8
Chapter
General Discussion
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GENERAL DISCUSSION
The general aim of the current thesis was to gain insight in factors that
predict depressive symptom change in mindfulness-based treatments (i.e.,
MBCT/MBSR) and Cognitive Behavioral Therapy (CBT) for improving affect. It was shown that MBCT and CBT for depression are based on similar
cognitive theories explaining depression and that the treatments mainly
consist of distinct treatment techniques. We argued that these techniques
may set overlapping and distinct change mechanisms in motion.
Our empirical findings supported the assumption that mindfulness
is a mechanism of change in mindfulness-based treatments as we showed
that daily changes in mindfulness preceded daily changes in affect during
mindfulness-based treatment. Yet, day-to-day changes in mindfulness and
repetitive thinking did not precede changes in depressive symptoms in
all individuals. In addition to that, daily changes in mindfulness, repetitive
thinking, and depressive symptoms seemed to occur together.
In two other studies, we showed that patients’ perceptions of treatment predict treatment outcomes in CBT and MBCT for diabetic patients
with depressive symptoms. Patients’ expectations of treatment outcomes
predicted post-treatment depressive symptom change and treatment
completion in both CBT and MBCT. Whereas patients’ outcome expectations seemed to be important in both CBT and MBCT, the predictive value
of the therapeutic alliance seems to depend on the type of treatment. It
was found that patients’ ratings of the therapeutic alliance were only predictive of outcomes in CBT, but not in MBCT.
The remaining part of this general discussion includes the clinical
implications of the findings, methodological considerations concerning
the studies included in the thesis, a discussion of the studies in a broader
perspective, and suggestions for future research.
8
Clinical implications
For trainers of mindfulness-based treatments, it is relevant to know that
emphasis on practicing mindfulness skills is not superfluous, as such skills
indeed seem beneficial for one’s daily wellbeing. Mindfulness trainers
commonly stress the importance of daily mindfulness practice. Our results
strengthen this recommendation as we showed that performing at least
one mindfulness exercise per day can result in daily increases in mindfulness. As has been observed in clinical practice, increasing one’s capacity
for mindfulness benefits many individuals, yet, not everyone. This is evidenced by the found individual differences in the strength and presence
of the lagged association between daily mindfulness and affect the day
after. Future research should show whether mindfulness predicts mood
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GENERAL DISCUSSION
of these individuals within the day or whether daily wellbeing of these
individuals is more likely to be improved through enhancing other skills in
different forms of treatment.
Besides training skills in treatment, it also seems important to take
patients’ outcome expectations into consideration in both MBCT and CBT,
as these beliefs are predictive of treatment outcomes. Before offering
psychological treatment, therapists could gather information on patients’
expectations for improvement in response to treatment. For example,
when both CBT and MBCT are available as treatments for depressive
symptoms, the choice for either one of them may be partially based on
patients’ expectations of the benefits of the treatments. As patients might
benefit more from the treatment of which they expect the most positive
outcomes, it also seems important for insurance companies to take this
into account. Reimbursing only one type of evidence-based treatment
for a specific disorder might not be the most cost-effective strategy since
psychological treatments can be more effective if patients have a choice
between types of treatment.
In addition to considering patients’ expectations when deciding
on the type of treatment, therapists could focus on optimizing patients’
outcome expectations. It has been suggested that patients’ expectations
can be improved by providing an insightful treatment rationale that helps
matching patients’ expectations to the treatment goals (Shapiro et al.,
1976). Others found that more positive outcome expectations and more
beneficial outcomes were fostered when motivational interviewing was
included as a prelude to CBT (Westra, Arkowitz, & Dozois, 2009). Yet, it
should be noted that trying to modify patients’ outcomes expectations
may not be useful in all cases. If patients’ expectations are a reflection of
their personality, for example of their levels of optimism, then these beliefs
might be difficult to change. Also if patients’ expectations are low because they did not respond to previous psychological treatment, optimizing patients’ outcome expectations might not result in better treatment
outcomes, but rather lead to disappointment as patients’ low expectations
may be realistic. Furthermore, optimizing patients’ expectations might not
correspond with the principle of mindfulness-based treatments that one
needs to learn by experiencing instead of understanding why treatment
might be beneficial (Segal et al., 2002). It is therefore suggested to take
the reasons for low outcome expectations and the type of treatment into
account when aiming to improve patients’ outcome expectations.
In CBT, therapists could not only pay attention to patients’ expectations, but also to the extent to which patients agree on the tasks and goals
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GENERAL DISCUSSION
of CBT as well as how they perceive the therapeutic bond. This seems
relevant as we showed that these aspects of the therapeutic alliance are
predictive of depressive symptom improvement in CBT. Shared decision
making on the treatment tasks in CBT seems important so that patients
do agree on the treatment tasks. Yet, future research is needed on which
specific therapist behaviors enhance the different aspects of the therapeutic alliance in CBT. In MBCT, it seems less important to focus on the
therapeutic bond and mutual agreement on the tasks as well as the goals
of MBCT as we did not find an association between patients’ ratings of the
therapeutic alliance and treatment outcomes.
8
Methodological considerations
Below, I will discuss several issues concerning the design and sample size
of the studies included in the thesis. In chapter 4 and 5, we adopted a
replicated-single subject design and an intensive longitudinal design including daily observations within individuals over the course of treatment.
With these unique designs and accompanying analyses, we were able to
study the temporal order of within-person change mechanisms during
mindfulness-based treatment.
Apart from the strengths of these designs, the lack of a control
condition in these studies precluded the investigation of the role of the
mindfulness-based treatments in the studied change mechanisms. Although the absence of a control condition does not matter concerning the
conclusions on the order of change, we are not sure whether the observed
temporal associations are due to the mindfulness-based treatment or
whether these also occur in daily life of individuals who do not receive
treatment.
Another limitation of the design of the studies described in chapter
4 and 5 is that we did not study whether the within-person associations
changed over time. For example, it could be that depressive feelings are
followed by ruminative responses at the start of the mindfulness training, but that this association diminishes as participants learn to be more
mindful at the end of the mindfulness-based treatment. The time-series
of the participants did not include enough measurements to test this
hypothesis. More observations (e.g., more within day assessments) would
have allowed us to compare within-person associations early in treatment with within-person associations late in treatment or after treatment.
Future studies might gain insight in if and how within-person associations
change due to psychological treatment.
In chapter 6 and 7, we did not study within-subject variation but
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GENERAL DISCUSSION
variation between-subjects in their outcome expectations and evaluations
of the therapeutic alliance in CBT and MBCT. A strength of these studies is
that they were embedded in a randomized controlled trial (RCT) on the efficacy of CBT and MBCT. The randomization of patients to treatment condition allowed us to study differences between CBT and MBCT in predictors
of treatment outcomes in an experimental way. Yet, a limitation of nesting
the studies within an efficacy trial is that only the type of treatment and
not the variables of interest were experimentally manipulated. Because
of that, we do not know if patients’ expectations, the therapeutic alliance,
and homework compliance are causally related to treatment outcomes.
For example, to examine the effect of homework practice on treatment
effectiveness, it would have been better to randomize patients into groups
with varying amounts of homework. However, variables such as patients’
expectations and the therapeutic alliance are difficult to manipulate in any
study design.
Apart from the study designs, it should also be noted that the studies described in chapter 6 and 7 were underpowered to find associations
with a small to moderate effect size. Furthermore, the small sample size
did not allow testing some of our hypotheses. For example, we aimed to
examine whether treatment outcomes could be explained by an interaction between the therapeutic alliance and the extent to which therapists
adhered to a treatment protocol. Also, we aimed to examine whether
homework compliance mediates the association between patients’ expectations and treatment outcomes. Unfortunately, the small sample precluded the investigation of these research questions.
A broader perspective: the common factors versus specific techniques argument
The studies in the current thesis contribute to the long lasting debate
in psychotherapy research on the role of specific treatment techniques
versus common (or non-specific) factors in predicting therapeutic change
(see. e.g., Barber, 2009; DeRubeis et al., 2005). According to proponents of
common factors, treatment effects are caused by factors that are shared
by all treatments, such as patients’ outcome expectations, the therapeutic
relationship, or therapists’ warmth (DeRubeis et al., 2005). Below, I will argue that showing that common factors predict treatment outcomes does
not imply that treatment techniques do not affect treatment outcomes.
The beliefs on the importance of common factors are mainly based
on two main findings. The first finding is that distinct psychological treatments using different techniques do not show large differences in their
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GENERAL DISCUSSION
8
effectiveness (e.g., Castonguay, Goldfried, Wiser, Raue, & Hayes, 1996; Ilardi
& Craighead, 1994). Proponents of the common factor hypothesis assume
that comparable treatment effects are due to the overlap between the
treatments, i.e., the non-specific elements of the treatments. The second
finding is that the therapeutic alliance has been consistently shown to predict treatment outcomes across a broad range of disorders and types of
psychological treatments (Horvath et al., 2011; Martin et al., 2000). Based
on this finding, some clinicians hold the belief that treatment techniques
and treatment protocols are not very important and that clinicians should
focus more on non-specific techniques, such as providing empathy and
understanding, to establish a strong therapeutic alliance (noticed during
work in the clinic).
These conclusions have been challenged by others (e.g., DeRubeis
et al., 2005). First, comparable treatment efficacy can also be explained
by different change mechanisms that are set in motion by distinct treatments. Borkovec and colleagues (2002) posed that psychological states
consist of interacting cognitive, behavioral, affective, and physiological
systems. They explained that if a treatment effectively changes one of
these elements, this may lead to change in all of them. Consistent with
this line of reasoning, we argued in Chapter 2 that the distinct treatment
techniques of CBT and MBCT might, through different mechanisms, lead
to depressive symptom change. For example, it has been shown that depressive feelings are enhanced by maladaptive thoughts about the self as
well as ruminative patterns of thinking. As a result of change in either one
of these factors, depressive feelings may diminish. We explained in Chapter 2 that the specific techniques of CBT may reduce maladaptive thoughts
about the self, whereas MBCT might reduce ruminative patterns of thinking. Change in either rumination or maladaptive thoughts may lead to
change in depressive symptoms. Thus, the use of different treatment
techniques might cause, by different means, similar treatment effects.
Next, I argue that the presence of an alliance-outcome association
does not necessarily mean that non-specific techniques are more important than specific treatment techniques in explaining treatment outcomes.
Researchers and clinicians may assume that the therapeutic relationship
is strengthened by the use of non-specific techniques such as warmth,
empathy, and understanding (e.g., Arnow et al., 2013; Barber, Connolly,
Crits-Christoph, Gladis, & Siqueland, 2000) and not by specific techniques.
Based on this, they might conclude that common factors are more important than specific treatment techniques. This assumption seems plausible
when thinking of the therapeutic relationship as the extent to which the
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GENERAL DISCUSSION
therapist provides empathic understanding and unconditional positive
regard, based on the early conceptualizations of the therapeutic relationship by Rogers (Elvins & Green, 2008). Yet, most empirical studies have
used Bordin’s conceptualization of the therapeutic alliance, including
mainly the extent to which the patient and the therapist agree on the
tasks as well as the goals of treatment, in addition to the bond between
the patient and therapist (Bordin, 1979). Mutual agreement on tasks and
goals reflect the collaborative working relationship between the patient
and therapist and do not seem to reflect the use of non-specific therapist
techniques. Few studies have investigated the association between nonspecific therapist techniques and the different aspects of the alliance as
conceptualized by Bordin (see Ackerman & Hilsenroth, 2003), with one
study showing that therapists’ level of empathy was only associated with
the patient-therapist bond, but not with agreement on tasks or agreement
on goals of treatment (Horvath & Greenberg, 1989). Thus, the therapeutic
alliance as conceptualized by Bordin (1979) might not necessarily be improved by employing non-specific techniques. Furthermore, I pose that specific treatment techniques might affect
patients’ ratings of the therapeutic alliance. It has been recognized that patients may report a stronger therapeutic alliance if the specific techniques
of a treatment fit the needs of a patient and when therapy goes well (Barber, 2009). In this way, specific treatment techniques might affect patients’
evaluations of the therapeutic alliance. In addition to that, the benefits
of a strong therapeutic alliance may depend on the extent to which the
alliance and the components of the alliance are central to a specific treatment. As explained in chapter 7, CBT focuses on mutually setting concrete
goals and tasks. Patients’ evaluations of agreement on goals and tasks
may therefore be more predictive of outcomes in CBT than in a treatment
that does not emphasize mutual agreement on goals and tasks, such as
MBCT. This hypothesis is strengthened by our finding that the therapeutic
alliance is predictive of subsequent depressive symptom change in CBT
but not in MBCT. These examples show that finding a positive allianceoutcome association does not necessarily imply that treatment techniques
are not important as they might interact with patients’ ratings of the therapeutic alliance.
In conclusion, it seems untenable to conclude that treatment techniques are not important for treatment outcomes based on the previously
mentioned research findings. If clinicians would act upon the belief that
specific treatment techniques are not that important, this might hamper
the efficacy of psychological treatments because most of the evidence121
8
GENERAL DISCUSSION
based psychological treatments are manualized treatments containing
mainly specific treatment techniques. This does not mean that treatment
techniques operate in isolation. It has since long been recognized that
therapeutic techniques have no meaning apart from their interpersonal
context (Butler & Strupp, 1986). It seems more plausible that the combination of and interaction between characteristics of the patient, the patienttherapist interrelationship, and specific treatment techniques influence
treatment outcomes.
8
The need for within-subject designs in the study of mechanisms of change
As discussed in chapter 3 and 4, within-subject designs are in particular
suitable for studying change processes during psychological treatments.
In this part of the discussion, I elaborate on a more general argument,
provided by others, on the need for within-subject designs when studying
psychological processes. In addition to that, I discuss a few ideas for future
research on therapeutic change mechanisms using within-subject designs.
Early researchers of psychological processes such as Skinner and
Pavlov performed experiments on individual subjects (or pigeons or dogs).
If the outcomes of an experiment could be replicated within that individual and within several other individuals, the findings were considered to be
consistent (see Barlow & Nock, 2009). Nowadays, limited generalizability is
an important point of critique concerning single-subject approaches. For
example, in the review process of our replicated single-subject time-series
study, most reviewers commented on the small sample which would preclude the possibility of generalizing to the population. At this moment in
time, it seems almost ‘not done’ to perform single-subject studies because
psychological science now focuses on finding general laws that can be
generalized to the population and the field has therefore moved from
person-specific research to group-level research.
More recently, researchers have started to acknowledge that
group-level research may be limited when one aims to study psychological processes (e.g., Hamaker, 2012; Rosmalen et al., 2012). Group-level
research may be problematic because the accompanying standard statistical methods focus on analyzing variation between individuals. The results
of these analyses give insight in averages across individuals, such as a
correlation between two variables. Yet, such an average correlation might
not be observed within each individual subject in the population and thus
might not give insight in general laws that apply to all individuals with
a similar nature (see Hamaker, 2012). Also, such analyses do not necessarily give insight in within-subject processes, e.g., when a person shows
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GENERAL DISCUSSION
behavior X, the consequence will be Z (see Hamaker, 2012). Moreover, a
between-person correlation (e.g., individuals who eat cake more often
than others are on average not happier than individuals who eat cake less
often) might be different from a within-person correlation (e.g., when I eat
cake, I feel happier).
Molenaar (2004) pointed out that the analysis of variation at the
group level will only be similar to intra-individual variation if two conditions are met. The first condition is that the studied characteristic is stable
over time, thus that there is no change from one moment in time to
another moment in time. The second condition is that individuals from
the population obey the same natural rules, e.g., that individuals show the
same (lagged) covariance between two variables (Hamaker et al., 2005).
In fact, these conditions are almost never met in research on psychological processes (Molenaar & Campbell, 2009). The first assumption does not
hold when a study examines psychological states, including behavior,
cognitions, or emotion, which inherently show variation over time (Molenaar & Campbell, 2009). Furthermore, the second assumption does not
necessarily hold as psychological processes might differ across individuals
(Molenaar, 2004). This is evidenced by our findings described in Chapter 3
and 4; increases in mindfulness were followed by improvements in depressive mood, but not in all individuals.
The arguments of Molenaar (2004;2009) and Hamaker (2005;2012)
show that between-subject approaches are mostly not suitable for studying mechanisms of change as they cannot capture change processes that
take place within-persons and because they are based on the assumption
that the same rules apply to all individuals. Therefore, the field would benefit from using alternative research methods that do allow making inferences on individual change processes (Hamaker, 2012).
The single-subject time-series approach and the intensive longitudinal approach presented in Chapter 3 and 4 might enrich the available
methodologies as they allow testing within-subject associations over time
in a quantitative way. These designs are especially valuable for studying
mechanisms of change in the context of psychological treatments. As we
showed in Chapter 3 and 4, these designs enable to examine whether
the factors that are assumed to cause symptom change indeed precede
changes in symptoms, or whether it is the other way around. By studying
more than one individual, one is able to show whether certain processes
hold for all individuals or whether these processes differ between individuals. Related to that, these designs may be suitable for studying if psychological treatments lead to change in maladaptive processes that enhance
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GENERAL DISCUSSION
depressive symptoms. For example, it could be studied whether individuals respond less with rumination to momentary depressive feelings when
they received a mindfulness-based treatment.
Furthermore, single-subject time-series designs might provide
knowledge on events or behavior that account for increases in depressive symptoms in a specific individual. This information might be used as
a diagnostic tool and form a basis for studying predictors and moderators
of treatment efficacy. In Chapter 2, we explained that CBT and MBCT teach
individuals different skills to cope with depressive thoughts and feelings.
CBT and MBCT might be more beneficial for patients that are in need of
these specific skills. Future studies could, for example, test whether MBCT
is more beneficial for individuals who consistently show strong associations between rumination and depressive feelings and whether CBT is
more beneficial for individuals who show a strong association between
decreases in performing pleasurable activities and depressive feelings.
If studies show that individuals indeed respond better to treatment
when there is intervened on the individual factors that elicit depressive
feelings, then such approaches could guide treatment choice in clinical
practice as well (based on presentations of Peter de Jonge). Gaining insight into which daily behaviors elicit depressive feelings or positive affect
in a specific individual might be therapeutic in and of itself (see Kramer
et al., 2014). Individuals might adapt their maladaptive behaviors if they
know which of their behaviors are followed by positive affect (Kramer et
al., 2014). In these ways, studying mechanisms of change using singlesubject time-series designs might help to bridge the gap between science
and practice.
8
Concluding remarks
In sum, the studies included in the thesis have provided insight in psychological change processes during mindfulness-based treatments and
factors that predict the efficacy of CBT and MBCT for depressive symptoms
in patients with diabetes. We showed that increases in mindfulness in
mindfulness-based treatments and patients’ outcome expectations in CBT
and MBCT predict depressive symptom change. These findings suggest
that it is important to focus on training specific skills and to take patients’
perceptions of treatment into consideration when providing psychological
treatments to patients with depressive symptoms.
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Summary
127
SUMMARY
Summary
Depressive symptoms may interfere with participating in normal daily
life activities and are associated with a low quality of life. Symptoms of
depression might even be more of a burden for individuals with a chronic
somatic disease, such as diabetes, because depression may negatively
affect the management of the disease. Although effective psychological
treatments are available for depressive symptoms, not all individuals
respond sufficiently to these treatments. An important next step is
therefore to investigate which factors contribute to symptom change in
psychological treatments.
The general aim of the present thesis is to gain insight in factors that
predict depressive symptom change in Cognitive Behavioral Therapy
(CBT) and mindfulness-based treatments (i.e., MBCT/MBSR). The thesis
focuses on three research questions: (1) What are the assumed working
mechanisms underlying CBT and Mindfulness-Based Cognitive Therapy
(MBCT) for depression? (2) Do daily changes in the assumed mechanisms
underlying mindfulness-based treatments indeed predict changes in daily
assessed depressive mood? (3) What is the role of patients’ evaluations of
the therapeutic alliance and patients’ outcome expectations in CBT and
MBCT for depressive symptoms in diabetic patients?
It is important to gain more insight in treatment-specific and
overlapping mechanisms of therapeutic action in CBT and MBCT in
order to generate hypotheses on for whom these treatments may be
most beneficial. The theoretical review in Chapter 2 reveals that both
treatments are built on similar cognitive theories explaining depression.
Based on these theories, it can be assumed that both CBT and MBCT
achieve change by adjusting related cognitive processes such as
decentering and automatic negative thinking. Yet, the review also shows
that when you take the distinct treatment techniques of CBT and MBCT
as a point of departure, a broader range of mechanisms may be at play. In
CBT, increased feelings of mastery and pleasure resulting from behavioral
activation might as well account for the effects of CBT on depression.
In MBCT, increased awareness and non-judgmental attention trained in
meditation and yoga exercises may also explain the benefits of MBCT
for depression. Future studies on therapeutic change mechanisms could
be strengthened by including both theory-driven and technique-driven
factors.
As described in Chapter 2, it is assumed that increases in mindfulness
and decreases in ruminative thinking contribute to improvements in
depressive mood in mindfulness-based treatments. Yet, little is known
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SUMMARY
about the dynamic interplay between these variables taking place
within individuals. To gain more insight in the causal chain of change,
we examined whether day-to-day changes in mindfulness and repetitive
thinking would precede, follow, or occur concurrent with daily changes in
mood during mindfulness-based treatments in Chapter 3 and 4.
In Chapter 3, we adopted a replicated single-subject design to
examine day-to-day associations between mindfulness, repetitive
thinking, and depressive symptoms during a mindfulness-based
treatment. Study participants were six women with depressive symptoms.
The results showed that changes in mindfulness and repetitive thinking
preceded changes in depressive symptoms in a few of the participants.
We did not find evidence for reverse causality; changes in depressive
symptoms did not predict later changes in mindfulness or repetitive
thinking in any of the participants. Another finding was that day-to-day
changes in mindfulness, repetitive thinking, and depressive symptoms
occur together, as all participants showed moderate to strong withinday associations between the variables. The findings suggest that the
studied change process may be operating fast as daily changes seemed
to go together. Also, the results imply that temporal precedence of daily
mindfulness and repetitive thinking may take place in some, but not all
individuals. Furthermore, the findings do not undermine the assumed
causal chain of change underlying mindfulness-based treatments as
associations in the opposite direction were not observed.
In Chapter 4, we used an intensive longitudinal design to examine
day-to-day associations between mindfulness, negative affect (NA), and
positive affect (PA) during Mindfulness-Based Stress Reduction (MBSR).
Study participants were 83 participants from the general population.
The results showed that day-to-day changes in mindfulness predicted
subsequent day-to-day changes in both NA and PA. Yet, there were
individual differences in the strength and the presence of the effect of
mindfulness on PA and NA. This indicates that being more mindful than
usual may have a beneficial effect on mood the next day in many, but
not in all individuals. The results showed that the relationship between
mindfulness and affect is not reciprocal; daily changes in NA and PA
did not predict increases in mindfulness the next day. Furthermore,
mindfulness home practice during the day predicted subsequent
increases in mindfulness. Thus, training mindfulness-skills seems a
beneficial means to improve one’s daily mood.
The second part of the thesis (Chapter 5, 6, and 7) focuses on
predictors of the efficacy of CBT and MBCT for depressive symptoms in
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SUMMARY
patients with diabetes. These studies were embedded in a randomized
controlled trial (RCT). The design of this trial is described in Chapter 5. The
trial aims included examining efficacy, moderators, mediators, common
factors, and treatment integrity in CBT and MBCT. Diabetes patients with
depressive symptoms (Beck Depression Inventory-II (BDI-II) score ≥ 14)
were randomized to direct CBT, direct MBCT, or a 3-months waiting list
control condition after which patients were again randomized to CBT or
MBCT. Both CBT and MBCT were individually delivered in 8 sessions of 45
to 60 minutes by trained therapists.
As described in Chapter 6, several previous studies indicated
that patients’ expectations of treatment outcomes affect the efficacy
of psychological treatments. Early expectancy theorists posed that
patients’ expectations may have an immediate effect on patients’ mental
state by creating hope. Others hypothesized that patients’ outcomes
expectations affect the extent to which patients are engaged in
psychological treatment. We tested these two hypotheses in Chapter
6 by examining whether patients’ outcome expectations are associated
with depressive symptom change early in treatment (i.e., immediate
effect) or late in treatment, and whether these beliefs predict dropout
from treatment and homework compliance (i.e., patients’ engagement).
A secondary aim of the study was to examine the association between
homework compliance and depressive symptom improvement. The
results showed that patients’ outcome expectations were predictive of
post-treatment depressive symptoms in CBT and MBCT, but not of early
and mid-treatment symptoms. Furthermore, patients were less likely
to drop out of CBT and MBCT and performed more homework in MBCT
when they reported higher outcome expectations. Finally, homework
compliance was not associated with depressive symptom improvement,
neither in CBT, nor in MBCT. The findings partially support the notion that
patients are more involved in treatment when they expect to improve in
response to treatment. The results undermine the hypothesis that patients’
expectations have an immediate effect on patients’ mental state. It seems
more plausible that mediating processes are at play that take a longer
time to affect depression.
Another important predictor of treatment outcomes is the
therapeutic alliance as perceived by patients. The therapeutic alliance
includes agreement between the patient and therapist on therapeutic
goals, mutual agreement on tasks, and the bond between the patient
and therapist. It may be that the importance of the therapeutic alliance
differs between CBT and MBCT because MBCT does not focus on two
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SUMMARY
central aspects of the therapeutic alliance (i.e., agreement on tasks and
agreement on goals) as much as CBT. In addition to that, several previous
studies found that the alliance-outcome association disappeared when
controlling for symptom change prior to the assessment of the alliance.
Therefore, we compared the alliance-outcome association in CBT and
MBCT, while controlling for prior depressive symptom change, in Chapter
7. The results showed that in CBT, subsequent depressive symptom
change was predicted by agreement on tasks, the quality of the bond, and
agreement on goals at borderline significance. In contrast, none of the
components of the therapeutic alliance were associated with subsequent
symptom change in MBCT. The finding that agreement on tasks and goals
are more important in explaining outcomes of CBT than of MBCT might be
explained by the fact that the exercises are more personalized in CBT than
in MBCT. Also, individuals are asked to disclose more private information
on their problems in CBT than in MBCT and it might therefore be more
important for patients to feel liked and respected by their therapist in CBT.
Thus, the alliance-outcome association may be affected by the type of
psychological treatment.
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Samenvatting
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SAMENVATTING
Samenvatting
Mensen met depressieve klachten hebben over het algemeen een
lagere kwaliteit van leven en functioneren slechter in het dagelijks
leven. Voor mensen met een chronische ziekte, zoals diabetes, kunnen
depressieve klachten nog meer een belasting vormen omdat de klachten
de regulering van de ziekte negatief kunnen beïnvloeden. Gelukkig
zijn er psychologische behandelingen beschikbaar die depressieve
klachten kunnen verminderen. Echter, niet alle mensen met depressieve
klachten hebben baat bij een psychologische behandeling. Het is
daarom belangrijk om te onderzoeken welke factoren bijdragen aan de
effectiviteit van psychologische behandelingen.
Het doel van dit proefschrift is om meer inzicht te krijgen
in factoren die afname in depressieve klachten voorspellen tijdens
Cognitieve Gedragstherapie (CGT) en mindfulness training (MBCT/MBSR).
In het proefschrift staan drie onderzoeksvragen centraal: (1) Wat zijn de
veronderstelde veranderingsmechanismen die de effectiviteit van CGT
en Mindfulness-Based Cognitieve Therapie (MBCT) kunnen verklaren? (2)
Gaan veranderingen in veronderstelde mechanismen inderdaad vooraf
aan veranderingen in stemming gedurende mindfulness training? (3)
Zijn percepties van de patiënt over de effectiviteit van therapie en de
therapeutische alliantie voorspellend voor het behandelproces en de
effectiviteit van CGT en MBCT voor diabetes patiënten met depressieve
klachten?
In Hoofdstuk 2 wordt uitgelegd dat CGT en MBCT ontwikkeld
zijn op basis van vergelijkbare theorieën over cognitieve processen die
depressieve klachten veroorzaken en versterken. Er wordt aangenomen
dat zowel CGT als MBCT effectieve behandelingen zijn voor depressie
omdat ze verandering teweeg brengen in cognitieve processen zoals
negatief automatisch denken en het kunnen waarnemen van ervaringen
vanaf enige afstand. Echter, beide behandelvormen maken gebruik van
verschillende behandeltechnieken, waardoor je verwacht dat hierdoor
ook andere veranderingsmechanismen in gang gezet worden. Zo is
gedragsactivatie (het doen van activiteiten die plezier of voldoening
teweeg brengen) een belangrijke behandeltechniek in CGT die niet
wordt toegepast in MBCT. De effectiviteit van CGT kan wellicht verklaard
worden doordat patiënten meer voldoening en plezier gaan ervaren door
gedragsactivatie. MBCT bestaat daarentegen voornamelijk uit meditatie
en yoga oefeningen die geen onderdeel zijn van CGT. MBCT zou ook
effectief kunnen zijn voor depressieve klachten doordat patiënten leren
in de meditatie en yoga oefeningen om hun aandacht te richten op
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SAMENVATTING
ervaringen in het hier en nu en deze niet te veroordelen of proberen te
veranderen. De conclusie van Hoofdstuk 2 is dan ook dat het zinvol is om
zowel op theorie gebaseerde veranderingsmechanismen als op techniek
gebaseerde mechanismen mee te nemen in toekomstig onderzoek.
Een belangrijk verondersteld veranderingsmechanisme van MBCT,
zoals beschreven staat in Hoofdstuk 2, is dat het verhogen mindfulness
zorgt voor een afname van piekeren en voor verbeteringen in stemming.
Er is echter nog maar weinig bekend over de wisselwerking tussen
deze variabelen in het dagelijks leven. In Hoofdstuk 3 en 4 worden
onderzoeken beschreven waarin we hebben onderzocht of veranderingen
in mindfulness en piekeren van de ene op de andere dag inderdaad
voorafgaan aan veranderingen in stemming van de ene op de andere dag,
of juist andersom, bij mensen die een mindfulness training volgen.
In Hoofdstuk 3 hebben we de relaties tussen dagelijkse
veranderingen in mindfulness, piekeren en depressieve klachten tijdens
een mindfulness training onderzocht met individuele tijdreeksanalyses.
Er namen zes vrouwen met depressieve klachten deel aan het onderzoek.
Bij slechts een paar deelnemers gingen dagelijkse veranderingen in
mindfulness of piekeren vooraf aan veranderingen in depressieve
klachten. Verbeteringen in mindfulness en piekeren kunnen dus leiden
tot verbeteringen in stemming, maar dit geldt niet voor iedereen. De
resultaten toonden ook aan dat er geen omgekeerde of wederkerige
effecten waren: veranderingen in depressieve klachten gingen bij geen
van de deelnemers vooraf aan veranderingen in mindfulness of piekeren.
Er was wel een matige tot sterke samenhang tussen de variabelen op
dezelfde dag. Dit duidt er op dat dagelijkse veranderingen in mindfulness,
piekeren en depressieve klachten samengaan. Mogelijke verklaringen
voor deze bevindingen zijn dat de veranderingsprocessen zo snel gaan
dat de effecten niet van de ene op de andere dag aanhouden of dat
mindfulness, piekeren en depressieve klachten sterk samenhangen en
gezamenlijk verklaard kunnen worden door een gedeelde onderliggende
gemoedstoestand.
In Hoofdstuk 4 hebben we wederom de temporele relaties
tussen mindfulness en stemming onderzocht, maar nu in een grotere
groep van 83 deelnemers uit de algemene bevolking die deelnamen aan
een Mindfulness-Based Stress Reductie programma (MBSR). Daarnaast
maakten we gebruik van multilevel analyses in plaats van individuele
tijdreeksanalyses. We onderzochten of dagelijkse veranderingen in
mindfulness voorafgingen aan veranderingen in Negatief Affect (NA) en
Positief Affect (PA), of andersom, tijdens MBSR. Uit de resultaten bleek
135
SAMENVATTING
dat dagelijkse veranderingen in mindfulness inderdaad vooraf gingen
aan dagelijkse veranderingen in NA en PA, en niet andersom. Echter, deze
effecten varieerden tussen deelnemers, wat er op duidt dat verbeteringen
in mindfulness niet bij iedereen leiden tot verbeteringen in stemming.
Daarnaast scoorden deelnemers hoger op mindfulness wanneer zij
eerder op de dag tenminste één mindfulness oefening hadden gedaan.
Het trainen van mindfulness in het dagelijks leven kan dus inderdaad
bijdragen aan dagelijks welbevinden.
De onderzoeken in het tweede deel van het proefschrift
(Hoofdstuk 5, 6 en 7) richtten zich op voorspellers van de effectiviteit
van MBCT en CBT. Deze onderzoeken zijn een onderdeel van een
gerandomiseerd gecontroleerd onderzoek (RCT). In Hoofdstuk 5 wordt
de opzet van deze RCT beschreven. Het doel van de RCT was om de
effectiviteit, voorspellers en mediatoren van effectiviteit in CBT en MBCT
te onderzoeken. Diabetes patiënten met depressieve klachten (Beck
Depression Inventory-II (BDI-II) score ≥ 14) werden gerandomiseerd en
ingedeeld in CGT, MBCT, of een wachtlijst conditie. Na de wachtlijst van
drie maanden werden patiënten wederom willekeurig ingedeeld in CGT of
MBCT. Zowel CGT als MBCT bestonden uit 8 individuele sessies van 45 tot
60 minuten.
Een aantal eerdere onderzoeken toonde aan dat verwachtingen
van patiënten over de effectiviteit van een behandeling voorspellen of
patiënten baat hebben bij behandeling. Een al lang bestaande hypothese
is dat positieve verwachtingen hoop creëren en daardoor een direct
effect hebben op de stemming van patiënten. Anderen veronderstellen
dat verwachtingen van patiënten invloed hebben op de mate waarin
patiënten zich inzetten in therapie. In Hoofdstuk 6 testen we deze
hypotheses door te onderzoeken of verwachtingen van patiënten
een directe verbetering in depressieve klachten voorspellen aan het
begin van CGT en MBCT of pas aan het eind van de behandeling. Ook
onderzochten we of verwachtingen van patiënten hun inzet bepalen
door verwachtingen te relateren aan vroegtijdige beëindiging van de
behandeling en het maken van huiswerk. Daarnaast onderzochten we de
relatie tussen het maken van huiswerk en verbeteringen in depressieve
klachten. Uit het onderzoek bleek dat patiënten met positievere
verwachtingen minder depressieve klachten hebben na CGT en MBCT
dan patiënten met lagere verwachtingen. Verwachtingen waren niet
gerelateerd aan depressieve klachten aan het begin of op de helft
van de behandeling. Ook toonden we aan dat de kans kleiner is dat
patiënten stoppen met CGT en MBCT en dat patiënten meer huiswerk
136
SAMENVATTING
maken tijdens MBCT als ze hogere verwachtingen hebben van de
effectiviteit van behandeling. Verder vonden we niet dat patiënten die
meer huiswerk maken ook meer baat hebben bij CGT en MBCT in termen
van klachtenreductie. De resultaten duiden er op dat verwachtingen
geen direct effect hebben op de stemming van patiënten maar dat
verwachtingen wellicht processen in gang zetten die pas later de
stemming beïnvloeden. Het lijkt er op dat verwachtingen de inzet van
patiënten beïnvloeden, aangezien ze gerelateerd zijn aan het stoppen met
CGT en MBCT en het maken van huiswerk in MBCT.
Uit eerder onderzoek bleek dat de therapeutische alliantie ook
behandeleffectiviteit voorspelt. Onder de therapeutische alliantie wordt
het gezamenlijk overeenkomen van therapiedoelen en therapietaken
en de band tussen de patiënt en de therapeut verstaan. Het zou kunnen
dat de therapeutische alliantie niet zo belangrijk is in MBCT omdat
twee aspecten van de therapeutische alliantie (het overeenkomen van
therapiedoelen en therapietaken) niet zo centraal staan in MBCT als in
CGT. Daarnaast toonden verscheidene onderzoeken aan dat er geen
relatie tussen de therapeutische alliantie en effectiviteit meer was als
er rekening gehouden werd met de afname in depressieve klachten
vlak voor de therapeutische alliantie werd gemeten. In Hoofdstuk 7
hebben we daarom het verband tussen de therapeutische alliantie
en klachtreductie vergeleken tussen CGT en MBCT, waarbij we
controleerden voor klachtreductie voorafgaand aan het vaststellen van
de therapeutische alliantie. Uit het onderzoek bleek dat depressieve
klachten meer afnamen in de CGT conditie wanneer patiënten meer
achter de overeengekomen therapie taken stonden, een sterkere band
tussen hen en de therapeut ervoeren, en meer achter de overeengekomen
therapie doelen stonden (bijna significant). In MBCT waren geen van de
aspecten van de therapeutische alliantie gerelateerd aan klachtreductie.
Wellicht is het belangrijker dat patiënten achter de therapie taken en
doelen staan in CGT staan omdat de oefeningen in CGT meer toegespitst
zijn op de persoonlijke situatie dan in MBCT. Daarnaast is het ook zo dat
patiënten meer informatie over hun problemen in het dagelijks leven
moeten delen in CGT dan in MBCT en dat het daarom belangrijker kan
zijn voor patiënten om een goede band met hun therapeut te ervaren
in CGT dan in MBCT. Concluderend kan gesteld worden dat het afhangt
van de therapievorm hoe belangrijk de therapeutische alliantie is voor de
effectiviteit.
137
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Dankwoord
Laat ik met de belangrijkste persoon tijdens mijn promotietraject
beginnen: Annika. Wat ben ik blij dat jij degene was met wie ik vier
jaar een onderzoeksproject heb uitgevoerd. Omdat jouw manier van
werken aansloot bij de mijne en je gestructureerd, planmatig, precies
en doelgericht werkt, is het project een succes geworden en kon ik
blindelings op jou vertrouwen. Het was heel fijn dat ik alles met je kon
bespreken en dat het vaak ook tot inzichten leidde, zowel op inhoudelijk
als persoonlijk vlak. Ik heb altijd veel steun gehad van jou.
Joke en Maya, jullie hebben het onderzoeksproject met hart en ziel geleid.
Ik heb jullie toewijding en betrokkenheid bij mij en het onderzoek zeer
gewaardeerd. Zonder jullie was het onderzoeksproject niet zo geslaagd
geweest en had ik niet de ontwikkeling kunnen doormaken die ik heb
doorgemaakt. Joke, jouw efficiënte manier van werken was een voorbeeld
voor mij en het was goed om soms terug te krijgen dat het ook minder
ingewikkeld kon. Maya, door jouw kritische vragen kregen artikelen meer
diepgang en leerde ik beter vragen te kiezen die meten wat je wilt weten.
Daarnaast was het goed voor me dat jullie me beiden stimuleerden om
goed voor mezelf te zorgen. Vooral ben ik erg dankbaar dat jullie zo
open stonden voor mijn ideeën, plannen en manier van werken. Jullie
stonden bijvoorbeeld meteen achter het idee om een extra onderzoek
met Elske op te zetten. Doordat ik de vrijheid kreeg om mijn eigen weg te
bewandelen, heb ik me kunnen ontwikkelen en heb ik kunnen ontdekken
in welke onderzoeksrichting ik werkelijk geïnteresseerd ben.
Ook dank ik mijn promotoren, Robbert en Paul. Zonder jullie was
dit project niet mogelijk geweest. Robbert, jouw optimisme en
benaderbaarheid heb ik erg gewaardeerd. Paul, het was fascinerend om
te zien hoe je in vijf minuten veel inhoudelijke, nuttige suggesties kon
aandragen of zelfs een complete supervisie kon geven.
Daarnaast wil ik de co-auteurs van de artikelen danken voor hun
belangrijke bijdrage, in het bijzonder Elske. Elske, je bent geweldig.
Allereerst de tijd en moeite die je hebt genomen om mij VAR analyses
te leren. De hoeveelheid vrijdagochtenden die je daar in hebt gestoken,
zijn voor mij heel waardevol geweest. Naast analyses heb je me ook
zoveel andere dingen meegegeven; gestructureerd teksten en analyses
opbouwen, hoe je iemand iets goed kan aanleren, ergens van overtuigd
blijven als je er in gelooft, humor in wetenschap, eerlijkheid en de kracht
161
van positieve feedback. Voor mij ben jij het ultieme voorbeeld.
Ook wil ik Ivan bedanken. Je weet niet hoe blij en dankbaar ik was toen
je ons aanbood om een artikel met je te schrijven over jouw gouden data
set. Het was een fijne samenwerking op afstand omdat je mij en Elske
vertrouwde en daarnaast zelf nauw betrokken bleef en meeschreef. Ook
hebben je kritische met humor doorspekte vragen op congressen en
symposia me vaak aan het denken gezet.
Naast de mensen die persoonlijk bij mijn promotietraject betrokken
waren, hebben heel veel mensen, waarvan velen vrijwillig, bijgedragen
aan het onderzoek naar MBCT en CBT voor diabetes patiënten. Allereerst
dank ik alle deelnemers aan het onderzoek voor het geven van
waardevolle feedback, invullen van de vragenlijsten en het delen van
hun problematiek. Ook ben ik een aantal mensen erg dankbaar dat we
het onderzoek op diabetes poli’s in verschillende ziekenhuizen konden
uitvoeren: Thera Links en Bruce Wolffenbuttel in het UMCG, Annemieke
Roos en Klaas Hoogenberg in het Martini ziekenhuis, Nynke Rauwerda
in het Ziekenhuis Rivierenland Tiel en Jet de Hoop in het Medisch
Centrum Leeuwarden. Verder hebben velen hard meegewerkt aan de
data verzameling en het voeren van intake gesprekken: Irina Bas, Rachel
Klokman, Janet Meijer, Ingrid van Netten en Saskia Nummerdor, bedankt.
Daarnaast wil ik de psychologen bedanken, waarvan velen vrijwillig MBCT
en CBT aan diabetes patiënten hebben gegeven: Gillian Kreugel, Willeke
Kasje, Kim van der Schoot, Irina Bas, Annika Tovote, Maya Schroevers, Joke
Fleer, Gemma Maters, Willem Swaak, Anne Oosterink, Jan Voorwinden,
Linda Geerligs, Hanna Tjalma, Nynke Groenewold, Nynke Rauwerda, Anne
Heideveld, Anne Louwerse, Loes Claessen, Joost Willems en Saskia Visser.
In het bijzonder wil ik Grieteke Pool bedanken voor haar geduldige en
inzichtgevende klinische supervisies. Ook wil ik Roel Schoemaker, Carmen
de Weerd en Marieke van der Werff bedanken voor het bekijken en scoren
van vele gefilmde therapiesessies.
Zo is er ook een heel aantal mensen dat heeft meegewerkt aan het
dagboekonderzoek dat is uitgevoerd bij het Centrum Integrale Psychiatrie
(CIP). Allereerst wil ik de deelnemers aan het onderzoek bedanken voor
het trouw invullen van de dagelijkse metingen en de positieve feedback.
Daarnaast is het onderzoek heel goed gefaciliteerd door de medewerkers
van het CIP: Anita La Crois-Blaauw, Rogier Hoenders, Erik van den Brink,
Jolieka Regterschot en in het bijzonder Karen van der Ploeg; dank voor je
162
steun en hulp en dat je mij in contact hebt gebracht met het CIP. Tenslotte
dank ik Jan Jacobs voor het meedenken met de analyses.
It was great to have such helpful colleagues whom I could ask anything
and to have a good time with; Adelita, Adriana, Angélica, Ans, Corinne,
Daphne, Fabiola, Franziska, Gemma, Grieteke, Jacques, Karin, Katerina,
Lei, Marike, Marrit, Mariët, Martine, Meirav, Monica, Moniek, Nardi, Nynke,
Somayeh, Vicky, Ying, and Yvette, thank you. Especially Eric, Truus, Renate,
and Annemieke, thank you for all your advice and assistance. It was also
supporting to be surrounded by a group of PhD-students who supported
me when another paper was rejected and to share the valuable ThankGod-it’s-Friday-drinks with. And Annika, Moniek, and Lei, thank you for
making exercise and conferences so enjoyable.
A separate word to my PhD friend, Giedre, my ‘secret’ third paranimf. It
was so valuable to talk with you about little struggles in our PhD, ‘normal
life’, the PhD ceremony and to put things into perspective. Thank you for
telling me to have holidays, for having holidays with you in Copenhagen,
and for making me feel welcome.
Lieve papa en Nanny, dank voor de diepgaande interesse in mijn
onderzoek en het vele meedenken. Lieve Pascal, mama, Jaap, Loes en
Laura dank voor jullie warme onvoorwaardelijke steun. Pascal, het was
heerlijk om bij jou thuis te komen na een dag werken (en natuurlijk dat
er dan vaak een hapje eten voor me klaar stond) en van gedachten te
kunnen wisselen over het onderzoek, of juist niet. Tot slot, Pascal en Geert,
dank jullie wel voor de prachtige omslag die jullie voor het proefschrift
hebben gemaakt.
163
Curriculum Vitae
Evelien Snippe was born on May 23, 1986 in
Groningen, The Netherlands. She graduated
from secondary school (Praedinius Gymnasium,
Groningen) in 2004. In 2007, she obtained her
Bachelor’s degree in Psychology at the University
of Groningen. After that, she decided to switch
to the faculty of Medical Sciences to start a
research master in Clinical and Psychosocial
Epidemiology. She graduated in 2009 (cum
laude). As she aimed to perform research in the
field of clinical health psychology, she started a
master in Clinical Psychology and graduated in
2010 (cum laude). She performed her clinical internship at Lentis, Center
for Integrative Psychiatry. During her second master, she started a PhD
project at the Department of Health Psychology, University of Groningen,
University Medical Center Groningen. She contributed to the design and
performance of a randomized controlled trial, for which she performed
clinical work as well. Currently, Evelien is working as a post-doctoral
researcher at the School for Mental Health and Neuroscience at Maastricht
University. From October 1st 2014 on, she will continue this post-doctoral
research at the Interdisciplinary Center Psychopathology and Emotion
Regulation at the University of Groningen.
164
List of publications
1. Schroevers, M.J., Snippe, E., Bas, I.V., Tovote, K.A., Fleer, J. (2011).
Mindfulness training in perspectief. Psychologie & Gezondheid, 39(1), 32-38.
2. Snippe, E., Maters, G.A., Wempe, J.B., Hagedoorn, M., Sanderman, R.
(2012). Discrepancies between patients’ and partners’ perceptions of
unsupportive behavior in chronic obstructive pulmonary disease. Journal
of Family Psychology, 26(3), 464-469.
3. Tovote, K.A. Fleer, J., Snippe, E., Bas, I.V., Links, T.P., Emmelkamp, P.M.G.,
Sanderman, R., Schroevers, M.J. (2013). Cognitive behavioral therapy and
mindfulness-based cognitive therapy for depressive symptoms in patients
with diabetes: design of a randomized controlled trial. BMC Psychology,
1(1).
4. Tovote, K.A. Fleer, J., Snippe, E., Peeters, A.C.T.M., Emmelkamp, P.M.G.,
Sanderman, R., Links, T.P., Schroevers, M.J. (2014). Individual MindfulnesBased Cognitive Therapy (MBCT) and Cognitive Behavior Therapy (CBT)
for Treating Depressive Symptoms in Patients with Diabetes: Results of a
Randomized Controlled Trial. Diabetes Care, doi:10.2337/dc13-2918/-/DC1.
165
SHARE- previous dissertations
This thesis is published within the Research Institute SHARE (Science
in Healthy Ageing and Health caRE) of the University Medical Center
Groningen / University of Groningen.
Further information regarding the institute and its research can be
obtained from our internetsite: www.share.umcg.nl
More recent theses can be found in the list below.
((co-) supervisors are between brackets)
2014
Suwantika AA
Economic evaluations of non-traditional vaccinations in middleincome countries: Indonesia as a reference case
(prof MJ Postma, dr K Lestari)
Behanova M
Area- and individual-level socioaeconomic differences in health and
health-risk behaviours; a comparison of Slovak and Dutch cities
(prof SA Reijneveld, dr JP van Dijk, dr I Rajnicova-Nagyova, dr Z
Katreniakova)
Dekker H
Teaching and learning professionalism in medical education
(prof J Cohen-Schotanus, prof T van der Molen, prof JW Snoek)
Dontje ML
Daily physical activity in patients with a chronic disease
(prof CP van der Schans, prof RP Stolk)
Gefenaite G
Newly introduced vaccines; effectiveness and determinants of
acceptance
(prof E Hak, prof RP Stolk)
Dagan M
The role of spousal supportive behaviors in couples’ adaptation to
colorectal cancer
(prof M Hagedoorn, prof R Sanderman)
Monteiro SP
Driving-impairing medicines and traffic safety; patients’perspectives
(prof JJ de Gier, dr L van Dijk)
Bredeweg S
Running related injuries
(prof JHB Geertzen, dr J Zwerver)
Mahmood SI
Selection of medical students and their specialty choices
(prof JCC Borleffs, dr RA Tio)
166
Krieke JAJ van der
Patients’ in the driver’s seat; a role for e-mental health?
(prof P de Jonge, prof M Aielllo, dr S Sytema, dr A Wunderink)
Jong LD de
Contractures and hypertonia of the arm after stroke; development,
assessment and treatment
(prof K Postema, prof PU Dijkstra)
Tiessen AH
Cardiovascular risk management in general practice
(prof K van der Meer, prof AJ Smit, dr J Broer)
Bodde MI
Complex Regional Pain Syndrome type 1 & amputation
(prof JHB Geertzen, prof PU Dijkstra, dr WFA van der Dunnen)
Lakke AE
Work capacity of patients with chronic musculoskeletal pain
(prof JHB Geertzen, prof MF Reneman, prof CP van der Schans)
Silarova B
Unraveling the role of sense of coherence in coronary heart disease
patients
(prof SA Reijneveld, dr JP van Dijk, dr I Rajnicova-Nagyova)
Weening-Dijksterhuis E
Physical exercise to improve or maintain Activities of Daily Living
performance in frail institutionalized older persons
(prof CP van der Schans, prof JPJ Slaets, dr MHG de Greef, dr W Krijnen)
Koolhaas W
Sustainable employability of ageing workers; the development of an
intervention
(prof JJL van der Klink, prof JW Groothoff, dr S Brouwer)
Flach PA
Sick leave management beyond return to work
(prof JW Groothoff, prof U Bültmann)
2013
Bosker BH
Pitfalls in traditional and innovative hip replacement surgery
(prof SK Bulstra, dr CCPM Verheyen, dr HB Ettema)
Holwerda A
Work outcome in young adults with disabilities
(prof JJL van der Klink, prof JW Groothoff)
Mohseninejad L
Uncertainty in economic evaluations: implications for healthcare decisions
167
(prof E Buskens, dr TL Feenstra)
Cornelius LR
A view beyond the horizon; a prospective cohort study on mental health
and long-term disability
(prof JJL van der Klink, prof JW Groothoff, dr S Brouwer)
Sobhani S
Rocker shoes for ankle and foot overuse injuries: a biomechanical and
physiological evaluation
(prof K Postema, prof ER van den Heuvel)
Pitel L
Sociocultural determinants, gender and health-related behaviour in
adolescence
(prof SA Reijneveld, dr JP van Dijk, dr A Madarasova-Geckova)
Majerníková M
Sef-rated health and mortality after kidney transplantation
(prof JW Groothoff, dr JP van Dijk, dr J Rosenberger, dr R Roland)
Verschuren J
Sexuality and limb amputation: perspectives of patients, partners and
professionals
(prof JHB Geertzen, prof PU Dijkstra, prof P Enzlin)
Riphagen-Dalhuisen J
Influenza vaccination of health care workers
(prof E Hak)
Hasselt FM van
Improving the physical health of people with severe mental illness;
the need for tailor made care and uniform evaluation of interventions
(prof AJM Loonen, prof MJ Postma, dr MJT Oud, dr PFM Krabbe)
Piening S
Communicating risk effectively
(prof FM Haaijer-Ruskamp, prof PA de Graeff, dr PGM Mol, dr SMJM Straus)
Siebelink MJ
The child as a donor; a multidisciplinary approach
(prof HBM van de Wiel, prof PF Roodbol)
Sidorenkov G
Predictive value of treatment quality indicators on outcomes in
patients with diabetes
(prof FM Haaijer-Ruskamp, prof D de Zeeuw)
For more 2013 and earlier theses visit our website
168

Cursus Mindfulness (MSBR/MBCT) voor (G)Gz

APPENDIX - Dissertations

Naam: Martine van Dongen-Boomsma Huidige functies Karakter

Ronald van Geyt kampioen

CV Bastiaan Rutjens 2014

The Neuroscience of Meditation: Mind of the meditator By

1 Cognitie bij MS-patiënten in MST: een Prevalentieonderzoek

Contents - European Heart Journal

Cover Page The handle http://hdl.handle.net/23294 holds

Anaerobe zuivering van huishoudelijk afvalwater

1 Curriculum Vitae Paul A. M. Van Lange Education Professional

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SLF.LD.Algemene voorwaarden.2015.03.25

Key Points EN - VU

Rapport Care4Care - Buddyzorg Limburg