Prevalence of loss and complicated grief among psychiatric outpatients.

OBJECTIVE: This study examined the prevalence of significant loss through the death of another person as well as complicated grief among patients at two psychiatric outpatient clinics for one year. METHODS: A total of 729 patients were interviewed about significant losses through death during their lives. Standard questionnaires were used to classify 235 patients who had experienced such losses into three groups: those who had minimal disturbance, those who had moderate complicated grief, and those who had severe complicated grief. Multivariate and univariate analyses of variance were used to test for differences in loss-specific variables (for example, pathological grief) and variables that were not specific to loss (for example, depression) among the three groups. RESULTS: More than half of the 729 patients reported that they had experienced one or more significant losses through death. About a third of all patients who came to the clinics met the criteria for either moderate or severe complicated grief. The average time since the loss was about ten years, indicating that these patients had long-term complicated grief. Significant differences in loss-specific variables and variables that were not specific to loss were detected among the three groups. Patients who had severe complicated grief scored higher than patients in the other two groups on both types of variables. Patients with moderate complicated grief had higher scores than those with minimal disturbance. CONCLUSIONS: Clinicians should routinely assess outpatients for loss and complicated grief and should consider addressing loss and complicated grief in treatment. Rather than a single classification of complicated grief, different levels should be considered.

Ambivalence and other relationship predictors of grief in psychiatric outpatients.

Ambivalence has been viewed as an important causal agent in the development of complicated grief. However, examination of studies commonly cited as supporting this belief reveals basic limitations in their methodology and conclusions. The current study examined associations between several relationship predictors (ambivalence, affiliation, and dependence) and both grief-specific symptoms and depression in two samples of psychiatric outpatients who had experienced loss of significant others. Findings from the first sample (N = 138) were used to test for evidence of cross-validation in the second sample (N = 139). Contrary to traditional belief, ambivalence was inversely related to severity of grief symptoms. In contrast, affiliation and dependence were directly related to severity of grief symptoms. None of the predictors provided evidence of cross-validation in the case of depression. Explanations for the findings and clinical implications are considered.

Follow-up findings for interpretive and supportive forms of psychotherapy and patient personality variables.

Follow-up findings at 6 and 12 months are reported for a clinical trial that investigated the efficacy of interpretive and supportive forms of short-term individual psychotherapy and the interaction of each form with the patient's quality of object relations (QOR) and psychological mindedness (PM). Patients in both forms maintained their posttherapy improvements at 6- and 12-month follow-up assessments. They did not differ significantly from each other. At 6 and 12 months, there was evidence for a direct relation between QOR and favorable outcome. At 12 months, there was also evidence for an interaction effect, which indicated a direct relation between QOR and favorable outcome for interpretive therapy and almost no relation for supportive therapy. Thus, QOR continued to be an important predictor of outcome at 6 and 12 months, with some evidence for persistence of an interaction effect. In contrast, no follow-up effects were found for PM.

Interpretive and supportive forms of psychotherapy and patient personality variables.

A randomized clinical trial investigated the efficacy of interpretive and supportive forms of short-term individual psychotherapy and the interaction of each form with the patient's quality of object relations (QOR) and psychological mindedness (PM). The psychiatric outpatient sample included 144 therapy completers and 27 dropouts. Eight experienced therapists provided distinct forms of manual-guided therapy. Outcome was assessed by a comprehensive battery. The dropout rate was higher for interpretive therapy than for supportive therapy. Patients in both forms improved, but they did not differ on outcome from each other. A multivariate interaction effect indicated a direct relation between QOR and outcome for interpretive therapy and almost no relation for supportive therapy. A multivariate main effect indicated a direct relation between PM and outcome for both forms. The relevance of patient personality to outcome in different forms of therapy is addressed.

Effective psychiatric day treatment: historical lessons.

This paper describes a successful day treatment program that provides four months of intensive psychodynamic group-oriented milieu treatment for patients with long-standing personality disorders, who commonly experience recurrent major depression, dysthymia, and excessive anxiety. The authors outline three factors that have contributed to the success of the program--optimal treatment-patientmatching, judicious use of authority in milieu therapy, and careful attention to maintaining close working relationships with referral sources. They provide an overview of the historical evolution of day treatment programs from earlier day hospital model to show day programs' neglect of these factors may have led to treatment failures. Such failures may have spurred recent suggestions that psychiatric day treatment programs should be replaced entirely by assertive community treatment. The authors argue that such a move could amount to abdication of psychiatry's responsibility to provide intensive milieu treatment that can be effectively offered only on a day treatment basis.

Patient characteristics and success in day treatment.

This study examined the ability of seven patient characteristics to predict success (remaining, benefiting) in a day treatment program for psychiatric outpatients. The sample consisted of 165 patients, most with affective and personality disorders, who participated in an intensive psychodynamically and group-oriented program within a controlled clinical trial. Two patient personality characteristics (psychological mindedness, quality of object relations) emerged as the strongest predictors. Other variables that contributed to the predictions, either singly or in an interaction with quality of object relations, were age, marriage, presence of a personality disorder, and previous psychiatric hospitalization. The patient's initial level of symptomatic disturbance was not a significant predictor. The advantage of using predictors that are relevant to the theoretical and technical orientation of a program is emphasized.

Psychological mindedness, work, and outcome in day treatment.

A recently completed clinical trial that investigated the effectiveness of a group-oriented, day treatment program provided an opportunity to pursue a multidimensional approach to the prediction of treatment outcome. The sample consisted of 99 psychiatric outpatients, most of whom had received diagnoses of affective and personality disorders. The predictor variables included a patient personality characteristic (psychological mindedness), a group process variable (patient work), and their interaction. Univariate analyses revealed significant direct relationships between psychological mindedness and both work and favorable outcome, and between work and favorable outcome. Multivariate analyses indicated that psychological mindedness and work had independent significant relationships (additive or interactive) with several of the outcome variables. In combination they accounted for up to a quarter of the outcome variance. The results demonstrate the benefit of using a theoretically consistent multidimensional approach. The time-efficient nature of the predictor measures used in the study make them particularly amenable for use by clinicians and researchers.

Staff-staff relations group.

This article describes, through the use of clinical examples, how a staff-staff relations group functions in a brief, evening, partial-hospitalization program, and how it differs from other groups within the program. It further illustrates how the appropriate use of this group allows staff to work together harmoniously and treat patients more effectively. This article also compares and contrasts this method of dealing with staff-staff and staff-patient conflict with other approaches.

Concentration and correspondence of transference interpretations in short-term psychotherapy.

This article provides a review of research on the relationship between aspects of transference interpretation and outcome in dynamic psychotherapy. It also presents the results of a recently completed study that focused on 2 aspects of transference interpretations, concentration and correspondence. Significant relationships between each of these 2 aspects and both therapeutic alliance and outcome were found, as well as an interaction effect for outcome. The relationships differed as a function of the patient personality characteristic known as quality of object relations. The results concerning correspondence were consistent with those of previous studies that investigated the correctness of interpretations. The overall findings suggest that (a) variation in technique may make a difference in brief dynamic therapy and (b) variation and impact of technique may have been masked in some previous studies and reviews.

A randomized trial of psychiatric day treatment for patients with affective and personality disorders.

OBJECTIVE: The outcome of a day treatment program for psychiatric outpatients with affective and personality disorders was evaluated. The program was dynamically oriented, intensive, group focused, and time limited (18 weeks). METHODS: The prospective trial used a randomized treatment-versus-control (delayed-treatment) design to examine 17 outcome variables covering five areas: interpersonal functioning, symptomatology, self-esteem, life satisfaction, and defensive functioning. Those variables, plus individualized treatment objectives, were monitored before and after the treatment and control periods and at follow-up an average of eight months later. RESULTS: Treated patients showed significantly better outcome than control patients for seven of the 17 outcome variables: social dysfunction, family dysfunction, interpersonal behavior, mood level, life satisfaction, self-esteem, and severity of disturbance associated with individual goals of treatment as rated by an independent assessor. The findings could not be accounted for by diagnosis or use of medication. Benefits were maintained over the follow-up period. The average treatment-versus-control effect size for all 17 variables was .71. CONCLUSIONS: The study supports the efficacy of an intensive day treatment program for patients who manifest significant difficulties associated with affective and personality disorders.

Understanding the relationship between transference interpretation and outcome in the context of other variables.

Transference interpretation has traditionally been regarded as a powerful distinguishing feature of dynamically oriented psychotherapy. The failure of early studies to demonstrate its impact on outcome may, in part, have been due to limitations in methodology and conceptual models. A recently completed clinical trial of short-term individual psychotherapy has provided evidence of associations between two aspects of transference interpretation and outcome. The two aspects were concentration (frequency expressed as a proportion of interventions) and correspondence (congruence with a patient formulation). The nature of the associations varied as a function of the patient characteristic known as quality of object relations. Also important was the therapeutic alliance. When the variables were considered together in a multivariate model and their relationships examined by means of multiple regression, substantial amounts of outcome variance were accounted for. The evidence from previous and recent studies suggests that technique can have an important impact on outcome in short-term individual psychotherapy. It also indicates that the impact of technique should be viewed in relation to patient and relationship variables.

Transference interpretations, therapeutic alliance, and outcome in short-term individual psychotherapy.

Relationships between the proportion of transference interpretations provided by therapists and both therapeutic alliance and therapy outcome were investigated for a sample of 64 patients who had received approximately 20 sessions of short-term individual psychotherapy within a controlled, clinical trial investigation. Inverse relationships were found between the proportion of transference interpretations and both therapeutic alliance and favorable therapy outcome for patients with a history of high quality of object relations. An examination of individual sessions revealed evidence that was consistent with two different, but not mutually exclusive, causal explanations. The first concerned the negative effects of high proportions of transference interpretations; the second concerned the reaction of the therapist to the presence of a weak therapeutic alliance. While the evidence from our study was correlational, it was sufficiently strong to warrant alerting clinicians to the possibility of negative treatment effects when high levels of transference interpretations are used with certain types of patients receiving short-term individual psychotherapy.

Quality of object relations versus interpersonal functioning as predictors of therapeutic alliance and psychotherapy outcome.

The purpose of the study was to compare an interview measure of quality of object relations to questionnaire and interview measures of recent interpersonal functioning with respect to the prediction of therapeutic alliance and psychotherapy outcome. The sample consisted of 64 patients who had received approximately 20 sessions of short-term individual psychotherapy within a controlled, clinical-trial investigation. Ratings of therapeutic alliance were provided independently by the patient and the therapist after each session. Outcome measures, which were provided by three sources (patient, therapist, and independent assessor), covered the areas of interpersonal functioning, psychiatric symptomatology, self-esteem, and life satisfaction. Quality of object relations, which characterizes the patient's lifelong pattern of relationships, was the best predictor. It was significantly related to patient-rated and therapist-rated therapeutic alliance and to patient improvement of both general symptomatology and specific target problems. The study also replicated previous studies that have reported significant relationships between therapeutic alliance and therapy outcome. The advantages of pretherapy predictors of therapy outcome, such as quality of object relations, are discussed.

The Quality of Object Relations Scale.

The Quality of Object Relations Scale (QORS) provides a methodological and theoretical framework for personality classification based on relative level and quality of object relations. The authors believe that many available clinical assessment systems have little heuristic value, and propose that the QORS yields more meaningful descriptions of people. They discuss its theoretical basis in psychoanalytic object relations theory, and how its construction and rationale represent an attempt to incorporate recent thought relevant to the classification of personality. They include criteria for its organizational levels, prototypical vignettes, and a case demonstration. They also explore methodological issues relevant to clinical use and present reliability and validity data derived from empirical studies.

Patient suitability and outcome in short-term individual psychotherapy.

The effects of short-term (time-limited), dynamically oriented individual therapy and the patient characteristic quality of object relations (QOR) were studied in a controlled clinical trial involving 8 experienced therapists and 144 psychiatric outpatients. A comprehensive set of outcome scores was monitored at 5-month intervals including a follow-up assessment. A strong treatment effect that was maintained at follow-up was found. The effect was evident in terms of statistical significance, effect size, and clinical significance. Evidence for an additive effect of the combination of treatment and QOR was also found. The best results were attained by high QOR therapy patients, and the worst results were attained by low QOR control patients. The results were suggestive of an optimal match between type of patient and type of therapy.

Large-group psychotherapy in a day treatment program.

The potential for psychotherapy in a large-group format has been discussed since the 1960s. Day treatment programs provide optimal support for such groups. One program type, which has maintained large-group psychotherapy as a central feature for over twenty years, is described. Essential features include an integrated therapeutic team, with clearly defined leadership, that is open to examination of its own process. Such groups may not only provide effective therapy, but are also readily amenable for teaching and research in psychotherapy.

The impact of data-based program modifications on the satisfaction of outpatients in group psychotherapy.

A previous assessment of patient satisfaction in our outpatient clinic indicated that patients in group psychotherapy were relatively dissatisfied with services in contrast to patients receiving other forms of therapy. A rational analysis on the part of program staff identified areas where modifications of the group therapy program could be implemented. These program changes are described. Satisfaction ratings of group therapy patients from a subsequent assessment project were compared to ratings from the initial study. Comparisons indicated that an improvement in the level of satisfaction of group patients was evident, providing support for the view that our program changes had had the desired beneficial impact. Results are discussed with regard to the value of ongoing evaluation and data-based modification of delivery services for the continuing improvement of patient care.