Building Resiliency in Dyads of Patients Admitted to the Neuroscience Intensive Care Unit and Their Family Caregivers: Lessons Learned From William and Laura.

Sustaining a stroke, regardless of its severity, is a life-changing and often traumatizing event that can lead to chronic depression, anxiety, and posttraumatic stress in both survivors and their family caregivers. Psychosocial interventions for emotional distress after stroke are limited, have emphasized psychoeducation rather than skills, treatment of chronic emotional distress rather than prevention, and have targeted either the patient or their caregiver without accounting for the context of their interpersonal relationship. Here we discuss "Recovering Together," a novel program for dyads of patients with stroke and their family caregivers aimed at preventing chronic emotional distress by using cognitive behavioral principles to teach resiliency and interpersonal communication skills beginning during hospitalization in a neuroscience intensive care unit and continuing after discharge via telehealth. We illustrate the case of a pilot dyad enrolled in the Recovering Together program, to showcase how patients and caregivers can engage with and benefit from it. This dyad's experience suggests that Recovering Together is credible, feasible, and useful. The potential dyadic benefit of this intervention lies not only in providing the opportunity to optimize recovery and prevent long-term emotional distress, but also in creating the space to come together as a pair and make meaning from critical illness.

Preventing Chronic Emotional Distress in Stroke Survivors and Their Informal Caregivers.

BACKGROUND/OBJECTIVE: Chronic emotional distress (e.g., depression, anxiety, post-traumatic stress) is common after stroke and interdependent between patients and their informal caregivers. We measured stroke survivors', caregivers', and neurocritical care nurses' views of primary drivers of distress during the stroke experience, and needs and preferences for the structure, topics, mode of delivery, and timing of an intervention to promote emotional recovery. METHODS: We conducted semi-structured interviews with 24 patient-caregiver dyads within the Neuroscience Intensive Care Unit (Neuro-ICU). Additionally, we conducted two focus groups with 15 nurses. Interviews and focus groups were audio-recorded, transcribed, and coded using NVivo 11 (QSR International) software. RESULTS AND CONCLUSIONS: The challenges and impacts of stroke most commonly reported by dyads were: uncertainty about future health, fear of recurrent strokes, negative emotions, and role changes post-stroke. Dyads and nurses agreed that resiliency skills such as mindfulness/focusing on the present, problem solving, gratitude/optimism, self-care, interpersonal communication and developing a supportive team of family, friends, and medical staff are beneficial to optimize recovery. The potential barrier to intervention delivery was accessibility, due to challenges of time and travel to appointments. Participants agreed that starting the intervention at hospitalization and continuing via live video after discharge is an ideal delivery modality. Stroke survivors, caregivers, and Neuro-ICU nurses believe that a resiliency skills-based intervention to prevent chronic emotional distress is necessary and urgent. This qualitative study provides valuable information on the challenges faced by dyads, intervention topics to prioritize, and strategies to maximize feasibility, acceptability, and effect.

When a Patient Is Reluctant To Talk About It: A Dual Framework To Focus on Living Well and Tolerate the Possibility of Dying.

Many patients with serious illness struggle to talk about the possibility of dying; yet basic prognostic awareness is crucial for informed decision making. In this article, we aim to help outpatient clinicians working with seriously ill patients ambivalent, uncomfortable, or fearful of further discussion about the future. We describe a dual framework that focuses on living well while acknowledging the possibility of dying and equips clinicians to help patients hold both possibilities. This dual framework facilitates the developmental process of living as fully as possible while also preparing for the possibility of dying.

Dialectical Behavior Therapy Group Skills Training for Bipolar Disorder.

There is growing evidence that the capacity for emotion regulation is compromised in individuals with bipolar disorder. Dialectical behavior therapy (DBT), an empirically supported treatment that specifically targets emotion dysregulation, may be an effective adjunct treatment for improving emotion regulation and residual mood symptoms in patients with bipolar disorder. In this open, proof-of-concept pilot study, 37 participants engaged in a 12-week DBT group skills training program, learning mindfulness, emotion regulation, and distress tolerance skills. Repeated measures mixed models revealed skill acquisition in the areas of mindfulness, emotion regulation and distress tolerance, as well as improved psychological well-being and decreased emotion reactivity. The results of this study support a burgeoning literature that DBT is a feasible adjunct intervention for patients with bipolar disorder.

Brief inpatient psychotherapeutic technique.

Trainees rotate onto the medical psychiatric inpatient unit at Massachusetts General Hospital every 6 weeks to learn how to conduct brief inpatient psychotherapy from two staff psychologists and one staff psychiatrist. This article focuses on four key therapeutic principles/techniques used when teaching these trainees about brief inpatient psychotherapy. These include support, affective experience and expression, chain analysis, and identification of relational styles/maladaptive relational patterns. We also briefly discuss our approach to training. Theoretical rationale, numerous clinical examples, and empirical support (of inpatient psychotherapy) are provided.

Development and evaluation of targeted psychological skills training for oncology nurses in managing stressful patient and family encounters.

PURPOSE/OBJECTIVES: To reduce workplace stress by developing a brief psychological skills training for nurses and to evaluate program feasibility, acceptability, and preliminary efficacy in decreasing burnout and stress. DESIGN: Intervention development and evaluation. SETTING: Outpatient chemotherapy unit at a comprehensive cancer center. SAMPLE: 26 infusion nurses and oncology social workers. METHODS: Focus groups were conducted with nurses. Results informed the development and evaluation of training for nurses. Participants completed the Maslach Burnout Inventory and Perceived Stress Scale post-training. MAIN RESEARCH VARIABLES: Burnout and stress. FINDINGS: Focus groups indicated strong commitment among nurses to psychosocial care and supported the idea that relationships with patients and families were sources of reward and stress. Stressors included factors that interfered with psychosocial care such as difficult family dynamics, patient behaviors and end-of-life care issues. Psychological skills training was developed to address these stressors. Evaluations suggested that the program was feasible and acceptable to nurses. At two months, participants showed reductions in emotional exhaustion (p = 0.02) and stress (p = 0.04). CONCLUSIONS: Psychological skills training for managing difficult encounters showed feasibility, acceptability, and potential benefit in reducing emotional exhaustion and stress. IMPLICATIONS FOR NURSING: Brief training that targets sources of clinical stress may be useful for nurses in outpatient chemotherapy units. KNOWLEDGE TRANSLATION: Specific stressors in relationships with patients and families present challenges to nurses' therapeutic use of self. Targeted psychological skills training may help nurses problem-solve difficult encounters while taking care of themselves. System-level strategies are needed to support and promote training participation.

Exploring therapeutic alliance in brief inpatient psychotherapy: a preliminary study.

BACKGROUND: Therapeutic alliance is one of the most widely investigated variables in psychotherapy research but few studies have explored its role in inpatient psychotherapy. Many factors likely contribute to the lack of inpatient alliance research including the short length of hospital stays, complexity of patient psychopathology and the burdensome quality of most alliance scales. This paper reports on the development and initial application of two comparable brief scales designed to capture patient and therapist alliance ratings. METHOD: Participants were 20 patients receiving supportive-expressive inpatient psychotherapy. The patients were predominantly depressed women. Baseline measures of distress, symptom severity and functioning were obtained at the first and third sessions. Measures of alliance were obtained at the second session. RESULTS: The brief alliance scales demonstrated adequate internal consistency and the individual items had good adjusted item-to-scale correlations. Consistent with the broad alliance literature, we found that patients rated alliance higher than therapists, patient and therapist alliance ratings were not significantly correlated, and level of functioning was significantly associated with both patients and therapists' alliance ratings. The perceived depth of psychotherapy was also significantly associated with alliance. Unexpectedly, alliance ratings were also negatively associated with improvement during hospitalization. CONCLUSIONS: Overall, the study demonstrates both the feasibility and potential benefit of conducting inpatient psychotherapy research.

Change in emotional processing during a dialectical behavior therapy-based skills group for major depressive disorder.

Across studies, paying attention to and analyzing one's emotions has been found to be both positively and negatively correlated with depression symptoms. One way of reconciling these seemingly contradictory findings is the possibility that attending to emotions in a skillful manner may help to reduce depression whereas attending to emotions with limited skill may be counterproductive. Dialectical behavior therapy (DBT) is a clinical intervention designed to foster adaptive awareness, expression, regulation, tolerance, and acceptance of emotions. Results of the present report come from a pilot study of a 16-week DBT-based skills training group for treatment-resistant major depressive disorder (MDD) as an adjunctive treatment to pharmacotherapy. Patients were randomized to treatment or a waitlist control group. A significant interaction revealed that increases in emotional processing were associated with decreases in depression symptoms in the DBT-based skills group; however, increases in emotional processing in the waitlist condition were associated with increases in depression. Results offer preliminary support for the idea that participating in DBT-based skills training may help individuals with treatment-resistant MDD to develop skills that facilitate processing emotions in a way that helps to reduce rather than exacerbate depression symptoms.

Adaptation of dialectical behavior therapy skills training group for treatment-resistant depression.

Treatment resistant depression is common, persistent, and results in substantial functional and social impairment. This study describes the development and preliminary outcome evaluation of a dialectical behavior therapy-based skills training group to treat depressive symptoms in adult outpatients for whom antidepressant medication had not produced remission. The 16-session, once-weekly group covered the 4 dialectical behavior therapy skill sets: mindfulness, interpersonal effectiveness, emotion regulation, and distress tolerance. Twenty-four patients with ongoing depressive symptoms despite stable, adequate medication treatment for major depressive disorder were randomly assigned to either the skills group or a wait-list condition. The depressive symptoms of participants who completed the study (9 wait-list participants, 10 skills group participants) were compared using a clinician-rated Hamilton rating scale for depression and then replicated using a self-report measure Beck depression inventory. Clinician raters were blind to each participant's assigned study condition. Skills group participants showed significantly greater improvements in depressive symptoms compared with the control condition. Effect sizes were large for both measures of depression (Cohen's d = 1.45 for Hamilton rating scale for depression and 1.31 for Beck depression inventory), suggesting that larger scale trials are warranted.

Concurrent validity of the Personality Assessment Inventory Borderline scales in patients seeking dialectical behavior therapy.

The purpose of this study was to explore the usefulness of the Personality Assessment Inventory (PAI; Morey, 1991) Borderline full scale (BOR) and subscales in the assessment of patients being evaluated for dialectical behavior therapy (DBT; Linehan, 1993). We administered 67 patients both the PAI and the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; American Psychiatric Association, 1994) Structured Clinical Interview for Axis II disorders (SCID-II; First, Spitzer, Gibbon, Williams, & Benjamin, 1997). Point biserial correlations showed a significant relationship between the presence of borderline personality disorder (BPD) and scores on the BOR and Schizophrenia (SCZ) scales. A regression analysis showed that among the BOR subscales, those measuring identity disturbance, self-harming behavior, and negative relationships were significantly related to the total number of SCID-II BPD criteria. Diagnostic efficiency statistics between the BOR scale and the number of SCID-II BPD criteria indicated that a T score cutoff of 65 optimally differentiates patients who do and do not meet criteria for BPD. The relationship between BOR and SCID-II BPD demonstrates the concurrent validity of the PAI and shows its usefulness in this setting.

Predicting length of stay on an acute care medical psychiatric inpatient service.

The goal of this study was to identify variables associated with length of stay (LOS) and to incorporate into the authors' routine preadmission assessment the measurement of these variables. A retrospective study of 80 discharged patients explored the association of 25 variables reflecting a mixture of patient/demographic variables, illness variables, and treatment variables with LOS. Multivariate analysis revealed that 10 variables independently accounted for 62% of the variance in LOS. The information used was obtained primarily in the preadmission screening. The predictive power of the variables shrank in the prospective study. However, fewer individual variables were significantly associated with LOS; the summed score of the variables predicted 17% of the LOS variance. Results indicated that factors important for estimating LOS are available at the time of admission, and these variables can be systematically assessed and incorporated into clinical decision making.

Development and application of a brief multi-faceted tool for evaluating inpatient psychiatric care.

Increasingly, hospitals are expected to monitor and document service delivery variables, such as treatment outcome and patient satisfaction with care, which are thought to be associated with the quality of care received by patients. Documenting the patient's collaboration in the treatment-planning process also has become more important. However, for many clinically oriented units, translating these expectations into a useable instrument and an efficient measurement procedure is a complex and difficult task. This paper outlines the development of a brief multi-faceted program evaluation instrument and assessment process for completing these tasks. The authors describe the rationale behind their approach to these measurement issues, and they introduce an instrument capable of effectively measuring both outcome and satisfaction. They also provide an overview of how they apply the instrument in their inpatient psychiatry service. The strengths and weakness of this assessment strategy are reviewed.