A Preliminary Study of the Interactive Effect of Avoidant Personality Disorder Symptoms and Expressive Suppression on the Outcome of a Psychodynamically Oriented Day Treatment Program.

Introduction: Patients with avoidant personality disorder (AvPD) pathology tend to have poor prognosis in psychotherapy, yet there has been little research conducted to better understand why their outcomes are limited, making it difficult to improve treatments for them. Expressive suppression is a dysfunctional emotion regulation strategy that may exacerbate avoidant tendencies, further complicating the therapeutic process. Methods: Using data from a naturalistic study (N = 34) of a group-based day treatment program, we examined whether there was an interactive effect of AvPD symptoms and expressive suppression on treatment outcome. Results: Findings revealed a significant moderating effect of expressive suppression on the association between AvPD symptoms and treatment outcome. The outcome for patients with more severe AvPD symptoms was particularly poor when they engaged in high levels of expressive suppression. Discussion: The findings suggest that the combination of significant AvPD pathology and high expressive suppression is associated with poorer responsiveness to treatment.

The Relationship Between Patients' Personality Traits, the Alliance, and Change in Interpersonal Distress in Intensive Group Treatment for Personality Dysfunction.

This study examined patients' personality traits as operationalized by the five-factor model in relation to early alliance and reduction of interpersonal distress through an intensive group treatment program for personality dysfunction. A sample of 79 consecutively admitted psychiatric outpatients with personality dysfunction who attended an 18-week intensive group treatment program completed the NEO Five-Factor Inventory at pretreatment, the Inventory of Interpersonal Problems at pre- and posttreatment, and the Edmonton Therapeutic Alliance Scale, a measure of the therapeutic alliance with the program therapist, at Session 5. Results indicated that patients who were relatively extraverted tended to rate the alliance with their program therapist higher and subsequently reported more improvement of interpersonal distress. The presence of a personality disorder did not moderate this mediation. Patients' extraversion likely promotes a bonding with the therapist and facilitates the interpersonal group work necessary for improvement. Assessing patients' level of extraversion before starting intensive group treatment might indicate which intervention strategies could be useful with that patient within the program frame.

Interpersonal problems and social dysfunction: Examining patients with avoidant and borderline personality disorder symptoms.

OBJECTIVE(S): Interpersonal problems are one of the most persistent difficulties facing those with personality disorders (PDs) and are linked with dysfunction across numerous social domains. Using an interpersonal model of PDs, we examined the indirect effects of Avoidant PD (AvPD) symptoms and social dysfunction through interpersonal problems, as well as Borderline PD (BPD) symptoms and social dysfunction. METHODS: Participants were 226 adults taking part in an outpatient treatment program. RESULTS: Using cross-sectional data from self-reported measures, we found that cold (b = 0.10, 95% confidence interval (CI) [0.038, 0.176]) and overly nurturant (b = 0.04, 95% CI [0.001, 0.090]) interpersonal problems showed an indirect association between AvPD symptoms and social dysfunction. The only significant indirect association between BPD symptoms and social dysfunction was overly nurturant (b = 0.05, 95% CI [0.001, 0.120]). CONCLUSIONS: Results may aid in the development of more individualized treatments for AvPD and BPD symptoms.

Different fixation constructs and the risk of non-union following first metatarsophalangeal joint arthrodesis.

BACKGROUND: The aim of this study was to determine if a single or separate construct with interfragmentary screw was associated with higher rates non-union following first metatarsophalangeal joint (MTPJ) arthrodesis. METHODS: A retrospective analysis of patients undergoing first MTPJ arthrodesis between April 2010 and June 2017 was performed. Patients who received either a single (Stryker Anchorage 1 MTP Cross Plate) or separate (Stryker Anchorage 1 MTP locking plate with one Asnis partially threaded compression screw) construct locking plate and interfragmentary compression screw were reviewed. Descriptive statistics were generated for sample demographics and between-group differences were calculated. Multivariable regressions explored internal fixation type and association with non-union. RESULTS: A total of 280 first MTPJ arthrodesis met the inclusion criteria and were reviewed. The incidence of non-union was 7.9% of procedures (22 joints). Following multivariable binary logistic regression, the single construct locking plate with interfragmentary compression screw was associated with an increased risk of non-union (OR 3.43, 95% CI 1.26-9.33), adjusting for age, gender and comorbidity. CONCLUSIONS: A single construct interfragmentary screw and locking plate (Stryker Anchorage 1 MTP Cross Plate) was associated with an increased incidence of non-union following first MTPJ arthrodesis.

Depression symptoms' impact on personality disorder treatment: Depression symptoms amplifying the interpersonal benefits of negative-affect expression.

BACKGROUND: While there is some evidence that patients with elevated depression symptoms experience greater benefits from negative-affect expression, this amplifying effect has not been investigated within a psychotherapeutic context. This is particularly notable considering the substantial evidence linking affect expression with desired outcomes across psychotherapeutic approaches. The primary purpose of the present study was to investigate if depression symptoms amplified (i.e., moderated) the association between negative-affect expression and reductions in interpersonal problems for patients in a psychiatric day treatment for personality disorders. The secondary purpose was to investigate milieu (i.e., other patients concurrently enrolled) negative-affect intensity and its association with patients' reductions in interpersonal problems. METHODS: Participants (N = 239) were patients consecutively admitted into a psychiatric day treatment program for people with personality disorders. Patients completed measures of (1) depression symptoms at pre-treatment, (2) interpersonal problems at pre- and post-treatment, and (3) negative-affect expression each week of treatment. RESULTS: The association between patient negative-affect expression and reductions in interpersonal problems was amplified by depression symptoms. Depression symptoms also amplified the association between milieu negative-affect intensity and reductions in interpersonal problems. CONCLUSIONS: Our findings indicate that depression symptoms amplified the therapeutic value of negative-affect expression and amplified the value of an affectively intense milieu. Practical and theoretical implications are discussed.

Narcissism and Quality of Life: The Mediating Role of Relationship Patterns.

Pathological narcissism is associated with decreased quality of life, even when accounting for psychiatric comorbidity, but the processes behind this association are unclear. Here, we evaluate whether disturbed relatedness accounts for the negative association between narcissistic pathology and quality of life. Patients in day hospital treatment for personality pathology (N = 218, 70% female; mean age, 37.3 years) completed measures of personality disorder features, quality of life, and global symptoms before beginning treatment. Quality of object relations was assessed through semistructured interviews. Regression-based mediation analyses showed that narcissistic personality traits relate to quality of life through quality of object relations, controlling for other personality disorders and psychiatric distress. These results highlight the importance of problematic relationship patterns for the low quality of life associated with pathological narcissism. Clinicians working with narcissistic individuals should consider psychotherapies that promote mature relatedness and should attend to facilitating the quality of patients' relationships.

The Effect of Hopelessness and Perceived Group Compatibility on Treatment Outcome for Patients With Personality Dysfunction.

Improvement in life satisfaction is hard to achieve for any patient with personality psychopathology, and possibly even moreso for those who feel hopeless at the start of treatment. The present research investigated the potential influence of hopelessness in the treatment of patients with personality dysfunction, using data from patients who completed an intensive group therapy program designed to reduce symptom distress and support optimal psychosocial functioning (N = 80). In the present study, we sought to examine whether hopelessness would moderate (i.e., strengthen or weaken) relations between compatibility ratings and life satisfaction outcome. Hopelessness had a significant moderating effect on the relationship between compatibility and outcome, suggesting that, for patients who entered treatment feeling more hopeless, higher appraisals of fit within the group facilitated better gains in life satisfaction. If replicated, the findings underlie the importance of focusing on increasing hope and perceived group affiliation in the treatment of personality dysfunction.

Improving social functioning and life satisfaction among patients with personality dysfunction: Connectedness and engagement in integrative group treatment.

Reduced social impairment and improved life satisfaction are important objectives in group treatment for patients with personality dysfunction. Knowledge regarding patient characteristics and group treatment processes that contribute to these outcomes, however, remains limited. Dispositional connectedness, the valuing of interpersonal connections, may be an important patient factor that influences patients' experience of group treatment in ways that facilitate therapeutic benefits. The present study investigated the roles of dispositional connectedness and group engagement in contributing to improvement in social functioning and life satisfaction through integrative group treatment for personality dysfunction. Seventy-nine patients who completed an integrative group treatment programme were assessed for dispositional connectedness at baseline and social functioning and life satisfaction at pretreatment and posttreatment; each also provided ratings of group engagement during treatment. Regression analyses using bootstrap confidence intervals found significant indirect effects for dispositional connectedness regarding improvement in both social functioning and life satisfaction, through the mediating effect of group engagement. Thus, patients who entered treatment with tendencies towards interpersonal connectedness perceived a higher level of engagement in the group environment. Group engagement in turn contributed to greater improvement in social functioning and to greater improvement in life satisfaction following treatment. The findings indicate dispositional connectedness as a salient characteristic in selecting patients for group treatment and highlight the role of an engaged interpersonal climate in facilitating improvement in social functioning and life satisfaction.

Improving self-esteem through integrative group therapy for personality dysfunction: Investigating the role of the therapeutic alliance and quality of object relations.

OBJECTIVE: We aimed to investigate change in self-esteem through intensive group treatment for personality dysfunction, by exploring: (a) the relationship between patients' experience of therapeutic alliance and improvement in self-esteem during treatment, including patients' quality of object-relations (QOR) as a possible moderator; and (b) the association between improvement in self-esteem during treatment, and depressive symptoms 9 months later. METHOD: Eighty patients with personality dysfunction, consecutively enrolled in a group-oriented treatment program, were assessed at pretreatment, posttreatment, and 9 months follow-up. RESULTS: Especially for patients with lower QOR, alliance predicted self-esteem change during treatment. In addition, change in self-esteem during treatment predicted follow-up depression severity, even when controlling for within-treatment symptom change. CONCLUSIONS: Patients with impoverished inner relational representations may benefit more from a secure alliance in terms of improving their self-esteem. Change in self-esteem may also be important in preventing relapse of depressive symptoms in people with personality dysfunction.

Where does it hurt? Location of pain, psychological distress, and alexithymia among outpatients seeking psychotherapy.

Objectives: Physical pain is prevalent among psychiatric outpatients, yet there has been little research regarding the types of pain reported. The purpose of this study was to survey outpatients seeking psychotherapy regarding pain locations and to examine associations between number of pain locations and psychiatric distress and alexithymia.Methods: Two hundred and seventeen patients were recruited from three Canadian hospitals that offer outpatient psychiatry services and short-term therapies. Participants were surveyed about their current physical pain using the Brief Pain Inventory. Participants also completed measures of psychiatric distress (Brief Symptom Inventory-18) and alexithymia (Toronto Alexithymia Scale-20).Results: The three most commonly reported pain locations were lower back, head, and neck. Findings revealed that anxiety, depression and alexithymia were associated with number of reported pain locations. Specifically, participants with three or more pain locations reported significantly higher depression, anxiety and alexithymia in comparison to those with no pain.Conclusions: Back, head and neck pains are highly prevalent among psychiatric outpatients. Multiple pain sites may reflect higher levels of psychiatric distress and greater impairment in emotional processing among psychiatric outpatients.

The attenuating effect of depression symptoms on negative-affect expression: Individual and group effects in group psychotherapy for personality disorders.

Across a breadth of psychotherapeutic approaches, feeling affect intensely and then talking about those feelings is a common means for increasing insight and other desired outcomes. While several naturalistic and laboratory studies have found that depression symptoms attenuate (i.e., weaken) the association between negative-affect intensity and negative-affect expression, depression's attenuating effect has not been examined in a psychotherapeutic context. The first aim of the present study was to examine if depression symptoms' attenuating effect on the association between negative-affect intensity and negative-affect expression extended into group psychotherapy. Our second aim was to examine group effects on patients' negative-affect expression. Participants (N = 239) were patients consecutively admitted into a psychodynamic group-psychotherapy day treatment program for people with personality disorders. Patients indicated their negative-affect intensity and negative-affect expression each week that they were in treatment. Depression symptoms were assessed at baseline. Results indicated that depression symptoms attenuated (i.e., moderated) the association between negative-affect intensity and negative-affect expression. Further, while the association between patient intensity and expression increased over the course of treatment, the moderating effect of depression on this association did not vary over treatment. Regarding group effects, group negative-affect intensity was associated with higher levels of patient negative-affect expression. Inversely, group affect expression was associated with lower levels of patient affect expression. Patient depression symptoms did not moderate the association between group negative-affect intensity and patient negative-affect expression. Our findings indicate that while group affect intensity and affect expression impacts patients' expression, depression's attenuating effect on negative-affect expression extends to patient effects but not group effects. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

A framework for establishing connections in physiotherapy practice.

The therapeutic relationship between practitioner and patient is embedded in the clinical interaction. Research using self-report tools has illustrated that positively evaluated therapeutic relationships can have favorable impacts on patient satisfaction with services and clinical outcomes. However, little is known about how physiotherapists develop the connections, or positive attachments, that help establish the therapeutic relationship. This study aimed to identify the various ways that physiotherapists establish meaningful connections with their patients. Interpretive description, a qualitative methodology, was used to structure the inductive and iterative design. Eleven physiotherapists and 7 patients from private practice clinics participated in semi-structured interviews to describe their experiences of the therapeutic relationship. Textual data were analyzed using qualitative content analysis and constant comparison. The iterative data generation and analysis process resulted in a framework composed of three "ways" (i.e. categories) of establishing connections: (1) acknowledging the individual, (2) giving-of-self, and (3) using the body as a pivot point. Findings were supported by various rigor strategies including peer debrief and external audit. This framework demonstrates that establishing connections is a multi-faceted endeavor with personal and professional characteristics. The findings provide practical knowledge that can be used to guide clinicians, educators, and researchers in addressing the therapeutic relationship.

What the patient wants: Addressing patients' treatment targets in an integrative group psychotherapy programme.

OBJECTIVES: Limited empirical attention has been devoted to individualized treatment objectives in intensive group therapy for personality dysfunction. This study investigated patients' ratings of distress associated with individual therapy goals - referred to as target object severity - in an intensive Evening Treatment Programme for patients with personality dysfunction. DESIGN: Change in target objective severity was examined in a sample of 81 patients who completed treatment in an intensive, integrative group therapy programme. METHODS: Correlation and regression analyses were used to examine associations between change in target object severity and patients' pre-treatment diagnosis, symptom distress, and treatment outcome expectancy, and between change in target objective severity and patients' ratings of group therapy process (group climate, therapeutic alliance, group cohesion). The relationship between change in target objective severity and longer-range life satisfaction was also examined in a subsample of patients who rated life satisfaction at follow-up. RESULTS: While change in target objective severity was not significantly related to pre-treatment variables, significant associations were found with several aspects of group therapy process. Patients' experience of a highly engaged group climate was uniquely associated with improvement in target object severity. Such improvement was significantly related to longer-term life satisfaction after controlling for general symptom change. CONCLUSION: The working atmosphere in group therapy contributes to patients' progress regarding individual treatment targets, and such progress is an important factor in later satisfaction. Attention to individualized treatment targets deserves further clinical and research attention in the context of integrative group therapy for personality dysfunction. PRACTITIONER POINTS: This study found that patients attending an integrative group treatment programme for personality dysfunction experienced significant improvement in severity of distress related to individual treatment objectives. Improvement in severity of distress related to individual treatment objectives was uniquely associated with patients' experience of an engaged, collaborative working atmosphere. Improvement in individual target objective severity was associated with patients' ratings of overall life satisfaction, rated an average of 9 months following termination, after controlling for change in general symptom severity.

Individual goal achievement in group psychotherapy: The roles of psychological mindedness and group process in interpretive and supportive therapy for complicated grief.

The ability to infer psychological meaning in behaviour-referred to as psychological mindedness-has been posited as a patient characteristic that contributes to the therapy process and consequently to therapeutic success. The present study was developed to examine the relationship between patients' psychological mindedness and improvement in patients' personal treatment goals in interpretive and supportive group therapies for complicated grief, along with patients' importance to group process. The study was conducted with a clinical sample of 109 patients (79% female; average 45 years old) receiving treatment for complicated grief. Patients provided severity of distress ratings for individual target objectives at pretreatment and posttreatment. Psychological mindedness was assessed prior to treatment using the video-based, interviewer-rated Psychological Mindedness Assessment Procedure. Patients' importance to the therapy process was rated by therapists and other patients in interpretive and supportive group therapy for complicated grief. Conditional process modelling tested whether psychological mindedness would contribute to patients' goal achievement through patients' importance to group process, moderated by type of therapy. A significant, conditional indirect effect was observed for psychological mindedness as a predictor of improvement in individual target objectives, through patients' importance to group process as rated by therapists, specifically in interpretive therapy. The findings indicate that patients' psychological mindedness significantly contributes to their achievement of individual goals through their contributions to group process in interpretive group therapy. Further research is needed to understand the facilitation of individual goal achievement in supportive therapy.

Narcissism and Interpersonal Problems Among Psychiatric Outpatients: What Is the Role of Defensive Style?

A growing body of evidence points to significant interpersonal problems associated with narcissism in clinical samples. Less well understood are the mechanisms by which narcissism negatively impacts one's interpersonal functioning. The present study investigated defensive style as a possible mediator of the relationship between narcissism and interpersonal problems. A sample of 53 adult psychiatric outpatients completed measures of narcissism, defensive style, interpersonal problems, and current symptom distress. Mediation analysis was conducted, controlling for current symptom distress, using 95% bootstrapped confidence intervals to examine the indirect effect of narcissism on interpersonal problems via defensive style. Narcissism was significantly associated with immature and neurotic defensive styles. Although narcissism was not directly related to interpersonal problems, a significant indirect effect was observed for narcissism on interpersonal problems via neurotic defensive style. This finding suggests that narcissism contributes to the use of neurotic defenses, which in turn influence one's interpersonal functioning.

The necessary conditions of engagement for the therapeutic relationship in physiotherapy: an interpretive description study.

BACKGROUND: The therapeutic relationship between patient and physiotherapist is a central component of patient-centred care and has been positively associated with better physiotherapy clinical outcomes. Despite its influence, we do not know what conditions enable a physiotherapist and patient to establish and maintain a therapeutic relationship. This knowledge has implications for how clinicians approach their interactions with patients and for the development of an assessment tool that accurately reflects the nature of the therapeutic relationship. Therefore, this study's aim was to identify and provide in-depth descriptions of the necessary conditions of engagement of the therapeutic relationship between physiotherapists and patients. METHODS: Interpretive description was the qualitative methodological orientation used to identify and describe the conditions that reflect and are practically relevant to clinical practice. Eleven physiotherapists with a minimum 5 years of clinical experience and seven adult patients with musculoskeletal disorders were purposively sampled from private practice clinics in Edmonton, Canada. The in-person, semi-structured interviews were completed in a location of the participant's choice and were audio recorded and transcribed. Qualitative content analysis was used to analyze the textual data and constant comparison techniques were integrated to refine the categories and sub-categories. Rigour strategies used throughout the study were peer debrief, interview notes, reflexive journaling, memoing, member reflections, audit trail, and external audit. RESULTS: Four conditions were identified as necessary for establishing a therapeutic relationship: present, receptive, genuine, and committed. These conditions represent the intentions and attitudes of physiotherapists and patients engaging in the clinical interaction. Although distinct, the conditions appear related as being present and receptive create a foundation for being genuine and committed. CONCLUSIONS: These conditions of engagement are needed for physiotherapist and patient to "be" in a therapeutic relationship. Although communication skills are important for advancing therapists' relational abilities, awareness and integration of intentions and attitudes are essential for shaping behaviors that develop the therapeutic relationship. These findings also suggest there are characteristics of the therapeutic relationship specific to physiotherapy. Therefore, theories from other contexts (e.g., psychotherapy) should be used judiciously to guide physiotherapy practice and research.

Body talk: Sex differences in the influence of alexithymia on physical complaints among psychiatric outpatients.

This study investigated the relationship between alexithymia and physical complaints among psychiatric outpatients, and whether sex moderated this relationship. Participants (N = 185) completed measures of physical complaints (bodily symptom burden, pain severity, pain interference), alexithymia, current symptom (depression, anxiety) distress, and somatosensory amplification (i.e., a person's tendency to be bothered by physical sensations). Hierarchical regression analyses were conducted, controlling for the influence of current psychiatric symptom distress and somatosensory amplification. Findings revealed differential relationships between alexithymia and physical complaints (pain interference) for women and men, in addition to main effects for sex and alexithymia. The findings suggest that the negative influence of alexithymia on bodily-related problems may not be universal.

Psychological Mindedness and Psychotherapy Process in Short-Term Group Therapy.

Psychological mindedness is regarded as an important patient characteristic that can influence the course of psychotherapy. The purpose of this study was to investigate the relationship between patients' capacity for psychological mindedness and aspects of the group psychotherapy process as experienced and rated by therapists and other group members. Participants were 110 patients who completed two forms of short-term group therapy for the treatment of complicated grief. Psychological mindedness was assessed at pretreatment by external raters using a video-interview procedure. Group therapists assessed patients' therapeutic work and therapeutic alliance following each group therapy session. Therapists and other group members rated each patient's expression of emotion and provided appraisals of their cohesion to each patient throughout the course of therapy. Psychological mindedness was found to be positively associated with several group process variables as rated by the therapist and other group members.

Short-Term Group Therapy for Complicated Grief: The Relationship Between Patients' In-Session Reflection and Outcome.

OBJECTIVE: The objective of the present study was to examine the nature of patients' work in two types of short-term group psychotherapy. The study sought to investigate the relationship between patients' psychodynamic work versus supportive work in group psychotherapy and treatment outcome at termination and at 6-month follow-up. Psychodynamic work refers to reflection regarding intrapsychic motivations, defenses, and relational patterns, and supportive work refers to practical problem solving. METHOD: Participants were 110 patients who completed two forms of group therapy for complicated grief: interpretive therapy and supportive therapy. Two types of patients' in-session activity-psychodynamic work and supportive work-were rated by group therapists in both treatments. Pre-post and follow-up outcome domains included general symptoms, grief symptoms, and life dissatisfaction/severity of target objectives. RESULTS: There was no significant difference in the nature of patients' therapeutic work between interpretive and supportive groups. Psychodynamic work was associated with pre-post improvement in grief symptoms. Psychodynamic work was also associated with further improvement in grief symptoms at 6-month follow-up, along with improvement in broader symptom domains. Supportive work was not associated with any pre-post or follow-up benefit. CONCLUSION: The findings provide evidence that psychodynamic work-focused on the development of insight and self-reflection-in group psychotherapy can contribute to further benefit after the completion of treatment. This finding cut across two approaches to short-term group therapy for complicated grief, suggesting that it may reflect a general curative mechanism of group treatments.

Intensive Evening Outpatient Treatment for Patients With Personality Dysfunction: Early Group Process, Change in Interpersonal Distress, and Longer-Term Social Functioning.

OBJECTIVE: Entrenched interpersonal difficulties are a defining feature of those with personality dysfunction. Evening treatment-a comprehensive and intensive group-oriented outpatient therapy program-offers a unique approach to delivering mental health services to patients with chronic personality dysfunction. This study assessed change in interpersonal problems as a key outcome, the relevance of such change to future social functioning, and the influence of early group processes on this change. METHOD: Consecutively admitted patients (N = 75) to a group-oriented evening treatment program were recruited; the majority were diagnosed with personality disorder. Therapy outcome was represented by scores on the Inventory of Interpersonal Problems. Follow-up outcome was represented by the global score of the Social Adjustment Scale. Group climate, group cohesion, and the therapeutic alliance were examined as process variables. RESULTS: Patients experienced substantial reduction in distress associated with interpersonal problems; early process factors that reflected a cohesive and engaged group climate and stronger therapeutic alliance were predictive of this outcome. Improvement in interpersonal distress was predictive of global social functioning six months later. The therapeutic alliance most strongly accounted for change in interpersonal problems at posttreatment and social functioning at follow-up. CONCLUSIONS: A comprehensive and integrated outpatient group therapy program, offered in the evening to accommodate patients' real-life demands, can facilitate considerable improvement in interpersonal problems, which in turn influences later social functioning. The intensity and intimacy of peer interactions in the therapy groups, and a strong alliance with the program therapists, are likely interacting factors that are particularly important to facilitate such change.