function, but has negative physical and psychological effects on the sufferer. Very often, medical interventions cannot resolve chronic pain, which results in an increased need for pain management strategies. Psychological interventions for pain target a variety of domains including physical functioning, mood, cognitive patterns, quality of life, and pain medication use. As such, they are useful additions to any medical treatment for pain.
From a psychological point of view, recurrent pain affects an individual’s cognitions, mood, daily functioning, and increases vulnerability to depressive symptoms, anxiety, and Post-traumatic Stress Disorder (PTSD). Chronic pain can also contribute to higher levels of disability, obesity, sleep problems, fatigue, and pain medication abuse. Due to the many negative symptoms associated with chronic pain, it is important to understand the three main psychological mechanisms related to pain that are suitable targets for intervention.
Pain catastrophizing refers to the magnification of the negative effects of pain, rumination about pain, and feelings of hopelessness in coping with pain. It also contributes to lower perceived levels of control over pain, lower social and emotional functioning, poorer coping and lower quality of life in the sufferer.
Pain-related fear is characterized by fear of injury or worsening of symptoms by performing activities that trigger pain. Pain-related fear is associated with lower physical functioning (increased disability) and quality of life. It also results in more passive, avoidant behaviors that can further increase disability and pain.
Pain acceptance refers to engaging mindfully in the present moment, nonjudgmentally acknowledging pain, stopping negative behaviors to try to stop the pain, and living a richer life despite the presence of pain. The two main benefits associated with pain acceptance are the willingness to experience pain, which lowers negative emotional reactions to pain; and continued engagement in valued activities, which increases positive emotions. Pain acceptance is the main target for mindfulness- and acceptance-based psychological therapies.
According to this theory, when individuals avoid painful behaviors, they actually contribute to the maintenance of chronic pain and depression. Therefore, the goal of behavior therapy is to gradually increase adaptive behaviors and decrease pain-avoidance behaviors. Through in vivo exposure therapy, individuals gradually engage in painful behaviors and when these behaviors are performed without serious negative consequences, they learn that their expectations about the consequences of physical movement and pain are unrealistic. As a part of this therapy, client and therapist develop a fear hierarchy including all forms of movement or situations the individual wants to avoid, and the client performs all those activities in a graded manner. Behavior therapy for chronic pain can be effective in reducing pain, and pain catastrophizing; as well as pain-related anxiety, depression and fear.
Cognitive-Behavioral Therapy (CBT)
CBT for pain aims to develop coping skills to manage pain and improve psychological functioning. Such skills can include structured relaxation, behavioral activation, e.g., scheduling of pleasurable events, assertive communication, and pacing of behaviors to avoid exacerbation of pain. CBT also targets maladaptive beliefs about pain by identifying thoughts and beliefs that are unhelpful with regards to pain and change them into more helpful ones that help increase positive functioning. CBT is the current gold standard in psychological pain management. CBT is also associated with reduced pain catastrophizing, disability, and longer-term improvements than medical treatment alone.
Mindfulness-Based Stress Reduction (MBSR)
MSBR is a protocol that includes meditation that was developed in Eastern philosophy and recently adopted as a Western intervention that enhances awareness and acceptance of physical and psychological sensations and disconnects psychological reactions from the physical sensations of chronic pain. In MSBR individuals learn mindful awareness and meditation, which help them view pain as simply a sensation, an experience that is not necessarily an indication of an underlying problem that needs to be attended to immediately. When an individual learns to recognize sensations and thoughts as something familiar, they are able to ameliorate their maladaptive responses to the experience of pain. Some advantages of MSBR are increased tolerance to pain, reduced rumination about pain, and increased mindful awareness and acceptance of pain. As part of MSBR, individuals commit to a practice of daily meditation and mindfulness and adopt a nonjudgmental attitude towards thoughts that creates emotional distance from thoughts. Unlike CBT, MSBR does not prescribe particular goals, only nonjudgmental observation.
Acceptance and Commitment Therapy (ACT)
ACT promotes an approach that emphasizes that thoughts do not need to be changed, instead only acknowledged and accepted as mental events. Acceptance of thoughts and emotions as simply mental events increases the individual’s ability to stay present and aware of personally relevant psychological and environmental factors. So individuals are able to adjust their behavior in a way that is consistent with their goals and values instead of just focusing on immediate relief from thoughts and emotions. ACT creates awareness and acceptance of pain, reduces focus on immediate pain relief and increases beneficial behavioral functioning. ACT focuses on goals and values as the impetus to direct behavior. It can effectively increase sufferers’ quality of life, self-efficacy while reducing depressive or anxious symptoms.
Both MSBR and ACT promote the acceptance of pain instead of emphasizing strategies to try to control pain. They both increase sufferers’ quality of life and well-being as well as engagement in more pain-independent activities.
Psychotherapy Pain Management Reference
Sturgeon, J.A. (2014). Psychological therapies for the management of chronic pain.Psychology Research and Behavior Management, 7, 115-124.
Monday September 15th 2014 - NYBH Staff
Adolescents and Suicide
Suicidal behavioral is a significant health concern for adolescents. It is the third leading cause of death preceded only by accidents and cancer for ages 10-14, and accidents and homicide for ages 15-19 (Martin et al., 2008). Almost 15% of high school students have seriously considered attempting suicide, 11% had an actual plan to commit suicide, and 7% made one or more suicide attempts (Eaton et al., 2008). Suicide attempts are defined as performing self-injurious behaviors with some intention to die and they can have very serious consequences. Suicide attempts are more prevalent than completed suicides and are associated with a significantly higher risk of successful suicides later in adolescence (Lewinsohn, Rhode, & Seeley, 1994). Research also shows that self-injurious behaviors in adolescence are also linked to future suicide attempts (Asarnow et al., 2011). Therefore, this high-risk population needs effective suicide prevention strategies. Even though there is a pressing need for effective treatment strategies, there is a surprising lack of options when it comes to evidence-based treatment plans.
Biosocial Theory and DBT
According to the biosocial theory, the primary contributing factor to suicidal and self-harm behaviors is difficulty regulating emotions (aka emotion dysregulation). Emotion dysregulation is thought to be the result of a biological predisposition to emotional vulnerability in a child and an invalidating home environment (Linehan, 1993). Emotional vulnerability refers to heightened sensitivity to experiencing emotion, increased emotional intensity, and slow return to baseline levels. An invalidating environment is one where the child’s communication of emotions is met with responses from parents or caregivers that are dismissive, trivializing, inconsistent or inappropriate. As a result of these factors, a child does not learn how to label and manage their own emotions (Linehan, 1993). As the child gets older, suicidal and self-injurious behavior becomes a coping strategy to manage severe emotion dysregulation. DBT can be particularly helpful for reducing emotion dysregulation and therefore suicidal behavior by teaching more adaptive coping skills.
Emotion regulation is defined as, “the ability of an individual to control, modify, change, and manage emotional reaction and expression to achieve one’s goals and effectively manage social, interpersonal relationships” (Cole, Martin, & Dennis, 2004). Emotion regulation skills are acquired by children though their interaction with caregivers. As infants, children lack internal resources for emotion regulation and therefore rely completely on the parent to regulate their emotional distress (Calkins & Hill, 2007). Caregivers help infants reduce distress by soothing them through rocking, singing, calm tone of voice, touching or distracting. This is how infants learn that their emotional distress can be attended to and ameliorated effectively. As infants become toddlers, they learn more verbal methods of regulating emotions such as self-distraction (playing with toys, singing to self), self-soothing statements (“It’s ok”) or behaviors (thumb-sucking, hugging, stuffed animal) and seeking comfort from caregivers by discussing feelings (Kopp, 2003). In adolescence, youth utilize mostly cognitive techniques to control their emotions, however, there are a few developmental and environmental factors that interfere with effective emotion regulation. Adolescents tend to experience higher levels of peer pressure and motivation to fit in, increased emotional arousability, and novelty seeking. At the same time, the adolescent brain is not completely developed yet and self-regulatory competence is not fully functioning during this emotionally vulnerable period (Galvan et al., 2006).
DBT Interventions for Adolescents, Parents and Families
As mentioned before, according to the biosocial theory (Linehan, 1993), suicidal adolescents have fewer skills to help them regulate emotions than others their age, which makes them similar to younger children in this regard. In order for them to become better at managing their emotions, they need to learn a range of skills they haven’t acquired during their development.
In a DBT program, clients attend weekly individual therapy sessions as well as weekly skills groups. Often phone coaching between sessions is also available and utilized. In case of suicidal adolescents, the individual therapist’s job is to analyze each self-injurious or suicidal behavior and determine which coping skills would be most beneficial in preventing the behavior from occurring in the future. This therapist also works with the parents and the family to ensure that they are not reinforcing the adolescent’s problem behaviors and that there is a reward system in place to reinforce positive behaviors (Miller et al., 2007). Skills groups are specifically designed to teach adolescents and their families a range of coping skills in a classroom-type format. Treating adolescents provides the unique opportunity for the therapist to help change the invalidating environment that has partly created the skills deficits and emotional dysregulation in the first place. Therefore emotion regulation skills are most effectively taught in a setting with both child and parents present.
The DBT program designed for adolescents has 4 main modules (Linehan, 1993). Mindfulness skills are used to teach clients to not judge their emotions in terms of good or bad, right or wrong, but just become aware of them without evaluating them or impulsively acting upon them. The interpersonal effectiveness module focuses mainly on skills to help cope with interpersonal problems and communicate needs to others. Distress tolerance skills help adolescents tolerate intense negative emotions without engaging in self-harming behaviors and can include distraction or self-soothing. In the emotion regulation module, youth learn ways they can decrease their emotional vulnerability in the long-run by engaging in more behaviors that elicit positive affect (e.g. scheduling pleasant activities) and reducing behaviors that elicit negative affect (e.g. facing fears). A unique element of DBT for adolescents is called the Middle Path module. In this module children learn how to understand other’s perspectives, find middle ground in a disagreement, and receive validation for their emotions and behaviors from caregivers (Miller et al., 2007).
Parents of suicidal adolescents seem to benefit greatly from learning to identify their own and their children’s emotions and learning about psychopathology. This helps parents understand that not every problematic behavior stems from defiance or willfulness but from mental health problems (Kennard et al., 2009). Parents also learn that children are doing the best they can and increase their ability to validate children’s emotional experiences (Linehan ,1993).
Family interventions aim to increase positive interactions and communication in a family so that children can share more information with the parents and parents can better identify risk factors for suicidal behavior and ensure the child’s safety (Klaus, Mobilio, & Kind, 2009). A specific technique is “Walking the Middle Path”, in which adolescents and their parents learn how to maintain a positive relationship through listening to each other’s point of view, avoiding extreme words, recognizing that different viewpoints can be true, and establishing middle path solutions that honor both parties’ needs (Miller et al., 2007).
Neece, C.L., Berk, S.M., & Combs-Ronto, L.A. (2013). Dialectical behavior therapy and suicidal behavior in adolescence: Linking developmental theory and practice. Professional Psychology: Research and Practice, 44, 257-265.
Martin, J. A., Kung, H. C., Mathews, T. J., Hoyert, D. L., Strobino, D. M., Guyer, B., & Sutton, S. R. (2008). Annual Summary of Vital Statistics: 2006. Pediatrics, 121, 788–801. doi:10.1542/peds.2007-3753
Eaton, D. K., Kann, L., Kinchen, S., Shanklin, S., Ross, J., Hawkins, J., . . . Wechsler, H. (2008). Youth risk behavior surveillance–United States, 2007. Morbidity and Mortality Weekly Report, Surveillance Summaries (Washington, DC: 2002), 57, 1–131.
Lewinsohn, P. M., Rohde, P., & Seely, J. R. (1994). Psychosocial risk factors for future adolescent suicide attempts. Journal of Consulting and Clinical Psychology, 62, 297–305. doi:10.1037/0022-006X.62.2.297
Asarnow, J. R., Porta, G., Spirito, A., Emslie, G., Clarke, G., Wagner, K. D., . . . Brent, D. A. (2011). Suicide attempts and nonsuicidal self-injury in the treatment of resistant depression in adolescents: Findings from the TORDIA study. Journal of the Academy of Child & Adolescent Psychiatry, 50, 772–781.
Linehan, M. M. (1993). Cognitive-behavioral treatment of borderline personality disorder. New York, NY: Guilford Press.
Cole, P. M., Martin, S. E., & Dennis, T. A. (2004). Emotion regulation as a scientific construct: Methodological challenges and directions for child development research. Child Development, 75, 317–333. doi:10.1111/j.1467-8624.2004.00673.x
Calkins, S. D., & Hill, A. (2007). Caregiver influences on emerging emotion regulation: Biological and environmental transactions in early development. In J. J. Gross (Ed.), Handbook of emotion regulation (pp.229–248). New York, NY: Guilford Press.
Kopp, C. B. (2003). Baby steps: A guide to your child’s social, physical, mental, and emotional development in the first two years (2nd ed.). New York, NY: Holt Paperbacks.
Galvan, A., Hare, T. A., Parra, C. E., Penn, J., Voss, K., Glover, G., & Case, B. J. (2006). Earlier development of the accumbens relative to orbitofrontal cortex might underlie risk-taking behavior in adolescents. The Journal of Neuroscience, 26, 6885–6892. doi:10.1523/JNEUROSCI.1062-06.2006
Miller, A. L., Rathus, J. H., & Linehan, M. M. (2007). Dialectical behavior therapy with suicidal adolescents. New York, NY: Guilford Press.
Kennard, B. D., Clarke, G. N., Weersing, V. R., Asarnow, J. R., Shamseddeen, W., Porta, G., . . . Brent, D. A. (2009). Effective components of TORDIA cognitive– behavioral therapy for adolescent depression: Preliminary findings. Journal of Consulting and Clinical Psychology, 77, 1033–1041. doi:10.1037/a0017411
Klaus, N. M., Mobilio, A., & King, C. A. (2009). Parent-adolescent agreement concerning adolescents’ suicidal thoughts and behaviors. Journal of Clinical Child and Adolescent Psychology, 38, 245–255. doi:10.1080/15374410802698412
Thursday February 27th 2014 - NYBH Staff
Depression Linked to Alcohol and Drug Use
The relationship between substance use and psychiatric disorders is increasingly well recognized, understood, and nuanced through evaluation and research. Varying studies have demonstrated a link between heavy use of alcohol and heightened depression symptoms (O’Donnell, Wardle, Dantzer, & Steptoe, 2006), and high percentages of drug use (26.3% of women and 29.4% of men) reported among depression patients (Roeloffs, Fink, Unutzer, Tang, & Wells, 2001). Despite the known connection between mental illness and substance abuse, there is less known about effective treatment methods for these dual diagnoses. One approach considered is motivational interviewing (MI), which is a directive style of counseling that is designed for short-term use among patients who may possess a certain level of ambivalence toward an identified issue. The goal of MI is to “resolve ambivalence” through a series of interactions involving the weighing of pros and cons of behavioral change, empathetic listening on the part of the therapist, and client-determined goals for change (Satre, Delucchi, Lichtmacher, Sterling, & Weisner, 2013, p. 323).
Motivational Interviewing for Depression Patients
The aim of one group of researchers was to better understand the efficacy of MI as a supplemental intervention to outpatient treatment as usual for patients with depression and concurrent substance abuse problems (Satre et al., 2013). These investigators hypothesized that, in a random trial, patients who experienced MI would show a reduction in hazardous drinking, and potentially in depression and drug use as well. The reasoning offered by Satre et al. (2013) for the aforementioned hypothesis is that alcohol is the most commonly used substance among depressed patients (Davis, Rush, Wisniewski, et al., 2005; Satre, Wolfe, Eisendrath, & Weisner, 2008). Participants, adults from a California clinic/hospital, were given one 45-minute MI session, followed by two 15-minute “booster sessions” at the 3- and 6-months intervals in treatment as usual. In contrast, the control group received a quick 5-minute meeting with a therapist, during which brochures regarding substance use and risks were provided and explained (Satre et al., 2013).
Implications for Drug and Alcohol Interventions
The results of the study by Satre et al. (2013) demonstrated that, at the 3 month marker, “MI had a significant impact on the primary outcome of interest, reduction in hazardous drinking; although no impact was found on cannabis use or depression symptoms” (p. 327). The researchers note the implications of these results as integral to the refinement of alcohol interventions which are critical to improved psychiatric care. Although alcohol abuse is more successfully treated in the early stages of use, large percentages of patients, unfortunately, do not seek help until a much later stage and, instead, pursue mental health treatment as their first endeavor (Satre et al., 2013). Thus, it is suggested by the researchers that substance use screening, which often includes MI, be performed for all new patients attending outpatient psychiatric services. This may expedite awareness and availability of resources and services integral to patients’ journey back to wellness.
Davis, L., Rush, J., Wisniewski, S., Rice, K., Cassano, P., & Jewell, M. (2005). Substance use disorder comorbidity in major depressive disorder: An exploratory analysis of sequenced treatment alternatives to relieve depression cohort. Comprehensive Psychiatry, 46, 81-89.
O’Donnell, K., Wardke, J., Dantzer, C., & Steptoe, A. (2006). Alcohol consumption and symptoms of depression in young adults from 20 countries. Journal of Studies on Alcohol, 67, 837-840.
Roeloffs, C., Fink, A., Unutzer, J., Tang, L., & Wells, K. (2001). Problematic substance use, depressive symptoms, and gender in primary care. Psychiatric Services, 52, 1251-1253.
Satre, D., Delucchi, K., Lichtmacher, J., Sterling, S., & Weisner, C. (2013). Motivational interviewing to reduce hazardous drinking and drug use among depression patients. Journal of Substance Abuse Treatment, 44, 323-329.
Satre, D., Wolfe, W., Eisendrath, S., & Weisner, C. (2008). Computerized screening for alcohol and drug use among adults seeking outpatient psychiatric services. Psychiatric Services, 59, 441-444.
Monday February 17th 2014 - NYBH Staff
Rising Antidepressant Use
Stress-related mental health issues such as perinatal depression are common and possibly grave complications of pregnancy. Therefore, treatment options have been studied in an attempt to provide the necessary care that would counterbalance these potential risks. However, a common dilemma arises: Is the gold standard of treatment for depression for the general population, which includes medication, applicable to pregnant women? The increasing use of antidepressants by women of reproductive age has made it imperative that we better understand the implications of these agents on the mother-to-be, the pregnancy itself, and the developing fetus.
Dilemma of the Mother-to-be
There have been so many conflicting reports, stories, opinions, and articles of late on the matter of adverse effects of taking antidepressants while pregnant. It is small wonder that, upon learning that she is expecting, a woman who struggles with depression and relies on medication for mood regulation, is confused, anxious, and concerned for her child’s and her own wellbeing. Fortunately (or unfortunately, perhaps) research focused on this issue is in no short supply in the scientific literature over the past few decades. Antidepressants, in fact, are studied in regard to their impact if taken during pregnancy more than any other drug (Einarson, A., 2013). Most recently, researchers have been pooling results of multiple studies and performing meta-analysis for a better understanding of the risks to a baby in utero that many believe or fear accompany a mother’s antidepressant use.
Risks of Continuation / Discontinuation of Medication
Investigators conclude that, over the last 30 years, the percentage of first-trimester exposure to antidepressants has increased from 1% to 7% (Patil, Kuller, & Rhee, 2011). Interestingly, this has happened, despite the fact that physicians and patients have displayed a tendency to overestimate the teratogenicity of using these medications during pregnancy, relative to the recognized and proven risk. On the one hand, this trend may motivate physicians to be more vigilant when giving out prescriptions. On the other hand, however, it may also lead pregnant patients—or females of child-bearing age—to self-discontinue their pharmacological treatment. Similarly to cases of non-pregnant patients, there is a high risk of relapse when antidepressant medicine is discontinued during pregnancy, which in turn poses its own series of risks. The precursor to this decision (continuation vs. discontinuation) is commonly the worry over the potential impact of the medications on the developing fetus.
Potential Effects of Antidepressants during Pregnancy
In a summary report of findings of previous studies, researchers highlight some of the adverse effects found to be related to the use of antidepressants during pregnancy (Patil, Kuller, & Rhee, 2011):
v Selective Serotonin Reuptake Inhibitors (SSRIs)
· Exposure to SSRIs during the later period of the third trimester may cause newborns to develop symptoms due to a direct toxic effect of the medication or from its discontinuation. These symptoms include: respiratory distress, cyanosis, apnea, seizures, temperature instability, feeding difficulty, vomiting, hypoglycemia, and irritability, among others. However, authors point out that thinning the medication during the last trimester in an informed and supervised manner may be considered as a way of minimizing these risks.
· Paroxetine, commonly known as Paxil, has been found to be associated with an increased risk of cardiac malformations in the developing fetus.
· When the woman is breastfeeding and taking an SSRI, it is important for both parents and their pediatrician to monitor whether the infant is showing signs of sedation, nausea, reduced suckling, or other signs of drug toxicity.
v Serotonin and Norepinephrine Reuptake Inhibitors (SNRIs)
· Similar to SSRIs, exposure to SNRIs in the late phase of the third trimester may cause discontinuation symptoms in newborns such as respiratory distress, cyanosis, apnea, seizures, temperature instability, feeding difficulty, vomiting, hypoglycemia, and irritability, among others.
There are several other classes of antidepressants besides the two shown herein; however, less research has been conducted on the effects they have on the pregnancy and the developing babies. So, are these results sufficient to discourage physicians and patients from using pharmacological treatments for depression during pregnancy? The answer is no, given the conflicting results regarding the safety of antidepressants—some of which report that there is not a strongly increased risk of malformations, preterm births, or low birth weight following prenatal exposure to antidepressants. What is definite is that pharmacological treatment of pregnant women with depression is a special challenge for clinicians, because it implies making a decision that needs to satisfy a very critical two-pronged objective: to provide the necessary care for the pregnant woman while not harming the fetus (Nordeng, van Gelder, Spigset, et al., 2012).
SSRI Recent Findings
Although SSRIs represent the class of drugs usually receiving criticism and being put under the microscope, a recent study indicated that the risk of autism for children of mothers who took these antidepressants during their pregnancies was minimal (Sørensen, Grønborg, Christensen, et al., 2013). Another analysis found that, while SSRIs taken late in pregnancy increased chances of lung problems in the baby, the association was reflected only for the late stages of pregnancy. Use of SSRIs earlier in the pregnancy was not linked to increased risk of pulmonary conditions in the babies (Grigoriadis, S., VonderPorten, E. H., Mamisashvili, L., et al., 2014). In fact, despite all the conflicting evidence, overall, there does not seem to be a clinically significant increased risk of adverse effects on the child that should prevent a woman who does need antidepressant medication from taking it during her pregnancy (Einarson, A., 2013). However, physicians should continue to prescribe these medications with caution to pregnant patients and to other female patients who might become pregnant.
Careful Evaluation Before Deciding
When having to make the decision regarding the type of treatment for a pregnant woman with depression, it is important that there be collaboration among the OB-GYN, psychiatrist, counselor, and patient. In this way, an informed decision can be made after weighing the evidence and doing a cost-benefit analysis of the options. The important thing is to know that there are options, and having the right team of health care professionals is likely to lead to the best outcomes.
Einarson, A. (2013). Antidepressant use during pregnancy: Navigating the sea of information. Canadian Family Physician, 59(9), 941-944.
Grigoriadis, S., & Robinson, G. E. (2007). Gender issues in depression. Annals of Clinical Psychiatry, 19(4), 247-255.
Grigoriadis, S., VonderPorten, E. H., Mamisashvili, L., Tomlinson, G., Dennis, C-L., Koren, G., Steiner, M., Mousmanis, P., Cheung, A., & Ross, L. E. (2014, Jan 14). Prenatal exposure to antidepressants and persistent pulmonary hypertension of the newborn: Systematic review and meta-analysis. BMJ, 348. doi: http://dx.doi.org/10.1136/bmj.f6932
Nordeng, H., van Gelder, M. M., Spigset, O., Koren, G., Einarson, A., & Eberhard-Gran, M. (2012). Pregnancy outcome after exposure to antidepressants and the role of maternal depression: Results from the Norwegian Mother and Child Cohort Study. Journal of Clinical Psychopharmacology, 32(2), 186-194.
Patil, A. S., Kuller, J. A., & Rhee, E. H. J. (2011). Antidepressants in pregnancy: A review of commonly prescribed medications. Obstetrical & Gynecological Survey, 66(12), 777-787.
Sørensen, M. J., Grønborg, T. K., Christensen, J., Parner, E. T., Vestergaard, M., Schendel, D., & Pedersen, L. H. (2013). Antidepressant exposure in pregnancy and risk of autism spectrum disorders. Clinical Epidemiology, 5(1), 449-459.
Saturday February 8th 2014 - NYBH Staff
Obesity in the United States
During a time in which nightly news reports and daily restaurant menu adjustments remind us of the rise in obesity throughout the United States, it seems to be no secret that a great many people consume significantly more food than necessary. The drive to seek out more well-balanced meals, fewer processed food products, and an overall more healthful diet has come to pervade the discourse of both the media and the general public. However, despite this ever-increasing consciousness, the prevalence of eating and exercise habits that are harmful to overall health has continued to be a challenge.
Reasons for Increase in Childhood Obesity
Childhood obesity studies have attributed the causes of this trend to larger meals and decreased physical activity. Adult studies conducted in the U.S. and England, however, as well as a recent meta-analysis of a wide range of research on the topic, have produced evidence indicating that distractions during the meals themselves might also contribute substantially to overeating habits.
Comparing Post-Lunch Perceptions and Behaviors
In a study published in The American Journal of Clinical Nutrition, researchers randomly selected participants and provided them identical meals. Half the participants were instructed to play a computer game while eating, however, and the other half were simply to eat their lunches without distractions. Those in the first group, upon evaluation several hours later, were significantly hungrier and more inclined to snack than were those in the second group. Not only did the “distracted” group eat a great deal more of a snack offered later, but they also had notably weaker memories regarding what they had eaten for lunch (only two to three hours earlier). Researchers have postulated--and have found empirical evidence supporting their hypothesis--that this hazy memory of what had been eaten previously became a marked contributor to overeating later in the day (Oldham-Cooper, Hardman, Nicoll, Rogers, & Brunstrom, 2011). These results have implications for more situations than playing a computer game while eating lunch. Examples: watching television, texting, talking on the phone, or doing homework while eating dinner; driving a car or reading the newspaper while snacking; working at your desk while having lunch. Multi-tasking can get us into trouble in multiple ways.
Dining Without Distractions
Although there is an abundance of data supporting wholesome, nutritious diets and regular exercise, it seems that what a person does (or doesn’t do) while eating is actually of great importance as well. If distraction causes weakened memory of our meals (and snacks) and, in turn, a greater tendency to eat more again throughout the remainder of the day, perhaps simply avoiding such distraction can be of great help to those who are trying to shed a few pounds – or simply trying to maintain their current weight. Despite the tendency to barrel through the day, multi-tasking along the way, we might now have a simple behavioral technique to help us bolster healthier eating habits with minimal effort. Who knew that a meal without distractions could be so beneficial?
Oldham-Cooper, R.E., Hardman, C. A., Nicoll, C. E., Rogers, P. J., & Brunstrom, J. M. (2011). Playing a computer game during lunch affects fullness, memory for lunch, and later snack intake. American Journal of Clinical Nutrition, 93(2), 308-313.
Robinson, E., Aveyard, P., Daley, A., Jolly, K., Lewis, A., Lycett, D., & Higgs, S. (2013). Eating attentively: A systematic review and meta-analysis of the effect of food intake memory and awareness on eating. American Journal of Clinical Nutrition, 97(4), 728-742.
Wednesday February 5th 2014 - NYBH Staff
The Impact of Depression
The World Health Organization (2012) reports that mental health disorders are the leading cause of disease burden in women from 15 to 44 years old, the age span in which also most pregnancies occur. In fact, depression alone is the leading cause of disability worldwide, and it affects more women than men. It should not surprise us, then, that 1 in 5 pregnant women experiences mental health problems, especially depression and anxiety (Qiao, Wang, Li, & Wang, 2012).
Maternal Stress During Pregnancy
It has been noticed that a mother’s psychological symptoms during pregnancy have consequences in terms of social, nutritional, and medical behaviors, and this in turn makes us think that there probably are similar consequences for the development of the fetus as well. Ibanez, Charles, Forhan, et al. (2012) describe a number of studies that have found maternal stress during pregnancy to have negative consequences. Some of the findings are that high levels of depression and/or anxiety are associated with:
· Impact on brain structures that play a role in mental health and can result in a future susceptibility to psychopathology.
· Higher risk of preterm birth or intrauterine growth restrictions.
· Higher risk for postpartum depression and associated complications such as mother-infant bonding difficulties as a consequence.
Anxiety and Depression
Co-morbidity of anxiety and depression is common in the general population, and, naturally, it is women who fit this criterion that report more of the severe depression and anxiety symptoms that are associated with the aforementioned consequences.
Outcomes Found in the Past
Several scientists interested in this line of research conducted a prospective cohort study in China, with women presenting anxious and depressive symptoms--but not anxiety and depressive disorders (Qiao, Wang, Li, & Wang, 2012). They report that, in the past, depression and anxiety of women during pregnancy have been associated with the following:
· Low birth weight of newborn
· Fetal growth restriction
· Increased nausea and vomiting during pregnancy
· Prolonged sick leave during pregnancy
· Planned cesarean delivery and/or use of epidural
· Changes in neonatal wellbeing and behavior
Outcomes Reported in Newer Research
Although they did find depressive and anxiety symptoms with several negative events during pregnancy and delivery, as well as postpartum, these effects seem to be less serious that those found in other studies. They conclude that these symptoms can be associated with the following outcomes:
· Prolonged pregnancy and no effect on birth weight, which is in contrast to most previous research that suggests prematurity and low birth weight
· Neonatal outcome does not deteriorate despite the women’s impaired mental health during pregnancy
· Unrecognized depressive or anxious symptoms disguised as somatic complaints such as headaches, chronic fatigue, or bleeding irregularities
No Clear Conclusions
As it can be evidenced by this abridged summary of some of the thousands of studies on the topic, there is no clear conclusion as to what the exact consequences and impacts of mental health problems associated with depression and anxiety are (on the woman or the baby) or their severity. It is also important to take into account the fact that women who experience depression and anxiety have been known to be more at risk for using nicotine and illicit drugs and are less likely to attend to their prenatal care, all factors of which could be causing or intensifying some of the more serious effects.
Importance of Mental Health Status
What does seem to be a common thread among studies is the fact that mental health status during pregnancy does have an impact some way or the other. Thankfully, there are options to manage this However, with options come questions, such as: What is the best treatment? Should I change the one I am currently on? How will medication affect me and my baby?
The last question brings up a very important and, at present, controversial issue: the use of antidepressants during pregnancy. This topic deserves its own discussion, especially in light of conflicting research results on the matter. For example, a recently published study (that explored the combined results of seven previously completed studies) reported a slight risk of lung disorders for babies of mothers who took SSRIs late in their pregnancy (Grigoriatis, Vonderporten, Mamisashvili, et al., 2014).
What do you think? It is wise for pregnant women to take antidepressant drugs during pregnancy? In which situations, if any, would it be appropriate or even beneficial to do so?
Depression and Pregnancy References
Grigoriatis, S., VonderPorten, E. H., Mamisashvili, L., et al. (2014, Jan 14). Prenatal exposure to antidepressants and persistent pulmonary hypertension of the newborn: Systematic review and meta-analysis. BMJ, 348. doi: http://dx.doi.org/10.1136/bmj.f6932
Ibanez, G., Charles, M. A., Forhan, A., et al. (2012). Depression and anxiety among women during pregnancy and neonatal outcome: Data from the EDEN mother-child cohort. Early Human Development, 88(8), 643-649.
Marcus, M., Yasamy, M. T., van Ommeren, M., et al. (2012). Depression: A global public health concern. WHO Department of Mental Health and Substance Abuse. Retrieved from http://www.who.int/mental_health/management/depression/who_paper_depression_wfmh_2012.pdf
Qiao, Y., Wang, J., Li, J., & Wang, J. (2012). Effects of depression and anxiety symptoms on pregnant, obstetric, and neonatal outcomes: A follow-up study. Journal of Obstetrics & Gynecology, 32(3), 237-240.
WHO methods and data sources for global burden of disease estimates 2000-2011 (2013, Nov). Department of Health Statistics and Information Systems, WHO, Geneva.
World Health Organization. (2012). Depression [Fact sheet]. Retrieved from http://www.who.int/mediacentre/factsheets/fs369/en/
Tuesday November 12th 2013 - NYBH Staff
Motivational interviewing (MI) has been reviewed considerably over the last twenty years in attempts to better understand its efficacy as a treatment intervention for substance abuse. This approach was initiated in 1982 by Miller (1983) after reflection on his previous work with people identified as “problem drinkers” (Stewart, 2012, p. 933). The underlying spirit of MI is to better understand clients’ experiences through three guiding principles: “Collaboration, autonomy, and evocation;” their aim is to promote client engagement and motivate clients to move from a state of ambivalence to a state of desiring to change (Stewart, 2012, p. 934). Stewart (2012), in a similar vein, reiterates Miller’s (1995) five outlined principles to assist clinicians in reaching the aforementioned goal: “Expressing empathy, developing discrepancy, avoiding argumentation, rolling with resistance, and supporting self-efficacy” (Stewart, 2012, p. 934).
How MI Effects Change in Substance Users
Over 200 clinical trials have been conducted of MI in various fields of application (Stewart, 2012; Miller & Rose, 2009). It is largely understood that MI works most effectively within populations of substance users who have considered treatment, but are still primarily ambivalent about change (Stewart, 2012). The specific skills and strategies implemented within MI are recognized by the acronym OARS, and consistent with the approach coined by the Addiction Technology Transfer Center (ATTC) in 2006: “Open-ended questions, affirmations, reflective listening, and summaries (Stewart, 2012; Miller & Rollnick, 2002; AATC, 2006). This approach is meant to induce change talk; the more a patient talks about change, the more likely he/she is to implement change (Stewart, 2012; MINT, 2008).
Future Focus for Studying Efficacy of MI
In order to better understand the efficacy and implementation practices of MI, Stewart (2012) conducted a literature review and discovered that there are reportedly “76.3 million people in the world with alcohol use disorders (WHO, 2009) with MI being utilized widely as a treatment of choice” (p. 935). Yet, upon further examination of research, MI seems to have the most significant impact when compared to no treatment in the control group versus control groups undergoing other, treatment-as-usual programs (Stewart, 2012). Further, Stewart (2012) noted that the strongest results for positive change in alcohol consumption occur immediately following the intervention and are less significant at short- and long-term follow-ups. Thus, Stewart (2012) proposes that it is important to focus on what moderates the outcome of MI and potential influence over the long term, versus simply focusing on its efficacy. Examples of moderators to consider are: “Treatment versus non-treatment seeking samples, readiness to change, age, gender, employment status, marital status, client expectations, duration of MI, and training” (Stewart, 2012, p. 936). Stewart (2012) further justifies this proposal with the notion that by better understanding the mechanisms by which MI works, the benefits of it can be extended over the long-term.
Substance Abuse References
Addiction Technology Transfer Center (ATTC) (2006). MIA Step: Motivational Interviewing Assessment, Supervisory Tools for Enhancing Proficiency. Northwest Frontier Addiction Technology Transfer Center, Department of Public Health and Preventative Medicine and Oregon Health and Science University, Salem, OR.
Miller, W. (1983). Motivational interviewing with problem drinkers. Behavioral Psychotherapy, 11, 147-172.
Miller, W. (1995). Motivational enhancement therapy with drug abusers (Online). Available at http://www.motivationalinterview.org/clinical/METDrugAbuse.PDF
Miller, W., & Rollnick, S. (2009). Ten things that motivational interviewing is not. Behavioral and Cognitive Psychotherapy, 37, 129-140.
Motivational Interviewing Network of Trainers (MINT). (2008). Motivational interviewing training for new trainers (Online). Available at http://www.motivationalinterviewing.org
Stewart, J. (2012). A critical appraisal of motivational interviewing within the field of alcohol misuse. Journal of Psychiatric and Mental Health Nursing, 19, 933-938.
World Health Organization (WHO). (2009). Management of substance use (Online). Available at http://www.who.int