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).

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.

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.

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.

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.

Perceived Case Management Needs and Service Preferences of Frequent Emergency Department Users: Lessons Learned in a Large Urban Centre.

OBJECTIVES: This study aimed to explore the service needs and preferences of frequent emergency department users with mental health and addictions concerns who participated in a brief intensive case management intervention. METHODS: We conducted semi-structured individual interviews with 20 frequent emergency department users with mental health and addictions challenges, 13 service providers involved in the delivery of a brief case management intervention, and a focus group with intervention case managers. Thematic analysis was used to explore perceived service user profiles, service needs and preferences of care. RESULTS: Service users experienced complex health and social needs and social isolation, while exhibiting resilience and the desire to contribute. They described multiple instances of stigmatization in interactions with healthcare professionals. Components of the brief intensive case management intervention perceived to be helpful included system navigation, advocacy, intermediation, and practical needs assistance. Frequent service users valued relational responsiveness, a non-judgmental stance, and a recovery orientation in case managers. CONCLUSION: Interventions for frequent service users in mental health may be enhanced by focusing on the engagement of formal and informal social supports, practical needs assistance, system navigation, advocacy and intermediation, and attention to the recovery goals of service users.

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.

Improving continuity of care for frequent users of emergency departments: service user and provider perspectives.

OBJECTIVE: This study explored service user and provider perspectives on barriers and facilitators of continuity of care for frequent users of emergency departments (ED) participating in a brief intensive case management intervention. METHOD: We conducted semistructured interviews with 20 frequent ED users with mental health and addiction challenges participating in a brief intensive case management intervention, eliciting experiences of care and care continuity. We interviewed 13 service providers working with this population. We used thematic analysis to determine shared and unique barriers and facilitators to continuity of care, and we gave priority to themes reported by both service users and providers. RESULTS: Within fragmented systems of care, strong working relationships between service users and providers, timely access to coordinated services and seamless transitions to needed supports increased perceived care continuity. Barriers to continuity of care included difficulties engaging this population, short intervention duration and the lack of a single accountable service provider to address health and social needs. CONCLUSION: Although brief intensive case management interventions have the potential to improve continuity of care for frequent ED users, continuity of care, especially for people with complex health and social needs, may be compromised by program and personal characteristics as well as lack of broader system integration.

Engagement in Group Psychotherapy Among Marginalized Individuals With Hepatitis C.

This article examines an innovative psychoeducational group model at a community-based hepatitis C treatment program in Toronto, Canada. Group support is increasingly used as part of community-based, interdisciplinary approaches to addressing the complex psychosocial needs and barriers to care of individuals living with and/or undergoing treatment for hepatitis C. This article articulates the theoretical framework and details of one such group model. It also examines group engagement and outcomes using data collected over three group cycles. Psychotherapeutic engagement was higher than might be anticipated for a highly marginalized population. Specifically, group cohesion measures were equivalent or higher compared to norms for other support/psychotherapy groups. This study suggests that individuals with complex psychosocial issues have the ability to engage meaningfully in group therapy.

What clinicians want: findings from a psychotherapy practice research network survey.

Practice research networks may be one way of advancing knowledge translation and exchange (KTE) in psychotherapy. In this study, we document this process by first asking clinicians what they want from psychotherapy research. Eighty-two psychotherapists in 10 focus groups identified and discussed psychotherapy research topics relevant to their practices. An analysis of these discussions led to the development of 41 survey items. In an online survey, 1,019 participants, mostly practicing clinicians, rated the importance to their clinical work of these 41 psychotherapy research topics. Ratings were reduced using a principal components analysis in which 9 psychotherapy research themes emerged, accounting for 60.66% of the variance. Two postsurvey focus groups of clinicians (N = 22) aided in interpreting the findings. The ranking of research themes from most to least important were-Therapeutic Relationship/Mechanisms of Change, Therapist Factors, Training and Professional Development, Client Factors, Barriers and Stigma, Technology and Adjunctive Interventions, Progress Monitoring, Matching Clients to Therapist or Therapy, and Treatment Manuals. Few differences were noted in rankings based on participant age or primary therapeutic orientation. Postsurvey focus group participants were not surprised by the top-rated items, as they were considered most proximal and relevant to therapists and their work with clients during therapy sessions. Lower ranked items may be perceived as externally imposed agendas on the therapist and therapy. We discuss practice research networks as a means of creating new collaborations consistent with KTE goals. Findings of this study can help to direct practitioner-researcher collaborations.

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.

Adapting ACT to serve culturally diverse communities: a comparison of a Japanese and a Canadian ACT team.

OBJECTIVE: The assertive community treatment (ACT) teams of Mount Sinai Hospital in Toronto and the KUINA Center, Hitachinaka, Japan, were compared with regard to ACT fidelity, organizational structure, populations served, and treatment outcomes. Ethnocultural adaptations to the ACT model made by both teams included enhanced family support and intervention, culturally and linguistically matched staff and patients when possible, culturally informed therapy, routine cultural assessments, culturally matched housing and community support, and flexible funding models. METHODS: Data were gathered by chart reviews (66 patients in Toronto and 40 patients in Japan), a satisfaction measure, a standard measure of ACT fidelity, and a pre-post measure of treatment outcomes (the Brief Psychiatric Rating Scale), and hospitalization days. RESULTS: Both teams achieved good fidelity to ACT and reductions in hospitalization and symptom severity. Family satisfaction scores were high. CONCLUSIONS: With culturally informed adaptations, ACT can be effective in a Canadian mixed ethnocultural population and a homogeneous Japanese population.