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.

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.

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.

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.

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

Narcissism and relational representations among psychiatric outpatients.

Pathological narcissism is associated with maladaptive interpersonal behavior, although less is known regarding the internal relational representations of narcissistic patients. The authors examined the relationship between pathological narcissism and two constructs that reflect internal representations of relational patterns: quality of object relations and attachment style. Patients attending a psychiatric day treatment program (N = 218) completed measures of narcissism, general psychiatric distress, and attachment style in terms of attachment avoidance and anxiety. A semistructured interview was used to assess quality of object relations. Multiple regression analysis was conducted, controlling for general psychiatric distress. Pathological narcissism was associated with anxious attachment, but not with avoidant attachment. Narcissism was also associated with lower levels of quality of object relations. The implications of these results are discussed in terms of internal representations of self-other relations.

A naturalistic trial of brief psychodynamic therapy for recurrent major depression.

We examined disposition, course, and outcome for 100 outpatients offered short-term individual dynamic therapy as a primary treatment for recurrent major depression. Evaluations using the Hamilton Rating Scale for Depression (HAM-D) were conducted regularly during the year after referral. Patients failing to show a response (50% decrease in pre-treatment HAM-D scores) were referred for consultation regarding "augmentation" of therapy with antidepressant medication. Nineteen referrals failed to meet inclusion-exclusion criteria, reflecting therapist overestimation of the severity of patients' depressive symptoms; referring therapists also missed other salient clinical issues. Fourteen patients completed assessments but did not start therapy; "decliners" were more likely to report previous admissions and thus may have opted for hospitalization. Sixty-seven patients started therapy; 18 dropped out (26.9%). Of the 49 therapy completers, 23 (46.9%) did not receive augmented treatment; 20 (40.8%) demonstrated evidence of recovery during the year while 3 (6.1%) did not. Of the 26 patients (53.1%) prescribed antidepressants, 16 (32.7%) demonstrated evidence of recovery and 10 (20.4%) did not. Patient clusters also showed distinct trajectories of change on the HAM-D over the year after referral. Patients who received augmented treatment but showed no evidence of recovery scored significantly higher on indices of alexithymia. Clinical implications of the findings are considered.

A naturalistic study of alexithymia among psychiatric outpatients treated in an integrated group therapy program.

OBJECTIVES: Alexithymia is common among psychiatric outpatients and can complicate treatment. There has been little research into whether alexithymia can be modified by psychological intervention, and whether change in alexithymia is related to other areas of improvement. The purpose of the present study was to examine whether participation in an integrated group therapy program could effect change in alexithymia, and whether such change is related to improvement in interpersonal functioning. DESIGN AND METHODS: Sixty-eight consecutively admitted psychiatric outpatients to a comprehensive group therapy program were evaluated at baseline, post-therapy, and 3-month follow-up using the Toronto Alexithymia Scale 20, the Beck Depression Inventory, and the Inventory of Interpersonal Problems-28. Associations among variables were evaluated with correlations and among group comparisons with t test, ANOVA, chi-square tests, and logistic regression. Change in alexithymia was examined using repeated measures ANOVA, controlling for change in depressive symptoms. RESULTS: Alexithymia, particularly difficulty identifying feelings, decreased significantly during the treatment period. Post-therapy levels of alexithymia were maintained during the 3 months following treatment completion. Changes in alexithymia were significantly associated with changes in interpersonal problems, both during therapy and during the follow-up period. CONCLUSIONS: The results of our study suggest that a comprehensive, integrated group therapy program can affect change in alexithymia, and that such change can be maintained once therapy is completed. Also, modifying alexithymia may contribute to improvement in interpersonal functioning.

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.

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.

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.

A survey of Canadian group psychotherapy association members' perceptions of psychotherapy research.

The present study reports on the findings of a Canadian survey of group therapists. The survey was conducted to solicit their perspectives of psychotherapy research. The goal of the survey was to identify topics and issues that were important to group therapists. Findings from the survey suggest that group therapists are interested in research, perhaps more than one might expect. However, respondents identified a number of factors that limit the appeal of research or impede the integration of research findings into practice. Several suggestions were offered for future research and for methods of communicating the findings of research to clinicians. The survey findings call for improved communication and collaboration between researchers and clinicians in order to achieve a more meaningful integration of science and practice in the group therapy field.

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.

Interpersonal problems associated with narcissism among psychiatric outpatients.

Narcissistic personality disorder is the subject of extensive discussion in the literature. Yet, the validity of this diagnostic category remains questionable. This is owed, in large part, to the relative absence of empirical work that has examined narcissism in clinical samples. Descriptions and findings from studies involving non-clinical samples suggest that narcissism is associated with considerable interpersonal impairment. The objective of the present study was to examine this possibility in a sample of psychiatric outpatients. Consecutively admitted patients (N=240) to a day treatment program completed measures of narcissism, interpersonal problems, and general psychiatric distress. Patients were categorized into high, moderate, and low narcissism groups. The groups were compared on overall interpersonal impairment, as well as on particular domains of interpersonal behavior. Treatment duration and discharge status were also compared among the three groups. Analysis of covariance and chi-square analyses were used. At baseline, higher levels of narcissism were significantly associated with greater interpersonal impairment. The interpersonal style of the more narcissistic patients was particularly characterized by domineering, vindictive, and intrusive behavior. At post-treatment, only the association between narcissism and intrusive behavior remained significant. Change in interpersonal difficulties following treatment did not differ significantly among the groups. However, failure to complete treatment was associated with narcissism. The results underscore the interpersonal impairment associated with narcissism and support the notion of narcissistic personality disorder as a valid diagnostic category.