Relation of therapeutic alliance and perfectionism to outcome in brief outpatient treatment of depression.

Prior analyses of the National Institute of Mental Health Treatment of Depression Collaborative Research Program demonstrated that perfectionism was negatively related to outcome, whereas both the patient's perception of the quality of the therapeutic relationship and the patient contribution to the therapeutic alliance were positively related to outcome across treatment conditions (S. J. Blatt et al, see record 1996-02770-018; J. L. Krupnick et al, see record 1996-05271-014). New analyses examining the relations among perfectionism, perceived relationship quality, and the therapeutic alliance demonstrated that (a) the patient contribution to the alliance and the perceived quality of the therapeutic relationship were independent predictors of outcome, (b) perfectionistic patients showed smaller increases in the Patient Alliance factor over the course of treatment, and (c) the negative relation between perfectionism and outcome was explained (mediated) by perfectionistic patients' failure to develop stronger therapeutic alliances. (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)     

Alliance predicts patients' outcome beyond in-treatment change in symptoms.

The authors examined the relations among therapeutic alliance, outcome, and early-in-treatment symptomatic improvement in a group of 86 patients with generalized anxiety disorders, chronic depression, or avoidant or obsessive–compulsive personality disorder who received supportive–expressive dynamic psychotherapy. Although alliance at Sessions 5 and 10, but not at Session 2, was associated with prior change in depression, alliance at all sessions significantly predicted subsequent change in depression when prior change in depression was partialed out. The results are discussed in terms of the causal role of the alliance in therapeutic outcome. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Interpersonal factors in brief treatment of depression: Further analyses of the National Institute of Mental Health Treatment of Depression Collaborative Research Program.

Previous analyses of data from the National Institute of Mental Health Treatment of Depression Collaborative Research Program indicate minimal differences in therapeutic outcome among 3 brief treatments for depression, but patients' pretreatment level of perfectionism had a significant negative relationship with residualized measures of clinical improvement. The present analyses indicate that the quality of the therapeutic relationship reported by patients early in treatment contributed significantly to the prediction of therapeutic change. The quality of the therapeutic relationship was only marginally predictive of therapeutic gain at low and high levels of perfectionism, but significantly predicted therapeutic gain at moderate levels of perfectionism. These findings suggest that the extensive efforts to compare different manual-directed treatments need to be balanced by commensurate attention to interpersonal dimensions of the therapeutic process. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Patients' versus informants' reports of personality disorders in predicting 7 1/2-year outcome in outpatients with depressive disorders.

Concordance between patients' and informants' reports of personality disorders (PDs) is low, raising the questions of which source provides more valid data and whether both contribute unique information. This study compared patients' and informants' reports of PDs in predicting outcome in a 7 1/2-year follow-up of 85 depressed outpatients. Patients and informants were independently evaluated using structured interviews; outcome was assessed using structured interviews with patients. Both patients' and informants' reports of PD diagnoses and dimensional scores independently predicted depression symptoms and global functioning at follow-up. However, only informants' reports made a unique contribution to predicting social adjustment. This finding indicates that both patients and informants provide unique information on Axis II psychopathology and argues for the use of both sources in the assessment of PDs. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Canadian perspectives on research in depression.

Depression is a serious mental health problem that will affect a large segment of the Canadian population either directly as a sufferer, or indirectly as a family member, friend or employer of a person who experiences depression. This special issue of the Canadian Journal of Behavioural Science highlights the significant contribution that Canadian psychologists are making to advance our understanding of the psychological basis of depression. Contributors deal with a number of issues such as the status of schema-based research on depression, comorbidity of depressive symptoms in adolescents, perfectionism and the persistence of depressive symptoms, gender differences in self-regulation and their relation to dysphoric mood, and personality influences on the "depressive realism" phenomena. In this introductory article, a brief summary of the main findings reported by each contributor to the special issue are discussed, and some conclusions are drawn about the status of psychological research on depression in Canada. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The contribution of group cohesion and group alliance to the outcome of group psychotherapy

The contribution to outcome of two group-process factors, group cohesion and group therapeutic alliance, was tested in the context of a randomized, controlled treatment trial for borderline personality disorder. Group members from four time-limited groups of an experimental model of group psychotherapy completed measures of group cohesion and group alliance at prespecified intervals across the 30-session therapy. Outcome was measured in terms of psychiatric symptoms, social adaptation, and indicators of behavioral dysfunction. The results showed that cohesion and alliance were correlated significantly and separately contributed to outcome on most of the dependent measures. Stepwise regression analyses showed, however, that when compared with cohesion, alliance accounted for more outcome variance on the dependent measures. The clinical implications of the findings and the limitations of the study are discussed.     

Preliminary relationships between adherence and outcome in dynamic deconstructive psychotherapy.

This study examined adherence to specific psychotherapeutic techniques as a predictor of outcome in dynamic deconstructive psychotherapy (DDP), a new psychodynamic therapy for treatment-resistant clients with borderline personality disorder (BPD). Ten clients dually diagnosed with BPD and alcohol use disorders underwent 12 months of DDP. Outcome indexes included measures of borderline symptoms, depression, dissociation, social support, alcohol misuse, parasuicide, and institutional care. Independent raters coded videorecorded sessions on adherence to DDP techniques, using a scale developed for this study, as well as therapeutic alliance and standard cognitive–behavioral and psychodynamic techniques. The adherence instrument demonstrated excellent interrater and test–retest reliability. Adherence to DDP techniques was positively related to improvement in BPD symptoms (ρ = .64) and most secondary outcomes. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Personality, negative social interactions, and depressive symptoms.

Examined the associations among the frequency of negative social interactions, personality traits, and depressive symptoms in university students. 176 Ss completed measures of negative social interactions, sociotropy, autonomy, perfectionism, and depressive symptoms. It was found in the total sample that higher depression symptoms scores were correlated significantly with the frequency of negative social interactions, sociotropy, autonomy, and socially prescribed perfectionism. Additional results indicate that the frequency of negative social interactions accounted for unique variance in depressive symptoms over and above the variance predicted by personality traits, but it did not interact with these personality traits to predict unique variance in depressive symptoms. It was also found that the reported frequency of negative social interactions was correlated positively with socially prescribed perfectionism, sociotropy, and autonomy, especially among women. The current findings are discussed in terms of their implications for specific vulnerability and stress generation models of personality, life events, and depressive symptoms. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Treatment expectancies, patient alliance and outcome: Further analyses from the National Institute of Mental Health Treatment of Depression Collaborative Research Program.

Prior analyses from the National Institute of Mental Health Treatment of Depression Collaborative Research program indicated that patients' expectancies of treatment effectiveness (S. M. Sotsky et al., 1991) and the quality of the therapeutic alliance (J. L. Krupnick et al., 1996) predicted clinical improvement. These data were reanalyzed to examine the hypothesis that the link between treatment expectancies and outcome would be mediated by patients' contribution to the alliance. Among 151 patients who completed treatment, this hypothesis was suported, suggesting that patients who expect treatment to be effective tend to engage more constructively in session, which help bring about symptom reduction. Therapists' expectancies for patient improvement also predicted outcome, although this association was not mediated by the alliance. None of the expectancy scales interacted with alliance ratings in the prediction of clinical improvement. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Change in coordination across phases of psychotherapy and outcome: Two mechanisms for the role played by patients' contribution to the alliance.

Investigated the mechanisms underlying associations between patients' contribution to the alliance and outcome by examining relations between change in the alliance over the course of treatment and improvement in Short-Term Dynamic Psychotherapy (STDP) and Brief Adaptive Psychotherapy (BAP). Findings for STDP were consistent with 1 model about the role played by the alliance, according to which change in the alliance over the course of therapy is the vehicle for overall improvement. Results for BAP were consistent with the other main position proposed in the literature, which argues that a positive alliance provides the foundation for successful treatment. Discussion includes suggesting that it might prove useful in future research to group therapy approaches in terms of these 2 models and that this idea may explain 2 apparently contradictory sets of findings from previous studies on relations between change in the alliance and outcome. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The role of the therapeutic alliance in psychotherapy and pharmacotherapy outcome: Findings in the National Institute of Mental Health Treatment of Depression Collaborative Research Program.

The relationship between therapeutic alliance and treatment outcome was examined for depressed outpatients who received interpersonal psychotherapy, cognitive-behavior therapy, imipramine with clinical management, or placebo with clinical management. Clinical raters scored videotapes of early, middle, and late therapy sessions for 225 cases (619 sessions). Outcome was assessed from patients' and clinical evaluators' perspectives and from depressive symptomatology. Therapeutic alliance was found to have a significant effect on clinical outcome for both psychotherapies and for active and placebo pharmacotherapy. Ratings of patient contribution to the alliance were significantly related to treatment outcome; ratings of therapist contribution to the alliance and outcome were not significantly linked. These results indicate that the therapeutic alliance is a common factor with significant influence on outcome. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Early alliance, alliance ruptures, and symptom change in a nonrandomized trial of cognitive therapy for avoidant and obsessive-compulsive personality disorders.

Participants were 30 adult outpatients diagnosed with avoidant personality disorder or obsessive-compulsive personality disorder who enrolled in an open trial of cognitive therapy for personality disorders. Treatment consisted of up to 52 weekly sessions. Symptom evaluations were conducted at intake, at Sessions 17 and 34, and at the last session. Alliance variables were patients' first alliance rating and "rupture-repair" episodes, which are disruptions in the therapeutic relationship that can provide corrective experiences and facilitate change. Stronger early alliances and rupture-repair episodes predicted more improvement in symptoms of personality disorder and depression. This work points to potentially important areas to target in treatment development for these personality disorders. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Perfectionism dimensions, perfectionistic attitudes, dependent attitudes, and depression in psychiatric patients and university students.

P. L. Hewitt and G. L. Flett's (1991b) model of perfectionism dimensions (i.e., self-oriented, other-oriented, and socially prescribed perfectionism) was compared with A. T. Beck's model (G. P. Brown & A.T. Beck, 2002) of dysfunctional attitudes (i.e., perfectionistic attitudes [PA] and dependent attitudes [DA]) in predicting depression in 70 psychiatric patients and 280 university students. Socially prescribed perfectionism uniquely predicted both PA and DA. Dysfunctional attitudes failed to consistently predict additional variance in depression beyond perfectionism dimensions (and vice versa). Evidence for Hewitt and Flett's specific vulnerability hypothesis and Beck's specific cognitive vulnerability hypothesis was equivocal. Beck's conceptualization of perfectionism as a unitary cognitive style obscures important information by overlooking the distinction between the self-related and socially based features of perfectionism. Hewitt and Flett's conceptualization of perfectionism as 3 distinct personality traits allows for precise conclusions by recognizing the differential contribution of the self-related and socially based features of perfectionism. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The destructiveness of perfectionism: Implications for the treatment of depression.

Reports in the public media indicate that intense perfectionism and severe self-criticism played a role in the suicide of three remarkably talented individuals. The role of perfectionism in these suicides is consistent with recent extensive investigations of aspects of perfectionism as well as further analyses of the NIMH Treatment of Depression Collaborative Research Program (TDCRP), indicating that intense perfectionism interfered significantly with therapeutic response in the various brief treatments for depression. Self-critical individuals, however, made substantial improvement in long-term intensive treatment. These findings suggest the value of considering psychopathology, especially depression, from a psychological rather than a symptomatic perspective; that different patients may be differentially responsive to various types of therapy; and that more extensive therapy may be necessary for many highly perfectionistic, self-critical patients. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Treatment preferences affect the therapeutic alliance: Implications for randomized controlled trials.

The influence of treatment preferences on the development of the therapeutic alliance was investigated. Seventy-five patients were followed while participating in a randomized controlled trial comparing supportive-expressive psychotherapy with sertraline or pill placebo in the treatment of major depressive disorder. Therapeutic alliance was assessed before treatment and at the 3rd, 5th, and 9th weeks of treatment. Among patients initially preferring psychotherapy, those receiving psychotherapy experienced increases in their alliance over time, whereas those receiving active medication or placebo experienced decreases. Among patients preferring pharmacotherapy, there were no differences in alliance development whether they received psychotherapy, active medication, or placebo. These relations were observed even when controlling for symptom severity. Thus, the congruence of patients' treatment preference and the treatment that they ultimately received influenced the development of the therapeutic alliance. Because alliance is a robust predictor of outcome, treatment preferences may need to be carefully considered in randomized controlled trial settings. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Perfectionism and relationship adjustment in pain patients and their spouses.

The authors assessed whether social facets of perfectionism were associated with indexes of dyadic and family adjustment. A sample of 83 pain patients and their spouses completed the Multidimensional Perfectionism Scale, Dyadic Adjustment Scale, Family Assessment Device, Beck Depression Inventory, and Multiaxial Pain Inventory. After controlling for depression, the authors found that pain patients' relationship adjustments were associated with their spouses' other-oriented perfectionism. Also, pain patients rated their other-oriented perfectionistic spouses as less supportive. Spouses' reports of poor dyadic and family adjustment were associated with their own socially prescribed perfectionism. The findings suggest that social aspects of perfectionism contribute to poor family adjustment. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Relational interpretations.

We review studies of relational interpretations as predictors of psychotherapy outcome and alliance. Investigations examining frequency of interpretations and outcome have yielded mixed findings. However, studies specifically of transference interpretations have converged toward the conclusion that high rates of transference interpretations can lead to poor outcome, particularly for patients with low quality of object relations. Several studies of the quality of interpretations have yielded consistent findings suggesting that relatively more favorable treatment outcomes are produced when therapists accurately address central aspects of patients' interpersonal dynamics. Few studies that have examined the relation between interpretations and the therapeutic alliance or tested the common clinical notion that interpretations have their greatest impact in the context of a positive alliance. Practice implications based upon this research literature are proposed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Concentration and correspondence of transference interpretations in short-term psychotherapy.

Provides a review of research on the relationship between aspects of transference interpretation and outcome in dynamic psychotherapy. It also presents the results of a recently completed study that focused on 2 aspects of transference interpretations: concentration and correspondence. Significant relationships between each of these 2 aspects and both therapeutic alliance and outcome were found, as well as an interaction effect for outcome. The relationships differed as a function of the patient personality characteristic known as quality of object relations. The results conerning correspondence were consistent with those of previous studies that investigated the correctness of interpretations. The overall findings suggest that (1) variation in technique may make a difference in brief dynamic therapy and (2) variation and impact of technique may have been masked in some previous studies and reviews. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Personality disorder symptoms and marital functioning.

Pathological personality is strongly linked with interpersonal impairment, yet no study to date has examined the relationship between concurrent personality pathology and dysfunction in marriage--a relationship that most people find central to their lives. In a cross-sectional study of a community sample of married couples (N = 82), the authors used multilevel modeling to estimate the association of self- and spouse-reported symptoms of personality disorder (PD) with levels of marital satisfaction and verbal aggression and perpetration of physical violence. Inclusion of self- and spouse report of total PD symptoms resulted in improved model fit and greater variance explained, with much of the improvement coming after the addition of spouse report. The incremental validity of spouse report for several of the 10 PD scales was supported for marital satisfaction and verbal aggression, particularly for the Borderline and Dependent PD scales. (PsycINFO Database Record (c) 2010 APA, all rights reserved)