No description available.

Thesis (M.S.)--Boston University / The purpose ot this thesis is to compare two groups of patients, namely those who were given an immediate appointment following intake and those who were assigned after a waiting period. The study is confined to patients treated by social workers in the Boston Veterans Administration Mental Hygiene Clinic. It aims to learn what similarities and differences exist between the two groups; the effect ot a waiting period on patient's stay in treatment; and to determine the relationship of a number of factors to length, and outcome of treatment. According to the literature more stress is placed on motivation in relation to patient's sta7 in treatment than another factor. "The major purpose of the intake interview is to determine motivation, which is important in assessing the patient's treatment potential."2 This study is also curious to learn whether there is a relationship between motivation and length of treatment. It is hoped that this study may show what factors indicate further consideration with regard to patients placed on the waiting list.

O subfinanciamento do tratamento cirúrgico das deformidades da coluna vertebral tem resultado em aumento progressivo das listas de espera nos centros de referência para tratamento de alta complexidade pelo sistema público de saúde. O objetivo do estudo foi caracterizar o modo como a gestão pública na saúde tem conduzido o tratamento das deformidades da coluna vertebral e avaliar as consequências clínicas, radiográficas e econômicas do atraso na realização do tratamento cirúrgico. O estudo foi realizado em três estágios: transversal, retrospectivo e prospectivo. Foram avaliados 60 pacientes com deformidades da coluna vertebral e que aguardavam tratamento cirúrgico até Dezembro de 2013, com idade entre 3 e 23 anos, 66,7% femininos, e de etiologias: neuromuscular (28,3%), congênita (26,7%), idiopática (25,0%), sindrômica (16,7%), doença de Marfan (1,7%) e neurofibromatose (1,7%). Os parâmetros avaliados foram idade, gênero, etiologia, origem, modo de encaminhamento, tempo de espera pelo encaminhamento, tempo de espera pelo tratamento cirúrgico, e necessidade de implantes não disponibilizados pelo sistema de gestão da saúde. No segundo estágio foram avaliados: qualidade de vida dos pacientes por meio do questionário SRS-22r e parâmetros radiográficos atuais, comparados aos parâmetros no momento do alistamento para o tratamento cirúrgico. No terceiro estágio, os pacientes foram distribuídos aleatoriamente em grupos cirúrgico e lista de espera. Os pacientes submetidos ao tratamento cirúrgico foram comparados aos que permaneceram na lista de espera quanto ao custo e à efetividade dos tratamentos, utilizando como desfecho a evolução dos parâmetros radiográficos e da pontuação no questionário SRS-22r. Foi observado que 91% dos pacientes foram originários das regionais de Ribeirão Preto e adjacentes. Apenas 25% dos pacientes receberam tratamento no centro primário. O tempo de espera pela consulta no centro de referência foi de medianos 8,5 meses, e, após o alistamento na fila de espera, os pacientes aguardaram medianos 13,5 meses pelo tratamento cirúrgico. 45% dos pacientes da fila de espera apresentaram necessidade de implantes não disponibilizados pelo sistema de gestão em saúde. A deformidade no plano coronal aumentou em média 18,7° durante o período de espera. Houve aumento no número de pacientes descompensados no plano coronal e sagital, e no número de pacientes com obliquidade pélvica. A pontuação mediana no questionário SRS-22r foi 3,73. O custo médio do tratamento dos pacientes submetidos à cirurgia foi R$71.139. Foi observada correção média da deformidade em -49,6% (-42,1°) e melhora na pontuação no questionário SRS-22r em 0,5 pontos. No grupo de pacientes submetidos ao seguimento clínico, o custo médio foi de R$377, com aumento médio da deformidade em 16,0% (11,0°); não houve diferença na pontuação no questionário SRS-22r. Os resultados do estudo indicam que novas políticas de gestão da saúde devam ser adotadas para o tratamento das deformidades da coluna vertebral com a finalidade de evitar a progressão da deformidade dos pacientes e viabilizar o tratamento definitivo / The underfunding of the surgical treatment of spinal deformities has resulted in steadily growing waiting lists in reference centers for high complexity treatment in publicly funded healthcare systems. The aim of the study was to characterize how the management of the public health system has been conducting the treatment of spinal deformities and to evaluate the clinical, radiological, and economic impact of the delay in performing the surgical treatment. The study was conducted in three stages: Cross-sectional, retrospective and prospective stages. Sixty patients with complex pediatric spinal deformities who were waiting for treatment until December 2013 were evaluated. The age range was 3-23 years-old, 66·7% were females, and the etiologies were: neuromuscular (28·3%), congenital (26·7%), idiopathic (25%), syndromes (16·7%), Marfan\'s disease (1·7%), and neurofibromatosis (1·7%). The evaluated parameters were age, gender, etiology, origin, method of referral, waiting time for the referral, waiting time for the surgical treatment, and the need for implants not reimbursed by the healthcare system. For the second stage, the health-related quality of life was assessed through the application of the SRS-22r questionnaire and the present radiographic measurements were compared to the initial parameters (at the time the patients were enrolled for surgery). For the third stage, the patients were randomly assigned into two groups: Surgery and Waitlist. The patients submitted to surgical treatment were compared to the patients who remained on the waiting list considering the costs and effectiveness of the treatments, using the progression of the radiographic parameters and the score in the SRS-22r questionnaire as outcome measures. The results of the study demonstrated that 91% of the patients were from the region of Ribeirão Preto and adjacent regions. Only 25% of the patients received treatment at primary care centers. Patients waited median 8.5 months for referral and 13.5 months for the surgical treatment. 45% of the patients on the waiting list had the necessity for implants not reimbursed by the healthcare system. The deformity\'s Cobb angle increased mean 18.7° during the waiting period. There was an increase in the number of patients with coronal or sagittal decompensation, and in the number of patients with pelvic obliquity. The median SRS-22r® total score was 3.73. The mean cost of treatment for the Surgery group was R$71,139. A deformity correction of mean -49.6% (-42.1°) and a health-related quality of life improvement of 0.5 points in the SRS-22r score were observed. In the Waitlist group, the mean cost was R$377, with a mean increase of the deformity of 16.0% (11.0°); there was no difference in the SRS-22r scores. The results of the study indicate that new policies on the public health management of spinal deformities should be adopted to avoid progression of the deformities and make the definitive treatment viable

Diss. (sammanfattning) Uppsala : Uppsala universitet, 2005. / Härtill 4 uppsatser.

Thesis (Ph.D. )--University of Tennessee Health Science Center, 2008. / Title from title page screen (viewed on April 24, 2008 ). Research advisor: Shelly White-Means, Ph.D. Document formatted into pages (xi, 101 p. : ill.). Vita. Abstract. Includes bibliographical references (p. 94-100).

O subfinanciamento do tratamento cirúrgico das deformidades da coluna vertebral tem resultado em aumento progressivo das listas de espera nos centros de referência para tratamento de alta complexidade pelo sistema público de saúde. O objetivo do estudo foi caracterizar o modo como a gestão pública na saúde tem conduzido o tratamento das deformidades da coluna vertebral e avaliar as consequências clínicas, radiográficas e econômicas do atraso na realização do tratamento cirúrgico. O estudo foi realizado em três estágios: transversal, retrospectivo e prospectivo. Foram avaliados 60 pacientes com deformidades da coluna vertebral e que aguardavam tratamento cirúrgico até Dezembro de 2013, com idade entre 3 e 23 anos, 66,7% femininos, e de etiologias: neuromuscular (28,3%), congênita (26,7%), idiopática (25,0%), sindrômica (16,7%), doença de Marfan (1,7%) e neurofibromatose (1,7%). Os parâmetros avaliados foram idade, gênero, etiologia, origem, modo de encaminhamento, tempo de espera pelo encaminhamento, tempo de espera pelo tratamento cirúrgico, e necessidade de implantes não disponibilizados pelo sistema de gestão da saúde. No segundo estágio foram avaliados: qualidade de vida dos pacientes por meio do questionário SRS-22r e parâmetros radiográficos atuais, comparados aos parâmetros no momento do alistamento para o tratamento cirúrgico. No terceiro estágio, os pacientes foram distribuídos aleatoriamente em grupos cirúrgico e lista de espera. Os pacientes submetidos ao tratamento cirúrgico foram comparados aos que permaneceram na lista de espera quanto ao custo e à efetividade dos tratamentos, utilizando como desfecho a evolução dos parâmetros radiográficos e da pontuação no questionário SRS-22r. Foi observado que 91% dos pacientes foram originários das regionais de Ribeirão Preto e adjacentes. Apenas 25% dos pacientes receberam tratamento no centro primário. O tempo de espera pela consulta no centro de referência foi de medianos 8,5 meses, e, após o alistamento na fila de espera, os pacientes aguardaram medianos 13,5 meses pelo tratamento cirúrgico. 45% dos pacientes da fila de espera apresentaram necessidade de implantes não disponibilizados pelo sistema de gestão em saúde. A deformidade no plano coronal aumentou em média 18,7° durante o período de espera. Houve aumento no número de pacientes descompensados no plano coronal e sagital, e no número de pacientes com obliquidade pélvica. A pontuação mediana no questionário SRS-22r foi 3,73. O custo médio do tratamento dos pacientes submetidos à cirurgia foi R$71.139. Foi observada correção média da deformidade em -49,6% (-42,1°) e melhora na pontuação no questionário SRS-22r em 0,5 pontos. No grupo de pacientes submetidos ao seguimento clínico, o custo médio foi de R$377, com aumento médio da deformidade em 16,0% (11,0°); não houve diferença na pontuação no questionário SRS-22r. Os resultados do estudo indicam que novas políticas de gestão da saúde devam ser adotadas para o tratamento das deformidades da coluna vertebral com a finalidade de evitar a progressão da deformidade dos pacientes e viabilizar o tratamento definitivo / The underfunding of the surgical treatment of spinal deformities has resulted in steadily growing waiting lists in reference centers for high complexity treatment in publicly funded healthcare systems. The aim of the study was to characterize how the management of the public health system has been conducting the treatment of spinal deformities and to evaluate the clinical, radiological, and economic impact of the delay in performing the surgical treatment. The study was conducted in three stages: Cross-sectional, retrospective and prospective stages. Sixty patients with complex pediatric spinal deformities who were waiting for treatment until December 2013 were evaluated. The age range was 3-23 years-old, 66·7% were females, and the etiologies were: neuromuscular (28·3%), congenital (26·7%), idiopathic (25%), syndromes (16·7%), Marfan\'s disease (1·7%), and neurofibromatosis (1·7%). The evaluated parameters were age, gender, etiology, origin, method of referral, waiting time for the referral, waiting time for the surgical treatment, and the need for implants not reimbursed by the healthcare system. For the second stage, the health-related quality of life was assessed through the application of the SRS-22r questionnaire and the present radiographic measurements were compared to the initial parameters (at the time the patients were enrolled for surgery). For the third stage, the patients were randomly assigned into two groups: Surgery and Waitlist. The patients submitted to surgical treatment were compared to the patients who remained on the waiting list considering the costs and effectiveness of the treatments, using the progression of the radiographic parameters and the score in the SRS-22r questionnaire as outcome measures. The results of the study demonstrated that 91% of the patients were from the region of Ribeirão Preto and adjacent regions. Only 25% of the patients received treatment at primary care centers. Patients waited median 8.5 months for referral and 13.5 months for the surgical treatment. 45% of the patients on the waiting list had the necessity for implants not reimbursed by the healthcare system. The deformity\'s Cobb angle increased mean 18.7° during the waiting period. There was an increase in the number of patients with coronal or sagittal decompensation, and in the number of patients with pelvic obliquity. The median SRS-22r® total score was 3.73. The mean cost of treatment for the Surgery group was R$71,139. A deformity correction of mean -49.6% (-42.1°) and a health-related quality of life improvement of 0.5 points in the SRS-22r score were observed. In the Waitlist group, the mean cost was R$377, with a mean increase of the deformity of 16.0% (11.0°); there was no difference in the SRS-22r scores. The results of the study indicate that new policies on the public health management of spinal deformities should be adopted to avoid progression of the deformities and make the definitive treatment viable

M.Tech. / The recent increase in demand for radiotherapy services has led to significant delays in commencement of radical radiation treatment in most centres. Radiobiological principles suggest that a delay in starting radiotherapy may have a negative impact on tumour local control. To cope with the growing demand for radiotherapy, modern improvement models need to be accepted and adapted in radiotherapy departments. The PLAN DO STUDY ACT (PDSA) model is an example of such an improvement model which explores new possibilities of improvement through experimentation. This study aimed to determine the causes of radiotherapy delays, and to develop and implement improvements for reducing radiotherapy delays from patients’ referral to a radiotherapy department to the start of radiotherapy at Gaborone Oncology in Botswana. The objectives were to determine the causes of radiotherapy delays, develop and implement improvements of reducing radiotherapy delays using the PDSA model for improvement, and evaluate the effectiveness of the model. Patients who had received radical radiotherapy for head and neck, breast and cervix tumours were analysed as they are the commonly treated cancers at Gaborone Oncology. A retrospective survey was conducted for one year to establish the causes of radiotherapy delays from patient referral to the department to the start of radiation treatment. The PDSA model for improvement was then implemented and monitored for evidence of improvement from May to December 2008. The PDSA model showed significant reduction in radiotherapy delays at Gaborone Oncology. The results showed a decrease in radiotherapy delays in head and neck, breast and cervix cancers from an average delay time of 18.5 days in May 2008 to 8.6 days by December 2008.

A doença hepática terminal reduz de forma significativa a qualidade de vida de pacientes e com o transplante do órgão é possível melhorar as condições de saúde. A sexualidade é aspecto central do ser humano durante todo o ciclo vital. É área complexa do comportamento humano, assim a sexualidade de candidatos e receptores de transplante de fígado não deve ser menosprezada. O presente estudo teve como objetivo analisar as evidências disponíveis na literatura sobre as alterações na sexualidade de candidatos e receptores de transplante de fígado. Trata-se de revisão integrativa da literatura: as bases de dados selecionadas para a busca dos estudos primários foram PubMed, CINAHL e LILACS. Os 16 estudos primários incluídos na revisão foram agrupados em três categorias: (1) sexualidade feminina (n=5); (2) sexualidade masculina (n=5) e; (3) sexualidade masculina e feminina (n=6). Na categoria 1, os principais temas de investigação foram contracepção, gravidez, disfunção sexual, presença de sintomas ginecológicos e doença sexualmente transmissível. Na categoria 2, o foco principal dos estudos primários agrupados foi a disfunção erétil e investigou-se também desejo/satisfação sexual e as consequências de homens que tiveram filhos, em regime imunossupressor com ácido mycofenólico. Na categoria 3, a avaliação da função sexual foi o principal tema abordado nas pesquisas analisadas. A sexualidade é problemática desafiadora, revestida por tabus e preconceitos, vivenciada de forma diferente pelos indivíduos. Assim, os pacientes podem apresentar dificuldades em relatar para os profissionais da saúde seus problemas, acarretando atraso do diagnóstico e tratamento, prolongando a sensação de desconforto e sentimento de angústia. A dificuldade em abordar sobre sexualidade também ocorre por parte dos profissionais de saúde que não recebem capacitação adequada. O conhecimento sobre as dúvidas e problemas vivenciados pelos candidatos e receptores de transplante de fígado pode proporcionar a implementação de intervenções direcionadas para prevenção, redução ou controle das complicações no período pré e pós-transplante. O presente estudo forneceu subsídios para encorajar os profissionais de saúde a incorporar a sexualidade na rotina de atendimento destes pacientes, bem como indicou lacunas no conhecimento para a condução de novas pesquisas com o propósito de implementar intervenções na pratica clínica para prevenir, minimizar e/ou controlar as alterações relacionadas à sexualidade do paciente, contribuindo para a melhoria da assistência de enfermagem e, consequentemente, para o sucesso do tratamento / The end-stage liver disease significantly reduces the quality of life of patients. However, with organ transplantation it is possible to improve health conditions. Sexuality is a central aspect of the human being throughout the life cycle. It is a complex area of the human behavior and therefore the sexuality of liver transplant candidates and recipients should not be overlooked. The present study aimed to analyze the evidence available in the literature on the changes in the sexuality of candidates and recipients of liver transplant. This is an integrative literature review, and the databases selected for the search of the primary studies were PubMed, CINAHL and LILACS. The 16 primary studies included in the review were grouped into three categories: (1) female sexuality (n = 5), (2) male sexuality (n = 5) and (3) male and female sexuality (n = 6). In category 1, the main research topics were contraception, pregnancy, sexual dysfunction, presence of gynecological symptoms and sexually transmitted disease. In category 2, the focus of the primary studies grouped was erectile dysfunction, it was also investigated the sexual desire/satisfaction, and the consequences of men who had children under immunosuppressive regimen with mycophenolic acid. In category 3, the evaluation of sexual function was the main topic addressed in the studies analyzed. Sexuality is a challenging problem, enrobed with taboos and prejudices, and experienced differently by individuals. Thus, patients may present difficulties in reporting their problems to health professionals, leading to delays in diagnosis and treatment, prolonging feelings of discomfort and distress. The difficulty in addressing sexuality also occurs on the part of health professionals who do not receive adequate training. Knowledge about the doubts and problems experienced by candidates and recipients of liver transplant can facilitate the implementation of interventions aimed at prevention, reduction or control of complications in the pre- and post-transplantation period. The present study provided subsidies to encourage health professionals to incorporate sexuality in the care routine of these patients, it also indicated gaps in knowledge for the conduct of new research with the purpose of implementing interventions in clinical practice to prevent, minimize and/or to control the changes related to the patient\'s sexuality, contributing to the improvement of nursing care and, consequently, to the success of the treatment

Obwohl therapeutisch angestrebte Veränderungen im Rahmen der kognitiven Verhaltenstherapie vor allem als Veränderungen des Erlebens und Verhaltens im Alltag des Patienten konzipiert werden, konzentriert sich die Psychotherapieforschung bei der Aufklärung relevanter Wirkmechanismen bislang eher auf Einflüsse der unmittelbaren therapeutischen Interaktion sowie auf den Beitrag konkreter Intervention. Prozesse außerhalb der therapeutischen Sitzungen wurden in ihrer Bedeutung für Veränderungen eher vernachlässigt. Es ist jedoch davon auszugehen, dass ein umfassenderes Verständnis dieser Prozesse helfen könnte, psychotherapeutische Behandlungen weiter zu optimieren und ihre Gesamteffektivität zu erhöhen. Die vorliegende Arbeit macht veränderungsrelevante Prozesse außerhalb des eigentlichen Therapiekontextes zum Ausgangspunkt verschiedener Überlegungen zur Optimierung verhaltenstherapeutischer Behandlungen. Dabei werden exemplarisch Prozesse in der Wartezeit zwischen Anmeldung zur Psychotherapie und Beginn der eigentlichen Behandlung sowie therapeutische Hausaufgaben als veränderungsrelevante Aktivitäten zwischen zwei Therapiestunden untersucht. Einen wichtigen Bereich potentieller Veränderungsprozesse stellen Einflüsse in der Zeit vor der Therapie dar. In der Überblicksarbeit „Wartezeit für Psychotherapiepatienten – und wie sie zu nutzen ist“ (Helbig, Hähnel, Weigel & Hoyer, 2004) wird zunächst die derzeitige Versorgungslage im Psychotherapiesektor in Bezug auf Wartezeiten dargestellt und damit assoziierte Probleme aufgezeigt. Es werden Empfehlungen für einen konstruktiven Umgang mit diesen Wartezeiten diskutiert sowie eine konkrete Vorgehensweise vorgeschlagen. In einer Praxiserhebung wurden darüber hinaus ca. 300 Patienten auf einer Warteliste für ambulante Verhaltenstherapie mit einem Kurzfragebogen zu eigeninitiierten problembezogenen Aktivitäten und Coping-Strategien befragt („What do patients do before it starts? Coping with mental health problems on a CBT waiting list“; Helbig & Hoyer, 2008). Es zeigte sich, dass das therapierelevante Verhalten in der Wartezeit erheblich variierte, jedoch fast alle Patienten bereits während der Wartezeit im Hinblick auf ihr Problem aktiv wurden. Überraschenderweise konnten keine klaren Assoziationen zwischen Patienten-Charakteristika und Art des gezeigten Selbsthilfe- oder Copingverhaltens nachgewiesen werden. Eine erste Exploration der Effekte von Selbsthilfe-Verhalten in der Wartezeit auf das Therapie-Ergebnis ergab hypothesenkonträr, dass aktive Selbsthilfe ein ungünstigeres Behandlungsergebnis im Hinblick auf depressive Symptome vorhersagte – hier bleibt jedoch offen, inwieweit dieses Ergebnis durch den fehlenden Erfolg der Selbsthilfestrategien und einen damit verbundenen Selbstwirksamkeitsverlust moderiert wird. Die Ergebnisse führten zu der Hypothese, dass systematische und erwiesenermaßen nutzbringende Angebote für Patienten in der Wartezeit helfen könnten, Kosten durch Inanspruchnahme weiterer Dienste zu sparen und die Selbstwirksamkeitserwartung von Patienten schon vor Beginn der Therapie zu erhöhen. Diese Annahme wurde anhand einer speziell für die Wartezeit entwickelten Intervention untersucht („Hilft wenig viel? Eine Minimalintervention für Patienten während der Wartezeit auf ambulante Verhaltenstherapie“; Helbig & Hoyer, 2007). In einer universitären Psychotherapieambulanz wurden 75 Patienten mit Angst- bzw. depressiven Störungen nach Anmeldung zur Behandlung kontrolliert einer Versuchs- oder einer Kontrollgruppe zugewiesen. Während die Kontrollgruppe wie üblich auf den Behandlungsbeginn wartete, erhielt die Versuchsgruppe bibliotherapeutische Materialien sowie ein Informationsblatt zur Überbrückung von Wartezeit. Beide Gruppen wurden vor und nach der Wartezeit im Hinblick auf Erwartungen und Einstellungen zur Behandlung sowie hinsichtlich ihrer Zufriedenheit mit der Einrichtung untersucht. Die Minimalintervention erbrachte differenziell positive Effekte, insbesondere bei Personen mit geringem Vorwissen über Psychotherapie; ein global positiver Einfluss auf die untersuchten Variablen konnte jedoch nicht nachgewiesen werden. Bei Teilnehmern mit depressiven Erkrankungen wurden sogar vereinzelt negative Effekte der Intervention beobachtet. Entsprechend wurde geschlussfolgert, dass ein patienten- und störungsübergreifendes Vorgehen in der Wartezeit für eine Optimierung der psychotherapeutischen Versorgung nicht Erfolg versprechend erscheint. Neben Prozessen in der Wartezeit auf Psychotherapie sind auch Prozesse zwischen den eigentlichen Therapiesitzungen ein möglicher Ansatzpunkt zur Steigerung der Gesamteffektivität. Trotz ihrer theoretischen Bedeutsamkeit existieren bislang nur wenige empirische Befunde zur Frage, wie Hausaufgaben zur Therapieeffektivität beitragen und wie sie gewinnbringend einzusetzen sind. Eine Befragung von 77 verhaltenstherapeutisch arbeitenden Psychotherapeuten ergab, dass der Einsatz von Hausaufgaben in der Praxis mit einer Vielzahl von Problemen behaftet ist: Nur ca. ein Drittel der vereinbarten Aufgaben wurde durch den Patienten wie geplant erledigt („Problems with homework in CBT: Rare exception or rather frequent?“; Helbig & Fehm, 2004). Die Hausaufgaben-Compliance war dabei positiv korreliert mit der Vergabe schriftlicher Materialien, einem späteren Therapiestadium sowie der allgemeinen Einstellung zu Hausaufgaben. Aus diesen Ergebnissen wurden konkrete Maßnahmen für einen gewinnbringenden Einsatz von Hausaufgaben abgeleitet. Aufgrund der überraschend häufigen Probleme im Umgang mit Hausaufgaben beschäftigte sich eine weitere Arbeit mit allgemeinen Empfehlungen für den effektiven Einsatz von Hausaufgaben und deren empirischer Fundierung („Der Einsatz von Hausaufgaben in der Psychotherapie. Empfehlungen und ihre empirische Fundierung“; Helbig & Fehm, 2005). Es konnte gezeigt werden, dass die Mehrzahl der in der Literatur genannten Empfehlungen noch nicht empirisch untersucht ist bzw. nicht nachgewiesenermaßen mit der Hausaufgabenerledigung assoziiert ist. In den bisher beschriebenen empirischen Arbeiten wurden Schwierigkeiten bei der aussagekräftigen Erfassung des Geschehens außerhalb des Therapiekontexts deutlich. Aus diesem Grund wurde im Rahmen einer weiteren Studie das Ecological Momentary Assessment (EMA) als ambulantes Monitoring-Verfahren auf seine Anwendbarkeit bei der Untersuchung von klinisch relevanten Veränderungsprozessen überprüft („Implementierung, Akzeptanz und Informationsgehalt eines „Ecological Momentary Assessment“-Ansatzes bei Patienten mit Panikstörung und Agoraphobie“; Helbig, Lang, Swendsen, Hoyer & Wittchen, 2009). Insgesamt konnte EMA gut in eine allgemeine Versorgungsstruktur implementiert werden und bot einen deutlichen Informationsgewinn gegenüber klassischen Erhebungsmethoden. In weiteren Studien sollte jedoch weiter untersucht werden, ob der Einsatz von EMA zu systematischen Stichprobenselektionseffekten führt. Die vorgestellten Befunde lassen den enormen Forschungsbedarf erkennen, der auf dem Gebiet veränderungsrelevanter Prozesse außerhalb der therapeutischen Beziehung und Intervention besteht. Aus diesem Grund wird abschließend eine weiterführende Forschungsagenda entwickelt und praxisnahe Vorschläge zur Optimierung der therapeutischen Versorgung abgeleitet. / Therapeutic outcome in cognitive-behaviour therapy (CBT) is often defined as lasting changes in cognitive, emotional and behavioural processes in a patient’s daily life. Psychotherapy research, on the contrary, mainly focuses on processes during therapeutic sessions and effects of specific interventions in examining mechanisms of change. Processes outside the therapeutic setting were mostly neglected, although it might be assumed that a comprehensive knowledge of these processes might help optimizing treatment and enhancing overall therapeutic effectiveness. The present dissertation is based on assumptions about the importance of change-relevant processes outside the direct therapist-patient-interaction on CBT outcome. Processes during waiting time for psychotherapy and therapeutic homework assignments are exemplarily scrutinized. Influences prior to therapy start are an important research subject in studying change processes outside the therapeutic setting. In a first paper, the status of German psychotherapy health care in relation to waiting times is reviewed, and related problems are discussed („Waiting time for psychotherapy – and how to make use of it“; Helbig, Hähnel, Weigel & Hoyer, 2004). Recommendations for using these waiting times for therapy preparation are proposed. Additionally, about 300 patients on a outpatient CBT waiting list were surveyed using a specifically developed questionnaire that retrospectively assessed problem-related activities and coping strategies („What do patients do before it starts? Coping with mental health problems on a CBT waiting list“; Helbig & Hoyer, 2008). It showed that patient behaviour during waiting time largely varied; however, almost all patients instigated activities in regard to their problem. Surprisingly, no clear associations between patient characteristics and coping behaviour could be found. A preliminary exploration of self-help effects during waiting on therapy outcome pointed out unfavourable effects of active self-help – however, it remained open whether failure in self-help and a related decrease of perceived self-effectiveness contributed to this surprising finding. It was concluded that a therapist initiated offer for using waiting times might help reduce additional health care utilization and promote patients’ self-effectiveness even prior to therapy start. This assumption was examined in a subsequent study on the effects of a minimal intervention for waiting list patients („Effects of a minimal intervention for patients on a CBT waiting list“; Helbig & Hoyer, 2007). 75 patients reporting depressive and anxiety disorders at intake were allocated to either waiting as usual or an intervention group. Patients in the intervention group received bibliotherapeutic materials and a leaflet informing about strategies that might help bridging the waiting time. Before and after waiting, consumer satisfaction, attitudes towards psychotherapy and treatment expectations were assessed in both groups. The minimal intervention had some positive effects, especially in patients with less knowledge about psychotherapy; however, there was no global improvement in the intervention group. In patients with depressive disorders, single adverse effects were observed. It was concluded that the use of therapy preparation strategies cannot overall be recommended, but has to take differences among patients into account. Besides processes prior to therapy start, intersession processes might be used for enhancing overall therapy effectiveness. Despite their theoretical importance, little is known about therapeutic homework assignments and their effective use. A survey among 77 behaviour therapists showed that only about one third of homework is completed as assigned („Problems with homework in CBT: Rare exception or rather frequent?“; Helbig & Fehm, 2004). Homework compliance was positively associated with providing written materials, a later stage of therapy and positive attitudes towards homework. Recommendations for homework assignment were derived from these findings. Due to the surprisingly frequent problems related to homework use, a review on recommendations for effective homework use and their empirical foundation was conducted („Homework recommendations in theory and research. Empirical results on the recommended use of homework“; Helbig & Fehm, 2005). It was shown that the majority of homework recommendations is not examined yet, or lacks empirical evidence. The empirical studies described above disclosed methodological difficulties in a meaningful assessment of intersession processes. Thus, a last study was designed to test the feasibility of an ambulatory assessment strategy (EMA) for examining clinically relevant mechanisms of change (“Feasibility, compliance and information content of an Ecological Momentary Assessment approach in patients with panic disorder and agoraphobia”; Helbig, Lang, Swendsen, Hoyer & Wittchen, 2009). Overall, EMA demonstrated feasibility in routine care as well as substantial information gains compared to questionnaire measures. Further studies should reappraise whether EMA is linked to systematic sample selection effects. Presented findings refer to a substantial need for further research on change-relevant processes outside the therapeutic setting. Against this background, the dissertation concludes with an intersession research agenda and with recommendations for enhancing therapeutic effectiveness.

Aims: The purpose of the qualitative study was to gain insight into the way parents experience and manage the waiting process following a referral to a Child and Adolescent Mental Health Service. The aim was to use the information for future service delivery and therapeutic engagement. Method: 6 parents whose child had been referred to a Child and Adolescent Mental Health Service and had been waiting for more than eight weeks were recruited using a purposive sampling method and participated in a semi-structured interview. The interviews were transcribed and analysed using the principles of Pidgeon & Henwood’s (1992) grounded theory techniques, facilitating the development and refinement of a theoretical model. Results: The resulting model highlights the waiting experience as fraught by loneliness, abandonment and self blame resulting in an interchanging role of being active or passive and the subsequent cycle they subside into. Some parents use the waiting time effectively by searching for their own answers but may eventually become passive following a belief that their parenting is insufficient. The disempowerment and self blame that is perpetuated through waiting intensifies the parents’ helplessness and results in a wide disparity between a negative self view and the idealised view of the professional. Conclusion: This study described the difficult experiences parents face while waiting for their child’s initial appointment. Parents need to be offered support, information and empowerment while waiting with ongoing communication from the service. Recommendations for future service and clinical delivery are provided.