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Basics of qualitative research: Grounded theory procedures and techniques

BACKGROUND: Somatoform disorders are characterised by chronic, medically unexplained physical symptoms (MUPS). Although different medications are part of treatment routines for people with somatoform disorders in clinics and private practices, there exists no systematic review or meta-analysis on the efficacy and tolerability of these medications. We aimed to synthesise to improve optimal treatment decisions.OBJECTIVES: To assess the effects of pharmacological interventions for somatoform disorders (specifically somatisation disorder, undifferentiated somatoform disorder, somatoform autonomic dysfunction, and pain disorder) in adults.SEARCH METHODS: We searched the Cochrane Depression, Anxiety and Neurosis Review Group's Specialised Register (CCDANCTR) (to 17 January 2014). This register includes relevant randomised controlled trials (RCTs) from The Cochrane Library (all years), MEDLINE (1950 to date), EMBASE (1974 to date), and PsycINFO (1967 to date). To identify ongoing trials, we searched ClinicalTrials.gov, Current Controlled Trials metaRegister, the World Health Organization International Clinical Trials Registry Platform, and the Chinese Clinical Trials Registry. For grey literature, we searched ProQuest Dissertation {\&} Theses Database, OpenGrey, and BIOSIS Previews. We handsearched conference proceedings and reference lists of potentially relevant papers and systematic reviews and contacted experts in the field.SELECTION CRITERIA: We selected RCTs or cluster RCTs of pharmacological interventions versus placebo, treatment as usual, another medication, or a combination of different medications for somatoform disorders in adults. We included people fulfilling standardised diagnostic criteria for somatisation disorder, undifferentiated somatoform disorder, somatoform autonomic dysfunction, or somatoform pain disorder.DATA COLLECTION AND ANALYSIS: One review author and one research assistant independently extracted data and assessed risk of bias. Primary outcomes included the severity of MUPS on a continuous measure, and acceptability of treatment.MAIN RESULTS: We included 26 RCTs (33 reports), with 2159 participants, in the review. They examined the efficacy of different types of antidepressants, the combination of an antidepressant and an antipsychotic, antipsychotics alone, or natural products (NPs). The duration of the studies ranged between two and 12 weeks.One meta-analysis of placebo-controlled studies showed no clear evidence of a significant difference between tricyclic antidepressants (TCAs) and placebo for the outcome severity of MUPS (SMD -0.13; 95{\%} CI -0.39 to 0.13; 2 studies, 239 participants; I(2) = 2{\%}; low-quality evidence). For new-generation antidepressants (NGAs), there was very low-quality evidence showing they were effective in reducing the severity of MUPS (SMD -0.91; 95{\%} CI -1.36 to -0.46; 3 studies, 243 participants; I(2) = 63{\%}). For NPs there was low-quality evidence that they were effective in reducing the severity of MUPS (SMD -0.74; 95{\%} CI -0.97 to -0.51; 2 studies, 322 participants; I(2) = 0{\%}).One meta-analysis showed no clear evidence of a difference between TCAs and NGAs for severity of MUPS (SMD -0.16; 95{\%} CI -0.55 to 0.23; 3 studies, 177 participants; I(2) = 42{\%}; low-quality evidence). There was also no difference between NGAs and other NGAs for severity of MUPS (SMD -0.16; 95{\%} CI -0.45 to 0.14; 4 studies, 182 participants; I(2) = 0{\%}).Finally, one meta-analysis comparing selective serotonin reuptake inhibitors (SSRIs) with a combination of SSRIs and antipsychotics showed low-quality evidence in favour of combined treatment for severity of MUPS (SMD 0.77; 95{\%} CI 0.32 to 1.22; 2 studies, 107 participants; I(2) = 23{\%}).Differences regarding the acceptability of the treatment (rate of all-cause drop-outs) were neither found between NGAs and placebo (RR 1.01, 95{\%} CI 0.64 to 1.61; 2 studies, 163 participants; I(2) = 0{\%}; low-quality evidence) or NPs and placebo (RR 0.85, 95{\%} CI 0.40 to 1.78; 3 studies, 506 participants; I(2) = 0{\%}; low-quality evidence); nor between TCAs and other medication (RR 1.48, 95{\%} CI 0.59 to 3.72; 8 studies, 556 participants; I(2) =14{\%}; low-quality evidence); nor between antidepressants and the combination of an antidepressant and an antipsychotic (RR 0.80, 95{\%} CI 0.25 to 2.52; 2 studies, 118 participants; I(2) = 0{\%}; low-quality evidence). Percental attrition rates due to adverse effects were high in all antidepressant treatments (0{\%} to 32{\%}), but low for NPs (0{\%} to 1.7{\%}).The risk of bias was high in many domains across studies. Seventeen trials (65.4{\%}) gave no information about random sequence generation and only two (7.7{\%}) provided information about allocation concealment. Eighteen studies (69.2{\%}) revealed a high or unclear risk in blinding participants and study personnel; 23 studies had high risk of bias relating to blinding assessors. For the comparison NGA versus placebo, there was relatively high imprecision and heterogeneity due to one outlier study. Although we identified 26 studies, each comparison only contained a few studies and small numbers of participants so the results were imprecise.AUTHORS' CONCLUSIONS: The current review found very low-quality evidence for NGAs and low-quality evidence for NPs being effective in treating somatoform symptoms in adults when compared with placebo. There was some evidence that different classes of antidepressants did not differ in efficacy; however, this was limited and of low to very low quality. These results had serious shortcomings such as the high risk of bias, strong heterogeneity in the data, and small sample sizes. Furthermore, the significant effects of antidepressant treatment have to be balanced against the relatively high rates of adverse effects. Adverse effects produced by medication can have amplifying effects on symptom perceptions, particularly in people focusing on somatic symptoms without medical causes. We can only draw conclusions about short-term efficacy of the pharmacological interventions because no trial included follow-up assessments. For each of the comparisons where there were available data on acceptability rates (NGAs versus placebo, NPs versus placebo, TCAs versus other medication, and antidepressants versus a combination of an antidepressant and an antipsychotic), no clear differences between the intervention and comparator were found.Future high-quality research should be carried out to determine the effectiveness of medications other than antidepressants, to compare antidepressants more thoroughly, and to follow-up participants over longer periods (the longest follow up was just 12 weeks). Another idea for future research would be to include other outcomes such as functional impairment or dysfunctional behaviours and cognitions as well as the classical outcomes such as symptom severity, depression, or anxiety.

Pharmacological interventions for somatoform disorders in adults.

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Qualitative research for education: An introduction to theories and methods

Attachment--and loss.

The authors discuss the components of consensual qualitative research (CQR) using open-ended questions to gather data, using words to describe phenomena, studying a few cases intensively, recognizing the importance of context, using an inductive analytic process, using a team and making decisions by consensus, using auditors, and verifying results by systematically checking against the raw data. The three steps for conducting CQR are developing and coding domains, constructing core ideas, and developing categories to describe consistencies across cases (cross analysis). Criteria for evaluating CQR are trustworthiness of the method, coherence of the results, representativeness of the results to the sample, testimonial validity, applicability of the results, and replicability across samples. Finally, the authors discuss implications for research, practice, and training.

A Guide to Conducting Consensual Qualitative Research

The authors reviewed the application of consensual qualitative research (CQR) in 27 studies published since the method's introduction to the field in 1997 by C. E. Hill, B. J. Thompson, and E. N. Williams (1997). After first describing the core components and the philosophical underpinnings of CQR, the authors examined how it has been applied in terms of the consensus process, biases, research teams, data collection, data analysis, and writing up the results and discussion sections of articles. On the basis of problems that have arisen in each of these areas, the authors made recommendations for modifications of the method. The authors concluded that CQR is a viable qualitative method and suggest several ideas for research on the method itself.

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Consensual Qualitative Research: An Update

The literature on empathy, primarily from counseling and psychotherapy and secondarily from social and developmental psychology, is reviewed. Obstacles that may account for theoretical confusions and empirical difficulties in studying empathy are highlighted. The decrease in empathy research in recent years appears attributable to the lack of clear focus and effective research tools as well as the shift in interest from empathy to other concepts such as the working alliance. It is argued that there is a need to return to studying empathy. Researchers should distinguish between dispositional and experiential empathy and between intellectual empathy and empathic emotions and indicate whether they are examining therapist or client experience of empathy. Suggestions for future research are offered.

The current state of empathy research

Nondisclosures in supervision were studied for 108 supervisees. Supervisees reported an average of 8.06 nondisclosures ranging in importance level. Negative reactions to the supervisor were the most frequent type of nondisclosure. The most frequent reasons for nondisclosures were perceived unimportance, that the nondisclosure was too personal, negative feelings, and a poor alliance. The manner of nondisclosure was usually passive. Most nondisclosures were discussed with someone else, typically a peer. Supervisor style was related to content of and reasons for nondisclosure. Supervisees were less satisfied when they reported more negative reactions to supervisors and when they did not disclose because of poor alliances, supervisor incompetence, and fear of political suicide. Thus, nondisclosure affects the process of supervision. Further research is needed on how nondisclosures in supervision affect supervision and therapy processes.

Nature, extent, and importance of what psychotherapy trainees do not disclose to their supervisors.

Preface Acknowledgments I. Overview Introduction to Helping An Overview of the Helping Process Ethical Issues in Helping Self-Awareness Cultural Awareness II. Exploration Stage Overview of the Exploration Stage Skills for Attending, Listening, and Observing Skills for Exploring Thoughts and Narratives Skills for Exploring Feelings Integrating the Skills of the Exploration Stage III. Insight Stage Overview of the Insight Stage Skills for Challenging Clients to Foster Awareness Skills for Facilitating Insight Skills for Immediacy Integrating the Skills of the Insight Stage IV. Action Stage Overview of the Action Stage Steps for Working with Four Action Tasks Integrating the Skills of the Action Stage V. Integration Putting It All Together: Working With Clients in the Three-Stage Model References Glossary Index About the Author

Clara E. Hill

Papers

A Guide to Conducting Consensual Qualitative Research

Consensual Qualitative Research: An Update

The current state of empathy research

Nature, extent, and importance of what psychotherapy trainees do not disclose to their supervisors.

Helping Skills: Facilitating Exploration, Insight, and Action