Use of the MMPI-2 Personality Disorder Scales in the Assessment of DSM-IV Antisocial, Borderline, and Narcissistic Personality Disorders

This study explored the diagnostic utility of the MMPI-2 Personality Disorder (MMPI-2 PD) scales to correctly classify three Cluster B Personality Disorders (Antisocial, Borderline, and Narcissistic Personality Disorder). Classification was compared against the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) chart diagnoses checked for interrater agreement. MMPI-2 PD scale scores for 53 outpatients diagnosed with a Cluster B Personality Disorder were contrasted with an Other Personality Disorder group ( n = 20) and a nonclinical population ( n = 67). Scores for both the overlapping and nonoverlapping scales of the MMPI-2 PD scales were used in calculating diagnostic efficiency statistics. In support of past findings, results suggest the MMPI-2 PD scales should be used conservatively; they are best at screening for presence or absence of a personality disorder, identifying members of personality disorder clusters, and identifying negative occurrences of specific personality disorders or personality disorder clusters. Findings endorse the use of both versions of the Antisocial Personality Disorder scale and the overlapping version of the Borderline Personality Disorder scale. Use of the Narcissistic Personality Disorder scales is recommended for negative predictive power values only. A multimodal approach is recommended, whereby assessment measures may be used conjointly to improve diagnostic efficiency.

A Review of Interpersonal-Psychodynamic Group Psychotherapy Outcomes for Adult Survivors of Childhood Sexual Abuse

This article discusses the use of interpersonal-psychodynamic group treatments for survivors of childhood sexual abuse. Empirically based interpersonal-psychodynamic group outcome studies are reviewed according to efficacy and effectiveness models of treatment outcome research. To facilitate the evaluation and comparison of clinically significant change across studies, effect size indicators were calculated when descriptive data were reported. Findings suggest that interpersonal-psychodynamic group therapy is an effective treatment approach for many survivors of childhood sexual abuse. Implications for future research are considered.

Client Attachment Status and Changes in Therapeutic Alliance Early in Treatment

Several studies have examined associations between client attachment status and therapeutic alliance. Most, however, measure alliance at a single time point only. This study is among the first to examine how client attachment relates to changes in the therapeutic alliance early in treatment. Forty-six outpatients from a university-based community clinic participated. Attachment status was assessed with the Relationship Questionnaire (Bartholomew & Horowitz, 1991) prior to beginning treatment. Participants rated therapeutic alliance after an evaluation feedback session and again early in psychotherapy. Fearful insecurity was associated with declines in therapeutic alliance, while attachment security was associated with increasing client-therapist bonds. Although unrelated to global alliance, preoccupied insecurity was associated with greater confident collaboration at both time points and declines in idealized relationship from the evaluation to the early therapy time point. Results are discussed in light of prior theoretical formulations and previous research. Limitations of the study are reviewed, implications for clinical practice are noted, and suggestions for future research are made.

KEY PRACTITIONER MESSAGE

Assessing client attachment status can provide clinicians with information that helps them identify clients at risk for difficulties establishing a therapeutic alliance. Clients high in attachment security are more likely to develop strong bonds with therapists during the early portion of treatment. Clients high in fearful insecurity are at risk for developing weaker alliances early in treatment. Such clients appear more likely to experience declines in client-therapist bond, goal-task agreement and overall alliance early in the treatment process. Clients high in preoccupied insecurity may enter therapy with great confidence in the therapist and willing to engage in therapy but report more conflicts with therapists in the early phase of treatment.

Patient Crying in Psychotherapy: Who Cries and Why?

AIM

The aim of the present study is to further the understanding of who cries in therapy and the relation of technique with crying behaviour in therapy.

METHOD

Psychological assessment feedback sessions, prior to the initiation of formal therapy for 52 patients beginning psychotherapy at a university-based clinic were coded for discrete crying segments. Data about patient characteristics and the process of the session were collected at the time of the session. Therapist's interventions were recorded verbatim and independently rated.

RESULTS

The number of times a patient cried during their session correlated negatively with global assessment of functioning scores and positively with measures of borderline personality disorder pathology as well as a measure of severity of childhood sexual abuse. Patients' crying behaviour demonstrated significant negative correlations with the overall experience of the session (bad/good), smoothness and positivity. Group differences between criers and non-criers reflected these trends as well. No significant correlations or group differences were found with regard to patient-rated or therapist-rated alliance as it relates to crying behaviour. Analysis indicates that therapist intervention prior to patient crying most often encouraged the exploration and expression of difficult affect, new perspectives on key issues or the patient's fantasies and wishes.

DISCUSSION

Our study addresses a significant gap in the clinical literature on crying. Crying behaviour seems to be related to certain clinical variables and has a negative impact on patient experience of the session in which they cry, although the alliance remained unaffected.

LIMITATIONS

Small sample, outpatients with mild/moderate psychopathology and graduate trainees provided therapy.

KEY PRACTITIONER MESSAGE

Patients with greater problems in emotional dysregulation, borderline personality disorder symptoms and greater severity of childhood sexual abuse are more likely to display greater affective intensity during the beginning of treatment. Results suggest that the alliance may remain strong despite patients experiencing a session in which they cried as difficult. Therapeutic interventions that focus on affect, new understanding of old patterns and patient fantasies with outpatient clinical populations appeared to be associated with crying in session.

Process and technique factors associated with patient ratings of session safety during psychodynamic psychotherapy

This study investigates the relationships between patient ratings of in-session safety with psychotherapeutic techniques and process. Ninety-four participants received Short-Term Dynamic Psychotherapy (STDP) at a university-based clinic. Patient experiences of therapeutic process were self-assessed early in treatment using the Session Evaluation Questionnaire (SEQ Stiles, 1980). Techniques implemented in session were identified using the Comparative Psychotherapy Process Scale (CPPS: Hilsenroth et al., 2005). Alliance was evaluated with the Combined Alliance Short Form-Patient Version (CASF-P; Hatcher and Barends, 1996). Safety significantly correlated with session depth, smoothness, and positivity. Safety was significantly related to the interaction of psychodynamic-interpersonal and cognitive-behavioral techniques, but to neither individual subscale Safety significantly correlated with CASF-P Total, Confident Collaboration, and Bond. Patient experiences of safety are consistent with exploration and depth of session content. Integration of some CB techniques within a psychodynamic model may facilitate a sense of safety. Safety is notably intertwined with the therapeutic relationship.

Introduction to the 50th anniversary special issue on psychotherapy outcome: a return to the beginning

Then and now, Psychotherapy is a home to those interested in expanding the research base of how and why psychotherapy is effective. In preparing to celebrate the 50th anniversary of our journal, we on the editorial board and Division 29 thought nothing could pay better homage to these issues than to reprint the seminal articles by Strupp and Eysenck on psychotherapy outcome from Volume 1. These reprinted articles will then be followed by papers from several of today's most prominent authors in psychotherapy process and outcome research who address the progress on these issues now, 50 years later, as well as provide important suggestions for how the field can move forward in future work. Again, this will be the first of several initiatives to celebrate this very special golden anniversary year!

Risk factors for medically serious suicide attempts: evidence for a psychodynamic formulation of suicidal crisis

This study explored a psychodynamic model for suicide risk by examining risk factors for medically serious suicide attempts, including assessments of affect flooding, negative self-schema / fragmentation, and impaired reality testing, closely approximating Maltsberger's psycho-dynamic formulation of suicide crisis. Baseline risk factors including age, gender, psychiatric symptoms, high-risk behaviors, and the Implicit Risk for Suicide Index (IRSI) were used to detect medically serious suicide attempts monitored for up to a year after the assessment. Twenty-five psychiatric inpatients who made life-threatening suicide attempts after assessment were compared to 25 inpatients and 25 psychotherapy outpatients who made no suicide attempts during follow-up. Statistical analysis revealed that a history of at least one suicide attempt and elevated IRSI scores accounted for 60 percent of the variance in detecting medically serious suicide attempts. Elevated IRSI accurately identified suicide attempt status above and beyond past suicide attempts and other empirically validated risk factors. Results are discussed in light of psychodynamic formulations of suicide risk.

Will patients accept randomization to psychoanalysis? A feasibility study

The feasibility of using a randomized design in a psychoanalytic outcome study was evaluated. Our hypothesis was that it would be feasible to randomize patients to psychoanalysis three or four times weekly on the couch for five years, supportive expressive therapy once or twice weekly for up to forty sessions, and cognitive behavior therapy once or twice weekly for up to forty sessions. Successful randomization was defined as a 30% recruitment rate among eligible patients. Recruitment began in September 2009 and closed in April 2010. A total of 132 subjects responded to study advertisements, 107 of whom (81%) were triaged out. The remaining 25 were scheduled for the first of two clinical interviews, and 21 of 25 (88%) completed the interview. Eleven of the 25 (44%) were determined to be eligible based on inclusion and exclusion criteria. Eight of the 11 accepted the idea of randomization and completed the diagnostic assessment phase. Calculated on the basis of 8 of 11 eligible patients accepting randomization, the 95% confidence interval was that 39% to 92% of eligible subjects would participate in a larger study of this design. Our findings support the feasibility of implementing an RCT comparing psychoanalysis as defined by the American Psychoanalytic Association (three or four times weekly on the couch for approximately five years) with shorter-term dynamic or cognitive behavioral therapy once or twice a week. Pre-treatment characteristics of these eight patients are presented, as are initial reliability data for the treatment adherence scales used in this trial.