A randomized controlled trial of a gender-focused addiction model versus 12-step facilitation for women veterans.

BACKGROUND AND OBJECTIVES: Substance use disorder (SUD) has increased among women, including military veterans, yet SUD treatment was historically designed for males. This randomized controlled trial compared 12 individual sessions of a gender-focused SUD recovery model, A Woman's Path to Recovery (WPR) to an evidence-based, non-gender-focused SUD model, 12-Step Facilitation (TSF) for 66 women veterans with current severe SUD. METHODS: The primary outcome was substance use; secondary outcomes were associated problems (e.g., psychological); coping skills, and 12-step attendance, with assessment at baseline, end-of-treatment, and 3-month followup. RESULTS: Substance use decreased over time, with no difference between conditions. Decreases occurred from baseline to end-of-treatment and baseline to followup and, for drug severity, also from end-of-treatment to followup. Effect sizes were large for alcohol and medium otherwise. Secondary outcomes were largely consistent with this pattern of improvement. Urinalysis/breathalyzer supported self-report. Treatment attendance was 62% for WPR and 57% for TSF (not significantly different). Twelve-step group attendance, surprisingly, did not increase in either condition. DISCUSSION AND CONCLUSIONS: WPR provides a useful addition to women's SUD treatment options, with outcomes no different than an established evidence-based model, TSF. Both showed positive impact on substance use and related areas. Our lack of differences based on gender-focus may reflect women veterans being acculturated to a male military environment. Limitations include lack of an untreated control, a sample limited to veterans, and use of a large effect size for power assumptions. SCIENTIFIC SIGNIFICANCE: This is the first RCT of a gender-focused approach for women veterans with SUD. (Am J Addict 2018;27:210-216).

Design and analysis of non-pharmacological treatment trials with multiple therapists per patient.

In trials of physical and talking therapies, nesting of patients within therapists has statistical implications analogous to those of cluster randomised trials. Nevertheless, the clustering effect may be more complex, as it interacts with treatment. For some therapies, individual patients may receive care from multiple therapists of the same type, so that patients are no longer strictly nested within therapists, creating a 'multiple-membership' relationship between patients and therapists. This paper considers methods of analysis and sample size estimation for trials with multiple-membership clustering effects. It is motivated by a trial of a psychotherapy for the treatment of adolescent depression with cognitive behavioural therapy. We tested methods and issues in a Monte Carlo simulation study, simulating trials with multiple membership. Results demonstrate satisfactory performance in terms of convergence and give estimates of the intra-cluster correlation coefficient and empirical test size similar to a simple hierarchical design. We derive formulae for sample size and power for multiple-membership trial designs. We then compare estimates of power from this formula with empirical power derived from the simulation study. Finally, we show that we can easily extend formulae for sample size and power to allow consideration of power and sample size for certain types of more complex interventions. These include situations where therapists of different types deliver separate components of the intervention, creating a cross-classified relationship, or where several therapists deliver a group-administered treatment, creating further levels.

Combining group-based exposure therapy with prolonged exposure to treat U.S. Vietnam veterans with PTSD: a case study.

Group-based exposure therapy (GBET) of 16-week duration was developed to treat combat-related posttraumatic stress disorder (PTSD) and decreased PTSD symptoms in 3 noncontrolled open trials with low attrition (0%-5%). Group-based exposure therapy has not produced as much PTSD symptom reduction as Prolonged Exposure (PE) within a U.S. Veterans Affairs PTSD treatment program, although PE had more dropouts (20%). This pilot study was of a model that combined key elements of GBET with components of PE in an effort to increase the effectiveness of a group-based treatment while reducing its length and maintaining low attrition. Twice per week, 8 Vietnam combat veterans with PTSD were treated for 12 weeks, with an intervention that included 2 within-group war trauma presentations per participant, 6 PE style individual imaginal exposure (IE) sessions per participant, daily listening to recorded IE sessions, and daily in vivo exposure exercises. All completed treatment and showed Significant reductions on all measures of PTSD with large effect sizes; 7 participants no longer met PTSD criteria on treating clinician administered interviews and a self-report measure at posttreatment. Significant reductions in depression with large effect sizes and moderate reductions in PTSD-related cognitions were also found. Most gains were maintained 6 months posttreatment.

[Multi-family group therapy in Germany]. / Multifamilientherapie in Deutschland.

Multi-family therapy, common group therapy with several families per one index patient, has been gaining popularity recently. This has occasioned an exploratory study of the status of implementation and common factors in all multi-family therapy programs in Germany. In a survey conducted across Germany, all providers of multi-family therapy interventions were requested to give a detailed description of their intervention. Quantitative data were analyzed with descriptive statistics, and verbal data were summarized categorically with qualitative content analysis. Of the 25 intervention programs examined 21 are directed at emotionally disturbed children and young people and their families; mainly with disturbances in social behavior. Over 4,000 families per year are treated in multi-family therapy, and five programs were systematically evaluated. MFT is characterized by systematically oriented group therapy methods. Those surveyed traced the effect of this form of intervention back to activating problems in the group, activating resources, changing perspective, learning models, experiencing self-efficacy, and the therapeutic relationship. Systematic studies of multi-family therapy in evaluations and in random controlled study designs are recommended.

Combined psychotherapies: searching for an order of operations in a disordered world.

Abstract Recent studies of psychotherapy demonstrate that therapists of different orientations-psychodynamic, cognitive-behavioral, interpersonal, and dialectical behavioral-provide beneficial treatment. Despite the stated adherence of clinicans to one orientation or another, review of session transcripts reveals a substantial overlap in the techniques utilized. Nonspecific or patient factors are the chief determinants of how therapy is conducted in practice. Nevertheless, the psychodynamic orientation offers the most comprehensive approach to therapy because it considers unconscious factors, including transference, enactments, and aspects of the patient's personal relationships. The psychodynamic formulation indicates the basis for determing how psychotherapy might best be conducted for the specific patient.

Cognitive-behavior therapy for depressed cancer patients in a medical care setting.

Major depression is the most common psychiatric disorder among cancer patients and is associated with decreased quality of life, significant deterioration in recreational and physical activities, relationship difficulties, sleep problems, more rapidly progressing cancer symptoms, and more metastasis and pain relative to nondepressed cancer patients. Although some research has explored the utility of psychological interventions with cancer patients, only one study to date has explored the potential benefits of cognitive-behavior therapy among cancer patients with well-diagnosed depression. Addressing this gap in the literature, this study represents an open clinical trial to assess the effectiveness of a brief Cognitive-Behavioral Treatment for Depression (CBTD) among depressed cancer patients in a medical care setting. Results revealed strong treatment integrity, good patient compliance, excellent patient satisfaction with the CBTD protocol, and significant pre-post treatment gains across a breadth of outcome measures assessing depression, anxiety, quality of life, and medical outcomes. These gains also were associated with strong effect sizes and generally maintained at 3-month follow-up. Behavioral activation interventions, especially when paired with cognitive techniques, may represent a practical medical care treatment that may improve psychological outcomes and quality of life among cancer patients. Study limitations and future research directions are discussed.

Attachment theory and multiple integrated treatments of borderline patients.

The clinical management of borderline personality disorder (BPD) commonly employs treatments administered in different settings by different clinicians (e.g., individual psychotherapy and drug prescriptions, or individual and group psychotherapies). The general consensus of clinicians on the importance of using different therapists and different settings simultaneously in treating borderline patients is acknowledged by the guidelines for the treatment of BPD provided by the American Psychiatric Association. This widespread type of clinical practice is not supported, however, by a unifying theoretical model explaining the specific effects of a multiple therapist, multi-setting approach in treating BPD.

Can we collaborate? Mistakes made when group and individual therapists ignore multiple realities.

Often, group therapists collaborate with individual therapists in conjoint treatment. Many of these patients start in individual therapy and are referred to the group to help facilitate the treatment and address interpersonal and relational issues that either cannot or will not be addressed in the individual work. Although this has the potential to foster incredible growth for patients, it may also cause problems in treatment when collaboration between therapists falls apart. The current paper will examine mistakes made when multiple realities about a patient are ignored during the pregroup screening and preparation, and feedback from group treatment is not integrated into individual therapy. Clinical examples will be used with specific recommendations for combined treatment planning and interventions. (PsycINFO Database Record

Long-term group psychotherapy for children with pervasive developmental disorders: evidence for group development.

This article highlights the clinical progress of three long-term psychotherapy groups for children with pervasive developmental disorders. Unique aspects of working with such children are addressed as well as their movement through the phases of group development. Clinical observations suggested that these groups did in fact pass through observable phases of cohesion, differentiation, and intimacy. Further, these children demonstrated noticeable social development both inside and outside the groups. They identified strongly with their groups, and after the settling-in period, there was remarkably little resistance to participation, especially given the children's tendencies for social avoidance. Vignettes are provided to illustrate both group developmental phases and noteworthy psychological experiences of the clinical process with children who have been diagnosed with pervasive developmental disorders.

Principles and practice of conjoint psychoanalytic treatment.

The authors describes the advantages of conjoint analytic treatment, which occurs when two or more analysts treat a patient in different settings: one provides the one-to-one relationship, and the other leads the group experience. The goal of this treatment is to increase the therapeutic possibilities for the patient. The advantages come from the use of multiple settings, transferences, observers, interpreters, and maturational agents. The author illustrates the advantages of the treatment with several case reports. He also points out the value of conjoint treatment for the analysts involved.

Observations on 67 patients who took Erhard Seminars Training.

The author describes the effects of Erhard Seminars Training (est) on 67 patients--49 who took est during the course of psychotherapy with him and 18 who were seen for evaluation, consultation, or treatment after having taken est. Responsiveness to est was assessed in terms of individually predefined psychodynamics and treatment goals. Of the 49 patients who took est during therapy, 30 were judged to show some positive response and 19 were rated unchanged. The author believes that est often has a strong influence toward psychotherapeutic movement in patients with good ego strength who are motivated to change.

Psychological regression and marital status: determinants in psychiatric management of burn victims.

Major burn trauma is ordinarily associated with psychological regression, which regularly assumes either an immature, dependent (childlike), or primitive (animal-like) form. Also, the severely burned patient is exquisitely responsive, both constructively and destructively, to behavioral nuances in his or her "significant other," typically, the spouse. Two variables, type of regression and marital status, provide an empirically derived rationale for the psychiatric treatment of behavioral problems affecting patient management, including especially (1) pain-related behavior, (2) intrusive reexperiencing of the trauma, (3) depletion/despair phenomena, and (4) problems related to scarring. Results are more favorable when regression is of the dependent type rather than primitive type. Treatment is enhanced when the partner in a committed relationship is included in the treatment program.

Issues involved in the treatment of an adolescent group.

At first we had a lot of information about what to expect from an adolescent group. But we quickly found an enormous gap between our information and the actual experience and gut feelings. It is important to anticipate many overwhelming feelings! It is also crucial for therapists to be open and honest with themselves and each other about their counter-transferences. Second, we discovered that it is not hopeless! However, it is essential to provide structure via firm, consistent limits and goals. Adolescents need to feel protected by therapists who can manage the group's turbulence. Third, creative techniques frequently provide ways of dealing with feelings. Four, a treatment group cannot survive with too many acters-out; one or two may add spice and give permission to others to recognize and express feelings. Also, despite the often chaotic atmosphere, serious treatment takes place. It has been helpful to have Mrs. Friedman as our supervisor. At critical points, when we were overwhelmed, she helped with her objectivity and support, offering a clearer vision of actual treatment issues when feelings were high. At times when we felt depleted, Mrs. Friedman's support replenished us and we were able to return to the group with enthusiasm. In conclusion, it has been fun working as co-therapists. We have found that the sharing and mutual confrontation contributed significantly to our professional growth.

The dialectical approach in group therapy.

A dialectical therapeutic approach has been used in treating individuals and families. Its application in group therapy is described with the aid of several anecdotal examples.

[Multiple psychotherapy--how many therapists are needed?]. / Multiple Psychotherapie--Wie viele Therapeuten braucht der Mensch?

For a variety of reasons it seems worthwhile to consider Multiple Psychotherapy: 1. A multicausal understanding of psychic and mental illnesses has already led to installing more and more multiple therapeutic settings. 2. Patients suffering from so-called early disturbances show a tendency to split their transference between different members of a therapeutic team. By intentionally employing several team members one may therapeutically make use of these split transferences. 3. As a consequence of the enormous general interest in the psychiatric and therapeutic professions a great number of helpers are at hand, who often do not have enough work and could usefully be brought into action in multiple treatment. This paper presents an overview over multiple Therapy literature and discusses it.

Systemic couple therapy for dysthymia.

We examined the effect of Systemic Couple Therapy on a patient diagnosed with dysthymic disorder and her partner. Marge and Peter, a middle-aged married couple, showed significant and meaningful changes in their pattern of interaction over the course of the therapy and, by the end of it, Marge no longer met the diagnostic criteria for dysthymic disorder. Her scores on the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I) and Beck Depression Inventory, Second Edition (BDI-II) were in the clinical range before treatment and in the nonclinical one at the end of therapy. Although scores on Dyadic Adjustment Scale showed different patterns, both members reported significant improvement. The analysis of change in the alliance-related behaviors throughout the process concurred with change in couple's pattern of interaction. Treatment effects were maintained at 12-month follow-up. Highlights in the therapy process showed the importance of relational mechanisms of change, such as broadening the therapeutic focus into the couple's pattern of interaction, reducing expressed emotion and resentment, as well as increasing positive exchanges. The results of this evidence-based case study should prompt further investigation of couple therapy for dysthymia disorder. Randomized clinical trial design is needed to reach an evidence-based treatment status.