The relationship of early alliance ruptures and their resolution to process and outcome in three time-limited psychotherapies for personality disorders.

This study examined the relationship of early alliance ruptures and their resolution to process and outcome in a sample of 128 patients randomly assigned to 1 of 3 time-limited psychotherapies for personality disorders: cognitive–behavioral therapy, brief relational therapy, or short-term dynamic psychotherapy. Rupture intensity and resolution were assessed by patient- and therapist-report after each of the first 6 sessions. Results indicated that lower rupture intensity and higher rupture resolution were associated with better ratings of the alliance and session quality. Lower rupture intensity also predicted good outcome on measures of interpersonal functioning, while higher rupture resolution predicted better retention. Patients reported fewer ruptures than did therapists. In addition, fewer ruptures were reported in cognitive–behavioral therapy than in the other treatments. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Evaluating alliance-focused intervention for potential treatment failures: A feasibility study and descriptive analysis.

This article describes a pilot study evaluating the feasibility of an approach developed to test the efficacy of a therapeutic intervention (brief relational therapy) for patients with whom it is difficult to establish a therapeutic alliance. In the first phase of the study, 60 patients were randomly assigned to either short-term dynamic therapy (STDP) or short-term cognitive therapy (CBT), and their progress in the first eight sessions of treatment was monitored. On the basis of a number of empirically derived criteria, 18 potential treatment failures were identified. In the second phase of the study, these identified patients were offered the option of being reassigned to another treatment. The 10 patients who agreed to switch treatments were reassigned either to the alliance-focused treatment, referred to as brief relational therapy (BRT), or a control condition. For patients coming from CBT, the control condition was STDP. For patients coming from STDP, the control condition was CBT. The results provide preliminary evidence supporting the potential value of BRT as an intervention that is useful in the context of alliance ruptures. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Influences of beliefs and personality disorders on treatment outcome in anxiety patients.

The present study investigated the effects of personality disorders (PDs) and specific PD-related beliefs on the results of (cognitive-)behavioral therapy for anxiety disorders in a sample of 398 outpatients. The authors used a prospective design in which relationships between PD variables before treatment and outcome measures at posttest and follow-up were evaluated with multilevel analyses. People with PDs and PD-related beliefs reported higher symptom levels at outcome. However, these effects were not as strong as might be expected on the basis of prevailing clinical thought in this area. Dropout rates were not influenced by the presence of 1 or more PDs or PD-related beliefs. Results indicate that treatment of anxiety disorders in patients with concomitant one or more PDs is appropriate. (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)     

Role of perfectionism and personality disorder features in response to brief treatment for depression.

Using data from the Treatment of Depression Collaborative Research Program (TDCRP), the authors compared the role of patients' perfectionism and features of personality disorder (PD) in the outcome of brief treatment for depression. Data were extracted as to patients' intake levels of symptoms; perfectionism; and PD features, measured as continuous variables, as well as their symptoms at termination; their contribution to the therapeutic alliance; and their satisfaction with social relations. Poorer therapeutic outcome was demonstrated for patients with elevated levels of perfectionism and odd-eccentric and depressive PD features. Patients' contribution to therapeutic alliance and satisfaction with social relations were predicted by perfectionism but not by PD features. Results highlight the central role played by patients' personality in the course of brief treatment for depression. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

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)     

Ethnicity and mental health treatment utilization by patients with personality disorders.

The authors examined the relationship between ethnicity and treatment utilization by individuals with personality disorders (PDs). Lifetime and prospectively determined rates and amounts of mental health treatments received were compared in over 500 White, African American, and Hispanic participants with PDs in a naturalistic longitudinal study. Minority, especially Hispanic, participants were significantly less likely than White participants to receive a range of outpatient and inpatient psychosocial treatments and psychotropic medications. This pattern was especially pronounced for minority participants with more severe PDs. A positive support alliance factor significantly predicted the amount of individual psychotherapy used by African American and Hispanic but not White participants, underscoring the importance of special attention to the treatment relationship with minority patients. These treatment use differences raise complex questions about treatment assessment and delivery, cultural biases of the current diagnostic system, and possible variation in PD manifestation across racial/ethnic groups. Future studies need to assess specific barriers to adequate and appropriate treatments for minority individuals with PDs. (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)     

Response to cognitive therapy in depression: The role of maladaptive beliefs and personality disorders.

This study examined whether personality disorder status and beliefs that characterize personality disorders affect response to cognitive therapy. In a naturalistic study, 162 depressed outpatients with and without a personality disorder were followed over the course of cognitive therapy. As would be hypothesized by cognitive theory (A. T. Beck & A. Freeman, 1990), it was not personality disorder status but rather maladaptive avoidant and paranoid beliefs that predicted variance in outcome. However, pre- to posttherapy comparisons suggested that although patients with or without comorbidity respond comparably to "real-world" cognitive therapy, they report more severe depressive symptomatology at intake and more residual symptoms at termination. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The role of transference work, the therapeutic alliance, and their interaction in reducing interpersonal problems among psychotherapy patients with Cluster C personality disorders.

The aim of the present study was to examine whether transference work, the therapeutic alliance, and their interaction predicted a reduction in interpersonal problems at treatment termination. Forty-nine patients with Cluster C personality disorders from a randomized controlled trial investigating the effectiveness of short-term dynamic psychotherapy and cognitive therapy were included. Transference work was measured with the Inventory of Therapeutic Strategies (Gaston & Ring, 1992), while the therapeutic alliance was measured with the Helping Alliance Questionnaire (Luborsky, Crits-Christoph, Alexander, Margolis & Cohen, 1983). Less emphasis on transference work predicted overall reduced interpersonal problems, whereas the effects of the therapeutic alliance did not reach statistical significance. An interaction effect was also demonstrated, indicating that greater emphasis on transference work performed on patients with lower therapeutic alliance ratings was associated with a smaller reduction in interpersonal problems at termination. However, the results also indicate that a low dose of transference work may be beneficial in reducing interpersonal problems. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Depressive manifestations and differential patterns of treatment outcome in an intensive partial hospitalization treatment program.

Patients with personality disorder demonstrate heterogeneity in symptom presentation and treatment needs. Methods of subtyping patient presentations may illuminate important patient-treatment matches. Previous studies of an intensive partial hospitalization approach for patients with affective and personality disorders had demonstrated significant treatment effects. The current study aimed at identifying differential patterns of treatment engagement and outcome within this context of substantial aggregate benefit. Our sample was comprised of 107 outpatients, all of whom presented with Diagnostic and Statistical Manual of Mental Disorders (4th ed., American Psychiatric Association, 1994) Axis II traits or full disorders. In a prior cluster analysis, measures of depressive symptom manifestation were employed to identify four distinct patient subgroups. The cluster designation was tested as an independent factor influencing in-treatment ratings (well-being, anxiety, depression) and pre- to posttreatment ratings of outcome. The patient clusters showed significantly different patterns of change in anxiety (slopes) over the course of treatment. Significant differences between clusters were also evident in the proportion of patients achieving clinically significant change on 3 central outcome indexes. Results are considered in terms of the match between the patient’s clinical presentation (e.g., anaclitic depression) and the treatment approach, with attention to implications for patient selection and preparation for the partial hospital program. (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)     

Clinical outcomes of an integrated treatment for depression and substance use disorders.

The authors compared longitudinal treatment outcomes for depressed substance-dependent veterans (N = 206) assigned to integrated cognitive–behavioral therapy plus standard pharmacotherapy (ICBT + P) or 12-step facilitation therapy plus standard pharmacotherapy (TSF + P). Drug and alcohol involvement and depressive symptomology were measured at intake and at 3-month intervals during treatment and up to 1 year posttreatment. Participants in both treatment conditions showed decreased depression and substance use from intake. ICBT + P participants maintained improvements in substance involvement over time, whereas TSF + P participants had more rapid increases in use in the months following treatment. Decreases in depressive symptoms were more pronounced for TSF + P than ICBT + P in the 6 months posttreatment. Within both treatment groups, higher attendance was associated with improved substance use and depression outcomes over time. Initial levels of depressive symptomology had a complex predictive relationship with long-term depression outcomes. Early treatment response predicted long-term substance use outcomes for a portion of the sample. Although both treatments were associated with improvements in substance use and depression, ICBT + P may lead to more stable substance use reductions compared with TSF + P. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Adolescent and parent therapeutic alliances as predictors of dropout in multidimensional family therapy.

The authors examined the relations between adolescent-therapist and mother-therapist therapeutic alliances and dropout in multidimensional family therapy for adolescents who abuse drugs. The authors rated videotapes of family therapy sessions using observational methods to identify therapist-adolescent and therapist-mother alliances in the first 2 therapy sessions. Differences in adolescent and mother alliances in families that dropped out of therapy and families that completed therapy were compared. Results indicate that both adolescent and mother alliances with the therapist discriminated between dropout and completer families. Although no differences were observed between the 2 groups in Session 1, adolescents and mothers in the dropout group demonstrated statistically significantly lower alliance scores in Session 2 than adolescents and parents in the completer group. These findings are consistent with other research that has established a relationship between therapeutic alliance and treatment response. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Review of Interpersonal Reconstructive Therapy: Promoting Change in Nonresponders.

Reviews the book, Interpersonal Reconstructive Therapy: Promoting Change in Nonresponders by Lorna Smith Benjamin (see record 2003-02042-000). Lorna Smith Benjamin offers a refreshing and unique treatment approach with this book, for a group of patients who are defined less by a specific diagnosis than by their failure to respond to one or more treatment trials. A master clinician, Benjamin has spent most of her career researching and treating the interpersonal processes of patients with personality disorders and other interpersonal problems. Benjamin is especially impressive when describing the causality of the proposed model and the treatment. Reviews of empirical research are interwoven throughout the middle chapters and are linked smartly to critical treatment issues (e.g., attachment theory, insight, empathy, the therapeutic alliance). Benjamin's own research tool, the Structural Analysis of Social Behavior (SASB), is referred to throughout, but mostly discussed in a single chapter. Those knowledgeable in SASB will immediately recognize it in most of the treatment concepts. Yet those who are not familiar with SASB will have no problem mastering this book, even if they entirely skip the SASB chapter and references. It's hard to imagine many clinicians not advancing their own thinking and practices about working with their most difficult patients by reading this book. Benjamin has advanced the understanding of working with difficult patients to a new level. Regardless of whether this book proves to be superior in clinical trials, Benjamin's unique contribution to thinking about therapy is already a classic. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Collaborative versus directive interventions in the treatment of eating disorders: Implications for care providers.

Given that individuals with eating disorders, are typically ambivalent about changing their eating patterns, what approach is most helpful in working with this challenging group? This research compared the responses of clients with eating disorders and those of care providers to written clinical vignettes. All participants rated collaborative interventions as more acceptable and more likely to produce positive clinical outcomes than directive interventions. In addition, clients who were least ready for change rated directive interventions as less acceptable and less likely to produce adherence than did clients who were more ready. Despite participants' clear preference for collaborative interventions, directive interventions were rated as equally likely to occur. The implications of participant preferences and reasons that these preferences may not be reflected in actual clinical practice are addressed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The Therapeutic Alliance in Cognitive-Behavioral Treatment of Children Referred for Oppositional, Aggressive, and Antisocial Behavior.

The authors examined the therapeutic alliance in evidence-based treatment for children (N = 185, 47 girls, 138 boys; ages 3-14 years) referred clinically for oppositional, aggressive, and antisocial behavior. Different alliances (child-therapist, parent-therapist) were assessed from each participant's perspective at 2 points over the course of treatment. As predicted, both child-therapist and parent-therapist alliances related to therapeutic change, family experience of barriers to participation in treatment, and treatment acceptability. Greater alliance was associated with greater therapeutic change, fewer perceived barriers, and greater treatment acceptability. The findings could not be attributed to the influence of socioeconomic disadvantage, parent psychopathology and stress, and child dysfunction or to rater effects (common rater variance in the predictors and criteria). (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Review of Roadblocks in Cognitive-Behavioral Therapy: Transforming Challenges Into Opportunities for Change.

This article provides a review of "Roadblocks in Cognitive-Behavioral Therapy: Transforming Challenges Into Opportunities for Change" (see record 2004-00137-000). In the nearly 50 years since cognitive-behavioral treatment (CBT) models were pioneered by Albert Ellis and Aaron Beck, CBT approaches have enjoyed a wide range of applications and considerable empirical and clinical success. A frequent criticism of the CBT model has been that its approaches favor technique and behavioral change over the "substance" of psychotherapy (e.g., therapeutic alliance, resistance, engagement). Designed primarily for clinicians, "Roadblocks in Cognitive-Behavioral Therapy" is well-written and easy to read. In keeping with the tradition of CBT, the authors rely on empirical research to support their tenets, while keeping the emphasis of each chapter on clinical utility. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Session and intersession experience related to treatment outcome in bulimia nervosa.

Treatment in bulimia nervosa is challenging, with rates of successful treatments for only about 50% of all patients. This study aimed to identify predictors of outcome through secondary analysis of data from a randomized clinical trial that compared inpatient and day hospital treatment for bulimia. Process measures included assessments of patients' in-session experiences, therapeutic alliance, and therapy-related intersession experiences (ISE). ISE measures were better predictors of outcome than pretreatment variables (e.g., social adjustment) or global therapeutic alliance. Outcome at 3 month follow-up was strongly related to the ISE dimension Recreating Therapeutic Dialogue with Negative Emotions, indicating a heightened risk of failure. Prediction of outcome by these variables showed a sensitivity of 0.86 and a specificity of 0.78, and 83% of patients could be correctly classified. These results show that certain aspects of ISE may serve as early and reliable indicators of long term treatment failure, prompting alternate treatment approaches and opening new directions of research. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Neurocognitive impairment associated with alcohol use disorders: Implications for treatment.

Between 50% and 80% of individuals with alcohol use disorders experience mild to severe neurocognitive impairment. There is a strong clinical rationale that neurocognitive impairment is an important source of individual difference affecting many aspects of addiction treatment, but empirical tests of the direct influence of impairment on treatment outcome have yielded weak and inconsistent results. The authors address the schism between applied-theoretical perspectives and research evidence by suggesting alternative conceptual models of the relationship between neurocognitive impairment and addiction treatment outcome. Methods to promote neurocognitive recovery and ways in which addiction treatments may be modified to improve psychosocial adaptation are suggested. Specific suggestions for future research that may help clarify the complex relations between neurocognitive impairment and addiction treatment are outlined. (PsycINFO Database Record (c) 2010 APA, all rights reserved)