Summary. Summary: Identification of risk factors and protective factors, and vulnerability and risk factors are important to

Transcription

1 Summary Summary: Identification of risk factors and protective factors, and vulnerability and risk factors are important to select target populations to select target variables to induce change (How) can we manipulate these factors? Which factors are stable, which unstable? Can we control unstable factors? How can we control unstable factors? How can we adapt to these conditions? 1 st or 2 nd order change/adaptation

2 Summary Summary: yes direct influence changeable Control? Causal Factors no frequent? no passivity, palliation unchangeable yes accommodation

3 Summary Summary: Important concept: Stressful events or conditions (psychology) Noxious Factor / Condition /Force Life event research: quantification of risk Background: Crisis model If basic resources are present: adequate functioning (irrespective of constitution) If stressors occur, deplete resources: functioning drops constitution sustains functioning chronic stress: constitution deteriorates Preventive interventions can target several components of crisis model diathesis-stress model

4 Mechanisms Etiological Background Vulnerability Stress Model (Diathesis Stress Model) Stressor Vulnerability Strain Disorder

5 Psychological applications: some stress theory

6 Mechanisms Stressors, Strain, Stress: Crisis and Critical Events Stressful events are called stressors extreme sensations (light, noise, pain) crowding, limited space dysfunctional relationships social evaluation traffic psychologically: threat! stressors are stressful to some, but not all people the perception of an event determines whether it is a stressor

7 Mechanisms Stressors, Strain, Stress: Crisis and Critical Events Stress is a state of tension caused by stressors and exerting strain on the individual Stress is a negative emotional experience accompanied by predictable biochemical changes physiological changes cognitive changes, and behavioral changes that are directed either toward altering the stressful event or accommodating to its effects e.g., Lazarus, 1999; Taylor, 2006

8 Mechanisms Stressors, Strain, Stress: Crisis and Critical Events Strain is the change in the system that arises from a state of stress Strain itself does not describe the force acting on the individual stressor stress behavior/response strain e.g., Lazarus, 1999; Taylor, 2006

9 Mechanisms Psychological Stress Process (Lazarus) Lazarus (e.g. 1983), and other emotion scholars (e.g., Arnold, 1969) adopted transactional perspectives on the stress process: Environment Person Appraisals primary: event significant? secondary: can I deal with it? Stressor Emotions Behavior (simplified model) e.g., Lazarus, 1999; Taylor, 2006

10 Mechanisms Personal Resources Threatening Environment Stress Transactional Stress Process: Person and Environment Person-Environment-Fit great stress= negative emotions, acute and strong response Can I meet demands? little stress = challenge Appraisals play a critical role: provide behavioral flexibility and economy (coping vs. emotion regulation; save energy) automatic and controlled e.g., Lazarus, 1999; Taylor, 2006

11 Mechanisms Transactional Stress Process: Behavior response to perceived threat (Walter Cannon (1932)): sympathetic nervous system and endocrine system aroused Fight: aggressive stress response ( primary control) Flight: evasive stress response ( secondary control): withdrawal, drugs, alcohol perceived control, power plays a role! adaptive: Allows quick response to threat problematic: Can cause problems on the long term e.g., Lazarus, 1999; Taylor, 2006

12 Mechanisms Transactional Stress Process: Selye s General Adaptation Syndrome Three Phases in reacting to a stressor 1. Alarm 2. Resistance Stressor 3. Exhaustion time e.g., Lazarus, 1999; Taylor, 2006

13 Mechanisms Transactional Stress Process: Social Behavior Extension to the fight-flight model: Social Stress Regulation (S. Taylor: tend and befriend ) f-f is often useful: increases control protection but: not the only way to increase control and protection affiliation as a stress-reponse: joint protection in threatening times perceived relational gap signals threat affiliation reduces stress response oxytocin plays probably a critical role, gender difference e.g., Lazarus, 1999; Taylor, 2006a, 2006b

14 Mechanisms Psychological Stress Process: Implications for Prevention? On a psychological level, all elements of the stress process are important targets of intervention Stressor Appraisals Emotions Behaviors (coping, problem solving) Social integration, affiliation e.g., Lazarus, 1999; Taylor, 2006a, 2006b

15 Intervention types on the background of a diathesis-stress perspective

16 Mechanisms Moderator Concepts: Critical Questions Diathesis Stress Model: Vulnerability and Resilience as Guidelines how can we identify vulnerability, resilience? post hoc from others: correlational research theoretical work what causes/promotes vulnerability? Can we influence vulnerability/resilience? Can we influence exposure?

17 Strategies targeting Stressors Stressor oriented Interventions Which preventive interventions can serve to reduce stressors? prevent stressors from occurring, reduce stressor strength fight e.g., teach parents educational techniques avoid stressors, reduce stress exposure flight e.g., lock away sexual offenders

18 Strategies targeting Vulnerability and Resources Vulnerability and Resilience oriented Interventions Which preventive interventions can serve to strengthen resilience or reduce vulnerability? preserve and maintain resources broad approach, diversity is relevant e.g., maintain access to social contacts or intellectual stimulation in elderly build new resources broad or problem specific e.g., teach parenting skills, provide knowledge replace vulnerabilities by newly acquired resources specific to identified problem area e.g., replace ruminative thoughts with positive emotion regulation skills can focus on individual or environment!

19 Strategies targeting Vulnerability and Resources Vulnerability and Resilience oriented Interventions Which preventive interventions can serve to strengthen resilience or reduce vulnerability? repair! vulnerability can be a result of a nocive/degenerative process e.g.: children develop vulnerability to anxiety and depression, partially due to overprotective parenting the actual vulnerability is rooted in dysfunctional cognitive schemas (e.g., the world is dangerous, you need protection to be safe, ) repairing those schemas reduces vulnerability e.g.: couples develop dysfunctional problem solving dynamics

20 Important prevention strategies and Designs

21 Strategies and Desings Person- vs. Context centered strategies When are person-centered strategies appropriate? When are context- or system-centered strategies appropriate? key question: where s the risk? High risk for a person? Risk for many persons?

22 Strategies and Desings Person- vs. Context centered strategies When are person-centered strategies appropriate? A few individuals at high risk behavior change is cost-effective and efficient

23 Strategies and Desings Person- vs. Context centered strategies When are person-centered strategies appropriate? When are context- or system-centered strategies appropriate? many individuals at some risk problem and/or risk influenced by context or system factors consequences of problems high overall costs

24 Principle 1 We want to maximize overall risk reduction!

25 Strategies and Desings Risk Different risk perspectives: absolute risk relative risk Absolute risk point of reference population standardized vs. unstandardized AR Relative risk Point of reference theoretically relevant factors: exposure to relevant condition; Comparative parameters

26 Strategies and Desings Risk the importance of adopting a broad view if risk is critical which aspect of risk? what is the extra risk or in other words: which aspect of risk shall we consider as acceptable, and which aspect shall we consider as target? attributable risk: which portion of the risk is attributable to the exposure to known riskconditions risk-ratio (or difference) / population frequency

27 Strategies and Desings Attributable risk How many are exposed? How many of those are concerned? 100 cases 0f 1000 exposed = cases of unexposed= 0.01 the relative risk is...?.1 /.01 = 10 OR = (.1/.9) / (.01/.99) =.11 /.0101 = and the attributable risk is...? = /.1=.09/.1 =.9 x 100 = 90%

28 Strategies and Desings Attributable risk For individual: subjective, individual absolute and relative risk is critical! From a public perspective, the risk that is attributable to a certain factor is critical!

29 Principle 2 We want to maximize the change caused by our intervention

30 1.Behavior Change Which Methods are indicated? Goals and characteristics of target individuals are crucial Maccoby & Solomon (1981) Requirements for change: Awareness Knowledge Motivation Skills Implementation Maintenance

31 1.Behavior Change Which Methods are indicated? Prochaska & Di Clemente, 1983, 1989: Stages of Change Precontemplation (stage 1) Denial, ignorance encourage individal to reflect behavior encourage introspection raise awareness of risk

32 1.Behavior Change Which Methods are indicated? Prochaska & Di Clemente, 1983, 1989: Stages of Change Contemplation (stage 2) Ambivalence, internal conflict, confusion consider pros and cons of initiating change encourage confidence in ability to induce change identify obstacles, barriers

33 Behavior Change Which Methods are indicated? Prochaska & Di Clemente, 1983, 1989: Stages of Change Preparation (stage 3) Experiment, try to induce change Collect information about change define goals plan action

34 Behavior Change Which Methods are indicated? Prochaska & Di Clemente, 1983, 1989: Stages of Change Action (stage 4) Take direct action Reward successes Seek social support

35 Behavior Change Which Methods are indicated? Prochaska & Di Clemente, 1983, 1989: Stages of Change Maintenance (stage 5) Maintain new behavior Avoid, learn how to deal with temptation!

36 Behavior Change Which Methods are indicated? Prochaska & Di Clemente, 1983, 1989: Stages of Change Relapse (stage 6) Find triggers of relapse, and bareers to success Reaffirm committment to change

37 Behavior Change Strategies to initiate change Goal awareness of problem motivation social reinforcement behavior training context control Strategy facts, information, insight communication, counseling group discussions behavior training change environment, laws etc.

38 Behavior Change Strategies Information Awareness Skills Counseling Education (procedural knowledge) Skills Motivation Training Exercise, role play, mental training System-related interventions Crisis- Intervention Stabilize, strengthen (skills), mobilize resources Perrez & Hilti, 2005

39 Research: Evaluation

40 Evaluation Evaluation: Research Questions Planning of preventive interventions What causes risk? Implementation of preventive interventions How can I establish change? Evaluation of preventive interventions Does intervention change factors? Does intervention reduce risk? Evaluation of Efficacy Schwarzer, 2002

41 Evaluation Evaluation of Efficacy: Research Requirements Scientific application of preventive intervention requires Etiological knowledge Technological knowledge Why is it not enough to assess whether an intervention reduces risk (incidence)? Schwarzer, 2002

42 Evaluation Evaluation: additional evaluation goals Acceptance? Cost-effectiveness? EVALUATION GOALS Prior to intervention Program development, prospective evaluation goals (what are goals? What is relevant? What are risk groups?): interviews, case studies, surveys During intervention Process research : are interventions implemented according to plans (manuals)? After intervention Outcome evaluation: Efficacy, differential efficacy (with respect to outcomes, risk groups) Schwarzer, 2002

43 Evaluation Evaluation: study designs Usually: field experiments quasi-experimental designs Problematic: Control groups Complexity of interventions, criteria Description and definition of success/change (Rossi et al., 2003)

44 Evaluation Evaluation of change Controlled trials Non-treatment controls Waiting-controls Randomization Alternative treatments Do controls allow for a valid comparison? Pre-post desings Longitudinal measurements

45 Evaluation Evaluation of change: longitudinal approaches How many measurements? pre post FU How to assess change? t1 t2 t3 t1 t2 t3 What is significant change? Effect size? Condition? Costs?

46 Evaluation Process evaluation models Mediation? Intervention change in factor change in risk Moderation Change in factor change in stress-distress association Change in factor change in stress-strain association Change in factor change in stress-response association Mediated Moderation Intervention change in factor change in stressdistress association