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.     

Indikation zur ambulanten Nachsorge (Curriculum Hannover) in der Psychosomatischen Rehabilitation

Outpatient psychosomatic aftercare (Curriculum Hannover) was introduced nationwide in 2000 by the pension scheme. The effectiveness and efficacy of outpatient psychosomatic aftercare has been widely researched. This publication presents an indication-model based on four levels (capacity, participation, activity and impairment) whereas empirical results and clinical experience concerning participation in psychosomatic outpatient aftercare following an in-patient rehabilitation are considered in accordance with the international classification of functioning, disability and health.     

Ambulant oder stationär?

A central issue in psychosomatic-psychotherapeutic consultations is whether to recommend outpatient or inpatient psychotherapy. In a prospective field study at a psychosomatic outpatient unit sociodemographic and clinical variables were compared for patients for whom outpatient treatment (N = 129) or inpatient treatment (N = 112) had been recommended. The assessments of the therapeutic alliance were made by the referring therapist and the therapist who conducted the therapy. The main findings were: The decision about what type of treatment to recommend was based mainly on the type and severity of the disorder, including the patient's functional level and personality structure. There was no difference between the patient groups in how the referring therapists assessed the initial therapeutic alliance, but there was a difference in how the treating therapists did, the relationship to the inpatients being rated significantly less favorably. The importance of the different treatment settings in interaction with the severity of the disorder is discussed. The initial therapeutic alliance in the consultation did not enable a prognosis about the therapeutic alliance during therapy.     

Inpatient versus outpatient treatment of substance abuse: Recent developments in the controversy

There has been considerable controversy the past decade on which is more effective, inpatient or outpatient treatment of substance abuse. During this same decade substance abuse treatment grew into a $40 billion industry with for-profit hospital programs accounting for as much as one-half the total figure. Recently, controlled studies have replaced the previous research literature which was largely composed of uncontrolled studies. A research consensus is developing that states inpatient rehabilitation has no advantages over outpatient treatment and that even hospitalization for detoxification is unnecessary for 90% of patients. Implications for public policy are that we are over-spending in the treatment of substance abuse by misallocating resources to the most intrusive intervention.Nicholas A. Cummings, PhD, is founder and chairman of the board of directors of American Biodyne and president of the Biodyne Institute, president of the National Academies of Practice, former president of the American Psychological Association, and founder of the four campuses of the California School of Professional Psychology.     

TRANSITIONAL EMPLOYMENT PROJECT

McLean Hospital is a private, non-profit psychiatric hospital in Massachusetts. It is an extensive treatment facility providing outpatient care, patient hospitalization, and an inpatient bed capacity of 328. The psychiatric modalities used are traditional milieu structuring, individual and group psychotherapy, behavior therapy interventions, family and couples therapy, psychopharmacology, and rehabilitation treatment strategies. As in other psychiatric hospitals, vocational rehabilitation treatment strategies were severely challenged in the 1970s with the Supreme Court decision in the case of Souder versus Brennan. In essence, the findings in this class action suit construed traditional, clinical/vocational programs as forms of employment, not therapy. Thus, the issues of work adjustment and employment preparation for the psychiatrically disabled client needed to be creatively readdressed. Rehabilitation staff were called upon to redefine the activities presented to clients not only from the viewpoint of desired therapeutic interventions but also in terms of the new legal constraints. The shortened length of inpatient hospitalization also highlighted the need for aftercare rehabilitation opportunities. Responding to these needs, the Rehabilitation Services Department of McLean Hospital developed an independent transitional employment corporation called Everywhere Limited.     

Hamburger Modell der integrierten Versorgung von schwer erkrankten Psychosepatienten

The Hamburg model designates an integrated care model for severely ill patients with psychotic disorders. Based on evidence-based knowledge it was developed in 2005 and implemented in 2006 and is financed since May 2007 via §140 SGB V (German Social Code, book V) as a yearly per patient rate by various health insurances. It comprises comprehensive and long-term treatment within a network of the University Medical Center Hamburg-Eppendorf and private psychiatrists. The treatment model consists of therapeutic assertive community treatment (ACT) and need-adapted inpatient and outpatient care. Since 2012 the model has been extended to the indications of first episode adolescent and young adult patients in the age range of 12–29 years. The present article summarizes the contents of the model, important patient characteristics and results of the long-term treatment.     

Legal issues raised in treating sex offenders

For the past 50 years the criminal justice system has distinguished sex offenders from other criminals. This has resulted in their differential treatment, with the goal being to eliminate their inappropriate behavior. This article discusses the history and status of mentally disordered sex offender (MDSO) statutes. A review of the legal issues which arise when treating a sex offender without statutory authorization is provided. A discussion of problems raised in treating the offender on both an inpatient and outpatient setting is presented. The article concludes with an analysis of the legal problems confronting the treatment provider in working with this group of individuals.     

Status der psychosomatischen Forschung im deutschsprachigen Bereich

Psychosomatic medicine aims at exploring the relationships between biological, psychological and social factors in onset, maintenance and treatment of psychosomatic disorders. The present article describes current topics and methodological approaches in the field of psychosomatic research. A bibliometric analysis of two German journals in 2009 and 2010 was conducted, yielding 43 articles dealing with different aspects of psychosomatic medicine: chronic illness, somatoform disorders and pain, trauma-related disorders, borderline personality disorder and attention deficit hyperactivity disorder. The results show that psychosomatic research covers a variety of topics with different research designs. However, there is still a paucity of controlled studies in the field.     

Couples Therapy for Drug Abusing Women in an Inpatient Setting: A Pilot Study

This article describes a pilot study to examine the usefulness of adding a couples therapy component to inpatient drug and alcohol treatment for women. The treatment model was modified from a 12-week integrative systems model that has been empirically supported in outpatient treatment settings. A team of student-therapists received intensive training and supervision in the modified version. This article discusses the ability of chemical dependency counselors to implement this model, includes pre and post treatment comparisons, and qualitative findings regarding the efficacy of the project. The treatment model promises to be usable, safe, and practical in inpatient settings, and merits a more thoroughgoing clinical trial.     

Differences in the severity of disturbance of behaviors in children receiving inpatient and outpatient psychiatric treatment.

This study was conducted to determine if there are differences in the severity of disturbance of behaviors exhibited by children receiving inpatient psychiatric treatment and those receiving outpatient psychiatric treatment based on their parents' judgments of the frequency of occurrence of those behaviors. The same behaviors were found to exist in both treatment groups, but the severity of disturbance of those behaviors in the inpatient sample was significantly greater than in the outpatient sample. The scale used in this study was found to be a valid and useful instrument for predicting inpatient and outpatient status of children. Pratice and research implications of this study are also discussed.     

Rechtliche Grundlagen der psychosomatischen Rehabilitation Auswirkungen auf die Psychotherapeut-Patient-Beziehung

The legal foundation of psychosomatic rehabilitation, which amounts to more than half of all inpatient psychotherapies performed in Germany, includes the duty of the patient to cooperate, the pre-condition that there is a chance for increasing or restoring patient’s ability to work, and the obligation for therapists, to perform a socio-medical rating of patient's ability to work as well as a judgement about his/her credibility concerning the asserted handicaps and disabilities. All this has an influence on the relationship between psychotherapist und patient and leads to problems in the treatment especially of those patients, who wish to retire. For the psychotherapist not only counter—transferences may be difficult to handle but also role conflicts resulting above all from the challenge being simultaneously psychotherapist and medical expert, who has to rate patient's ability for work and his credibility. To keep capacity of acting, the psychotherapist should reflect these issues and make them transparent for the patient. Sufficient supervision is very important. This will not only improve patient's, but also pension scheme's profit.     

The prostitutes' syndrome

When female patients, at critical periods in their lives, receive suggestions regarding promiscuous and unacceptable behavior, they may at a later time in life act upon these suggestions. However, involvement in promiscuous sexual behavior results in guilt, which will often be seen clinically in the form of depressive neuroses or psychosomatic illness. Several case histories are presented, and implications for treatment are discussed.M.D. is a psychiatrist in private practice in Memphis, Tennessee, maintaining an active inpatient and outpatient practice of psychotherapy.With Dr. Sexton, he maintains a private practice in Memphis.     

Training with computer-supported motor imagery in post-stroke rehabilitation.

Converging lines of evidence suggest that motor imagery (the mental simulation of a motor act within working memory) is associated with subliminal activation of the motor system. This observation has led to the hypothesis that cortical activation during motor imagery may affect the acquisition of specific motor skills and help the recovery of motor function. In this paper, we describe a clinical protocol in which we use interactive tools to stimulate motor imagery in hemiplegic stroke patients, thereby helping them to recover lost motor function. The protocol consists of an inpatient and an outpatient phase, combining physical and mental practice. In the inpatient phase, patients are trained in a laboratory setting, using a custom-made interactive workbench (VR Mirror). After discharge, patients use a portable device to guide mental and physical practice in a home setting. The proposed strategy is based on the hypotheses that: (a) combined physical and mental practice can make a cost-effective contribution to the rehabilitation of stroke patients, (b) effective mental practice is not possible without some form of support, from a therapist (as in our inpatient phase) or from technology (as in the outpatient phase), (c) the inclusion of an outpatient phase will allow the patient to practice more often than would otherwise be possible, therefore increasing the speed and/or effectiveness of learning, and (d) the use of interactive technology will reduce the patient's need for skilled support, therefore improving the cost-effectiveness of training.     

Alkoholabhängigkeit in der psychiatrischen Klinik

In Germany 2.4?% of the population suffer from alcohol dependency and 3.8?% of adults from alcohol abuse. Despite an extensive number of options available for addiction therapy only a minority of affected persons receive addiction-specific therapy. This results in a chronification of the disease and a reduction of approximately 15 years in life expectancy. Background knowledge of the foundations of alcohol addiction leads to a new understanding of the processual course of the disease as well as to new therapy interventions. Individualized treatment includes a combination of outpatient, partial inpatient or inpatient therapeutic measures and range from medical advice for reduction of alcohol consumption, to qualified withdrawal treatment up to pharmacological relapse prophylaxis and long-term weaning treatment. Under current therapeutic conditions abstinence quotas of 50-70?% over 1 year can be achieved. Treating physicians must have sufficient diagnostic certainty and furthermore must be in command of motivating discourse techniques, knowledge on the therapeutic options of outpatient and inpatient withdrawal treatment, pharmaceutical relapse prophylaxis and mediation in rehabilitation measures.     

Inpatient Standards of Care and the Suicidal Patient. Part I: General Clinical Formulations and Legal Considerations

The most common legal action involving psychiatric care is the failure to reasonably protect patients from harming themselves. In this regard it is critical to understand that courts have tended to impose much stricter standards on inpatient than on outpatient care; that at the present time, most malpractice actions involve clinical activities related to inpatient care (negligent admission, treatment, supervision, discharge, etc.). This article reviews the current climate in the legal and clinical formulation of standards of care for hospitalized adult suicidal patients. It suggests general guidelines for effective assessment, management, and treatment procedures that balance the need for high-quality care by a reasonable and prudent practitioner with the requirements of court-determined and statutory standards. The authors specifically discuss court cases that show common failure situations in inpatient care, discharge planning, and follow-up (e.g., problems in pharmacotherapy, the decision to hospitalize, the assessment of imminence and lethality, etc.). The paper also emphasizes the crucial element of clinical judgment in developing any inpatient standard of care.     

Die Praxis der Konzentrativen Bewegungstherapie (KBT)

In a survey the 458 members of the German Association for Concentrative Movement Therapy (DAKBT) were asked in a questionnaire, to answer the question how the actual therapeutic practice of Concentrative Movement Therapy (KBT) in Germany looks like. They were asked about their therapeutic setting, the patients diagnoses and the duration of treatment. 67.5% of the questionnaires were sent back. 191 of those who answered, are working as professional psychotherapists, 62.8% of them with out-patients, 51.3% in hospitals, 17.8% in both therapeutic fields. Besides group psychotherapy most of them offer individual therapy, especially with out-patients. It is shown, that besides psychosomatic disorders (being a wellknown indication) KBT is also applied in a broad variety of other psychic disorders. Half of the outpatient treatments is finished within 50 meetings. Female patients and patients with personality or eating disorders show up a greater number of contacts in out-patient individual treatment. The results verify that in practice KBT is no longer confined to a supplementary group therapy.     

A Short-Term,Family-Oriented,Child and Adolescent Psychiatric Inpatient Treatment Program

We describe a short-term inpatient treatment program whose purpose is to integrate the different interventions in the child, his or her family, and the outpatient professional network. The interaction between the family and the ward is the basic structural element of child psychiatric inpatient treatment. The child, the family, the professional outpatient network, and the ward community together form an extended therapeutic system. Inpatient treatment can be understood as a coevolving process between these systems. The essential feature in our working model is the continuous, daily nursing staff supervision and a focus on interactions in the extended therapeutic system.     

Predictors of Perceived Need for Medical Care in an Inpatient Rehabilitation Unit: An Update

Limited awareness of illness, or poor insight, has been associated with poor treatment outcomes and prognoses in both psychiatric and medical populations. We examined predictors of insight in a sample of 403 patients in an inpatient rehabilitation unit at a Midwest Veterans Affairs Medical Center. A multiple regression analysis revealed that age, depression, IQ, and a measure of judgment were significant predictors of acknowledgement of illness. Younger age, higher IQ, better judgment, and depression were associated with better insight. By identifying risk factors for poor insight, these findings have significant clinical implications for healthcare providers.     

Evaluation of inpatient dialectical-behavioral therapy for borderline personality disorder--a prospective study

Dialectical-Behavioral Therapy for Borderline Personality Disorder (DBT) developed by M. Linehan is specifically designed for the outpatient treatment of chronically suicidal patients with borderline personality disorder. Research on DBT therapy, its course and its results has focused to date on treatments in an outpatient setting. Hypothesizing that the course of therapy could be accelerated and improved by an inpatient setting at the beginning of outpatient DBT, we developed a treatment program of inpatient therapy for this patient group according to the guidelines of DBT. It consists of a three-month inpatient treatment prior to long-term outpatient therapy. In this pilot study 24 female patients were compared at admission to the hospital, and at one month after discharge with respect to psychopathology and frequency of self-injuries. Significant improvements in ratings of depression, dissociation, anxiety and global stress were found. A highly significant decrease in the number of parasuicidal acts was also reported. Analysis of the average effect sizes shows a strong effect which prompts the development of a randomized controlled design.