Dropout in Institutional Emotional Crisis Counseling and Brief Focused Intervention

12 Pages·2005·0.13 MB·English

Dropout in Institutional Emotional Crisis
Counseling and Brief Focused Intervention
M.Marini,MSc,M.Semenzin,MD,F.Vignaga,MD,
M. Gardiolo, MD, A. Drago, MD, F. Caon, MSc,
M. Benetazzo, MD, C. Pavan, MD, A. Piotto, MD,
L. Federico, MD, B. Corinto, MD, L. Pavan, MD
Increasinglyscarceeconomicresourcesprompttheneedformoreefficientformsof
healthcare;hence,briefoutpatientcrisisinterventionhastherapeuticandpreventivegoals
withrespecttosuiciderisk.Theaimofthisstudywastoassesswhichfactorspredict
nonnegotiatedterminationoftreatment.Patientswhodroppedoutoftreatment
(n¼26)werecomparedwiththosewhoconcludedtreatment(n¼102).Intervention,
whichresembledoutpatient-focusedbriefsupportingpsychotherapy,consistedof
10weeklysessionslasting45–50min.Thefirstsessionenvisagedaninitialconsultation;the
following2sessionsconsistedofin-depthassessment,presentationoftheintervention,and
abatteryoftests.AxisI,AxisIIpersonality(StructuredClinicalInterviewforDSMIV,AxisII
PersonalityDisorders),depression(HamiltonDepressionRatingScale,BeckDepression
Inventory),anxiety(State-TraitAnxietyInventory),anger(State-TraitAngerExpression
Inventory),socialadaptation(SocialAdaptationSelf-EvaluationScale),andglobal
functioning(GlobalAssessmentScale)werealsoclinicallyevaluated.Thetotaldropoutrate
inthestudywas20.3%.Logisticregressionanalysisidentifiedborderlinepersonality
disorderasapredictorofdropout,whichwasassociatedwithameanageoflessthan
30years,aprevalenceoffemalegender,andthetendencytoactout(dropoutinthefinal
sessions)andslightlycorrelatedwithapropensityforinterpersonaldeficitsandlower
resourcesorsocialsupport.NomajordifferenceswereobservedinAxisI,andtheadopted
clinicalinstrumentsdidnotseemabletopredictdropoutbyclinical–symptomatological
‘‘magnitude.’’Evenincrisissituations,droppingoutappearstobecorrelatedwith
borderlinepersonalitydisorder(DiagnosticandStatisticalManualofMentalDisorders
[4thed.]).Theextenttowhichthisdependsoncrisisremissionorposesabarrierto
treatmentremainstobeseen.[BriefTreatmentandCrisisIntervention5:356–367(2005)]
KEY WORDS: dropout, crisis, anxiety, depression, borderline personality.
Mentalhealthcareisundermountingpressure mental health services for specific or focused
to reduce treatment duration as a result of problems that require counseling or brief
increasing demand and limited resources intervention (Koss & Shiang, 1994). Others
(Barkham, Shapiro, Hardy, & Rees, 1999). seek urgent help because they feel they have
Accordingly, there is a growing need to assess lost hope, perceive no way forward, lack the
service efficiency and related dropout rates means to cope with their personal circum-
(Thorma¨hlenetal.,2003).Manypeopleaddress stances, and, in some cases, are unable to
ªTheAuthor2005.PublishedbyOxfordUniversityPress.Allrightsreserved.Forpermissions,pleasee-mail:
[email protected].
356
Dropout in Institutional Emotional Crisis Counseling
pinpoint the nature of their problem. These as an important liaison between patients and
components make up the emotional crisis, longer term therapies. In some cases, interven-
which differs from psychiatric and psychotic tion is conducted in successive stages, over a
crises in structural severity, evolution, and period of a few years; investment centers on
treatment method (Pavan, 2003). motivating treatment and creating a first brief
Brief psychotherapy is generally indicated experienceoffocusedallianceora‘‘safetynet’’
for patients with clear insight into their prob- in times of intolerable pain.
lem,whoarestronglymotivatedtowardchange. Working through and overcoming an expe-
Where patients are not so accessible, a few rience of this type is an important source of
weeksofexploratorytherapyandself-discovery developmental achievement (Erikson, 1959,
maybehelpfulbeforeembarkingonbrieftreat- 1968) and maturative adaptation (Andreoli,
ment(Prochaska,Norcross,&DiClemente,1994; Lalive,&Garrone,1986).Indeed,learningunder
Steenbarger,1994,2002;Steenbarger&Budman, emotionalcircumstancesismoreenduringthan
1998). Dropout rates are often high, accounting learning tackled in ordinary states of experi-
forasmanyas50%ofpatientsbeforetheeighth encing (Greenberg, Rice, & Elliott, 1993).
session(Garfield,1994). It may be particularly interesting to study
In thepresenceofpersonality disorders,too, nonnegotiated termination of therapy in an
limited accessibility seems to orient profes- institutional, emotional first-aid setting, which
sionalstowardaseriesoftargetedbrieftherapies oftencoincideswiththefirst‘‘critical’’encoun-
rather than single, ongoing, long-term treat- ter between the patient and the chance to
ments (Linehan, Cochran, & Kehrer, 2001), or acknowledge his/her distress. Optimum man-
brief but immediately available crisis manage- agementthusrequiresrapidintervention,crisis
mentinterventions(Roth&Fonagy,1996),and acknowledgment, and the development and
containment of maladaptive behaviors and mutually agreed termination of a relationship,
suicide risk (Kaplan, Sadock, & Grebb, 1997a). spanning a reasonably tolerable, programmed
Clinically, the crisis situation is manifested time period. Successful intervention may ulti-
through a wide array of symptoms associated mately facilitate referral to ‘‘outside’’ help or
with acute (or anxious–depressive) diagnostic access to a more appropriate, otherwise un-
pictures and heterogeneous ‘‘defensive’’ and approachable treatment.
personologicalstyles.Theaimistosupportthe Inrecentyears,interestincrisisintervention
patient and encourage recovery of ‘‘possible hasbeengrowing(Reisch,Schlatter,&Tschacher,
normal functioning’’ (Pavan, 2003). Which is 1999) and has diversified in response to dwin-
why crisis interventions are traditionally de- dling resources (Dauwalder & Ciompi, 1995).
scribed as rather eclectic (Beutler & Clarkin, However,fewstudieshaveassessedtheefficacy
1990; Wolberg, 1980). of specific crisis interventions compared to
In other situations (in which a personality conventional treatments (van der Sande et al.,
disorder is present), crisis intervention serves 1997). Roberts, Everly, and Camasso (2005)
demonstratedthatbothanacutecrisisstateand
FromtheInstituteofClinicalPsychiatry,Departmentof the symptomatology that accompanies it can
Neurosciences,PadovaUniversity.
frequently be alleviated through intensive
Contactauthor:LuigiPavan,FullProfessorofPsychiatry,
InstituteofClinicalPsychiatry,DipartimentodiNeuro- crisis intervention. Because positive treatment
scienze,Universita` degliStudidiPadova,ViaGiustiniani5,
effects seem to disappear after 12 months,
35128Padova,Italy.E-mail:[email protected]
Roberts, Everly, and Camasso recommended
doi:10.1093/brief-treatment/mhi027
AdvanceAccesspublicationOctober12,2005 that empirically based augmentation therapy
Brief Treatment and Crisis Intervention /5:4 November2005 357
MARINI ETAL.
and crisis intervention booster sessions 12 5. Psychiatric interventions in the previous
months post-treatment be planned and imple- 2 years
mented.ThePadovagrouphasundertakenout-
come assessment studies (Marini, Semenzin, & Counseling and Emotional Crisis
Pavan, 2003; Pavan et al., 2003), and compar- Psychotherapy
ative studies are underway on the effect of
Figure 1 shows how the emotional crisis
augmentation versus‘‘treatment as usual.’’
psychotherapy(ECP)outpatientserviceisposi-
The aim of this study is to assess the aspects
tioned within the organizational framework of
that influence the dropout phenomenon in a
Padova University Hospital Complex, in re-
first-aid,briefinterventionsettingbyevaluating
lation to other mental health clinics and other
delivery of emotional crisis intervention at the
medical services.
DepartmentofPsychiatryofPadovaUniversity.
Patientsreceivetheirfirstappointmentwithin
2 or 3 days of first contact. Intervention con-
Materials and Methods sists of 10 weekly sessions lasting 45–50 min.
Thesearedividedintoafirstsessionproviding
counselingfollowedbytwosessionscomprising
Objectives
in-depth assessment, presentation of the inter-
The aim of the work was to identify predic- vention,andabatteryoftests.Whereindicated,
torsofdropoutthroughanalysisofsociodemo- this is followed by the actual intervention
graphic and outcome characteristics. (sevensessions).Thetotalcostise88.Thetests
arethenreadministeredattheendoftheinter-
Inclusion Criteria
vention,andsubsequentfollow-upsessionsare
agreedonandprovidedfree-of-charge.
Crisisintervention,basedonthemodeladopted
at the Department of Psychiatry of Padova
Technique
University (Pavan & Banon, 1996, 1999), is
addressed to young people and adults experi-
Treatment is similar to outpatient-focused brief
encing emotional crisis, often accompanied by
supporting psychotherapy. Helping the patient
aninitialdiagnosisofmooddisorderoranxiety,
reestablish previous functioning level is the
whoareabletodirectlyorindirectlyformulate
main objective. The technique is eclectic with
an urgent request for help.
a large pedagogic component; it uses rational
and critical potentiality but also explores and
Exclusion Criteria
acknowledges emotions, seeking any associa-
Subjects presenting any of the following were tionsbetweenexternalandinternalevents,with
excluded: a view to working through and stressing pos-
itive aspects of the patient’s personal history.
1. Diagnosis of schizophrenia or other Interpretation is not generally applied. Consid-
psychotic disorders, or conditions eration is, instead, constantly given to separa-
requiring hospitalization. tionandconclusionoftheECP,particularlywith
2. Severe, chronic, or debilitating diseases. patientswithcomplexpersonalitystructures.
3. Psychiatric disorders associated with General intervention runs along the follow-
a general medical condition. ing lines:
4. Substance dependence not correlated
with the crisis. 1. Containment of feelings of impotence.
358 Brief Treatment and Crisis Intervention /5:4 November2005
Dropout in Institutional Emotional Crisis Counseling
STRESSORS Pdissytrcehsos-pathological Emergency Room Psychiatric on-call service AdmSPisDsiCon to
Intensive Care
RESOURCE General Practitioner
VULNERABILITY
CRISIS Repetitive
SITUATION compulsion Suicidology Service
Affective Disorder Clinic
ECP
EMOTIONAL CRISIS
CRISIS HYPOTHESIS INTERVENTION Other Specialists
Eating Disorder Clinic
Resolution
Psychiatric Service
for Students
Mid-long-term Mental Health Centre
psychotherapy
FIGURE1
Theoreticalmodelofcrisisevolution—thepartunderlinedinthetopleft-handcornersummarizesthetheoreticalcrisis
modelproposedbyAndreolietal.(1986).Internalorexternalstressfuleventsmaydetermineacrisisstemmingfrom
resourceavailabilityandvulnerabilityofthesubject.Althoughthecrisismaybespontaneouslyresolved,thereisadanger
ofpsychopathologicaldegeneration,occasionallythroughrepetitivecompulsionandmaintenanceofthecrisissituation,
withchieflyegosyntoniccharacteristics.Thecrisishypothesis(whichtendstobemoreegodystonic)marksanopening
towardthesearchforadaptivesolutionsortreatmentandpavesthewaytowardcrisisresolution.
CrisisinterventionmodeladoptedbyPadovaHospital,Italy—thepartofthefigurethatisnotunderlinedrepresentsthe
crisismodeladoptedbytheECPinPadova.GeneralPractitioner:referraltotheECPmaybedirectlyfacilitatedbythe
patient’sownfamilydoctor.Psychiatricon-callservice:patientsgoingtotheemergencyroomarefirstassessedbythe
physicianoncallwhomaysuggestthatthepatientmakeapsychiatricappointmentormaycontactthepsychiatriston
call.ThepsychiatristoncallmayinturnconsiderreferringthepatienttotheECP.Suicidologyservice:thesuicidology
servicehasconsultantswhomaybecontactedbytheemergencyroomorbyotherwardsatPadovaHospitalfollowingan
attemptedsuicide.TheconsultantsmayreferthepatienttotheECPinassociationwithotherinterventionsdeemed
appropriate.Insomecases,theECPconsultswiththesuicidologyserviceinrelationtopatientsexpressingserious
suicidalideation.Psychiatricserviceforstudents:thepsychiatricserviceforstudentsisaservicesubsidizedbytheESU
(theBoardfortheRighttoUniversityStudy),whichprovidesinterventionforthoseuniversitystudentsrequestingit.
TheECPisonetypeofinterventionthatmightbeproposed.Affectivedisorderclinic,Eatingdisorderclinic,Other
specialists,andMentalhealthcenter:patientsmaybereferredtotheECPfromthesespecialistclinicsorbyother
specialistswhencircumstancessodemand.Likewise,whenpatientsdonotmeetinclusioncriteriaforcrisis
intervention,theECPmayinturnreferpatientstotheseunits.Medium/long-termpsychotherapy:insomecases,
interventionbytheECPmaygiverisetoarequestformedium/long-termtherapy.Insuchcases,therequestis
assessed,andwhereappropriate,thissolutionisrecommended.
2. Helpinmaintaininginnerworld/external 4. Historicizing of the event in its
world boundaries. fantasmatic dimension.
3. Fostering of object reinsertion by 5. Promotion of controlled experience of
tolerating ambivalence. pain and depression.
Brief Treatment and Crisis Intervention /5:4 November2005 359
MARINI ETAL.
Patientsmaybereferredforlong-termtherapy 2. State-Trait Anxiety Inventory
during or after crisis treatment as warranted. (Spielberger, 1983),
Wherenecessary,medicationcanbeprescribed. 3. State-Trait Anger Expression Inventory
(Spielberger, 1988; the first 20 items),
4. Social Adaptation Self-Evaluation Scale
Recruitment and Description of the Sample
(Bosc, 1997).
Thestudyconsidered128cases(meanage31.4
years,SD¼9.0;range17–58;18%males),con- During the period between the first and third
secutively seen at the Emotional Crisis Clinic clinical sessions, patients were invited for an
of the Department of Psychiatry of Padova interviewfordiagnosticpurposes(accordingto
University, from March 2002 to September Diagnostic and Statistical Manual of Mental
2003. Thirty-two cases (mean age 33.2 years, Disorders, 4th ed., text revision [DSM-IV-TR]
SD ¼ 8.6) that did not meet the inclusion criteria; Zimmerman, 1994), conducted by an
criteria were excluded. independent rater (clinical psychologist or
Dropout is defined as psychiatrist) with the aid of:
A dropout from psychotherapy is one who 1. SCID II (Maffei et al., 1997),
has been accepted for psychotherapy, who 2. Hamilton Depression Rating Scale, 21
actually has at least one session of therapy, items (Hamilton, 1960),
andwhodiscontinuestreatmentonhisorher 3. Global Assessment Scale (Endicott,
own initiative by failing to come for any Spitzer, Fleiss, & Cohen, 1976),
futurearrangedvisitswiththetherapist[...] 4. Assessment of stressful life events,
Individualswhonevershowupfortheirfirst accordingtoDSM-IV-TRcriteria,AxisIV
appointmentwouldbeviewedasrejectorsof (American Psychiatric Association
therapy rather than premature terminators [APA], 2000).
since therapy had not yet been instituted.
(Garfield, 1994) Therapy was conducted by 10 therapists who
took part in the research (seven females and
Therapy was completed by 102 subjects; 26 three males; mean age 29.7 6 1.02 years), who
discontinuedtherapybetweenthe5thand10th were residents in Psychiatry in their second,
session. None of the 128 subjects who met the third, or fourth year of specialist training.
inclusion criteria rejected therapy (dropout at
the fourth session).
Statistical Analysis
Thechi-squaretechniquewasusedtocompare
Assessment
categorical variables between early dropout
During the first session, after filling in the and the remaining group; when the expected
informed consent form, the following self- frequencies were below five, Fisher’s exact
rating tests were administered to patients test was used. Means were compared using
agreeingto take part in the study: the analysis of variance test; normal distribu-
tion was verified by the Kolmogorov–Smirnov
1. Beck Depression Inventory, 21 items test. Alternatively, Mann–Whitney’s U test
(Beck, Ward, Mendelson, Moch, & was applied. Logistic regression was used to
Erbauch, 1961), determine the independent contribution of
360 Brief Treatment and Crisis Intervention /5:4 November2005
Dropout in Institutional Emotional Crisis Counseling
personalitytoearlyterminationoftreatment.In of medication (v2 ¼ 2.4, df ¼ 1, p ¼ .65),
the latter analysis, age and personality disor- distribution of Axis I (DSM-IV-TR) diagnoses
derswereincludedascovariates(ascontinuous (v2¼0.79,df¼1,p¼.96),anddistributionof
variables based on the number of positive stressful lifeevents(v2 ¼3.8,df ¼ 1,p¼ .41).
criteria identified by SCID II). Gender was
excludedasaconfoundingvariableconsidering Rating Scales
thenonuniformstratificationofthesample.The
Nosignificantdifferencesemergedonthescales
SPSS statistical package (version 12) was used
administered at the start of treatment (Table 2)
for analysis purposes.
for depression, anxiety, anger, and global
functioning.Therewasinsteadaslightlylower
propensity, on the Social Adaptation Self-
Results
Evaluation Scale for relational activities in
dropouts (Table 2).
The total dropout rate was 20.31%. The mean
pointofdropoutwasatsession6.262.3(range Of the total sample (N ¼ 128), 51.4%
presented at least one personality disorder
5–9).Therewasaslightagedifferencebetween
(DSM-IV, APA, 1994). Many cases met the
the two groups (Table 2), F ¼ 6.8, df ¼ 1,
criteriaformorethanonedisorder.In29.5%of
p ¼ .01.
the cases the patients presented at least two
disorders and in 17.3%, three, and 9.5% met
Gender
the criteria for at least four personality
There was a slight difference between the two disorders. These came in different combina-
groups in frequency distribution by gender tions. At least one Cluster B disorder was
(Table1).Acertaindifferenceinagebygender observed in 41.7%, followed by Cluster C
wasalsoobserved(male¼35.32610.8,range (23.5%)andClusterA(18.3%).Specifically,the
20–58;female¼30.7 68.6,range17–51),F¼ most representative were borderline (35.7%),
3.8, p < .05. narcissistic (18.3%), obsessive (20%), oppos-
itive (13.9%), depressive (13.9%), avoidant
(10.4%), and paranoid (15.7%).
Socioeconomic Variables
Alogisticregressionmodelidentifiedborder-
A slight difference was found in the distribu-
line personality disorder as a predictor of
tion of occupation, v2 ¼ 8.8, df ¼ 1, p ¼ .04
dropout, odds ratio 1.32, p < .032 (Table 3).
(Table1).Studentsandhousewivesappearedto
Age and personality disorder were included in
be at higher risk of dropout, whereas being
this latter analysis as covariates (as continuous
unemployedseemedtohaveaprotectiveeffect.
variables based on the number of positive
No differences emerged in educational level
criteria detected on SCID II). Gender was
based on completed cycles of Italian formal
excludedasaconfoundingvariableconsidering
education, F ¼ 1.06, df ¼ 1, p ¼ ns (Table 2).
the sample’s heterogeneous stratification.
Therewerenosignificantdifferencesformarital
status,v2¼1.6,df¼1,p¼.66(Table1).
Discussion
Referral, Diagnosis, and Treatment
Althoughthestudyislimitedbythesmallsize
No differences were observed with respect to of the sample, the total dropout rate of 20.3%
referral(v2¼0.74,df¼1,p¼.96),assumption seemsquiteagoodoutcome,whencomparedto
Brief Treatment and Crisis Intervention /5:4 November2005 361
MARINI ETAL.
TABLE1.DemographicandClinicalCharacteristicsofDropoutsandControlPatients
Dropoutpatients Controlpatients
(n=26) (n=102) Test
Characteristics n % n % v2 df p
Gender 4.4 1 .04
Male 1 4.3 22 95.7
Female 25 23.8 80 76.2
Maritalstatus 1.6a 1 .66
Nevermarried 16 61.5 57 55.9
Married 5 19.2 30 29.4
Separated(cid:1)divorced 4 15.4 10 9.8
Widowed 1 3.8 5 4.9
Occupation 8.8a 1 .04
Paidemployment 10 38.5 54 52.9
Unemployed 0 0 12 11.8
Student 12 46.2 26 25.5
Housewife 4 15.4 7 6.9
Retired 0 0 3 2.9
Referredby 0.74a 1 .96
User 5 19.2 22 21.6
Generalpractitioner 4 15.4 16 15.7
Specialist 6 23.1 26 25.5
Emergency/casualty 9 34.6 33 32.4
Relativesorfriends 2 7.7 5 4.9
MainAxisIDSM-IVdiagnosis 0.79a 1 .96
Majordepressiveepisode 11 42.3 43 42.2
PAD 2 7.7 9 8.8
Generalizedanxietydisorder 5 19.2 18 17.6
Suiciderisk 2 7.7 5 4.9
Adjustmentdisorder 6 23.1 27 26.5
Medication 2.4a 1 .65
None 15 57.7 44 43.1
BDZ 2 7.7 6 5.9
SSRI 5 19.2 24 23.5
SSRIþBDZ 4 15.4 23 22.5
Other 0 0 5 4.9
Lifeevents 3.8a 1 .41
Familyproblems 5 19.2 17 16.7
Relationalproblems 9 34.6 34 33.3
Professionalproblems 2 7.7 19 18.6
Otherpsychosocialproblems 3 11.5 4 3.9
Others 7 26.9 28 27.5
Note.PAD¼panicattackdisorder;BDZ¼benzodiazepine;SSRI¼selectiveserotoninreuptakeinhibitor.
aCorrectedbyFisher’sexacttest.
362 Brief Treatment and Crisis Intervention /5:4 November2005
Dropout in Institutional Emotional Crisis Counseling
TABLE2.ComparisonofClinicalCharacteristicsAssessedonRatingScalesBetweenDropoutsandControls
Dropoutpatients Controlpatients Test
Variable (n=26;mean6SD) (n=102;mean6SD) statistic df p
Age 28.168.2 33.569.6 F=6.80 1 .01
Educationyears 11.463.3 12.263.4 F=1.06 1 nsa
BDI 22.4612.4 22.2611.8 F=0.004 1 ns
HAM-D 15.365.7 15.467.4 F=0.003 1 ns
STAI-State 52.2613.6 54.1612.3 F=0.479 1 ns
STAI-Trait 52.4612.1 51.9611.5 F=0.034 1 ns
STAXI-State 14.365.1 15.166.2 F=0.309 1 ns
STAXI-Trait 21.065.3 19.965.3 F=0.810 1 ns
GAS 68.9611.4 67.068.5 F=0.789 1 ns
SASS 30.365.7 40.768 Ub=119 .05
Note.BDI¼BeckDepressionInventory;HAM-D¼HamiltonDepressionRatingScale;STAI¼State-TraitAnxietyInventory;STAXI¼State-Trait
AngerExpressionInventory;GAS¼GlobalAssessmentScale;SASS¼SocialAdaptationSelf-EvaluationScale.
ans¼nonsignificant.bMann–Whitney’sUtest.
general rates reported in the literature, which to seek treatment at the ECP takes various
range from 30% to 50% (Chiesa, Drahorad, & forms based on specific characteristics, such as
Longo, 2000; Garfield, 1994). This may un- the presence of certain personality disorders.
doubtedly depend on the different treatment Thereisaslightdifferenceinagebetweenthe
durationsandselectiondeterminedbyinclusion two groups of our study, with dropouts being
and exclusion criteria. However, many au- younger:afindingnotalwaysconfirmedbythe
thors stress that the crisis situation is a partic- literature (Greenspan & Kulish, 1985; Sledge,
ularly apt time to engage patients because it Moras,Hartley,&Levine,1990).Recentstudies
takes advantage of the urgency of their have, instead, linked the younger age of
distress. As we will see below, the motivation dropouts to borderline personality disorders
(Smith, Koenigsberg, Yeomans, Clarkin, &
Selzer, 1995; Thorma¨hlen et al., 2003). The
TABLE3.LogisticRegressionDropoutPredictors slightdifferencesobservedinoccupationcould
be explained in part by the younger age con-
Odds
nected with being a student and the gender
B Wald p ratio
factor with being a housewife. Unfortunately,
Age (cid:1)0.055 2.2 .131 0.946
smallnumbersandgreateracknowledgmentof
Avoidant 0.119 0.419 .517 1.127
distress among females (Kaplan, Sadock, &
Dependent 0.221 1.3 .248 1.24
Obsessive-compulsive 0.019 0.011 .918 1.01 Grebb, 1997b) prevent us from drawing con-
Oppositive 0.120 0.334 .563 1.128 clusions in this respect, although there is
Depressive (cid:1)0.559 4.9 .02 0.572 a higher incidence of nonnegotiated discontin-
Paranoid (cid:1)0.053 0.070 .792 0.949
uation of treatment by females.
Schizotypal 0.028 0.032 .858 1.02
There do not appear to be any substantial
Schizoid 0.085 0.190 .663 1.08
differences in Axis I according to the method
Histrionic (cid:1)0.150 0.399 .528 0.861
Narcissistic 0.182 1.47 .225 1.2 used, and the clinical instruments adopted
Borderline 0.283 4.6 .032 1.32 are unable to predict dropout on the basis
CoXandSnellR2¼.214;v2¼21.8;p<.03. of clinical–symptomatological ‘‘magnitude.’’
Brief Treatment and Crisis Intervention /5:4 November2005 363
MARINI ETAL.
What does emerge is the generally high borderline pathology, compromise motivation
presence of Axis II pathologies (DSM-IV, to seek services elsewhere or at some future
APA, 1994), particularly in the dropout group time.Follow-upstudiesinthisrespectwouldbe
(Chiesa et al., 2000; Thorma¨hlen et al., 2003). helpfultoevaluatewhethercrisisinterventions
Incidence rates appear higher especially in haveafacilitatingeffectonthetendencytoseek
Cluster B (borderline, narcissistic, and histri- treatment. In the 2 years following the study,
onic)andClusterC(oppositiveandslightlyless none of the patients who underwent therapy
pronounced depressive personality) disorders. attempted suicide. However, some subse-
In logistic regression analysis, these greater quently repeated the crisis intervention with
borderline traits seem to predict dropout. similar forms of discontinuation.
Generallyspeaking,theBorderlinesyndrome Adropoutdoesnotalwaysequatetoafailure
proposed by DSM-IV envisages a pervasive (Pekarik, 1992a, 1992b). Two cases in our
patternofinstabilityininterpersonalrelations, sample (females with borderline personality)
self-image, and affects, with marked impul- dropped out of treatment with the therapist
sivity, a tendency to avoid abandonment or (eighth and ninth session) but kept the
separation, and a prevalence among female appointment with the ‘‘tester,’’ displaying a
gender, with a tendency to abate toward the significantreductioninsymptoms.Theefficacy
third–fourth decade, with increasing age. of crisis intervention in terms of reduction
Considering the limits of our study and with in symptoms (Marini et al., 2003; Pavan et al.,
all due caution, our data seem to confirm 2003) does not rule out spontaneous remission
borderline personality disorder as predictive and does not solve the problem of aftercare
of dropout risk linked to when indicated. It also does not solve the
marketing capacity of an institution to attract
1. Youngerageofdropouts(under30years)
patients in need, with more specific forms of
and older control group members.
treatment (Andreoli & Bonatti, 1992; Andreoli
2. Prevalence of female gender.
et al., 1986; Dauwalder& Ciompi, 1995).
3. Tendency to act out and avoid
Psychoanalytic–psychodynamic therapy, di-
abandonment (dropping out in the final
alectical behavior therapy, and psychoeduca-
sessions).
tional approaches have all proved helpful in
4. Slight correlation with deficient
working with borderline personality. These
interpersonal relations and less resources
therapies are based on the premise of a strong
or social support.
therapeutic alliance. Inherent in such an alli-
Interestingly, no patient discontinued therapy ance is the importance of a clearly structured
at the start of intervention (first three treatmentframework(Goin,2001).Inourcase,
sessions).Thissuggeststhatthecrisissituation the ECP served as the first institutional link
might facilitate engagement. Obviously, other for these patients.
aspects also have an influence, such as moti- Reducing hospitalization through improve-
vationandexpectationsoftherapy(Lambert& ments in outpatient services does reduce costs
Lambert, 1984), in addition to the role played and does benefit individuals with borderline
by the quality of preparation before ECP by personalitydisorder(Comtoisetal.,2003).This
other services that refer the patient to ECP studyfoundthatthosewithborderlineperson-
(Figure 1). ality disorders drop out of brief outpatient
What does need to be established, however, crisisinterventionatasignificantlyhigherrate
is whether the relational patterns, typical of than do those without borderline personality
364 Brief Treatment and Crisis Intervention /5:4 November2005
Dropout in Institutional Emotional Crisis Counseling
disorders.Atthesametime,theECPseemedto Conclusion
offer an acceptable solution to these acute
patients (no one dropped out at the start of Even in crisis situations, dropping out appears
therapy). to be correlated with borderline personality
Although a readily available resource may disorder. The extent to which this depends on
have therapeutic ends, its purpose is chiefly crisis remission or poses a barrier to treatment
preventive.Afewcounselingsessionsmaynot remainstobeseen.Theprovisionofoutpatient
be enough to stem borderline patients’ great crisis intervention using brief (10 sessions)
needforsupportintheacutephaseandtofoster interventions will help some but not all those
motivation to undertake other long-term referred for or seeking such treatment. Those
therapies. However, long waiting lists, major withborderlinepersonalitydisordersarelikely
economic costs, or undetermined treatment to need additional inpatient or ongoing treat-
prospectsmayhaveadecisiveroleindiverting ment. Because the disorder itself presents bar-
patients away from treatment. It will be rierstoaccessingorremainingintreatment,crisis
necessarytoassesswhetherandtowhatextent intervention may act as a bridge to additional
a response subjectively perceived as ‘‘frustrat- treatment for this group.
ing’’ or which fails to meet the ‘‘real’’ request
for help may profoundly or even definitively
sever alliance, precluding what might other- References
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Brief Treatment and Crisis Intervention /5:4 November2005 365