c. donald williams m.d.1 “group therapy in the treatment of injured workers” 1997 apa annual...

C. Donald Williams M.D. 1

““Group Therapy in the Treatment Group Therapy in the Treatment of Injured Workers”of Injured Workers”

1997 APA Annual Meeting1997 APA Annual Meeting

Current Uses of Group Therapy

C. Donald Williams, M.D.C. Donald Williams, M.D.


Introduction and BackgroundIntroduction and Background

Patients with workplace injuries have presented difficult challenges to clinicians

Confusion regarding approach to these patients, for historical reasons and because of their clinical complexity

A quick fix action oriented approach works with only some of these patients

Developmental and psychodynamic factors have typically been ignored


Combat Military vs. Injured Combat Military vs. Injured Worker ~ DifferencesWorker ~ Differences

Anticipated traumaAnticipated trauma <30 years of age<30 years of age Less established re: Less established re:

family and careerfamily and career Immediate medical Immediate medical

and psychiatric careand psychiatric care Goal--to function for Goal--to function for

months to a year in months to a year in combatcombat

Unexpected injuryUnexpected injury >40 years>40 years Established, with Established, with

family and careerfamily and career Delayed psychiatric Delayed psychiatric

carecare Goal--to achieve Goal--to achieve

durable decades long durable decades long recovery as workerrecovery as worker


Combat Military vs. Injured Combat Military vs. Injured Workers ~ SimilaritiesWorkers ~ Similarities

Both offer strong advocacy for the claimant Both offer strong advocacy for the claimant afterafter discharge from service or job discharge from service or job

Primary and secondary gain for eachPrimary and secondary gain for each– Developmental histories significant in Developmental histories significant in

determining prognosisdetermining prognosis Adequacy of initial intervention critical Adequacy of initial intervention critical

– Skill of clinicians, diagnositic accuracySkill of clinicians, diagnositic accuracy– Treatment delayTreatment delay


Contributors to Major DepressionContributors to Major Depression

Loss of role status within family and Loss of role status within family and community with loss of self-esteemcommunity with loss of self-esteem

Loss of daily routine, with loss of its Loss of daily routine, with loss of its defensive and sublimatory aspectsdefensive and sublimatory aspects

Chronic painChronic pain– ““I can’t do what I used to”I can’t do what I used to”

Loss of hope of recoveryLoss of hope of recovery


Group Therapy Selection CriteriaGroup Therapy Selection Criteria

Group therapy alone with pharmacotherapyGroup therapy alone with pharmacotherapy– Depressed patientsDepressed patients– Pain disorder patientsPain disorder patients

Combined group and individual therapy Combined group and individual therapy – Borderline personality disorder and axis 1 Borderline personality disorder and axis 1

disorderdisorder– Panic disorder with agoraphobiaPanic disorder with agoraphobia– Complex medication managementComplex medication management


Group Psychotherapy ~ General Group Psychotherapy ~ General Advantages for Injured WorkersAdvantages for Injured Workers

Group Psychotherapy offers a more cost Group Psychotherapy offers a more cost effective, intense, and accelerated treatment effective, intense, and accelerated treatment for many patients for these reasons:for many patients for these reasons:– Newer patients learn from patients who have already Newer patients learn from patients who have already

progressed in treatment in open ended groupsprogressed in treatment in open ended groups– Concrete learning from other group members’ Concrete learning from other group members’

experiences makes therapy accessible for patients that experiences makes therapy accessible for patients that find abstract reasoning difficultfind abstract reasoning difficult

– Decreases sense of isolation, and being “different and Decreases sense of isolation, and being “different and damaged”damaged”


Group Therapy for Personality Group Therapy for Personality Disordered PatientsDisordered Patients

Peer pressure and confrontation helpfulPeer pressure and confrontation helpful Opportunity to introject and internalize new Opportunity to introject and internalize new

realities in predictable settingrealities in predictable setting Opportunity to combine insight with Opportunity to combine insight with

internalization to transform old character internalization to transform old character traits into new onestraits into new ones

The group patient “has” his/her problems in The group patient “has” his/her problems in the group, therefore they are harder to denythe group, therefore they are harder to deny


Diagnoses and ComorbidityDiagnoses and Comorbidity

Comorbidity was the rule– All but 3 patients carried two or more diagnoses

90% were diagnosed with depression 40% were diagnosed with anxiety disorders

– Panic disorder, generalized anxiety disorder, and PTSD present in roughly equal proportions

26% were diagnosed with pain disorders 80% were diagnosed with an axis 2 disorder


% Incidence of Psychiatric Disorders in Series % Incidence of Psychiatric Disorders in Series of 60 Consecutive Injured Workersof 60 Consecutive Injured Workers

Depression Panic/Anx Pain Dis. Axis 20

102030405060708090

100

Depression Panic/Anx Pain Dis. Axis 2


Combined TherapyCombined Therapy

Combined individual and group psychotherapy is the Combined individual and group psychotherapy is the treatment of choice for many patients with Panic Disorder treatment of choice for many patients with Panic Disorder andand Depression, Depression, and/orand/or B.P.D B.P.D

– Complex symptom presentation often requires Complex symptom presentation often requires individual sessions to unravel individual sessions to unravel

– For almost all patients with B.P.D. as one of their For almost all patients with B.P.D. as one of their diagnoses because of dyadic issuesdiagnoses because of dyadic issues

» Individual attention and confrontation needed, but Individual attention and confrontation needed, but group component can limit regression (have two group component can limit regression (have two patients with B.P.D., not just one, in group)patients with B.P.D., not just one, in group)


DiscussionDiscussion

EvaluationEvaluation requires requires– Premorbid status be taken into accountPremorbid status be taken into account– Sophisticated bio-psycho-social approachSophisticated bio-psycho-social approach

TreatmentTreatment requires requires– That comorbid conditions be recognizedThat comorbid conditions be recognized– Both symbolic and concrete learningBoth symbolic and concrete learning– Individualized group and/or individual mixIndividualized group and/or individual mix– Session frequency determined by conditionSession frequency determined by condition


SummarySummary

Evaluation and treatment of injured workers Evaluation and treatment of injured workers requires sophisticated diagnosis and requires sophisticated diagnosis and treatmenttreatment

Military treatment models employed with Military treatment models employed with this population work poorlythis population work poorly

Multiple diagnoses are the ruleMultiple diagnoses are the rule Group psychotherapy or combined therapy Group psychotherapy or combined therapy

offers advantages over traditional modelsoffers advantages over traditional models

c. donald williams m.d.1 “group therapy in the treatment of injured workers” 1997 apa annual...

Documents