Therapists’ attachment, patients’ interpersonal problems and alliance development over time in inpatient psychotherapy.

The focus of this study is the investigation of the relation between patients’ interpersonal problems, therapists’ attachment representations, and the development of the therapeutic alliance over time. The authors investigated weekly alliance ratings of 281 psychotherapy inpatients, treated by 12 psychotherapists. Alliance quality was measured with the Inpatient Experience Scale. Multilevel regression models showed that patients’ interpersonal problems were associated with the level of alliance quality. Therapists’ attachment security was not related to alliance development, but higher attachment preoccupation of therapists was associated with lower levels of alliance quality. In addition, an interaction effect between therapists’ degree of attachment preoccupation and patients’ interpersonal problems explained variations of the alliance development curve over time. Limitations of the study are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Interpersonal styles of chronically depressed outpatients: Profiles and therapeutic change.

Theoretical accounts posit that chronically depressed individuals are perceived as hostile and/or submissive, which compromises their ability to satisfy their interpersonal needs. The current study assessed the interpersonal tenets of McCullough's (2000) chronic depression theory and examined change in interpersonal functioning following McCullough's treatment for chronic depression (viz., Cognitive-Behavioral Analysis System of Psychotherapy; CBASP). Data derive from a randomized 12-week clinical trial that compared the efficacy of CBASP, nefazodone, and their combination for chronic depression. To assess patients' interpersonal impacts, CBASP therapists completed the Impact Message Inventory (IMI) following an early and a late session. IMI data were compared to normative and clinical comparison samples to assess depression-related interpersonal profiles and clinically significant change in interpersonal functioning. As predicted, chronically depressed patients were initially perceived as more submissive and hostile than the comparison groups. Patients' interpersonal impacts on their therapists changed in adaptive, theoretically predicted ways by the end of CBASP treatment, either with or without medication. Individual-level clinical significance data were less robust. The findings generally substantiate McCullough's interpersonal theory and provide preliminary evidence of change in interpersonal impacts following treatment. (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)     

Interpersonal problems and the psychotherapy context: The construct validity of the Inventory of Interpersonal Problems.

This research investigated the construct validity of the Inventory of Interpersonal Problems (IIP; L. M. Horowitz, S. E. Rosenberg, B. A. Baer, G. Ure?o, & V. S. Villase?or, 1988) in the context of psychodynamic psychotherapy. The interpersonal circumplex was used to categorize patients reporting interpersonal distress into 1 of 4 problem quadrants: Friendly Dominant, Hostile Dominant, Hostile Submissive, and Friendly Submissive. At several points in treatment, therapists assessed their patients' personality disturbances, global functioning, and assets and liabilities for therapy. Patients described their in-session experiences using the Therapy Session Report (D. E. Orlinsky & K. I. Howard, 1975). The 4 problem types each had a coherent and distinctive set of correlates. Patients' interpersonal problems were articulated in therapists' perceptions and evaluations, and in the kinds of interpersonal and intrapsychic themes (wants, hopes, feelings, behaviors, etc.) that characterized patients' retrospective accounts of the therapy sessions. The results add to knowledge about the IIP, interpersonal problems, and the psychotherapy context. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Review of Interpersonal psychotherapy of depression.

Reviews the book, Interpersonal psychotherapy of depression by Gerald L. Klerman, Myrna M. Weissman, Bruce J. Rounsaville, and Eve S. Chevron (1984). The authors state their intention to "describe the theoretical and empirical basis for interpersonal psychotherapy of depression," and also "offer a guide to the planning and conduct of the therapy." They do both, and waste no words. The book is organized into three parts. In the first part, the authors present an overview of the theory of the interpersonal approach of the use of interpersonal psychotherapy for depression, objectively offer both favorable and unfavorable findings from completed studies, and outline several studies in progress. The chapters in Part Two clarify how one conducts interpersonal therapy of depression. Part Three addresses the combination of psychotherapy with pharmacotherapy and the professional requirements of the therapist. This book is clearly written, well referenced, and easily understood by beginners who might not have the perspective, as well as by busy veterans who want to learn something new without plowing through mountains of theory and data. It would be useful for students in training, and extremely valuable to the legions of relatively inexperienced front-line mental health center therapists who are required to use time-limited approaches with depressed patients, often without having much structure for what they are doing. More experienced therapists who treat ambulatory depressed patients will add to their clinical skills and enjoy the process. The authors have turned their manual into a useful book that competes most favorably with other texts on short-term approaches to therapy. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Client attachment style and the psychotherapist's interpersonal stance.

Attachment style is proposed as an important client variable that psychotherapists may need to assess in order to tailor their interpersonal stance in psychotherapy. The authors draw on J. Bowlby's (1969, 1973, 1978) attachment theory and describe the therapeutic implications of 3 adult attachment styles: Anxious/Ambivalent, Avoidant, and Secure. Results are summarized from a psychotherapy research program, including the finding that attachment style was related to symptomatology and to therapists' perceptions of the therapeutic alliance. Case illustrations of clients displaying the 3 types of attachment style are presented to illustrate how therapists can productively alter their interpersonal stance to enhance treatment outcome. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The Therapeutic Process As a Predictor of Change in Patients' Important Relationships During Time-Limited Dynamic Psychotherapy.

Components of the therapeutic process have been shown to be moderately strong predictors of change in patients' global interpersonal functioning during therapy. The authors sought to extend this research by examining how the therapeutic process in time-limited dynamic psychotherapy related to change in patients' perceptions of a specific relationship as rated by the Structural Analysis of Social Behavior. Results showed that ratings of therapist warmth at Session 3 predicted increased warmth and decreased hostility in patient behavior at posttreatment. Therapist warmth at Session 16 was predictive of a decrease in submissive behavior by patients toward their significant other. The importance of the association between the therapeutic process and patients' important interpersonal relationships is discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Patient pretreatment interpersonal problems and therapeutic alliance in short-term cognitive therapy.

The growing consensus regarding the importance of interpersonal process in psychotherapy, as well as of interpersonal factors in self-definition, has underscored the relevance of examining patient interpersonal functioning as it relates to the development of the therapeutic alliance. This study examined the relationship of patient pretreatment interpersonal functioning, as measured by the Inventory of Interpersonal Problems and the Millon Clinical Multiaxial Inventory (MCMI), to the therapeutic alliance, as measured early in treatment by a patient self-report version of the Working Alliance Inventory. On the basis of an interpersonal circumplex interpretation, the results generally indicated that friendly-submissive interpersonal problems were positively related to the development of aspects of the alliance and that hostile-dominant problems were negatively related to the development of aspects of the alliance early in short-term cognitive therapy. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Interpersonal complementarity and the therapeutic alliance: A study of relationship in psychotherapy.

Examined the relationship between the therapeutic alliance and interpersonal complementarity during the early stage of psychotherapy. 36 pairs of patients (aged 18–57 yrs) and therapists from 14 outpatient settings recorded their perceptions of their therapeutic alliance, using a working alliance inventory, and rated each other's therapy behaviors on the Checklist of Interpersonal Transactions. There were positive associations between patient–therapist interpersonal complementarity and both patients' and therapists' perceptions of the alliance. The more extreme/abnormal the patient's interpersonal behavior, the more both patient and therapist perceived a less positive working alliance. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The relationship between interpersonal schemas and depressive symptomatology.

Turkish university students (187 men and 191 women), 17–27 years old, participated in this study. They completed the Interpersonal Schema Questionnaire (C. Hill & J. Safran, 1994) and the Beck Depression Inventory (A. Beck, A. Rush, B. Shaw, and G. Emery, 1979). This study extended the research that was conducted by Hill and Safran (1994). The results of this study revealed that individuals in the high-depressive symptomatology group expected less complementary responses from significant others in friendly, dominant, and submissive situations. They expected more complementary responses from them in hostile situations. They also rated their expected responses from others as more undesirable than did individuals in the low-depressive symptomatology group. These findings seem to be congruent with cognitive and interpersonal theories of depression. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Effects of transference work in the context of therapeutic alliance and quality of object relations.

Objective: Transference interpretation is considered as a core active ingredient in dynamic psychotherapy. In common clinical theory, it is maintained that more mature relationships, as well as a strong therapeutic alliance, may be prerequisites for successful transference work. In this study, the interaction between quality of object relations, transference interpretation, and alliance is estimated. Method: One hundred outpatients seeking psychotherapy for depression, anxiety, and personality disorders were randomly assigned to 1 year of weekly sessions of dynamic psychotherapy with transference interpretation or to the same type and duration of treatment, but without the use of transference interpretation. Quality of Object Relations (QOR)–lifelong pattern was evaluated before treatment (P. H?glend, 1994). The Working Alliance Inventory (A. O. Horvath & L. S. Greenberg, 1989; T. J. Tracey & A. M. Kokotovic, 1989) was rated in Session 7. The primary outcome variable was the Psychodynamic Functioning Scales (P. H?glend et al., 2000), measured at pretreatment, posttreatment, and 1 year after treatment termination. Results: A significant Treatment Group × Quality of Object Relations × Alliance interaction was present, indicating that alliance had a significantly different impact on effects of transference interpretation, depending on the level of QOR. The impact of transference interpretation on psychodynamic functioning was more positive within the context of a weak therapeutic alliance for patients with low quality of object relations. For patients with more mature object relations and high alliance, the authors observed a negative effect of transference work. Conclusion: The specific effects of transference work was influenced by the interaction of object relations and alliance, but in the direct opposite direction of what is generally maintained in mainstream clinical theory. (PsycINFO Database Record (c) 2011 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)     

The impact of perceived interpersonal functioning on treatment for adolescent depression: IPT-A versus treatment as usual in school-based health clinics.

Objective: Aspects of depressed adolescents’ perceived interpersonal functioning were examined as moderators of response to treatment among adolescents treated with interpersonal psychotherapy for depressed adolescents (IPT-A; Mufson, Dorta, Moreau, & Weissman, 2004) or treatment as usual (TAU) in school-based health clinics. Method: Sixty-three adolescents (12–18 years of age) participated in a clinical trial examining the effectiveness of IPT-A (Mufson, Dorta, Wickramaratne, et al., 2004). The sample was 84.1% female and 15.9% male (mean age = 14.67 years). Adolescents were 74.6% Latino, 14.3% African American, 1.6% Asian American, and 9.5% other. They came primarily from low-income families. Adolescents were randomly assigned to receive IPT-A or TAU delivered by school-based mental health clinicians. Assessments, completed at baseline and at Weeks 4, 8, and 12 (or at early termination), included the Hamilton Rating Scale for Depression (Hamilton, 1967), the Conflict Behavior Questionnaire (Robin & Foster, 1989), and the Social Adjustment Scale–Self-Report (Weissman & Bothwell, 1976). Results: Multilevel modeling indicated that treatment condition interacted with adolescents’ baseline reports of conflict with their mothers and social dysfunction with friends to predict the trajectory of adolescents’ depressive symptoms over the course of treatment, controlling for baseline levels of depression. The benefits of IPT-A over TAU were particularly strong for the adolescents who reported high levels of conflict with their mothers and social dysfunction with friends. Conclusions: Replication with larger samples would suggest that IPT-A may be particularly helpful for depressed adolescents who are reporting high levels of conflict with their mothers or interpersonal difficulties with friends. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Effects of psychotherapy training and intervention use on session outcome.

Objective: This study was an investigation of the relationships among therapist training variables, psychotherapy process, and session outcome in a psychotherapy training clinic. The aims were to assess the relationship between “training as usual” and intervention use in individual psychotherapy, to investigate the relationship between therapist intervention use and session outcome, and to test whether training variables moderate this relationship. Method: Graduate student therapists (n = 19; mean age = 27 years; 79% women; 84% White) provided information about their training and completed a measure of intervention use (Multitheoretical List of Therapeutic Interventions; McCarthy & Barber, 2009) and clients (n = 42; mean age = 33 years; 64% women; 95% White) completed a measure of session outcome (Session Progress Scale; Kolden, 1991) after each session of individual psychotherapy. Results: With regard to intervention use and session outcome, no main effects were found for the training variables. Consequently, tests of moderation were not performed. The final model for intervention use and session outcome yielded main effects for time-varying interpersonal therapy and time-varying common factor use, and a 3-way interaction among time-varying cognitive–behavioral (CBT) intervention use, between-patient common factor use, and between-therapist common factor use. Patients who received more common factor interventions on average rated sessions as less helpful when more CBT interventions were employed; this finding was stronger for patients who were being treated by therapists with higher average levels of common factor use. Conclusions: Implications for training are discussed, with particular attention paid to the importance of clinical decision making and the complex interaction between common and unique technical factors in practice. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Interpersonal types among psychiatric patients.

The aims of the study were to isolate some of the main interpersonal behavior types within a sample of nonpsychotic psychiatric patients in psychotherapy, to determine the constancy of the isolated types across the 3 subsamples of 150 cases, and to identify any systematic differences among them. Each patient was described by his therapists on the 15 factors of the Interpersonal Behavior Inventory. The 4 replicated types were (1) inhibited, submissive, abasive; (2) agreeable, nurturant, sociable; (3) hostile, mistrustful, detached; (4) dominant, competitive, exhibitionistic. Some diagnositc and occupational differences were found. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The effect of androgyny on the quality of psychotherapeutic relationships.

Tested the hypothesis that androgynous therapists would form more favorable psychotherapy relationships with their clients than masculine or feminine therapists. 52 psychology practicum dyads (therapists aged 26–40 yrs, clients aged 18–30 yrs) were examined in the context of in vivo psychotherapy sessions. The therapists and clients each completed the Bem Sex-Role Inventory—Revised, and clients also completed the Barrett-Lennard Relationship Inventory. Results indicate that androgynous therapists were judged to produce more favorable relationships, regardless of gender. It is suggested that this superior relationship with androgynous therapists may be attributed to their uniqueness in dealing with problem-solving and interpersonal situations and their ability to blend masculine and feminine orientations. They can be assertive, yet supportive; engage in activities both traditionally gender appropriate and non-sex-typed; demonstrate a greater array of personal behavior and emotionality; organize cognitive data in non-gender-related ways; and combine an open, naturalistic interviewing style with directiveness. (19 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Predictors of the longitudinal course of postpartum depression following interpersonal psychotherapy.

Objective: We examined the course and predictors of postpartum depression in the 18 months following interpersonal psychotherapy (IPT). Method: We enrolled 120 community women with major depression in a 12-week randomized trial of individual IPT during the postpartum period (O'Hara, Stuart, Gorman, & Wenzel, 2000). At 6, 12, and 18 months posttreatment, women participated in clinical interviews to establish the course of depression over the previous 6 months. We used survival analyses to characterize recovery and recurrence in the follow-up and growth curve modeling techniques to identify predictors of change in depression during the follow-up period. Potential predictors included severity, chronicity, and personal history of depression. Results: Of 35 women who recovered with acute treatment, 20 (57%) achieved sustained recovery during follow-up; average time to recurrence was 33.40 weeks (SD = 18.43 weeks). Over 80% of women who did not recover with acute treatment experienced recovery at some point during follow-up; average time to recovery was 28.60 weeks (SD = 17.51 weeks). Time depressed each month decreased over the follow-up period. Posttreatment depressive severity and length of the index episode predicted changes in depression over time. Posttreatment depression severity, personal history of depression, and weeks of treatment in the follow-up were significant predictors of time depressed during follow-up. Conclusions: IPT resulted in long-term benefits past the termination of acute treatment, even for women who did not initially recover. Though the vast majority of women who did not recover with acute treatment did recover during the follow-up period, continuation of IPT may accelerate the process. (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)     

A component analysis of cognitive-behavioral therapy for generalized anxiety disorder and the role of interpersonal problems.

Clients with generalized anxiety disorder (GAD) received either (1) applied relaxation and self-control desensitization, (2) cognitive therapy, or (3) a combination of these methods. Treatment resulted in significant improvement in anxiety and depression that was maintained for 2 yrs. The large majority no longer met diagnostic criteria; a minority sought further treatment during follow-up. No differences in outcome were found between conditions; review of the GAD therapy literature suggested that this may have been due to strong effects generated by each component condition. Finally, interpersonal difficulties remaining at posttherapy, measured by the Inventory of Interpersonal Problems Circumplex Scales (L. E. Alden, J. S. Wiggins, & A. L. Pincus, 1990) in a subset of clients, were negatively associated with posttherapy and follow-up improvement, suggesting the possible utility of adding interpersonal treatment to cognitive-behavioral therapy to increase therapeutic effectiveness. (PsycINFO Database Record (c) 2010 APA, all rights reserved)