Lost in Transition: Examining Transitions in Psychotherapy Training.

OBJECTIVE: Disruptions are inevitable during psychiatry residency training and can affect resident learning and patient care. This exploratory study examined the nature and impact of transitions in psychotherapy training. METHODS: PGY2-5 residents (45/150; 30% response rate) and psychotherapy supervisors (46/247; 18.6% response rate) were surveyed about transitional events during residency training in psychotherapy. RESULTS: Supervisors and residents ranked the frequency of occurrence of transitional events and their impact very similarly, as well as the "feed forward" items when transitioning to a new supervisor. Residents feeling confused or overwhelmed with the balancing of learning differing models with differing levels of comfort or knowledge was ranked as the issue that occurred most frequently by both supervisors and residents. CONCLUSIONS: This study highlights issues that arise at transitions during psychotherapy training in psychiatry residency. Strategies for managing these periods are discussed, with a focus on resident learning and improved continuity of patient care.

Characteristics of outpatients in an addictions clinic for co-occurring disorders.

BACKGROUND AND OBJECTIVES: To examine characteristics of treatment-seeking outpatients from a clinic for co-occurring disorders within an urban psychiatric hospital. METHODS: Patients (n = 131) completed six self-report scales including the Brief Symptom Inventory and Toronto Alexithymia Scale. RESULTS: The most common substance use disorders were: alcohol (62%), tobacco (50%), cannabis (22%), cocaine/stimulants (18%). The most common psychiatric disorders were: mood (65%), psychotic (24%) and anxiety disorders (24%). Many of the scales correlated with the global psychiatric severity score. Patients with mood disorders had superior interpersonal functioning global scores and reported reduced drug use and reduced advice seeking. Patients with psychotic disorders had higher global psychiatric severity scores and reported higher advice seeking. CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE: This preliminary study indicates that among a heterogeneous sample of patients with co-occurring disorders the more symptomatic patients may present with a wider range of impairments along with some specific differences based on psychiatric diagnosis.

Applying motivational interviewing principles in a modified interpersonal group for comorbid addiction.

The application of motivational interviewing (MI) principles in modified interpersonal group therapy (MIGT) addresses two gaps in the literature. First, it explicitly extends MIGT to non-abstinent, addicted patients who are in the precontemplative and contemplative stages of change in contrast to most MIGT models where abstinence is usually required. Second, it provides a novel, process-oriented group intervention for MI, in contrast to current applications of group-based MI which are more structured in their format. The main modification in technique was to prioritize the horizontal exploration of substance use disclosures with a focus on the here-and-now experience of disclosure and the interpersonal impact on the group, in order to: (1) encourage members to openly discuss their ambivalence and shifting motivational states, (2) harness the evocative impact of substance use disclosures between members to elicit change talk (self-motivational statements), and (3) selectively reinforce change talk when it emerges from these exchanges. The authors illustrate these concepts with a case report of an open-ended MIGT group with comorbid mental illness and addiction.

Clinical barriers to effective pharmacotherapy in co-occurring psychiatric and substance use disorders.

Prescribing medications to patients with cooccurring psychiatric and substance use disorders often evokes distressing emotional responses from both clinician and patient that affect the delivery of appropriate pharmacological treatment. One important polarization revolves around the clinician under-prescribing to avoid feeling like he or she is overmedicating the patient versus over-prescribing when risk levels are minimized. A case report illustrates some common, rapidly shifting responses to both medication and clinician. These reactions include 1) an idealized, passive relation to the medication followed by disappointment in its weakness, 2) minimizing the danger of medication through idiosyncratic and potentially dangerous overuse to replicate effects of the addictive substance, or 3) experiencing the medication as harmful, leading to phobic avoidance and underutilization. The recommended clinical response is to avoid these polarizations and to engage with the patient's suffering and dangerous behavior by 1) taking reasonable pharmacological risks, 2) establishing provisions for safe use and frequent monitoring, 3) conveying tolerance for idiosyncratic use within safe limits, 4) regular exploration of the meaning of the medication with links to both the addiction history and the treatment relationship, and 5) frequent psychoeducation.

Addictive behaviors in comorbid addiction and mental illness: preliminary results from a self-report questionnaire.

OBJECTIVE: : The objective of this study was to pilot a new self-report screening instrument, the addictive behaviors questionnaire (ABQ), which screens for a broad range of impulsive-compulsive behaviors, in a treatment-seeking psychiatric population with comorbid addiction. METHODS: : Psychiatric outpatients (N = 94) being treated for comorbid addiction and mental illness were approached consecutively by their therapists to fill out a number of self-report measures, in addition to the ABQ, including the Addiction Severity Index, Toronto Alexithymia Scale, and Reflective Activity Scale. The ABQ was evaluated both as a continuous measure and as a categorical measure using clinically relevant cutoff scores for each behavior. It was tested for internal reliability, test-retest reliability, and correlation with other scales. RESULTS: : The completion rate for the ABQ was 74%. It demonstrated good internal reliability (continuous measure α = 0.81, categorical measure alpha = 0.82) and good test-retest reliability (continuous r = 0.68, categorical r = 0.76). The total ABQ score positively correlated with alexithymia (continuous r = 0.45, P < 0.001; categorical r = 0.37, P < 0.001) and negatively correlated with reflective activity (continuous r = -0.29, P < 0.01; categorical r = -0.27, P < 0.05). The behaviors that were most commonly endorsed as problematic were overeating, unhealthy relationships, excessive TV watching, and excessive shopping. Based on cutoff scores, 61% of the sample endorsed at least one problematic behavior and 31% endorsed 2 or more behaviors. CONCLUSIONS: : These preliminary results suggest that the ABQ is reliable and easily administered by clinicians treating comorbid addiction in an outpatient setting. Further study is required with larger sample sizes, normative data, and comparable scales to help establish construct validity and cutoff scores.

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.