Adverse outcomes in group psychotherapy: risk factors, prevention, and research directions.

Group forms of therapy have been growing at a rapid rate, in part because of their documented effectiveness and economic considerations such as managed care. It is therefore becoming increasingly important to assess the psychological risks of these interventions. The author provides an overview of the published literature and conference presentations on negative effects in adult outpatient groups. Although much of the literature on adverse outcomes in group therapy focuses on single risk factors (e.g., negative leader, group process, or patient characteristics), the author argues that an interactional model should be encouraged. Means of reducing casualties are also discussed, as well as methodological issues and research directions.

A symposium on psychotherapy in the age of managed care.

This article is based upon a symposium presented at Vanderbilt University Medical Center on the Department of Psychiatry's 50th anniversary (September 20, 1997). The panel of psychotherapy scholar-clinicians discusses issues including: whether or not managed care and psychotherapy are compatible; the relevance of the Consumer Reports' psychotherapy study to MCOs' emphasis on brief therapy; how MCOs impact upon the therapist-patient relationship; the effects of MCOs on the psychotherapist's personal and professional identity; and training psychotherapists in the era of managed care. The paper is dedicated to Pietro Castelnuovo-Tedesco, M.D., Vanderbilt's Blakemore Professor of Psychiatry, who died on January 24, 1998.

Perspectives of treatment efficacy with the substance dependent physician: a national survey.

A national survey was conducted to assess the judgments of two sets of respondents (administrators of state physician health programs and highly experienced clinicians) about the effectiveness of treatment programs for chemically dependent physicians. Administrators consistently estimated higher rates of patient success (and less relapse) than their practitioner counterparts. Clinicians also identified factors (patient, therapist, group composition, context) they believed to be the most robust predictors of outcome with chemically impaired doctors. Implications of the findings for the conceptualization and design of prospective treatment outcome studies are addressed.

Confidentiality dilemmas in group psychotherapy with substance-dependent physicians.

OBJECTIVE: The purposes of this article are 1) to review federal and state laws relevant to confidentiality in group therapy with impaired physicians and 2) to provide empirical data concerning the actual confidentiality practices and experiences of group therapists treating chemically impaired physicians. METHOD: In the clinical research phase, 25 state medical societies identified 45 rehabilitation centers as those to which the societies preferentially referred chemically impaired physicians. Fifty-one group leaders from 33 of these rehabilitation centers completed the survey questionnaire employed in this project. RESULTS: Because of the risk of potentially irreversible social and professional injury, physician patients were exceedingly concerned about breaches of confidentiality. Co-members' infractions most often involved the violator sharing with close friends and family members the name and abuse history of a fellow physician. In contrast, transgressors rarely leaked information about a co-member's drug-related illegal behaviour. CONCLUSIONS: Chemically impaired physicians would feel safer in sharing secrets in group therapy if more jurisdictions adopted legislation making co-members liable for violating confidentiality. Currently the pertinent body of law is confusing and inconsistent and provides little protection to impaired physicians who enter group therapy. The authors propose ideas for model legislation.

Confidentiality in group psychotherapy: empirical findings and the law.

Empirical research suggests that group therapists generally discuss with prospective clients the importance of maintaining confidentiality, but are unlikely to inform them of the significant potential for violations of confidentiality. Therapists believe information about the risk of unauthorized disclosures will reduce the number of patients willing to enter group therapy and will inhibit the therapeutic dialogue. Therapists' failure to provide information sufficient to obtain informed consent, however, produces serious ethical problems and potential legal problems as well. The law of informed consent varies in different jurisdictions such that identical factual scenarios could produce different legal outcomes depending on the jurisdiction in which the case occurs. In spite of the proliferation of group interventions, empirical studies of confidentiality in group therapy have lagged behind similar research in individual psychotherapy.

Effects of confidentiality limitations on the psychotherapeutic process.

This review article examines the impact of confidentiality limitations on the psychotherapeutic process. Findings from analogue studies with nonpatienis indicate that perceived confidentiality limitations will deter people from seeking therapy and will inhibit self-disclosures once they are in treatment. However these findings da not hold up in research with actual therapy patients. A methodological issue is whether the subject pool for clinical studies is primarily persons at risk for only mild to moderate social injury if their communications are repeated to others. In the few studies of persons at risk for serious sociolegal consequences, warnings of mandatory reporting served as a barrier to therapeutic disclosure or entry into treatment.

Guarding confidentiality in clinical groups: the therapist's dilemma.

This study examines the confidentiality practices of highly experienced, well-trained group psychotherapists. A provocative finding was that practitioners rarely inform prospective clients of confidentiality limitations. Their reluctance to do so appears to be based upon the belief that it might discourage persons from entering treatment, as well as having negative ramifications for the therapeutic process (e.g., members may be less likely to talk about unprotected topics). The prevalence and content of breaches in confidentiality are explored. Ethical, legal, clinical, and educational implications of these and other findings are addressed. Research recommendations are offered.

Group therapy with the antisocial spinal-cord-injured patient.

This conceptual article attempts to help health care professionals deepen their understanding of the psychological characteristics of antisocial spinal cord-injured patients that predispose them to injury, being a disruptive influence on the medical floor, oppositional acting out with physicians, and potentially thwarting effective treatment. Group techniques are described that appear to improve the adaptation of these patients to their traumatic injury and hospital environment.

Psychiatric resident dismissal: a national survey of training programs.

The authors report on a nationwide survey of psychiatric residency training directors who responded to a questionnaire designed to elicit information on the magnitude of the problem of unacceptable performance by residents. One hundred six program directors reported on 5,591 internship or residency positions from 1981 to 1985. A total of 184 residents (3.3%) were prematurely terminated or persuaded to resign; departmental deliberations were held on an additional 139 residents (2.5%). Reasons for dismissal and indications during the selection process that a trainee might prove problematic are discussed. A provocative finding was that 37% of terminated residents were accepted into other psychiatry training programs.

Relationship between medical students' participation in a behavioral science discussion group and performance on a cognitive task.

The authors investigated the association between first-year medical students' verbal participation in a behavioral science discussion group, course satisfaction, and performance on a cognitive task (a written essay). Results showed that students who were sociometrically selected as having enhanced the group discussion performed better on the course essay and evaluated the course more favorably than their reticent counterparts. Some shortcomings of this exploratory research are discussed, as are future research recommendations.

Patient attrition in dynamically oriented treatment groups.

Clinical and empirical studies of premature terminators from dynamically oriented therapy groups are reviewed. While many studies focus on the personality characteristics of dropouts, the authors recommend conceptualizing such patients in terms of the interaction of patient, group, and therapist. On the basis of this model, the authors offer clinical recommendations for reducing the number of dropouts. Multivariate experimental designs for studying attrition in group psychotherapy are discussed, and the authors suggest possible directions for future research.

The female mid-life sex change applicant: a comparison with younger female transsexuals and older male sex change applicants.

This paper reports on a survey approach to the study of the aging (40 years of age and older) female requesting sex reassignment surgery (SRS). A profile of 13 cases presenting at a cross-section of gender identity clinics in North America is presented. The mid-life SRS applicant is also compared on selected characteristics with a younger female transsexual group and with the aging male sex change applicant. Findings suggest that the mid-life female SRS applicant is closely akin to the aging, conflicted homosexual, whereas the mid-life male SRS applicant appears more closely associated with the aging transvestite.

The mid-life male sex-change applicant: a multiclinic survey.

Directors of coordinators of a cross-section of North American Gender Identity Clinics provided descriptive information on 1,637 sex-change applicants and psychosocial, psychosexual, and psychiatric data on 21 middle-aged male candidates. To determine the age relatedness of the findings, the mid-life male candidates were then compared on selected characteristics with a random sample of younger biological males seeking sexual reassignment at the Vanderbilt Gender Identity Clinic. The results are consistent with previous findings highlighting the factors at mid-life that intensify the male transsexual's desire for sexual transformation. Viewing the aging gender dysphoria patient's surgical request from a developmental perspective promotes appreciation of his predicament and informed consideration of his treatment options.

Epidemic grieving at a birthday party: a case of mass hysteria.

In modern Western culture, "mass hysteria" has typically taken the form of an outbreak of a mysterious physical disorder among adolescent girls in whom no organic etiology or precipitant can be identified. If properly managed (i.e., diagnosis confirmed and publicly announced), the illness is usually of relatively short duration. This is a report of an incident of contagious hysteria among preadolescent girls, manifested as grieving reactions during what should have been a happy event--a birthday party. The complex relation between situational, developmental, physical, and personality factors in mass hysteria are discussed.

The internship year in psychiatry: a status report.

The reinstitution of the "internship" requirement by the American Board of Psychiatry and Neurology resulted in the development of a 4-year residence by most residency programs. The authors distributed a questionnaire to more than 200 psychiatry residency directors to collect data concerning the new "internship" year. Their results indicate that there is considerable diversity in the content of the "internship" and general satisfaction with the quality of the experience.

Physical self-concept changes in a mildly, facially disfigured neurofibromatosis patient following communication skill training.

The authors discuss the case of a mildly disfigured patient with Neurofibromatosis from the perspectives of his distorted body image, need to attribute problems in his social and work lives to unrealistic assessment of his disfigurement, changes in his self-concept following communication training, and the need for physicians and others working with these persons to treat their emotional, as well as physical, pain.