Summary: 20.3.
• Identification of risk factors and protective
factors, and vulnerability and risk factors are
important to
Summary
– select target populations
– to select target variables to induce change
• (How) can we manipulate these factors?
– Which factors are stable, which unstable?
– Can we control unstable factors?
• How can we control unstable factors?
• How can we adapt to these conditions?
– 1st or 2nd order change/adaptation
Summary: 20.3.
Summary
changeable
yes
direct influence
no 
frequent?
no  passivity,
palliation
Control?
Causal
Factors
unchangeable
yes 
accommodation
Summary: 20.3.
• Important concept:
– Stressful events or conditions (psychology)
– Noxious Factor / Condition /Force
Summary
• Life event research:  quantification of risk
• Background: Crisis model
– If basic resources are present: adequate functioning
(irrespective of constitution)
– If stressors occur, deplete resources: functioning
drops
• constitution sustains functioning
• chronic stress: constitution deteriorates
– Preventive interventions can target several
components of crisis model
•  diathesis-stress model
Etiological Background
Vulnerability – Stress – Model
(Diathesis – Stress – Model)
Mechanisms
Stressor
Vulnerability
Strain
Disorder
Psychological applications:
… some stress theory…
Stressors, Strain, Stress: Crisis and Critical Events
• Stressful events are called stressors
Mechanisms
•
•
•
•
•
•
extreme sensations (light, noise, pain)
crowding, limited space
dysfunctional relationships
social evaluation
traffic
psychologically: threat!
• stressors are stressful to some, but not all
people
• the perception of an event determines
whether it is a stressor
Stressors, Strain, Stress: Crisis and Critical Events
Mechanisms
• Stress is a state of tension caused by
stressors and exerting strain on the
individual
• Stress is a negative emotional experience
accompanied by predictable
–
–
–
–
–
biochemical changes
physiological changes
cognitive changes, and
behavioral changes
that are directed either toward altering the
stressful event or accommodating to its effects
e.g., Lazarus, 1999; Taylor, 2006
Stressors, Strain, Stress: Crisis and Critical Events
• Strain is the change in the system that arises
from a state of stress
• Strain itself does not describe the force
acting on the individual
Mechanisms
stressor
stress
behavior/response
strain
e.g., Lazarus, 1999; Taylor, 2006
Psychological Stress Process (Lazarus)
• Lazarus (e.g. 1983), and other emotion
scholars (e.g., Arnold, 1969) adopted
transactional perspectives on the stress
process:
Environment
Person
primary: event significant?
secondary: can I deal with it?
Mechanisms
Appraisals
Stressor
Emotions
Behavior
(simplified model)
e.g., Lazarus, 1999; Taylor, 2006
Transactional Stress Process: Person and Environment
Mechanisms
Personal
Resources
Can I meet
demands?
Stress
Threatening
Environment
• Person-Environment-Fit
great stress= negative emotions, acute
and strong response
little stress = challenge
• Appraisals play a critical role:
– provide behavioral flexibility and economy
• (coping vs. emotion regulation; save energy)
– automatic and controlled
e.g., Lazarus, 1999; Taylor, 2006
Transactional Stress Process: Behavior
• response to perceived threat (Walter Cannon
(1932)):
Mechanisms
– sympathetic nervous system and endocrine
system aroused
– Fight: aggressive stress response ( primary
control)
– Flight: evasive stress response ( secondary
control): withdrawal, drugs, alcohol
– perceived control, power plays a role!
• adaptive: Allows quick response to threat
• problematic: Can cause problems on the long
term
e.g., Lazarus, 1999; Taylor, 2006
Transactional Stress Process:
Selye’s General Adaptation Syndrome
Three Phases in reacting to a stressor
2. Resistance
Mechanisms
1. Alarm
Stressor
3. Exhaustion
time
e.g., Lazarus, 1999; Taylor, 2006
Transactional Stress Process: Social Behavior
Mechanisms
• Extension to the fight-flight model: Social
Stress Regulation (S. Taylor: „tend and
befriend“)
– f-f is often useful: increases control  protection
– but: not the only way to increase control and
protection
– affiliation as a stress-reponse: joint protection in
threatening times
– perceived relational gap  signals threat 
affiliation  reduces stress response
– oxytocin plays probably a critical role, gender
difference
e.g., Lazarus, 1999; Taylor, 2006a, 2006b
Psychological Stress Process: Implications for Prevention?
• On a psychological level, all elements of the
stress process are important targets of
intervention
Mechanisms
–
–
–
–
Stressor
Appraisals
Emotions
Behaviors (coping, problem solving)
– Social integration, affiliation
e.g., Lazarus, 1999; Taylor, 2006a, 2006b
Intervention types
on the background of a diathesis-stress perspective
Moderator Concepts: Critical Questions
• Diathesis Stress Model: Vulnerability and
Resilience as Guidelines
• how can we identify vulnerability, resilience?
• post hoc
• from others: correlational research
• theoretical work
Mechanisms
– what causes/promotes vulnerability?
• Can we influence vulnerability/resilience?
• Can we influence exposure?
Stressor oriented Interventions
Strategies targeting Stressors
• Which preventive interventions can serve to
reduce stressors?
– prevent stressors from occurring, reduce stressor
strength
• fight
• e.g., teach parents educational techniques
– avoid stressors, reduce stress exposure
• flight
• e.g., lock away sexual offenders
Strategies targeting Vulnerability and
Resources
Vulnerability and Resilience oriented Interventions
• Which preventive interventions can serve to
strengthen resilience or reduce vulnerability?
– preserve and maintain resources
• broad approach, diversity is relevant
• e.g., maintain access to social contacts or intellectual
stimulation in elderly
– build new resources
• broad or problem specific
• e.g., teach parenting skills, provide knowledge
– replace vulnerabilities by newly acquired resources
• specific to identified problem area
• e.g., replace ruminative thoughts with positive emotion
regulation skills
– can focus on individual or environment!
Strategies targeting Vulnerability and
Resources
Vulnerability and Resilience oriented Interventions
• Which preventive interventions can serve to
strengthen resilience or reduce vulnerability?
– repair! vulnerability can be a result of a
nocive/degenerative process
• e.g.: children develop vulnerability to anxiety and
depression, partially due to overprotective parenting
– the actual vulnerability is rooted in dysfunctional
cognitive schemas (e.g., the world is dangerous, you
need protection to be safe, …)
– repairing those schemas reduces vulnerability
• e.g.: couples develop dysfunctional problem solving
dynamics
Important prevention strategies and Designs
Person- vs. Context centered strategies
Strategies and Desings
• When are person-centered strategies
appropriate?
• When are context- or system-centered
strategies appropriate?
key question: where‘s the risk?
High risk for a person?
Risk for many persons?
Person- vs. Context centered strategies
• When are person-centered strategies
appropriate?
Strategies and Desings
– A few individuals at high risk
– behavior change is cost-effective and efficient
Person- vs. Context centered strategies
Strategies and Desings
• When are person-centered strategies
appropriate?
• When are context- or system-centered
strategies appropriate?
– many individuals at „some“ risk
– problem and/or risk influenced by context or
system factors
– consequences of problems  high overall costs
Principle 1
We want to maximize overall risk reduction!
Risk
• Different risk perspectives:
– absolute risk
– relative risk
Strategies and Desings
• Absolute risk
– point of reference  population
– standardized vs. unstandardized AR
• Relative risk
– Point of reference theoretically relevant factors:
exposure to relevant condition;
– Comparative parameters
Risk – the importance of adopting a broad view
• if risk is critical – which aspect of risk?
Strategies and Desings
• what is the „extra“ risk
– or in other words: which aspect of risk shall we
consider as acceptable, and which aspect shall
we consider as target?
• attributable risk: which „portion“ of the risk
is attributable to the exposure to known riskconditions
– risk-ratio (or difference) / population frequency
Attributable risk
• How many are exposed? How many of those
are concerned?
Strategies and Desings
– 100 cases 0f 1000 exposed = 0.1
– 1000 cases of 100‘000 unexposed= 0.01
– the relative risk is...?
• .1 / .01 = 10
• OR = (.1/.9) / (.01/.99) = .11 / .0101 = 10.89
– and the attributable risk is...?
• .1 - .01 = .09
• .1-.01/.1= .09/.1 = .9 x 100 = 90%
Attributable risk
• For individual: subjective, individual absolute
and relative risk is critical!
Strategies and Desings
• From a public perspective, the risk that is
attributable to a certain factor is critical!
Principle 2
We want to maximize the change caused by our
intervention
Which Methods are indicated?
1.Behavior Change
• Goals and characteristics of target
individuals are crucial
• Maccoby & Solomon (1981)
– Requirements for change:
•
•
•
•
•
•
Awareness
Knowledge
Motivation
Skills
Implementation
Maintenance
Which Methods are indicated?
1.Behavior Change
• Prochaska & Di Clemente, 1983, 1989:
Stages of Change
– Precontemplation (stage 1)
•
•
•
•
Denial, ignorance
 encourage individal to reflect behavior
 encourage introspection
 raise awareness of risk
Which Methods are indicated?
1.Behavior Change
• Prochaska & Di Clemente, 1983, 1989:
Stages of Change
– Contemplation (stage 2)
•
•
•
•
Ambivalence, internal conflict, confusion
 consider pros and cons of initiating change
 encourage confidence in ability to induce change
 identify obstacles, barriers
Which Methods are indicated?
Behavior Change
• Prochaska & Di Clemente, 1983, 1989:
Stages of Change
– Preparation (stage 3)
•
•
•
•
Experiment, try to induce change
Collect information about change
 define goals
 plan action
Which Methods are indicated?
Behavior Change
• Prochaska & Di Clemente, 1983, 1989:
Stages of Change
– Action (stage 4)
• Take direct action
• Reward successes
• Seek social support
Which Methods are indicated?
Behavior Change
• Prochaska & Di Clemente, 1983, 1989:
Stages of Change
– Maintenance (stage 5)
• Maintain new behavior
• Avoid, learn how to deal with temptation!
Which Methods are indicated?
Behavior Change
• Prochaska & Di Clemente, 1983, 1989:
Stages of Change
– Relapse (stage 6)
• Find triggers of relapse, and bareers to success
• Reaffirm committment to change
Strategies to initiate change
Behavior Change
• Goal
– awareness of
problem
– motivation
– social
reinforcement
– behavior training
– context control
• Strategy
– facts, information,
insight
– communication,
counseling
– group discussions
– behavior training
– change
environment, laws
etc.
Strategies
• Information
Behavior Change
– Awareness
– Skills
• Counseling
– Education (procedural knowledge)
– Skills
– Motivation
• Training
– Exercise, role play, mental training
• System-related interventions
• Crisis- Intervention
– Stabilize, strengthen (skills), mobilize resources
Perrez & Hilti, 2005
Research: Evaluation
Evaluation: Research Questions
• Planning of preventive interventions
– What causes risk?
• Implementation of preventive interventions
Evaluation
– How can I establish change?
• Evaluation of preventive interventions
– Does intervention change factors?
– Does intervention reduce risk?
• Evaluation of Efficacy
Schwarzer, 2002
Evaluation of Efficacy: Research Requirements
• Scientific application of preventive
intervention requires
Evaluation
– Etiological knowledge
– Technological knowledge
• Why is it not enough to assess whether an
intervention reduces risk (incidence)?
Schwarzer, 2002
Evaluation: additional evaluation goals
• Acceptance?
• Cost-effectiveness?
Evaluation
EVALUATION GOALS
• Prior to intervention
– Program development, prospective evaluation goals
(what are goals? What is relevant? What are risk
groups?): interviews, case studies, surveys
• During intervention
– Process research : are interventions implemented
according to plans (manuals)?
• After intervention
– Outcome evaluation: Efficacy, differential efficacy
(with respect to outcomes, risk groups)
Schwarzer, 2002
Evaluation: study designs
• Usually: field experiments
• quasi-experimental designs
Evaluation
• Problematic:
– Control groups…
– Complexity of interventions, criteria
– Description and definition of success/change
(Rossi et al., 2003)
Evaluation of change
• Controlled trials
Evaluation
–
–
–
–
–
Non-treatment controls
Waiting-controls
Randomization
Alternative treatments
Do controls allow for a valid comparison?
• Pre-post desings
• Longitudinal measurements
Evaluation of change: longitudinal approaches
• How many measurements?
pre
post
FU
Evaluation
• How to assess change?
t1
t2
t3
t1
• What is significant change?
– Effect size?
– Condition?
– Costs?
t2
t3
Process evaluation models
• Mediation?
– Intervention  change in factor  change in risk
Evaluation
• Moderation
– Change in factor  change in stress-distress association
– Change in factor  change in stress-strain association
– Change in factor  change in stress-response association
• Mediated Moderation
– Intervention  change in factor change in stressdistress association