Finding the ideal place for a psychotherapeutic intervention in a stepped care approach--a brief overview of the literature and preliminary results from the Project PREDICT

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.

The place of additional individual psychotherapy in the treatment of alcoholism: a randomized controlled study in nonresponders to anticraving medication-results of the PREDICT study

BACKGROUND

Goal of the presented study is to evaluate whether alcohol-dependent patients given additional individual psychotherapy after a heavy relapse during pharmacotherapy remain abstinent for longer than those who continue with pharmacotherapy alone.

METHODS

In a randomized, multicenter study, 109 alcohol-dependent patients who had suffered a heavy relapse either while receiving anticraving medication or placebo were randomized into 2 groups. One group received medication, medical management, and additional individual, disorder-specific, cognitive-behavioral psychotherapy, while the control group received medication and medical management only. Main outcome was defined as days until first heavy relapse.

RESULTS

Fifty-four patients were randomized to the psychotherapy group, 55 to the control group. Intention-to-treat and completer analyses found no differences between groups, whereas as-treated analyses (patients who actually received psychotherapy compared with those who did not) found a significant effect of psychotherapy.

CONCLUSIONS

Our data indicate that patients that are willing to attend psychotherapy benefit from receiving psychotherapy in addition to pharmacotherapy. We suggest that it may be beneficial to consider patients' preferences concerning psychotherapy at an earlier stage during treatment.

Behavioral treatment of insomnia: a proposal for a stepped-care approach to promote public health

Chronic insomnia is a highly prevalent condition that has psychological and medical consequences for those who suffer from it and financial consequences for both the individual and society. In spite of the fact that nonpharmacologic treatment methods have been developed and shown to be as or more effective than medication for chronic insomnia, these methods remain greatly underutilized due to an absence of properly trained therapists and a general failure in dissemination. A stepped-care model implemented in a primary-care setting offers a public health solution to the problem of treatment accessibility and delivery of behavioral treatments for insomnia. Such a model would provide graduated levels of cognitive behavioral intervention, with corresponding increases in intensity and cost, including self-help, manualized group treatment, brief individual treatment, and finally, individualized behavioral treatment provided by a specialist. To provide such a systematic approach, future research would need to confirm several aspects of the model, and a cadre of professionals would need to be trained to administer manualized care in both group and individualized formats.

What works for patients in outpatient treatment for alcohol addiction? An explorative study into clients' evaluation of subjective factors and therapy satisfaction

This explorative survey investigated clients' evaluation of therapy elements and other supportive factors within a randomized controlled trial. The treatment of patients with alcohol dependence consisted of pharmacotherapy (acamprosate/naltrexone/placebo) and biweekly medical management (MM). Forty-nine study participants were surveyed with a questionnaire to measure both the patients' satisfaction with the therapy and the subjective assessment of treatment elements and supportive factors.Study participants were highly satisfied with the treatment. The supportive factors previously identified by Orford et al1 were confirmed. 'Pharmacotherapy' was rated significantly less effective than 'MM' and 'global study attendance' (P < 0.001). The significant differences in the evaluation of treatment elements point to a preference for regular low-key contacts rather than for medication. Such contacts based on MM could be a useful intervention in clinical care, and its effectivity should be examined more closely in further research.

Alcohol and drug treatment systems in public health perspective: mediators and moderators of population effects

This article describes a public health approach to the study of service systems for people with substance use disorders. Such an approach is broadly conceived to include the consideration not only of specialized services for alcohol and drug dependence, but also of medical care and social welfare services that interact with and complement specialized drug and alcohol services. After describing a conceptual model of the substance abuse service system, we discuss how systems of care may contribute to population health and social welfare by reducing the societal burden of substance use disorders. The article then summarizes key systems issues pertaining to mediators and moderators of effective treatment systems. The potential benefits of systems thinking in relation to the management of substance use disorders are described. It is suggested that systems concepts and research may help to improve access, efficiency, economy, continuity of care, and effectiveness, thereby improving the population impact of treatment services.

Understanding addiction--mediators and moderators of behaviour change processes: an introduction

We provide an introduction into a highly important research area for the improvement of preventive and therapeutic measures in the field of substance use disorders: a better understanding of core mediators and moderators of change processes, especially during critical phases like onset, progression, cessation and relapse. Based on a brief description of 12 papers on related projects we detail relevant research issues like the role of impaired cognitive control functions or the narrow "window of opportunity" for early interventions during adolescence.