Treatment dropout among veterans and their families: Quantitative and qualitative findings.

BACKGROUND: Psychotherapy noncompletion rates for veterans and their families are high. This study sought to (a) measure noncompletion rates of such patients at a university-based treatment center, (b) compare veteran and family member attrition rates, (c) identify dropout predictors, and (d) explore clinicians' perspectives on treatment noncompletion. METHOD: Using quantitative and qualitative approaches, we analyzed demographic and clinical characteristics of 141 patients (90 military veterans; 51 family members) in a university treatment center. We defined dropout as not completing the time-limited therapy contract. Reviewing semistructured interview data assessing clinicians' perspectives on their patients' dropout, three independent raters agreed on key themes, with interrater coefficient kappa range .74 to 1. RESULTS: Patient attrition was 24%, not differing significantly between veterans and family members. Diagnosis of major depression (MDD) and exposure-based therapies predicted noncompletion, as did higher baseline Hamilton Depression Rating Scale (HDRS) total scores, severe depression (HDRS > 20), lack of Beck Depression Inventory weekly improvement, and history of military sexual trauma. Clinicians mostly attributed noncompletion to patient difficulties coping with intense emotions, especially in exposure-based therapies. CONCLUSION: Noncompletion rate at this study appeared relatively low compared to other veteran-based treatment centers, if still unfortunately substantial. Patients with comorbid MDD/PTSD and exposure-based therapies carried greater noncompletion risk due to the MDD component, and this should be considered in treatment planning. Ongoing discussion of dissatisfaction and patient discontinuation, in the context of a strong therapeutic alliance, might reduce noncompletion in this at-risk population. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Psychotherapy at a Distance.

The 2020 COVID-19 pandemic has abruptly overwhelmed normal life. Beyond the fear and fatality of the virus itself comes a likely wave of psychiatric disorders. Simultaneously, social distancing has changed overnight how psychiatrists and other mental health professionals must treat patients. Telepsychotherapy, until now a promising but niche treatment, has suddenly become treatment as usual. This article briefly reviews the limited clinical evidence supporting different modes of telepsychotherapy, then focuses on how remote therapy affects clinicians and their patients.

Alliance challenges in the treatment of a narcissistic patient: the case of Alex.

People with pathological narcisism, with their conflicted sense of grandiosity and vulnerability, often pose a variety of therapeutic challenges, which may impede these patients' ability to benefit from psychotherapy. To offer a case illustration and provide insight into the intrinsic difficulties of working with this patient group, we examined the treatment of a fictional character, Alex, from the TV series In Treatment. Based on the Shedler-Westen Assessment Procedure-200 we diagnosed Alex with pathological narcissism, and evaluated the treatment process (seven sessions) by reporting on measurements of session-by-session change in explicit working alliance, implicit language alliance, and ruptures and repairs. Over the course of treatment, the working alliance (Working Alliance Inventory-Observer scale) fluctuated with a particularly low bond at session five, identified as a rupture (Rupture Resolution Rating System). Language analysis (Linguistic Inquiry and Word Count) showed that the unconscious aspects of the alliance started to deteriorate just before the rupture occurred. The results illustrate how therapists might be pulled to collude with narcissistic patients' grandiosity, with the risk of neglecting their vulnerability. This fictional portrayal of a treatment with a narcissistic patient may be widely shared with researchers, students and therapists alike, offering a common locus of scholarly attention, and an innovative tool for teaching. Given the lack of empirical treatments for pathological narcissism and the great therapeutic challenges narcissistic patients present, further research and development of clinical guidelines are warranted.