C. Donald Williams M.D.1 “Group Therapy in the Treatment of Injured Workers” 1997 APA Annual Meeting Current Uses of Group Therapy C. Donald Williams, M.D.

C. Donald Williams M.D.2 Introduction and Background n n Patients with workplace injuries have presented difficult challenges to clinicians n n Confusion regarding approach to these patients, for historical reasons and because of their clinical complexity n n A quick fix action oriented approach works with only some of these patients n n Developmental and psychodynamic factors have typically been ignored

C. Donald Williams M.D.3 Combat Military vs. Injured Worker ~ Differences n Anticipated trauma n <30 years of age n Less established re: family and career n Immediate medical and psychiatric care n Goal--to function for months to a year in combat n Unexpected injury n >40 years n Established, with family and career n Delayed psychiatric care n Goal--to achieve durable decades long recovery as worker

C. Donald Williams M.D.4 Combat Military vs. Injured Workers ~ Similarities n Both offer strong advocacy for the claimant after discharge from service or job n Primary and secondary gain for each –Developmental histories significant in determining prognosis n Adequacy of initial intervention critical –Skill of clinicians, diagnositic accuracy –Treatment delay

C. Donald Williams M.D.5 Contributors to Major Depression n Loss of role status within family and community with loss of self-esteem n Loss of daily routine, with loss of its defensive and sublimatory aspects n Chronic pain –“I can’t do what I used to” n Loss of hope of recovery

C. Donald Williams M.D.6 Group Therapy Selection Criteria n Group therapy alone with pharmacotherapy –Depressed patients –Pain disorder patients n Combined group and individual therapy –Borderline personality disorder and axis 1 disorder –Panic disorder with agoraphobia –Complex medication management

C. Donald Williams M.D.7 Group Psychotherapy ~ General Advantages for Injured Workers n Group Psychotherapy offers a more cost effective, intense, and accelerated treatment for many patients for these reasons: –Newer patients learn from patients who have already progressed in treatment in open ended groups –Concrete learning from other group members’ experiences makes therapy accessible for patients that find abstract reasoning difficult –Decreases sense of isolation, and being “different and damaged”

C. Donald Williams M.D.8 Group Therapy for Personality Disordered Patients n Peer pressure and confrontation helpful n Opportunity to introject and internalize new realities in predictable setting n Opportunity to combine insight with internalization to transform old character traits into new ones n The group patient “has” his/her problems in the group, therefore they are harder to deny

C. Donald Williams M.D.9 Diagnoses and Comorbidity n n Comorbidity was the rule – –All but 3 patients carried two or more diagnoses n n 90% were diagnosed with depression n n 40% were diagnosed with anxiety disorders – –Panic disorder, generalized anxiety disorder, and PTSD present in roughly equal proportions n n 26% were diagnosed with pain disorders n n 80% were diagnosed with an axis 2 disorder

C. Donald Williams M.D.10 % Incidence of Psychiatric Disorders in Series of 60 Consecutive Injured Workers

C. Donald Williams M.D.11 Combined Therapy n Combined individual and group psychotherapy is the treatment of choice for many patients with Panic Disorder and Depression, and/or B.P.D –Complex symptom presentation often requires individual sessions to unravel –For almost all patients with B.P.D. as one of their diagnoses because of dyadic issues »Individual attention and confrontation needed, but group component can limit regression (have two patients with B.P.D., not just one, in group)

C. Donald Williams M.D.12 Discussion n Evaluation requires –Premorbid status be taken into account –Sophisticated bio-psycho-social approach n Treatment requires –That comorbid conditions be recognized –Both symbolic and concrete learning –Individualized group and/or individual mix –Session frequency determined by condition

C. Donald Williams M.D.13 Summary n Evaluation and treatment of injured workers requires sophisticated diagnosis and treatment n Military treatment models employed with this population work poorly n Multiple diagnoses are the rule n Group psychotherapy or combined therapy offers advantages over traditional models