Group Therapy for Patients With Medical Illness.

This article aims to review the expanding role of group psychotherapy in the treatment of individuals with medical illnesses, an area that has expanded dramatically during the past 30 years. The fundamental principles of adaptation of group therapies for specialized clinical populations are articulated. Clarity of goals and thoughtful alignment with patient interests and needs are at the heart of building a strong therapeutic alliance and potentiate the effectiveness of group therapy. This article also discusses the conceptual underpinnings of group therapies and the ways in which group therapeutic factors gain expression with these clinical populations. This article also focuses on breast cancer, in light of its clinical prominence and the development of group therapies for individuals with the disease. These therapies address clinical concerns for women along the continuum of the disease, including familial and genetic predisposition, primary breast cancer, adaptation to illness and its treatment, metastatic disease, and dealing with mortal illness.

Psychotherapy Competency Milestones: an Exploratory Pilot of CBT and Psychodynamic Psychotherapy Skills Acquisition in Junior Psychiatry Residents.

OBJECTIVE: Psychiatry residents train in Psychodynamic Psychotherapy and Cognitive Behavioral Therapy (CBT), evidence-supported treatments used in mental health care that can facilitate clinical reasoning, foster therapeutic alliances, and improve clinical outcomes. However, empirically derived milestones are needed to evaluate competency. This exploratory pilot examined changes over 1 year of training in junior psychiatry residents' competency milestone elements in Psychodynamic Psychotherapy and CBT. METHODS: Seventy-nine randomly selected audio-recorded sessions from differing phases of Psychodynamic Psychotherapy and CBT with five junior residents and ten patients were rated using the Psychotherapy Process Q-sort (PQS). RESULTS: In both treatments, patient engagement with attention to in-session emotions improved. In CBT, residents were directive, supported patients' self-efficacy, emphasized patients' accepting responsibility for their problems, discussed homework such as thought records, and focused on termination in the concluding sessions. In Psychodynamic Psychotherapy, residents attended to emotional arousal and linked patients' feelings or perceptions to past situations or behavior. Growth and hierarchical linear modeling differentiated these treatments, with CBT v. Psychodynamic adherence to PQS modality-specific ideal elements being 52% v.19%. CONCLUSION: Teaching and observation using empirically derived observable psychotherapy practice behaviors is feasible and can be used to assess milestone elements for competency-based education of psychiatry trainees.

A randomized controlled trial of a supportive expressive group intervention for women with a family history of breast cancer.

OBJECTIVE: Women with a family history of breast cancer (BC) often overestimate their BC risk. Heightened psychological distress may interfere with risk comprehension and screening adherence. The primary purpose of this study was to test the efficacy of a 12-week manual-based supportive-expressive (SE) group intervention for this population. METHODS: Using a randomized control trial design, this study compared two interventions: a standard risk-counseling arm (RC) compared with that plus SE group intervention. The primary study outcome was BC anxiety. Secondary outcomes included psychosocial functioning, risk comprehension, BC knowledge, and screening behaviors. RESULTS: A total of 161 women with a family history of BC were randomized into SE (N = 108) or RC (N = 53). Participants in both study arms significantly improved on measures of BC anxiety, psychosocial functioning, risk comprehension, and BC knowledge, with no statistical difference between study arms. Benefits were sustained at 1 year. BC screening rates were high in both arms at baseline and follow-up. CONCLUSIONS: SE group therapy as an added intervention to the risk counseling was well-received, however, did not demonstrate superiority to RC alone. Future studies on treatment matching are needed to further our understanding of interventions that can support women with a family history of BC to work through residual issues, including loss and grief.

Brief case management versus usual care for frequent users of emergency departments: the Coordinated Access to Care from Hospital Emergency Departments (CATCH-ED) randomized controlled trial.

BACKGROUND: Frequent users of hospital emergency departments (EDs) are a medically and socially vulnerable population. This article describes the rationale for a brief case management intervention for frequent ED users with mental health and/or addiction challenges and the design of a randomized trial assessing its effectiveness. METHODS/DESIGN: Eligible participants are adults in a large urban centre with five or more ED visits in the past year, with at least one prior visit for a mental health or addictions reason. Participants (N = 166) will be randomized to either 4 to 6 months of brief case management or usual care, and interviewed every 3 months for 1 year. Consent will be sought to access administrative health records. A subset of participants (N = 20) and service providers (N = 13) will participate in qualitative data collection. DISCUSSION: Addressing the needs of frequent ED users is a priority in many jurisdictions. This study will provide evidence on the effectiveness of brief case management, compared to usual care, on reducing ED visits among frequent ED users experiencing mental health or substance misuse problems, and inform policy and practice in this important area. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01622244 . Registered 4 June 2012.

Integrating care for frequent users of emergency departments: implementation evaluation of a brief multi-organizational intensive case management intervention.

BACKGROUND: Addressing the needs of frequent users of emergency departments (EDs) is a health system priority in many jurisdictions. This study describes stakeholder perspectives on the implementation of a multi-organizational brief intervention designed to support integration and continuity of care for frequent ED users with mental health and addictions problems, focusing on perceived barriers and facilitators to early implementation in a large urban centre. METHODS: Coordinating Access to Care from Hospital Emergency Departments (CATCH-ED) is a brief case management intervention bridging hospital, primary and community care for frequent ED users experiencing mental illness and addictions. To examine barriers and facilitators to early implementation of this multi-organizational intervention, between July and October 2012, 47 stakeholders, including direct service providers, managers and administrators participated in 32 semi-structured qualitative interviews and one focus group exploring their experience with the intervention and factors that helped or hindered successful early implementation. Qualitative data were analyzed using thematic analysis. RESULTS: Stakeholders valued the intervention and its potential to support continuity of care for this population. Service delivery system factors, including organizational capacity and a history of collaborative relationships across the healthcare continuum, and support system factors, such as training and supervision, emerged as key facilitators of program implementation. Operational challenges included early low program referral rates, management of a multi-organizational initiative, variable adherence to the model among participating organizations, and scant access to specialty psychiatric resources. Factors contributing to these challenges included lack of dedicated staff in the ED and limited local system capacity to support this population, and insufficient training and technical assistance available to participating organizations. CONCLUSIONS: A multi-organizational brief intervention is an acceptable model to support integration of hospital, primary and community care for frequent ED users. The study highlights the importance of early implementation evaluation to identify potential solutions to implementation barriers that may be applicable to many jurisdictions.

Psychotherapy Knowledge Translation and Interpersonal Psychotherapy: Using Best-Education Practices to Transform Mental Health Care in Canada and Ethiopia.

Psychotherapies, such as Interpersonal Psychotherapy (IPT), that have proven effective for treating mental disorders mostly lie dormant in consensus-treatment guidelines. Broadly disseminating these psychotherapies by training trainers and front-line health workers could close the gap between mental health needs and access to care. Research in continuing medical education and knowledge translation can inform the design of educational interventions to build capacity for providing psychotherapy to those who need it. This paper summarizes psychotherapy training recommendations that: adapt treatments to cultural and health organizational contexts; consider implementation barriers, including opportunity costs and mental health stigma; and engage local opinion leaders to use longitudinal, interactive, case-based teaching with reflection, skills-coaching, simulations, auditing and feedback. Community-based training projects in Northern Ontario, Canada and Ethiopia illustrate how best-education practices can be implemented to disseminate evidence-supported psychotherapies, such as IPT, to expand the therapeutic repertoire of health care workers and improve their patients' clinical outcomes.

Improving physician-patient communication through coaching of simulated encounters.

OBJECTIVE: Effective communication between physicians and their patients is important in optimizing patient care. This project tested a brief, intensive, interactive medical education intervention using coaching and standardized psychiatric patients to teach physician-patient communication to family medicine trainees. METHODS: Twenty-six family medicine trainees (9 PGY1, 11 PGY2, 6 fellows) from five university-affiliated hospitals conducted four once-weekly, 30-minute videotaped interviews with "difficult" standardized patients. After each interview, trainees received 1 hour of individual coaching that incorporated self-assessment and skills-teaching from experienced psychiatrists. Two follow-up interviews with standardized patients occurred 1 week and an average of 6 months post-intervention. Trainee self-reported physician-patient communication efficacy was measured as a control 1 month before the intervention; during the month of the intervention; and an average of 6 months after the intervention. Coach-rated physician-patient communication competence was measured each week of the intervention. RESULTS: Improvements in physician-patient communication were demonstrated. Self-efficacy for physician-patient communication improved significantly during the intervention, in contrast to no improvement during the control period (i.e., training-as-usual). This improvement was sustained during the follow-up period. CONCLUSIONS: This innovative educational intervention was shown to be highly effective in improving trainee communication competence and self-efficacy. Future applications of this brief model of physician training have potential to improve communication competence and, in turn, can improve patient care.

When Chinese Culture Encounters Western Interpersonal Group Psychotherapy.

This paper describes the decade-long, successful experience of developing a group therapy training program for mental health professionals in China. The perspectives of two Western group therapy instructors/supervisors and of a Chinese colleague who participated broadly in the program are described. We explore our understanding of Western ideas about group therapy and how these were experienced in the Chinese context. We address the opportunities that emerged at the interface of two very different cultures, and the challenges of translating and integrating Western group therapy principles and practices within a culture with a very different history and worldview.

Training community-based psychotherapists to maintain a therapeutic alliance: A psychotherapy practice research network study.

The goal of this study was to test the efficacy of training community-based psychotherapists who were part of a practice research network to be more attuned to their patients' experiences of the therapeutic relationship. We were particularly interested in the effect of therapist training on the congruence of alliance ratings with their patients. Forty psychotherapists who treated 117 patients were randomly assigned to receive either no training or training, whose learning objectives were to help therapists to develop and maintain a therapeutic alliance. The training included workshops and ongoing consultations to help the clinician to strengthen the therapeutic relationship with the use of mentalizing, attachment theory, countertransference management, and metacommunication. Therapeutic alliance and well-being outcomes were measured at each of six consecutive early psychotherapy sessions. We used the truth and bias model and response surface analysis within a multilevel modeling context to test hypotheses. There was a significantly faster rate of alliance growth in the training versus the no training condition when the alliance was rated by therapists, but not when rated by patients. Trained therapists experienced greater temporal congruence in alliance ratings with their patients compared to untrained therapists. Patient well-being outcomes improved in a session when trained therapists and their patients agreed in their positive alliance ratings in a previous session. This association not significant among untrained therapists. Training therapists in key interpersonally focused skills may lead them to be better attuned to their patients' experiences of the therapeutic relationship. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Computer-assisted resilience training to prepare healthcare workers for pandemic influenza: a randomized trial of the optimal dose of training.

BACKGROUND: Working in a hospital during an extraordinary infectious disease outbreak can cause significant stress and contribute to healthcare workers choosing to reduce patient contact. Psychological training of healthcare workers prior to an influenza pandemic may reduce stress-related absenteeism, however, established training methods that change behavior and attitudes are too resource-intensive for widespread use. This study tests the feasibility and effectiveness of a less expensive alternative - an interactive, computer-assisted training course designed to build resilience to the stresses of working during a pandemic. METHODS: A "dose-finding" study compared pre-post changes in three different durations of training. We measured variables that are likely to mediate stress-responses in a pandemic before and after training: confidence in support and training, pandemic-related self-efficacy, coping style and interpersonal problems. RESULTS: 158 hospital workers took the course and were randomly assigned to the short (7 sessions, median cumulative duration 111 minutes), medium (12 sessions, 158 minutes) or long (17 sessions, 223 minutes) version. Using an intention-to-treat analysis, the course was associated with significant improvements in confidence in support and training, pandemic self-efficacy and interpersonal problems. Participants who under-utilized coping via problem-solving or seeking support or over-utilized escape-avoidance experienced improved coping. Comparison of doses showed improved interpersonal problems in the medium and long course but not in the short course. There was a trend towards higher drop-out rates with longer duration of training. CONCLUSIONS: Computer-assisted resilience training in healthcare workers appears to be of significant benefit and merits further study under pandemic conditions. Comparing three "doses" of the course suggested that the medium course was optimal.

Multi-family psycho-education group for assertive community treatment clients and families of culturally diverse background: a pilot study.

This study evaluates the incorporation of Multi-Family Psycho-education Group (MFPG) to an Assertive Community Treatment Team developed to serve culturally diverse clients who suffers from severe mental illness. Participants included Chinese and Tamil clients and their family members. Family members' well-being, perceived burden, and acceptance of clients were assessed before and after the intervention. Focus group interviews with clinicians were conducted to qualitatively examine MFPG. Family members' acceptance increased after MFPG. Regular attendance was associated with reduction in perceived family burden. Culturally competent delivery of MFPG enhanced family members' understanding of mental illness and reduced stress levels and negative feelings towards clients.

Interpersonal group psychotherapy for comorbid alcohol dependence and non-psychotic psychiatric disorders.

Alcohol-dependent patients (N = 15) with comorbid non-psychotic psychiatric disorders were treated with Modified Interpersonal Group Therapy (MIGT) for eight weeks, 16 sessions, in a pilot intervention trial. Analysis of the group participants demonstrated that they achieved statistically significant improvements at post-treatment in four of five self-report outcome measures: number of drinking days, number of heavy drinking days, the Brief Symptom Inventory, and the Beck Depression Inventory. Furthermore, the improvements in heavy drinking days and the Brief Symptom Inventory were maintained at two and eight months post-treatment. This study yields preliminary evidence in support of MIGT as a useful treatment approach for an alcohol-dependent population with psychiatric comorbidity.

Applying the lessons of SARS to pandemic influenza: an evidence-based approach to mitigating the stress experienced by healthcare workers.

We describe an evidence-based approach to enhancing the resilience of healthcare workers in preparation for an influenza pandemic, based on evidence about the stress associated with working in healthcare during the SARS outbreak. SARS was associated with significant long-term stress in healthcare workers, but not with increased mental illness. Reducing pandemic-related stress may best be accomplished through interventions designed to enhance resilience in psychologically healthy people. Applicable models to improve adaptation in individuals include Folkman and Greer's framework for stress appraisal and coping along with psychological first aid. Resilience is supported at an organizational level by effective training and support, development of material and relational reserves, effective leadership, the effects of the characteristics of "magnet hospitals," and a culture of organizational justice. Evidence supports the goal of developing and maintaining an organizational culture of resilience in order to reduce the expected stress of an influenza pandemic on healthcare workers. This recommendation goes well beyond the provision of adequate training and counseling. Although the severity of a pandemic is unpredictable, this effort is not likely to be wasted because it will also support the health of both patients and staff in normal times.

Evidence-based group psychotherapy: using AGPA's practice guidelines to enhance clinical effectiveness.

Practice guidelines represent a useful approach to facilitate the delivery of evidence-based mental health care. In this article, we detail group psychotherapy practice guidelines developed by the American Group Psychotherapy Association (AGPA). Combining the research literature with expert consensus, the AGPA has created a resource that should prove useful for psychotherapists, administrators, and patients. We illustrate the guidelines through a series of clinical dilemmas and challenges.

Horror films: tales to master terror or shapers of trauma?

The authors review the literature of cinematic-related psychiatric case reports and report the case of a 22-year-old woman who presented with intrusive thoughts of demonic possession and flashbacks of the film The Exorcist. Cinematic neurosis may be considered a form of psychological crisis shaped by exposure to a film narrative that is emotionally and culturally significant to the individual. The structure of horror films are examined from the perspectives of trauma theory, narrative theory, and borderline personality organization theories, using the film The Exorcist as an example. Within this framework, the horror film can be seen as a cultural tale that provides a mechanism for attempting mastery over anxieties involving issues of separation, loss, autonomy, and identity. An individual will identify with narrative elements that resonate in personal life experiences and cultural factors embedded within the film, which carry levels of either stress that will be mastered, or act as a trauma to the viewer. The outcome of this exposure is related to how the individual's personality structure is organized in combination with the stresses they are experiencing.

The Interpersonal Model of Group Psychotherapy.

The interpersonal model of group psychotherapy, predicated on the early work of Harry Stack Sullivan and subsequently developed into a comprehensive model of group psychotherapy by Irvin Yalom, is described in this article. Using the common clinical illustration and descriptions of group members, the authors address the theoretical underpinnings of the interpersonal model of group psychotherapy; ways of maximizing patient engagement; group leadership principles; and the group leader's responsibility to facilitate the group effectively within the here-and-now. Core elements that will be addressed include the group leader's role in fostering group cohesion; receptive and expressive aspects of empathy; and interpersonal feedback and therapeutic metacommunication.

The effect of brief case management on emergency department use of frequent users in mental health: Findings of a randomized controlled trial.

Frequent users of hospital emergency departments (EDs) are a medically and socially vulnerable population. The Coordinated Access to Care from Hospital EDs (CATCH-ED) study examined the effectiveness of a brief case management intervention in reducing ED use and improving health outcomes among frequent ED users with mental health or addiction challenges in a large urban centre. Adults (≥18 years of age) who had five or more ED visits in the past 12-months, with at least one visit for mental health or addictions problems were randomized to either brief case management (N = 83) or usual care (N = 83) and followed for 12 months. The primary outcome of effectiveness was the frequency of ED visits during 12 months after study enrolment. Secondary outcomes included days in hospital, mental health and addiction symptom severity and health-related quality of life, measured by the SF-12. Compared to usual care, CATCH-ED participants saw a 14% reduction in frequency of ED visits during the 12-month post-randomization period [rate ratio (RR) = 0.86, 95% CI 0.64-1.15)], however, this finding did not reach statistical significance. There were also no statistically significant differences between the groups at 12 months in the number of days spent in hospital (RR = 1.16, 95% CI 0.59-2.29), physical (1.50, 95% CI -2.15-5.15) or mental (-3.97, 95% CI -8.13-0.19) component scores of the SF-12, severity of psychiatric symptoms (-0.41, 95% CI -2.30-1.49), alcohol (0.053 95% -0.017-0.12) or drug (-0.0027, 95% CI -0.0028-0.023) use. Compared to usual care, a brief case management intervention did not result in significantly reduced ED use or improved health outcomes among frequent ED users with mental health or addictions challenges in a large urban centre in Canada. Future studies need to evaluate the availability and accessibility of community-based resources for individuals with frequent ED use.

A group intervention to promote healthy self-concepts and guide recovery in first episode schizophrenia: A pilot study.

The stress associated with managing a first episode of schizophrenia and the secondary psychological sequelae may predispose young people to the phenomenon of illness engulfment, whereby personal identity is lost and replaced with a sense of self defined entirely by the illness. The overall objective of this pilot project was to provide an initial evaluation of the impact of a novel group intervention targeting improvement of self-concept (engulfment) and overall quality of life for young adults recovering from a first episode of schizophrenia. Fifty-two young adults diagnosed with a DSM-IV schizophrenia spectrum disorder were sequentially assigned to either a 12-week group intervention that provided members with opportunities to attain healthy self-concepts or a control group that received high quality treatment as usual. The two groups were compared on pretreatment, post-treatment, and 3-month post-treatment measures of engulfment, quality of life, and psychiatric symptoms. Allowing for dropouts, 26 subjects remained in the treatment group and 14 subjects in the control group after the 3-month follow-up. Participants in the treatment group demonstrated significant improvement in engulfment, quality of life (intrapsychic subscale) and symptoms, while the comparison group did not change. These preliminary results provide support for the benefits of a group intervention designed to enhance self-concept and to minimize the engulfing effects of illness.