Barry Rosenfeld - US grants

DESCRIPTION (provided by applicant): As mental health and palliative care researchers struggle to understand how individuals cope with and react to the dying process, the importance of hopelessness has gradually emerged as a critical construct. A growing literature, including several studies by our research group, has identified hopelessness as a principle explanatory variable in end-of-life despair, including the desire for hastened death, interest in physician assisted suicide, and suicidal ideation. Yet understanding what it means to be "hopeless" in the context of a terminal illness has received little attention to date. Confusion abounds as to whether hopelessness in the face of terminal illness simply refers to a realistic appraisal of one's prognosis (i.e., the absence of any hope for a cure), the patient's expectations for the immediate future (e.g., the absence of meaning and value in the last weeks or months of life), or reflects a general pessimistic cognitive style that may even pre-date the diagnosis or terminal phase of illness. Given the growing realization of the central role that hopelessness plays in psychological adjustment to terminal illness, the need to better understand and measure the construct of hopelessness among terminally ill individuals is clear. In this project we seek to fill this void by first exploring the construct of hopelessness in the context of life threatening/terminal illness and to subsequently develop a tool to facilitate the measurement of this construct. To accomplish these aims we will utilize a series of steps, beginning with individual interviews with palliative care experts and terminally ill cancer patients, followed by the development and refinement of a brief self-report measure that will be validated in a large sample of terminally ill and ethnically diverse cancer patients. The development of such a measure will help foster more sophisticated studies examining the role of hopelessness in end-of-life care as well as help facilitate the development of clinical interventions aimed at reducing end-of-life despair.

[unreadable] DESCRIPTION (provided by applicant): Stalking, or repetitive harassment, has been increasingly recognized as a significant public health problem because of both the high frequency with which it occurs as well as the detrimental impact on victims. Research has identified stalking offenders that target former intimates and those with a personality disorder as representing a particularly high risk for both violent behavior and continued stalking (recidivism). Former intimates also comprise the largest proportion of stalking offenders, accounting for 60% or more of this population, or hundreds of thousands of stalking cases each year nationwide. As the psychological factors that lead to stalking and harassment are increasingly recognized, the need for clinical interventions designed to target these issues has emerged. Dialectical Behavior Therapy (DBT) represents a particularly desirable approach for treating stalking offenders given the high rates of borderline, antisocial, and narcissistic personality disorder diagnoses among this population. DBT also has both empirical and broad clinical support as the preferred treatment modality for borderline personality disorder and is increasingly used with multi-diagnostic difficult-to-manage patients, criminal offenders, and individuals with antisocial personality characteristics. Further, DBT emphasizes behavior change and improving interpersonal effectiveness, two important needs in this population, as well as helping identify precipitants to stalking behaviors and developing/reinforcing an alternative behavioral repertoire. The present study proposes to assess the feasibility and efficacy of DBT in reducing recidivism and decreasing violence. We intend to compare our modified DBT program ("Project SHARP") which has been in development and pilot testing for the past 18 months to a "treatment as usual" intervention (an anger management/accountability group intervention) in a sample of stalking offenders. We intend to compare outcome for offenders who complete DBT to those who complete this alternative treatment and with treatment drop-outs in order to assess the efficacy and effectiveness of this intervention. All participants will be assessed using a battery of clinician-rated, self report and behavioral measures before and after the 6-month intervention and again 6 months after completing treatment. In addition, recidivism will be assessed through periodic review of criminal justice records in order to identify participants who have re-offended with either continued stalking behavior or other criminal behavior. [unreadable] [unreadable] [unreadable]

? DESCRIPTION (provided by applicant): There are few major medical treatment decisions that are not, or should not, be influenced by a patient's understanding of his or her prognosis. Particularly among patients with advanced or life-limiting illness, decisions to pursue curative treatments and if so, how aggressively, whether to consider end-of-life options such as hastening death or physician assisted suicide, and even whether to sign a do-not- resuscitate order can be influenced by the patient's perception of whether his or her illness is curable or inevitably fatal - and if so, how quickly. Yet this research is often handicapped by the lack of a systematic tool for measuring a patient's understanding of his or her prognosis. Research focusing on prognostic understanding has been remarkably limited, and primarily comprised of studies that simply compare a patient's assessment of the curability of his or her disease to the physician's assessment of curability. Such studies fail to recognize the potential range of issues encompassed by the broader construct of prognostic understanding, such as life expectancy, potential utility of available interventions, and expectations regarding disease progression and functional decline. Thus, while the limited accuracy of physician assessments of prognosis are well documented, little attention has focused on how to best assess a patient's understanding of information related to prognosis. The present application seeks to fill this void by developing a systematic measure of prognostic understanding. Such an instrument has multiple potential uses, including facilitating physician discussions of prognosis (e.g., by identifying specific area of inaccuracy and/or misunderstanding) as well as research (e.g., analyzing the factors that influence patient decision-making). To accomplish these aims, we will first explore the phenomena of prognostic understanding using cognitive interviews of 15 experts drawn from oncology, palliative care, and psycho-oncology settings, as well as 15 patients with advanced cancer. A 2-stage open-coding process and Thematic Content Analysis framework will be used to identify critical themes, passages, and phrases, which will in turn then be used to develop a conceptual framework and a set of candidate items that might comprise a self-report scale. Candidate items will be reviewed by a second set of experts and cancer patients for clarity, thoroughness, and redundancy, and the revised items will be administered to 300 patients with advanced cancer, along with measures of psychological distress and social support. Classical test theory and item-response theory analyses will be used to identify items with the strongest psychometric properties. Physicians who care for these patients will also be asked to complete the same instrument, providing preliminary data on the accuracy of patient perceptions as well as variables that might correspond to these perceptions.