Parallel process and the forced termination of a milieu group

Parallel process has been observed in the social work and psychiatric literature as an element in the psychodynamics of individual treatment and supervisory relationships. This paper suggests that it is present during group treatment as well and examines its emergence during the termination phase of a milieu group. A review of the literature on both parallel process and termination with groups is presented. It is noted that the conditions necessary for the emergence of parallel process are exactly those found during the termination period of group treatment. Clinical illustrations from the forced termination of a milieu group are presented, documenting a variety of parallel processes which were observed. The dynamics of these processes are examined. Potential indicators of parallel process are discussed, as well as implications for both treatment and supervision.     

Self-regulation of distance in supportive psychotherapy

The authors present the case of a schizophrenic man treated in the setting of a supportive care clinic. The course of treatment from beginning to termination is illustrated by treatment vignettes and by excerpts from the patient's letters to the therapists. Case discussion centers around the handling of the classic schizophrenic conflict over intimacy versus isolation. The authors stress that the therapists must be acutely sensitive to the patient's need and ability to regulate his or her own emotional and therapeutic distance over the course of treatment. They make a case for utilizing this conceptual framework in the treatment of chronic psychiatric patients in supportive clinic settings.     

Therapists’ Responses to Treatment Termination: An Inquiry into the Variables that Contribute to Therapists’ Experiences

The study investigates predictors of emotional responses to treatment termination in a sample of 48 professional social workers and 92 student social workers in Israel. The findings show that the respondents found treatment termination to be moderately difficult, and client initiated terminations to be especially difficult and to bring in its wake particularly negative emotions. They also show that the aftermath of the termination was related to the process. The less abrupt the termination, the more control the therapists had over the termination process, the more central the therapeutic relationship was to them, the more they attained the therapeutic goals, the less they believed that the therapy had failed, the more choice they had in the treatment termination, and the more they wanted the termination, the more positive self-feelings the therapist reported. The paper suggests that treatment termination is better viewed as a transition than a loss and discusses the clinical implications of the findings.     

Effective Contracting of Social Services

The continued growth in the use of privatization for the delivery of social services increases the need for a systematic method to analyze the contracting process. Using a modified form of the basic systems model, the authors examine the impact of antecedents and situational factors and explore the use of traditional management steps in the contracting process. The authors focus on one state's experience with contracting to explore the implications of such a model.     

Young women who underwent induced abortion

Premarital sex is becoming increasingly more common in China. As a result, there is a greater need for pregnancy termination, often in very young women. This paper presents case vignettes of 4 Chinese women who were forced, by a variety of circumstances, to undergo induced abortion. C, a 23-year-old shop assistant, was planning marriage and had obtained housing when she discovered she was pregnant. However, her shop manager, whose sexual advances she had spurned, refused to give her a letter of reccommendation for a marriage certificate. M came from the countryside to Shanghai, hoping that through her work as a maid, she would be able to amass modern possessions such as a television and stereo. When this proved impossible on her wage of 40 yuan/month, she engaged in prostitution for 10 yuan/night and did not even know the name of the man who impregnated her. W, a 13-year-old aspiring actress, found that having sexual relations with the director of her theater troupe was the only way to get a leading role. She won the role, but was unable to perform due to her pregnancy. B, a college woman, planned to marry when she learned she was pregnant but broke off the relationship when she discovered the extent of her financee's possessiveness. She became engaged to another man, but he rejected her when she revealed that she was not a virgin. These vignettes demonstrate the extent to which modernization has placed Chinese women in complex psychological situations as they struggle to liberate themselves from traditionalism.     

The expression of mourning in an eight-year-old girl

This is a case of a just-turned eight-year-old girl whose mother was murdered on September 18, 1983. Since the child was already in treatment, the mourning process started immediately and continued until the end of June 1984. The case is distinctive because of the relative ease with which this child was engaged in the process and educated to it. Unconscious feelings readily emerged because they had been so recently repressed. The mourning was accomplished mainly through the process of interpretation of her play and behavior, although at times she would bring things up directly. The focus of therapy remained on the mourning during the entire nine months of treatment.     

Adult Day Centers and Mental Health Care

ABSTRACT

This research focused on the mental health issues at adult day centers and used a cluster analysis to profile older persons who received these services. The sample included 280 participants who attended adult day care. The data were collected from intake files using a biopsychosocial framework to guide the selection of variables from January 1, 1999 to December 31, 2000. A cluster analysis revealed two distinct profiles of participants. The first profile was characterized by women, who were single, African-American, had low incomes, relied more on public funding, and had no psychiatric diagnoses. The second profile was differentiated with more men, who were married, relied more on private funding, and had higher incomes and psychiatric diagnoses. Participants clustered in the second profile, including those diagnosed with psychiatric disorders, disenrolled at a faster rate than those in the first profile, including older adults without psychiatric disorders. Both profiles were similar in age, education, caregiving, religious affiliation, household size, and service intensity. They also resembled each other with respect to functional limitations, nutrition risk, and prior nursing home placement. Slight differences were found in frequency of previous hospitalizations and years of education. Recommendations for strengthening the mental health training of social workers employed at adult day centers were made.     

Correlates of Clients’ emotional and Behavioral Responses to Treatment Termination

This study investigates the associations between clients’ emotional and behavioral responses to treatment termination and eight sets of indepentent variables, covering the source of termination (client, therapist, external source); the termination process (speed, centrality, control, choice, and desire), and the perceived outcome (failure, goal achievement) of the therapy. Subjects were 92 student therapists and 40 professional therapists, who reported on their clients’ perceptions, experiences, and responses. All the variables examined were associated with one or another client response. The findings support the view of treatment termination not only as a loss experience but also as a transition. They highlight the need for therapists to pay careful attention to both the source and the process of treatment termination.     

Premature Return to School following a Psychotic Episode

Abstract

A college mental health service professional often finds that a student who has had an episode of psychiatric illness is eager to return to fulltime status before he or she seems ready for this undertaking. The mental health professional may advise that the student stay out of school for a longer period, but often this advice is rejected.

Approaches to dealing with the problem of return to school following an academic leave prompted by a psychotic episode include the requirement that the student maintain a minimum time out of school and be in treatment during the attempt to return to academic life. The assessment of a student's psychological status at the time of a proposed return often raises the problem of dual agency. Although the college mental health professional is apt to place a high value on maximizing the student's chances of having things work out to his or her liking, the administrator to whom the mental health professional is ultimately responsible is probably inclined to place the needs and well-being of the campus community above those of the student seeking to return.

While the proposed return of a student to academic work following a psychotic episode poses many difficult questions, considerable experience is available to aid in the task of those charged with making this decision. The authors propose two helpful approaches.     

Therapeutic stations and the chronically treated mentally ill

Readmissions to mental hospitals are often cited as evidence of the failure of the contemporary mental health system. This essay proposes a different interpretation of readmission. Building on fieldwork and participant observation methods, the authors argue that the "veteran" patient is less a victim of poor psychiatric care and misdirected reform than he is a citizen with few personal resources, using public services to cope with the exigencies of life. Lacking family, job, and income, the ex-patient incorporates the hospital and other "therapeutic stations" into a resource pool upon which he or she can call when the need arises. The essay also discusses the implications of these findings for assessments of the community mental health movement.     

Psychopathology in pathological gamblers seeking treatment

High rates of psychiatric symptoms have been reported in pathological gamblers. This study of psychiatric comorbidity in pathological gamblers is the first to use structured psychiatric interviews assessing DSM-III-R Axis I and II disorders. The Structured Clinical Interview for DSM III-R (SCID-P, SCID-II) was administered to 40 (25 male, 15 male) pathological gamblers seeking outpatient treatment in Minnesota for gambling, and 64 (41 male, 23 female) controls. High lifetime rates of Axis I (92%) but not Axis II (25%) psychopathology were found in pathological gamblers as compared to controls. No differences between male and female gamblers were found in rates of affective, substance use or personality disorders. Females had higher rates of anxiety disorders and histories of physical/sexual abuse. Possible associations between psychiatric disorders and pathological gambling are discussed along with gambler typologies and implications for future research.The authors wish to gratefully acknowledge the assistance of: Gary Christenson, M.D., Carol Peterson, Ph.D., William Meller, M.D., Thomas Mackenzie, M.D.     

Client and program factors associated with dropout from court mandated drug treatment

To examine why court mandated offenders dropout of drug treatment and to compare their characteristics, treatment experiences, perceptions, and outcomes with treatment completers, we analyzed self-reported and administrative data on 542 dropouts (59%) and 384 completers (41%) assessed for Proposition 36 treatment by thirty sites in five California counties during 2004. At intake, dropouts had lengthier criminal histories, lower treatment motivation, more severe employment and psychiatric problems, and more were using drugs, especially heroin. Relatively fewer dropouts received residential treatment and their retention was much shorter. A similar proportion of dropouts received services as completers and the mean number of services received per day by dropouts was generally more, especially to address psychiatric problems, during the first three months of treatment. The most commonly offender-reported reasons for dropout included low treatment motivation (46.2%) and the difficulty of the Proposition 36 program (20.0%). Consequences for dropout included incarceration (25.3%) and permission to try treatment again (24.0%). Several factors predicting drug treatment dropout were identified. Both groups demonstrated improved functioning at one-year follow-up, but fewer dropouts had a successful outcome (34.5% vs. 59.1%) and their recidivism rate was significantly higher (62.9% vs. 28.9%) even after controlling for baseline differences. Understanding factors associated with drug treatment dropout can aid efforts to improve completion rates, outcomes, and overall effectiveness of California's Proposition 36 program. Findings may also aid a broader audience of researchers and policy analysts who are charged with designing and evaluating criminal-justice diversion programs for treating drug-addicted offenders.     

Characteristics of the Homeless Mentally III in Case Management: Differentiation Using Major Diagnostic Categories

The homeless mentally ill are more disabled than other homeless people and require more services, but important variations exist. This study examined relationships between broad Axis I diagnostic clusters and demographic and service variables for 328 clients receiving case management at a community program for the chronic mentally ill homeless. Demographic characteristics, medical history, educational, psychological, and marital history, and case management variables were examined for psychotic, affective, and miscellaneous other clients. Differences were found in such areas as suicide attempts and current suicide status, psychiatric treatment history, education, overall impairment of functioning, length of time homeless, and time in case management but not in status at termination or number of senlices required. Psychotics had lower adaptive functioning, spent less time in case management, but had as successful outcomes as affective clients. Psychiatric diagnosis provides information that might assist case management for the homeless mentally ill.     

Characteristics of the homeless mentally ill in case management: Differentiation using major diagnostic categories

The homeless mentally ill are more disabled than other homeless people and require more services, but important variations exist. This study examined relationships between broad Axis I diagnostic clusters and demographic and service variables for 328 clients receiving case management at a community program for the chronic mentally ill homeless. Demographic characteristics, medical history, educational, psychological, and marital history, and case management variables were examined for psychotic, affective, and miscellaneous other clients. Differences were found in such areas as suicide attempts and current suicide status, psychiatric treatment history, education, overall impairment of functioning, length of time homeless, and time in case management but not in status at termination or number of services required. Psychotics had lower adaptive functioning, spent less time in case management, but had as successful outcomes as affective clients. Psychiatric diagnosis provides information that might assist case management for the homeless mentally ill.     

Everytime we say Goodbye: Forced Termination Revisited,a Commentary

The topic of forced termination has received relatively little attention, particularly student interns’ experiences of termination. In this commentary, I will explore some theories that help illuminate the process of ending. Using a case vignette, the worker’s subjectivity and the way that it impacts termination responses is explored. Cathy Siebold, DSW is Training Analyst, Supervisor and Faculty at The Psychoanalytic Psychotherapy Study Center and The New Jersey Training Institute for Psychoanalysis and Faculty at Massachusetts Institute of Psychoanalysis. She is an adjunct Faculty, New York University School of Social Work on the Editorial Board of CSWJ, and Education Chair of the National Membership Committee on Psychoanalysis. Author of a Book on the Hospice Movement and articles about termination, object relations theory and attachment theory     

视界

26岁的黄诗琦为87岁的外婆拍摄了两组照片，上传到网上后感动了众多网友。一组是外婆去年初的样子：活泼可爱，健步如飞；另外一组是她外婆去年8月突发脑溢血后，现在的样子：神情恍惚，几乎站不起来。“还是那个地方，但外婆已经不是当初的外婆……你答应过要等我结婚生子，所以你要好好活着，健康活着……2014年，我们一起努力，孝不能迟。”黄诗琦为这些图片配上“最珍贵时刻”的标题。     

Nine-year psychiatric trajectories and substance use outcomes: an application of the group-based modeling approach

This study identifies longitudinal psychiatric trajectories of 934 adult individuals entering chemical dependency treatment in a private, managed care health plan and examines the relationship of these trajectories with substance use (SU) outcomes. The authors apply a group-based modeling approach to identify trajectory groups based on repeated measures of psychiatric severity for 9 years and identify four distinct groups. Results of multivariate logistic generalized estimating equation models find an association between psychiatric trajectories and long-term SU. Older cohorts and life course measures of marital status and employment status as individuals changed over time are related to drug and some alcohol outcomes.     

Termination of one therapist in co-led group psychotherapy

This article describes the termination of one group co-therapist without replacement. The period between J. W's announced departure and actual leaving brought into vivid perspective transference issues toward the co-therapists as a parental dyad. The rupture of this dyad had powerful consequences, which are discussed. In addition the therapist who remained (T.S.) had the unique opportunity to observe the group members reactions to termination after the termination actually took place. The group is presented and some process material is included.     

The Termination Stage in Bowen's Family Systems Theory

The termination stage has always been recognized as an important aspect of the clinical intervention process. Careful attention to that stage is even more critical in the current practice environment of short-term intervention and demands for measurable outcomes. Bowen's family systems theory, while well established in the field of clinical practice, does not incorporate clear directives for the practitioner about the ending stage of intervention. Still, its major concepts for assessment and intervention suggest a range of termination activities that can affirm and summarize a family's gains. In this article the authors offer a variety of ending strategies for use within family systems theory.     

Advances in Sex Offender Treatment and Challenges for the Future

Abstract

This paper describes what the authors believe to be the major advances, the areas of debate, and the future direction of sexual offender treatment as we leave the 20th century and enter the new millennium. In the area of sex offender treatment, the modification of relapse prevention for use with sex offenders has had a profound effect on the way that therapy is done. Additionally, the development of the selective serotonin reuptake inhibitors and other pharmacotherapies has moved the field more toward a bio-psychosocial model of etiology and treatment, and focused more attention on comorbid psychiatric disorders in the treatment of sexual offenders. The late 1990s saw major advances in the development of actuarial prediction tools for recidivism, and a concerning move toward phallometric stimuli with unclear reliability and validity. Additionally, the development of the Abel Screen for Sexual Interest has provided a promising, but as yet unvalidated, alternative to phallometry. The 1990s were also a period of considerable growth in the application of sexual offender treatment to special populations, such as adolescents, the developmentally disabled, women and children. The major challenge for the future is to develop methodologically sound research on which to base our decisions about the treatments to apply, the unique needs of special populations, and the assessment of dangerousness.