Evaluation of intensive inpatient treatment of patients with severe personality disorders.

OBJECTIVE: The purpose of this study was to determine whether severe personality disorders improve or deteriorate with intensive inpatient treatment. METHODS: Overall 216 patients diagnosed as having personality disorders by DSM-III-R criteria were prospectively monitored at two private psychiatric hospitals from admission through discharge to one-year follow-up. RESULTS: Substantial positive change in the sample was recorded at discharge, and the improvements held up at one-year follow-up. The proportion of patients with scores of 50 or more on the Global Assessment Scale was 3.7 percent at the time of admission. By discharge the proportion had increased to 55.1 percent, and by one-year follow-up it had risen to 66.3 percent. CONCLUSIONS: These results suggest that patients with severe personality disorders benefit from intensive inpatient treatment. We found no evidence that hospitalization of such patients is associated with regression or deterioration of function.

Tailoring the psychotherapy to the borderline patient.

Views still differ as to the optimal psychodynamic treatment of borderline patients. Recommendations range from psychoanalysis and exploratory psychotherapy to an explicitly supportive treatment aimed at strengthening adaptive defenses. The authors contend that no single approach is appropriate for all patients in this wide-ranging diagnostic category, which spans a continuum from close-to-neurotic to close-to-psychotic levels of functioning. Careful differentiations based on developmental considerations, ego structures, and relationship patterns provide the basis for the optimal treatment approach.

Transference interpretation in the psychotherapy of borderline patients: a high-risk, high-gain phenomenon.

The effectiveness of transference interpretation in the psychodynamic psychotherapy of patients with borderline personality disorder has been highly controversial. Both highly expressive approaches that stress the value of transference interpretation and supportive strategies that eschew transference work have been advocated in the literature. We review this literature and identify three emerging trends in thought: (1) Primarily interpretive approaches should be reserved for patients with greater levels of ego strength. (2) Whichever technique is used, a strong therapeutic alliance is the foundation of treatment. (3) Expressive and supportive techniques should not be juxtaposed as polarized opposites; supportive interventions often pave the way for transference interpretation. Our psychotherapy process study revealed that transference interpretations tended to have greater impact--both positive and negative--than other interventions made with patients with borderline personality disorder. We conclude that such factors as neuropsychologically based cognitive dysfunction, a history of early trauma, patterns of object relations involving interpersonal distance, masochistic tendencies, and anaclitic rather than introjective psychopathology are among the patient characteristics that influence the impact of transference interpretation on the therapeutic alliance. Bias toward expressive technique and countertransference issues appear to be relevant to the therapist's difficulty in shifting to a more supportive approach when indicated.

Child abuse and treatment difficulty in inpatient treatment of children and adolescents.

This study examined the associations between abuse and staff perceived treatment difficulty in sixty-nine hospitalized children and adolescents. Subjects were rated on a treatment difficulty scale, and clinical charts were reviewed for evidence of physical abuse, sexual abuse, abuse between parents, and parental history of abuse. Subjects with histories of abuse were not rated as more difficult or less responsive to treatment than other patients. Physically abused youngsters were rated as more self-destructive and more accessible to treatment than non-abused children, while sexually abused youngsters were self-destructive and demanding, and their families were seen as more distant and unavailable.

Rorschach correlates of treatment difficulty and of the therapeutic alliance in psychotherapy with female psychiatric hospital patients.

The authors examined the relationship of Rorschach-based rating scales to treatment difficulty and to the therapeutic alliance in the psychotherapy of severely disturbed psychiatric hospital patients. They also examined how the Rorschach measures were related to specific impediments in the patients' ability to form a therapeutic alliance and to improve in the alliance. The statistically significant correlations appear primarily for women. The findings of central interest are: (1) Female patients with better thought organization and object relations capacities, as measured by the Rorschach, tend to be more difficult to treat; (2) those women who manifest higher Aggression-Malevolence scores on the Rorschach tend to have better therapeutic alliances; and (3) improvement in the therapeutic alliance with female patients is significantly related to higher severity of psychological disturbance on the Rorschach test.

Perceived treatment difficulty and therapeutic alliance on an adolescent psychiatric hospital unit.

On an 8-bed adolescent psychiatric unit, 69 patients were rated over the course of more than one year [corrected]. A set of rating scales was used to determine the relationships of treatment and therapeutic alliance difficulties with staff ratings of patient qualities, family issues, and treatment outcome. Findings underscore the clinical relevance of treatment difficulty and therapeutic alliance in conceptualizing the therapeutic action of the hospital treatment.

Difficult patients in extended psychiatric hospitalization: a research perspective on the patient, staff and team.

A series of publications has emerged from a comprehensive research project on difficulties in extended psychiatric hospital treatment, each of which describes factors that may influence difficulty: staff perceptions, difficult patient profiles, countertransference, intrapsychic features, organic brain impairment, problematic areas of treatment. This paper is intended to provide an overview and clinical integration of those diverse findings and an application of the findings to clinical conceptualization. The research supplements existing knowledge about treatment difficulty and countertransference in dyads by providing information about how such phenomena are influenced by clinical teams, by professional roles or disciplines, and by the treatment delivery system. Finally, I will describe future issues, questions and research efforts that are generated by these findings.

Assessing difficulties in the hospital treatment of children and adolescents.

There are few studies of treatment difficulty with children and adolescents. The authors describe a preliminary phase of research in this area, specifically the development of a set of rating scales to assess factors in treatment difficulty, a study of interrater reliability, and factor analyses of the content of these scales. The next steps in this ongoing research project are outlined.

Scales for assessing family intervention during psychiatric hospitalization.

Because ample evidence from both clinical and research realms has demonstrated that family intervention can be crucial for the process and outcome of psychiatric hospital treatment, greater attention should be given to assessing the extent and content of such interventions. The authors present their rating system for assessing the focus of family interventions during psychiatric hospitalization; they also provide results of a study of the interrater reliability of the scales and a factor analysis of the scales. These Family Intervention Scales are designed for application in hospitals that vary widely in structure, setting, staffing patterns, and program emphasis. The factor analysis yields four factors that make good clinical and conceptual sense: Information-Education, Family System Approach, Family Therapeutic Alliance, and Spouse Involvement.

Rorschach correlates of treatment difficulty in a long-term psychiatric hospital.

There are no studies of the use of the Rorschach test to predict possible treatment difficulties with hospitalized psychiatric patients. To explore this area, the authors assessed the Rorschach protocols of 114 patients using 19 example-anchored rating scales. They conducted a factor analysis of the scales and correlated the resulting factor scores with the extent and type of treatment difficulty. Although there were few significant findings, the Rorschach factors of Dysphoric Affect, Mirroring, and Depreciation may warrant further investigation of their predictive value for treatment difficulty. Rorschach measures of severity of psychological disturbance, inability to represent aggression in ideation, and depreciation may help treaters anticipate types of treatment difficulty.

Scales to assess the emphasis of psychiatric hospital treatment.

There are few studies of psychiatric hospital treatment that include measures of the treatment process. Perhaps the greatest neglect exists in the failure to collect from the clinicians their observations about the treatment interventions they most emphasize in each patient's treatment. The purpose of this paper is to report the development of a set of rating scales that call on hospital clinical staff to assess the relative prominence of various forms of interventions, namely, degree of restriction, vocational and avocational activities, therapeutic and community groups, medication, degree of supportive versus expressive emphasis and individual psychotherapy. We present a study of interrater reliability in a variety of hospital settings and results of a factor analysis of a portion of the scales.

The effect of therapist interventions on the therapeutic alliance with borderline patients.

The authors draw attention to the problems of establishing and maintaining a therapeutic alliance in the psychotherapy of the borderline patient. They elaborate an extensive methodology designed to study the manner in which shifts in collaboration occur in response to therapist interventions. This report demonstrates how one particular borderline patient increased his ability to collaborate with the therapist in response to a transference focus in the psychotherapy. Methodological problems are noted as are directions for future research. Only a series of patients studied with this or with similar methodology will allow for a sophisticated and empirical rationale for choosing a particular form of psychotherapy for a particular kind of borderline patient.

Problems to anticipate in treating difficult patients in a long-term psychiatric hospital.

In a previous report, the authors identified four dimensions of patient pathology associated with treatment difficulty: withdrawn psychoticism, character pathology, violence-agitation and suicidal-depressed behavior. In a subsequent study, they linked these dimensions to patterns of countertransference. The present research extends the two prior reports by examining the relations of the patient pathology dimensions to staff members' dissatisfaction with four areas of treatment: interpersonal approaches, structure and control, quality of teamwork, and medication. The major findings are: withdrawn psychoticism primarily relates to dissatisfaction with interpersonal treatment approaches; character pathology entails dissatisfaction with the level of structure and control; violence-agitation poses particular problems for teamwork; and suicidal-depressed behavior is unrelated to dissatisfaction with any dimension of treatment. The authors propose that these various problems in treatment are, in part, mediated by patterns of countertransference which they described in the prior paper. These findings should help staff members to focus their attention on areas of treatment in which problems are bound to arise in work with different types of difficult patients.

An anatomy of countertransference: staff reactions to difficult psychiatric hospital patients.

Countertransference among hospital staff was investigated as part of ongoing research on difficult-to-treat psychiatric hospital patients. Staff's ratings of their emotional reactions to 127 patients on long-term units were analyzed by factor analysis, and the resulting factors were correlated by discipline with patient problem behaviors. Among the conclusions were that different forms of psychopathology elicit characteristic patterns of emotional reaction from staff; that some dimensions of psychopathology, particularly suicidal-depressed behavior and violence-agitation, elicit different emotional reactions among different disciplines, thus laying the groundwork for division among staff; and that the more difficult the process of hospital treatment, the more likely staff will experience a variety of emotions.

Profiles of difficult psychiatric hospital patients.

In a study of 127 long-term psychiatric hospital patients perceived as difficult to treat, investigators used hierarchical grouping analysis to differentiate ten profile groups of patients. The groups are based on four dimensions or clusters of characteristics previously derived by factor analysis: withdrawn psychoticism, severe character pathology, suicidal-depressed behavior, and violence-agitation. The ten profile groups are described and are related to staff ratings of overall treatment difficulty, prognosis, sex, diagnosis, and other variables. The main conclusion is that treatment difficulty stems in large part from the compounding of different dimensions of severe psychopathology. Thus a pan-symptomatic group, with high scores on all four dimensions, ranks highest in overall treatment difficulty.

Patterns of staff perception of difficult patients in a long-term psychiatric hospital.

In a study to determine which psychiatric patients are perceived by staff as most difficult to treat, clinical staff from several disciplines rated problem behaviors of 127 long-term inpatients in a private psychiatric hospital; staff also rated overall treatment difficulty, progress, and prognosis. No single patient characteristic determined staff's perception of patients as difficult to treat. Instead, four clusters of patient characteristics contributed to this perception; in decreasing order of influence, they are withdrawn psychoticism, severe character pathology, suicidal-depressed behavior, and violence-agitation. The study also showed that the patients who are considered particularly difficult are perceived as improving less and as having a poor prognosis.