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Constantino MJ, Coyne AE, Gaines AN, Goodwin BJ, Muir HJ, Critchfield KL, Westra HA, Antony MM. Therapist verification of patient self-concepts as a responsive precondition for early alliance development and subsequent introject change. Psychother Res 2023:1-15. [PMID: 38158827 DOI: 10.1080/10503307.2023.2297995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 12/15/2023] [Indexed: 01/03/2024] Open
Abstract
OBJECTIVE Social psychological research has indicated that people strive for self-consistent feedback and interactions, even if negative, to preserve the epistemic security of knowing themselves. Without such self-verification, any interpersonal exchange may become frustrated, anxiety-riddled, and at risk for deterioration. Thus, it may be important for therapists to meet patients' self-verification needs as a responsive precondition for early alliance establishment and development. We tested this hypothesis with patients receiving cognitive behavioral therapy for generalized anxiety disorder-a condition that may render one's self-verification needs especially strong. We also tested the hypothesis that better early alliance quality would relate to subsequent adaptive changes in and posttreatment level of patients' self-concepts. METHOD Eighty-four patients rated their self-concepts at baseline and across treatment and follow-up, their postsession recollection of their therapist's interpersonal behavior toward them during session 2, and their experience of alliance quality rated after sessions 3-6. RESULTS As predicted, the more therapists verified at session 2 a patient's baseline self-concepts (which trended toward disaffiliative and overcontrolling, on average), the more positively that patient perceived their next-session alliance. Moreover, better session 3 alliance related to more adaptive affiliative and autonomy-granting self-concepts at posttreatment. CONCLUSION Results are discussed within a therapist responsiveness framework.
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Affiliation(s)
- Michael J Constantino
- Department of Psychological and Brain Sciences, University of Massachusetts Amherst, Amherst, MA, USA
| | - Alice E Coyne
- Department of Psychology, American University, Washington, DC, USA
| | - Averi N Gaines
- Department of Psychological and Brain Sciences, University of Massachusetts Amherst, Amherst, MA, USA
| | - Brien J Goodwin
- Department of Psychological and Brain Sciences, University of Massachusetts Amherst, Amherst, MA, USA
| | - Heather J Muir
- Department of Psychological and Brain Sciences, University of Massachusetts Amherst, Amherst, MA, USA
| | | | - Henny A Westra
- Department of Psychology, York University, Toronto, Canada
| | - Martin M Antony
- Department of Psychology, Toronto Metropolitan University, Toronto, Canada
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Woehrle PL, Critchfield KL, Anolik S, Bobal C, Pempek TA, Skowron EA. Multigenerational patterns of parenting-at-risk: A test of interpersonal specificity using copy process theory. J Clin Psychol 2023; 79:186-200. [PMID: 35819800 PMCID: PMC9742119 DOI: 10.1002/jclp.23412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 04/20/2022] [Accepted: 05/28/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVES This study tests ways in which the perception of intergenerational continuity in parenting behaviors among child-maltreatment (CM) and non-CM families conform to Benjamin's (2006) Copy Process Theory, which considers three copy processes: Identification (be like him/her), Recapitulation (behave as if he/she is still present and in charge), and Introjection (treat myself as he/she treated me). METHOD Across two home visits and a laboratory session, 171 mothers of preschoolers (M = 3.7 years) completed the SASB Intrex Questionnaire relative to herself, her history with her parents, and her present relationship with her child. RESULTS Mothers' retrospective reports of her interactions with caregivers were correlated with the quality of self-reported parenting processes in interactions with her preschooler. Analyses indicated high rates of intergenerational copying in both samples for each copy process. While copying in general was observed in nearly all mothers (roughly 80%-90%) and emphasized warm, securely attached patterns, the copying of hostility and/or lack of affiliation occurred in copied profiles for about one-third of mothers. About the more problematic profiles, CM mothers tended to rate themselves as being in the child-like position they experienced in their own childhood, with themes involving hostile control perceived from their child. By contrast, non-CM mothers copied disaffiliative themes primarily in relation to themselves. CONCLUSION Findings verify that interpersonal patterns and internalized relational histories are important keys for understanding CM risk. The use of a method that offers interpersonal specificity at the level of individual profiles has application to clinical practice with at-risk parents.
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Critchfield KL, Harvell-Bowman L. Death anxiety and existential concerns among patients experiencing chronic or recurrent suicidal ideation in Interpersonal Reconstructive Therapy. CLIN PSYCHOL-UK 2022. [DOI: 10.1080/13284207.2022.2120386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Harvell-Bowman LA, Critchfield KL, Ndzana F, Stucker E, Yocca C, Wilgus K, Hurst A, Sullivan K. Of Love and Death: Death Anxiety, Attachment, and Suicide as Experienced by College Students. Omega (Westport) 2022:302228221100636. [PMID: 35533365 DOI: 10.1177/00302228221100636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Drawing from the mental health crisis present on college campuses, we investigate the psychological processes associated with suicidal ideation among undergraduate students. Specifically, we used Terror Management Theory to investigate how individuals who have a history of suicidal ideation handle traditional death anxiety in coordination with Benjamin's theory underlying Interpersonal Reconstructive Therapy to explore specific attachment-based mechanisms that may allow for exceptions to the perceived meaning of death. Results show it was the fantasy of suicide itself, including its relevance in the lives of others, that was used to alleviate fear of death among the suicidal.
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Affiliation(s)
| | | | | | | | | | | | - Amanda Hurst
- 3745James Madison University, Harrisonburg, VA, USA
- Immaculata University, Pennsylvania, PA, USA
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Critchfield KL, Gazzillo F, Kramer U. Case formulation of interpersonal patterns and its impact on the therapeutic process: Introduction to the issue. J Clin Psychol 2022; 78:379-385. [PMID: 35139241 DOI: 10.1002/jclp.23322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 01/18/2022] [Accepted: 01/19/2022] [Indexed: 11/09/2022]
Abstract
Authors included in this issue of the Journal of Clinical Psychology: In-Session come from diverse theoretical orientations but discuss methods of case conceptualization that share these assumptions: (1) that interpersonal patterns are salient to a good understanding of patient personality and problems and (2) that an individual formulation is helpful in responsively tailoring in-session processes to meet therapeutic goals. We believe these assumptions resonate with many practitioners working across settings, levels of severity, and theoretical orientations. Each author offers an overview of theory as well as a detailed case description that emphasizes the implications of each formulation for the subsequent process of therapy. A final paper provides commentary across the source papers. The issue is thus evocative not only about clinical practice issues but also of underlying theory. It speaks to the challenges and possibilities of transtheoretical integrated practice and research within our focal domain of common interest, interpersonal relationships.
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Affiliation(s)
| | - Francesco Gazzillo
- Department of Dynamic and Clinical Psychology, and Health Studies, "Sapienza" University of Rome, Rome, Italy
| | - Ueli Kramer
- Department of Psychiatry, Institute of Psychotherapy and General Psychiatry, University Hospital Center and University of Lausanne, Lausanne, Switzerland.,University of Windsor, Windsor, Ontario, Canada
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Critchfield KL, Mackaronis JE, Thapa P, Cechak P. A brief overview of safety planning in interpersonal reconstructive therapy. Psychotherapy (Chic) 2021; 59:168-173. [PMID: 34941337 DOI: 10.1037/pst0000415] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Most research to date with Interpersonal Reconstructive Therapy (IRT: Benjamin, 2006) involves application with patients who qualify for the acronym "CORDS": Comorbid, Often Rehospitalized, Dysfunctional, and Suicidal. A case formulation (CF) based on interpersonal copy process theory defines links between presenting symptoms and patterns of affect, cognition, and behavior that invoke safety or threat and were learned and internalized in close relationships. The "gift of love" (GOL) hypothesis is that the wish to receive love and acceptance from specific internalized attachment figures organizes and propels problem patterns and their associated symptoms. Through a series of steps, IRT seeks to help patients become aware of and learn about their copied patterns, including where they were learned, the role they play in maintaining connection with internalized attachment figures, and their functions in the present. The goal is to help a patient differentiate from their "family in the head" and pursue healthy behaviors and self-concepts. With awareness and differentiation comes the possibility of letting go of problematic quests for love and acceptance from the internalized attachments and to choose healthy alternatives instead. As an integrative method, safety planning in IRT shares much with other approaches. What is unique is how therapists utilize the CF to guard against unsafe behavior as an ongoing part of the treatment process with patients with suicidality. This article provides an overview and illustration emphasizing these unique aspects of the IRT approach to safety planning in the context of individual psychotherapy with adults. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
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Critchfield KL, Thapa P, Panizo MT, Conceição N. Using interpersonal reconstructive therapy to address comorbid problems organized by attachment-based learning: The case of Don. J Clin Psychol 2021; 78:396-408. [PMID: 34914841 DOI: 10.1002/jclp.23292] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 11/15/2021] [Accepted: 12/01/2021] [Indexed: 11/09/2022]
Abstract
Feature heterogeneity and diagnostic overlap occur regularly among patients in clinical settings. In interpersonal reconstructive therapy (IRT), a case formulation focused on patterns learned in close attachment relationships guides intervention choices. This study illustrates how IRT formulation and treatment proceed, and how it may also fail when there is not close adherence to underlying principles. Don is a music professor in his 40's with a significant trauma history and complex diagnostic profile that includes many hospitalizations and suicide attempts. He qualified for several diagnostic and statistical manual of mental disorders personality disorders via formal diagnostic interviews (obsessive-compulsive, avoidant, passive-aggressive, narcissistic), as well as major depression, generalized anxiety, and substance abuse. Don's formulation demonstrates how self-destruction can function as a "gift of love" to internalized representations of important caregivers. Data from work with patients like Don confirm the usefulness of Benjamin's IRT lens for navigating comorbidity, as well as the importance of underlying principles of change.
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Affiliation(s)
- Kenneth L Critchfield
- Ferkauf Graduate School of Psychology, Yeshiva University, New York City, New York, USA
| | - Priyata Thapa
- Department of Graduate Psychology, James Madison University, Harrisonburg, Virginia, USA
| | - Mariafé T Panizo
- Student Health and Counseling Services, California State University, Sacramento, California, USA
| | - Nuno Conceição
- Research Center for Psychological Science (CICPSI), Faculdade de Psicologia, Universidade de Lisboa, Lisbon, Portugal
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Critchfield KL, Dobner-Pereira J, Stucker E. Interpersonal Wishes and Fears with Regard to Internalized Attachment Figures: Differing Focus of Two Case Formulation Methods that use SASB. PCSP 2021. [DOI: 10.14713/pcsp.v17i1.2089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
This commentary is organized in parallel with Westerman’s (2021b) comparison to include focus on (1) the formulation methods used by IRT and Interpersonal Defense Theory, and then (2) their treatment implications. In each major section, comments center first on comparison of the approaches in general, and then turn to a focus on the details of Sharon’s case. In sum, we wish to underscore the need for continued empirical work in both IRT and Interpersonal Defense Theory traditions as ways to advance our field. We see each method as offering a different scope and focal areas of concern. With a mind toward the advancement of research and application along both lines of thought, our commentary provides an overview of how we see areas of alignment, divergence, and their potential meaning for theory and practice. The two methods share a great deal in terms of assumptive worldviews, prioritization of relational material, and even specific measurement methodology (SASB). Where the methods diverge, we believe it is primarily because they seek answers to different kinds of questions.
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Abstract
This paper sets the stage for subsequent papers in this set of articles, which collectively offer a comparative examination of two approaches to case formulation and treatment by examining the same case from the two theoretical perspectives. One approach is based on Interpersonal Defense Theory (e.g., Westerman, 2018, 2019), the other is Interpersonal Reconstructive Therapy (IRT, Benjamin, 2006, 2018). In this paper, we present the goals of the project and its design, which was novel in some respects. We also introduce the case by presenting basic clinical information about the patient, Sharon (pseudonym), and describing the short-term therapy approach that was employed. The concluding section introduces the subsequent papers in this set, which includes a commentary by Stanley Messer that raises fundamental methodological/philosophy of science issues about comparing the relative merits of different therapy approaches and a reply to that commentary that addresses the important questions it poses.
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Westerman MA, Critchfield KL. Philosophical Considerations and Research Ideas About Comparing the Two Approaches: Messer’s Comments Point the Way Forward. PCSP 2021. [DOI: 10.14713/pcsp.v17i1.2091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
In his commentary, Stanley Messer (2021) posed the question of whether it is possible to evaluate the relative merits of different case formulation approaches to psychotherapy. He went on to maintain, based on the pragmatic theory of truth, that it is possible to compare different case formulation approaches, and pointed to a program of research that he and his collaborators conducted as an example for possible future research (Collins Messer, 1991; Holland, Roberts, Messer, 1998; Messer, Tishby, Spillman, 1992; Tishby Messer, 1995). In this reply, we express our appreciation for Messer’s remarks, with which we agree in large measure, and attempt to highlight and build upon some of the points he made. We discuss Dewey’s (1896) classic critique of the reflex arc concept to point out other ways the philosophical perspective of pragmatism supports the view that different approaches to therapy are not incommensurate. We also offer a number of suggestions for future research comparing psychotherapy based on Interpersonal Defense Theory and IRT, or any two case formulation approaches to therapy. At many points, our suggestions follow along the lines of Messer’s research. We also emphasize the value of case formulation-based studies, not only with regard to research comparing approaches to treatment, but for investigating other issues about therapy as well.
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Critchfield KL, Dobner-Pereira J, Stucker E. The Case of Sharon Considered from the Vantage Point of Interpersonal Reconstructive Therapy. PCSP 2021. [DOI: 10.14713/pcsp.v17i1.2087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
In Interpersonal Reconstructive Therapy (IRT: Benjamin, 2003/2006; 2018) a case formulation is used to tailor interventions to each patient’s unique patterns. Using the IRT lens, psychopathology is understood as reflecting attempts to adapt to current environments using maladaptive rules and values that were learned and internalized in the context of close attachment relationships. IRT identifies precise ways in which early learning shapes present experience. Additionally, the "gift of love" (GOL) hypothesis posits that motivation to repeat maladaptive ways is linked to the wish to receive love and acceptance from specific internalized attachment figures by repeating their ways and values for the patient. The IRT case formulation has been shown to be reliable and valid (Critchfield, Benjamin, Levenick, 2015). The therapy adherence measure is also reliable (Critchfield, Davis, Gunn, Benjamin, 2008) and correlates well with retention as well as reduced symptoms and rehospitalization rates (Karpiak, Critchfield, Benjamin, 2011) among "difficult to treat" patients characterized as having high levels of personality disorder, chronic and severe problems, and prior failed treatment attempts. To illustrate the case formulation process, an IRT formulation is applied to the case of a 28-year-old female patient for whom a poor outcome was documented.
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Siegel ML, Gullestad Binder EM, J. Dahl HS, Czajkowski NO, Critchfield KL, Høglend PA, Ulberg R. Erratum: Therapeutic Atmosphere in Psychotherapy Sessions. Int. J. Environ. Res. Public Health 2020, 17, 4105. Int J Environ Res Public Health 2020; 17:ijerph17145241. [PMID: 32698533 PMCID: PMC7399913 DOI: 10.3390/ijerph17145241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 07/15/2020] [Indexed: 06/11/2023]
Abstract
The authors wish to make the following correction to their paper [...].
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Affiliation(s)
- Marte L. Siegel
- Department of Psychology, University of Oslo, Forskningsveien 3A, 0373 Oslo, Norway; (H.S.J.D.); (N.O.C.)
| | - Eva M. Gullestad Binder
- Department of Psychology, University of Oslo, Forskningsveien 3A, 0373 Oslo, Norway; (H.S.J.D.); (N.O.C.)
| | - Hanne Sofie J. Dahl
- Department of Psychology, University of Oslo, Forskningsveien 3A, 0373 Oslo, Norway; (H.S.J.D.); (N.O.C.)
- Vestfold Hospital Trust, Halfdan Wilhelmsens alle 17, 3103 Tønsberg, Norway
| | - Nikolai O. Czajkowski
- Department of Psychology, University of Oslo, Forskningsveien 3A, 0373 Oslo, Norway; (H.S.J.D.); (N.O.C.)
| | - Kenneth L. Critchfield
- James Madison University, Department of Graduate Psychology, Harrisonburg, VA 22807, USA;
| | - Per A. Høglend
- Division of Mental Health and Addiction, University of Oslo, Kirkeveien 166, 0450 Oslo, Norway; (P.A.H.); (R.U.)
| | - Randi Ulberg
- Division of Mental Health and Addiction, University of Oslo, Kirkeveien 166, 0450 Oslo, Norway; (P.A.H.); (R.U.)
- Department of Psychiatry, Diakonhjemmet Hospital, Forskningsveien 7, 0370 Oslo, Norway
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Siegel ML, Gullestad Binder EM, Dahl HSJ, Czajkowski NO, Critchfield KL, Høglend PA, Ulberg R. Therapeutic Atmosphere in Psychotherapy Sessions. Int J Environ Res Public Health 2020; 17:ijerph17114105. [PMID: 32526849 PMCID: PMC7312465 DOI: 10.3390/ijerph17114105] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 05/28/2020] [Accepted: 06/02/2020] [Indexed: 11/22/2022]
Abstract
There is uncertainty concerning what the active ingredients in psychotherapy are. The First Experimental Study of Transference interpretations (FEST) was a randomized controlled trial of the effects of transference work (TW) in psychodynamic psychotherapy. Women with low quality of object relations (QOR) showed a large positive effect of transference work, while men with high QOR showed a slight negative effect. The present study aimed to expand the knowledge from the FEST by investigating the therapeutic atmosphere with Structural Analysis of Social Behavior (SASB). Two-way ANOVAs were conducted to investigate differences between SASB cluster scores between subgroups. The therapeutic atmosphere was characterized by Protect–Trust, Affirm–Disclose and Control–Submit. Multilevel modeling was used to assess the relationship between a therapist variable and outcomes for men and women. Contrary to expectations, no significant differences in therapeutic atmosphere between subgroups (with or without TW in women with low QOR and men with high QOR) were observed using the process measure SASB.
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Affiliation(s)
- Marte L. Siegel
- Department of Psychology, University of Oslo, Forskningsveien 3A, 0373 Oslo, Norway; (H.S.J.D.); (N.O.C.)
- Correspondence: (M.L.S.); (E.M.G.B.)
| | - Eva M. Gullestad Binder
- Department of Psychology, University of Oslo, Forskningsveien 3A, 0373 Oslo, Norway; (H.S.J.D.); (N.O.C.)
- Correspondence: (M.L.S.); (E.M.G.B.)
| | - Hanne Sofie J. Dahl
- Department of Psychology, University of Oslo, Forskningsveien 3A, 0373 Oslo, Norway; (H.S.J.D.); (N.O.C.)
- Vestfold Hospital Trust, Halfdan Wilhelmsens alle 17, 3103 Tønsberg, Norway
| | - Nikolai O. Czajkowski
- Department of Psychology, University of Oslo, Forskningsveien 3A, 0373 Oslo, Norway; (H.S.J.D.); (N.O.C.)
| | - Kenneth L. Critchfield
- Department of Graduate Psychology, James Madison University, Harrisonburg, VA 22807, USA;
| | - Per A. Høglend
- Division of Mental Health and Addiction, University of Oslo, Kirkeveien 166, 0450 Oslo, Norway; (P.A.H.); (R.U.)
| | - Randi Ulberg
- Division of Mental Health and Addiction, University of Oslo, Kirkeveien 166, 0450 Oslo, Norway; (P.A.H.); (R.U.)
- Department of Psychiatry, Diakonhjemmet Hospital, Forskningsveien 7, 0370 Oslo, Norway
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Critchfield KL, Mackaronis JE, Benjamin LS. Characterizing the integration of CBT and psychodynamic techniques in interpersonal reconstructive therapy for patients with severe and comorbid personality pathology. Journal of Psychotherapy Integration 2017. [DOI: 10.1037/int0000092] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Knobloch-Fedders LM, Critchfield KL, Staab EM. Informative Disagreements: Associations Between Relationship Distress, Depression, and Discrepancy in Interpersonal Perception Within Couples. Fam Process 2017; 56:459-475. [PMID: 26698189 DOI: 10.1111/famp.12201] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
This study evaluated the associations between relationship distress, depression symptoms, and discrepancy in interpersonal perception within couples. After completing a series of discussion tasks, couples (N = 88) rated their behavior using the circumplex-based Structural Analysis of Social Behavior Model (SASB; Benjamin, 1979, 1987, 2000). Overall, couple members were strikingly similar in their interpersonal perceptions, and tended to see themselves as friendly, reciprocal in their focus, and balanced between connection and separateness. As hypothesized, however, perceptual discrepancy was related to relationship distress and depression. Relationship distress was associated with discrepancy regarding transitive behavior focused on the partner, while depression was associated with disagreement about intransitive, self-focused behavior. Analysis of affiliation and autonomy revealed that relationship distress was associated with seeing oneself as reacting with more hostility than the partner sees, and perceiving one's partner as more hostile, more controlling, and less submissive than he or she does. Partners of depressed individuals viewed themselves as more controlling than their mate did. Men's depression was associated with disagreement between partners regarding men's self-focused behavior. Results underscore the importance of considering interpersonal perception when conceptualizing relationship distress and depression within intimate relationships.
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Affiliation(s)
- Lynne M Knobloch-Fedders
- The Family Institute at Northwestern University, Evanston, IL
- Department of Psychology, Northwestern University, Evanston, IL
| | | | - Erin M Staab
- Rollins School of Public Health, Emory University, Atlanta, GA
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Gunn HE, Critchfield KL, Mackaronis JE, Rau HK, Cribbet MR, Troxel WM, Williams PG. Affiliative interpersonal behaviors during stress are associated with sleep quality and presleep arousal in young, healthy adults. Sleep Health 2017; 3:98-101. [PMID: 28346164 DOI: 10.1016/j.sleh.2016.12.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Revised: 10/26/2016] [Accepted: 12/05/2016] [Indexed: 10/20/2022]
Abstract
OBJECTIVES This study examined the association between stress-related interpersonal behaviors, presleep arousal (PSA), and sleep quality. METHODS Sixty-four participants (53% female) described a recent stressful interpersonal event that was coded for overall degree of affiliation (warmth vs hostility) and autonomy (independence vs interdependence). Cognitive and somatic PSA and sleep quality were examined using regression with affiliation and autonomy scores as predictors. Specific interpersonal behaviors that comprise overall affiliation were also examined. RESULTS More affiliation (warmth) was associated with lower cognitive PSA (β=-.32) and better sleep quality (β=-.28). Autonomy was not associated with sleep quality or PSA. The specific behavior trust in others was associated with better sleep quality (rs=-.25). CONCLUSIONS Behaviors during stress reflect underlying dimensions of interpersonal security. Findings underscore importance of interpersonal frameworks for understanding associations between stress and sleep, and provide support for the anthropological theory that interpersonal security is necessary for healthy sleep.
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Affiliation(s)
- Heather E Gunn
- Department of Psychology, University of Utah, Salt Lake City, UT, USA; Department of Psychiatry, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA.
| | - Kenneth L Critchfield
- Department of Psychology, University of Utah, Salt Lake City, UT, USA; Department of Psychology at James Madison University, Harrisonburg, VA, USA
| | | | - Holly K Rau
- Department of Psychology, University of Utah, Salt Lake City, UT, USA
| | - Matthew R Cribbet
- Department of Psychology, University of Utah, Salt Lake City, UT, USA; Department of Psychology, Texas Tech University, Lubbock, TX, USA
| | - Wendy M Troxel
- Department of Psychiatry, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA and RAND Corporation, Pittsburgh, PA, USA
| | - Paula G Williams
- Department of Psychology, University of Utah, Salt Lake City, UT, USA
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Critchfield KL, Benjamin LS, Levenick K. Reliability, Sensitivity, and Specificity of Case Formulations for Comorbid Profiles in Interpersonal Reconstructive Therapy: Addressing Mechanisms of Psychopathology. J Pers Disord 2015. [PMID: 26200851 DOI: 10.1521/pedi.2015.29.4.547] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Interpersonal Reconstructive Therapy (IRT) case formulations describe psychosocial mechanisms of affective and personality pathology in ways that enhance the effectiveness of psychotherapy for individuals. With a valid and reliable IRT case formulation, a clinician is in a better position to draw upon effective techniques to maximize treatment effects. The case formulation and treatment models for IRT were described in depth along with the IRT treatment model by Benjamin (2003/2006). Data in this report from 93 adult inpatients with complex and comorbid presentations suggest that the case formulation is highly reliable and unique to individuals, and that symptoms reflect current interpersonal stresses linked to early interactions involving forms of hostility in relation with attachment figures and corresponding to three basic patterns in adulthood: identification (be like him or her), recapitulation (act as you did with him or her), and introjection (treat yourself as you were treated).
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Abstract
The principle of complementarity in interpersonal theory states that an actor’s behavior tends to “pull, elicit, invite, or evoke” responses from interaction partners who are similar in affiliation (i.e., warmth vs. hostility) and opposite in control (i.e., dominance vs. submissiveness). Furthermore, complementary interactions are proposed to evoke less negative affect and promote greater relationship satisfaction. These predictions were examined in two studies of married couples. Results suggest that complementarity in affiliation describes a robust general pattern of marital interaction, but complementarity in control varies across contexts. Consistent with behavioral models of marital interaction, greater levels of affiliation and lower control by partners—not complementarity in affiliation or control—were associated with less anger and anxiety and greater relationship quality. Partners’ levels of affiliation and control combined in ways other than complementarity—mostly additively, but sometimes synergistically—to predict negative affect and relationship satisfaction.
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Knobloch-Fedders LM, Critchfield KL, Boisson T, Woods N, Bitman R, Durbin CE. Depression, relationship quality, and couples’ demand/withdraw and demand/submit sequential interactions. J Couns Psychol 2014; 61:264-79. [DOI: 10.1037/a0035241] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Ulberg R, Amlo S, Critchfield KL, Marble A, Høglend P. Transference interventions and the process between therapist and patient. ACTA ACUST UNITED AC 2014; 51:258-69. [PMID: 24634996 DOI: 10.1037/a0034708] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Interpreting the transference has been considered a core ingredient in psychodynamic psychotherapy. The effects of analyzing the transference are probably dependent on certain characteristics of the interventions themselves and the context in which transference interventions are given. The present study describes the development and use of a therapy process rating scale (Transference Work Scale; TWS) constructed to identify, categorize, and explore work with the transference. TWS has subscales that rate timing, content, and valence of the transference interventions, as well as response from the patient. Transcribed segments (10 min) from 51 different patients were scored with TWS by 2 independent raters. The interrater agreement on the TWS items was good to excellent. Clinical examples of transference work were also rated using the Structural Analysis of Social Behavior (SASB). TWS and SASB supplement each other. TWS might be a potentially useful tool to explore the interaction of timing, category, and valence of transference work in predicting in-session patient response as well as treatment outcome.
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Affiliation(s)
| | | | | | - Alice Marble
- Division of Mental Health and Addiction, University of Oslo
| | - Per Høglend
- Division of Mental Health and Addiction, University of Oslo
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Knobloch-Fedders LM, Knobloch LK, Durbin CE, Rosen A, Critchfield KL. Comparing the interpersonal behavior of distressed couples with and without depression. J Clin Psychol 2013; 69:1250-68. [PMID: 23794374 DOI: 10.1002/jclp.21998] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE This study compared the interpersonal behavior of distressed couples with depression in one partner (n = 23) to distressed couples without depression in either partner (n = 38). METHOD Participants (mean age = 44 years old) were recruited at an urban outpatient mental health center. Couples discussed the three best things in their relationship, and their interactions were coded using Structural Analysis of Social Behavior (Benjamin, 1987). RESULTS Self- and partner-focused hostility were associated with actors' and partners' relationship distress. Actors' hostility towards partners was positively associated with partners' depression status, but negatively associated with partners' depression symptoms. Actors' control behavior was positively associated with their relationship distress. Whereas the behavior of depressed individuals did not differ from a control sample of nondepressed individuals, partners of depressed individuals displayed more partner-focused hostility and submissiveness than controls. CONCLUSIONS Results underscore the importance of considering partner effects when conceptualizing depression within distressed relationships.
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Abstract
The American Psychological Association Task Force headed by Castonguay and Beutler (2006) distilled general treatment principles common to all therapies from the empirical literature. As part of this work, Critchifield and Benjamin (2006a, 2006b) summarized principles for treatment of personality disorder. The principles are pragmatic in the sense that they are based on evidence of what works, and clinicians are encouraged to apply them in ways that fit the unique presentation and needs of a given patient. An important element of the recommended approach is that it be coherent, well-coordinated, and agreed upon by the patient. Additional principles emphasize the importance of an individual's attachment and trauma history. A complex case example is presented to illustrate one way in which emphasis on an individual's relational learning history can be used to further refine and extend wisdom inherent in the cross-cutting principles and move in the direction of an integrative treatment that is closely tailored to specific case features. A research approach is also outlined for how to test the validity of principles that prescribe differential use of technique to address diverse patient presentations.
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Affiliation(s)
- Kenneth L Critchfield
- University of Utah Neuropsychiatric Institute and Department of Psychology, Salt Lake City, UT 84108, USA.
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Critchfield KL, Clarkin JF, Levy KN, Kernberg OF. Organization of co-occurring Axis II features in borderline personality disorder. British Journal of Clinical Psychology 2010; 47:185-200. [PMID: 17845740 DOI: 10.1348/014466507x240731] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVES Considerable heterogeneity exists in the comorbid Axis II features that frequently accompany borderline personality disorder (BPD). These features have potential to be meaningfully organized, relate to specific BPD presentation, and have implications for treatment process and outcome. The present study explored patterns of Axis II comorbidity in order to identify subtypes of BPD. DESIGN A well-defined sample of 90 patients diagnosed with BPD was recruited as part of an RCT study. Participants were administered the International Personality Disorder Examination (Loranger, 1999) to diagnose BPD and assess comorbid Axis II features. Other measures were also administered to assess aspects of current work and relationship functioning, symptomatology, and self-concept. METHODS AND RESULTS Q-factoring was used to develop subtypes based on commonly occurring Axis II profiles, identifying three: Cluster A (elevated paranoid and schizotypal features), Cluster B (elevated narcissistic and histrionic features), and Cluster C (elevated avoidant and obsessive-compulsive features). An additional factor analysis revealed two dimensions underlying the comorbid features identifiable as: extraversion versus introversion and antagonism versus constraint. Validity of these two maps of comorbidity was explored in terms of the BPD criteria themselves, as well as on work and relationship functioning, identity diffusion, views of self and others, positive and negative affect, behavioural dyscontrol, and symptomatic distress. CONCLUSIONS Clinically meaningful subtypes can be identified for BPD based on co-occurring Axis II features. Further research is needed to replicate and further establish base-rates of these subtypes as well as their differential implications for treatment.
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Abstract
Repeated interpersonal patterns are central to case conceptualization and treatment planning in interpersonal and attachment-based approaches to therapy. In this study, raters (133 college students, 165 inpatients) provided data on the Intrex questionnaire (Benjamin, 2000) about self-treatment, relationship with a significant other, and remembered interactions with parents in childhood. Within-subject profiles were inspected for precise behavioral matches conforming to 3 "copy process" (CP) patterns: identification (behaving like an important other), recapitulation (behaving as if the other person is still present and in charge), and introjection (treating the self the way another did). We observed CP evidence in most individual ratings. Consistent with expectation, nonclinical raters tended to copy a securely attached pattern of affiliation, low hostility, and moderate degrees of enmeshment and differentiation. Only patients copied maladaptive behavior at greater than base rate expectation. We discuss implications and provide recommendations for use of Intrex in individual assessment of CP.
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Affiliation(s)
- Kenneth L Critchfield
- University Neuropsychiatric Institute, University of Utah, Salt Lake City, UT 84112, USA.
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Stern BL, Caligor E, Clarkin JF, Critchfield KL, Horz S, MacCornack V, Lenzenweger MF, Kernberg OF. Structured Interview of Personality Organization (STIPO): preliminary psychometrics in a clinical sample. J Pers Assess 2010; 92:35-44. [PMID: 20013454 DOI: 10.1080/00223890903379308] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
In this article, we describe the development and preliminary psychometric properties of the Structured Interview of Personality Organization (STIPO), a semistructured interview designed for the dimensional assessment of identity, primitive defenses, and reality testing, the three primary content domains in the model of personality health and disorder elaborated by Kernberg (1984; Kernberg & Caligor, 2005). Results of this investigation, conducted in a clinical sample representing a broad range of personality pathology, indicate that identity and primitive defenses as operationalized in the STIPO are internally consistent and that interrater reliability for all 3 content domains is adequate. Validity findings suggest that the assessment of one's sense of self and significant others (Identity) is predictive of measures of positive and negative affect, whereas the maladaptive ways in which the subject uses his or her objects for purposes of regulating one's self experience (Primitive Defenses) is predictive of measures of aggression and personality disorder traits associated with cluster B personality disorders. We discuss implications of these findings in terms of the theory-driven and trait-based assessment of personality pathology.
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Affiliation(s)
- Barry L Stern
- Columbia University College of Physicians and Surgeons and the Columbia Center for Psychoanalytic Training and Research, New York, NY 10017, USA.
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Magnavita JJ, Levy KN, Critchfield KL, Lebow JL. Ethical considerations in treatment of personality dysfunction: Using evidence, principles, and clinical judgment. ACTA ACUST UNITED AC 2010. [DOI: 10.1037/a0017733] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Critchfield KL, Levy KN, Clarkin JF, Kernberg OF. The relational context of aggression in borderline personality disorder: using adult attachment style to predict forms of hostility. J Clin Psychol 2008; 64:67-82. [PMID: 18161033 DOI: 10.1002/jclp.20434] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Attachment theory provides a framework for understanding and predicting critical aspects of aggression in the personality disorders. An association between borderline personality disorder (BPD) and insecure forms of adult attachment marked by high relationship anxiety has been repeatedly observed in the empirical literature. Aggression also has been linked to insecure attachment. The present study extends previous work by exploring the degree to which the underlying attachment dimensions of relationship anxiety and avoidance are associated in BPD with the following forms of hostility: (a) direct aggression (verbal or physical) initiated towards others, (b) expectation/perception of aggression from others (including "reactive" counteraggression when/if provoked), (c) aggression directed towards the self in the form of suicidality or parasuicidality, and (d) affective experience of irritability or anger. The issue was studied in a sample of 92 patients diagnosed with BPD. Results show significant association between more fearful forms of attachment (simultaneous presence of relationship anxiety and avoidance) and the more reactive form of aggression involving expectation of hostility from others. Self-harm was significantly associated only with relational avoidance while anger and irritability were associated only with relational anxiety. Implications for understanding relational aspects of BPD aggression in research and clinical work are discussed.
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Affiliation(s)
- Kenneth L Critchfield
- IRT Clinic, University of Utah Neuropsychiatric Institute, Salt lake City, UT 84108, USA.
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Critchfield KL, Benjamin LS. Internalized representations of early interpersonal experience and adult relationships: a test of copy process theory in clinical and non-clinical settings. Psychiatry 2008; 71:71-92. [PMID: 18377207 DOI: 10.1521/psyc.2008.71.1.71] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Studies connecting childhood experience and adult psychopathology often focus on consequences of abuse and neglect. Copy process theory (Benjamin, 2003) states that constructive as well as destructive experiences shape adult behavior with surprising interpersonal specificity. Childhood perceptions and social learning are encoded in memory and then "copied" in 3 basic ways in subsequent relationships: Identification (behaving as he or she behaved), Recapitulation (behaving as one behaved when with him or her), and Introjection (treating oneself as he or she was treated). The first step in evaluating copy process theory is to verify that the predicted correspondence between adult relational patterns and internal representation of early experience can be observed in different adult samples. Remembered interpersonal patterns from childhood and perceptions of adult relational patterns were measured using the Structural Analysis of Social Behavior (SASB). Strong evidence was found for each copy process in a sample of psychiatric inpatients (N = 161) and a college sample (N = 133). Positive and negative behaviors were copied in both. Evidence suggests that gender, patient status, and rated state may influence whether, and in which forms, copying occurs.
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Abstract
Early sessions from three variants of cognitive-behavioral therapy (CBT) were examined to replicate work done in psychodynamic-interpersonal treatments linking interpersonal process to outcome (W. P. Henry, T. E. Schacht, & H. H. Strupp, 1986, 1990). Cases were available from a component study of CBT for generalized anxiety disorder (T. D. Borkovec, M. G. Newman, A. L. Pincus, & R. Lytle, 2002) and were selected to form good and poor outcome groups maintained through a 1-year follow-up. A third group was also examined that had initial positive outcomes and marked decline by follow-up (n = 8 for each). Structural analysis of social behavior (SASB) was used to identify interpersonal behaviors. Contrary to the authors' expectation, SASB variables were not strong predictors of outcome, and lower levels of interpersonal hostility were found than was the case in previous work. Findings are discussed in light of differences observed between treatment variants and the role that manuals may have in standardizing some aspects of the therapeutic relationship.
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Critchfield KL, Levy KN, Clarkin JF. The Personality Disorders Institute/Borderline Personality Disorder Research Foundation Randomized Control Trial for Borderline Personality Disorder: reliability of Axis I and II diagnoses. Psychiatr Q 2007; 78:15-24. [PMID: 17102935 DOI: 10.1007/s11126-006-9023-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The Personality Disorder Institute/Borderline Personality Disorder Research Foundation randomized control trial (PDI/BPDRF RCT) is a randomized control trial comparing three treatments for borderline personality disorder (BPD). An important issue for any RCT is diagnostic reliability, demonstration of which is necessary to evaluate claims of a treatment's efficacy for a given population. The present paper examines the interrater reliability of Axis I and II disorders in the context of a high base rate of BPD features for participants referred for inclusion in the RCT. Our results indicate good to excellent levels of interrater reliability for all Axis I and II disorders in this context. Assessors were able to reliably diagnose BPD, exclusionary criteria, and comorbid diagnoses. This data is important for comparing findings and sample composition across different studies using similar sampling strategies, especially as treatments are increasingly being developed and tested for BPD.
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Affiliation(s)
- Kenneth L Critchfield
- New York-Presbyterian Hospital, Joan and Sanford I Weill Medical College of Cornell University, New York, NY, USA.
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Abstract
Structural analysis of social behavior (SASB) is a model that can be used to assess interpersonal and intrapsychic interactions in terms of three underlying dimensions: (a) focus (other, self, introject), (b) affiliation-hostility (love-hate), and (c) interdependence-independence (enmeshment-differentiation). Assessment of individuals or groups in terms of these dimensions can be made by self-ratings on the SASB Intrex questionnaires, ratings by others using the same questionnaires, or by objective observer ratings. Data generated by questionnaires or formal codes yield identical summary parameters, making it possible to compare directly objective observer assessments with self-ratings, if desired. The goal of this chapter is to help the reader understand the structure of SASB, become aware of how it has been used in studying interpersonal and intrapsychic events, assess its validity, assess the substance and relevance of criticisms, and consider future possibilities.
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Affiliation(s)
- Lorna Smith Benjamin
- Neuropsychiatric Institute and Department of Psychology, University of Utah, Salt Lake City, Utah 84108, USA.
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Critchfield KL, Benjamin LS. Principles for psychosocial treatment of personality disorder: Summary of the APA Division 12 Task Force/NASPR review. J Clin Psychol 2006; 62:661-74. [PMID: 16538666 DOI: 10.1002/jclp.20255] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
A wide variety of clinical problems and relational styles are collected under the diagnostic heading of personality disorder (PD). These disorders involve maladaptive, persistent ways of thinking, feeling, and behaving that are associated with both functional impairment and disturbed interpersonal relationships. Personality disorders are difficult to treat, and challenge a therapist's ability to intervene helpfully, in part because the maladaptive patterns can impact the therapy relationship itself. Therapeutic principles were derived by Task Force review from the small body of research conducted to date with this family of disorders and include characteristics of clients and therapists, their relationship together, and essential elements of technique. The importance of a collaborative relationship as well as a treatment that is comprehensive, empathic, patiently applied, and flexibly tailored to presenting problems are dominant themes across principles. Treatment research with PD is in its early stages and many important areas remain uncharted. The Task Force principles are here summarized in hopes of providing general guidance to clinicians working with PD, as well as to outline research needs for the area.
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Critchfield KL, Levy KN, Clarkin JF. The relationship between impulsivity, aggression, and impulsive-aggression in borderline personality disorder: an empirical analysis of self-report measures. J Pers Disord 2004; 18:555-70. [PMID: 15615667 DOI: 10.1521/pedi.18.6.555.54795] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Impulsivity has been repeatedly identified as a key construct in BPD; however, its precise definition seems to vary especially regarding the overlap with aggression. The term impulsive-aggression , also generally seen as central to an understanding of BPD, seems to address itself to the interface between the two, but has itself been used inconsistently in the literature, sometimes having reference to a unitary phenotypic dimension, and at other times suggesting some combination of distinct traits. This study examined the relationship between multiple measures of impulsivity, aggression, and impulsive-aggression in a BPD sample ( N = 92) in order to clarify the relationship between these measured constructs in this clinical population. Results show little relationship between measures of aggression and impulsivity in BPD, with measures of impulsive-aggression correlating strongly with measures of aggression only. Implications of the present results for future research and clinical work with BPD are discussed.
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Affiliation(s)
- Kenneth L Critchfield
- New York Presbyterian Hospital, Joan and Sanford I. Weill Cornell Medical College, USA.
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