International Journal of Group Psychotherapy
ISSN: 0020-7284 (Print) 1943-2836 (Online) Journal homepage: http://www.tandfonline.com/loi/ujgp20
Contribution of an Intake Group to Psychiatric Inpatient Milieu Therapy John P. Houlihan To cite this article: John P. Houlihan (1977) Contribution of an Intake Group to Psychiatric Inpatient Milieu Therapy, International Journal of Group Psychotherapy, 27:2, 215-223, DOI: 10.1080/00207284.1977.11492294 To link to this article: https://doi.org/10.1080/00207284.1977.11492294
Published online: 29 Oct 2015.
Submit your article to this journal
View related articles
Citing articles: 1 View citing articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ujgp20
Contribution of an Intake Group to Psychiatric Inpatient Milieu Therapy
JOHN P. HOULIHAN, PH.D.
LIE
early sessions of psychotherapy are very important in the patient's development of a therapeutic alliance suggests the potenti al value of pretraining for therapy (Bednar and Lawlis, 1971). Bednar et al. (1974) reviewed several studies involving pretraining for group psychotherapy; these pointed to accelerated group development and greater patient improvement following such pretraining. The specific goals of preparing patieBts for psychotherapy include the fostering of positive but realistic expectations, describing and demystifying the therapeutic process, modeling therapy processes, and providing for more effective and economical therapy. Hoehn-Saric and his co-workers (1964) and Orne and Wender (1968) reported a procedure of pretraining for psychotherapy which consisted of a preliminary interview focu sing on the rationale of verbal psychotherapy, appropriate patient-therapist role expectations, OBSERVATION THAT T H E
Dr. Houlihan was a Captain in the U.S. Air Force Biomedical Sciences Corps assigned as a clinical psychologist, Mental Heal th Service, Malcom Grow USAF Medical Center, Andrews AFB , Washington , D .C. The views expressed in this report are those of the a uthor and do not necessarily reflect those of the U.S . Air Force or the Department of Defense . He is currently Director of Research and Training, Dallas County MH-MR Center. A version of this paper was presented at the Behavioral Sciences Symposium , USAF School of Aerospace Medicine , Brooks AFB, Texas , April 21-23, 1975.
215
216
john P. Houlihan
the typical unsteady course of individual psychotherapy, and realistic expectations of improvement. Such preparation yielded more positive psychotherapy process, including better attendance and easier establishment of a therapeutic relationship , plus greater improvement, in terms of global personal effectiveness and specific symptom reduction, after four months of treatment. With respect to pretraining for group psychotherapy, Yalom et al. (1967) reported the effects of an explicatory session prior to treatment which emphasized positive expectancy, group cohesiveness , and here-and-now interaction. Such preparation yielded more relevant here-and-now interaction, somewhat greater faith in treatment , but no differences in perceived group cohesion when compared to a control group. Martin and Shewmaker (1962) observed positive effects of providing group therapy patients with written instructions outlining the rationale , role expectations, and process of group therapy. The authors noted increased self·disclosure, interpretation, confrontation, and hope resulted from the patients' periodic rereading of the instructions during the course of therapy. Truax , Shapiro, and Wargo (1968) employed audio tapes of "good" therapy sessions as vicarious pretraining for group psychotherapy. This vicarious pretraining contributed to enhanced selfconcept , especially ideal self-concept, and less pathological MMPI profiles after three months of group therapy for psychiatric inpatients and institutionalized adolescents relative to groups receiving no pretraining. And finally, Heider (1973) adapted the interview format of Orne and Wender (1968) to the pretraining of psychiatric inpatients for group psychotherapy on a milieu therapy unit. This interview preparation resulted in more rapid and higher quality working alliances relative to unprepared patients . A somewhat greater level of mutual satisfaction in the therapy relationship was noted by both therapists and patients . The purpose of the present quasi-experimental investigation was to assess the effects of an intake psychotherapy group , which emphasized pretraining for gr~up therapy, on patients' response to inpatient milieu treatment. The dependent measures were those of pace of individual psychological reintegration and integration into the therapeutic community plus the time required for formulation of a post-hospital disposition plan.
Contribution of an Intake Group
217
METHOD Subjects Thirty-eight consecutive patients admitted to an inpatient mental health unit served as subjects in this investigation. The majority of the patients were active-duty military male personnel. Patients ranged in age from 17 to 39 years, with a median age of 21 years . Thirteen patients were diagnosed as psychotic, eight as neurotic, three as alcoholic, ten as personality disorders, three as situational adjustment reactions, and one as an organic brain syndrome. Individual medication regimens were prescribed by the unit psychiatrist.
Procedures No significant deviations from the unit routine were necessitated by this quasi-experimental investigation. Newly admitted patients were typically first interviewed by the unit psychiatrist for formal evaluation and then assigned to attend the intake group at its next meeting. The intake group met for one hour four days per week. The intake group was led by the unit clinical psychologist (the author) and by a unit nurse or technician. The size of the intake group was dependent upon the number of recent admissions and ranged from two to eight patients. The aims of the intake group were to provide : (a) familiarization to the unit, (b) clinical assessment in an interpersonal context , and (c) pretraining in the process of group psychotherapy. Specifically, familiarization to the unit consisted of information-giving about the operation of the therapeutic milieu, introduction of the new patient to the other new patients and to staff, and the answering of questions. The clinical assessment consisted of asking the new patient to "tell his (her) story" to the group . The patients and therapists attempted to help the new patient identify the present problem areas by giving first impressions and asking questions. The group focus then switched to the patient's treatment goals, "What do you want to accomplish here?'' The feasibility of the goals, the appropriateness of the inpatient setting in achieving them, and additional or alternative goals were discussed. And finally and most importantly, pretraining
218
John P. Houlihan
for group therapy consisted of the therapists' fostering relevant patient-to-patient verbal interaction and emphasizing recognition and expression of feelings. This pretraining often required the therapists' proselytizing on the therapeutic effects of honest, feelingoriented , person-to -person interaction and directive structuring and modeling of such behaviors . The patient's tenure in the intake group was determined by mutual decision among patient , therapists , and other group members. In practice , transfer from the intake group to one of the ongoing traditional inpatient psychotheraPY groups took place after two to eight sessions according to the general criteria of sufficient reality orientation , adequate group interaction skills , and evidence of motivation . During the initial days of hospitalization while a patient was a member of the inta~~e group , he participated in all unit activities with the exception of re creational therapy, which conflicted with the time scheduled for the intake group sessions , and ongoing traditional group therapy , for which the intake group was a preparation. The three ongoing therapy groups were characterized by their open-ended , eclectic , insight orientation with emphasis upon both then -and-there and here -a nd-now content. Cotherapist pairs were psychiatrist and occupational therapist, psychologist and nurse , social worker and experienced technician . Each ongoing group consisted of five to six patient members and served as the primary treatment modality of the unit.
Dependent Variables This particular inpatient milieu unit operated on a staff team approach in which treatment plans and eventually disposition recommendations were arrived at by a consensus among nurses , social worker, psychologist, and psychiatrist within weekly team meetings . Disposition planning actually occurred at either of two points in the hospital course. First of all , a preliminary disposition decision was made while the patient was in the intake group. That is , it was decided whether or not continued inpatient treatment was required . If further hospitalization was necessary , the patient was transferred to one of the three ongoing therapy groups . Alternatives to further inpatient treatment included referral to the outpatient clinic , an alcohol treatment unit, or simply hospital
Contribution of an Intake Group
219
discharge . The second phase of disposition planning involved those patients who were retained as inpatients and, thus, transferred to an ongoing therapy group. For these patients, final disposition decisions were made after they had participated in ongoing group therapy fo r varying lengths of time . The unit treatment program cen tered around daily patient government, group therapy, occupational and recreational therapy sessions. A patient category system ranged from category 1 (restricted to unit ; suicide or elopement precaution) through category 4 (geographic independence and assuming responsibility for others). Changes in individual patient's categories were determined by the patient government consensus twice weekly during the unit community meeting. All patients were admitted to the unit as either category one or two. T he numerical category system , specifically, the change in positive functioning as reflected in the difference in category from the first intake group to that two weeks later , was selected as a convenient meaningful dependent measure . The second dependent measure was the number of days elapsed from the first intake group sessions to the staffs formulation of a disposition plan (for example, eventual transfer to a Veterans Administration facility for further treatm ent or return to active d uty with outpatient follow-up treatm ent).
Design A quasi-experimental design , the Nonequivalent Control Group Design (Campbell and Stanley, 1963), was implemented as follows: (a) the experimental group consisted of 19 consecutive admissions to the unit during a one-month period while the intake group was in full operation, as it had been for the previous year; (b) the control group consisted of 19 consecutive admissions to the unit during the m onth immediately following in which the intake group had been discon tin ued due to unavoidable changes, not reductions, in unit staffing. That is , the experimental group patients participated in the intake group before joining an ongoing traditional inpatient therapy group while the control group patients were assigned to an ongoing unit therapy group from the omet. The main effects of participation in the intake group on the patients' rate of personal and community integration, as measured by category change, and on
220
John P. Houlihan
speed of disposition planning were confounded with various possible effects of history in this design. RESULTS Although no attempt was made to match patients in the experimental group with those in the control group, a comparison of the two groups with respect to age, sex, diagnosis, and admission category (1 versus 2) composition revealed no significant systematic differences.
Change in Category It was hypothesized that participation in the intake group would provide for more rapid psychological reintegration of the patient and his more rapid integration into the unit milieu . Positive change in category during the initial two weeks of hospitalization was selected as a concrete measure of clinical-interpersonal improvement. This hypothesized positive contribution of the intake group was supported in that the experimental group patients evidenced greater upward change in category than did the control group pati~nts. On the average, the experimental group patients achieved approximately one higher category during the first two weeks than did the control group patients during the same initial period. Stated in another way, in the experimental group 89 percent of the patients achieved a positive change of at least two categories and 37 percent improved by three category steps , while in the control group only 58 percent of the patients achieved a positive change of at least two categories and only 21 percent increased by three category steps. This difference in magnitude of category change is in the predicted direction and is statistically significant as assessed by the Mann-Whitney test, U (19, 19) = 120 , p < .05, onetailed.
Speed of Disposition Planning In addition to positive individual patient therapeutic effects , it was hypothesized that the operation of the intake group would facilitate both individual patient assessment and forming of future treatment recommendations. And, therefore, it would serve to speed the
Contribution of an Intake Group
221
staffs disposition planning for each patient. Length of hospitalization elapsed from hospital admission to completion of a patient's individual disposition plan was selected as the dependent measure of speed of disposition. The hypothesized positive contribution of the intake group was not supported in that the experimental group patients were in the hospital on the average of 13.5 days prior to the formulation of a firm disposition plan, while the control group patients required 16.3 days prior to disposition. Although this difference is in the predicted direction, it is not statistically significant as assessed by the Mann-Whitney test, U(19, 19) = 149, p= .20. Despite the lack of significant difference between experimental and control groups, closer inspection of the disposition data revealed an interesting pattern involving the type of disposition made. Specifically, for those patients whose psychological disturbance necessitated medical separation from active duty and eventual transfer to a Veterans Administration facility for further treatment, it made no difference whether or not they had participated in the intake group in terms of the days required to make that decision: a mean of 18.1 days for the experimental patients and 15.9 days for the control patients. 1 However, for those patients with better prognoses who were returned to active duty, participation in the intake group seemed to allow for quicker disposition decisions: a mean of 10.8 days for the experimental patients and 16.6 days for control patients. 2 A posteriori Kruksal-Wallis tests of group differences at reduced error rates (Kirk, 1968) yielded no significant differences among the days-to-disposition measure for the four subgroupings. Therefore, the operation of the intake group did not sig1 It should be noted that a period of approximately four weeks typically elapsed from the decision to recommend medical separation from active duty and the actual transfer of the patient to a VA facility . During this period the patient remained in active inpatient treatment. Due to the wide geographic dispersion of patients transferred to a VA facility close to their home, no attempt was made to follo w a patient's progress after transfer. 2 In contrast to those patients who were m edically separated from active duty, a period of approximately three to fiv e days typically elapsed from the decision for return to duty and the actual hospital discharge of the patient. Due to the wide geogra phic dispersion of patients returned to their active duty stations, no attempt was m ade to follow a patient's progress at the mental health clinic to which he was
referre d .
222
john P. Houlihan
nificantly influence the speed of disposition planning in general or with respect to specific disposition options.
DISCUSSION The results of this quasi-experimental investigation indicate that new patients' participation in the unit intake group resulted in faster advancement in the milieu category system . More rapid psychological reintegration and more rapid integration into the process ofthe unit milieu are inferred from this finding. The intake group's emphases on pretraining for group psychotherapy and informationgiving are seen as the likely factors influencing this positive therapeutic response. Alternative explanations of this finding have arisen from discussions with the professionals and paraprofessionals who actually staff the unit . Although they were naive as to the actual dependent meaures employed, the positive category change findings did not surprise them . Some agreed with the author's inference of pretraining for group therapy and information-giving as the major contributors. They reported that patients who had participated in the intake group were more active and productive earlier in the process of the ongoing group therapy than were those patients who entered directly into the ongoing group therapy without pretraining. Other focused on the politics of the situation in that the new patients came to know and elicit support from fellow new patients in the intake group. This , in turn, facilitated their campaigning for the patient votes needed for category upgrading. Other staff, those who had participated as intake group cotherapists at one time or another , felt that the intake group repeatedly provided modeling of category change behavior by other group members and that this example plus group pressure to carry out the behavior combined to produce more rapid category progression in the intake group . The present study does not allow for determining the validity of these plausible alternative explanations of the phenomenon; it can only be noted that the effect of the intake group on new patient advancement in the category system is seen by the unit staff as a positive, therapeutic one. On the other hand , the operation of the intake group was found
Contribution of an Intake Group
223
not to affect the time required by staff for disposition planning significantly. And finally, the author's anecdotal experience in leading the intake group suggests at least one additional positive contribution which was not specifically examined. That is, during the past year new staff members, including social workers, nurses, medical students, and technicians, who had participated as cotherapists in the intake group reported that such participation added to their own orientation and adjustment process . Specifically, new staff members found that the experiential learning of u:'J.it policies, day-to-day routine, and the unit "ethic" or "tone" was accomplished rather painlessly by participating in the intake group for a week or two. REFERENCES Bednar. R. L., and Lawlis, G. F. (1971), Empirical Research in Group Psychotherapy. Jn: Handbook of Psychotherapy and B ehavior Change, ed. A. E. Bergin and S. L. Garfield . New York: Wiley. ___ , Weet, C., Evensen, P. , Lanier, D. , a nd Melnick, J. (1974), Empirical Guidelines for Group Therapy : Pretraining , Cohesion , Modeling.]. Applied B ehav. Sci., 10:149-165 . Campbell , D. T., and Stanley, ]. C. (1963), Experimental and Quasi-Experimental Designs for R esearch. Chicago: Rand McNally. Heider , J. B. (1973), Preparation of Lower Class Patients for Expressive Group Psychotherapy.]. Consult. & Clin . Psycho/., 41:251-260. Hoehn-Saric, R ., Frank, J. D. , Imber, S. D., Nash, E. H., Stone, A . R . , and Battle , C. C. (1964), Systematic Preparation of Patit- ,l ts for Psychotherapy!. Effects on Therapy Behavior and Outcome.]. Psychiat. Res., 2: 267 -281. Kirk, R . E. (1968), Experimental Design: Procedures for the Behavioral Sciences. Belmont , Calif. : Brooks/ Cole. Martin, H., and Shewmaker, K. (1962) , Written Instructions in Group Psychotherapy. Group Therapy, 15 :24-29. Orne , M. T ., and Wender, P. H. (1968), Anticipatory Socialization for Psychotherapy: Method and Rationale . A mer.]. Psychz'at., 124:1202-1212. Truax , C . B., Shapiro,]. G ., and Wargo, D. G. (1968), The Effects of Alternate Sessions and Vicarious Therapy Pretraining on Group Psychotherapy. This journal, 18 :186- 198. Yalom, I. D. , Houts , P. S., Newell, G., and Rand, K. H. (1967) , Preparation of Patients for Group Therapy. Arch. Gen. Psychiat., 17 :416-427.
Dr. Houlihan's address: 1200 Stemmons T ower North 2710 St emmons Freeway Dallas, Texas 75207
ISSN: 0020-7284 (Print) 1943-2836 (Online) Journal homepage: http://www.tandfonline.com/loi/ujgp20
Contribution of an Intake Group to Psychiatric Inpatient Milieu Therapy John P. Houlihan To cite this article: John P. Houlihan (1977) Contribution of an Intake Group to Psychiatric Inpatient Milieu Therapy, International Journal of Group Psychotherapy, 27:2, 215-223, DOI: 10.1080/00207284.1977.11492294 To link to this article: https://doi.org/10.1080/00207284.1977.11492294
Published online: 29 Oct 2015.
Submit your article to this journal
View related articles
Citing articles: 1 View citing articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ujgp20
Contribution of an Intake Group to Psychiatric Inpatient Milieu Therapy
JOHN P. HOULIHAN, PH.D.
LIE
early sessions of psychotherapy are very important in the patient's development of a therapeutic alliance suggests the potenti al value of pretraining for therapy (Bednar and Lawlis, 1971). Bednar et al. (1974) reviewed several studies involving pretraining for group psychotherapy; these pointed to accelerated group development and greater patient improvement following such pretraining. The specific goals of preparing patieBts for psychotherapy include the fostering of positive but realistic expectations, describing and demystifying the therapeutic process, modeling therapy processes, and providing for more effective and economical therapy. Hoehn-Saric and his co-workers (1964) and Orne and Wender (1968) reported a procedure of pretraining for psychotherapy which consisted of a preliminary interview focu sing on the rationale of verbal psychotherapy, appropriate patient-therapist role expectations, OBSERVATION THAT T H E
Dr. Houlihan was a Captain in the U.S. Air Force Biomedical Sciences Corps assigned as a clinical psychologist, Mental Heal th Service, Malcom Grow USAF Medical Center, Andrews AFB , Washington , D .C. The views expressed in this report are those of the a uthor and do not necessarily reflect those of the U.S . Air Force or the Department of Defense . He is currently Director of Research and Training, Dallas County MH-MR Center. A version of this paper was presented at the Behavioral Sciences Symposium , USAF School of Aerospace Medicine , Brooks AFB, Texas , April 21-23, 1975.
215
216
john P. Houlihan
the typical unsteady course of individual psychotherapy, and realistic expectations of improvement. Such preparation yielded more positive psychotherapy process, including better attendance and easier establishment of a therapeutic relationship , plus greater improvement, in terms of global personal effectiveness and specific symptom reduction, after four months of treatment. With respect to pretraining for group psychotherapy, Yalom et al. (1967) reported the effects of an explicatory session prior to treatment which emphasized positive expectancy, group cohesiveness , and here-and-now interaction. Such preparation yielded more relevant here-and-now interaction, somewhat greater faith in treatment , but no differences in perceived group cohesion when compared to a control group. Martin and Shewmaker (1962) observed positive effects of providing group therapy patients with written instructions outlining the rationale , role expectations, and process of group therapy. The authors noted increased self·disclosure, interpretation, confrontation, and hope resulted from the patients' periodic rereading of the instructions during the course of therapy. Truax , Shapiro, and Wargo (1968) employed audio tapes of "good" therapy sessions as vicarious pretraining for group psychotherapy. This vicarious pretraining contributed to enhanced selfconcept , especially ideal self-concept, and less pathological MMPI profiles after three months of group therapy for psychiatric inpatients and institutionalized adolescents relative to groups receiving no pretraining. And finally, Heider (1973) adapted the interview format of Orne and Wender (1968) to the pretraining of psychiatric inpatients for group psychotherapy on a milieu therapy unit. This interview preparation resulted in more rapid and higher quality working alliances relative to unprepared patients . A somewhat greater level of mutual satisfaction in the therapy relationship was noted by both therapists and patients . The purpose of the present quasi-experimental investigation was to assess the effects of an intake psychotherapy group , which emphasized pretraining for gr~up therapy, on patients' response to inpatient milieu treatment. The dependent measures were those of pace of individual psychological reintegration and integration into the therapeutic community plus the time required for formulation of a post-hospital disposition plan.
Contribution of an Intake Group
217
METHOD Subjects Thirty-eight consecutive patients admitted to an inpatient mental health unit served as subjects in this investigation. The majority of the patients were active-duty military male personnel. Patients ranged in age from 17 to 39 years, with a median age of 21 years . Thirteen patients were diagnosed as psychotic, eight as neurotic, three as alcoholic, ten as personality disorders, three as situational adjustment reactions, and one as an organic brain syndrome. Individual medication regimens were prescribed by the unit psychiatrist.
Procedures No significant deviations from the unit routine were necessitated by this quasi-experimental investigation. Newly admitted patients were typically first interviewed by the unit psychiatrist for formal evaluation and then assigned to attend the intake group at its next meeting. The intake group met for one hour four days per week. The intake group was led by the unit clinical psychologist (the author) and by a unit nurse or technician. The size of the intake group was dependent upon the number of recent admissions and ranged from two to eight patients. The aims of the intake group were to provide : (a) familiarization to the unit, (b) clinical assessment in an interpersonal context , and (c) pretraining in the process of group psychotherapy. Specifically, familiarization to the unit consisted of information-giving about the operation of the therapeutic milieu, introduction of the new patient to the other new patients and to staff, and the answering of questions. The clinical assessment consisted of asking the new patient to "tell his (her) story" to the group . The patients and therapists attempted to help the new patient identify the present problem areas by giving first impressions and asking questions. The group focus then switched to the patient's treatment goals, "What do you want to accomplish here?'' The feasibility of the goals, the appropriateness of the inpatient setting in achieving them, and additional or alternative goals were discussed. And finally and most importantly, pretraining
218
John P. Houlihan
for group therapy consisted of the therapists' fostering relevant patient-to-patient verbal interaction and emphasizing recognition and expression of feelings. This pretraining often required the therapists' proselytizing on the therapeutic effects of honest, feelingoriented , person-to -person interaction and directive structuring and modeling of such behaviors . The patient's tenure in the intake group was determined by mutual decision among patient , therapists , and other group members. In practice , transfer from the intake group to one of the ongoing traditional inpatient psychotheraPY groups took place after two to eight sessions according to the general criteria of sufficient reality orientation , adequate group interaction skills , and evidence of motivation . During the initial days of hospitalization while a patient was a member of the inta~~e group , he participated in all unit activities with the exception of re creational therapy, which conflicted with the time scheduled for the intake group sessions , and ongoing traditional group therapy , for which the intake group was a preparation. The three ongoing therapy groups were characterized by their open-ended , eclectic , insight orientation with emphasis upon both then -and-there and here -a nd-now content. Cotherapist pairs were psychiatrist and occupational therapist, psychologist and nurse , social worker and experienced technician . Each ongoing group consisted of five to six patient members and served as the primary treatment modality of the unit.
Dependent Variables This particular inpatient milieu unit operated on a staff team approach in which treatment plans and eventually disposition recommendations were arrived at by a consensus among nurses , social worker, psychologist, and psychiatrist within weekly team meetings . Disposition planning actually occurred at either of two points in the hospital course. First of all , a preliminary disposition decision was made while the patient was in the intake group. That is , it was decided whether or not continued inpatient treatment was required . If further hospitalization was necessary , the patient was transferred to one of the three ongoing therapy groups . Alternatives to further inpatient treatment included referral to the outpatient clinic , an alcohol treatment unit, or simply hospital
Contribution of an Intake Group
219
discharge . The second phase of disposition planning involved those patients who were retained as inpatients and, thus, transferred to an ongoing therapy group. For these patients, final disposition decisions were made after they had participated in ongoing group therapy fo r varying lengths of time . The unit treatment program cen tered around daily patient government, group therapy, occupational and recreational therapy sessions. A patient category system ranged from category 1 (restricted to unit ; suicide or elopement precaution) through category 4 (geographic independence and assuming responsibility for others). Changes in individual patient's categories were determined by the patient government consensus twice weekly during the unit community meeting. All patients were admitted to the unit as either category one or two. T he numerical category system , specifically, the change in positive functioning as reflected in the difference in category from the first intake group to that two weeks later , was selected as a convenient meaningful dependent measure . The second dependent measure was the number of days elapsed from the first intake group sessions to the staffs formulation of a disposition plan (for example, eventual transfer to a Veterans Administration facility for further treatm ent or return to active d uty with outpatient follow-up treatm ent).
Design A quasi-experimental design , the Nonequivalent Control Group Design (Campbell and Stanley, 1963), was implemented as follows: (a) the experimental group consisted of 19 consecutive admissions to the unit during a one-month period while the intake group was in full operation, as it had been for the previous year; (b) the control group consisted of 19 consecutive admissions to the unit during the m onth immediately following in which the intake group had been discon tin ued due to unavoidable changes, not reductions, in unit staffing. That is , the experimental group patients participated in the intake group before joining an ongoing traditional inpatient therapy group while the control group patients were assigned to an ongoing unit therapy group from the omet. The main effects of participation in the intake group on the patients' rate of personal and community integration, as measured by category change, and on
220
John P. Houlihan
speed of disposition planning were confounded with various possible effects of history in this design. RESULTS Although no attempt was made to match patients in the experimental group with those in the control group, a comparison of the two groups with respect to age, sex, diagnosis, and admission category (1 versus 2) composition revealed no significant systematic differences.
Change in Category It was hypothesized that participation in the intake group would provide for more rapid psychological reintegration of the patient and his more rapid integration into the unit milieu . Positive change in category during the initial two weeks of hospitalization was selected as a concrete measure of clinical-interpersonal improvement. This hypothesized positive contribution of the intake group was supported in that the experimental group patients evidenced greater upward change in category than did the control group pati~nts. On the average, the experimental group patients achieved approximately one higher category during the first two weeks than did the control group patients during the same initial period. Stated in another way, in the experimental group 89 percent of the patients achieved a positive change of at least two categories and 37 percent improved by three category steps , while in the control group only 58 percent of the patients achieved a positive change of at least two categories and only 21 percent increased by three category steps. This difference in magnitude of category change is in the predicted direction and is statistically significant as assessed by the Mann-Whitney test, U (19, 19) = 120 , p < .05, onetailed.
Speed of Disposition Planning In addition to positive individual patient therapeutic effects , it was hypothesized that the operation of the intake group would facilitate both individual patient assessment and forming of future treatment recommendations. And, therefore, it would serve to speed the
Contribution of an Intake Group
221
staffs disposition planning for each patient. Length of hospitalization elapsed from hospital admission to completion of a patient's individual disposition plan was selected as the dependent measure of speed of disposition. The hypothesized positive contribution of the intake group was not supported in that the experimental group patients were in the hospital on the average of 13.5 days prior to the formulation of a firm disposition plan, while the control group patients required 16.3 days prior to disposition. Although this difference is in the predicted direction, it is not statistically significant as assessed by the Mann-Whitney test, U(19, 19) = 149, p= .20. Despite the lack of significant difference between experimental and control groups, closer inspection of the disposition data revealed an interesting pattern involving the type of disposition made. Specifically, for those patients whose psychological disturbance necessitated medical separation from active duty and eventual transfer to a Veterans Administration facility for further treatment, it made no difference whether or not they had participated in the intake group in terms of the days required to make that decision: a mean of 18.1 days for the experimental patients and 15.9 days for the control patients. 1 However, for those patients with better prognoses who were returned to active duty, participation in the intake group seemed to allow for quicker disposition decisions: a mean of 10.8 days for the experimental patients and 16.6 days for control patients. 2 A posteriori Kruksal-Wallis tests of group differences at reduced error rates (Kirk, 1968) yielded no significant differences among the days-to-disposition measure for the four subgroupings. Therefore, the operation of the intake group did not sig1 It should be noted that a period of approximately four weeks typically elapsed from the decision to recommend medical separation from active duty and the actual transfer of the patient to a VA facility . During this period the patient remained in active inpatient treatment. Due to the wide geographic dispersion of patients transferred to a VA facility close to their home, no attempt was made to follo w a patient's progress after transfer. 2 In contrast to those patients who were m edically separated from active duty, a period of approximately three to fiv e days typically elapsed from the decision for return to duty and the actual hospital discharge of the patient. Due to the wide geogra phic dispersion of patients returned to their active duty stations, no attempt was m ade to follow a patient's progress at the mental health clinic to which he was
referre d .
222
john P. Houlihan
nificantly influence the speed of disposition planning in general or with respect to specific disposition options.
DISCUSSION The results of this quasi-experimental investigation indicate that new patients' participation in the unit intake group resulted in faster advancement in the milieu category system . More rapid psychological reintegration and more rapid integration into the process ofthe unit milieu are inferred from this finding. The intake group's emphases on pretraining for group psychotherapy and informationgiving are seen as the likely factors influencing this positive therapeutic response. Alternative explanations of this finding have arisen from discussions with the professionals and paraprofessionals who actually staff the unit . Although they were naive as to the actual dependent meaures employed, the positive category change findings did not surprise them . Some agreed with the author's inference of pretraining for group therapy and information-giving as the major contributors. They reported that patients who had participated in the intake group were more active and productive earlier in the process of the ongoing group therapy than were those patients who entered directly into the ongoing group therapy without pretraining. Other focused on the politics of the situation in that the new patients came to know and elicit support from fellow new patients in the intake group. This , in turn, facilitated their campaigning for the patient votes needed for category upgrading. Other staff, those who had participated as intake group cotherapists at one time or another , felt that the intake group repeatedly provided modeling of category change behavior by other group members and that this example plus group pressure to carry out the behavior combined to produce more rapid category progression in the intake group . The present study does not allow for determining the validity of these plausible alternative explanations of the phenomenon; it can only be noted that the effect of the intake group on new patient advancement in the category system is seen by the unit staff as a positive, therapeutic one. On the other hand , the operation of the intake group was found
Contribution of an Intake Group
223
not to affect the time required by staff for disposition planning significantly. And finally, the author's anecdotal experience in leading the intake group suggests at least one additional positive contribution which was not specifically examined. That is, during the past year new staff members, including social workers, nurses, medical students, and technicians, who had participated as cotherapists in the intake group reported that such participation added to their own orientation and adjustment process . Specifically, new staff members found that the experiential learning of u:'J.it policies, day-to-day routine, and the unit "ethic" or "tone" was accomplished rather painlessly by participating in the intake group for a week or two. REFERENCES Bednar. R. L., and Lawlis, G. F. (1971), Empirical Research in Group Psychotherapy. Jn: Handbook of Psychotherapy and B ehavior Change, ed. A. E. Bergin and S. L. Garfield . New York: Wiley. ___ , Weet, C., Evensen, P. , Lanier, D. , a nd Melnick, J. (1974), Empirical Guidelines for Group Therapy : Pretraining , Cohesion , Modeling.]. Applied B ehav. Sci., 10:149-165 . Campbell , D. T., and Stanley, ]. C. (1963), Experimental and Quasi-Experimental Designs for R esearch. Chicago: Rand McNally. Heider , J. B. (1973), Preparation of Lower Class Patients for Expressive Group Psychotherapy.]. Consult. & Clin . Psycho/., 41:251-260. Hoehn-Saric, R ., Frank, J. D. , Imber, S. D., Nash, E. H., Stone, A . R . , and Battle , C. C. (1964), Systematic Preparation of Patit- ,l ts for Psychotherapy!. Effects on Therapy Behavior and Outcome.]. Psychiat. Res., 2: 267 -281. Kirk, R . E. (1968), Experimental Design: Procedures for the Behavioral Sciences. Belmont , Calif. : Brooks/ Cole. Martin, H., and Shewmaker, K. (1962) , Written Instructions in Group Psychotherapy. Group Therapy, 15 :24-29. Orne , M. T ., and Wender, P. H. (1968), Anticipatory Socialization for Psychotherapy: Method and Rationale . A mer.]. Psychz'at., 124:1202-1212. Truax , C . B., Shapiro,]. G ., and Wargo, D. G. (1968), The Effects of Alternate Sessions and Vicarious Therapy Pretraining on Group Psychotherapy. This journal, 18 :186- 198. Yalom, I. D. , Houts , P. S., Newell, G., and Rand, K. H. (1967) , Preparation of Patients for Group Therapy. Arch. Gen. Psychiat., 17 :416-427.
Dr. Houlihan's address: 1200 Stemmons T ower North 2710 St emmons Freeway Dallas, Texas 75207
