Time-Limited Dynamic Psychotherapy as a Model for Short-Term Inpatient Groups

The present article proposes a method, practiced by the author, to adapt time-limited dynamic psychotherapy (TLDP), a short-term individual psychodynamic therapy, for use with inpatient psychotherapy groups. Characteristics of TLDP which suggest the usefulness of such an adaptation, including short-term duration, specific treatment focus, rapid conceptualizations and broad selection of patients, and emphasis on the here-and-now in therapy, are discussed. The general approach to treatment, a supportive stance that involves an identification of maladaptive interpersonal issues, and then working on these issues without directly confronting the patients, is described. Specific therapeutic techniques for common inpatient group situations are also discussed.     

Theorietreue und Variationen

Interventional techniques can be integrated into inpatient group psychotherapy. Our approach is not meant to be a wild eclecticism but an empirically founded interventional repertoire that contains psychoanalytical, depth psychological, behavioral and hypnotic therapeutic interventions. A “uniform solution” for an integrative therapy is not possible. A tension between theory conformity and variations remains inherent to psychotherapy for a multitude of reasons. An interventional repertoire is illustrated by case examples which use operationalized psychodynamic diagnostics (OPD). The results must be appraised within the time frame of inpatient treatment. The conception in guideline psychotherapy that the individual approaches cannot be mixed because they would lose their effectiveness, does not correspond to our experiences. The chances and risks of switching interventions must be considered.     

A dynamic/expressive approach to brief inpatient group psychotherapy

Therapeutic action occurs in groups when patients simultaneously become more accepting of their own thoughts and feelings and increase their capacity to share more benign and mature interpersonal relationships with the therapist and other patients. This orientation can guide practitioners of brief inpatient group psychotherapy in choosing when to use interpersonal, problemsolving, or object relations techniques, or more traditional dynamic/expressive techniques. While the brief inpatient modality requires an increase in suppressive techniques compared to the longterm outpatient modality, suppression must be used judiciously, to facilitate rather than interfere with selfunderstanding and development of therapeutic relationships. Specific technical choices are derived from this principle and illustrated with a case example.     

Clinical Validity of Prototype Personality Disorder Ratings in Adolescents

A growing body of research shows that personality pathology in adolescents is clinically distinctive and frequently stable into adulthood. A reliable and useful method for rating personality pathology in adolescent patients has the potential to enhance conceptualization, dissemination, and treatment effectiveness. The aim of this study is to examine the clinical validity of a prototype matching approach (derived from the Shedler Westen Assessment Procedure–Adolescent Version) for quantifying personality pathology in an adolescent inpatient sample. Sixty-six adolescent inpatients and their parents or legal guardians completed forms of the Child Behavior Checklist (CBCL) assessing emotional and behavioral problems. Clinical criterion variables including suicide history, substance use, and fights with peers were also assessed. Patients’ individual and group therapists on the inpatient unit completed personality prototype ratings. Prototype diagnoses demonstrated substantial reliability (median intraclass correlation coefficient =.75) across independent ratings from individual and group therapists. Personality prototype ratings correlated with the CBCL scales and clinical criterion variables in anticipated and meaningful ways. As seen in prior research with adult samples, prototype personality ratings show clinical validity across independent clinician raters previously unfamiliar with the approach, and they are meaningfully related to clinical symptoms, behavioral problems, and adaptive functioning.     

Evaluation of the Computerized Assessment System for Psychotherapy Evaluation and Research (CASPER) as a measure of treatment effectiveness with psychiatric inpatients

Assessment procedures to evaluate inpatient treatment effectiveness can provide information to inform clinical practice. The Computerized Assessment System for Psychotherapy Evaluation and Research (CASPER) represents a standardized approach to assess patients' target problems that combines elements of individualized and nomothetic approaches. Although previous evaluations of CASPER with other patient populations have been encouraging, its use as a measure of change with an inpatient population has not been examined. In this study, 75 psychiatric inpatients completed CASPER and the Behavior and Symptom Identification Scale-32 (BASIS-32) at hospital admission and discharge. Results supported the concurrent validity of CASPER as a measure of pre- and posttreatment functioning and suggested that CASPER may provide a sensitive measure of change during inpatient treatment. Findings also supported the notion that patients' ratings of the extent to which their treatment focused on the problems they identified as a high priority were related to their overall treatment satisfaction.     

Large groups in treatment and training settings

A review of published work over the past decade and a half supports the effectiveness of the large group in clinical settings. Greater sophistication among practitioners has led to combining administrative, psychotherapeutic, and sociotherapeutic large groups and to the use of effective treatment teams and clearly defined contracts in inpatient hospital work. Some research findings suggest that large treatment groups are as effective as small therapy groups with some patient populations. There appears to be a movement toward convergence in the techniques employed by individual, small group, and large group therapists in practice, while not in theory. This positive trend in the mental health field may lead to more flexible practitioners.He is also on the board of the A. K. Rice Institute and a faculty member of the Cincinnati Psychoanalytic Institute. He would like to thank Walter Stone and Peter Herr for their comments and Lorna Volk for editing.     

Kombination von Settings und Verfahren in der Psychotherapie

Literature research and own clinical experiences confirm the significance of a combined use of settings and methods in the area of inpatient and outpatient psychotherapy. For inpatient treatment, the combined use of methods, such as individual psychotherapy, group therapy, creative therapies, and sport, are an essential part of the treatment. In outpatient treatment, the regulations of the German insurance do not permit such combinations. Nevertheless, they occur and are often proactively initiated by the patients. The various combined use of psychotherapy and psychotropics is very well studied, but also the combination of settings, i.e. supplementary inpatient treatment, day treatment, and outpatient treatment have to be considered. While administering their therapies, psychotherapists should keep in mind possibly concurrently ongoing treatments as well as former therapies and their effects on the patients. With the exception of combinations with psychotropic treatment, there exist almost no empirical data in this important field.     

Clinical,Studies in Psychiatry by H. S. Sullivan

A structured group therapy approach for psychiatric inpatients is presented. After reviewing the literature indicating that insight-oriented approaches are not effective with severely disturbed patients, the data supporting an interpersonal, cognitive, problem-solving approach with such patients is reviewed. A rationale for combining this cognitive problem-solving approach and Yalom's interpersonal approach with psychiatric inpatients is then presented. This structured group therapy approach, called the problem-solving support group (PSSG) is discussed, defining the nature and composition, screening procedures, methods, and techniques of the PSSG. Its use with psychiatric patients is illustrated by therapy protocols depicting the nature of the therapeutic interactions during the group, while also demonstrating what the group appears to be accomplishing for its members.     

Insight-oriented group psychotherapy of latency-age children in an acute care setting

Traditional approaches to group therapy with latency-age children have stressed activity and nonverbal therapeutic interventions. These approaches originated in the 1940s with Slavson's activity aroup therapy. A review of the literature of the past 25 years reveals that many clinicians have increasingly employed verbal techniques with latencyage groups. Most such reports describe groups for latency-age out-patients. In this paper, a verbal, interpretive technique for group therapy with latency-age inpatients is described. Clinical vignettes are included to illustrate this technique. Our experience suggests that such a technique can become an integral part of the inpatient treatment program for the latency-age child.     

Voices from the Inaudible: The Patients Speak by Theodor Reik

Fifty-one inpatients, hospitalized on average for 21 days, were studied by means of discharge debriefing interviews. An unstructured, mandatory, and functionally heterogeneous psychotherapy group was compared with a structured, voluntary, and functionally homogeneous psychotherapy group. Statistical analysis of the patients' valuation of the group psychotherapy experiences and of their rankings of traditional group psychotherapy curative factors were performed. Results demonstrated that group psychotherapy was a highly valued component of the overall inpatient treatment. Structural modifications aimed at increasing the here and now, and interpersonal focus of the group meetings, such as the use of patient agendas and group rehashes, significantly affected the patients' group experiences. A comparison of both types of inpatient groups with an outpatient group psychotherapy sample suggests certain guidelines for the goal setting and conduct of inpatient group psychotherapy, recognizing the specific and heterogeneous needs and capacities of the patients treated.     

Announcement

Abstract

Empathy has consistently been identified as an important quality of psychotherapists. Understanding unique ways that empathy emerges in group therapy may assist group therapists in fostering empathy. Rogerian and selected psychodynamic and interpersonal perspectives on empathy are discussed. Group psychotherapy poses a challenge for empathic responding, but also a rich opportunity for utilizing a more varied embodied approach to empathy.     

„Cognitive Behavioral Analysis System of Psychotherapy“

There are a number of evidence-based methods of psychotherapy for the treatment of depression but most treatment approaches have shown low or moderate success in the subgroup of chronic depression (duration >?2 years) as compared to episodic depression. This could be related to a higher rate of early trauma and specific deficits in cognitive and interpersonal functioning within this group of patients. James McCullough has developed a psychotherapeutic approach known as cognitive behavioral analysis system of psychotherapy (CBASP) specifically for chronic depression to overcome these deficits. In CBASP early negative experiences are associated with current interpersonal problems and a systematic relearning process is initiated. The approach integrates behavioral, cognitive and interpersonal strategies. The CBASP approach is empirically supported by study results and has shown to be effective in both inpatient and outpatient settings. This article presents the development of the approach and therapeutic strategies as well as techniques of CBASP are described.     

Predicting Response to Intensive Multimodal Inpatient Treatment: A Comparison of Single- and Multiple-Class Growth Modeling Approaches

In a modest body of research, personality functioning assessed via performance-based instruments has been found to validly predict treatment outcome and, to some extent, differential response to treatment. However, state-of-the-science longitudinal and mixture modeling techniques, which are common in many areas of clinical psychology, have rarely been used. In this article, we compare multilevel growth curve modeling (MLM) and latent class growth modeling (LCGM) approaches with the same data set to illustrate the different research questions that can be addressed by each method. Global Assessment of Functioning (GAF) scores collected at 6 points during the course of a long-term multimodal inpatient treatment of 58 severely and persistently mentally ill adults were used to model the trajectory of treatment outcome. Pretreatment Rorschach-based markers of personality functioning and other markers of psychiatric severity were examined as covariates in each modeling approach. The results of both modeling approaches generally indicated that more psychologically impaired clients responded less favorably to treatment. The LCGM approach revealed 2 unique trajectories of improvement (a persistently low group and a higher starting, improving group). Personality functioning and baseline psychiatric variables significantly predicted group membership and the rate of change within the groups. A side-by-side examination of these 2 methods was found to be useful in predicting differential treatment response with personality functioning variables.     

A time-limited dynamic approach to adolescent inpatient group psychotherapy

In response to sharply curtailed lengths of stay of adolescents in an inpatient psychiatric program, new therapeutic modalities need to be implemented. A time-limited dynamic approach to adolescent inpatient group psychotherapy is presented. The model integrates psychoanalytic and crisis theory into a group format. The primary focus in this model is upon resolution of problematic interpersonal interactions as they are related to the current crisis state. The group process, as related to the adolescent, involves three phases. These include an initial intake phase, which incorporates an ego-functioning assessment; a second or middle phase which focuses on making actions ego-alien; and the termination phase, which incorporates the learning experience and how it relates to the resolution of precipitators of the admission.     

The Therapeutic Community Sing: Music Therapy Inpatient Group Process

Early psychoanalytic authors and music educators in both Europe and the United States pointed to the contemporary use of music therapy as a powerful modality in an inpatient psychiatric unit. The inpatient community sing is discussed in its capacity to address both individual and group goals. A clinical vignette from such a group is presented and discussed.     

Inpatient Brief Group Therapy for Anorexia Nervosa: Patient Experience

There is increasing interest in group therapy for the treatment of eating disorders. However, there is a lack of research evaluating group therapy that reflects on patient feedback in order to inform practice and improve treatment. This exploratory qualitative study attempted to evaluate patient feedback about the group therapy offered on a specialist inpatient eating disorders program. This qualitative analysis of patients’ feedback highlights areas for improvement that can be targeted to increase the effectiveness of the psychotherapy groups in the future. The research has implications for making inpatient hospitalization more effectively tailored to patients’ needs. This study also helps to improve qualitative research protocols.     

Prospective payment: its impact on psychology's role in health care

This article describes the new Medicare payment system based on diagnosis-related groups (DRGs) and its impact on professional psychology. DRGs represent medically oriented notions about how many inpatient days a prudent physician needs to effectively treat a patient who suffers from a specified disease. However, for the most part, DRGs ignore the behavioral variables that moderate entry into the tertiary care system and the subsequent use of hospital resources. Under DRGs, the development and use of behavioral treatments for somatic disorders could be discouraged. For example, many newer behavioral medicine techniques may be more time-consuming and/or expensive than traditional treatment options (e.g., bed rest vs. biofeedback for low back pain) and thus not fall within the time period or "trim points" alloted for such disorder, regardless of comparative effectiveness. Also, under the new system, psychologists can no longer bill separately for their inpatient services. It is argued that the framers of health care policies should recognize and support health psychologists in light of the fact that many of their techniques can reduce the cost and consumption of health care through programs that: reduce behavioral risk factors, increase compliance with medical regimens, and prepare patients psychologically for stressful medical procedures.     

Multiple-family group treatment of outpatients with schizophrenia: impact on service utilization

The impact of multiple-family group treatment (MFGT) on outpatient and inpatient mental health service utilization of 97 persons with schizophrenia was investigated. Participants were randomly assigned to standard care (n = 44) or standard care plus MFGT (n = 53). Service use for a year prior to randomization, the 2-year study period, and a 1-year follow-up were examined. Relative to standard care participants, the MFGT group had reduced community hospitalization during year 1 of the intervention and reduced state hospitalization at follow-up. During the intervention period, MFGT participants demonstrated a significant increase in outpatient utilization as a direct consequence of the intervention. However, when service use was summed across 3 years post-randomization, no group differences were observed. Results suggest that implementation of MFGT in a community mental health setting reduces inpatient service at specific time periods, without significantly increasing outpatient service utilization. These findings add to other outcomes from this study that demonstrate decreased psychiatric symptoms and caregiver distress.     

Group therapy in Leningrad

The author traces the development of group therapy in the Soviet Union based on a review of the literature and his experiences in Leningrad as a Faculty Exchange Scholar. Although early approaches used hypnotherapy and educational techniques, the Bolshevik revolution introduced the concept of the collective, which subsequently influenced group therapy. Recently, personality-focused models and approaches similar to those in the West have been advocated, especially at the Bekhterev Institute in Leningrad. The author describes his experiences supervising two Soviet clinicians who coled a therapy group for inpatient schizophrenics using techniques he developed in the United States.     

The Hispanic Treatment Program: Principles of effective psychotherapy

The Hispanic Treatment Program was an inpatient psychotherapy Unit at the Colorado State Hospital that operated from October 1979 to February 1982. Staffed exclusively with personnel of Hispanic heritage, the Program emphasized the use of linguistic and cultural elements, as well as the customs and beliefs characteristic of Hispanic culture. A specialized inpatient treatment unit for Hispanic patients with psychotic (especially, schizophrenia) disturbances, the Program offered a unique opportunity to these patients by providing a variety of psychotherapies conducted in a culturally-sensitive manner. Spanish and English were used in a manner conducive to enhancing the treatment process, with flexibility in use of language.This project was supported by Grant No. ROlMH29016-01A2, awarded by the National Institute of Mental Health, Center for Minority Group Mental Health.The authors acknowledge Gregorio Kort, M.D. and Wayne Smyer, M.A. and other staff for their contributions to the development and success of the Hispanic Treatment Program.Original version of paper was selected for the First Senior Award given by the Psychological Services Center's (NYSCP) Minority Mental Health Award Competition.