Efficacy of Solution-Focused Brief Therapy for Distress among Parents of Children with Congenital Heart Disease in China

Efficacy of Solution-Focused Brief Therapy for Distress among Parents of Children with Congenital... Abstract Chinese parents of children with congenital heart disease (CHD) experience significant psychological distress due to the child’s illness and hospitalization. Unfortunately, there are few psychosocial interventions for parental distress in China. This pilot study aimed to examine the efficacy of solution-focused brief therapy (SFBT) in a Chinese hospital for parental distress using a randomized controlled trial design. The participants included 40 Chinese parents of a currently hospitalized child diagnosed with CHD who were assessed to have psychological distress. Parents were randomized into either the intervention (n = 25) or the hospital medical social work treatment as usual (TAU) (n = 28) group. The Chinese Brief Symptom Inventory-18 and Chinese version of Herth Hope Index were administered before and after the interventions. Results of the intent-to-treat analysis indicated a significant decrease in parental distress and increase in parents’ levels of hope in the intervention group compared with the TAU group. This study supported SFBT administered in a hospital setting as a promising intervention for reducing distress among Chinese parents with children diagnosed with CHD. hospital, parental distress, randomized controlled trial, solution-focused brief therapy Congenital heart disease (CHD) is among the world’s most common congenital defects (Dolk, Loane, & Garne, 2011), and its prevalence has increased by 11 percent in children from 2000 to 2010 worldwide (Marelli et al., 2014). In the United States, 1 percent of all children at birth suffer from CHD (Marelli et al., 2014); CHD’s prevalence in China is 7 percent among live births, which translates into 100,000 to 150,000 new cases annually (National Center for Cardiovascular Disease, 2006). The overall mortality rate caused by CHD had a 62.4 percent relative increase (114 to 229 per 10 million people per year) from 2003 to 2010 in China, with an even higher rate in rural areas (Hu, Yuan, Rao, Zheng, & Hu, 2014; F. Liu et al., 2015). Pediatric patients with CHD are among the most vulnerable patient populations and, other than the health care team, they almost exclusively depend on their parents during treatment and recovery. This puts considerable burden on their parents, who often face multiple psychosocial challenges, including high levels of psychological distress. Psychological distress is defined as “the unique discomforting, emotional state [like depression or anxiety] experienced by an individual in response to a specific stressor or demand . . . to the person” (Ridner, 2004, p. 539). Psychological distress is complicated by the fact that parents who are taking care of their child who has CHD have very limited resources for their own psychological well-being (J. Liu et al., 2011). Parents’ psychological distress affects their quality of life and limits optimal parenting and care during the treatment of their children (Hearps et al., 2013; Lawoko & Soares, 2006), and may even pose a threat to children’s quality of care and recovery. Intense parental distress contributes to poorer doctor–patient communication (Wei, Roscigno, Hanson, & Swanson, 2015), undermines the capacity of parental care (Latal, Helfricht, Fischer, Bauersfled, & Landolt, 2009), and may be detrimental to the parent–child relationship (Long & Marsland, 2011). The impact of psychological distress on parenting and patient care may further be associated with negative patient experience, greater likelihood of medical errors (X. Liu, Rohrer, et al., 2015), higher depressive symptoms, increased loneliness, and lower quality of life for CHD patients (Luyckx et al., 2014). This creates a need for social workers to provide psychosocial interventions and support to parents of CHD patients who experience psychological distress. Most Chinese parents, however, are unwilling to receive psychosocial interventions outside of the hospital while their child is hospitalized for treatment. For those who are willing to seek external psychosocial care, their options are limited as China’s mental health services system is still in the preliminary stages of development. Therefore, for parents to be receptive to psychosocial interventions for distress, these interventions need to be delivered in the hospital setting in which their child is receiving treatment. Whereas previous studies have established the importance of alleviating parental distress of CHD patients, research on interventions for parental distress is limited and even scarcer in China. A meta-analysis of Western literature (Donker, Griffiths, Cuijpers, & Christensen, 2009) revealed that psychoeducation can reduce symptoms of depression and psychological distress in various settings, but the effect size was small (d = 0.2). Two reviews (Meyer & Mark, 1995; Sheard & Maguire, 1999) of psychosocial interventions for adult oncology patients indicated the benefits of interventions for patients’ emotional adjustment (d = 0.24) and anxiety (d = 0.42). Another related and more relevant meta-analysis (Pai, Drotar, Zebracki, Moore, & Youngstrom, 2006) reported that psychological interventions seemed promising for parental distress in pediatric oncology settings (d = 0.35). Authors of these reviews indicated the importance of addressing common challenges when delivering psychosocial interventions in hospital settings. These challenges translated into three common characteristics for the interventions: (1) the necessity to be brief (Davis et al., 2013), (2) efficient and quick to establish a therapeutic alliance (Scott et al., 2008), and (3) a clinical process that uses a collaborative and patient-centered approach (Arean, Alvidrez, Barrera, Robinson, & Hicks, 2002). Unfortunately, studies have not focused on ways to incorporate these features into hospital interventions that can also address parental distress of children with CHD (Brosig, Whitstone, Frommelt, Frisbee, & Leuthner, 2007). In fact, all existing studies in China that addressed pediatric patients and their family members’ psychosocial well-being in hospitals were limited to case management and brief psychosocial supports mainly provided by nurses (for example, Chen, Zhang, Huang, & Wang, 2016; L. Wang, 2014). To our knowledge, only one study (Yang, Yang, Li, Li, & Tang, 2015) focused on anxiety of parents of pediatric patients with CHD in Chinese hospitals, and no studies specifically examined interventions aimed at reducing parents’ psychological distress. Therefore, there is a need for brief interventions that have potential to address these concerns (Yang et al., 2015). Given the prevalence of pediatric CHD in China and the importance of addressing parental psychological distress, it is essential for researchers and practitioners to work together to develop interventions that (a) can effectively target parental psychological distress, (b) are culturally competent to the Chinese population, and (c) are consonant with medical settings. Solution-focused brief therapy (SFBT) is an intervention that may meet all these requirements. SFBT SFBT is a strengths-oriented intervention that originated from brief family therapy and has received sufficient empirical support as potentially effective in addressing psychological distress (Franklin, 2015; Gingerich, Kim, Stams, & MacDonald, 2012). Theoretically grounded in constructivist approaches to communication and social interaction theories (de Shazer, 1991), the co-construction process of SFBT shifts and focuses clients’ attention to their existing resources and solutions. Consequently, the intervention increases positive expectancies and emotions, like hope and optimism, to address feelings of sadness, worry, fear, and other emotions that are central psychological components of depression and anxiety (Beck & Haigh, 2014). Over the past 10 years, several clinical trials have supported the effectiveness of SFBT for decreasing psychological distress (Franklin, 2012; Gingerich & Peterson, 2013), and two recent meta-analytical studies reported small effect sizes d = 0.24 (Schmit, Schmit, & Lenz, 2016) and d = 0.26 (Kim, 2008) for SFBT in the treatment of symptoms from internalizing disorders like depression and anxiety. Another recent meta-analysis reported a large treatment effect (d = 1.26, p < .001) for SFBT studies that had been conducted with Chinese populations (Kim et al., 2015), with the largest overall treatment effects of the studies reviewed having taken place in Chinese hospital settings (d = 0.94, p < .001) (Gong & Xu, 2015). More important, SFBT has been recommended for hospitals due to the consistency of its features with such settings (Burns, 2016). First, SFBT is brief and has been found to create positive therapeutic change within three to five sessions (Gingerich et al., 2012). Second, SFBT has been delivered in various practice settings with diverse client populations and has clinically been reported to be used in medical settings with satisfactory therapeutic relationships and with preliminary studies demonstrating its effectiveness (Franklin, 2015). In addition, SFBT takes a collaborative stance whereby clients set their own goals and are encouraged to take charge of their outcomes. This creates a patient-centered approach that is recommended for hospital settings (de Shazer et al., 2007). Finally, SFBT has been reported to be able to engage the least clinically cooperative clients (see, for example, Tohn & Oshlag, 1996; Trepper, Dolan, McCollum, & Nelson, 2006). These factors indicate the potential of SFBT to help in relieving distress of parents caring for a child with a severe illness. Furthermore, these characteristics alleviate common challenges in delivering psychosocial interventions in medical settings. This article reports on a pilot randomized controlled trial in a tertiary Chinese hospital that examined the effectiveness of SFBT in reducing distress among Chinese parents of children with CHD. This study tested the following two hypotheses: (1) SFBT intervention with distressed parents will be more effective than a hospital medical social work treatment as usual (TAU) in decreasing parental distress, depressive symptoms, level of anxiety, and somatization, and increasing parents' level of hope. (2) The between-group (SFBT versus TAU) treatment effect size will be significantly different, favoring SFBT. METHOD Study Setting, Eligibility, and Recruitment Study Settings The pilot study was led by the Department of Medical Social Work at Shanghai Children’s Medical Center (SCMC) affiliated with Shanghai Jiaotong University School of Medicine. The investigation was conducted at SCMC’s Department of Pediatric Cardiovascular Surgery and the Department of Cardiology. A medical social worker was assigned as the research coordinator for this study. The two departments have over 150 beds and a capacity of serving close to 4,000 patients with CHD yearly. Eligibility Eligible participants were at least 21 years old, and the primary parental caregiver of a pediatric patient with CHD who also met a gender-specific Brief Symptom Inventory-18 (BSI-18) cutoff score (>10 for male and >13 for female respondents) (Zabora et al., 2001). The treatment was a four-session intervention occurring over a minimum of 10 days after initial referral contact. Participants who did not have the capacity to give informed consent or who were unable to receive all four sessions were not eligible for study participation. Recruitment Procedures Study participants were obtained through three routes: (1) referral from physicians or nursing staff, (2) referral from the Department of Medical Social Work through daily rounds at the heart center, and (3) self-referral. Individuals who showed interest in participating were guided to the Department of Medical Social Work main office to provide informed consent. Parents referred into the study were screened using the BSI-18 Chinese version (J. Wang, Kelly, Liu, Zhang, & Hao, 2013). Based on its cutoff score, medical social workers identified eligible participants. The research coordinator subsequently met with each eligible participant in person to explain the study and the informed consent procedure. The study used a pretest–posttest design with random assignment. Eligible patients were randomized into either intervention or TAU groups. Random assignment was conducted using a computerized random number generator on the number of 100. Over the course of seven months, the research team contacted 92 participants. Twenty-eight participants refused to participate in the study when approached, and an additional 11 patients were excluded because they did not meet the minimum criteria for BSI-18 score at baseline, resulting in 53 being randomized (25 to the SFBT group and 28 to the TAU group). During treatment, seven participants dropped out of the SFBT group for various reasons and six participants dropped out of the TAU group, leaving 18 in SFBT and 22 in TAU (see Figure 1). Figure 1: View largeDownload slide : CONSORT Flowchart of Parent Recruitment Notes: CONSORT = Consolidated Standards of Reporting Trials; SFBT = solution-focused brief therapy; TAU = treatment as usual. Figure 1: View largeDownload slide : CONSORT Flowchart of Parent Recruitment Notes: CONSORT = Consolidated Standards of Reporting Trials; SFBT = solution-focused brief therapy; TAU = treatment as usual. Intervention Training Six graduate-level providers were trained by two trainers in SFBT. Both trainers are experienced licensed clinical social workers with an average of five years of clinical experience. A 16-hour intensive training on SFBT was offered on two separate days to the three SFBT providers. The training consisted of a four-hour session of teaching SFBT theories and applications, a four-hour session of didactic teaching and discussion of the Solution Focused Therapy Treatment Manual for Working with Individuals, 2nd Version (Solution Focused Brief Therapy Association [SFBTA], 2013), a four-hour session of observation of the trainer using SFBT with actual clients, followed by a four-hour session of student role play using SFBT. The three providers for the TAU or control group were blind to the experimental group intervention and received a 16-hour intensive training in general medical social work practice on two separate days based on SCMC’s existing medical social work services protocol. The training consisted of a four-hour session of teaching general medical social work practice; a four-hour session of didactic teaching and discussion of cognitive–behavioral therapy, client-centered practice, and case management; a four-hour observation session of the trainer using general practice with actual clients; and subsequently, a four-hour session of student role play using the general practice approach. Supervision and Fidelity Ongoing supervision was offered for all study providers. An SFBT trainer met with the three SFBT providers on a weekly basis to address any clinical issues encountered. With clients’ permission, the SFBT trainer randomly observed the client–social worker encounters behind a one-way mirror to ensure treatment fidelity. Similar arrangements were made for the TAU providers. During observation, the supervisor of the SFBT social workers used an evaluation form (available through contacting the corresponding author) of 10 criteria derived from the Solution Focused Therapy Treatment Manual for Working with Individuals (SFBTA, 2013). The supervisor rated each criterion from 1 = poorly performed to 10 = very well performed, with a total score from 10 to 100. Ten sessions of three providers observed had an average score of 72.3, which indicated satisfactory fidelity of SFBT. SFBT and TAU Interventions Participants in the SFBT group received four structured individual sessions of the intervention. In general, the intervention followed the manual (SFBTA, 2013). In the first session, providers started with building rapport with the client by using solution-oriented language and interview techniques (for example, solution talk, formula first session question, and pre-session change) to create an environment that can host a productive conversation. Later in the first session, providers closely followed the clients’ frame of reference and used future-oriented techniques (for example, miracle questions, “what if” questions, and goal-setting techniques) to develop treatment goals on which participants were willing to work and that were relevant to their psychological distress. In the second and third sessions, providers started by checking in with participants using various SFBT techniques (for example, scaling questions, coping questions, exception questions) to solicit progress or improvements made since the last meeting, specifically focusing on any success and resilience in coping with challenges. After checking in with clients, providers co-constructed solutions to solve participants’ ongoing psychological challenges, using SFBT techniques including miracle questions, coping questions, relational questions, and exception questions. The purpose of using these questions was to shift clients’ focus to their strengths and past positive coping strategies and to identify if and what they can do differently to further alleviate psychosocial challenges in caring for their child. By the end of sessions 2 and 3, participants had a plan or solution to an issue that they co-constructed with the provider and knew how to apply the solution. During the last session, providers checked in with the participants, informed them that it was the last session of the study, and offered resources if the participants wished to continue receiving services. The providers then reviewed and reinforced progress and solutions established so far and discussed with the participants ways to maintain their progress and continue to implement the solutions they co-constructed. Finally, a referral was made for those who wished to continue services. For those who wanted to discontinue, the providers checked to see whether participants had any unresolved concerns and then terminated the service. TAU paralleled the SFBT protocol and was based on the existing treatment protocol at the Department of Medical Social Work. Providers focused on assessing the nature of clients’ problem, building rapport, and collaboratively developing goals with the clients to alleviate parents’ emotional and psychological distress. The second and third sessions focused on emotional regulation or behavioral change, activation, or both, using a general practice approach that integrates cognitive–behavioral therapy and a client-centered approach. The fourth session was centered at ending the professional relationship and reinforcing progress made so far. The providers started the session by reviewing the treatment process with the participant, inviting the participant to reflect on the progress made so far and challenges that remained. Providers also discussed with the participants ways to maintain the progress made during the service. Providers asked if the participant was willing to continue service but not as part of the study. For those who wished to continue, a referral was made by the end of the session. Data Collection and Outcome Measures Baseline scores were obtained after parents consented, and the same scales were used at posttreatment two weeks after the baseline. Primary Outcome Parental distress was measured using the Chinese version of the BSI-18. BSI-18 is the most concise measure (Derogatis, 2001) of psychological distress and has been recommended for hospital settings (Carlson, Waller, & Mitchell, 2012; Christ, Messner, & Behar, 2015). BSI-18 is a shortened version of the previous BSI (53 items) (Derogatis, 1993), which contains three dimensions with six items each. The three dimensions are somatization (for example, nausea), depression (for example, feeling blue), and anxiety (for example, nervousness or shakiness inside). J. Wang et al. (2013) systematically tested the factorial structure of the Chinese version of the BSI-18 and supported using it with the Chinese population. The authors (J. Wang et al., 2013) were contacted and permission was granted for BSI-18's use in the present study. Participants rated each symptom on a five-point Likert scale ranging from 0 = not at all to 4 = extremely, with higher scores indicating greater levels of distress. The BSI-18 has demonstrated satisfactory validity (Andreu et al., 2008) and reliability (Recklitis et al., 2006). The scale had satisfactory internal consistency in the present study, with an overall Cronbach’s alpha of .94. Secondary Outcome Level of hope was measured by the Herth Hope Index (HHI) (Herth, 1992) Chinese version, which is a shortened form of the Herth Hope Scale (Herth, 1991). The HHI is a 12-item Likert scale ranging from 1 = strongly disagree to 4 = strongly agree. Negative items were reversed so that the total score ranged from 12 to 48, with higher scores indicating greater levels of hope. Previous studies reported satisfactory psychometric properties of HHI in medical settings (Haugan, Utvær, & Moksnes, 2013), and the Chinese version of HHI has been reported as being reliable and valid (Chan, Li, Chan, & Lopez, 2012, p. 2079). In this study, the scale was tested and found to have very good internal consistency, with an overall Cronbach’s alpha of .885. Power and Data Analysis Power analysis revealed that a total sample size of 84 was required to achieve 80 percent power to detect a medium effect size (f = .4) using fixed-effect analysis of covariance (ANCOVA) for two groups with an alpha level of .05. Because this is a pilot study, we followed Browne’s (1995) recommendation of a minimum of 30 participants. To increase the statistical power, ANCOVA was used for intervention outcome, with posttest score as the dependent variable, pretest score as the covariate, and treatment condition as the fixed factor. ANCOVA only tests whether the treatment condition is superior to the control but not the magnitude of treatment effect or the difference in the magnitude between groups. Therefore, within- and between-group treatment effect size (Hedges’ g) was calculated as recommended by Cooper, Hedges, and Valentine (2009). This study used intent-to-treat analysis for ANCOVA and Hedges’ g. To handle missing data for participants who did not complete posttreatment evaluation, this study used single imputation of group means recommended by Armijo-Olivo, Warren, and Magee (2009) when the proportion of missing data was low (22 percent in this study). This study was approved by the medical institutional review board of ethics at SCMC affiliated with Shanghai Jiaotong University School of Medicine. RESULTS Sample Description Participants’ demographic information including age, gender, marital status, education, and income were collected. However, most demographic variables had significant missing data and only age and gender of the primary parent caretaker were consistently reported. Parents who completed (n = 18) and dropped out of (n = 7) the SFBT intervention did not differ in average age (32.16 and 31.43, respectively) and gender (61.1 percent and 42.9 percent female, respectively). Similarly, the age and gender differences of parents in TAU between those who completed (n = 22) and those who dropped out (n = 6) were not significant: average age of 29.96 and 25.5, and 63.6 percent and 66.7 percent female, respectively. There were no significant differences in age and gender between SFBT and TAU group members. Parents’ baseline somatization score in the treatment group (M = 9.80, SD = 5.23) did not differ significantly from those in the TAU group (M = 8.11, SD = 5.83). However, parents in SFBT and TAU differed significantly in baseline scores of parental distress, depression, anxiety, and hope scores (see Table 1). Table 1: Comparison of Demographic and Baseline Evaluation between Completers and Dropouts, and between Groups Variable  Treatment Group  Within-Group Difference p  Control Group  Within-Group Difference p  Between-Group Difference p  Complete (n = 18) M (SD)  Dropout (n = 7) M (SD)  Complete (n = 22) M (SD)  Dropout (n = 6) M (SD)  Age  32.16 (6.23)  31.43 (4.43)  .778  29.96 (6.22)  25.5 (3.51)  .367  .116  Gender (female %)  61.1  42.9  .409  63.6  66.7  .891  .579  Parental distress  43.00 (13.10)  41.43 (10.21)  .779  33.95 (16.41)  35.00 (6.45)  .881  .029   Somatization  10.39 (5.84)  8.29 (2.98)  .378  8.41 (6.43)  7.00 (2.83)  .609  .273   Depression  15.22 (4.93)  14.29 (4.60)  .669  11.32 (6.19)  11.67 (5.24)  .901  .020   Anxiety  17.39 (4.17)  18.86 (5.84)  .387  14.23 (5.88)  16.33 (3.78)  .416  .031  Herth Hope Index  32.44 (4.71)  27.71 (7.52)  .070  38.96 (5.24)  36.00 (3.03)  .215  .000  Variable  Treatment Group  Within-Group Difference p  Control Group  Within-Group Difference p  Between-Group Difference p  Complete (n = 18) M (SD)  Dropout (n = 7) M (SD)  Complete (n = 22) M (SD)  Dropout (n = 6) M (SD)  Age  32.16 (6.23)  31.43 (4.43)  .778  29.96 (6.22)  25.5 (3.51)  .367  .116  Gender (female %)  61.1  42.9  .409  63.6  66.7  .891  .579  Parental distress  43.00 (13.10)  41.43 (10.21)  .779  33.95 (16.41)  35.00 (6.45)  .881  .029   Somatization  10.39 (5.84)  8.29 (2.98)  .378  8.41 (6.43)  7.00 (2.83)  .609  .273   Depression  15.22 (4.93)  14.29 (4.60)  .669  11.32 (6.19)  11.67 (5.24)  .901  .020   Anxiety  17.39 (4.17)  18.86 (5.84)  .387  14.23 (5.88)  16.33 (3.78)  .416  .031  Herth Hope Index  32.44 (4.71)  27.71 (7.52)  .070  38.96 (5.24)  36.00 (3.03)  .215  .000  Treatment Outcome Effect The results of within-group effect size, between-group effect size, and ANCOVA for the group differences on parental distress, depression subscore, anxiety subscore, somatization subscore, and HHI score are presented in Table 2. SFBT had large within-group effect sizes for all outcomes ranging from d = 0.59 (somatization) to d = 1.43 (anxiety). All effect sizes were statistically significant as evidenced by the 95 percent confidence intervals (CIs) not containing zero, which indicates significant improvements after receiving SFBT. In contrast, TAU only had significant within-group treatment effect for anxiety (d = 0.47, 95% CI [0.08, 0.86]) but insignificant effect sizes (not different from zero) for other outcomes. In addition, between-group effect sizes were statistically significant and favored SFBT for all outcomes ranging from d = 0.54 (somatization) to d = 1.43 (anxiety). This indicates that participants receiving SFBT had significantly greater improvements than those in TAU. Table 2: Results of Treatment Effect Sizes and Between-Group Comparison (ANCOVA) Outcome  Within-Group Effect Size [95% CI]  Between-Group Effect Size [95% CI]  F test (df = 1)  Parental distress    1.277 [0.908, 1.646]  16.526***   Treatment  1.273 [0.740, 1.805]       Control  0.378 [–0.001, 0.762]      Somatization    0.541 [0.245, 0.837]  2.623   Treatment  0.591 [0.165, 1.017]       Control  0.123 [–0.249, 0.495]      Depression    1.268 [0.895, 1.640]  12.877***   Treatment  1.273 [0.741, 1.806]       Control  0.309 [–0.070, 0.689]      Anxiety    1.434 [1.004, 1.864]  15.810***   Treatment  1.426 [0.864, 1.989]       Control  0.467 [0.077, 0.858]      Hope level    1.353 [0.918, 1.788]  4.989*   Treatment  0.821 [0.366, 1.277]       Control  –0.566 [–0.966, –0.166]      Outcome  Within-Group Effect Size [95% CI]  Between-Group Effect Size [95% CI]  F test (df = 1)  Parental distress    1.277 [0.908, 1.646]  16.526***   Treatment  1.273 [0.740, 1.805]       Control  0.378 [–0.001, 0.762]      Somatization    0.541 [0.245, 0.837]  2.623   Treatment  0.591 [0.165, 1.017]       Control  0.123 [–0.249, 0.495]      Depression    1.268 [0.895, 1.640]  12.877***   Treatment  1.273 [0.741, 1.806]       Control  0.309 [–0.070, 0.689]      Anxiety    1.434 [1.004, 1.864]  15.810***   Treatment  1.426 [0.864, 1.989]       Control  0.467 [0.077, 0.858]      Hope level    1.353 [0.918, 1.788]  4.989*   Treatment  0.821 [0.366, 1.277]       Control  –0.566 [–0.966, –0.166]      Notes: ANCOVA = analysis of covariance; CI = confidence interval. All results reported were based on intent-to-treat analysis. *p < .05. ***p < .001. ANCOVA revealed that parents receiving SFBT had significantly lower parental distress (F = 16.53, p < .001), symptoms of depression (F = 12.9, p < .001), and anxiety (F = 15.81, p < .001) and higher level of hope (F = 4.99, p < .05) postintervention. Although SFBT was not superior to TAU in reducing parents’ somatization (F = 2.62, p = .11), both the within- and between-group effect sizes for somatization were significant, supporting the meaningful improvements in somatization for parents who received SFBT. DISCUSSION This pilot study examined the effectiveness of SFBT within a hospital setting for reducing psychological distress of Chinese parents whose children have CHD. There are currently no empirically supported treatments for working with Chinese parents whose children have CHD, and this study is the first one to examine the use of SFBT on the distress of parents of children with CHD. Consequently, this study is particularly significant to the treatment of parents who face the diagnosis of CHD in their children. CHD is a condition that has worldwide significance and a high prevalence rate among pediatric patients in China (X. Liu, Liu, et al., 2015; Marelli et al., 2014). The development of effective interventions is important to health care social workers and other health professionals who provide support and mental health treatment to distressed parents whose children suffer from CHD. Overall the findings of the study supported the effectiveness of SFBT in a hospital setting with Chinese parents and laid the foundation for future studies on the SFBT intervention with parents who experience distress due to having a child with CHD. In particular, this study suggests that SFBT is superior to TAU in alleviating depression and anxiety in Chinese parents and in increasing their hope as indicated by assessments on standardized measures. The effect sizes for SFBT were 1.27 and 1.43 for depression and anxiety, respectively, indicating large treatment effects (Cohen, 1988) of SFBT for parental distress. Franklin (2015) reported that literature is accumulating to suggest that SFBT may be a culturally competent and effective intervention for the Chinese population, and this study provides additional evidence. These findings are also consistent with other outcome studies that have been conducted in North America and China showing that SFBT is effective with internalizing disorders within medical and mental health settings (for example, Kim et al., 2015; Schmit et al., 2016). Other studies have shown that the effect sizes of SFBT with internalizing disorders has ranged from small to large (Kim, 2008; Kim et al., 2015; Schmit et al., 2016). It is noteworthy that larger effect sizes have been achieved in China as compared with other countries (Kim et al., 2015); this study achieved similarly promising results, adding support to the applicability and effectiveness of SFBT with Chinese parents of children with CHD. Beyond the overall significant treatment effect of SFBT for parental distress, the present study revealed that SFBT significantly improves parents’ level of hope, which has been shown in other SFBT studies (Reiter, 2010; Taathadi, 2014). Positive emotions (for example, hope) are important goals for SFBT and may potentially mediate the relationship between SFBT and other therapeutic outcomes (Kim & Franklin, 2015). The increase of hope in medical settings is important in helping patients cope with chronic conditions like CHD (Luyckx et al., 2014). It is recommended that the mediating effects of hope be investigated in future studies of SFBT and may offer significant implications for change mechanisms of SFBT as an effective treatment in health care social work. Somatization symptoms were also assessed in this study; however, SFBT was not superior to TAU in improving participants’ somatization subscores. Most empirical evidence supporting the effectiveness of SFBT has focused on internalizing disorders (for example, depression, anxiety) or social relational outcomes (for example, interpersonal relationship, family connectedness). To our knowledge, only one other study that was conducted in Latin America examined the relationship between SFBT and somatization (Schade, Torres, & Beyebach, 2011) and found a positive reduction in the symptoms. Somatization symptoms are often associated with internalizing disorders and have been reported to be an indicator of symptoms of depression for Asian ethnic groups (Sulaiman et al., 2014); this suggests that the effect of SFBT with somatization deserves further investigation in future studies. With that said, given the significant positive within- and between-group effect sizes favoring SFBT for somatization, it is possible that SFBT did have a meaningful effect on parents’ somatization, but this pilot study did not have enough statistical power to capture the difference as compared with TAU. Limitations This study has several limitations. First, service providers in the study were all master’s level interns. Although they all received ongoing training and supervision, lacking postgraduate experience may have compromised treatment fidelity. However, the fidelity assessment indicated that they implemented with good quality. Second, it was a pilot study with a small sample size. Thus, the study was statistically underpowered in detecting significance. However, because significant differences were found on two out of the three subscales on the BSI-18 and on the HHI, this shows potential for future effectiveness studies. In addition, no follow-up data were collected, thus limiting our ability to assess whether gains were maintained overtime. Finally, the study took place at only one hospital in Shanghai, thus limiting generalizability of the results. Future trials are encouraged to include providers who are more experienced, to have a larger sample size, and to include multiple hospital settings. Conclusion SFBT is a brief intervention that has promise for use in hospital settings to reduce the psychological distress of Chinese parents who have children with CHD. 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Efficacy of Solution-Focused Brief Therapy for Distress among Parents of Children with Congenital Heart Disease in China

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Oxford University Press
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© 2017 National Association of Social Workers
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0360-7283
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1545-6854
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10.1093/hsw/hlx045
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Abstract

Abstract Chinese parents of children with congenital heart disease (CHD) experience significant psychological distress due to the child’s illness and hospitalization. Unfortunately, there are few psychosocial interventions for parental distress in China. This pilot study aimed to examine the efficacy of solution-focused brief therapy (SFBT) in a Chinese hospital for parental distress using a randomized controlled trial design. The participants included 40 Chinese parents of a currently hospitalized child diagnosed with CHD who were assessed to have psychological distress. Parents were randomized into either the intervention (n = 25) or the hospital medical social work treatment as usual (TAU) (n = 28) group. The Chinese Brief Symptom Inventory-18 and Chinese version of Herth Hope Index were administered before and after the interventions. Results of the intent-to-treat analysis indicated a significant decrease in parental distress and increase in parents’ levels of hope in the intervention group compared with the TAU group. This study supported SFBT administered in a hospital setting as a promising intervention for reducing distress among Chinese parents with children diagnosed with CHD. hospital, parental distress, randomized controlled trial, solution-focused brief therapy Congenital heart disease (CHD) is among the world’s most common congenital defects (Dolk, Loane, & Garne, 2011), and its prevalence has increased by 11 percent in children from 2000 to 2010 worldwide (Marelli et al., 2014). In the United States, 1 percent of all children at birth suffer from CHD (Marelli et al., 2014); CHD’s prevalence in China is 7 percent among live births, which translates into 100,000 to 150,000 new cases annually (National Center for Cardiovascular Disease, 2006). The overall mortality rate caused by CHD had a 62.4 percent relative increase (114 to 229 per 10 million people per year) from 2003 to 2010 in China, with an even higher rate in rural areas (Hu, Yuan, Rao, Zheng, & Hu, 2014; F. Liu et al., 2015). Pediatric patients with CHD are among the most vulnerable patient populations and, other than the health care team, they almost exclusively depend on their parents during treatment and recovery. This puts considerable burden on their parents, who often face multiple psychosocial challenges, including high levels of psychological distress. Psychological distress is defined as “the unique discomforting, emotional state [like depression or anxiety] experienced by an individual in response to a specific stressor or demand . . . to the person” (Ridner, 2004, p. 539). Psychological distress is complicated by the fact that parents who are taking care of their child who has CHD have very limited resources for their own psychological well-being (J. Liu et al., 2011). Parents’ psychological distress affects their quality of life and limits optimal parenting and care during the treatment of their children (Hearps et al., 2013; Lawoko & Soares, 2006), and may even pose a threat to children’s quality of care and recovery. Intense parental distress contributes to poorer doctor–patient communication (Wei, Roscigno, Hanson, & Swanson, 2015), undermines the capacity of parental care (Latal, Helfricht, Fischer, Bauersfled, & Landolt, 2009), and may be detrimental to the parent–child relationship (Long & Marsland, 2011). The impact of psychological distress on parenting and patient care may further be associated with negative patient experience, greater likelihood of medical errors (X. Liu, Rohrer, et al., 2015), higher depressive symptoms, increased loneliness, and lower quality of life for CHD patients (Luyckx et al., 2014). This creates a need for social workers to provide psychosocial interventions and support to parents of CHD patients who experience psychological distress. Most Chinese parents, however, are unwilling to receive psychosocial interventions outside of the hospital while their child is hospitalized for treatment. For those who are willing to seek external psychosocial care, their options are limited as China’s mental health services system is still in the preliminary stages of development. Therefore, for parents to be receptive to psychosocial interventions for distress, these interventions need to be delivered in the hospital setting in which their child is receiving treatment. Whereas previous studies have established the importance of alleviating parental distress of CHD patients, research on interventions for parental distress is limited and even scarcer in China. A meta-analysis of Western literature (Donker, Griffiths, Cuijpers, & Christensen, 2009) revealed that psychoeducation can reduce symptoms of depression and psychological distress in various settings, but the effect size was small (d = 0.2). Two reviews (Meyer & Mark, 1995; Sheard & Maguire, 1999) of psychosocial interventions for adult oncology patients indicated the benefits of interventions for patients’ emotional adjustment (d = 0.24) and anxiety (d = 0.42). Another related and more relevant meta-analysis (Pai, Drotar, Zebracki, Moore, & Youngstrom, 2006) reported that psychological interventions seemed promising for parental distress in pediatric oncology settings (d = 0.35). Authors of these reviews indicated the importance of addressing common challenges when delivering psychosocial interventions in hospital settings. These challenges translated into three common characteristics for the interventions: (1) the necessity to be brief (Davis et al., 2013), (2) efficient and quick to establish a therapeutic alliance (Scott et al., 2008), and (3) a clinical process that uses a collaborative and patient-centered approach (Arean, Alvidrez, Barrera, Robinson, & Hicks, 2002). Unfortunately, studies have not focused on ways to incorporate these features into hospital interventions that can also address parental distress of children with CHD (Brosig, Whitstone, Frommelt, Frisbee, & Leuthner, 2007). In fact, all existing studies in China that addressed pediatric patients and their family members’ psychosocial well-being in hospitals were limited to case management and brief psychosocial supports mainly provided by nurses (for example, Chen, Zhang, Huang, & Wang, 2016; L. Wang, 2014). To our knowledge, only one study (Yang, Yang, Li, Li, & Tang, 2015) focused on anxiety of parents of pediatric patients with CHD in Chinese hospitals, and no studies specifically examined interventions aimed at reducing parents’ psychological distress. Therefore, there is a need for brief interventions that have potential to address these concerns (Yang et al., 2015). Given the prevalence of pediatric CHD in China and the importance of addressing parental psychological distress, it is essential for researchers and practitioners to work together to develop interventions that (a) can effectively target parental psychological distress, (b) are culturally competent to the Chinese population, and (c) are consonant with medical settings. Solution-focused brief therapy (SFBT) is an intervention that may meet all these requirements. SFBT SFBT is a strengths-oriented intervention that originated from brief family therapy and has received sufficient empirical support as potentially effective in addressing psychological distress (Franklin, 2015; Gingerich, Kim, Stams, & MacDonald, 2012). Theoretically grounded in constructivist approaches to communication and social interaction theories (de Shazer, 1991), the co-construction process of SFBT shifts and focuses clients’ attention to their existing resources and solutions. Consequently, the intervention increases positive expectancies and emotions, like hope and optimism, to address feelings of sadness, worry, fear, and other emotions that are central psychological components of depression and anxiety (Beck & Haigh, 2014). Over the past 10 years, several clinical trials have supported the effectiveness of SFBT for decreasing psychological distress (Franklin, 2012; Gingerich & Peterson, 2013), and two recent meta-analytical studies reported small effect sizes d = 0.24 (Schmit, Schmit, & Lenz, 2016) and d = 0.26 (Kim, 2008) for SFBT in the treatment of symptoms from internalizing disorders like depression and anxiety. Another recent meta-analysis reported a large treatment effect (d = 1.26, p < .001) for SFBT studies that had been conducted with Chinese populations (Kim et al., 2015), with the largest overall treatment effects of the studies reviewed having taken place in Chinese hospital settings (d = 0.94, p < .001) (Gong & Xu, 2015). More important, SFBT has been recommended for hospitals due to the consistency of its features with such settings (Burns, 2016). First, SFBT is brief and has been found to create positive therapeutic change within three to five sessions (Gingerich et al., 2012). Second, SFBT has been delivered in various practice settings with diverse client populations and has clinically been reported to be used in medical settings with satisfactory therapeutic relationships and with preliminary studies demonstrating its effectiveness (Franklin, 2015). In addition, SFBT takes a collaborative stance whereby clients set their own goals and are encouraged to take charge of their outcomes. This creates a patient-centered approach that is recommended for hospital settings (de Shazer et al., 2007). Finally, SFBT has been reported to be able to engage the least clinically cooperative clients (see, for example, Tohn & Oshlag, 1996; Trepper, Dolan, McCollum, & Nelson, 2006). These factors indicate the potential of SFBT to help in relieving distress of parents caring for a child with a severe illness. Furthermore, these characteristics alleviate common challenges in delivering psychosocial interventions in medical settings. This article reports on a pilot randomized controlled trial in a tertiary Chinese hospital that examined the effectiveness of SFBT in reducing distress among Chinese parents of children with CHD. This study tested the following two hypotheses: (1) SFBT intervention with distressed parents will be more effective than a hospital medical social work treatment as usual (TAU) in decreasing parental distress, depressive symptoms, level of anxiety, and somatization, and increasing parents' level of hope. (2) The between-group (SFBT versus TAU) treatment effect size will be significantly different, favoring SFBT. METHOD Study Setting, Eligibility, and Recruitment Study Settings The pilot study was led by the Department of Medical Social Work at Shanghai Children’s Medical Center (SCMC) affiliated with Shanghai Jiaotong University School of Medicine. The investigation was conducted at SCMC’s Department of Pediatric Cardiovascular Surgery and the Department of Cardiology. A medical social worker was assigned as the research coordinator for this study. The two departments have over 150 beds and a capacity of serving close to 4,000 patients with CHD yearly. Eligibility Eligible participants were at least 21 years old, and the primary parental caregiver of a pediatric patient with CHD who also met a gender-specific Brief Symptom Inventory-18 (BSI-18) cutoff score (>10 for male and >13 for female respondents) (Zabora et al., 2001). The treatment was a four-session intervention occurring over a minimum of 10 days after initial referral contact. Participants who did not have the capacity to give informed consent or who were unable to receive all four sessions were not eligible for study participation. Recruitment Procedures Study participants were obtained through three routes: (1) referral from physicians or nursing staff, (2) referral from the Department of Medical Social Work through daily rounds at the heart center, and (3) self-referral. Individuals who showed interest in participating were guided to the Department of Medical Social Work main office to provide informed consent. Parents referred into the study were screened using the BSI-18 Chinese version (J. Wang, Kelly, Liu, Zhang, & Hao, 2013). Based on its cutoff score, medical social workers identified eligible participants. The research coordinator subsequently met with each eligible participant in person to explain the study and the informed consent procedure. The study used a pretest–posttest design with random assignment. Eligible patients were randomized into either intervention or TAU groups. Random assignment was conducted using a computerized random number generator on the number of 100. Over the course of seven months, the research team contacted 92 participants. Twenty-eight participants refused to participate in the study when approached, and an additional 11 patients were excluded because they did not meet the minimum criteria for BSI-18 score at baseline, resulting in 53 being randomized (25 to the SFBT group and 28 to the TAU group). During treatment, seven participants dropped out of the SFBT group for various reasons and six participants dropped out of the TAU group, leaving 18 in SFBT and 22 in TAU (see Figure 1). Figure 1: View largeDownload slide : CONSORT Flowchart of Parent Recruitment Notes: CONSORT = Consolidated Standards of Reporting Trials; SFBT = solution-focused brief therapy; TAU = treatment as usual. Figure 1: View largeDownload slide : CONSORT Flowchart of Parent Recruitment Notes: CONSORT = Consolidated Standards of Reporting Trials; SFBT = solution-focused brief therapy; TAU = treatment as usual. Intervention Training Six graduate-level providers were trained by two trainers in SFBT. Both trainers are experienced licensed clinical social workers with an average of five years of clinical experience. A 16-hour intensive training on SFBT was offered on two separate days to the three SFBT providers. The training consisted of a four-hour session of teaching SFBT theories and applications, a four-hour session of didactic teaching and discussion of the Solution Focused Therapy Treatment Manual for Working with Individuals, 2nd Version (Solution Focused Brief Therapy Association [SFBTA], 2013), a four-hour session of observation of the trainer using SFBT with actual clients, followed by a four-hour session of student role play using SFBT. The three providers for the TAU or control group were blind to the experimental group intervention and received a 16-hour intensive training in general medical social work practice on two separate days based on SCMC’s existing medical social work services protocol. The training consisted of a four-hour session of teaching general medical social work practice; a four-hour session of didactic teaching and discussion of cognitive–behavioral therapy, client-centered practice, and case management; a four-hour observation session of the trainer using general practice with actual clients; and subsequently, a four-hour session of student role play using the general practice approach. Supervision and Fidelity Ongoing supervision was offered for all study providers. An SFBT trainer met with the three SFBT providers on a weekly basis to address any clinical issues encountered. With clients’ permission, the SFBT trainer randomly observed the client–social worker encounters behind a one-way mirror to ensure treatment fidelity. Similar arrangements were made for the TAU providers. During observation, the supervisor of the SFBT social workers used an evaluation form (available through contacting the corresponding author) of 10 criteria derived from the Solution Focused Therapy Treatment Manual for Working with Individuals (SFBTA, 2013). The supervisor rated each criterion from 1 = poorly performed to 10 = very well performed, with a total score from 10 to 100. Ten sessions of three providers observed had an average score of 72.3, which indicated satisfactory fidelity of SFBT. SFBT and TAU Interventions Participants in the SFBT group received four structured individual sessions of the intervention. In general, the intervention followed the manual (SFBTA, 2013). In the first session, providers started with building rapport with the client by using solution-oriented language and interview techniques (for example, solution talk, formula first session question, and pre-session change) to create an environment that can host a productive conversation. Later in the first session, providers closely followed the clients’ frame of reference and used future-oriented techniques (for example, miracle questions, “what if” questions, and goal-setting techniques) to develop treatment goals on which participants were willing to work and that were relevant to their psychological distress. In the second and third sessions, providers started by checking in with participants using various SFBT techniques (for example, scaling questions, coping questions, exception questions) to solicit progress or improvements made since the last meeting, specifically focusing on any success and resilience in coping with challenges. After checking in with clients, providers co-constructed solutions to solve participants’ ongoing psychological challenges, using SFBT techniques including miracle questions, coping questions, relational questions, and exception questions. The purpose of using these questions was to shift clients’ focus to their strengths and past positive coping strategies and to identify if and what they can do differently to further alleviate psychosocial challenges in caring for their child. By the end of sessions 2 and 3, participants had a plan or solution to an issue that they co-constructed with the provider and knew how to apply the solution. During the last session, providers checked in with the participants, informed them that it was the last session of the study, and offered resources if the participants wished to continue receiving services. The providers then reviewed and reinforced progress and solutions established so far and discussed with the participants ways to maintain their progress and continue to implement the solutions they co-constructed. Finally, a referral was made for those who wished to continue services. For those who wanted to discontinue, the providers checked to see whether participants had any unresolved concerns and then terminated the service. TAU paralleled the SFBT protocol and was based on the existing treatment protocol at the Department of Medical Social Work. Providers focused on assessing the nature of clients’ problem, building rapport, and collaboratively developing goals with the clients to alleviate parents’ emotional and psychological distress. The second and third sessions focused on emotional regulation or behavioral change, activation, or both, using a general practice approach that integrates cognitive–behavioral therapy and a client-centered approach. The fourth session was centered at ending the professional relationship and reinforcing progress made so far. The providers started the session by reviewing the treatment process with the participant, inviting the participant to reflect on the progress made so far and challenges that remained. Providers also discussed with the participants ways to maintain the progress made during the service. Providers asked if the participant was willing to continue service but not as part of the study. For those who wished to continue, a referral was made by the end of the session. Data Collection and Outcome Measures Baseline scores were obtained after parents consented, and the same scales were used at posttreatment two weeks after the baseline. Primary Outcome Parental distress was measured using the Chinese version of the BSI-18. BSI-18 is the most concise measure (Derogatis, 2001) of psychological distress and has been recommended for hospital settings (Carlson, Waller, & Mitchell, 2012; Christ, Messner, & Behar, 2015). BSI-18 is a shortened version of the previous BSI (53 items) (Derogatis, 1993), which contains three dimensions with six items each. The three dimensions are somatization (for example, nausea), depression (for example, feeling blue), and anxiety (for example, nervousness or shakiness inside). J. Wang et al. (2013) systematically tested the factorial structure of the Chinese version of the BSI-18 and supported using it with the Chinese population. The authors (J. Wang et al., 2013) were contacted and permission was granted for BSI-18's use in the present study. Participants rated each symptom on a five-point Likert scale ranging from 0 = not at all to 4 = extremely, with higher scores indicating greater levels of distress. The BSI-18 has demonstrated satisfactory validity (Andreu et al., 2008) and reliability (Recklitis et al., 2006). The scale had satisfactory internal consistency in the present study, with an overall Cronbach’s alpha of .94. Secondary Outcome Level of hope was measured by the Herth Hope Index (HHI) (Herth, 1992) Chinese version, which is a shortened form of the Herth Hope Scale (Herth, 1991). The HHI is a 12-item Likert scale ranging from 1 = strongly disagree to 4 = strongly agree. Negative items were reversed so that the total score ranged from 12 to 48, with higher scores indicating greater levels of hope. Previous studies reported satisfactory psychometric properties of HHI in medical settings (Haugan, Utvær, & Moksnes, 2013), and the Chinese version of HHI has been reported as being reliable and valid (Chan, Li, Chan, & Lopez, 2012, p. 2079). In this study, the scale was tested and found to have very good internal consistency, with an overall Cronbach’s alpha of .885. Power and Data Analysis Power analysis revealed that a total sample size of 84 was required to achieve 80 percent power to detect a medium effect size (f = .4) using fixed-effect analysis of covariance (ANCOVA) for two groups with an alpha level of .05. Because this is a pilot study, we followed Browne’s (1995) recommendation of a minimum of 30 participants. To increase the statistical power, ANCOVA was used for intervention outcome, with posttest score as the dependent variable, pretest score as the covariate, and treatment condition as the fixed factor. ANCOVA only tests whether the treatment condition is superior to the control but not the magnitude of treatment effect or the difference in the magnitude between groups. Therefore, within- and between-group treatment effect size (Hedges’ g) was calculated as recommended by Cooper, Hedges, and Valentine (2009). This study used intent-to-treat analysis for ANCOVA and Hedges’ g. To handle missing data for participants who did not complete posttreatment evaluation, this study used single imputation of group means recommended by Armijo-Olivo, Warren, and Magee (2009) when the proportion of missing data was low (22 percent in this study). This study was approved by the medical institutional review board of ethics at SCMC affiliated with Shanghai Jiaotong University School of Medicine. RESULTS Sample Description Participants’ demographic information including age, gender, marital status, education, and income were collected. However, most demographic variables had significant missing data and only age and gender of the primary parent caretaker were consistently reported. Parents who completed (n = 18) and dropped out of (n = 7) the SFBT intervention did not differ in average age (32.16 and 31.43, respectively) and gender (61.1 percent and 42.9 percent female, respectively). Similarly, the age and gender differences of parents in TAU between those who completed (n = 22) and those who dropped out (n = 6) were not significant: average age of 29.96 and 25.5, and 63.6 percent and 66.7 percent female, respectively. There were no significant differences in age and gender between SFBT and TAU group members. Parents’ baseline somatization score in the treatment group (M = 9.80, SD = 5.23) did not differ significantly from those in the TAU group (M = 8.11, SD = 5.83). However, parents in SFBT and TAU differed significantly in baseline scores of parental distress, depression, anxiety, and hope scores (see Table 1). Table 1: Comparison of Demographic and Baseline Evaluation between Completers and Dropouts, and between Groups Variable  Treatment Group  Within-Group Difference p  Control Group  Within-Group Difference p  Between-Group Difference p  Complete (n = 18) M (SD)  Dropout (n = 7) M (SD)  Complete (n = 22) M (SD)  Dropout (n = 6) M (SD)  Age  32.16 (6.23)  31.43 (4.43)  .778  29.96 (6.22)  25.5 (3.51)  .367  .116  Gender (female %)  61.1  42.9  .409  63.6  66.7  .891  .579  Parental distress  43.00 (13.10)  41.43 (10.21)  .779  33.95 (16.41)  35.00 (6.45)  .881  .029   Somatization  10.39 (5.84)  8.29 (2.98)  .378  8.41 (6.43)  7.00 (2.83)  .609  .273   Depression  15.22 (4.93)  14.29 (4.60)  .669  11.32 (6.19)  11.67 (5.24)  .901  .020   Anxiety  17.39 (4.17)  18.86 (5.84)  .387  14.23 (5.88)  16.33 (3.78)  .416  .031  Herth Hope Index  32.44 (4.71)  27.71 (7.52)  .070  38.96 (5.24)  36.00 (3.03)  .215  .000  Variable  Treatment Group  Within-Group Difference p  Control Group  Within-Group Difference p  Between-Group Difference p  Complete (n = 18) M (SD)  Dropout (n = 7) M (SD)  Complete (n = 22) M (SD)  Dropout (n = 6) M (SD)  Age  32.16 (6.23)  31.43 (4.43)  .778  29.96 (6.22)  25.5 (3.51)  .367  .116  Gender (female %)  61.1  42.9  .409  63.6  66.7  .891  .579  Parental distress  43.00 (13.10)  41.43 (10.21)  .779  33.95 (16.41)  35.00 (6.45)  .881  .029   Somatization  10.39 (5.84)  8.29 (2.98)  .378  8.41 (6.43)  7.00 (2.83)  .609  .273   Depression  15.22 (4.93)  14.29 (4.60)  .669  11.32 (6.19)  11.67 (5.24)  .901  .020   Anxiety  17.39 (4.17)  18.86 (5.84)  .387  14.23 (5.88)  16.33 (3.78)  .416  .031  Herth Hope Index  32.44 (4.71)  27.71 (7.52)  .070  38.96 (5.24)  36.00 (3.03)  .215  .000  Treatment Outcome Effect The results of within-group effect size, between-group effect size, and ANCOVA for the group differences on parental distress, depression subscore, anxiety subscore, somatization subscore, and HHI score are presented in Table 2. SFBT had large within-group effect sizes for all outcomes ranging from d = 0.59 (somatization) to d = 1.43 (anxiety). All effect sizes were statistically significant as evidenced by the 95 percent confidence intervals (CIs) not containing zero, which indicates significant improvements after receiving SFBT. In contrast, TAU only had significant within-group treatment effect for anxiety (d = 0.47, 95% CI [0.08, 0.86]) but insignificant effect sizes (not different from zero) for other outcomes. In addition, between-group effect sizes were statistically significant and favored SFBT for all outcomes ranging from d = 0.54 (somatization) to d = 1.43 (anxiety). This indicates that participants receiving SFBT had significantly greater improvements than those in TAU. Table 2: Results of Treatment Effect Sizes and Between-Group Comparison (ANCOVA) Outcome  Within-Group Effect Size [95% CI]  Between-Group Effect Size [95% CI]  F test (df = 1)  Parental distress    1.277 [0.908, 1.646]  16.526***   Treatment  1.273 [0.740, 1.805]       Control  0.378 [–0.001, 0.762]      Somatization    0.541 [0.245, 0.837]  2.623   Treatment  0.591 [0.165, 1.017]       Control  0.123 [–0.249, 0.495]      Depression    1.268 [0.895, 1.640]  12.877***   Treatment  1.273 [0.741, 1.806]       Control  0.309 [–0.070, 0.689]      Anxiety    1.434 [1.004, 1.864]  15.810***   Treatment  1.426 [0.864, 1.989]       Control  0.467 [0.077, 0.858]      Hope level    1.353 [0.918, 1.788]  4.989*   Treatment  0.821 [0.366, 1.277]       Control  –0.566 [–0.966, –0.166]      Outcome  Within-Group Effect Size [95% CI]  Between-Group Effect Size [95% CI]  F test (df = 1)  Parental distress    1.277 [0.908, 1.646]  16.526***   Treatment  1.273 [0.740, 1.805]       Control  0.378 [–0.001, 0.762]      Somatization    0.541 [0.245, 0.837]  2.623   Treatment  0.591 [0.165, 1.017]       Control  0.123 [–0.249, 0.495]      Depression    1.268 [0.895, 1.640]  12.877***   Treatment  1.273 [0.741, 1.806]       Control  0.309 [–0.070, 0.689]      Anxiety    1.434 [1.004, 1.864]  15.810***   Treatment  1.426 [0.864, 1.989]       Control  0.467 [0.077, 0.858]      Hope level    1.353 [0.918, 1.788]  4.989*   Treatment  0.821 [0.366, 1.277]       Control  –0.566 [–0.966, –0.166]      Notes: ANCOVA = analysis of covariance; CI = confidence interval. All results reported were based on intent-to-treat analysis. *p < .05. ***p < .001. ANCOVA revealed that parents receiving SFBT had significantly lower parental distress (F = 16.53, p < .001), symptoms of depression (F = 12.9, p < .001), and anxiety (F = 15.81, p < .001) and higher level of hope (F = 4.99, p < .05) postintervention. Although SFBT was not superior to TAU in reducing parents’ somatization (F = 2.62, p = .11), both the within- and between-group effect sizes for somatization were significant, supporting the meaningful improvements in somatization for parents who received SFBT. DISCUSSION This pilot study examined the effectiveness of SFBT within a hospital setting for reducing psychological distress of Chinese parents whose children have CHD. There are currently no empirically supported treatments for working with Chinese parents whose children have CHD, and this study is the first one to examine the use of SFBT on the distress of parents of children with CHD. Consequently, this study is particularly significant to the treatment of parents who face the diagnosis of CHD in their children. CHD is a condition that has worldwide significance and a high prevalence rate among pediatric patients in China (X. Liu, Liu, et al., 2015; Marelli et al., 2014). The development of effective interventions is important to health care social workers and other health professionals who provide support and mental health treatment to distressed parents whose children suffer from CHD. Overall the findings of the study supported the effectiveness of SFBT in a hospital setting with Chinese parents and laid the foundation for future studies on the SFBT intervention with parents who experience distress due to having a child with CHD. In particular, this study suggests that SFBT is superior to TAU in alleviating depression and anxiety in Chinese parents and in increasing their hope as indicated by assessments on standardized measures. The effect sizes for SFBT were 1.27 and 1.43 for depression and anxiety, respectively, indicating large treatment effects (Cohen, 1988) of SFBT for parental distress. Franklin (2015) reported that literature is accumulating to suggest that SFBT may be a culturally competent and effective intervention for the Chinese population, and this study provides additional evidence. These findings are also consistent with other outcome studies that have been conducted in North America and China showing that SFBT is effective with internalizing disorders within medical and mental health settings (for example, Kim et al., 2015; Schmit et al., 2016). Other studies have shown that the effect sizes of SFBT with internalizing disorders has ranged from small to large (Kim, 2008; Kim et al., 2015; Schmit et al., 2016). It is noteworthy that larger effect sizes have been achieved in China as compared with other countries (Kim et al., 2015); this study achieved similarly promising results, adding support to the applicability and effectiveness of SFBT with Chinese parents of children with CHD. Beyond the overall significant treatment effect of SFBT for parental distress, the present study revealed that SFBT significantly improves parents’ level of hope, which has been shown in other SFBT studies (Reiter, 2010; Taathadi, 2014). Positive emotions (for example, hope) are important goals for SFBT and may potentially mediate the relationship between SFBT and other therapeutic outcomes (Kim & Franklin, 2015). The increase of hope in medical settings is important in helping patients cope with chronic conditions like CHD (Luyckx et al., 2014). It is recommended that the mediating effects of hope be investigated in future studies of SFBT and may offer significant implications for change mechanisms of SFBT as an effective treatment in health care social work. Somatization symptoms were also assessed in this study; however, SFBT was not superior to TAU in improving participants’ somatization subscores. Most empirical evidence supporting the effectiveness of SFBT has focused on internalizing disorders (for example, depression, anxiety) or social relational outcomes (for example, interpersonal relationship, family connectedness). To our knowledge, only one other study that was conducted in Latin America examined the relationship between SFBT and somatization (Schade, Torres, & Beyebach, 2011) and found a positive reduction in the symptoms. Somatization symptoms are often associated with internalizing disorders and have been reported to be an indicator of symptoms of depression for Asian ethnic groups (Sulaiman et al., 2014); this suggests that the effect of SFBT with somatization deserves further investigation in future studies. With that said, given the significant positive within- and between-group effect sizes favoring SFBT for somatization, it is possible that SFBT did have a meaningful effect on parents’ somatization, but this pilot study did not have enough statistical power to capture the difference as compared with TAU. Limitations This study has several limitations. First, service providers in the study were all master’s level interns. Although they all received ongoing training and supervision, lacking postgraduate experience may have compromised treatment fidelity. However, the fidelity assessment indicated that they implemented with good quality. Second, it was a pilot study with a small sample size. Thus, the study was statistically underpowered in detecting significance. However, because significant differences were found on two out of the three subscales on the BSI-18 and on the HHI, this shows potential for future effectiveness studies. In addition, no follow-up data were collected, thus limiting our ability to assess whether gains were maintained overtime. Finally, the study took place at only one hospital in Shanghai, thus limiting generalizability of the results. Future trials are encouraged to include providers who are more experienced, to have a larger sample size, and to include multiple hospital settings. Conclusion SFBT is a brief intervention that has promise for use in hospital settings to reduce the psychological distress of Chinese parents who have children with CHD. 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It’s your single place to instantly
discover and read the research
that matters to you.

Enjoy affordable access to
over 12 million articles from more than
10,000 peer-reviewed journals.

All for just $49/month

Explore the DeepDyve Library

Unlimited reading

Read as many articles as you need. Full articles with original layout, charts and figures. Read online, from anywhere.

Stay up to date

Keep up with your field with Personalized Recommendations and Follow Journals to get automatic updates.

Organize your research

It’s easy to organize your research with our built-in tools.

Your journals are on DeepDyve

Read from thousands of the leading scholarly journals from SpringerNature, Elsevier, Wiley-Blackwell, Oxford University Press and more.

All the latest content is available, no embargo periods.

See the journals in your area

Monthly Plan

  • Read unlimited articles
  • Personalized recommendations
  • No expiration
  • Print 20 pages per month
  • 20% off on PDF purchases
  • Organize your research
  • Get updates on your journals and topic searches

$49/month

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14-day Free Trial

Best Deal — 39% off

Annual Plan

  • All the features of the Professional Plan, but for 39% off!
  • Billed annually
  • No expiration
  • For the normal price of 10 articles elsewhere, you get one full year of unlimited access to articles.

$588

$360/year

billed annually
Start Free Trial

14-day Free Trial