The therapeutic relationship in the brief treatment of depression: Contributions to clinical improvement and enhanced adaptive capacities.

Using data from the National Institute of Mental Health Treatment for Depression Collaborative Research Program, the authors examined the impact on treatment outcome of the patient's perception of the quality of the therapeutic relationship and contribution to the therapeutic alliance. Shared variance with early clinical improvement was removed from these relationship measures. Multilevel modeling demonstrated that a perceived positive therapeutic relationship early in treatment predicted more rapid decline in maladjustment subsequent to the relationship assessment. This effect occurred equally across all 4 treatment conditions. A positive early therapeutic relationship also predicted better adjustment throughout the 18-month follow-up as well as development of greater enhanced adaptive capacities (EAC). Controlling a wide range of patient characteristics did not eliminate the effects of the therapeutic relationship on rate of improvement during treatment and on EAC. Thus, independent of type of treatment and early clinical improvement, the therapeutic relationship contributes directly to positive therapeutic outcome. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The relationship of perfectionism, depression, and therapeutic alliance during treatment for depression: Latent difference score analysis.

The authors examined the longitudinal relationship of patient-rated perfectionism, clinician-rated depression, and observer-rated therapeutic alliance using the latent difference score (LDS) analytic framework. Outpatients involved in the Treatment for Depression Collaborative Research Program completed measures of perfectionism and depression at 5 occasions throughout treatment, with therapeutic alliance measured early in therapy. First, LDS analyses of perfectionism and depression established longitudinal change models. Further LDS analyses revealed significant longitudinal interrelationships, in which perfectionism predicted the subsequent rate of depression change, consistent with a personality vulnerability model of depression. In the final LDS model, the strength of the therapeutic alliance significantly predicted longitudinal perfectionism change, and perfectionism significantly predicted the rate of depression change throughout therapy. These results clarify the patterns of growth and change for these indicators throughout depression treatment, demonstrating an alternative method for evaluating longitudinal dynamics in therapy. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The therapeutic alliance in schema-focused therapy and transference-focused psychotherapy for borderline personality disorder.

This study investigated the quality and development of the therapeutic alliance as a mediator of change in schema-focused therapy (SFT) and transference-focused psychotherapy (TFP) for borderline personality disorder. Seventy-eight patients were randomly allocated to 3 years of biweekly SFT or TFP. Scores of both therapists and patients for the therapeutic alliance were higher in SFT than in TFP. Negative ratings of therapists and patients at early treatment were predictive of dropout, whereas increasingly positive ratings of patients in the 1st half of treatment predicted subsequent clinical improvement. Dissimilarity between therapist and patients in pathological personality characteristics had a direct effect on growth of the therapeutic alliance but showed no relationship with clinical improvement. The authors conclude that the therapeutic alliance and specific techniques interact with and influence one another and may serve to facilitate change processes underlying clinical improvement in patients with borderline personality disorder. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Evaluating an alliance-focused treatment for personality disorders.

This paper presents a study with the aim of evaluating the relative efficacy of an alliance-focused treatment, brief relational therapy, in comparison to a short-term dynamic therapy and a cognitive-behavioral therapy on a sample of highly comorbid personality disordered patients. Results indicated that the three treatments were equally effective on standard statistical analyses of change, including those conducted on repeated measures and residual gain scores. Some significant differences were indicated regarding clinically significant change and reliable change, favoring the brief relational and cognitive-behavioral models. There was also a significant difference regarding dropout rates, favoring brief relational therapy. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Patients' expectancies, the alliance in pharmacotherapy, and treatment outcomes in bipolar disorder.

Bipolar disorder is characterized by a chronic and fluctuating course of illness. Although nonadherence to pharmacotherapy is a frequent problem in the disorder, few studies have systematically explored psychosocial factors related to treatment discontinuation. Previous research with depressed patients receiving psychotherapy has suggested that expectancies for improvement are related to treatment outcomes and that the therapeutic alliance may partially mediate this relationship. The current study found evidence for a similar relationship between patients' initial expectancies for improvement, patient and doctor-rated alliance, and long-term outcomes in bipolar patients treated with pharmacotherapy for up to 28 months following an acute episode. The results highlight the need for the assessment of expectancies and alliance in bipolar treatment and suggest possible targets for psychosocial interventions. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Assessing and interpreting personality change and continuity in patients treated for major depression.

Structural, mean- and individual-level, differential, and ipsative personality continuity were examined in 599 patients treated for major depression assigned to 1 of 6 forms of a 6-month pharmaco-psychotherapy program. Covariation among traits from the Five Factor model remained invariant across treatment, and patients described themselves as slightly more extraverted, open to experience, agreeable and conscientious, and substantially more emotional stable after treatment. Trait changes were only to a small extent explained by changes in depression severity. There was evidence for differential, individual-level, and ipsative stability, with stable personality profiles in terms of shape and to a lesser extent in terms of scatter and elevation. Traits remain relatively stable, except for emotional stability, despite the depressive state and the psychopharmacological interventions. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Shorter term treatment of borderline personality disorder: A developmental, self-, and object relations approach.

After a brief summary of J. F Masterson's developmental, self-, and object relations approach to long-term, intensive psychotherapy of the borderline personality disorder, an adaptation of this approach to shorter term treatment is proposed. The time constraints of abbreviated treatment require the following limited goals for the patient: (a) increased control of maladaptive defenses, (b) learning about the fundamental dynamics related to the focal symptom or problematic behavior, and (c) improved adaptation. Requisite modifications of technique include (a) limited frequency of sessions, (b) focalized treatment, (c) an emphasis on adaptation, and (d) a reliance on confrontation as the primary therapeutic intervention. A brief case study is presented for illustrative purposes. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Pharmacologic treatment of personality disorder.

This article reviews the recent literature on pharmacologic treatment of personality disorders, discusses the existing models that pharmacotherapy of these disorders, and reviews specific classes of medication that appear to play a beneficial role. Antipsychotics, mood stabilizers. antidepressants, benzodiazepines, and opioid antagonists are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Negative mood, depressive symptoms, and major depression after smoking cessation treatment in smokers with a history of major depressive disorder.

Negative mood, depressive symptoms, and major depressive episodes (MDEs) were examined in 179 smokers with a history of major depression in a trial comparing standard smoking cessation treatment to treatment incorporating cognitive-behavioral therapy for depression (CBT-D). Early lapses were associated with relatively large increases in negative mood on quit date. Mood improved in the 2 weeks after quit date among those returning to regular smoking but not among those smoking moderately. Continuous abstinence was associated with short- and long-term reductions in depressive symptoms. MDE incidence during follow-up was 15.3% and was not associated with abstinence. Unexpected was that CBT-D was associated with greater negative mood and depressive symptoms and increased MDE risk. Results suggest complex bidirectional associations between affect and smoking outcomes. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Development of personality disorder symptoms and the risk for partner violence.

In a community sample (N = 543) followed over 20 years, the authors studied associations among childhood family violence exposure, personality disorder (PD) symptoms, and adult partner violence. PD symptoms (DSM-III-R Clusters A, B, and C) in early adulthood partially mediated the effect of earlier childhood risks on the odds of perpetrating partner violence. The authors tested whether stability of PD symptoms from adolescence to the early 20s differs for individuals who later perpetrated partner violence. Cluster A ("Odd/Eccentric") symptoms declined less with age among partner violent versus nonviolent men and women. Cluster B ("Dramatic/Erratic") symptoms were more stable through late adolescence in partner violent men, compared with nonviolent men and violent women. Cluster C ("Anxious") symptoms were most stable among partner violent men. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The use and nature of present-focused interventions in cognitive and behavioral therapies for depression.

To improve cognitive and behavioral therapies (CBT) for depression, several approaches recommend an increased focus on the occurrence of problems as they occur in the therapeutic relationship or in relation to the live therapy process, referred to as present-focused. A lingering question has been the degree to which CBT therapists already engage in present-focused work. This study utilized sessions from recent trials of CBT for depression and, in Phase I, raters identified present-focused interventions on a turn-by-turn basis. Phase II raters used a qualitative analysis to determine categories of present-focused interventions. Results indicated that therapists rarely focused on the therapeutic relationship; when they did, it was often transient and lacking in the elaborations suggested by newer approaches. Therapists more often performed therapy process and emotion focused interventions, but these also tended to lack elaboration. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Role orientation, the action-thought dimension, and outcome in psychiatric disorder.

The case histories of 251 patients were examined in order to investigate the relationship between symptoms manifested and a outcome measures, length of hospitalization and rehospitalization. As predicted, patients whose total symptomatology was characterized by a turning against the self had a shorter period of hospitalization than patients whose symptoms predominately fell into the avoidance of others category. No simple relationship was found between the Thought-Action emphasis in symptomatology and outcome. Patients of high social competence having a thought orientation were found to have the shortest period of hospitalization, low competence thought patients the longest period of hospitalization, and high and low competence action patients fell between these 2 groups. Thought patients had a greater likelihood of being rehospitalized than action patients. However, the likelihood of being rehospitalized was found to be influenced by the individual's competence level. (25 ref.) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Assessment and treatment of social anxiety disorder.

Despite being associated with a high degree of distress, disability, and functional limitation, social anxiety disorder (SAD) often goes undetected and untreated. The disorder is receiving increased attention amid the development of various models of psychosocial treatments and through direct-to-consumer advertising campaigns launched by the pharmaceutical industry. While pharmacotherapy and psychosocial interventions appear to be efficacious as monotherapy, the best strategy over the long-term may be a combination approach. Rating instruments specific to SAD are available and are useful in allowing clinicians and patients to more objectively determine the outcome of treatment. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Client attachment to therapist: Relation to client personality and symptomatology, and their contributions to the therapeutic alliance.

This study examined the relation of client attachment to the therapist to diverse facets of the therapeutic alliance, client personality, and psychopathological symptoms, as well as the relative importance of therapeutic attachments, personality, and symptomatology in predicting the alliance. Eighty clients in ongoing therapy completed measures of client attachment to therapist (CATS), personality (6FPQ), psychopathological symptoms (BSI), and therapeutic alliance (WAI–Short, CALPAS, HAQ). Secure and Avoidant–Fearful attachment to the therapist correlated positively and negatively, respectively, with total and subscale alliance scores. Preoccupied-Merger therapeutic attachment was unrelated to the alliance. Exploratory analyses suggested however that the relationship between Preoccupied–Merger attachment and the alliance was moderated by the extent to which clients were distressed. Clients' therapeutic attachments were unrelated to basic personality dimensions. Preoccupied–Merger attachment to the therapist correlated significantly with several symptom dimensions. Clients' therapeutic attachments emerged as superior and more consistent predictors, relative to client personality and symptomatology, of the therapeutic alliance. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The role of readiness to change in response to treatment of adolescent depression.

The effect of readiness to change on treatment outcome was examined among 332 adolescents (46% male, 74% Caucasian), ages 12 through 17 years (M = 14.6, SD = 1.5), with major depressive disorder who were participating in the Treatment for Adolescents With Depression Study (TADS). TADS is a randomized clinical trial comparing the effectiveness of fluoxetine (an antidepressant medication), cognitive–behavioral therapy, their combination, and a pill placebo. An abbreviated Stages of Change Questionnaire was used to obtain 4 readiness to change scores: precontemplation, contemplation, action, and maintenance. The association between each readiness score and depression severity across 12 weeks of acute treatment for depression, as measured by the Children’s Depression Rating Scale—Revised, was examined. Although treatment response was not moderated by any of the readiness scores, baseline action scores predicted outcome: Higher action scores were associated with better outcome regardless of treatment modality. Furthermore, treatment effects were mediated by change in action scores during the first 6 weeks of treatment, with increases in action scores related to greater improvement in depression. Assessing readiness to change may have implications for tailoring treatments for depressed adolescents. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Client interpersonal and cognitive styles as predictors of response to time-limited cognitive therapy for depression.

This study examined the relationship between cognitive and interpersonal styles and outcome among 24 clients who received time-limited cognitive therapy for depression. The authors hypothesized that this relationship would be mediated by therapeutic alliance. They found that clients' interpersonal style, particularly an underinvolved style, was predictive of treatment outcome. As predicted, the impact of this style on outcome was mediated through the therapeutic alliance. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Gender differences in autonomic indicators of antisocial personality disorder features.

We investigated the autonomic indicators of antisocial personality disorder (APD) features in a mixed gender student sample. One hundred college students (50 men, 50 women) were administered an interview of APD and self-report measures of aggression and psychopathy. Participants completed a passive coping task and viewed emotionally valenced slideshows while their electrodermal activity (EDA), pre-ejection period (PEP), and respiratory sinus arrhythmia (RSA) were measured. Associations between APD features and autonomic reactivity were examined, controlling for aggression and psychopathy. APD features were associated with EDA hyporeactivity in men, but not women, during passive coping. While viewing threatening slides, APD features were associated with RSA hyperreactivity in women and with PEP hyperreactivity in men. APD features were associated with RSA hyperreactivity in women, but not men, while viewing slides of others in distress. These findings suggest that APD features are characterized by parasympathetic nervous system dysfunction in women but sympathetic nervous system dysfunction in men. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The heterogeneous structure of schizotypal personality disorder: Item-level factors of the schizotypal personality questionnaire and their associations with obsessive-compulsive disorder symptoms, dissociative tendencies, and normal personality.

A. Raine et al.'s (1994) 3-factor scheme is currently the most widely accepted model of schizotypal personality disorder (SPD). Factor analytic studies of the Schizotypal Personality Questionnaire (SPQ; A. Raine, 1991) subscales, which represent the 9 Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria for SPD, have provided the model's primary support. The use of only 9 modeled variables, however, limits the number of factors that can be extracted. To explicate this structure more fully, the authors conducted item-level factor analyses of the SPQ in a large student sample that completed the instrument twice within a 2-week interval. The authors' analyses failed to support either the 3-factor model of SPD or the 9 existing DSM-based subscales of the SPQ. Instead, 5 replicable dimensions emerged that capture recurrent symptom pairings found in the broader SPD literature: Social Anhedonia, Unusual Beliefs and Experiences, Social Anxiety, Mistrust, and Eccentricity/Oddity. These factors are only weakly correlated with each other and show differential correlational patterns with the Big Five personality traits, dissociative tendencies, and symptoms of obsessive-compulsive disorder. Moreover, they are congruent with dimensional models of personality psychopathology. Implications for SPD in DSM-V are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Therapist interpretation, patient-therapist interpersonal process, and outcome in psychodynamic psychotherapy for avoidant personality disorder.

[Correction Notice: An erratum for this article was reported in Vol 43(3) of Psychotherapy: Theory, Research, Practice, Training (see record 2006-12148-017). The correct legend for Figure 1 on page 500 should read as follows: Figure 1. The SASB circumplex model, cluster version, interpersonal surfaces. Adapted from Benjamin (1993), Interpersonal diagnosis and treatment of personality disorders. New York: Guilford Press, copyright Guilford Press, and from: Benjamin (1987), Use of the SASB dimensional model to develop treatment plans for personality disorders, I: Narcissism. Journal of Personality Disorders, 1, 43-70, copyright Guilford Press.] The authors examined the link between interpretive techniques, the therapeutic relationship, and outcome in psychodynamic psychotherapy. Two independent teams of judges each coded one early session from patients diagnosed with avoidant personality disorder. Results revealed (a) an inverse association between concentration of interpretation and favorable patient outcome; (b) that small amounts of disaffiliative patient-therapist transactions before, during, and after interpretations were reliably or meaningfully associated with negative patient change; and (c) concentration of interpretation was positively associated with disaffiliative therapy process before and during interpretation and negatively associated with affiliative patient responses to interpretation. The results suggest that therapists who persisted with interpretations had more hostile interactions with patients and had patients who reacted with less warmth than therapists who used interpretations more judiciously. (PsycINFO Database Record (c) 2010 APA, all rights reserved)