Enhanced adaptive capacities after brief treatment for depression.

Using data from the National Institute of Mental Health-sponsored Treatment of Depression Collaborative Research Program, the authors examined predictors of the intensity of depressive symptoms after the brief treatment of depression. Multilevel modeling was applied to measures of depression and stress assessed at termination and at 6-, 12-, and 18-month follow-ups. The slope of depression on stress was used to index stress reactivity. Patients with high mean levels of stress experienced more intense depressive symptoms, but this effect was moderated by patients' reports of the extent to which they had acquired enhanced adaptive capacities (EACs) in treatment. Patients who reported high EAC early in the follow-up were more resilient in the face of stress than those with low EAC. Greater EACs were found for patients who received psychotherapy than medication or placebo and, across all treatments, for patients with a stronger therapeutic alliance. These findings suggest that treatments should be evaluated in terms of their impact on patients' developing adaptive capacities as well as the reduction of symptomatology.

Mental representation, severe psychopathology, and the therapeutic process.

Mental representation is a central construct in psychological development. A method for assessing the developmental level of representation of self and significant figures is described, and changes in the developmental level of these representations are reported in a sample of forty seriously disturbed, treatment-resistant adolescents and young adults in intensive, psychoanalytically oriented inpatient treatment lasting more than a year. Increased differentiation-relatedness of descriptions of self and significant figures (mother, father, and therapist) was significantly correlated with improved clinical functioning. Over the course of treatment, representations moved from descriptions of self and significant figures dominated by polarization and splitting to representations involving the emergence and consolidation of object constancy. Improved clinical functioning was correlated with more positive descriptions of self, mother, and therapist and, paradoxically, with more negative descriptions of father. Two prototypical case studies of these self- and significant-figure descriptions are presented, one for a borderline patient and one for a schizophrenic. Intense negative affect, predominantly anger, and a relative preservation of self-reflexivity are typical of the self- and object representations of borderline individuals, but representations in schizophrenic individuals are characterized by affective muting and marked disturbance in reflexive self-awareness. The assessment of cognitive-affective schemas of self and significant others provides a method for investigating therapeutic change and for identifying important differences among various forms of psychopathology.

Levels of interpersonal concerns and social functioning in early adolescent boys and girls.

Previous research has shown that the Interpersonal Concerns factor of the Depressive Experiences Questionnaire (DEQ; Blatt, D'Affliti, & Quinlan, 1976, 1979; Depressive Experiences Questionnaire for Adolescent [DEQ-A]; Blatt, Schaffer, Bers, & Quinlan, 1992) assesses 2 levels of interpersonal relatedness in young adults and older adolescents: neediness and relatedness. However, studies investigating the relation of the DEQ and DEQ-A with social functioning have not used the Neediness and Relatedness subscales of the Interpersonal Concerns factor. This study investigated (a) whether the Neediness and Relatedness subscales can be differentiated in a sample of early adolescents and (b) how the 2 subscales are differentially associated with indexes of social functioning. Results indicate that this differentiation of Neediness and Relatedness, and their associations with social functioning, emerges in early adolescence, especially for girls.

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

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

Psychotherapy for depression: current and future directions in research, theory, practice and public policy.

This article is based on a symposium held at the 1998 Annual Meeting of Society for Psychotherapy Research (Snow Bird, Utah). Recognized experts addressed current and future directions in psychotherapy for depression from the perspectives of process and outcome research, basic research, theoretical models, clinical practice and training, and public policy. The specific issues discussed at the symposium included the strengths and limitations of major forms of psychotherapy; the therapeutic factors common and unique to different approaches; the future viability of current theories of depression; the role of treatment manuals in clinical practice and training; the development of new interventions based on basic research; and the priorities that should guide federal funding.

A multivariate model of gender differences in adolescents' internalizing and externalizing problems.

Gender differences observed in interpersonal and self-critical vulnerabilities, reactivity to stressful life events, quality of relationships, and self-concepts inform a multivariate theoretical model of the moderating effects of gender on internalizing and externalizing problems in adolescence. To test this model, data were collected in a 1-year prospective study from an ethnically diverse sample of 460 middle school students. Increases in girls' internalizing symptoms, compared with boys', were partly explained by greater stability in girls' interpersonal vulnerabilities and greater magnitude in coefficients linking girls' relationships with parents and peers and internalizing problems. Boys' risks for externalizing problems, compared with girls', were partly explained by the greater stability in boys' vulnerability to self-criticism. Coefficients for most pathways in the model are similar for boys and girls.

Vulnerability to depression: reexamining state dependence and relative stability.

Treatment-related decreases in Dysfunctional Attitudes Scale (DAS; Weissman & Beck, 1978) scores have been interpreted as evidence that dysfunctional attitudes are state-dependent concomitants of depression. Data from the National Institute of Mental Health Treatment of Depression Collaborative Research Program were used to reexamine the stability of dysfunctional attitudes. Mean scores for Perfectionism, Need for Approval, and total DAS decreased after 16 weeks of treatment. However, test-retest correlations showed that the DAS variables displayed considerable relative stability. Structural equation models demonstrated that dysfunctional attitudes after treatment were significantly predicted by initial level of dysfunctional attitudes as well as by posttreatment depression. The relative stability of dysfunctional attitudes was even higher during the 18-month follow-up period. The results were consistent with Beck's (1967) and Blatt's (1974) theories of vulnerability.

Contributions of psychoanalysis to the understanding and treatment of depression.

Psychoanalysis continues to make important contributions to basic clinical understanding of adaptive and maladaptive psychological development, and particularly to the understanding of depression and its treatment. This paper demonstrates that a basic theoretical conceptualization, central to many of Freud's fundamental contributions, has provided the basis for a wide range of contemporary psychoanalytic and nonpsychoanalytic formulations of personality development and organization; for understanding various forms of psychopathology in adults as deriving from disruptions of normal developmental processes, especially personality disorders and depression; and for conducting research on psychotherapeutic process and outcome in both brief and long-term intensive treatment.

When and how perfectionism impedes the brief treatment of depression: further analyses of the National Institute of Mental Health Treatment of Depression Collaborative Research Program.

Perfectionism has previously been identified as having a significant negative impact on therapeutic outcome at termination in the brief (16-week) treatment of depression (S. J. Blatt, D. M. Quinlan, P. A. Pilkonis, & T. Shea, 1995) as measured by the 5 primary outcome measures used in the National Institute of Mental Health Treatment of Depression Collaborative Research Program (TDCRP). The present analyses of other data from the TDCRP indicated that this impact of perfectionism on therapeutic outcome was also found in ratings by therapists, independent clinical evaluators, and the patients and that this effect persisted 18 months after termination. In addition, analyses of comprehensive, independent assessments made during the treatment process indicated that perfectionism began to impede therapeutic gain in approximately 2/3 of the sample, in the latter half of treatment, between the 9th and 12th sessions. Implications of these findings are discussed, including the possibility that more perfectionistic patients may be negatively impacted by anticipation of an arbitrary, externally imposed termination date.

Impairment of self-representation in schizophrenia: the roles of boundary articulation and self-reflexivity.

Since the time of Kraepelin, clinicians and researchers have regarded disturbances in the sense of self as an essential feature of the clinical phenomenology of schizophrenia. Through a qualitative analysis of a schizophrenic patient's self-descriptions, this article illustrates the roles of boundary aberrations and hyperreflexivity (i.e., excessive focus on oneself) in producing the identity disturbances associated with this disorder. In this patient's self-descriptions, reflexive self-awareness resulted in confusion and perplexity, as if a core self or basic self-other boundaries were lacking altogether. In contrast, a qualitative analysis of a borderline patient's self-descriptions suggested that a sense of identity, in turn the result of better boundary articulation, was present but unstable and highly reactive to changes in mood. Psychotherapeutic implications of impairments in self-representation are discussed.

Characteristics of effective therapists: further analyses of data from the National Institute of Mental Health Treatment of Depression Collaborative Research Program.

Analyses of the data of the National Institute of Mental Health-sponsored Treatment of Depression Collaborative Research Program have primarily examined the effects of types of treatment and patient characteristics on outcome, but scant attention has been directed toward evaluating the contributions of the therapist. With an aggregate of residualized therapeutic change scores of the 5 primary outcome measures for each patient at termination as an overall measure of improvement, an average therapeutic effectiveness measure was derived for each of the 28 therapists based on the outcome of the patients they saw in active treatment. The distribution of the therapists was divided into thirds, and comparisons indicate that more effective therapists are more psychological minded, eschew biological interventions (i.e., medication and electroconvulsive therapy) in their ordinary clinical practice, and expect outpatient treatment of depression to take longer than did moderately and less effective therapists.

Attachment and separateness in the experience of symbiotic relatedness.

Symbiosis is a central theoretical construct in a number of psychoanalytic formulations of personality development, yet its validity has recently been challenged. On the basis of a model of development that views self identity as emerging through a dialectical interaction of two primary developmental lines--attachment and separateness--we suggest that the intrapsychic state of undifferentiation denoted by the term symbiosis refers to two distinct kinds of experience. In terms of attachment it refers to an experience of merger; in terms of separateness, to fusion. An examination of these two dimensions clarifies some of the contemporary challenges to the concept of symbiosis and furthers the understanding of the role of the varied experiences of symbiotic unity in development as well as in psychopathology.

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

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

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

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

Subscales within the dependency factor of the Depressive Experiences Questionnaire.

Recent theoretical formulations differentiate two types of depressive experiences: one focused on interpersonal issues, such as loss, abandonment, and loneliness; the other focused on issues of self-esteem, such as failure, guilt, and lack of self-worth and autonomy. The Depressive Experiences Questionnaire (DEQ; Blatt, D'Afflitti, & Quinlan, 1976, 1979) assesses these two types of depression. Symptom-based measures of depression (i.e., the Beck Depression Inventory, Beck, Rush, Shaw, & Emery, 1979) have highly significant correlations with the DEQ Self-Criticism factor but only marginally significant correlations with the DEQ Dependency (or interpersonal) factor. Through the use of facet theory and Smallest Space Analysis (Guttman, 1982a), two facets were identified within the DEQ Dependency factor that appear to assess two different levels of interpersonal relatedness. One facet, labelled dependence, includes items expressing feelings of helplessness; fears and apprehensions about separation and rejection; and intense, broad-ranging concerns about possible loss unrelated to a particular relationship. The second facet, labelled relatedness, includes items that consider feelings of loss and loneliness in reaction to disruption of a relationship with a particular person. The dependence facet had significantly higher correlations with measures of depression, whereas the relatedness facet had significantly higher correlations with measures of psychological well-being, especially in women. Thus, the DEQ Dependency factor appears to contain two facets that assess interpersonal relatedness at different developmental levels and correlate differentially with measures of depression and of psychological well-being.

Impact of perfectionism and need for approval on the brief treatment of depression: the National Institute of Mental Health Treatment of Depression Collaborative Research Program revisited.

Patients in the National Institute of Mental Health Treatment of Depression Collaborative Research Program (TDCRP) were administered at intake with the Dysfunctional Attitude Scale (DAS; A. N. Weissman & A. T. Beck, 1978). Factor analyses of the DAS in the TDCRP data as well as in several independent samples reveal two primary factors: an interpersonal factor, Need for Approval, and a self-critical factor, Perfectionism. This study explored the hypotheses that these factors, assessed prior to treatment, would have differential interactions with the two forms of psychotherapy evaluated in the TDCRP as well as differential relationships to various outcome measures (depression, clinical functioning, and social adjustment). DAS Perfectionism had consistently significant negative relationships with all the outcome measures in all four treatment conditions. Contrary to expectations, however, there were no significant interactions between the two DAS factors and the four types of brief treatment (cognitive-behavioral therapy, interpersonal therapy, imipramine, and placebo).

Assessment of object relatedness through a lexical content analysis of the TAT.

A variety of psychological tests and scoring systems have been developed to assess object representation, including schemata using Rorschach responses, the Thematic Apperception Test (TAT), Early Memories, and Loevinger's Sentence Completion Test for Ego Development. This article presents an alternative approach to assessing TAT responses for possible indices of self/other schemata. In this study, we explored a lexically based, quantitative approach for assessing object relations in a sample of hospitalized psychiatric patients for whom extensive clinical, psychological test, and behavioral data were available. To test the relationship between lexical choice and individuals' representational schemata, we subjected verbatim transcripts of TAT responses to a computerized content analysis and then correlated content profiles with independent assessments of object representation and interpersonal relations derived from other psychological test assessments and from behavioral and clinical observation. These included the Urist (1977) Mutuality of Autonomy score and Blatt, Brenneis, Schimek, and Glick's (1976) Developmental Analyses of the Concept of the Object, as well as ratings of clinical behavior as expressed in independently derived clinical case reports. The findings suggest that lexical choices in TAT narratives represent a highly reliable, valid means of assessing the quality of object relations, particularly unconscious or preconscious aspects of such representations.