Difficult Terminations in Group Therapy: A Self Psychologically Informed Perspective

In group therapy, terminations that are neither planned nor anticipated are sometimes referred to as difficult. This complex issue of difficult terminations is used as a vehicle to challenge the prevailing, though often unspoken, assumption that the goal of the group therapist is to keep the members in the group. The author presents the notion that the leader needs to maintain a balance between the group as a treatment context, and the goal of that context. The goal of group-as-treatment context is to provide for the therapeutic needs of each individual patient in the group. Self psychology provides a basis for redefining the therapy group as a treatment context. A specific rationale, goal, and process of that redefinition is presented along with illustrative case material. With this understanding, unanticipated terminations can be as readily accepted and understood as ones that are planned. All terminations are viewed as further opportunities to understand how a patient defines his or her sense of self, sense of other, and sense of self with other.     

Premature termination: A clinical study

Ten patients who terminated prematurely from 10 different therapy groups were interviewed using a semistructured interview protocol. Half the subjects were patients in private therapy groups; the other half were patients in clinic therapy groups. Among the issues inquired about were subjects' initial attitudes about group treatment; the nature of the preparation process; subjects' experience of the group therapist, other group members, and the group process; their reasons for leaving their groups; and the nature of the termination process. The findings reported focus on patients' perceptions of therapists' motives; the importance of establishing appropriate treatment goals; the handling of negative feelings about the group and/or the group therapist; the issue of narcissistic injury; the experience of the balance between giving and receiving; the difficulties caused by unresolved conflicts within groups; and the problems posed by inadequate preparation for the group experience. Guidelines for practices aimed at minimizing premature terminations are offered.     

Dynamic Group Experiences for Teachers and Students in the Classroom

Throughout the development of object relations theory and self psychology, the importance of attachments, availability, absences, limitations, and endings have been factors that have informed theory and practice. This article examines the multiple meanings and impacts of terminations in group psychotherapy at the intrapsychic, interpersonal, and group-as-a-whole levels, from the perspective of contemporary object relations theory and self psychology. Emphasis is placed on the initiation of a mourning process, with the dynamics of guilt, shame, and aggression toward objects who are separate or inaccessible, and the experience of a shortcoming or absence, associated with a loss of self-object oneness, soothing and idealization from the narcissistic sector of the personality. Therapeutic opportunities afforded by terminations and the importance of resolving countertransference reactions are highlighted.     

Sex differences in conformity: Instrumental or communal response?

Male and female introductory psychology students (N=88) were asked to read a clinical case history and the opinion consensus of either (a) their peers, (b) advanced psychology students, or (c) Ph.D. clinical psychologists that the patient should be hospitalized for at least 90 days (an extreme treatment). Subjects then indicated on a scale of 10 to 90 days, the length of hospitalization they thought best. In a significant interaction effect (sex of subject × expertise of source) males were least influenced by the opinions of their peers and increasingly influenced as the source became more expert. Females, however, seemed most influenced by their peer group, recommending longest hospitalization terms in that condition. Results are interpreted in terms of sex-role identification and the emergence of an instrumental (task) or communal set.     

The archaic superego: the guard of instincts from childhood to adolescence

In it's first part, this paper describes and explores different kinds of terminations of psychoanalytic treatments; forced and unilaterally decided ones, as well as terminations in interrupted and successful analyses. Following this, the author describes the process of termination, and discusses the alleged positive value of planned post-termination contacts with analysands. Finally, the author emphasises the importance of more systematic empirical research on psychoanalytic treatment.     

Seeing the baby: The impact of ultrasound technology

This paper reports results of a study of prenatal diagnosis patients who underwent ultrasound examinations and lost their pregnancies through miscarriage or elective terminations. The majority of the women felt that viewing the ultrasound image influenced their relationship to the fetus and their coping with the pregnancy loss. The women commented on the power of ultrasound to make their pregnancies more real as well as the painful yet sometimes beneficial consequences of seeing the fetus. Clinical implications are considered for health professionals who provide prenatal diagnostic services or counseling after pregnancy loss.     

The Influence of Individual Attachment Styles on Group Members’ Experience of Therapist Transitions

Abstract

Attachment theory has recently been applied to clinical practice in an effort to improve understanding and treatment of the maladaptive relational patterns clients bring to therapy. While most of this research has focused on individual therapy, interest in the application of attachment theory to group psychotherapy is growing. This paper will explore the impact of clients’ attachment styles on their experiences of co-therapist transition in an ongoing psychodynamic therapy group. This discussion will elucidate how knowledge of attachment theory and an understanding of clients’ individual attachment styles can be useful in predicting responses to therapist-initiated terminations and transitions.     

Social Pressures in Informal Groups by L. S. Festinger,S. Schacter and K. Back

The rising cost of health care within the private and public sectors has created an increased demand for the management of benefit dollars. This trend has significant implications for group psychotherapists, as group modalities offer cost-effective ways of delivering services to traditional outpatient and inpatient populations. Continued cosl-containment pressures and increasing attention to outcome studies will fitel trends toward briefer, manualized group treatments and intensive group outpatient programs as alternatives to hospitalization. Quality-based demands will challenge payors to (a) address biases against group psychotherapy among providers and patients and (b) integrate recent process-and-outcome research in determining the appropriateness of group versus individual modalities for particular patients and presenting problems.     

AN EVALUATION OF ORIENTATION AND ASSESSMENT EFFECTIVENESS IN THE WORK INCENTIVE PROGRAM

The purpose of this study was to evaluate the effectiveness of a Work Incentive (WIN) Orientation and Assessment Program which was designed to (a) assess enrollee attitudes and abilities, and (b) provide enrollee pre-employment test orientation. A sample of 155 WIN enrollees was divided into two groups; the experimental group received two weeks of orientation and assessment. Results were obtained by using two criteria: First, the number of terminations prior to completing the EDP was examined for each group, and second, the total number of referrals to each of three major components was examined. Findings revealed a significantly lower number of terminations among the experimental group, but did not yield any difference in the number of referrals per component. It is suggested that further studies of this type include a more refined measure of enrollee success and satisfaction in various WIN components.     

The Emergence of Suicidal Ideation During the Post‐Hospital Treatment of Depressed Patients

There is a paucity of research on the emergence of suicidal ideation in recently hospitalized patients undergoing treatment for depression. As part of a larger clinical trial, patients (N = 103) with major depression without suicidal ideation at hospital discharge were followed for up to 6 months while receiving study‐related outpatient treatments. Fifty‐five percent reported the emergence of suicidal ideation during the outpatient period, with the vast majority (79%) exhibiting this problem within the first 2 months post‐discharge. Seventy percent of those reporting severe suicidality prior to hospitalization exhibited a reemergence of suicidal ideation post‐discharge. However, 29% without significant suicidality at the index hospitalization later developed suicidal ideation during the outpatient treatment period. A faster time to the emergence of suicidal ideation was predicted by both higher prehospitalization levels of suicidal ideation as well as greater depression severity at hospital discharge. Overall, rates of emergent suicidal ideation found in the current sample of recently hospitalized patients were higher than those reported in previous outpatient samples.     

Termination of parental rights conflicts: Small-group therapy with adolescent boys

Abstract

In the 1990s Children's Village, a residential treatment center, has been able to return fewer boys to their families of origin and has sought court-supported terminations of parental rights (TPRs). A clinically sound approach was formulated to support the boys during and after the TPR process. Coleaders conducted group therapy with small numbers (2, 4, 5) of boys aged 10 to 14 years. The task was to help them relinquish the parent as a discharge resource. Impact of the groups varied with the boys' ages and the presence or absence of an identified peer leader. An identified date for ending resulted in vigorous therapeutic work in the final meetings.     

Impact of a Suicide‐Specific Intervention within Inpatient Psychiatric Care: The Collaborative Assessment and Management of Suicidality

A growing body of literature indicates that suicidal patients differ from other psychiatric patients with respect to specific psychological vulnerabilities and that suicide‐specific interventions may offer benefits beyond conventional care. This naturalistic controlled‐comparison trial (n = 52) examined outcomes of intensive psychiatric hospital treatment (mean length of stay 58.8 days), comparing suicidal patients who received individual therapy from clinicians utilizing the Collaborative Assessment and Management of Suicidality (CAMS) to patients whose individual therapists did not utilize CAMS. Propensity score matching was used to control for potential confounds, including age, sex, treatment unit, and severity of depression and suicidality. Results showed that both groups improved significantly over the course of hospitalization; however, the group receiving CAMS showed significantly greater improvement on measures specific to suicidal ideation and suicidal cognition. Results are discussed in terms of the potential advantages of treating suicide risk with a suicide‐specific intervention to make inpatient psychiatric treatment more effective in reducing risk for future suicidal crises.     

Internet Versus Group Cognitive-Behavioral Treatment of Distress Associated With Tinnitus: A Randomized Controlled Trial

Tinnitus distress can be reduced by means of cognitive-behavior therapy (CBT), and the treatment can be delivered in different ways. The most recent format is Internet-based self-help. The aim of this study was to compare this treatment (n = 26) with standard group-based CBT (n = 25) in a randomized controlled trial. Outcomes on self-report inventories measuring tinnitus distress were evaluated immediately after and 1 year after treatment. Results showed that both groups had improved, and there were few differences between them. The effect size for the Internet treatment was d = 0.73 (95% CI = 0.16–1.30) and for the group treatment was d = 0.64 (95% CI = 0.07–1.21). The Internet treatment consumed less therapist time and was 1.7 times as cost-effective as the group treatment. At pretreatment patients rated the Internet treatment as less credible than the group treatment. In conclusion, Internet treatment for tinnitus distress merits further investigation, as the outcomes achieved are promising.     

The impact of pre-employment integrity testing on employee turnover and inventory shrinkage losses

A major home improvement chain located primarily in the western United States initiated the use of thePersonnel Selection Inventory, a written integrity test, as part of its pre-employment hiring process. For two years only, those job applicants who passed this test and other pre-employment criteria were hired by the chain. Following the introduction of the inventory, there was: (1) a 50% reduction in the number of employee terminations for theft, illegal drug use, and violence over a five year period and (2) a savings in shrinkage losses that amounted to over two million dollars over a two year period.     

Family Centered Brief Intensive Treatment: A Pilot Study of an Outpatient Treatment for Acute Suicidal Ideation

Family Centered Brief Intensive Treatment (FC BIT), a hospital diversion treatment program for individuals with acute suicidal ideation, was developed to treat suicidal clients and their families. Individuals who met criteria for hospitalization were treated as outpatients using FC BIT (n = 19) or an intensive outpatient treatment without the family component (IOP; n = 24). Clients receiving FC BIT identified family members or supportive others to participate in therapy. FC BIT clients had significantly greater improvement at the end of treatment compared to IOP clients on measures of depression, hopelessness, and suicidality. Further research is needed to test the efficacy of FC BIT.     

The Efficacy of an Integrated Theoretical Approach to Group Psychotherapy for Male Inmates

To assess the efficacy of an interpersonal process-oriented and cognitive-behavioral group psychotherapy program, 36 incarcerated male adults were assigned to either a treatment group (n = 20) or a no treatment control group (n = 16). Outcome measures consisted of paper-pencil self-report instruments, institutional behavioral data, and structured interviews with the group therapists (n = 3). Results indicated no significant changes in inmates' level of defensiveness, empathy, or institutional behavior; however, the inmates reported universally positive reactions to the treatment program. The group therapists also perceived the treatment program as efficacious, particularly in fostering a cohesive group atmosphere and increasing inmate responsibility for group leadership. Implications for practice and research are discussed.     

Efficacy of Dialectical Behavior Therapy for Adolescents in a Partial Hospitalization Program

This study evaluated dialectical behavior therapy for adolescents (DBT‐A) vs. treatment as usual within a 6‐week partial hospitalization program. The 103 adolescent participants (mean age = 15.27 years) were predominantly girls (n = 63, 61%) with a variety of primary mental health diagnoses. Results indicated that DBT‐A was superior for decreasing symptoms of depression and interpersonal sensitivity, but no statistically significant difference was detected for anxiety or hostility. Implications for treating youth with transdiagnostic identities are discussed.     

The influence of individual attachment styles on group members' experience of therapist transitions

Attachment theory has recently been applied to clinical practice in an effort to improve understanding and treatment of the maladaptive relational patterns clients bring to therapy. While most of this research has focused on individual therapy, interest in the application of attachment theory to group psychotherapy is growing. This paper will explore the impact of clients' attachment styles on their experiences of co-therapist transition in an ongoing psychodynamic therapy group. This discussion will elucidate how knowledge of attachment theory and an understanding of clients' individual attachment styles can be useful in predicting responses to therapist-initiated terminations and transitions.     

Termination of Mental Health Services for Children

In this paper, we examine the termination of children's mental health services. Analyses were based on the 901 families in the Fort Bragg Evaluation Project who participated at Wave 1 and Wave 2 six months later. The project compared a full continuum of care provided at a demonstration site with traditional care at two comparison sites. The results showed that in most cases families and providers were partners in decisions to terminate treatment. About half of the clients self-terminated or were terminated solely at the discretion of the provider. Providers tended to play a more dominant role in terminating restrictive services; families played a more central role in terminating outpatient care. Regardless of initial psychopathology, children in single-headed households, whose parents were dissatisfied with services, did not expect their child to cooperate with treatment and did not expect treatment to help their child, were more likely to terminate care than others. While the Demonstration site had significantly fewer terminations, the sites did not differ with regard to the reasons for termination, who participated in termination decisions, or the factors that affected the likelihood to terminate care. Of most interest, mental health outcomes among children who had terminated all care did not vary by reasons for termination or by who participated in the termination decision.