Here are half a dozen research papers that have recently interested me in the broad areas of emotional and relationship "intelligence" (all details & abstracts to these studies are given further down this blog posting).  Kelley et al report on "Patient and practitioner influences on the placebo effect" which in this study was " ... twice as large as the effect attributable to treatment group assignment."  Practitioners assigned to give warm, empathic consultations achieved considerably better outcomes than those assigned to neutral consultations, although the " ... practitioners differed markedly in effectiveness, despite standardized interactions."  The placebo benefits were mostly experienced by more extrovert patients.  The findings make me think of good attachment relationships - see last month's post on "Attachment, compassion & relationships".  Stinson & colleagues report on a related phenomenon " ... interpersonal warmth explains the self-fulfilling prophecy of anticipated acceptance."  They found that "People's expectations of acceptance often come to create the acceptance or rejection they anticipate. The authors tested the hypothesis that interpersonal warmth is the behavioral key to this acceptance prophecy: If people expect acceptance, they will behave warmly, which in turn will lead other people to accept them; if they expect rejection, they will behave coldly, which will lead to less acceptance."  Not rocket science, but encouraging to find the research confirmed this mechanism against " ... four plausible alternative explanations."  I guess the Beatles got it right, often "In the end the love you take is equal to the love your make."  

But how can we learn to be more this way?  Krasner et al's fascinating study on the "Association of an Educational Program in Mindful Communication With Burnout, Empathy, and Attitudes Among Primary Care Physicians" addresses this beautifully, showing that " ... an intensive educational program in mindfulness, communication, and self-awareness is associated with improvement in primary care physicians' well-being, psychological distress, burnout, and capacity for relating to patients."  I already knew a fair amount about mindfulness training, but I hadn't really come across another technique they used in this study - appreciative inquiry.  If you're a health professional who's interested to find out more, Mick Krasner is co-leading an intensive two day programme on these approaches in the States next May - maybe you could include it in your Spring holiday plans!? 

Chambers et al take a more academic look at some of this territory in their paper "Mindful emotion regulation: An integrative review" where they compare mindfulness-based methods with more traditional cognitive therapy approaches.  Marques et al highlight the way that anxious individuals tend to avoid rather than approach emotions - scoring lower than controls on both emotional processing and emotional expression.  Schartau & colleagues report on "Seeing the bigger picture: training in perspective broadening reduces self-reported affect and psychophysiological response to distressing films and autobiographical memories."  I think it's important in the general enthusiasm for mindfulness-based approaches, that we don't lose sight of the great potential value of reappraisal methods - see for example an earlier blog post on "Reappraising reappraisal."  

Kelley, J. M., A. J. Lembo, et al. (2009). "Patient and Practitioner Influences on the Placebo Effect in Irritable Bowel Syndrome." Psychosom Med 71(7): 789-797.  [Abstract/Full Text] 
Objective: To determine whether placebo responses can be explained by characteristics of the patient, the practitioner, or their interpersonal interaction. Methods: We performed an analysis of videotape and psychometric data from a clinical trial of patients with irritable bowel syndrome who were treated with placebo acupuncture in either a warm empathic interaction (Augmented, n = 96), a neutral interaction (Limited, n = 97), or a waitlist control (Waitlist, n = 96). We examined the relationships between the placebo response and a) patient personality and demographics; b) treating practitioner; and c) the patient-practitioner interaction as captured on videotape and rated by the Psychotherapy Process Q-Set. Results: Patient extraversion, agreeableness, openness to experience, and female gender were associated with placebo response, but these effects held only in the augmented group. Regression analyses controlling for all other independent variables suggest that only extraversion is an independent predictor of placebo response. There were significant differences between practitioners in outcomes; this effect was twice as large as the effect attributable to treatment group assignment. Videotape analysis indicated that the augmented group fostered a treatment relationship similar to a prototype of an ideal healthcare interaction. Conclusions: Personality and gender influenced the placebo response, but only in the warm, empathic, augmented group. This suggests that, to the degree a placebo effect is evoked by the patient-practitioner relationship, personality characteristics of the patient will be associated with the placebo response. In addition, practitioners differed markedly in effectiveness, despite standardized interactions. We propose that the quality of the patient-practitioner interaction accounts for the significant difference between the groups in placebo response.

Stinson, D. A., J. J. Cameron, et al. (2009). "Deconstructing the "reign of error": interpersonal warmth explains the self-fulfilling prophecy of anticipated acceptance." Pers Soc Psychol Bull 35(9): 1165-78. [PubMed] 
People's expectations of acceptance often come to create the acceptance or rejection they anticipate. The authors tested the hypothesis that interpersonal warmth is the behavioral key to this acceptance prophecy: If people expect acceptance, they will behave warmly, which in turn will lead other people to accept them; if they expect rejection, they will behave coldly, which will lead to less acceptance. A correlational study and an experiment supported this model. Study 1 confirmed that participants' warm and friendly behavior was a robust mediator of the acceptance prophecy compared to four plausible alternative explanations. Study 2 demonstrated that situational cues that reduced the risk of rejection also increased socially pessimistic participants' warmth and thus improved their social outcomes.

Krasner, M. S., R. M. Epstein, et al. (2009). "Association of an Educational Program in Mindful Communication With Burnout, Empathy, and Attitudes Among Primary Care Physicians." JAMA 302(12): 1284-1293.  [Abstract/Full Text]          
Context Primary care physicians report high levels of distress, which is linked to burnout, attrition, and poorer quality of care. Programs to reduce burnout before it results in impairment are rare; data on these programs are scarce. Objective To determine whether an intensive educational program in mindfulness, communication, and self-awareness is associated with improvement in primary care physicians' well-being, psychological distress, burnout, and capacity for relating to patients. Design, Setting, and Participants Before-and-after study of 70 primary care physicians in Rochester, New York, in a continuing medical education (CME) course in 2007-2008. The course included mindfulness meditation, self-awareness exercises, narratives about meaningful clinical experiences, appreciative interviews, didactic material, and discussion. An 8-week intensive phase (2.5 h/wk, 7-hour retreat) was followed by a 10-month maintenance phase (2.5 h/mo). Main Outcome Measures Mindfulness (2 subscales), burnout (3 subscales), empathy (3 subscales), psychosocial orientation, personality (5 factors), and mood (6 subscales) measured at baseline and at 2, 12, and 15 months. Results Over the course of the program and follow-up, participants demonstrated improvements in mindfulness (raw score, 45.2 to 54.1; raw score change [{Delta}], 8.9; 95% confidence interval [CI], 7.0 to 10.8); burnout (emotional exhaustion, 26.8 to 20.0; {Delta} = -6.8; 95% CI, -4.8 to -8.8; depersonalization, 8.4 to 5.9; {Delta} = -2.5; 95% CI, -1.4 to -3.6; and personal accomplishment, 40.2 to 42.6; {Delta} = 2.4; 95% CI, 1.2 to 3.6); empathy (116.6 to 121.2; {Delta} = 4.6; 95% CI, 2.2 to 7.0); physician belief scale (76.7 to 72.6; {Delta} = -4.1; 95% CI, -1.8 to -6.4); total mood disturbance (33.2 to 16.1; {Delta} = -17.1; 95% CI, -11 to -23.2), and personality (conscientiousness, 6.5 to 6.8; {Delta} = 0.3; 95% CI, 0.1 to 5 and emotional stability, 6.1 to 6.6; {Delta} = 0.5; 95% CI, 0.3 to 0.7). Improvements in mindfulness were correlated with improvements in total mood disturbance (r = -0.39, P < .001), perspective taking subscale of physician empathy (r = 0.31, P < .001), burnout (emotional exhaustion and personal accomplishment subscales, r = -0.32 and 0.33, respectively; P < .001), and personality factors (conscientiousness and emotional stability, r = 0.29 and 0.25, respectively; P < .001). Conclusions Participation in a mindful communication program was associated with short-term and sustained improvements in well-being and attitudes associated with patient-centered care. Because before-and-after designs limit inferences about intervention effects, these findings warrant randomized trials involving a variety of practicing physicians.

Chambers, R., E. Gullone, et al. (2009). "Mindful emotion regulation: An integrative review." Clin Psychol Rev 29(6): 560-72.  [PubMed] 
This review aims to integrate the constructs of mindfulness and emotion regulation. Research into both of these areas is relatively new, and while several reviews have emerged for each area independently, none has directly proposed a conceptual integration. The current review explores how key axioms and assumptions of traditional psychological models of emotion regulation and the psychological interventions that are derived from them (e.g., cognitive behavior therapy) differ fundamentally from mindfulness-based approaches in terms of the underlying processes they address. Accordingly, mindfulness and emotion regulation are each reviewed, followed by a conceptual integration. Fundamental difficulties arising from the attempt to integrate the two domains are highlighted, especially as to the "reality" of thoughts, the relationship between thoughts and emotions, and the need to move beyond a valence model of emotion. Finally, a model is proposed outlining the likely critical processes and mechanisms that underlie "mindful emotion regulation."

Marques, L., R. E. Kaufman, et al. (2009). "A comparison of emotional approach coping (EAC) between individuals with anxiety disorders and nonanxious controls." CNS Neurosci Ther 15(2): 100-6.  [PubMed]
Emotional regulation deficits are described as a core component of anxiety disorders (ADs), yet there remains a paucity of data examining this issue in patients diagnosed with ADs. We hypothesized that help-seeking individuals with ADs would report lower levels of emotional approach coping (EAC), which includes emotional processing (EP) and emotional expression (EE), than nonanxious controls. Diagnostic interviews and a validated self-report scale assessing emotional approaches to coping (emotional approach coping scale [EACS]) were administered to 101 nonanxious controls and 92 patients with a primary AD (29 generalized anxiety disorder, 40 social anxiety disorder, and 23 panic disorder). Patients with each AD demonstrated significantly lower EAC, including both EP and EE, than nonanxious controls. Lower EAC was also associated with higher anxiety sensitivity and higher anxiety symptom severity. Overall, gender did not moderate the anxiety-EAC effect, but the results suggested that women utilize EAC to a greater degree than men. Clinical techniques designed to improve emotional coping may be beneficial to individuals with ADs.

Schartau, P. E., T. Dalgleish, et al. (2009). "Seeing the bigger picture: training in perspective broadening reduces self-reported affect and psychophysiological response to distressing films and autobiographical memories." J Abnorm Psychol 118(1): 15-27. [PubMed] 
Appraising negative experiences in ways that reduce associated distress is a key component of successful emotion regulation. In 4 studies, the authors examined the effects of systematically practicing appraisal skills using a computer-mediated cognitive bias modification (CBM) methodology. In Studies 1-3, healthy participants practiced applying appraisal themes linked to the idea of seeing the bigger picture to a series of distressing training films, either during each film (Study 1) or immediately after each film (Studies 2 and 3). Control participants watched the same films with no appraisal instructions. Participants who practiced appraisal, compared with controls, exhibited reduced levels of self-reported negative emotional (Studies 1-3) and electrodermal (Study 1) responses to a final test film that all participants were instructed to appraise. In Study 4, a comparable effect of appraisal practice was found using distressing autobiographical memories for participants with higher levels of negative affect. Appraisal practice also led to reduced intrusion and avoidance of the target memories in the week poststudy, compared with prestudy levels, and relative to the no-practice controls. The findings are discussed in terms of the broader literature on CBM.