Increasing the Therapeutic Dosage by Combining Cognitive Behavior Group Therapy With a Monitored Self-Help Group

Objective: A problem in psychotherapy is the limited availability of psychotherapists. This can not only delay the start of therapy but also curtail the number of sessions and the therapeutic dosage. An option to extend the therapeutic dose without an increase in therapist time may be to combine group psychotherapy with a self-help group. The goal of the present study is to investigate how patients judge this treatment mode and to what degree the contents of a regular group treatment are pursued in a parallel self-help group.Method: Seventy-two psychosomatic inpatients participated in cognitive behavior group therapy and parallel self-help group, which was monitored by the therapist during the regular group therapy sessions. Patients in both groups filled in a questionnaire that asked for the content of the group session, how patients had experienced the interaction, and what they had taken from the group.Results: Patients reported that in the self-help group, they discussed similar topics as in the regular group therapy, like how to deal with anxiety or sadness, how to interact with other people, and how to cope with their mental disorder and problems at work, in the family, or with friends. Patients indicated that there was more relaxed chatting in the self-help group, whereas learning new behavior was reported more frequently for the regular group therapy.Conclusions: In the regular group therapy and the guided self-help group, similar topics were discussed, which suggests that a combination of both can extend the therapeutic process and increase the therapeutic dosage without costs for the therapist or the institution.

Differential Effectiveness of Open Versus Closed Psychotherapy Groups: A Systematic Review

OBJECTIVE

This systematic review aimed to provide an overview of the state of research on the effectiveness of open versus closed psychotherapy groups, from the beginning of empirical research on these groups to the present.

METHODS

A literature search in seven databases and a supplementary search of the reference lists of 23 relevant articles were conducted between August 2022 and October 2023. Seventy-two articles were identified and screened for eligibility.

RESULTS

Twenty-seven articles met the inclusion criteria and were included in the review. Outcomes are reported by study design (randomized controlled trial, quasi-experimental, descriptive). Information on each study's sample, setting, types of groups, process versus outcome measures, and outcome evaluation is provided. Findings suggest that open and closed psychotherapy groups have the same effect on reducing symptoms of mental disorders. Perception of group cohesion was phase dependent in closed group therapies, whereas cohesion was perceived as more constant in open group therapies.

CONCLUSIONS

The question of how group therapy format may affect therapeutic outcomes and processes has been posed over the past 50 years, but trials are heterogeneous and robust conclusions cannot be made. Systematic research on the differential effectiveness of open versus closed psychotherapy groups is scarce. On the basis of empirical findings to date, no global superiority of either open or closed group therapy exists. Open and closed group therapies are equally effective, presumably because of different effect factors. An indication for open or closed group therapy must be made according to clinical requirements on a case-by-case basis.

Group Therapy with Peer Support Provider Participation in an Acute Psychiatric Ward: 1-Year Analysis

(1) Background: Group psychotherapy improves therapeutic process, fosters identification with others, and increases illness awareness; (2) Methods: In 40 weekly group sessions held in an acute psychiatric ward during one year, we retrospectively evaluated the inpatients' participation and the demographic and clinical variables of the individuals hospitalized in the ward, the group type according to Bion's assumptions, the main narrative themes expressed, and the mentalization processes by using the Mentalization-Based Therapy-Group Adherence and Quality Scale (MBT-G-AQS); (3) Results: The "working" group was the prevailing one, and the most represented narrative theme was "treatment programs"; statistically significant correlations were found between the group types according to Bion's assumptions and the main narrative themes (Fisher's exact, p = 0.007); at our multivariate linear regression, the MBT-G-AQS overall occurrence score (dependent variable) was positively correlated with the number of group participants (coef. = 14.87; p = 0.011) and negatively with the number of participants speaking in groups (coef. = -16.87, p = 0.025); (4) Conclusion: our study suggests that the group shows consistent defense mechanisms, relationships, mentalization, and narrative themes, which can also maintain a therapeutic function in an acute ward.

Understanding the benefits of extrinsic emotion regulation in depression

Depression is a serious psychiatric illness that negatively affects people's feelings, thoughts, and actions. Providing emotion regulation support to others, also termed Extrinsic Emotion Regulation (EER), reduces depressive symptoms such as perseverative thinking and negative mood. In this conceptual review paper, we argue that EER may be especially beneficial for individuals with depression because it enhances the cognitive and affective processes known to be impaired in depression. Behavioral studies have shown that EER recruits processes related to cognitive empathy, intrinsic emotion regulation (IER), and reward, all impaired in depression. Neuroimaging data support these findings by showing that EER recruits brain regions related to these three processes, such as the ventrolateral prefrontal cortex which is associated with IER, the ventral striatum, which is associated with reward-related processes, and medial frontal regions related to cognitive empathy. This conceptual review paper sheds light on the mechanisms underlying the effectiveness of EER for individuals with depression and therefore offers novel avenues for treatment.

Telehealth Psychoeducational Groups With Latinx College Students: Findings From Focus Groups

The literatures examining psychoeducational groups and telehealth services have demonstrated positive results but less is known about the efficacy of psychoeducational telehealth groups. This study examines the perspectives of 105 Latinx college students who participated in an 8-session psychoeducational group via a telehealth platform during the COVID-19 pandemic. The research questions included (a) What was the experience of these Latinx college students participating in telehealth psychoeducational groups? and (b) What were the potential perceived advantages and disadvantages of implementing telehealth psychoeducational groups? Postintervention, a total of 16 focus groups were convened with a total of 105 Latinx college students (average number of participants per group = 6). Interviews were coded using conventional qualitative analysis and yielded four main themes: (1) group cohesion, which involved group members feeling that they were connected and that the group was a safe space; (2) group leaders, which involved leaders' preparation and knowledge and their ability to foster a safe environment); (3) cultural issues, which involved cultural values and acculturative and first-generation stress.; and (4) telehealth implementation, wherein participants described advantages and disadvantages of the telehealth approach. We discuss study limitations and directions for future research.

Group Cohesion in Psychoeducational Groups with Latinos: Examining Cultural Correlates

Group psychotherapy is an effective therapeutic modality for the treatment of many mental health and related issues. Group therapy is cost-effective and could decrease barriers to mental health services for ethnic minority populations, including Latinx people. Group cohesion is a therapeutic factor associated with positive outcomes in group psychotherapy according to meta-analyses. While information exists regarding the associations of group cohesion to other variables that may affect the effectiveness of group psychotherapy, there is no published research exploring the relationships between group cohesion and the Latinx cultural correlates of acculturation, machismo, caballerismo, marianismo, personalismo, individualism, and collectivism. We analyzed pre- and post-data from 235 Latinx college students who participated in eight sessions of one of two types of psychoeducational groups (one for dating violence prevention and one for stress management), using a multivariate general linear model (GLM) examining the relationships between our gender and cultural variables on two total group cohesion measures (GCS and GSRS). This finding partially supports our hypotheses regarding the association between cultural correlates and group cohesion: collectivistic attitudes among Latinx group members were associated with improved group cohesion. These findings have relevance for the implementation of group psychotherapy with Latinx people.

Brief App-Based Cognitive Behavioral Therapy for Anxiety Symptoms in Psychiatric Inpatients: Feasibility Randomized Controlled Trial

Background

Psychiatric inpatients often have limited access to psychotherapeutic education or skills for managing anxiety, a common transdiagnostic concern in severe and acute mental illness. COVID-19–related restrictions further limited access to therapy groups on inpatient psychiatric units. App-based interventions may improve access, but evidence supporting the feasibility of their use, acceptability, and effectiveness in psychiatric inpatient settings is limited. MindShift CBT is a free app based on cognitive behavioral therapy principles with evidence for alleviating anxiety symptoms in the outpatient setting.

Objective

We aimed to recruit 24 participants from an acute general psychiatric inpatient ward to a 1-month randomized control study assessing the feasibility and acceptability of providing patients with severe and acute mental illness access to the MindShift CBT app for help with managing anxiety symptoms.

Methods

Recruitment, data collection, analysis, and interpretation were completed collaboratively by clinician and peer researchers. Inpatients were randomized to two conditions: treatment as usual (TAU) versus TAU plus use of the MindShift CBT app over 6 days. We collected demographic and quantitative data on acceptability and usability of the intervention. Symptoms of depression, anxiety, and psychological distress were measured in pre- and poststudy surveys for preliminary signals of efficacy. We conducted individual semistructured interviews with participants in the MindShift CBT app group at the end of their trial period, which were interpreted using a standardized protocol for thematic analysis.

Results

Over 4 weeks, 33 inpatients were referred to the study, 24 consented to participate, 20 were randomized, and 11 completed the study. Of the 9 randomized participants who did not complete the study, 7 were withdrawn because they were discharged or transferred prior to study completion, with a similar distribution among both conditions. Among the enrolled patients, 65% (13/20) were admitted for a psychotic disorder and no patient was admitted primarily for an anxiety disorder. The average length of stay was 20 days (SD 4.4; range 3-21) and 35% (7/20) of patients were involuntarily admitted to hospital. Small sample sizes limited accurate interpretation of the efficacy data. Themes emerging from qualitative interviews included acceptability and usability of the app, and patient agency associated with voluntary participation in research while admitted to hospital.

Conclusions

Our study benefitted from collaboration between peer and clinician researchers. Due to rapid patient turnover in the acute inpatient setting, additional flexibility in recruitment and enrollment is needed to determine the efficacy of using app-based psychotherapy on an acute psychiatric ward. Despite the limited sample size, our study suggests that similar interventions may be feasible and acceptable for acutely unwell inpatients. Further study is needed to compare the efficacy of psychotherapeutic apps with existing standards of care in this setting.

Trial Registration

ClinicalTrials.gov NCT04841603; https://clinicaltrials.gov/ct2/show/NCT04841603

The effectiveness of internal cohesion psychotherapy in treating young clients with depression and anxiety disorders: The role of developmental assets in Kosovo context

The positive youth development approach (PYD) is widely used as a meaningful framework to guide research, policy, and intervention, to support young people to develop their full potential. Psychotherapy, on the other hand, is a verbal and psychological procedure that can be a suitable solution to mental health concerns, which are prevalent among youth. This study aimed to explore the potential role of developmental assets in treating clients with depression and anxiety disorders using Internal Cohesion Psychotherapy (ICP). In total, 10 young people who took at least five sessions of ICP were part of this study. In-depth semi-structured interviews were conducted to gather information about clients’ experiences with ICP and their perception/opinions on the presence of developmental assets in their lives. The results confirm the effectiveness of ICP in treating depression and anxiety, while clients acknowledge the role of developmental assets in their psychotherapeutic process. The current study has important theoretical, practical, and research implications. It provides evidence on how clients use their developmental assets in maximizing the effectiveness of the ICP process. The usage of developmental assets to enhance the effectiveness of psychotherapy opens a new path for further research and can serve as a foundation ground for intervention on mental health among youth.

The Effectiveness of Transactional Analysis Treatments and Their Predictors: A Systematic Literature Review and Explorative Meta-Analysis

Objectives:

Despite many studies on transactional analysis (TA) psychotherapy, there are no comprehensive reviews or meta-analyses on its effectiveness. We conducted a systematic literature review and meta-analysis on TA psychotherapeutic treatments to examine the extent of psychological and psychosocial change in pre-post studies, the effects compared with other treatments in randomized clinical trials, and factors explaining these effects and differences.

Method:

We conducted a systematic literature review and meta-analysis according to Meta-Analysis of Observational Studies in Epidemiolog (MOOSE) and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines in Pubmed, Medline, PsycInfo, Web-of-Knowledge, and scholar.google.com .

Results:

Overall, 41 clinical trials of TA treatments had moderate to large effects on psychopathology (Hedges’s g = .66), social functioning ( g = .62), self-efficacy ( g = .80), ego-state functioning ( g = .69), well-being ( g = .33), and behavior ( g = .56). Compared with control conditions, TA had moderate to large effects on psychopathology ( g = .61), social functioning ( g = .69), self-efficacy ( g = .88), ego-states ( g = .70), well-being ( g = .85), and behavior ( g = .46). TA was more effective on most outcomes in individuals, groups, and families than in schools or prisons. Psychopathology changes were significantly predicted by improvements in ego-states, self-efficacy, social functioning, and client–practitioner relationship ( r² range = .27–.43). Treatments were more effective if they included systematic assessment, treatment stages, psycho-education, TA-unique techniques, and an experiential focus ( r² range = .03–.31).

Conclusions:

TA may be considered an effective treatment for many clients.

Effectiveness of live health professional-led group eHealth interventions for adult mental health: A systematic review of randomized controlled trials

Background

The COVID-19 pandemic has had adverse impacts on mental health and substance use worldwide. Systematic reviews suggest eHealth interventions can be effective at addressing these problems. However, strong positive eHealth outcomes are often tied to the intensity of web-based therapist guidance, which has time and cost implications that can make the population scale-up of more effective interventions difficult. A way to offset cost while maintaining the intensity of therapist guidance is to offer eHealth programs to groups rather than more standard one-on-one formats.

Objective

This systematic review aims to assess experimental evidence for the effectiveness of live health professional–led group eHealth interventions on mental health, substance use, or bereavement among community-dwelling adults. Within the articles selected for our primary aim, we also seek to examine the impact of interventions that encourage physical activity compared with those that do not.

Methods

Overall, 4 databases (MEDLINE, CINAHL, PsycINFO, and the Cochrane Library) were searched in July 2020. Eligible studies were randomized controlled trials (RCTs) of eHealth interventions led by health professionals and delivered entirely to adult groups by videoconference, teleconference, or webchat. Eligible studies reported mental health, substance use, or bereavement as primary outcomes. The results were examined by outcome, eHealth platform, and intervention length. Postintervention data were used to calculate effect size by study. The findings were summarized using the Synthesis Without Meta-Analysis guidelines. Risk of bias was assessed using the Cochrane Collaboration Tool.

Results

Of the 4099 identified studies, 21 (0.51%) RCTs representing 20 interventions met the inclusion criteria. These studies examined mental health outcomes among 2438 participants (sample size range: 47-361 participants per study) across 7 countries. When effect sizes were pooled, live health professional–led group eHealth interventions had a medium effect on reducing anxiety compared with inactive (Cohen d=0.57) or active control (Cohen d=0.48), a medium to small effect on reducing depression compared with inactive (Cohen d=0.61) or active control (Cohen d=0.21), and mixed effects on mental distress and coping. Interventions led by videoconference, and those that provided 8-12 hours of live health professional–led group contact had more robust effects on adult mental health. Risk of bias was high in 91% (19/21) of the studies. Heterogeneity across interventions was significant, resulting in low to very low quality of evidence. No eligible RCT was found that examined substance use, bereavement, or physical activity.

Conclusions

Live eHealth group interventions led by health professionals can foster moderate improvements in anxiety and moderate to small improvements in depression among community-based adults, particularly those delivered by videoconference and those providing 8-12 hours of synchronous engagement.

Trial Registration

PROSPERO CRD42020187551; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=187551

International Registered Report Identifier (IRRID)

RR2-10.1186/s13643-020-01479-3

Predictors for successful psychotherapy: Does migration status matter?

Background

We investigated, if migration status, and additional sociodemographic and clinical factors, are associated with somatization and depressiveness at admission and with remission after inpatient psychotherapy.

Methods

Multiple linear and binary logistic regression analyses were used to identify predictors for severity of somatoform and depressive symptoms at admission of inpatient psychotherapy (T0), and for remission after inpatient psychotherapy (T1). We tested the association between symptoms concerning somatization (PHQ-15: Patient-Health-Questionnaire Somatization Module) and depression (PHQ-9: Patient-Health-Questionnaire Depression Module) and several sociodemographic and clinical factors in 263 patients at admission. For remission after treatment, we additionally included severity of symptoms at admission, number of diagnoses and duration of treatment in the regression models. Remission after treatment was defined as response plus a post value of less than 10 points in the respective questionnaire. Clinical relevance was interpreted using effect sizes (regression coefficients, Odds Ratio (OR)) and Confidence Intervals (CI).

Findings

Significant and clinically relevant predictors for high symptom severity at T0 were lower education (β = -0.13, p = 0.04), pretreatment(s) (β = 0.205, p = 0.002) and migration status (β = 0.139, p = 0.023) for somatization, and potential clinically relevant predictors (|β|>0.1) for depression were living alone (β = -0.116, p = 0.083), pretreatment(s) (β = 0.118, p = 0.071) and migration status (β = 0.113, p = 0.069). At T1 patients with pretreatment(s) (OR = 0.284 [95% CI: 0.144, 0.560], p<0.001) and multiple diagnoses (OR = 0.678 [95% CI: 0.472, 0.973], p = 0.035) were significantly and clinically relevant less likely to show a remission of depressive symptoms. In addition, a potentially clinically meaningful effect of migration status on remission of depressive symptoms (OR = 0.562 [95% CI: 0.264, 1.198], p = 0.136) cannot be ruled out. For somatoform symptoms pretreatment(s) (OR = 0.403, [95% CI: 0.156, 1.041], p = 0.061) and education (OR = 1.603, [95% CI: 0.670, 3.839], p = 0.289) may be regarded as clinically relevant predictors for remission.

Conclusion

The results of our study suggest that migration status has a clinically relevant influence on severity of somatoform and depressive symptoms at admission. Clinical relevance of migration status can also be assumed regarding the remission of depression. Migration status and further factors affecting the effectiveness of the treatment should be analyzed in future research among larger samples with sufficient power to replicate these findings.

Recent Developments in Group Psychotherapy Research

This article reviews group psychotherapy research published within the past 30 years, predominantly focusing on outcomes of group treatments for patients with various mental disorders. Additionally, meta-analyses on the efficacy of group treatments for patients with cancer or chronic pain are summarized. Results strongly support the use of group therapy and demonstrate outcomes equivalent to those of individual psychotherapy. The research also appears to emphasize the effect of feedback on outcomes in group treatments and an association between treatment outcomes and group cohesion and alliance. Other promising developments in the field of group therapy are discussed.

A clinical effectiveness trial comparing ACT and CBT for inpatients with depressive and mixed mental disorders

Abstract Objective: Meta-analyses show that Acceptance and Commitment Therapy (ACT) is an efficacious treatment for a wide range of mental health problems. However, few studies have examined the effectiveness of ACT in naturalistic inpatient settings and in direct comparison to Cognitive Behavior Therapy (CBT). The aim of this study was to investigate the effectiveness of ACT and CBT with regard to depression, general symptom strain and life satisfaction. Method: 177 inpatients in a psychiatric ward were included in the study and assigned to either ACT or CBT group intervention. All patients were assessed with the SCID-I interview and disorder-specific questionnaires as well as with a satisfaction with life scale. To control for confounding variables, amongst others, treatment integrity was evaluated. Results: Both the ACT and CBT intervention showed a large, statistically significant and stable symptom reduction over six months across all outcomes. Both approaches led to small improvement in life satisfaction. With regards to depressive symptoms, more than half of the patients reliably recovered due to therapy. Conclusion: ACT and CBT were similarly effective in treating patients with depressive and other mental disorders in a routine clinical setting. ACT is a viable alternative to CBT for treating inpatients.

Effectiveness of Inpatient Psychotherapy for Patients With and Without Migratory Background: Do They Benefit Equally?

BACKGROUND

Research on the effectiveness of inpatient psychotherapy for migrant patients predominantly concludes that they have greater symptom severity at admission and benefit less from psychotherapy. This study aims to compare symptom severity and effects of psychotherapy regarding depression, somatoform disorders, anxiety disorders, and posttraumatic stress disorder (PTSD) in a sample of patients with and without migratory background (MB).

METHODS

Symptom severity of 263 patients (T0, pretreatment) and 256 patients (T1, posttreatment) was assessed using the Patient Health Questionnaire somatization module (PHQ-15), depression module (PHQ-9), and general anxiety disorder module (GAD-7), and the PTSD Checklist (PCL-5). Calculations were made for a completer sample and an intention-to-treat (ITT) sample. To investigate the effectiveness of psychotherapy, we calculated effect sizes (Cohen's d) and clinically significant changes using the reliable change index (RCI).

RESULTS

Patients with MB showed significantly higher symptom burden at admission for somatization (p = 0.025, d = 0.345) and posttraumatic symptoms (p = 0.008, d = 0.424) than patients without MB. At discharge, patients with MB reported significantly higher severity regarding all assessed symptoms (somatization: p = 0.001, d = 0.507; depression: p = 0.045, d = 0.313; anxiety: p = 0.012, d = 0.428; traumatization: p = 0.040, d = 0.329) compared with non-migrant patients. Patients without MB improved significantly regarding all assessed symptoms (somatization: p < 0.001, d = -0.304; depression: p < 0.001, d = -0.692; anxiety: p < 0.001, d = -0.605; posttraumatic symptoms: p < 0.001, d = -0.204). Patients with MB improved significantly concerning depression (p < 0.001, d = -0.649) and anxiety (p = 0.002, d = -0.441). Occurrence of comorbidity was high (87.1% had more than one psychiatric diagnosis). Neurotic, stress-related, and somatoform disorders (F4) and personality disorders (F6) were more frequent among patients with MB.

CONCLUSIONS

Patients with MB showed higher symptom severity at admission. Our study demonstrated a significant reduction of depressive and anxiety symptoms among patients with MB receiving psychotherapy. Further research is needed to identify interventions that effectively improve somatization and posttraumatic stress for patients with MB, since these symptoms were not significantly reduced.

Psychosomatic-psychotherapeutic treatment in an evening clinic: a qualitative examination of patients' expectations and experiences

Background

Over a course of 10 weeks the psychosomatic–psychotherapeutic evening clinic at the University of Heidelberg offers an intensive and multimodal 3-h treatment program on three evenings a week. The clinic aims at accommodating patients who on the one hand do not fit the criteria of partial or full-time inpatient therapy, but on the other hand requires a more intensified therapy dose than the usual German outpatient settings can cater for. In the presented monocentric, qualitative study, we wanted to examine this treatment concept with regard to the patients’ specific concerns, expectations, and individual experiences. By contrasting differences in intensity of outpatient and inpatient treatment, we aimed to identify those characteristics of the evening clinic setting that were perceived as especially helpful.

Method

Each of the 25 patients was interviewed twice, using semi-structured interviews. The interviews took place before (T0) and after (T1) the 10-week treatment interval. A qualitative content analysis of the transcribed interviews was performed using the software “MaxQDA”.

Results

We identified a total of 1609 separate codes and grouped them into 33 topics and 5 overarching categories. Here, we found some aspects independent of the therapeutic setting, and others concerning the patients’ specific expectations and experiences resulting from the particularities of the evening clinic as an outpatient setting including certain inpatient characteristics. This included the possibility of patients continuing to work and being able to fulfil social obligations, i.e. childcare or caring for relatives, while at the same time undergoing intensive psychotherapeutic treatment.

Conclusions

Our results show that the evening clinic concept is particularly suitable for patients with mental and psychosomatic disorders who require intensified multimodal therapy while continuing to meet their obligations in their private and working lives. However, in comparison to other therapeutic methods, this concept generated greater stress and time challenges. Patients should therefore have a reasonably good standard of functioning in everyday life and sufficient coping resources. This is especially important for patients who continue working in their jobs while undergoing treatment. So far, there is a lack of quantitative data which would be needed to evaluate the effectiveness of this novel setting.

Therapeutic factors that promote recovery in high-risk adolescents intensive group psychotherapeutic MBT programme

BACKGROUND

The aim of this study was to investigate whether therapeutic factors as identified by Yalom and potential additional therapeutic factors could be found in the qualitative individual reports of high-risk adolescents with personality disorders at the end of an intensive group psychotherapeutic MBT programme and whether the therapeutic factors were related to therapy outcomes.

METHODS

At the end of treatment, 70 adolescents were asked to write a farewell letter. Content analysis of the letters was performed by two independent raters, using the 12 therapeutic factors of Yalom and potential additional therapeutic factors as coding categories. The factors were related to outcome, operationalized as a decrease in psychological symptoms as measured with the Symptom Check List 90 (SCL-90).

RESULTS

All therapeutic factors of Yalom and four new factors were identified in the letters, ranging from 1 to 97%. The factors of 'cohesion' (97%), 'interpersonal learning output' (94%), 'guidance' (98%) and 'identification' (94%) were found in most letters. By contrast, 'universality' (1%), 'family re-enactment' (3%) and 'instillation of hope' (1%) were found in very few letters. The factors 'interpersonal learning input', 'self-esteem' and 'turning point' were significantly associated with therapeutic recovery.

CONCLUSIONS

Large presence differences were encountered in therapeutic factors associated with resilience processes and the resolution of psychological distress. Although a relationship was found between certain factors and change in symptoms, it was unclear whether the factors had led to such change. Further research seems important for treatment in general and for the personalization of treatment.

Cognitive Behavioral Analysis System of Psychotherapy as group psychotherapy for chronically depressed inpatients: a naturalistic multicenter feasibility trial

The Cognitive Behavioral Analysis System of Psychotherapy (CBASP) is a relatively new approach in the treatment of chronic depression (CD). Adapted as group psychotherapy for inpatients, CBASP is attracting increasing attention. In this naturalistic multicenter trial, we investigated its feasibility after 10 sessions of CBASP group therapy over a treatment time of at least 5 to a maximum of 10 weeks. Treatment outcome was additionally assessed. Across four centers, 116 inpatients with CD (DSM-IV-TR) attended CBASP group psychotherapy. Feasibility was focused on acceptance, and evaluated for patients and therapists after five (t1) and ten sessions (t2) of group psychotherapy. Observer- and self-rating scales (Hamilton Depression Rating Scale-24 items, HDRS₂₄; Beck Depression Inventory-II, BDI-II; World Health Organization Quality of Life assessment, WHOQOL-BREF) were applied before group psychotherapy (t0) and at t2. Dropouts were low (10.3%). Patients' evaluation improved significantly from t1 to t2 with a medium effect size (d = 0.60). Most of the patients stated that the group had enriched their treatment (75.3%), that the size (74.3%) and duration (72.5%) were 'optimal' and 37.3% wished for a higher frequency. Patients gave CBASP group psychotherapy an overall grade of 2 ('good'). Therapists' evaluation was positive throughout, except for size of the group. Outcome scores of HDRS₂₄, BDI-II, and WHOQOL-BREF were significantly reduced from t0 to t2 with medium to large effect sizes (d = 1.48; d = 1.11; d = 0.67). In this naturalistic open-label trial, CBASP, when applied as inpatient group psychotherapy, was well accepted by patients and therapists. The results point towards a clinically meaningful effect of inpatient treatment with CBASP group psychotherapy on depression and quality of life. Other potential factors that could have promoted symptom change were discussed. A future controlled study could investigate the safety and efficacy of CBASP group psychotherapy for inpatients.

Understanding Long-term Outcome from the Patients' Perspective: A Mixed Methods Naturalistic Study on Inpatient Psychotherapy

OBJECTIVE

The complex phenomenon of psychotherapy outcome requires further conceptual and methodological developments that facilitate clinically meaningful research findings. In this study, we rely on an idiosyncratic and process-oriented understanding of treatment effects in order to investigate long-term outcome. A conceptual model of long-term outcome is presented that comprises both a taxonomy of change and explanatory factors.

METHOD

A mixed methods naturalistic study was conducted in an inpatient psychotherapy setting. Long-term quantitative outcome data are complemented with a data-driven thematic analysis of interviews with 22 participants, five to six years after ending inpatient psychotherapy.

RESULTS

Long-term outcome findings show improved well-being for the majority of former patients and this until five to six years after treatment. From the patients' perspectives, long-term changes can be situated on different interrelated existential levels: reconnection to others and (the meaning of) life, a revelation, an altered self, life changes, and altered expectations and ideas about recovery and treatment. The complex interplay of the person, the therapy centre, the outside world and the evolution over time helped explain the experienced changes and individual differences.

CONCLUSION

The findings support the value of an idiosyncratic and process-oriented understanding of outcome and recovery as well as substantiate the importance of multiple methods and perspectives when studying the effects of psychotherapy.

Exploring the relationship between activities and emotional experience using a diary in a mental health inpatient setting

Mental health inpatient milieus have repeatedly been found to be associated with passivity, social disengagement, and low levels of interaction with staff. However, little is known about patients' experiences related to different ward activities. In the present study, we aimed to study the reports of activities and associated experiences of patients admitted to acute psychiatric inpatient wards. Disengaged, inactive, and solitary activities were hypothesized to be associated with less reward and more distress than their counterparts. We also aimed to investigate if such activities predicted distress, and if they were associated with clinical severity. Participants (n = 102) recorded their activities along with concurrent ratings of reward and distress in a structured 1-day diary, and nurses provided clinical severity ratings. On average, 3.74 of the 11 hours assessed (34%) were spent doing nothing, only 0.88 hours (8%) were spent with staff, and most of the time was spent in solitude. Doing nothing, being alone, and passivity were associated with the greatest levels of distress and lowest levels of reward, whereas informal socializing demonstrated the opposite pattern. Distress was not predicted by activity or reward when adjusting for baseline distress. Clinical severity was not associated with the amount of time spent alone or the experience of reward during activity. In conclusion, the risk for passivity and social disengagement during admission prevails. This activity pattern could have detrimental emotional consequences and warrants action, but more studies are needed to determine if activity actually precedes emotional experience.

From feelings of imprisonment to group cohesion: A qualitative analysis of group analytic psychotherapy with dual diagnosed patients admitted to an acute inpatient psychiatric unit

OBJECTIVES

Group cohesion, the establishment of hope, and the expression of feelings have been said to be the basic ingredients of group psychotherapy. To date, there is few literature describing therapeutic processes in short stay settings such as acute psychiatric wards and with special patient groups such as addictions. Our goal with this study is to describe and analyze group processes in such contexts.

METHODS

We used a qualitative methodology combining constant comparative methods and hermeneutical triangulation to analyze therapeutic narratives in the context of a group analytic process carried following Foulkes' and Yalom's styles.

RESULTS

The results provide a picture of the therapeutic process including the use of norms to strengthen group cohesion facilitating the expression of emotions in early stages of group development.

CONCLUSIONS

This analysis is intended to be a guide for practitioners implementing group therapy in contexts involving several constraints, such as acute psychiatric wards.

Group Process and Therapeutic Protocol of Intensive Transdiagnostic Group Cognitive-Behavioral Therapy for Anxiety and Personality Disorders in a Day Clinic

This brief report presents group processes and the treatment protocol of intensive, transdiagnostic group cognitive-behavior therapy for anxiety with comorbid personality disorders in a day clinic. It describes the history of and rationale for the development of this 3-month, 15-hour a week group treatment and the utilization of group processes during this therapy. The authors argue that the group format presented here allows the treatment of personality disorders that are frequently comorbid with anxiety disorders.

Group Cognitive-Behavioral Therapy for Anxiety Disorders With Personality Disorders in Day Clinic Setting

PURPOSE

Short-term group cognitive-behavioral therapy (GCBT) with weekly homogeneous group sessions for treating specific anxiety disorders is relatively well developed and recognized. However, 12 weeks of intensive daily therapy for mixed anxiety and personality disorders is not. The current article aims to fill this gap by presenting the method of intensive transdiagnostic GCBT for anxiety disorders with comorbid personality disorders in a day hospital setting. Preliminary studies showed that participants exhibited significant improvement during this type of treatment.

CONCLUSIONS

This article reviews the advantages of group therapy that is transdiagnostic over the homogeneous group and individual therapy formats.

PRACTICE IMPLICATIONS

The detailed description of the current therapeutical program may facilitate the development of similar programs in day clinic settings.

Day clinic and inpatient psychotherapy of depression (DIP-D): qualitative results from a randomized controlled study

OBJECTIVE

Depressive disorders are among the most common psychiatric disorders. For severely depressed patients, day clinic and inpatient settings represent important treatment options. However, little is known about patients' perceptions of the different levels of care. This study aimed to obtain an in-depth analysis of depressive patients' experiences of day clinic and inpatient treatment in a combined clinical setting.

METHODS

Following a randomized controlled trial comparing day clinic and inpatient psychotherapy for depression (Dinger et al. in Psychother Psychosom 83:194-195, 2014), a sample of depressive patients (n = 35) was invited to participate in a semi-structured interview during an early follow up 4 weeks after discharge. A qualitative analysis of interview transcripts was performed following the principles of constructivist thematic analysis.

RESULTS

Following analysis, 1355 single codes were identified from which five main categories and 26 themes were derived for both groups. In regard to patient group integration and skill transfer to everyday life, distinct differences could be observed between the day clinic and inpatient group.

CONCLUSION

While adjustment to therapeutic setting and patient group integration seem to be facilitated by inpatient treatment, the day clinical setting appears to promote treatment integration into patients' everyday contexts, aiding treatment-related skill transfer to everyday life as well as alleviating discharge from clinic treatment. Further studies on depressive subject groups in day clinic and inpatient treatment should investigate aspects of group cohesion and treatment integration in relation to therapeutic outcome.

Inpatient and Day-Clinic Experience Scale (IDES) - a Psychometric Evaluation

OBJECTIVES

The Inpatient and Day-Clinic Experience Scale (IDES) was developed to assess common factors in a multimodal psychotherapy setting from the patients' perspective. The questionnaire measures different aspects of therapeutic relationships, a positive self-view and a critical attitude towards therapy.

METHODS

Three samples (total N = 821) were used to evaluate the psychometric properties and factor structure of the questionnaire.

RESULTS

Confirmatory analyses show a good model fit and support the proposed structure with 25 items and seven scales. In addition, reliability indices were stable throughout multiple assessments over time. Concerning validity, early IDES process measures were moderately associated with symptomatic improvement.

CONCLUSIONS

The IDES is a psychometrically reliable questionnaire for the evaluation of process factors in inpatient and day-clinic psychotherapy settings.

Developing an Inpatient Group Psychotherapy Program: Challenges and Lessons Learnt

In Iran, inpatient group psychotherapy has been limited to transient practices for research purposes or fulfilling personal interest of therapists. The goal of this paper is to share and explain the experience of developing an inpatient group psychotherapy program in Roozbeh Psychiatric Hospital, Tehran, Iran. After theoretical delineation and preparation of a draft of the program guideline, two pilot sessions were held. Based on this initial experience a final treatment guideline was prepared. Afterwards, the program was continued for more than 1 year in a female ward at Roozbeh Psychiatric Hospital. The output of this exercise was a guideline that covers important topics in development of inpatient group psychotherapy. It is concluded that inpatient group psychotherapy has its unique challenges. Of the most important challenges that can be mentioned in this regard are the participation of patients with significant differences in levels of psychopathology and psychiatric signs and symptoms, and high comorbidity with specific personality traits or disorders. Other challenges relevant to the structure of the group include items such as very limited time for working through and inevitable out-of-group contacts.

Behavioral activation in acute inpatient psychiatry: a multiple baseline evaluation

BACKGROUND AND OBJECTIVES

The present study employed a multiple baseline study design with repeated measures to explore clinical outcomes, therapy mechanisms, and feasibility of Behavioral Activation for persons admitted to inpatient psychiatry.

METHODS

Six adult inpatients with depressive symptoms and different psychiatric disorders were randomized to different lengths of baseline standard inpatient treatment. Subsequently a 5-day, 10-session Behavioral Activation protocol was added. Daily self-report outcome and process measures were administered and supplemented with hourly self-reports and clinician assessments before and after each study phase.

RESULTS

After a relatively stable baseline, at least four participants showed marked gradual improvements both in terms of outcome as well as activation and avoidance as Behavioral Activation was initiated. The temporal relation between process and outcome differed somewhat across metrics. In most instances however, change in activation and avoidance either coincided or preceded decreased depression.

LIMITATIONS

We did not include some relatively common disorders, did not control for the effects of increased attention, did not investigate treatment integrity, and did not conduct follow-up after discharge. Raters were not blind and measures were mainly focused on depressive symptoms. All received concurrent medical treatment.

CONCLUSIONS

This preliminary study further supports the promise of Behavioral Activation as an inpatient treatment for persons with a variety of psychiatric disorders. Results also lends preliminary support for the purported mechanisms of Behavioral Activation.

Group CBT for psychosis in acute care: a review of outcome studies

There is evidence that group cognitive behavioural therapy for psychosis (CBTp) is an effective treatment, but much of this research has been conducted with outpatient populations. The aim of this review was to determine the utility of group CBTp for inpatients. We systematically searched Scopus, Web of Science and EBSCO electronic databases to identify relevant research. We reviewed the resulting articles and included those which had been conducted with inpatients, with symptoms of psychosis, using cognitive behaviour therapy, delivered in a group format. Fourteen articles relating to ten studies were identified. Two were randomized controlled trials; two were cohort studies and the rest were pre-/post-intervention studies. There was considerable heterogeneity between the studies and all had methodological limitations. The findings suggest positive trends towards the reduction of distress associated with psychotic symptoms, increased knowledge of symptoms, decreased affective symptoms and reduced readmissions over several years. However, there is currently not enough evidence to draw any strong conclusions regarding the utility of group CBTp for inpatients due to the small number of studies and limitations in quality and generalizability. Therefore, this review indicates the need for further research, particularly large, methodologically rigorous, randomized controlled trials.

Do patients' symptoms and interpersonal problems improve in psychotherapeutic hospital treatment in Germany? A systematic review and meta-analysis

Background

In Germany, inpatient psychotherapy plays a unique role in the treatment of patients with common mental disorders of higher severity. In addition to psychiatric inpatient services, psychotherapeutic hospital treatment and psychosomatic rehabilitation are offered as independent inpatient treatment options. This meta-analysis aims to provide systematic evidence for psychotherapeutic hospital treatment in Germany regarding its effects on symptomatic and interpersonal impairment.

Methodology

Relevant papers were identified by electronic database search and hand search. Randomized controlled trials as well as naturalistic prospective studies (including post-therapy and follow-up assessments) evaluating psychotherapeutic hospital treatment of mentally ill adults in Germany were included. Outcomes were required to be quantified by either the Symptom-Checklist (SCL-90-R or short versions) or the Inventory of Interpersonal Problems (IIP-64 or short versions). Effect sizes (Hedges’ g) were combined using random effect models.

Principal Findings

Sixty-seven papers representing 59 studies fulfilled inclusion criteria. Meta-analysis yielded a medium within-group effect size for symptom change at discharge (g = 0.72; 95% CI 0.68–0.76), with a small reduction to follow-up (g = 0.61; 95% CI 0.55–0.68). Regarding interpersonal problems, a small effect size was found at discharge (g = 0.35; 95% CI 0.29–0.41), which increased to follow-up (g = 0.48; 95% CI 0.36–0.60). While higher impairment at intake was associated with a larger effect size in both measures, longer treatment duration was related to lower effect sizes in SCL GSI and to larger effect sizes in IIP Total.

Conclusions

Psychotherapeutic hospital treatment may be considered an effective treatment. In accordance with Howard’s phase model of psychotherapy outcome, the present study demonstrated that symptom distress changes more quickly and strongly than interpersonal problems. Preliminary analyses show impairment at intake and treatment duration to be the strongest outcome predictors. Further analyses regarding this relationship are required.

Group therapy in public mental health services: approaches, patients and group therapists

Group therapy is used extensively within public mental health services, but more detailed knowledge is needed. All 25 health authorities in Norway were invited to describe their groups: theory, primary tasks, interventions, structure, patients and therapists. Four hundred twenty-six groups, 296 in community mental health centres and 130 in hospitals, were categorized into nine types, based on theoretical background. Psychodynamic groups were most frequent, followed by cognitive-behavioural, psycho-educative, social skills/coping and art/expressive groups. Weekly sessions of 90 min and treatment duration <6 or >12 months was most frequent. Main diagnosis for 2391 patients: depression (517), personality disorder (396), schizophrenia/psychosis (313) and social phobia (249). Patients with depression or personality disorder were mostly in psychodynamic groups, psychosis/bipolar disorder in psycho-educative groups. Cognitive-behavioural groups were used across several diagnoses. Most therapists were nurses, only 50% had a formal training in group therapy. There is a plethora of groups, some based on one theoretical school, while others integrate theory from several 'camps'. Patients with similar diagnosis were offered different group approaches, although some trends existed. More research evidence from regular clinical groups is needed, and clinician-researcher networks should be developed. More group therapists with formal training are needed.

Brief heterogeneous inpatient psychotherapy groups: a process-oriented psychoeducational (POP) model

In the United States, there is currently an increase in admissions to psychiatric hospitals, diagnostic heterogeneity, briefer stays, and a lack of inpatient research. Most traditional group therapy models are constructed for longer-term homogeneous patients. Diagnostically homogeneous groups even outperform heterogeneous groups. However, changes in health care have created a clinical dilemma in psychiatric hospitals where groups have become characterized by brief duration, rapid turnover, and diagnostic heterogeneity. A literature review offered little in the way of treatment recommendations, let alone a model or empirical basis, for facilitating these types of groups. Common factors from group therapy studies were extracted. Based on an integration of these studies, a process-oriented psychoeducational (POP) treatment model is recommended. This model is theoretically constructed and outlined for future study.

Scl-90-R symptom profiles and outcome of short-term psychodynamic group therapy

Background. Psychodynamic group psychotherapy may not be an optimal treatment for anxiety and agoraphobic symptoms. We explore remission of SCL-90-R Global Severity Index (GSI) and target symptoms in 39 sessions of psychodynamic group therapy. Methods. SCL-90-R “target symptom” profile and GSI remission according to Danish norms were identified in 239 patients and evaluated according to reliable and clinical significant change. Results. Four major groups of target symptom cases (depression, interpersonal sensitivity, anxiety, and phobic anxiety) covered 95.7% of the sample. As opposite to phobic anxiety and anxiety patients, patients with interpersonal sensitivity obtained overall the most optimal outcome. The phobic anxiety scale, social network support, and years of school education were independent predictors of GSI remission, and a low anxiety score and absence of phobic anxiety target symptoms were independent predictors of remission of target symptom pathology. Conclusions. The negative results as associated with the SCL-90-R phobic anxiety scale and the phobic anxiety target symptom group are largely in agreement with recent studies. In contrast, whatever the diagnoses, patients with interpersonal sensitivity target symptom may be especially suited for psychodynamic group therapy. The SCL-90-R subscales may allow for a more complex symptom-related differentiation of patients compared with both diagnoses and GSI symptom load.