Individual goal achievement in group psychotherapy: The roles of psychological mindedness and group process in interpretive and supportive therapy for complicated grief.

The ability to infer psychological meaning in behaviour-referred to as psychological mindedness-has been posited as a patient characteristic that contributes to the therapy process and consequently to therapeutic success. The present study was developed to examine the relationship between patients' psychological mindedness and improvement in patients' personal treatment goals in interpretive and supportive group therapies for complicated grief, along with patients' importance to group process. The study was conducted with a clinical sample of 109 patients (79% female; average 45 years old) receiving treatment for complicated grief. Patients provided severity of distress ratings for individual target objectives at pretreatment and posttreatment. Psychological mindedness was assessed prior to treatment using the video-based, interviewer-rated Psychological Mindedness Assessment Procedure. Patients' importance to the therapy process was rated by therapists and other patients in interpretive and supportive group therapy for complicated grief. Conditional process modelling tested whether psychological mindedness would contribute to patients' goal achievement through patients' importance to group process, moderated by type of therapy. A significant, conditional indirect effect was observed for psychological mindedness as a predictor of improvement in individual target objectives, through patients' importance to group process as rated by therapists, specifically in interpretive therapy. The findings indicate that patients' psychological mindedness significantly contributes to their achievement of individual goals through their contributions to group process in interpretive group therapy. Further research is needed to understand the facilitation of individual goal achievement in supportive therapy.

Effect of alexithymia on the process and outcome of psychotherapy: a programmatic review.

Most psychotherapeutic approaches assume that individuals have some access to their emotions. Thus, patients who are unable to identify, differentiate, and articulate their emotions present therapists with a difficult challenge. Such patients may suffer from alexithymia. Despite much attention in the clinical literature, research on alexithymia in the treatment setting has been sparse. Thus, many of the assumptions about psychotherapeutic treatment of alexithymic patients remain untested. This article summarizes findings from a series of studies that examined the effect of alexithymia on various aspects of the psychotherapeutic enterprise. Findings indicated that alexithymia has little effect on patients' treatment preferences, yet there was some tendency for alexithymic patients to prefer group therapy. However, alexithymia was associated with poor outcome in both traditional psychodynamic psychotherapy and supportive therapy. This negative effect was found in individual and group psychotherapies. In the context of group therapy, higher levels of alexithymic features elicited negative reactions from one's therapist, which partially contributed to the poor outcome experienced by such patients. Finally, the negative reaction that therapists had toward patients with high alexithymia appeared to be in response to the lack of positive emotion expressed by these patients. Clinical implications and ideas for future research are considered.

Predicting response to day treatment for personality disorder.

OBJECTIVE: Efforts to improve the effectiveness of day treatment should attend to factors that influence treatment response. Our prospective study identified predictors of response to day treatment for personality disorder (PD). METHOD: Patients with a PD, consecutively admitted to a day treatment program, were assessed with self-report and interview measures. Predictors included personality characteristic, demographic, initial disturbance, and PD variables. Patients' overall response to treatment was classified as better, same, or worse, based on change in multiple outcome measures. A comprehensive approach to multivariate modelling was used. RESULTS: The likelihood of being classified as better significantly increased if the patient was more psychologically minded, used avoidance-oriented coping strategies, and had a high level of baseline symptom severity. Probability of being classified as better decreased if the patient had a substance use disorder and a history of high service use. CONCLUSIONS: Identifying factors that affect response to day treatment can help clinicians make better selection decisions or take measures to modify treatment.

Interpersonal predictors of outcome following short-term group therapy for complicated grief: a replication.

The current study represented a replication of previous research, addressing measures of interpersonal relatedness as predictors of outcome for dynamically oriented, short-term group (STG) psychotherapy for patients presenting with complicated grief. In an analysis of data from a comparative trial of two forms (interpretive, supportive) of STG therapy (n = 107), Ogrodniczuk, Piper, McCallum, Joyce and Rosie reported that three distinct indices of interpersonal relatedness-quality of object relations, current social functioning and attachment insecurity-each had significant relationships with measures of treatment outcome, with attachment insecurity emerging as the strongest predictor. The current study (n = 110) was based on data from a subsequent trial of the two therapy approaches that examined the effect of group composition on outcome, by Piper, Ogrodniczuk, Joyce, Weideman and Rosie. Predictor variables and outcome factors involved in the current analyses were similar or identical to those employed by Ogrodniczuk et al., and an identical analytic strategy was followed. Only the patient's attachment insecurity emerged as a strong predictor of psychotherapy outcome, providing a replication of the key finding from the previous study. The clinical implications and limitations of the results are discussed.

Integrated group therapy for a heterogeneous outpatient sample.

This pilot study examined the effects of an innovative 12-week integrated group therapy program for a diagnostically heterogeneous sample of psychiatric outpatients. The study also investigated whether locus of control could predict outcome. The sample consisted of 52 patients who completed treatment. Patients demonstrated statistically significant change on all outcome variables. Effect sizes indicated moderate to large changes on all but one outcome variable. About 50% and 25% of patients made clinically significant and reliable change on measures of depressive and anxious symptoms, respectively. Chance locus of control was inversely associated with improvement. These preliminary findings suggest that a relatively short, but intense and integrated group therapy program may be effective for mixed outpatient samples. Patients who believe that their health is largely affected by chance are less likely to benefit from treatment. Clinical services with limited resources should consider offering an inclusive, comprehensive group therapy program.

Development of the Readiness for Psychotherapy Index.

Evaluation of the probability of success is an important task when selecting patients for psychotherapy. Discussions of selection criteria for psychotherapy often focus on variables that reflect the patient's "readiness." Readiness refers to the patient's positive attitude and preparedness to enter into a therapeutic relationship for the purpose of resolving problems. Although the concept of readiness is generally regarded as highly important, no widely accepted measure of it exists. The objective of the present study was to develop an efficient yet comprehensive measure of readiness for psychotherapy, called the Readiness for Psychotherapy Index (RPI). The study resulted in a 20-item scale that assessed 4 aspects of readiness. All 4 factors had high internal consistencies (> or = 0.70). We found evidence for the convergent and discriminant validity of the RPI. The findings suggest that the RPI may be a useful tool that can be used to assist with the selection of patients for psychotherapy.

Predictors of premature termination of day treatment for personality disorder.

BACKGROUND: Premature termination is a common problem in the treatment of personality disorder. Efforts to improve compliance should begin by recognising risk factors for premature termination. This prospective study identified predictors of premature termination from a day treatment program for personality disorder. METHODS: Consecutively admitted patients with a personality disorder (n = 197) were assessed with self-report and interview measures. Patient personality characteristics were the primary predictors. Others were demographic, initial disturbance, and personality disorder variables. Cox proportional hazards regression was used. RESULTS: Risk of terminating prematurely significantly increased if the patient had been previously hospitalised for psychiatric difficulties, was younger, had fewer prior contacts with health and social services, and had more severe borderline personality disorder traits. CONCLUSIONS: Information about which patients are at high risk for premature termination can help clinicians take measures to modify the risk. This might involve selection decisions, pre-treatment preparation, close monitoring during treatment, or addition of adjunctive interventions.

Alexithymia and therapist reactions to the patient: expression of positive emotion as a mediator.

This study examined patient's expression of emotion as a mediator of the relationship between patient alexithymia and therapist reactions to the patient. We analyzed data from 107 psychiatric outpatients who participated in a randomized controlled trial of two forms of group therapy for complicated grief. Patient alexithymia was assessed using the Toronto Alexithymia Scale-20. Patient's expression of emotion was assessed via sociometric ratings provided by other group members. Therapist reactions to the patient were assessed via therapist's ratings of each member in the group. Patient's expression of positive emotion met all the requirements for being considered a mediator. The findings indicated that the higher the level of alexithymia (specifically, greater difficulty communicating feelings and greater tendency to engage in externally oriented thinking), the less expression of positive emotion by the patient, and the more negative the therapist's reactions to the patient. The mediation provided by expression of positive emotion accounted for over half of the direct effect of alexithymia on therapist reactions to the patient. Future work needs to consider whether a therapist's awareness of a patient's limited capacity to express positive emotions and the negative influence that this can have on his/her reactions to his/her patients can help improve the therapeutic experience with alexithymic patients.

Underutilization of short-term group therapy: enigmatic or understandable?

Given the evidence for the efficacy, applicability, and efficiency of the group therapies, they appear to be underutilized by clinicians, therapists, and researchers. This article considers reasons for their underutilization. The article also considers procedures for lessening patient and therapist tendencies to resist participating in the group therapies relative to individual therapies. Underutilization not only deprives patients of effective treatment for a wide range of problems but deprives therapists from experiencing fascinating and rewarding therapeutic processes. That has been the experience of the author after more than 35 years of conducting and studying group therapies.

Group composition and group therapy for complicated grief.

This prospective study investigated the impact of group composition on the outcome of 2 forms of time-limited, short-term group therapy (interpretive, supportive) with 110 outpatients from 18 therapy groups, who presented with complicated grief. The composition variable was based on the patient's level of quality of object relations. The higher the percentage of patients in a therapy group who had a history of relatively mature relationships, the better the outcome for all patients in the group, regardless of the form of therapy or the individual patient's quality of object relations score. The findings have direct clinical implications for composing short-term therapy groups for outpatients with complicated grief and possibly for other types of group therapies and patient problems.

Therapeutic alliance and cohesion variables as predictors of outcome in short-term group psychotherapy.

The current study explored the relative ability of aggregate therapeutic alliance and cohesion variables to predict short-term group therapy outcome. Data were collected from a comparative trial of two forms of time-limited group psychotherapy for complicated grief (Piper, McCallum, Joyce, Rosie, & Ogrodniczuk, 2001). The therapeutic alliance and elements of the cohesion construct were measured from the perspectives of each patient and the group therapist at intervals during the groups; scores were aggregated across assessments. Hierarchical multiple regression analyses, adjusting for the effects of treatment approach (interpretive vs. supportive) and specific group membership, demonstrated that the patient-rated alliance was a consistent predictor of outcome. Two cohesion measures, reflecting other participants' (therapist, other members) views of the patient's "fit" with the group, also accounted for variation in outcome. Implications of the findings for research and clinical practice, and the limitations of the measurement approach taken in this study, are considered.

National Registry of Psychotherapies.

In the United States, there is a National Registry of Evidence-Based Programs and Practices (NREPP), which is a listing of treatments and interventions in psychotherapy. In 2012, NREPP invited our research team to submit an application for registration of our short-term interpretive group therapy for patients experiencing complicated grief, which we had used since 1986. From the beginning, we experienced difficulties that seemed to be largely attributable to a lack of professional skills required of the director. The director and her team used the metaphor of American football to describe parts of application process. Despite continuing difficulties, we finally completed the application process on time. Eventually, the reviews of the application were completed and the application was approved. The information we provide in this article mainly concerns the trials and tribulations associated with the application process. Overall, the process was frustrating and time-consuming. Consideration of additional variables, such as patient personality characteristics, would likely have provided a more useful set of findings.

Short-Term Group Therapy for Complicated Grief: The Relationship Between Patients' In-Session Reflection and Outcome.

OBJECTIVE: The objective of the present study was to examine the nature of patients' work in two types of short-term group psychotherapy. The study sought to investigate the relationship between patients' psychodynamic work versus supportive work in group psychotherapy and treatment outcome at termination and at 6-month follow-up. Psychodynamic work refers to reflection regarding intrapsychic motivations, defenses, and relational patterns, and supportive work refers to practical problem solving. METHOD: Participants were 110 patients who completed two forms of group therapy for complicated grief: interpretive therapy and supportive therapy. Two types of patients' in-session activity-psychodynamic work and supportive work-were rated by group therapists in both treatments. Pre-post and follow-up outcome domains included general symptoms, grief symptoms, and life dissatisfaction/severity of target objectives. RESULTS: There was no significant difference in the nature of patients' therapeutic work between interpretive and supportive groups. Psychodynamic work was associated with pre-post improvement in grief symptoms. Psychodynamic work was also associated with further improvement in grief symptoms at 6-month follow-up, along with improvement in broader symptom domains. Supportive work was not associated with any pre-post or follow-up benefit. CONCLUSION: The findings provide evidence that psychodynamic work-focused on the development of insight and self-reflection-in group psychotherapy can contribute to further benefit after the completion of treatment. This finding cut across two approaches to short-term group therapy for complicated grief, suggesting that it may reflect a general curative mechanism of group treatments.

Psychological Mindedness and Psychotherapy Process in Short-Term Group Therapy.

Psychological mindedness is regarded as an important patient characteristic that can influence the course of psychotherapy. The purpose of this study was to investigate the relationship between patients' capacity for psychological mindedness and aspects of the group psychotherapy process as experienced and rated by therapists and other group members. Participants were 110 patients who completed two forms of short-term group therapy for the treatment of complicated grief. Psychological mindedness was assessed at pretreatment by external raters using a video-interview procedure. Group therapists assessed patients' therapeutic work and therapeutic alliance following each group therapy session. Therapists and other group members rated each patient's expression of emotion and provided appraisals of their cohesion to each patient throughout the course of therapy. Psychological mindedness was found to be positively associated with several group process variables as rated by the therapist and other group members.

Treatment compliance among patients with personality disorders receiving group psychotherapy: what are the roles of interpersonal distress and cohesion?

It is often assumed that patients with personality disorders have worse compliance in psychotherapy (i.e., attend fewer sessions) than patients without personality disorders. Such an assumption can have negative consequences for the treatment of patients with personality disorders. It also denies the presence of variability in session attendance among patients with personality disorders. Research that attempts to identify the factors that are associated with variability in session attendance among patients with personality disorders is needed. The present study examined the role of interpersonal distress as a predictor of session attendance for patients with personality disorders (n = 72) in two different forms of group psychotherapy (interpretive, supportive). The study also investigated whether patients' cohesion to their group mediated the effect of interpersonal distress on attendance. Findings indicated that interpersonal distress had a strong, direct association with attendance in supportive group therapy, but minimal association in interpretive group therapy. High levels of interpersonal distress were associated with higher attendance in supportive therapy. Furthermore, cohesion to the group accounted for about two-thirds of the effect of interpersonal distress on attendance in supportive group therapy, thus providing compelling evidence for its role as a mediator. Possible explanations and clinical implications of these findings are discussed.

Use of the social relations model by group therapists: application and commentary.

This article presents research findings concerning the relationship of patient positive regard to the outcome of time-limited, short-term group therapy for psychiatric outpatients with complicated grief. The Social Relations Model (SOREMO) of David Kenny was used to investigate this relationship. While the patient's ratings of positive regard of others in the group, known as the Perceiver Effect, accounted for the most variation of the patients' ratings, the other patients' rating of the patient's positive regard, known as the Target Effect, was directly related to favorable change. In addition, a simpler method was used to calculate variables that were analogous to the Perceiver Effect and Target Effect variables of the SOREMO. These variables yielded similar outcome findings. Because of limitations and difficulties associated with learning and using the SOREMO, the simpler method represents a more feasible choice for group therapists who are primarily clinicians or group therapists who wish to collect a small amount of data on an ongoing basis. Even experienced group therapy researchers are likely to find the SOREMO program challenging to use.

When it is not a good fit: Clinical errors in patient selection and group composition in group psychotherapy.

Group psychotherapy provides unique opportunities for clinical errors in the selection of patients and composition of therapy groups. This article introduces some of the difficulties and complexities that can be associated with group composition and patient selection errors. Clinical vignettes from psychodynamic/interpersonal psychotherapy groups are used to illustrate three variations of group composition and selection errors. The first vignette depicts an error in selecting a disruptive patient into a fledgling group. The second vignette portrays an unsuccessful integration of a withdrawn, inhibited patient into an active, exploratory group. The third scenario illustrates challenges associated with poor quality of object relations in homogeneous group composition. Although research on group therapy composition and patient selection is limited, relevant empirical literature is integrated in our discussion of clinical implications and recommendations. (PsycINFO Database Record

Strategies for reducing patient-initiated premature termination of psychotherapy.

Rates of patient-initiated premature termination in different forms of psychotherapy are consistently high. Patient-initiated premature termination is recognized as a significant obstacle to the effective and efficient use of psychotherapy. The literature describes many strategies for preventing premature termination, but lacks integration. This review attempts to provide a concise and comprehensive summary of the strategies that research or clinical experience have suggested may be useful for minimizing patient-initiated premature termination. A search was conducted on the MEDLINE, PsycINFO, and EMBASE databases for literature published between January 1970 and March 2004. Retrieved articles were published in English in peer-reviewed journals and focused on psychotherapy for adults. Thirty-nine publications that discussed strategies for preventing or reducing patient-initiated premature termination of psychotherapy were identified. Surprisingly, only 15 of these were research studies. Most of the retrieved literature consisted of clinical descriptions. The strategies can be assigned to nine categories: pretherapy preparation, patient selection, time-limited or short-term contracts, treatment negotiation, case management, appointment reminders, motivation enhancement, facilitation of a therapeutic alliance, and facilitation of affect expression. Research supports some of the strategies for reducing premature termination. However, methodologically sound studies of prevention strategies remain few in number.