Skip Navigation

Institution: CLOCKSS Sign In as Personal Subscriber

Brief Treatment and Crisis Intervention Advance Access originally published online on October 12, 2005
Brief Treatment and Crisis Intervention 2005 5(4):356-367; doi:10.1093/brief-treatment/mhi027
This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow All Versions of this Article:
5/4/356    most recent
mhi027v1
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Alert me to new issues of the journal
Right arrow Add to My Personal Archive
Right arrow Download to citation manager
Right arrowRequest Permissions
Right arrow Disclaimer
Google Scholar
Right arrow Articles by Marini, M.
Right arrow Articles by Pavan, L.
Right arrow Search for Related Content
PubMed
Right arrow Articles by Marini, M.
Right arrow Articles by Pavan, L.
Social Bookmarking
Add to CiteULike   Add to Connotea   Add to Del.icio.us  
What's this?

© The Author 2005. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oxfordjournals.org.

Original Article

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

From the Institute of Clinical Psychiatry, Department of Neurosciences, Padova University

Contact author: Luigi Pavan, Full Professor of Psychiatry, Institute of Clinical Psychiatry, Dipartimento di Neuroscienze, Università degli Studi di Padova, Via Giustiniani 5, 35128 Padova, Italy. E-mail: psichiatria{at}unip.it

Increasingly scarce economic resources prompt the need for more efficient forms of health care; hence, brief outpatient crisis intervention has therapeutic and preventive goals with respect to suicide risk. The aim of this study was to assess which factors predict nonnegotiated termination of treatment. Patients who dropped out of treatment (n = 26) were compared with those who concluded treatment (n = 102). Intervention, which resembled outpatient-focused brief supporting psychotherapy, consisted of 10 weekly sessions lasting 45–50 min. The first session envisaged an initial consultation; the following 2 sessions consisted of in-depth assessment, presentation of the intervention, and a battery of tests. Axis I, Axis II personality (Structured Clinical Interview for DSM IV, Axis II Personality Disorders), depression (Hamilton Depression Rating Scale, Beck Depression Inventory), anxiety (State-Trait Anxiety Inventory), anger (State-Trait Anger Expression Inventory), social adaptation (Social Adaptation Self-Evaluation Scale), and global functioning (Global Assessment Scale) were also clinically evaluated. The total dropout rate in the study was 20.3%. Logistic regression analysis identified borderline personality disorder as a predictor of dropout, which was associated with a mean age of less than 30 years, a prevalence of female gender, and the tendency to act out (dropout in the final sessions) and slightly correlated with a propensity for interpersonal deficits and lower resources or social support. No major differences were observed in Axis I, and the adopted clinical instruments did not seem able to predict dropout by clinical–symptomatological "magnitude." Even in crisis situations, dropping out appears to be correlated with borderline personality disorder (Diagnostic and Statistical Manual of Mental Disorders [4th ed.]). The extent to which this depends on crisis remission or poses a barrier to treatment remains to be seen.

KEY WORDS: dropout, crisis, anxiety, depression, borderline personality

Mental health care is under mounting pressure to reduce treatment duration as a result of increasing demand and limited resources (Barkham, Shapiro, Hardy, & Rees, 1999). Accordingly, there is a growing need to assess service efficiency and related dropout rates (Thormählen et al., 2003). Many people address mental health services for specific or focused problems that require counseling or brief intervention (Koss & Shiang, 1994). Others seek urgent help because they feel they have lost hope, perceive no way forward, lack the means to cope with their personal circumstances, and, in some cases, are unable to pinpoint the nature of their problem. These components make up the emotional crisis, which differs from psychiatric and psychotic crises in structural severity, evolution, and treatment method (Pavan, 2003).

Brief psychotherapy is generally indicated for patients with clear insight into their problem, who are strongly motivated toward change. Where patients are not so accessible, a few weeks of exploratory therapy and self-discovery may be helpful before embarking on brief treatment (Prochaska, Norcross, & DiClemente, 1994; Steenbarger, 1994, 2002; Steenbarger & Budman, 1998). Dropout rates are often high, accounting for as many as 50% of patients before the eighth session (Garfield, 1994).

In the presence of personality disorders, too, limited accessibility seems to orient professionals toward a series of targeted brief therapies rather than single, ongoing, long-term treatments (Linehan, Cochran, & Kehrer, 2001), or brief but immediately available crisis management interventions (Roth & Fonagy, 1996), and containment of maladaptive behaviors and suicide risk (Kaplan, Sadock, & Grebb, 1997a).

Clinically, the crisis situation is manifested through a wide array of symptoms associated with acute (or anxious–depressive) diagnostic pictures and heterogeneous "defensive" and personological styles. The aim is to support the patient and encourage recovery of "possible normal functioning" (Pavan, 2003). Which is why crisis interventions are traditionally described as rather eclectic (Beutler & Clarkin, 1990; Wolberg, 1980).

In other situations (in which a personality disorder is present), crisis intervention serves as an important liaison between patients and longer term therapies. In some cases, intervention is conducted in successive stages, over a period of a few years; investment centers on motivating treatment and creating a first brief experience of focused alliance or a "safety net" in times of intolerable pain.

Working through and overcoming an experience of this type is an important source of developmental achievement (Erikson, 1959, 1968) and maturative adaptation (Andreoli, Lalive, & Garrone, 1986). Indeed, learning under emotional circumstances is more enduring than learning tackled in ordinary states of experiencing (Greenberg, Rice, & Elliott, 1993).

It may be particularly interesting to study nonnegotiated termination of therapy in an institutional, emotional first-aid setting, which often coincides with the first "critical" encounter between the patient and the chance to acknowledge his/her distress. Optimum management thus requires rapid intervention, crisis acknowledgment, and the development and mutually agreed termination of a relationship, spanning a reasonably tolerable, programmed time period. Successful intervention may ultimately facilitate referral to "outside" help or access to a more appropriate, otherwise unapproachable treatment.

In recent years, interest in crisis intervention has been growing (Reisch, Schlatter, & Tschacher, 1999) and has diversified in response to dwindling resources (Dauwalder & Ciompi, 1995). However, few studies have assessed the efficacy of specific crisis interventions compared to conventional treatments (van der Sande et al., 1997). Roberts, Everly, and Camasso (2005) demonstrated that both an acute crisis state and the symptomatology that accompanies it can frequently be alleviated through intensive crisis intervention. Because positive treatment effects seem to disappear after 12 months, Roberts, Everly, and Camasso recommended that empirically based augmentation therapy and crisis intervention booster sessions 12 months post-treatment be planned and implemented. The Padova group has undertaken outcome assessment studies (Marini, Semenzin, & Pavan, 2003; Pavan et al., 2003), and comparative studies are underway on the effect of augmentation versus "treatment as usual."

The aim of this study is to assess the aspects that influence the dropout phenomenon in a first-aid, brief intervention setting by evaluating delivery of emotional crisis intervention at the Department of Psychiatry of Padova University.


   Materials and Methods
TOP
 Materials and Methods
Results
 Discussion
 Conclusion
 References
 
Objectives
The aim of the work was to identify predictors of dropout through analysis of sociodemographic and outcome characteristics.

Inclusion Criteria
Crisis intervention, based on the model adopted at the Department of Psychiatry of Padova University (Pavan & Banon, 1996, 1999), is addressed to young people and adults experiencing emotional crisis, often accompanied by an initial diagnosis of mood disorder or anxiety, who are able to directly or indirectly formulate an urgent request for help.

Exclusion Criteria
Subjects presenting any of the following were excluded:

  1. Diagnosis of schizophrenia or other psychotic disorders, or conditions requiring hospitalization.
  2. Severe, chronic, or debilitating diseases.
  3. Psychiatric disorders associated with a general medical condition.
  4. Substance dependence not correlated with the crisis.
  5. Psychiatric interventions in the previous 2 years

Counseling and Emotional Crisis Psychotherapy
Figure 1 shows how the emotional crisis psychotherapy (ECP) outpatient service is positioned within the organizational framework of Padova University Hospital Complex, in relation to other mental health clinics and other medical services.



View larger version (18K):
[in this window]
[in a new window]
  		FIGURE 1 Theoretical model of crisis evolution—the part underlined in the top left-hand corner summarizes the theoretical crisis model proposed by Andreoli et al. (1986). Internal or external stressful events may determine a crisis stemming from resource availability and vulnerability of the subject. Although the crisis may be spontaneously resolved, there is a danger of psychopathological degeneration, occasionally through repetitive compulsion and maintenance of the crisis situation, with chiefly egosyntonic characteristics. The crisis hypothesis (which tends to be more egodystonic) marks an opening toward the search for adaptive solutions or treatment and paves the way toward crisis resolution.

Crisis intervention model adopted by Padova Hospital, Italy—the part of the figure that is not underlined represents the crisis model adopted by the ECP in Padova. General Practitioner: referral to the ECP may be directly facilitated by the patient's own family doctor. Psychiatric on-call service: patients going to the emergency room are first assessed by the physician on call who may suggest that the patient make a psychiatric appointment or may contact the psychiatrist on call. The psychiatrist on call may in turn consider referring the patient to the ECP. Suicidology service: the suicidology service has consultants who may be contacted by the emergency room or by other wards at Padova Hospital following an attempted suicide. The consultants may refer the patient to the ECP in association with other interventions deemed appropriate. In some cases, the ECP consults with the suicidology service in relation to patients expressing serious suicidal ideation. Psychiatric service for students: the psychiatric service for students is a service subsidized by the ESU (the Board for the Right to University Study), which provides intervention for those university students requesting it. The ECP is one type of intervention that might be proposed. Affective disorder clinic, Eating disorder clinic, Other specialists, and Mental health center: patients may be referred to the ECP from these specialist clinics or by other specialists when circumstances so demand. Likewise, when patients do not meet inclusion criteria for crisis intervention, the ECP may in turn refer patients to these units. Medium/long-term psychotherapy: in some cases, intervention by the ECP may give rise to a request for medium/long-term therapy. In such cases, the request is assessed, and where appropriate, this solution is recommended.

 
Patients receive their first appointment within 2 or 3 days of first contact. Intervention consists of 10 weekly sessions lasting 45–50 min. These are divided into a first session providing counseling followed by two sessions comprising in-depth assessment, presentation of the intervention, and a battery of tests. Where indicated, this is followed by the actual intervention (seven sessions). The total cost is {euro}88. The tests are then readministered at the end of the intervention, and subsequent follow-up sessions are agreed on and provided free-of-charge.

Technique
Treatment is similar to outpatient-focused brief supporting psychotherapy. Helping the patient reestablish previous functioning level is the main objective. The technique is eclectic with a large pedagogic component; it uses rational and critical potentiality but also explores and acknowledges emotions, seeking any associations between external and internal events, with a view to working through and stressing positive aspects of the patient's personal history. Interpretation is not generally applied. Consideration is, instead, constantly given to separation and conclusion of the ECP, particularly with patients with complex personality structures.

General intervention runs along the following lines:

  1. Containment of feelings of impotence.
  2. Help in maintaining inner world/external world boundaries.
  3. Fostering of object reinsertion by tolerating ambivalence.
  4. Historicizing of the event in its fantasmatic dimension.
  5. Promotion of controlled experience of pain and depression.
Patients may be referred for long-term therapy during or after crisis treatment as warranted. Where necessary, medication can be prescribed.

Recruitment and Description of the Sample
The study considered 128 cases (mean age 31.4 years, SD = 9.0; range 17–58; 18% males), consecutively seen at the Emotional Crisis Clinic of the Department of Psychiatry of Padova University, from March 2002 to September 2003. Thirty-two cases (mean age 33.2 years, SD = 8.6) that did not meet the inclusion criteria were excluded.

Dropout is defined as

A dropout from psychotherapy is one who has been accepted for psychotherapy, who actually has at least one session of therapy, and who discontinues treatment on his or her own initiative by failing to come for any future arranged visits with the therapist [...] Individuals who never show up for their first appointment would be viewed as rejectors of therapy rather than premature terminators since therapy had not yet been instituted. (Garfield, 1994)

Therapy was completed by 102 subjects; 26 discontinued therapy between the 5th and 10th session. None of the 128 subjects who met the inclusion criteria rejected therapy (dropout at the fourth session).

Assessment
During the first session, after filling in the informed consent form, the following self-rating tests were administered to patients agreeing to take part in the study:

  1. Beck Depression Inventory, 21 items (Beck, Ward, Mendelson, Moch, & Erbauch, 1961),
  2. State-Trait Anxiety Inventory (Spielberger, 1983),
  3. State-Trait Anger Expression Inventory (Spielberger, 1988; the first 20 items),
  4. Social Adaptation Self-Evaluation Scale (Bosc, 1997).
During the period between the first and third clinical sessions, patients were invited for an interview for diagnostic purposes (according to Diagnostic and Statistical Manual of Mental Disorders, 4th ed., text revision [DSM-IV-TR] criteria; Zimmerman, 1994), conducted by an independent rater (clinical psychologist or psychiatrist) with the aid of:
  1. SCID II (Maffei et al., 1997),
  2. Hamilton Depression Rating Scale, 21 items (Hamilton, 1960),
  3. Global Assessment Scale (Endicott, Spitzer, Fleiss, & Cohen, 1976),
  4. Assessment of stressful life events, according to DSM-IV-TR criteria, Axis IV (American Psychiatric Association [APA], 2000).
Therapy was conducted by 10 therapists who took part in the research (seven females and three males; mean age 29.7 ± 1.02 years), who were residents in Psychiatry in their second, third, or fourth year of specialist training.

Statistical Analysis
The chi-square technique was used to compare categorical variables between early dropout and the remaining group; when the expected frequencies were below five, Fisher's exact test was used. Means were compared using the analysis of variance test; normal distribution was verified by the Kolmogorov–Smirnov test. Alternatively, Mann–Whitney's U test was applied. Logistic regression was used to determine the independent contribution of personality to early termination of treatment. In the latter analysis, age and personality disorders were included as covariates (as continuous variables based on the number of positive criteria identified by SCID II). Gender was excluded as a confounding variable considering the nonuniform stratification of the sample. The SPSS statistical package (version 12) was used for analysis purposes.


   Results
TOP
 Materials and Methods
 Results
Discussion
 Conclusion
 References
 
The total dropout rate was 20.31%. The mean point of dropout was at session 6.2 ± 2.3 (range 5–9). There was a slight age difference between the two groups (Table 2), F = 6.8, df = 1, p = .01.

Gender
There was a slight difference between the two groups in frequency distribution by gender (Table 1). A certain difference in age by gender was also observed (male = 35.32 ± 10.8, range 20–58; female = 30.7 ± 8.6, range 17–51), F = 3.8, p < .05.


View this table:
[in this window]
[in a new window]
  		TABLE 1. Demographic and Clinical Characteristics of Dropouts and Control Patients

 
Socioeconomic Variables
A slight difference was found in the distribution of occupation, {chi}2 = 8.8, df = 1, p = .04 (Table 1). Students and housewives appeared to be at higher risk of dropout, whereas being unemployed seemed to have a protective effect. No differences emerged in educational level based on completed cycles of Italian formal education, F = 1.06, df = 1, p = ns (Table 2). There were no significant differences for marital status, {chi}2 = 1.6, df = 1, p = .66 (Table 1).


View this table:
[in this window]
[in a new window]
  		TABLE 2. Comparison of Clinical Characteristics Assessed on Rating Scales Between Dropouts and Controls

 
Referral, Diagnosis, and Treatment
No differences were observed with respect to referral ({chi}2 = 0.74, df = 1, p = .96), assumption of medication ({chi}2 = 2.4, df = 1, p = .65), distribution of Axis I (DSM-IV-TR) diagnoses ({chi}2 = 0.79, df = 1, p = .96), and distribution of stressful life events ({chi}2 = 3.8, df = 1, p = .41).

Rating Scales
No significant differences emerged on the scales administered at the start of treatment (Table 2) for depression, anxiety, anger, and global functioning. There was instead a slightly lower propensity, on the Social Adaptation Self-Evaluation Scale for relational activities in dropouts (Table 2).

Of the total sample (N = 128), 51.4% presented at least one personality disorder (DSM-IV, APA, 1994). Many cases met the criteria for more than one disorder. In 29.5% of the cases the patients presented at least two disorders and in 17.3%, three, and 9.5% met the criteria for at least four personality disorders. These came in different combinations. At least one Cluster B disorder was observed in 41.7%, followed by Cluster C (23.5%) and Cluster A (18.3%). Specifically, the most representative were borderline (35.7%), narcissistic (18.3%), obsessive (20%), oppositive (13.9%), depressive (13.9%), avoidant (10.4%), and paranoid (15.7%).

A logistic regression model identified borderline personality disorder as a predictor of dropout, odds ratio 1.32, p < .032 (Table 3). Age and personality disorder were included in this latter analysis as covariates (as continuous variables based on the number of positive criteria detected on SCID II). Gender was excluded as a confounding variable considering the sample's heterogeneous stratification.


View this table:
[in this window]
[in a new window]
  		TABLE 3. Logistic Regression Dropout Predictors

 

   Discussion
TOP
 Materials and Methods
 Results
 Discussion
Conclusion
 References
 
Although the study is limited by the small size of the sample, the total dropout rate of 20.3% seems quite a good outcome, when compared to general rates reported in the literature, which range from 30% to 50% (Chiesa, Drahorad, & Longo, 2000; Garfield, 1994). This may undoubtedly depend on the different treatment durations and selection determined by inclusion and exclusion criteria. However, many authors stress that the crisis situation is a particularly apt time to engage patients because it takes advantage of the urgency of their distress. As we will see below, the motivation to seek treatment at the ECP takes various forms based on specific characteristics, such as the presence of certain personality disorders.

There is a slight difference in age between the two groups of our study, with dropouts being younger: a finding not always confirmed by the literature (Greenspan & Kulish, 1985; Sledge, Moras, Hartley, & Levine, 1990). Recent studies have, instead, linked the younger age of dropouts to borderline personality disorders (Smith, Koenigsberg, Yeomans, Clarkin, & Selzer, 1995; Thormählen et al., 2003). The slight differences observed in occupation could be explained in part by the younger age connected with being a student and the gender factor with being a housewife. Unfortunately, small numbers and greater acknowledgment of distress among females (Kaplan, Sadock, & Grebb, 1997b) prevent us from drawing conclusions in this respect, although there is a higher incidence of nonnegotiated discontinuation of treatment by females.

There do not appear to be any substantial differences in Axis I according to the method used, and the clinical instruments adopted are unable to predict dropout on the basis of clinical–symptomatological "magnitude." What does emerge is the generally high presence of Axis II pathologies (DSM-IV, APA, 1994), particularly in the dropout group (Chiesa et al., 2000; Thormählen et al., 2003). Incidence rates appear higher especially in Cluster B (borderline, narcissistic, and histrionic) and Cluster C (oppositive and slightly less pronounced depressive personality) disorders. In logistic regression analysis, these greater borderline traits seem to predict dropout.

Generally speaking, the Borderline syndrome proposed by DSM-IV envisages a pervasive pattern of instability in interpersonal relations, self-image, and affects, with marked impulsivity, a tendency to avoid abandonment or separation, and a prevalence among female gender, with a tendency to abate toward the third–fourth decade, with increasing age.

Considering the limits of our study and with all due caution, our data seem to confirm borderline personality disorder as predictive of dropout risk linked to

  1. Younger age of dropouts (under 30 years) and older control group members.
  2. Prevalence of female gender.
  3. Tendency to act out and avoid abandonment (dropping out in the final sessions).
  4. Slight correlation with deficient interpersonal relations and less resources or social support.
Interestingly, no patient discontinued therapy at the start of intervention (first three sessions). This suggests that the crisis situation might facilitate engagement. Obviously, other aspects also have an influence, such as motivation and expectations of therapy (Lambert & Lambert, 1984), in addition to the role played by the quality of preparation before ECP by other services that refer the patient to ECP (Figure 1).

What does need to be established, however, is whether the relational patterns, typical of borderline pathology, compromise motivation to seek services elsewhere or at some future time. Follow-up studies in this respect would be helpful to evaluate whether crisis interventions have a facilitating effect on the tendency to seek treatment. In the 2 years following the study, none of the patients who underwent therapy attempted suicide. However, some subsequently repeated the crisis intervention with similar forms of discontinuation.

A dropout does not always equate to a failure (Pekarik, 1992a, 1992b). Two cases in our sample (females with borderline personality) dropped out of treatment with the therapist (eighth and ninth session) but kept the appointment with the "tester," displaying a significant reduction in symptoms. The efficacy of crisis intervention in terms of reduction in symptoms (Marini et al., 2003; Pavan et al., 2003) does not rule out spontaneous remission and does not solve the problem of aftercare when indicated. It also does not solve the marketing capacity of an institution to attract patients in need, with more specific forms of treatment (Andreoli & Bonatti, 1992; Andreoli et al., 1986; Dauwalder & Ciompi, 1995).

Psychoanalytic–psychodynamic therapy, dialectical behavior therapy, and psychoeducational approaches have all proved helpful in working with borderline personality. These therapies are based on the premise of a strong therapeutic alliance. Inherent in such an alliance is the importance of a clearly structured treatment framework (Goin, 2001). In our case, the ECP served as the first institutional link for these patients.

Reducing hospitalization through improvements in outpatient services does reduce costs and does benefit individuals with borderline personality disorder (Comtois et al., 2003). This study found that those with borderline personality disorders drop out of brief outpatient crisis intervention at a significantly higher rate than do those without borderline personality disorders. At the same time, the ECP seemed to offer an acceptable solution to these acute patients (no one dropped out at the start of therapy).

Although a readily available resource may have therapeutic ends, its purpose is chiefly preventive. A few counseling sessions may not be enough to stem borderline patients' great need for support in the acute phase and to foster motivation to undertake other long-term therapies. However, long waiting lists, major economic costs, or undetermined treatment prospects may have a decisive role in diverting patients away from treatment. It will be necessary to assess whether and to what extent a response subjectively perceived as "frustrating" or which fails to meet the "real" request for help may profoundly or even definitively sever alliance, precluding what might otherwise have developed. The alternatives would be self-treatment with irregular stopgap solutions that spell considerable human, economic, and social costs (Arfken et al., 2004).

From this perspective, services may be forced to envisage an area for crisis listening to prevent situations degenerating into acts of parasuicide and the need for hospital admission. A positively shared experience may potentially open the door to a treatment relationship that transcends the therapeutic couple. Within an institutional setting, the relationship becomes stable, readily available, sufficiently "standardized," without becoming intrusive, and potentially represents a "functional" facility that may significantly help lower barriers to treatment.

Obviously, it will be important to study which other factors influence dropout, as motivation, the working alliance, the therapeutic alliance, aspects governing the relationship, and patient–therapist expectations. Further research is warranted, but is beyond the absolutely preliminary objectives of this study.


   Conclusion
TOP
 Materials and Methods
 Results
 Discussion
 Conclusion
References
 
Even in crisis situations, dropping out appears to be correlated with borderline personality disorder. The extent to which this depends on crisis remission or poses a barrier to treatment remains to be seen. The provision of outpatient crisis intervention using brief (10 sessions) interventions will help some but not all those referred for or seeking such treatment. Those with borderline personality disorders are likely to need additional inpatient or ongoing treatment. Because the disorder itself presents barriers to accessing or remaining in treatment, crisis intervention may act as a bridge to additional treatment for this group.


   References
TOP
 Materials and Methods
 Results
 Discussion
 Conclusion
 References
 

    American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author.

    American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text revision). Washington, DC: Author.

    Andreoli, A., & Bonatti, R. (1992). Intervento di crisi e trattamento combinato della depressione. Tribuna Medica Ticinese, 57, 98–105.[find it @ Stanford]

    Andreoli, A., Lalive, J., & Garrone, G. (1986). Crise ed intervention de crise en psichiatrie [Crisis and crisis intervention in psychiatry]. Lyon, France: Simep.

    Arfken, C. L., Zeman, L. L., Yeager, L., White, A., Mischel, E., & Amirsadri, A. (2004). Case-control study of frequent visitors to an urban psychiatric emergency service. Psychiatric Services, 55, 295–301.[Abstract/Free Full Text]

    Barkham, M., Shapiro, D. A., Hardy, G. E., & Rees, A. (1999). Psychotherapy in two-plus-one session: Outcome of a randomized controlled trial of cognitive-behavioral and psychodynamic-interpersonal therapy for subsyndromal depression. Journal of Consulting and Clinical Psychology, 67, 201–211.[CrossRef][ISI][Medline][find it @ Stanford]

    Beck, A. T., Ward, C. H., Mendelson, M., Moch, J., & Erbauch, J. (1961). An inventory for measuring depression. Archives of General Psychiatry, 4, 561–571.

    Beutler, L. E., & Clarkin, J. F. (1990). Systematic treatment selection toward targeted therapeutic interventions. New York: Brunner/Mazel.

    Bosc, M. (1997). Social Adaptation Self-Evaluation Scale. European Neuropsychopharmacolgy, 7, 57–70.

    Chiesa, M., Drahorad, C., & Longo, S. (2000). Early termination of treatment in personality disorder treated in a psychotherapy hospital. British Journal of Psychiatry, 177, 107–111.[Abstract/Free Full Text]

    Comtois, K. A., Russo, J., Snowden, M., Srebnik, D., Ries, R., & Roy-Byrne, P. (2003). Factors associated with high use of public mental health services by person with borderline personality disorder. Psychiatric Services, 54, 1149–1154.[Abstract/Free Full Text]

    Dauwalder, J. P., & Ciompi, L. (1995). Cost effectiveness over 10 years: A study of community-based social psychiatry in the 1980s. Social Psychiatry and Psychiatric Epidemiology, 30, 171–184.[CrossRef][ISI][Medline][find it @ Stanford]

    Endicott, J., Spitzer, R., Fleiss, J., & Cohen, J. (1976). The Global Assessment Scale. Archives of General Psychiatry, 33, 766–771.[Abstract/Free Full Text]

    Erikson, E. (1959). Identity and the life cycle. Psychological Issues, 1, 1–171.

    Erikson, E. (1968). Identity: Youth and crisis. New York: Norton.

    Garfield, S. L. (1994). Research on client variables in psychotherapy. In A. E. Bergin & S. L. Garfield (Eds.), Handbook of psychotherapy and behaviour change (4th ed., pp. 190–228). New York: John Wiley & Sons.

    Goin, M. K. (2001). Borderline personality disorder: The importance of establishing a treatment framework. Psychiatric Services, 52, 167–168.[Free Full Text]

    Greenberg, L. S., Rice, L., & Elliott, R. (1993). Facilitating emotional change: The moment-by-moment process. New York: Guilford.

    Greenspan, M., & Kulish, N. M. (1985). Factors in premature termination in long term psychotherapy. Psychotherapy, 22, 75–82.[find it @ Stanford]

    Hamilton, M. A. (1960). A rating scale for depression. Journal of Neurology, Neurosurgery, and Psychiatry, 23, 56–62.

    Kaplan, H. I., Sadock, B. J., & Grebb, J. A. (1997a). Brief psychotherapy and crisis intervention. In H. I. Kaplan, B. J. Sadock., & J. A. Grebb (Eds.), Kaplan and Sadock's synopsis of psychiatry; behavioral sciences, clinical psychiatry (pp. 833–837). Baltimore: Williams & Wilkins.

    Kaplan, H. I., Sadock, B. J., & Grebb, J. A. (1997b). Epidemiology biostatistics and social psychiatry. In H. I. Kaplan, B. J. Sadock, & J. A. Grebb (Eds.), Kaplan and Sadock's synopsis of psychiatry; behavioral sciences, clinical psychiatry (pp. 192–200). Baltimore: Williams & Wilkins.

    Koss, M. P., & Shiang, J. (1994). Research on brief psychotherapy. In A. E. Bergin & S. L. Garfield (Eds.), Handbook of psychotherapy and behaviour change (4th ed., pp. 664–700). New York: Wiley.

    Lambert, R. G., & Lambert, M. J. (1984). The effects of role preparation for psychotherapy on immigrant clients seeking mental health services in Hawaii. Journal of Community Psychology, 12, 263–275.[ISI][Medline][find it @ Stanford]

    Linehan, M. M., Cochran, B. N., & Kehrer, C. A. (2001). Dialectical behaviour therapy for borderline personality disorder. In D. H. Barlow (Ed.), Clinical handbook of psychological disorders (3rd ed., pp. 470–522). New York: Guilford.

    Maffei, C., Fossati, A., Agostoni, I., Barraco, A., Bagnato, M., Deborah, D., et al. (1997). Interrater reliability and internal consistency of the structured clinical interview for DSM IV Axis II personality disorders (SCID II), version 2.0. Journal of Personality Disorders, 11, 279–284.[ISI][Medline][find it @ Stanford]

    Marini, M., Semenzin, M., & Pavan, L. (2003). Alcuni dati preliminari sulla valutazione dell'intervento di crisi [Some preliminary data on the evaluation of crisis intervention]. In L. Pavan (Ed.), Le psicoterapie brevi [The brief psychotherapies]. Padova, Italy: Cleup.

    Pavan, L. (2003). La Psicoterapia della Crisi Emozionale [Psychotherapy of emotional crisis]. Milano, Italy: Franco Angeli.

    Pavan, L., & Banon, D. (1996). Trauma vulnerabilità, crisi emozionale (l'intervento di crisi come psicoterapia breve di sostegno) [Trauma, vulnerability, emotional crisis (crisis intervention as brief supportive psychotherapy)]. Torino, Italy: Bollati Boringhieri.

    Pavan, L., & Banon, D. (1999). Intervento di crisi come psicoterapia breve di sostegno [Crisis intervention as brief supportive psychotherapy]. In G. B. Cassano, P. Pancheri, L. Pavan, A. Pazzagli, L. Ravizza, R. Rossi, E. Smeraldi, & V. Volterra (Eds.), Trattato Italiano di Psichiatria [Italian Treatise on Psychitary] (pp. 3629–3635). Milano, Italy: Masson.

    Pavan, L., Fusco, E., Gambaro, F., Granà, S., Marini, M., Padoani, W., et al. (2003). Open trial on crisis psychotherapy in Padova (Italy). Brief Treatment and Crisis Intervention, 3, 32–38.[find it @ Stanford]

    Pekarik, G. (1992a). Relationship of client's reasons for dropping out of treatment to outcome and satisfaction. Journal of Clinical Psychology, 48, 91–98.[ISI][Medline][find it @ Stanford]

    Pekarik, G. (1992b). Postreatment adjustment of clients who drop out early vs. late in treatment. Journal of Clinical Psychology, 48, 379–387.[ISI][Medline][find it @ Stanford]

    Prochaska, J. O., Norcross, J. C., & DiClemente, C. C. (1994). Changing for good. New York: Avon.

    Reisch, T., Schlatter, P., & Tschacher, W. (1999). Efficacy of crisis intervention. Crisis, 20, 78–85.[CrossRef][Medline][find it @ Stanford]

    Roberts, A. R., Everly, G., Jr., & Camasso, M. J. (2005, February). Statistical analysis of 36 crisis intervention studies. Plenary address at the 5th World Congress of the International Critical Incident Stress Foundation, Marriott Harbor Hotel, Baltimore.

    Roth, A., & Fonagy, P. (1996). What works for whom? A critical review of psychotherapy research. New York: Guilford.

    Sledge, W. H., Moras, K., Hartley, D., & Levine, M. (1990). Effect of time-limited psychotherapy on patient dropout rates. American Journal of Psychiatry, 147, 1341–1347.[Abstract/Free Full Text]

    Smith, T. E., Koenigsberg, H. W., Yeomans, F. E., Clarkin, J. F., & Selzer, M. A. (1995). Predictors of dropout in psychodynamic psychotherapy. Journal of Psychotherapy Practice and Research, 4, 205–213.[Abstract/Free Full Text]

    Spielberger, C. D. (1983). State-Trait Anxiety Inventory. A comprehensive bibliography. Palo Alto, CA: Consulting Psychologists Press.

    Spielberger, C. D. (1988). State-Trait Anger Expression Inventory (S.T.A.X.I.). Professional manual. New York: Psychological Assessment Resources.

    Steenbarger, B. N. (1994). Duration and outcome in psychotherapy: An integrative review. Professional Psychology—Research and Practice, 25, 111–119.

    Steenbarger, B. N. (2002). Brief therapy. In M. Hersen & W. Sledge (Eds.), Encyclopedia of psychotherapy (pp. 349–358). New York: Elsevier.

    Steenbarger, B. N., & Budman, S. H. (1998). Principles of brief and time-effective therapies. In G. P. Koocher, J. C. Norcross, & S. S. Hill (Eds.), Psychologists' desk reference (pp. 283–287). New York: Oxford University Press.

    Thormählen, B., Weinryb, R. M., Norén, K., Vinnars, B., Bågedahl-Strindlund, M., & Barber, J. P. (2003). Patient factors predicting dropout from supportive-expressive psychotherapy for patients with personality disorders. Psychotherapy Research, 13, 493–509.[CrossRef][ISI][find it @ Stanford]

    van der Sande, R., van Rooijen, L., Buskens, E., Allart, E., Hawton, K., van der Graaf, Y., et al. (1997). Intensive in-patient and community intervention versus routine care after attempt suicide—A randomized controlled intervention study. British Journal of Psychiatry, 171, 35–41.[Abstract/Free Full Text]

    Wolberg, L. R. (1980). Handbook of short-term psychotherapy. New York: Thieme-Stratton.

    Zimmerman, M. (1994). Interview guide for evaluating DSM-IV psychiatric disorders and mental status examination. East Greenwich: Psych Product Press.


Add to CiteULike CiteULike   Add to Connotea Connotea   Add to Del.icio.us Del.icio.us    What's this?



This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow All Versions of this Article:
5/4/356    most recent
mhi027v1
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Alert me to new issues of the journal
Right arrow Add to My Personal Archive
Right arrow Download to citation manager
Right arrowRequest Permissions
Right arrow Disclaimer
Google Scholar
Right arrow Articles by Marini, M.
Right arrow Articles by Pavan, L.
Right arrow Search for Related Content
PubMed
Right arrow Articles by Marini, M.
Right arrow Articles by Pavan, L.
Social Bookmarking
Add to CiteULike   Add to Connotea   Add to Del.icio.us  
What's this?