The Group Life of the Schizophrenic Patient: A Social Work Investigation by Leslie John Shellhase

Abstract

We used a randomized clinical trial to investigate the interaction of two patient personality characteristics (quality of object relations [QOR] and psychological mindedness [PM]) with two forms of time-limited, short-term group therapy (interpretive and supportive) for 139 psychiatric outpatients with complicated grief. Findings differed depending on the outcome variable (e.g., grief symptoms, general symptoms) and the statistical criterion (e.g., statistical significance, clinical significance, magnitude of effect). Patients in both therapies improved. For grief symptoms, a significant interaction effect was found for QOR. High-QOR patients improved more in interpretive therapy and low-QOR patients improved more in supportive therapy. A main effect was found for PM. High-PM patients improved more in both therapies. For general symptoms, clinical significance favored interpretive therapy over supportive therapy. Clinical implications concerning patient-treatment matching are discussed.     

Interpersonal predictors of group therapy outcome for complicated grief

This study investigated three aspects of patients' interpersonal functioning as predictors of outcome for two forms of group psychotherapy for complicated grief. Patients presented with a variety of death losses and met criteria for complicated grief. The three aspects of interpersonal functioning were the patient's (1) attachment to the lost person, (2) quality of object relations (QOR), and (3) level of recent social role functioning. A more secure attachment to the lost person and better social role functioning were associated with more favorable outcome in both forms of therapy. In addition, patients with higher QOR had more favorable outcome in interpretive therapy while lower QOR patients had more favorable outcome in supportive therapy. The results suggest that each aspect of interpersonal functioning is important to consider when treating patients for complicated grief.     

Quality of object relations as a moderator of the relationship between pattern of alliance and outcome in short-term individual psychotherapy

In this study, we investigated the personality variable quality of object relations (QOR) as a moderator of the relationship between the pattern of the therapeutic alliance and treatment outcome in two forms (interpretive, supportive) of short-term individual psychotherapy. In a sample of 72 psychiatric outpatients who completed interpretive therapy, QOR emerged as a moderator for the outcome factor general symptomatology and dysfunction. For high-QOR patients, an increasing level of alliance was directly related to benefit, whereas for low-QOR patients, a decreasing level of alliance was directly related to benefit. An explanation for these findings emphasized the importance of patients repeating their typical pattern of maladaptive interpersonal behavior in the therapy sessions in the context of the therapist working with the transference. In a sample of 72 psychiatric outpatients who completed supportive therapy, QOR did not emerge as a moderator. These findings in combination with evidence from previous studies suggest that QOR should be investigated as a moderator variable in future studies of short-term psychotherapy.     

NEO-five factor personality traits as predictors of response to two forms of group psychotherapy

The relationships between patient personality variables and outcome for 107 psychiatric outpatients with complicated grief who completed either interpretive or supportive short-term group therapy were investigated. The personality variables were assessed prior to treatment with the NEO-Five Factor Inventory (NEO-FFI). For patients in both forms of therapy, extraversion, conscientiousness, and openness were directly associated with favorable treatment outcome. In contrast, neuroticism was inversely related to favorable outcome for patients in both forms of therapy. Agreeableness was directly related to favorable improvement in grief symptomatology for patients in interpretive therapy, but not for those in supportive therapy. The results highlight the importance of assessing patient personality in order to predict response to short-term group therapy. Possible explanations and clinical implications of these findings are discussed.     

Upward and Downward Counterfactual Thought After Loss: A Multiwave Controlled Longitudinal Study

Counterfactual thoughts, mental simulations about how a situation may have turned out differently (i.e., “if only …, then …”), can reduce mental health after stressful life-events. However, how specific counterfactual thought types relate to post-loss mental health problems is unclear. We hypothesized that self-referenced upward counterfactuals (i.e., “If only I had done …, then the current situation would be better”) may serve as cognitive avoidance, thereby perpetuating loss-related distress. Conversely, downward counterfactuals (i.e., “If … had happened, then the current situation could have been [even] worse”) may facilitate benefit finding, thereby reducing distress. In a longitudinal survey, self-referent, other-referent, and nonreferent upward counterfactuals, and nonreferent downward counterfactuals were assessed at baseline. Prolonged grief and depression symptoms were assessed at baseline, and 6- and 12-month follow-ups. Multiple regression analyses assessed associations between counterfactual thoughts and symptom levels in 65 recently bereaved people who generated counterfactual thoughts about the loss-event. Moderator analyses assessed the unicity of significant effects in the previous step, by comparing these effects in 59 people generating loss-related counterfactuals with those in 59 propensity-score matched participants generating counterfactuals about other negative life-events. Multivariate analyses showed that nonreferent upward counterfactuals were uniquely strongly positively associated with prolonged grief and depression symptoms concurrently. Self-referent upward counterfactuals were uniquely positively associated with prolonged grief and depression symptoms longitudinally. Moderator analyses confirmed that thinking about how one’s (in)actions could prevent a death uniquely exacerbated prolonged grief and depression severity. Prolonged grief treatment may be improved by targeting self-blame and guilt.     

The influence of contextual contrast on syntactic processing: evidence for strong-interaction in sentence comprehension

The present study compares the processing of unambiguous restrictive and non-restrictive relative clauses (RCs) within both a null context and a supportive discourse using a self-paced reading methodology. Individuals read restrictive RCs more slowly than non-restrictive RCs in a null context, but processed restrictive RCs faster than non-restrictive RCs in supportive context, resulting in an interaction between context and RC type. These results provide evidence for two theoretical points. First, principles analogous to those in referential theory [Altmann G. T. M., & Steedman, M. (1988). Interaction with context during human sentence processing. Cognition, 30, 191-238; Crain, S., & Steedman, M. (1985). On not being led up the garden path: The use of context by the psychological parser. In D. Dowty, L. Karttunnen, A. Zwicky (Eds.), Natural language parsing. Cambridge, UK: Cambridge University Press] apply not only in resolving ambiguity but also in processing unambiguous sentences. Second, the discourse context can guide and facilitate interpretive processing. This result suggests that intrasentential factors such as syntax are not autonomous from contextual processing, contrary to the modularity hypothesis [Fodor, J. A. (1983). Modularity of mind. Cambridge, MA: MIT Press].     

Separation and Traumatic Distress in Prolonged Grief: The Role of Cause of Death and Relationship to the Deceased

A distinction has been drawn between symptoms of separation distress (e.g., yearning/longing for the lost relationship) and traumatic distress (e.g., numbness, anger/bitterness) in prolonged grief disorder (PGD), a chronic and severe form of grieving that has been shown to predict a range of negative mental and physical health outcomes. The present study relied upon information from 947 recently bereaved young adults and tested the hypothesis that levels of separation distress primarily would be influenced by aspects of the relationship with the deceased (i.e., primary attachment figures vs. more distant relationships), whereas levels of traumatic distress would be influenced more by situational factors surrounding the death itself (i.e., cause of death). Results generally supported this hypothesis with a few important qualifications. Implications for the assessment and treatment of bereaved individuals are discussed.     

A controlled study of effectiveness and patient suitability for short-term group psychotherapy

A controlled, clinical trial investigation of short-term psychoanalytically oriented group psychotherapy (STG) was conducted which included eight psychotherapy groups led by experienced therapists. Patient psychological mindedness (PM) was investigated as a selection criterion and prognostic variable. Seventy-nine psychiatric outpatients experiencing prolonged or delayed grief reactions were matched for level of PM and then randomly assigned to STG or a wait list. There was repeated measurement of several areas and sources of outcome. Results indicated a strong main effect for STG but not for PM on outcome, and minimal evidence for an interaction effect. Benefits were maintained at six-month follow-up. Psychological mindedness emerged as highly predictive of attrition. A clinical discussion is presented wherein the efficacy of STG is considered as reflecting a good patient-treatment match.     

Countertransference in Activity Group Therapy

A controlled, clinical trial investigation of short-term psychoanalytically oriented group psychotherapy (STG) was conducted which included eight psychotherapy groups led by experienced therapists. Patient psychological mindedness (PM) was investigated as a selection criterion and prognostic variable. Seventy-nine psychiatric outpatients experiencing prolonged or delayed grief reactions were matched for level of PM and then randomly assigned to STG or a wait list. There was repeated measurement of several areas and sources of outcome. Results indicated a strong main effect for STG but not for PM on outcome, and minimal evidence for an interaction effect. Benefits were maintained at six-month follow-up. Psychological mindedness emerged as highly predictive of attrition. A clinical discussion is presented wherein the efficacy of STG is considered as reflecting a good patient—treatment match.     

Therapeutic alliance and cohesion variables as predictors of outcome in short-term group psychotherapy

The current study explored the relative ability of aggregate therapeutic alliance and cohesion variables to predict short-term group therapy outcome. Data were collected from a comparative trial of two forms of time-limited group psychotherapy for complicated grief (Piper, McCallum, Joyce, Rosie, & Ogrodniczuk, 2001). The therapeutic alliance and elements of the cohesion construct were measured from the perspectives of each patient and the group therapist at intervals during the groups; scores were aggregated across assessments. Hierarchical multiple regression analyses, adjusting for the effects of treatment approach (interpretive vs. supportive) and specific group membership, demonstrated that the patient-rated alliance was a consistent predictor of outcome. Two cohesion measures, reflecting other participants' (therapist, other members) views of the patient's "fit" with the group, also accounted for variation in outcome. Implications of the findings for research and clinical practice, and the limitations of the measurement approach taken in this study, are considered.     

Dialectical Behavior Group Therapy is Feasible and Reduces Emotional Dysfunction in Multiple Sclerosis

We examined whether dialectical behavior therapy (DBT) was feasible and effective in multiple sclerosis (MS). A convenience sample of 20 patients with anxiety or depression symptoms received either DBT (n = 10) or standard medical care (n = 10). The DBT protocol was found to be feasible in the MS population studied (e.g., good retention and acceptability). For the DBT group, significant improvements were demonstrated in self-rated and clinician-rated depressive symptoms, clinician-rated anxiety symptoms, self-rated general psychopathology symptoms, and quality of life. In contrast, the standard medical care group retained for exploratory purposes showed no significant improvements. This pilot work provides preliminary support for the utility of DBT in MS, but further work is needed to clarify this benefit using a large, randomized controlled approach.     

The size of the cross-lingual masked phonological priming effect does not depend on second language proficiency

Using a masked phonological priming paradigm, Brysbaert, Van Dyck, and Van de Poel (1999) showed that Dutch-French bilinguals perform better at identifying tachistoscopically presented L2 words (e.g., oui [yes]) when those words are primed by L1 words or nonwords that are homophonic to the L2 target word according to the L1 grapheme-phoneme conversion rules (e.g., wie [who]). They noted that this priming effect was smaller for balanced bilinguals than for less proficient bilinguals, although the interaction failed to reach significance. Findings of Gollan, Forster, and Frost (1997) suggest that this could be attributed to a greater reliance on phonology in L2 reading, caused by a smaller proficiency in this language. However, in this study we show that the Dutch-French cross-lingual phonological priming effect is equally large for perfectly balanced and less proficient bilinguals. Our findings are in line with more recent work of Van Wijnendaele and Brysbaert (2002).     

Interpersonal consequences of seeking self-esteem

This study examines the interactive effects of self-esteem, contingencies of self-worth, and ego threat on supportiveness and liking. Targets high or low in self-esteem and academic contingency receive failure test feedback or no evaluative feedback. Then, targets interact with another participant who discloses a personal problem; afterward, both participants complete questionnaires assessing targets' supportiveness and liking. High self-esteem, highly contingent targets feel less supportive and like partners less after interacting under threat than under no threat. Partners, in turn, perceive these targets to be less supportive and less likeable. Low self-esteem, highly contingent targets show the reverse pattern, although these findings do not reach statistical significance. Further analyses reveal that the interpersonal effects of ego threat were caused by threats in a specific domain of contingency (e.g., academics) rather than being a contingent person in general or having external or internal contingent self-worth. Implications for self-esteem and interpersonal processes are discussed.     

The Core Emotion Themes of Conjugal Loss

Previous studies have associated emotion and appraisal with long-term bereavement outcome. The present study extended this research by coding conjugal bereavement narratives for core relational themes (CRT) that served as emotional summaries of unique combinations of appraisal features. A range of CRTs was evidenced at 6 months after loss, with positive CRTs, such as love/affection and pride, occurring most frequently. As a way to examine competing models of coping with loss, CRTs were grouped by goal-congruence (positive/negative) and appraisal features (self/interpersonal) into four thematic categories, and they were compared with 6-, 14-, and 25-month outcome. Results contradicted the traditional grief work perspective, but they were consistent with the alternative view that recovery is fostered by identity continuity and a continued emotional bond with the deceased. With initial symptoms and Dyadic Adjustment Scale scores controlled, enhanced self themes (e.g., self-pride) and interpersonal affirmation themes (e.g., pride in the deceased) were each associated with improved functioning over time, whereas interpersonal discord themes (e.g., anger at the deceased) were associated with chronic grief.     

Intergenerational potential: effects of social interaction between older adults and adolescents

The present study aimed to investigate the potentially facilitative effect of the interaction between older adults and adolescents. For older adults, the interaction was expected to compensate for age-related deficits (e.g., cognitive performance, cognitive-affective complexity). In case of the adolescents, an optimization of development was expected (e.g., prosocial behavior, communion goals). Ninety older women (70-74 years) and 90 adolescent girls (14-15 years) were randomly assigned to 3 experimental conditions. In each of the conditions, nonfamiliar dyads collaborated on 1 task. The conditions varied according to the age composition and the type of contextual demand (high vs. low support of generativity [older adults] and identity formation [adolescents]). Individual performance measures were assessed immediately after the interaction. As expected, intergenerational settings characterized by high support of generativity and identity formation resulted in more prosocial behavior in adolescents. Furthermore, the results lent partial support to the hypothesis that in older adults, this setting facilitated higher complexity of emotion regulation as well as higher levels of performance in measures of speed and word fluency.     

The value of RCT evidence depends on the quality of statistical analysis

The authors examined statistical practices in 193 randomized controlled trials (RCTs) of psychological therapies published in prominent psychology and psychiatry journals during 1999-2003. Statistical significance tests were used in 99% of RCTs, 84% discussed clinical significance, but only 46% considered-even minimally-statistical power, 31% interpreted effect size and only 2% interpreted confidence intervals. In a second study, 42 respondents to an email survey of the authors of RCTs analyzed in the first study indicated they consider it very important to know the magnitude and clinical importance of the effect, in addition to whether a treatment effect exists. The present authors conclude that published RCTs focus on statistical significance tests ("Is there an effect or difference?"), and neglect other important questions: "How large is the effect?" and "Is the effect clinically important?" They advocate improved statistical reporting of RCTs especially by reporting and interpreting clinical significance, effect sizes and confidence intervals.     

The Effectiveness of Group Metacognitive Therapy for Generalised Anxiety Disorder: A Pilot Study

Generalised anxiety disorder (GAD) responds well to individually delivered metacognitive therapy (MCT). The current study investigated the effectiveness of MCT administered to groups of patients with GAD in a general outpatient treatment centre. Thirty-three consecutively referred adult patients with GAD were assessed before treatment (pretreatment), after the last treatment session (posttreatment), and six months after treatment had ended (follow-up). Analyses of treatment effects were conducted for all patients entering the study (i.e., intent-to-treat analysis, using the last-observation-carried-forward procedure), and repeated for the patients who completed treatment (completers analysis), using paired samples t-tests. Further, effect sizes (ESs) and indices of clinical significance were calculated, and compared with those reported in studies into the efficacy and effectiveness of individually delivered MCT for GAD. Among both the intent-to-treat and the completers sample, large pre- to posttreatment reductions in symptoms of worry, trait-anxiety, and general psychopathology. The magnitude of change and the degree of clinical significance were smaller than those reported in studies into the effectiveness of individually delivered MCT for GAD, whereas the attrition rate (27 %) was higher. It is tentatively concluded that MCT for GAD can be effectively delivered in a group format in a heterogenous clinical practice setting. Further evaluation is clearly indicated.     

Paranoia and narcissism in psychoanalytic theory. Contributions of self psychology to the theory and therapy of the paranoid disorders

Many factors go into a choice of a therapeutic focus: the patient's psychopathology; the therapist's training, countertransference reactions, and ideological beliefs; and, importantly, a decision about what seems most amenable to treatment and change. As a theory, self psychology describes one aspect of the paranoid process; as such, it is an incomplete theory that complements rather than invalidates more classical theories. As a technique, however, it suggests a style and focus conducive to working with paranoid patients, one that is markedly supportive, nonconfrontational, yet also interpretive. In this context, it must be remembered how difficult it is to treat paranoid patients psychotherapeutically, much less to keep them in treatment. The strategies discussed above do not wholly replace other dynamic approaches (e.g., counterprojective techniques), nor are they universally applicable. Some patients may be more amenable than others. However, the techniques provide a very supportive framework that may help the therapist to be more available to and in contact with the paranoid patient. More broadly, this paper's application of self psychology to the theory and therapy of the paranoid disorders further illustrates the practical utility of this approach. Attention to the narcissistic developmental line, interpersonal selfobject relationships, intrapsychic conflicts and deficits, and empathic immersion in the patients's world are important adjuncts to the psychotherapy of paranoid patients. Rather than an either/or dichotomy, the principle of overdetermination suggests a both/and relationship between self psychology and traditional theory, such that the self psychological approach complements rather than contradicts the classical psychoanalytic theory. The vicissitudes of the self simply add another perspective or vantage point from which to understand and respond to the patient, one which has perhaps more applicability for preoedipally disordered patients.