The therapeutic contracting program: a comprehensive continuum of care model

Home-Based Cognitive-Behavioral Therapy Successfully Treats Severe, Chronic, and Refractory Obsessive-Compulsive Disorder

A 28-year-old, married, Caucasian female with obsessive-compulsive disorder was referred for home-based cognitive-behavioral therapy. At the time of intake, she obtained a severe rating on the Yale-Brown Obsessive-Compulsive Scale, and was considered chronic and treatment refractory after failing previous trials of behavior therapy and pharmacotherapy. Prior treatment attempts in traditional settings were unsuccessful because she failed to generalize gains beyond such settings. She was evaluated at baseline, after treatment, and again at an 18-month follow-up. Performing endstate functioning and reliable change assessment as described by Jacobson andTruax, the authors found that the patient realized clinically significant gains after treatment, and that she maintained those gains at follow-up. This illustrates that severe, chronic, and refractory patients may benefit by receiving cognitive-behavioral therapy as a home-based intervention. The need for replication, further controlled trials, and the implications this case may have upon future research are discussed.

Cognitive and behavioral changes related to symptom improvement among patients with a mood disorder receiving intensive cognitive-behavioral therapy

OBJECTIVE

To examine the relationship between cognitive and behavioral changes associated with cognitive-behavioral therapy (CBT) and treatment response in an intensive partial hospital (PH) setting.

METHODS

Study participants were 105 patients with mood disorders receiving treatment in a private psychiatric PH setting. The flexible treatment model used evidence-based CBT interventions adapted to the PH context, with emphases on psychoeducation and skills training. Participants completed self-report measures at admission and discharge to assess psychological distress, depression, negative automatic thoughts, and behavioral activation. Mean treatment duration was 9 days.

RESULTS

Decreased negative automatic thoughts and increased behavioral activation predicted reduction of depressive symptoms; however, only decreased negative automatic thoughts was predictive of patients' overall level of psychological distress.

CONCLUSIONS

These results suggest that a CBT intervention adapted for use in a PH setting can be an effective treatment for severe mood disorders. Furthermore, although the design used in this study precludes causal inferences, depressive symptom improvement appears to be associated with decreased negative automatic thoughts and increased behavioral activation. Implications for the delivery of CBT in PH programs and future directions for research are discussed.

Short-term cognitive behavioral partial hospital treatment: a pilot study

OBJECTIVE

Brief, cost-contained, and effective psychiatric treatments benefit patients and public health. This naturalistic pilot study examined the effectiveness of a 2-week, cognitive-behavioral therapy (CBT) oriented partial hospital program.

METHODS

Study participants were 57 patients with mood, anxiety, and/or personality disorders receiving treatment in a private psychiatric partial hospital (PH) setting. A flexible treatment model was used that adapts evidence-based CBT treatment interventions to the PH context with emphases on psychoeducation and skills training. Participants completed self-report measures at admission and after 1 and 2 weeks, to assess stabilization and functional improvements, with added attention to the acquisition of cognitive and behavioral skills. The data were analyzed using repeated measures analyses of variance and correlation.

RESULTS

Participants reported a decrease in symptoms and negative thought patterns, improved satisfaction with life, and acquisition and use of cognitive and behavioral skills. Skill acquisition was correlated with symptom reduction, reduced negative thought patterns, and improved satisfaction with life.

CONCLUSIONS

Results of this pilot study suggest that a 2-week PH program can be effective for a heterogeneous patient population with mood, anxiety, and/or personality disorders. These findings are promising given the prevalence of treatments of such brief duration in private sector PH programs subject to the managed care marketplace. Future studies are planned to test this flexible PH treatment model, with particular attention to the effectiveness of the CBT approach for the treatment of different disorders and to whether effectiveness is sustained at follow-up. Further study should also examine whether skill acquisition is a mechanism of change for symptom reduction and functional improvements.

Fixed values and a flexible partial hospital program model

Since the 1990s, societal and economic factors have constrained mental health care service delivery in the United States. Partial hospital (PH) programs have been presented with the challenge of using limited resources to treat complex patients in very short time frames; yet predominant psychosocial models and evidence-based treatment approaches have not adjusted sufficiently to the combined demands of patient care and the new health care environment. An updated PH model can advance existing psychosocial theory and practice. The basic assumption of the model is that both clinical and organizational aspects of a PH program must be inherently adaptable to maintain consistent effectiveness. The set of fixed values described here are instrumental in establishing priorities, guiding decision making, and creating a proactive, flexible organization. These values are drawn from the history of psychosocial and milieu treatments from the 1930s to the present and from assumptions and practices of cognitive-behavioral therapy, and are augmented by insights from psychodynamic psychiatry, business management, and leadership. The PH treatment approach aims to translate evidence-based cognitive-behavioral treatments into pragmatic interventions with emphases on psychoeducation and skills training. The context is brief treatment (i.e., one to two weeks) for mood, anxiety, and personality disordered patients in a private sector, managed care environment. Elements of this model may be generalized to inpatient, residential, and intensive outpatient programs, as well as to those that are starting up or being reorganized.

Home-based behavior therapy for obsessive-compulsive disorder: a case series with data

The effectiveness of "home-based" exposure and response prevention was assessed in a series of 11 subjects with obsessive-compulsive disorder (OCD). Patients received 24 treatment sessions in a range of natural settings and situations. Sixty-four percent of the patients responded to behavior therapy in these settings, and 36% achieved lasting improvements in their OCD symptoms. Implications for the impact on consumers of this seldom-used application of behavior therapy are discussed and some recommendations for future research are made.