John S. Rosie

Patient Personality and Time-limited Group Psychotherapy for Complicated Grief

Abstract We used a randomized clinical trial to investigate the interaction of two patient personality characteristics (quality of object relations [QOR] and psychological mindedness [PM]) with two forms of time-limited, short-term group therapy (interpretive and supportive) for 139 psychiatric outpatients with complicated grief. Findings differed depending on the outcome variable (e.g., grief symptoms, general symptoms) and the statistical criterion (e.g., statistical significance, clinical significance, magnitude of effect). Patients in both therapies improved. For grief symptoms, a significant interaction effect was found for QOR. High-QOR patients improved more in interpretive therapy and low-QOR patients improved more in supportive therapy. A main effect was found for PM. High-PM patients improved more in both therapies. For general symptoms, clinical significance favored interpretive therapy over supportive therapy. Clinical implications concerning patient-treatment matching are discussed.

Time-limited day treatment for personality disorders: Integration of research and practice in a group program.

Historical Evolution of Day Treatment Psychiatric Partial Hospitalisation A Review of the Research Utilization of Partial Hospitalisation Alternative Psychosocial Treatments for Affective Disorders and Personality Disorders The Edmonton Day Treatment Programme Two Weeks in the Life of the Day Treament Programme Clinical Trial Evaluation of Treatment Efficacy Prediction of Success in the Day Treatment Programme Relationships Among Psychological Mindedness, Patient Work, and Favourable Outcome in the Day Treatment Programme The Psychosocial Environment as a Predictor of Outcome in the Day Treatment Programme Case Illustrations from the Day Treatment Programme Themes and Future Directions.

Patient characteristics and success in day treatment.

This study examined the ability of seven patient characteristics to predict success (remaining, benefiting) in a day treatment program for psychiatric outpatients. The sample consisted of 165 patients, most with affective and personality disorders, who participated in an intensive psychodynamically and group-oriented program within a controlled clinical trial. Two patient personality characteristics (psychological mindedness, quality of object relations) emerged as the strongest predictors. Other variables that contributed to the predictions, either singly or in an interaction with quality of object relations, were age, marriage, presence of a personality disorder, and previous psychiatric hospitalization. The patients initial level of symptomatic disturbance was not a significant predictor. The advantage of using predictors that are relevant to the theoretical and technical orientation of a program is emphasized.

Group composition and group therapy for complicated grief.

This prospective study investigated the impact of group composition on the outcome of 2 forms of time-limited, short-term group therapy (interpretive, supportive) with 110 outpatients from 18 therapy groups, who presented with complicated grief. The composition variable was based on the patients level of quality of object relations. The higher the percentage of patients in a therapy group who had a history of relatively mature relationships, the better the outcome for all patients in the group, regardless of the form of therapy or the individual patients quality of object relations score. The findings have direct clinical implications for composing short-term therapy groups for outpatients with complicated grief and possibly for other types of group therapies and patient problems.

Differentiating Symptoms of Complicated Grief and Depression Among Psychiatric Outpatients

Objective: This study examined whether dimensions of complicated grief (CG) could be distinguished from dimensions of depression and whether these dimensions were differentially affected by group psychotherapy for CG. Method: A total of 398 psychiatric outpatients who had experienced one or more significant death losses provided ratings on standard measures of grief and depression. Factor analysis of the 56 items from these measures was used to explore the possibility that grief and depression symptoms would form separate dimensions of distress. Subsamples of the patients also participated in 1 of 2 forms of short-term group therapy for CG. Repeated-measures analysis of variance and calculation of effect sizes were performed to examine changes in the dimensions following treatment. Results: The grief items formed 3 distinct clusters representing different dimensions of CG. None of the depression items loaded highly on these grief dimensions. The depression items formed 2 distinct clusters. Two of the grief dimensions demonstrated the most improvement following group therapy that addressed CG. There was also evidence for differential effectiveness of the 2 forms of group therapy. Conclusions: When assessing psychiatric patients who have death losses, clinicians should consider different types of grief reactions. Different types of grief reactions may be responsive to different treatments. In the absence of depressive symptoms, clinicians should not assume the absence of CG.

NEO-five factor personality traits as predictors of response to two forms of group psychotherapy.

Abstract The relationships between patient personality variables and outcome for 107 psychiatric outpatients with complicated grief who completed either interpretive or supportive short-term group therapy were investigated. The personality variables were assessed prior to treatment with the NEO-Five Factor Inventory (NEO-FFI). For patients in both forms of therapy, extraversion, conscientiousness, and openness were directly associated with favorable treatment outcome. In contrast, neuroticism was inversely related to favorable outcome for patients in both forms of therapy. Agreeableness was directly related to favorable improvement in grief symptomatology for patients in interpretive therapy, but not for those in supportive therapy. The results highlight the importance of assessing patient personality in order to predict response to short-term group therapy. Possible explanations and clinical implications of these findings are discussed.

Psychological Mindedness, Work, and Outcome in Day Treatment

A recently completed clinical trial that investigated the effectiveness of a group-oriented, day treatment program provided an opportunity to pursue a multidimensional approach to the prediction of treatment outcome. The sample consisted of 99 psychiatric outpatients, most of whom had received diagnoses of affective and personality disorders. The predictor variables included a patient personality characteristic (psychological mindedness), a group process variable (patient work), and their interaction. Univariate analyses revealed significant direct relationships between psychological mindedness and both work and favorable outcome, and between work and favorable outcome. Multivariate analyses indicated that psychological mindedness and work had independent significant relationships (additive or interactive) with several of the outcome variables. In combination they accounted for up to a quarter of the outcome variance. The results demonstrate the benefit of using a theoretically consistent multidimensional approach. The time-efficient nature of the predictor measures used in the study make them particularly amenable for use by clinicians and researchers.

Interpersonal predictors of group therapy outcome for complicated grief.

Abstract This study investigated three aspects of patients’ interpersonal functioning as predictors of outcome for two forms of group psychotherapy for complicated grief. Patients presented with a variety of death losses and met criteria for complicated grief. The three aspects of interpersonal functioning were the patient’s (1) attachment to the lost person, (2) quality of object relations (QOR), and (3) level of recent social role functioning. A more secure attachment to the lost person and better social role functioning were associated with more favorable outcome in both forms of therapy. In addition, patients with higher QOR had more favorable outcome in interpretive therapy while lower QOR patients had more favorable outcome in supportive therapy. The results suggest that each aspect of interpersonal functioning is important to consider when treating patients for complicated grief.

Social Support as a Predictor of Response to Group Therapy for Complicated Grief

This study investigated the effect of perceived social support on the outcome of group therapy for patients who experienced complicated grief following a variety of death losses. One hundred and seven psychiatric outpatients, who received either interpretive or supportive group therapy, rated their perceptions of social support from three sources (family, friends, and a special person) prior to treatment onset. For patients in both forms of therapy, perceived social support from friends was directly associated with favorable treatment outcome. In contrast, perceived social support from family was inversely related to outcome for patients in both forms of therapy. Perceived social support from a special person was directly related to favorable improvement in grief symptomatology for patients in interpretive therapy, but unrelated for those in supportive therapy. The results highlight the importance of assessing the level of support patients perceive from their social networks. The findings also suggest that the effect of perceived social support may also depend on the source of the support. Possible explanations and clinical implications of these findings are discussed.

Re: Day treatment for personality disorders.

Both authors refer to day treatment as an evidence-based alternative for patients in crisis (1, p 439; 2, p 446). It is important to understand that the day treatment program we studied, using a randomized controlled design, is not for patients in crisis (3,4). This program is designed for patients who are able to tolerate intensive selfand behavioural exploration. It corresponds to Livesley’s stage of “exploration and change” (2, p 448) in the sequence of strategies for treating personality disorder. Such day treatment programs are highly specialized, requiring competent leadership and several years of staff training to become effective (5). Day treatment programs should be distinguished from day hospitals, which are units designed as an alternative to inpatient care (6). Ideally, day hospitals for patients with personality disorders might operate on Livesley’s principles of “safety and managing crises” and “containment” (2, p 446).