phrenia, chronic psychosis, organic brain damage, mental retardation, mania, ...... significantly more strongly with this item than. W&L subjects. (F= 4.48, df= 1,28,.
A Preliminary Cognitive-Behavioral for Inpatients Disorders I
.\
N
‘
11
1;
S
l
.
0
\1
I
H
\
N
K
R
group,
I
\,.
-r
A randomized, effectiveness
R
ii
R
and
it
on Line/ian’s
with was
I
study
P
,
I.
behavioral
II 11
evaluated
the
therapy
be/wv-
on parasuicidality, control
by self report
observations
in their
usefulness term unit and
lives outside
I)
was
P
atients with borderline personality disorder (BPD) constitute an estimated 10%_ 25% of all inpatient psychiatric admissions.’
sonal
challenged
their
Sub-
on
anger
and
functioning,2
and
often
patients with behaviors,
difficulties
often
responses
staff.35
exacerbates the patients’ ingness, and an escalating
anger and
disBPD. par-
in interper-
provoke
in
and
angry
This
in
turn
and demandself-perpetuat-
ing cycle begins. There is a need for effective inpatient treatments for these patients.57 Although various aspects of such treatment, such
to
The
Practice
as establishing regression,
ics of inpatient group personality disorder The
Received
preventing have been
lack
therapy patients.
of research
patients August
for BPD
1, 1994;
or other
on inpatient
is surprising; revisedJanuary
24,
1995;
and Psychology, University of Michigan, Address correspondence to Dr. Springer,
Ann
of Psychiatry, Arbor,
MI
Copyright
PRACTICE
9150,
1500
E. Medical
ac-
of PsyAnn Depart-
Medical Center
CenDrive,
48109-0120 © 1996
AND
Departments
of Michigan
University
Room
the
therapy
chiatry Arbor.
UH-9C,
From
groups
group
February
ter,
7, 1995.
a review), the specif-
cepted
ment
OF PSYCHOTHERAPY
treatment contracts, using medications,
and
described recently (see Miller8 for little has been discussed concerning
for these
JOURNAL
are
staff
rejecting
on a short-
(The Journal of Psychotherapy Research 1996; 5:57-71)
I)
ticularly
measures
the hospital.
.
couraged by working with These patients’ characteristic
group.
on the unit.
of this type ofgroup is discussed.
D
.
Inpatient
with personality a problem-solving
jects in both groups improved signficantly most change measures, although no signqIcant between-group d(/ferences were found. However, the treatment group patients viewed the intervention as more beneficial them
.
NI
.
K
dialectical
a discussion
assessed
P
.
Pii.I)
S
.
controlled
group focused
Change
U
1)u(:1111;I,
ior therapy, for inpatients disorders. The treatment, compared
i;
ii
of Short-Term Group Therapy Personality
With
of a cognitive-behavioral
based
skills
C
N
1. o
i
N
P
Report
American
RESEARCH
Psychiatric
Press,
Inc.
58
(I)up
has been atric
widely
units
practiced
for decades,9
on inpatient
psychi-
personality
disor-
and
der patients constitute a large inpatients. Group therapy could treatment
modality
for these
ting their difficulties ing to be observed therefore
to be
addressed
quickly than in could be especially psychiatric
more
number
erature
important
the
on
clinical
inpatient
groups
disorders;9’#{176}”2’3 however, ture is sparse. To our published conducted agnoses
treatment exclusively of personality
Although studies cluded
patients were group.’5’7 These insight-oriented peutic
value
ward.
Douglas’8
found
an
acute In
it was
lem-solving
therapy have inpatients, these separate found that or no theraor
short-term Coch#{233} and oriented
may
unclear
group
care
a
a cognitively
group
However,
has been with dioutcome
contrast,
that
problem-solving
lit-
personality
controlled
not studied as studies, in general, groups have little
on
inpatient
and
theoretical for
group disorder
was
be of some value. whether this probany more beneficial
than a playreading “placebo” the diagnoses of the patients
group;
further, not speci-
were
fied. Barley et al.’4 demonstrated of inpatient cognitive-behavioral
psychotherapy
group
compared
condition. Barley their personality cal behavior ment that
therapy’92#{176} (DBT)
centered each
nized length
nary decrease
with
and colleagues disorders unit on
patient
around
three
a 3-month
of hospitalization
research
separate
attends.
findings
the
a control
transformed into a dialectiunit with treatDBT groups
Groups
cycle,
with
are
orga-
an average
of 106 days. Prelimishowed a significant
in parasuicidality
suicidal behaviors) among DBT unit when compared
the program
its initiation.
When
contrasted with a general psychiatry which DBT was not practiced, the on the general
a similar
unit
did
unit rate not
on of
differ
(seif-mutilative
and
patients on the with patients hos-
VOLUMES
NUMBER
#{149}
time.
Linehan’9’2#{176}has developed
self-destructive her repertoire
a comprehen-
behaviors and of more effective
increase his or ways of coping
with intense affects and interpersonal difficulties. DBT follows a psychoeducational format that focuses on skill acquisition in four areas: mindfulness (nonjudgmental acceptance the experience of the moment), regulation emotion, interpersonal effectiveness, and tress tolerance. DBT focuses on enabling individual ing them actions into
to accept her feelings and to differentiate so that
feeling Linehan
intense
affects
without feelings do not
of of disthe judgfrom
translate
out of control of one’s behaviors. et al.22 conducted a controlled,
randomized for severely
study of the effectiveness of DBT dysfunctional, chronically
parasuicidal
female
line personality women assigned signed
outpatients
disorder. to DBT
to a control
with
They with
condition
a weekly
skills
group.
border-
compared 22 women
22 as-
of treatment
as
usual in the community. The DBT included 1 year of weekly individual and
Recently, effectiveness
before
sive outpatient treatment program for patients with BPD that has been adapted by others for inpatient use.”2’ The goal of Linehan’s DBT model is to decrease the patient’s maladaptive,
outcome study with inpatients disorder.’4
of inpatient personality
unit
during
directly
the empirical literaknowledge, only one
several
and
over
contributions and
I)ISoRI)II1S
PE1*ONIiIY
on the same
instituted
parasuicides
decrease.”
of
enlarged
permit-
was
I()I
functiona group and
therapy.’#{176} This as the lengths of
hospitalizations
A have
patients,
individual beneficial
pitalized
percentage of be a valuable
in interpersonal directly within
(I3i
There
condition therapy
were
four
assessment points, at pretreatment and at 4month intervals throughout the year. Linehan et al. found significantly in the DBT patients parasuicidality,
greater toward
decreased
improvement decreased
medical
risk
of
parasuicides, increased continuation in therapy, and decreased inpatient days. No between-group differences were demonstrated on measures indicative of internal experiences (depression, and reasons showed results the
1
improvement of this study
small
WINTER
#{149}
hopelessness, suicidal ideation, for living). Patients in both groups
sample
1996
are size,
on these measures. The impressive in light of and
the
researchers
SPIUNCER
59
ETII..
conclude
jects
because
ment effect. A recent follow-up study found that DBT subjects maintained improvement in some of these areas at 6-month and 12-
focus
of the CC
come
to feel
month
ships
strated
that
the
study
posttreatment
demonstrates
intervals.23
Linehan and her the effectiveness
outpatient
women
length
colleagues2223 of year-long
with
disorder. Barley effectiveness on average
a treat-
demonDBT for
borderline
personality
et al.’4 demonstrated an inpatient unit of stay
was
over
DBT’s where the
3 months,
and
they extended Linehan’s findings to include both male and female inpatients with various personality disorders, not only BPD. The purpose of the present study was to examine
whether
DBT
could
be successfully
modified for a short-term inpatient setting an average stay of less than 2 weeks and positive
results.
whether
DBT
This could
study
geneous patient population han and colleagues,22’23 patients with other addition to BPD and as women. A modified ing group, had been
order were paired
personality that included
skills
train-
group.
Personality
study by a
procedure.
no between-group differences (depression, hopelessness, and suicidal ideation) would be replicated in an inpatient sample. The second
dicted
that
addressed areas where was expected. It was CC
group
demonstrate greater dressed in that group:
subjects
become
less
angry
JOURNAL
than
pre-
areas ademotion
regulation, interpersonal effectiveness, distress tolerance. Specifically, 1) CC should
dif-
would
change in mindfulness,
control
this
demonstrate
through
fewer
undermining unit when
discharge whether
lives
tively
the
it should subjects
lessons
research
be
cogni-
taught
questions
and
in
from II
i: ‘I
were
in what
benefited NI
dis-
Although of a post-
the
hospital stay. A questionto assess this knowledge.
whether they
and
hospital,
whether
during their was designed
the of
study to determine the lessons of the group the
apprehend
felt that
treatment-
effectiveness,
outside
Exploratory
improvement or
than W&L subjects. without the results
to determine
group naire
a more subjects
should better learn regarding regulation
follow-up patients apply
possible
toward group
while on the inpatient with control subjects;
interpersonal
tress tolerance it is not possible
relationbe evident
behavioral
and 4) CC subjects lessons of the group emotion,
external
their
should
self-injurious
behaviors compared
should
their
0
the I)
designed
ways
subjects
groups.
S
5u bjects
dis-
The first set of hypotheses addressed replication of the findings of Linehan et al.22 It was predicted that the areas in which they found
set of hypotheses ferential change
over
in a change in locus-of-control internal orientation; 3) CC should
is a major
subjects
in
and
A discussion group, (W&L) group, was
who consented to the to one or the other group
randomization
control
others,
Coping (CC) group, on the unit for 2 years
began. Lifestyles
as a control
patients assigned
of the DBT
more
anger
2) CC
particularly
with
to their
disorders in men as well
with
group;
surroundings,
to evaluate
the Creative in existence
developed
explored
to a less homo-
than that of Lineone that included
version
before the research the Wellness and
also
be applied
with show
dealing
and subjects sub-
OF PSYCHOTHERAPY
Subjects
were
recruited
from
among
adults admitted to a general inpatient psychiatric unit at a university hospital. Exclusionary diagnostic criteria were the following: schizophrenia,
chronic
damage, disorder.
(For
separate tients or
patients
brief
in fewer
eating
disorder,
than
four
Patients
CC
unit’s
group
within
the
a
was followed.) that
group who
would
sessions had
during past
Patherapy
hospitalizations
approached.
pitalization
with
brain or eating
for electroconvulsive
very
in the
mania,
protocol
scheduled
for
organic
retardation,
treatment
result not
psychosis,
mental
were
participated
a previous year
were
hosalso
ex-
cluded. Of were
the
31 subjects
female
PRACTICE
and
AND
in the
10 (32.3%)
RESEARCH
study,
21
were
male.
(67.7%) The
(uoi
60
mean
age
(± SD)
average, according Level
ple
the III;
of
the
than
tiaxial
was
70
4 (30.8%)
9.85.
sample
Additional -
IV.
A subsam-
diagnostic
the
criteria by
Millon 1125
for Mul-
(MCMI-II).
(69.2%)
were
demographic
female
information education, sample and
is reported
on suband marital for the BPD
in Table
terviews. weekday
admitted 67 met
to the unit none of the
exclusionary criteria and were asked to participate. Of those approached, 46 (69%) gave their informed consent. Two of the 46 did not meet criteria
for
any
MCMI-II,25
personality
our
excluded
from
complete
the
disorder
diagnostic
screen,
the study.
Five
research;
2 additional
completed the study but data analyses, 1 because and 1 because of receiving
on and
the were
of the 44 did not subjects
were excluded of incomplete ECT. Thirty-one
from data of
the remaining 37 subjects attended at least four group sessions, and these 31 subjects were included jects did
in the data analysis. Although 2 subnot have valid MCMI-II protocols, 1
due to nondisclosure self-depreciation,
both
with perpsychia-
trists. Patients disorder
who
were
met
criteria
randomly
for
assigned
tive Coping skills training Wellness and Lifestyles
personality to the Crea-
group discussion
or
to the control
by a paired randomization procedure. Within several days after admission, and prior to attending their first group session, subjects
group
completed
a battery
of questionnaires
VOLUMES
and
in-
NUMBER
#{149}
group
every
was
and senior Linehan’s
inpatient
devel-
clinicians on DBT for use
unit.
The
group
is
follows a 10-session format that is repeated if the patient is hospitalized for more than 10 weekdays. The group meets for 45 minutes every weekday, complete written
and patients homework
tween
The
sessions.
are expected assignments
10 sessions
on emotion
and and
5
4 on interper-
1 on distress Lifestyles
for the purposes
the one of the authors nurses on the unit, who
to be-
comprise
regulation,
effectiveness, The Wellness
tolerance. group was
of the research
by
(T.S.) and one of the became the principal
group leader. The W&L group was designed to discuss issues of interest to patients and relevant to their lives, but not in a psychotherapeutic manner. Introspection and increased self-understanding goals of the topics: hobbies, group
group.
were explicitly There were
recreation, health and current was
not
particular
W&L group at the same
interests
met time
as highly
of
not to be five session
and fitness, events. The structured
group. The group leader day’s topic and then tailor
and 1 due to extreme were included in the
study because both were diagnosed sonality disorders by their inpatient
Coping
a short-term
tires
patients period,
I)IoRII:IP.
then attended the group just before their discharge.
Creative
developed Of the 188 over an 8-month
PI;RON.IJI’\
psychoeducational and is led or co-led by nurses experienced in leading groups for inpatients with personality disorders. The group
sonal Proced
They until
The
lessons
1.
i’oR
oped by nursing staff the unit 7’21by adapting on
scoring
Clinical
Version
subjects
race, religion, for the entire
subsample
On status, was
were male; the mean age was 31 subjects did not differ from the in mean socioeconomic status.
BPD
entire
years.
disorder
on
of the BPD
jects’ status
Level
met
Inventory,
Nine
31.4 ± 9.24
personality
greater
±
mode
13 subjects
borderline
and
was
subjects’ socioeconomic to Hollingshead’s index,24
(BF
families, control as the
would introduce the discussion
the group
members.
for 45 minutes each as the CC group.
CC the to the The
weekday
Nleastires
Subjects completed interviews shortly after
questionnaires and admission and just be-
fore discharge. Patient measures fell into the following categories: initial diagnostic/screening measure; other initial measures; change measures; and discharge measures. The initial diagnostic/screening measure termine whether subjects met or more personality disorders; to determine whether subjects
1
WINTER
#{149}
1996
was used to decriteria for one it was also used in the experi-
4lRIN(;IR
mental
61
iT-IL.
and
control
groups
Other
initial
comparable. for descriptive
purposes
rability
two
were
of the administered
were
diagnostically
measures and
groups.
were
to assess Change
at admission
comparability were as follows:
used
compa-
The
measures
and
again
treatment change. were administered
be-
behavior of each
about
personality when
disorder a scale
given
on the sonality DSM-III
was
rent
were beneficial the patient’s
used
to screen
demonstrated
measures
TABLE!.
use
the
patient’s
given
Demographic subsample
correlated
on
PHI
scores
between
per-
characteristics
of entire
Characteristic
Entire n
The
Female
therapist
et al.22
76% acts
notes
r= 0.94
to
physician/nurse
agree-
between ratings
Social was
Adjustment used
to
Scale assess
Self-Report28 overall
social
functioning.
sample
Sam pie
from
lethality.
(SAS-SR)
the
of parasuicide
Linehan
ranged
and
cur-
is reported in derated for medical
of parasuicide
and
col-
and
Interview22 used to as-
history
personnel.
number PHI
medical
with
to determine
lifetime
reliabilities
ment
was
medications. History interview
by medical that
for a target
therapy
episodes. Each parasuicide tail by the subject and then
for
that
outpatient
Parasuicide a semistructured
severity
(THI),
a thor-
information
of psychotropic
groups
obtained history
study,
current
two
Interview22
that
treatment this
The (PHI), sess
diagnoses, which were score exceeded 70. Data
scale scores are highly Axis II diagnoses.27
Other
on
report
MCMI
original
For
in the
History
interview
psychiatric
lected
on the unit was gathered by a review subject’s inpatient chart. The measures
are as follows: The MCMI-II2
ough period.
Finally, discharge measures to determine whether and
how the group interventions to subjects. Information
Treatment
a structured
fore discharge to assess change over the course of hospitalization and to assess any betweengroup differences in pretreatment-to-post-
of patients
and
(n
=
borderline
31)
personality
BPD
disorder
Sub sample
(BPD)
(n
=
13)
%
n
%
21
67.7
9
69.2
27 2 1 1
87.1 6.5 3.2 3.2
13 0 0 0
100.0
Religion Protestant Catholic Jewish Other
12 5 1 13
38.7 16.1 3.2 41.9
5 3 1 4
38.5 23.1
Education Partial high school High school graduate Partial college or specialized College graduate Graduate degree or training
2 4 19 2 4
6.5 12.9 61.3 6.5 12.9
1 3 8 1 0
77 23.1 61.5 7.7
15 6 2 2 3 3
48.4 19.4 6.5 6.5 9.7 9.7
7
53.8
1 1 2 0 2
7.7
gender
Race White African Hispanic Asian
American
training
Marital status Never married First marriage Remarried Separated Divorced Other
JOURNAL
OF PSYCHOTHERAPY
PRACTICE
AND
RESEARCH
7.7 30.8
7.7 15.4 15.4
of
62
Demographic and
each
assessed Factor
information
subject’s
was
collected,
socioeconomic
status
you was
according to Hollingshead’s Index of Socioeconomic Status.24
Four
Change measures administered after admission and again just before discharge were the Beck Depression Inventory29 (BDI); the Hopelessness Scale3#{176} (HS); the Adult Suicidal Ideation Questionnaire3’ (ASIQ); the StateTrait
Anger
Expression
Inventory;32;
nal-External Locus of Control Creative Coping Questionnaire34 The CCQ developed study,
is a 32-item
and the (CCOJ. the present
Scale33;
for
questionnaire
jects’ feelings and beliefs addressed in DBT and
the Inter-
assessing
sub-
about issues directly the CC group (emo-
FOR Pl:RoN;I
CR1’
(;ROt-P
learned
handle
in the group
difficult
encounter Interview,34
in
SlY
1)l’)Rl)l’l
will help
or painful
you to better
situations
your life?”). In respondents were
you
may
the Discharge asked similar
questions in an open-ended format. Data on acting-out behaviors on the were gathered by a daily review of each tient’s chart. Acting-out behaviors were fined as physically
anything the self-injurious
patient did that was or harmful to another
person, contained or violence, or
a verbal demonstrated
undermine
or
cluded being safety,
his
unit pade-
her
threat an
of self-injury attempt to
treatment.
1) threats of self-harm able to take responsibility thus requiring a check
They
in-
or suicide; 2) not for one’s own every 15 minutes
tional control, interpersonal effectiveness, and distress tolerance). Items are rated on a 7-point Likert-type scale. The questionnaire reflected topics included in the manual developed and
by nurses; 3) signing a petition to leave the hospital in 3 days (which is every voluntary patient’s right) against the advice of the inpa-
used Items
or more; without
by the nurses who lead the CC were found to have face validity
group
leaders,
and
the wording
is designed
that items are not obviously correct” (so as not to pull sponses
to please
A pilot on
normal
the
study
group. by the so
“correct” or “infor “correct” re-
tient
ting
treatment
team;
objects;
volunteers
CCQwas who
control group. any demographic
by an average of 16 days, to be comparable to the
length of hospitalization On the basis of the was
excluded
owing
change. to obtain
pilot
for the study study, one
to large
The remaining the total score
present study. Two measures were administered
developed to subjects
discharge: The
Questionnaire34
Discharge
behaviors oneself
i-.
t
variability items were used in the
for this study just prior to includes
were and
disorder
16 subjects 15 in the The
diagnoses
in the Creative Wellness and
groups variables on
the
mentioned above, 2 of the receive MCMI-II diagnoses reports. Of the remaining multiple
diagnoses,
particularly
MCMI-II.25
you
believe
that
VOLUME
things
5
NUMBER
#{149}
As
combinations
of DSM-III-R2 clusters A (odd) and C (anxious) or clusters B (dramatic) and C. The most prominent diagnosis for each subject-that for which he or she received the highest score-was usually a cluster C diagnosis (19
subjects received the diagnosis (CC of 16; W&L group: 5 of!!). Chi-square
often did the topics to your own personal
Coping Lifestyles
31 subjects did not owing to invalid 29, most received
group overall?” “How discussed in group relate “Do
a
did not differ on or in personality
subjects). ferences MCMI-II
and
with
I
I.
eight questions about the group rated on a 5-point, Likert-type scale. (Questions included “How helpful did you find the [CC or W&L]
concerns?”
for 1 day
comparable
time points which was
in pre-post summed
or burning
R
conducted
were
There group
item
7) self-mutilative
and
such as wrist-cutting cigarette.
to the patients in terms of age and education level.34 Volunteers completed the CCQat two
average patients.
food
to leave the locked unit (AWOL attempt); 6) hit-
researchers).
of the
separated thought
4) refusing
5) attempting permission
sis showed
1
WINTER
#{149}
There were no between-group difin the number of subjects with an diagnosis of BPD; 13 of the 29
that
1996
this
was
not
group: 8 analy-
a statistically
sig-
PRlN(;FR
ET
nificant
63
-IL.
difference.
Two
receive MCMI-II protocols. No significant were
found
W&L
use for
not
differences
(Time
more
therapeutic
original
research plan called for offering who did not consent to the research
option
1) on measures
(SAS-SR), parasuicide treatment history (THI),
of psychotropic
The
did
to invalid
between-group
of social functioning history (PHI), and admission. reported
owing
tients
at admission
including
subjects
diagnoses
data sample.
are
at
therefore The mean
out
ever,
it was
garding
overall
social
Re-
functioning,
scored an average of 2.68 1 to 5, with 5 indicating
subjects
predicted, over
Measures
± 0.49 on a scale of poor social adjust-
ences
completed
at Time
at Time there were at Time
CC
with no
reported
as
a covariate
in
analyses
Table
2,
2.37, therefore of
change
As
detailed
in
W&L:
11.9 ± 4.3)
group
sessions
± 2.0; for
or
the
there
number
by subjects
W&L: 5.5 ± 1.6). The average size of the groups
the
CC
group
(3.1,
range
1-5,
in the
the CC patient
group. who
during
a previous
past
year
research) 2) patients usually
(and
research
mode
because
hospitalization
was therefore
they were These
did
=3)
attended
within
excluded
not
there on these
df
were no change
the
Time
significant
(see Table We predicted
ANCOVAs
as covariate
between-group
differ-
the
would
2). that
CC
failed
to
any
unit was reveal
scales Inventory
group
in anger, locus of of coping skills, than not
the W&L supported.
between-group of the State-Trait or on knowledge
of coping skills (CCQ). Regarding locus of control, the ANCOVA revealed a trend opposite to what
was
came
internal
more
predicted: in their
CC subjects, who more internal (F= Chi-square analysis revealed
the
became 3.11, df= of acting opposite
W&L
subjects
orientation
bethan
only somewhat 1,28, P= 0.09). out on the unit of what
was
pre-
the the
Table
to fill out
participation
directed
to
the CC group by their treatment team because the team believed the CC group would be
JOURNAL
HS:
1=2.95,
dicted: significantly more CC subjects engaged in some form of acting out during their hospitalization (x2 = 4.13, df= 1, P< 0.05; see
again; and the study,
want
still offered patients were
from
ASIQ:
show a greater improvement control, increased knowledge
also
because 1) every in the CC group
participated in the group who declined to join
questionnaires, in the group.
larger
1-3, mode = patients not
usually
This occurred participated
6.3
P
