Assessing Self-Definition and Relatedness in Level of Personality Functioning.

The two polarities model (TPM) of personality organizes psychological assessment and psychotherapy and connects to personality disorder diagnosis using the DSM-5 Alternative Model for Personality Disorders (AMPD). The authors developed scales assessing the TPM from an existing self-report measure for level of personality functioning (LPF), a core component of the AMPD. Iterative content analyses of the LPF measure yielded scales for Autonomy and Communion corresponding to dimensions of the TPM. The scales were refined via internal consistency analyses using a measure of psychological attachment and studied in development and validation samples. Associations with relevant external criteria were explored in a series of multiple regressions. The new content-based LPF scales were illustrated with a case vignette. Although the new Autonomy/Communion scales await further validation prior to clinical use, initial evidence suggests that they may bridge the nomological nets of the TPM and AMPD and potentially offer clinical utility in assessment and treatment planning.

Quality of Internalized Object Representations and Suicidality in Individuals With Anaclitic and Introjective Personality Styles.

Research has shown differences in the characteristics of suicidal behavior in individuals with dependent (anaclitic) versus self-critical (introjective) personality styles. Questions remain, however, as to what factors distinguish suicidal from nonsuicidal individuals within each personality style. The current study examined clinical and interpersonal correlates of suicidality in 124 patients attending residential treatment for complex psychiatric disorders, with the aim of clarifying how social cognition and quality of internalized object representations relate to suicidality in individuals with anaclitic versus introjective personality organizations. Higher anaclitic and lower introjective traits each predicted higher frequency of prior attempts. Furthermore, higher anaclitic and lower introjective traits interacted with the affective-interpersonal quality of object representations to predict prior attempts, such that each trait was associated with more frequent past attempts in the context of poorer quality of object relations. The treatment implications of these findings are discussed, and areas for future research are considered.

Flexibility and Rigidity in Object Relational Functioning: Assessing Change in Suicidal Ideation and Global Psychiatric Functioning Using the SCORS-G.

The Social Cognition and Object Relations Scale-Global Rating Method (SCORS-G; Westen, 1995 ) has been widely used as an assessment measure of object relational functioning across a number of stimuli. This study used the SCORS-G to investigate associations between global impairments and rigidity in quality of object relations with changes in suicidal ideation and psychiatric functioning over time. Participant narratives describing actual interpersonal experiences were collected using the Relationship Anecdote Paradigm (Luborsky, 1998 ) from a sample of individuals diagnosed with complex psychopathology completing residential psychiatric treatment. We found that a greater range in affective quality and emotional investment in relationship scores at admission into treatment were significantly related to a reduction in suicidal ideation as well as improvements in global psychiatric functioning at 5-year follow-up. Thus, participants who acknowledged having both healthy as well as troubled relationships in their daily lives were less suicidal and less likely to experience disruptive psychiatric symptoms over time than those who described more restricted or uniform relational experiences on entering treatment. Implications for calculating range scores and using various narrative techniques when applying the SCORS-G method are discussed.

The persistent shadow of suicide ideation and attempts in a high-risk group of psychiatric patients: A focus for intervention.

OBJECTIVE: Patients with a history of suicidal ideation or attempts, especially if they have serious psychopathology with repeated hospitalizations, are burdened by ongoing risk for suicide. We studied this high-risk group to assess their psychological status following their most recent suicide attempt, in contrast to equally ill patients without a suicide history. Further, among suicidal patients, we compared those with only ideation, with a non-medically serious suicide attempt and with medically serious suicide attempts. We also report on the development of a new measure of psychic pain. METHODS: Patients in residential treatment (n=131) completed self-report questionnaires about suicide history, impulsiveness, psychic pain, resilience, and reasons for living. A series of univariate ordinal logistic regressions identified variables to include in a multivariable logistic regression to examine the odds associated with increasing levels of suicidality. RESULTS: A history of suicidal ideation or suicide attempts is associated with proportionally more psychic pain and fewer current reasons for living. Prior history of abuse, impulsiveness, and general resilience were not significantly associated with suicidal severity. CONCLUSIONS: For patients who have suicidal ideation, or have attempted suicide, and also have additional risk factors including past hospitalization, treatments should include both understanding the sources of psychic pain and promoting individual discovery of reasons for living.

Suicidality in High-Risk Psychiatric Patients: The Contribution of Protective Factors.

OBJECTIVE: This study's objective was determine the incremental association of reasons for living to the lifetime number of suicide attempts in relation to other known risk and protective factors in a sample of psychiatric patients with extensive psychopathology in residential treatment. METHODS: Participants (n = 131) completed a demographic questionnaire that also asked for information about lifetime suicide history, psychiatric history, trauma, and abuse history. Additional measures of resilience, reasons for living (RFL), and impulsiveness were completed. RESULTS: A history of sexual abuse was associated with an increasing lifetime number of suicide attempts, while a history of physical abuse and trait impulsiveness were not associated with the lifetime number of suicide attempts. Survival and coping beliefs, a subscale of the Reasons for Living Inventory (RFLI), was found to add incremental predictive validity to the number of lifetime suicide attempts. A composite fear variable, combining fear of suicide and fear of social consequences of suicide, was negatively correlated with lifetime number of attempts but did not add incremental validity to the prediction of lifetime number of suicide attempts. CONCLUSION: In a sample of participants with significant psychiatric impairment, the protective factor of survival and coping beliefs may be an important barrier to repeated suicide attempts and may be considered a suicide-specific resilience measure. Understanding the psychological processes contributing to the development of such protective factors as resilience, meaning in life, and coping resources is an important area of study and a potential avenue for targeted therapeutic intervention in high-risk populations.

Residents' experience of screening, brief intervention, and referral to treatment (SBIRT) as a clinical tool following practical application: A mixed-methods study.

BACKGROUND: Screening, brief intervention, and referral to treatment (SBIRT), an evidence-based validated system for providing early detection and brief treatment of substance use disorders, has been widely used in the training of medical residents across specialties at a number of sites. This article investigates the effectiveness of SBIRT training during short-term follow-up at Albany Medical Center, one of the initial Substance Abuse and Mental Health Services Administration (SAMHSA) grantees. METHODS: Training outcomes were measured by training satisfaction following opportunities to apply SBIRT skills in clinical work, the rate at which these techniques were applied in clinical work, and the degree to which residents felt that the SBIRT training provided skills that were applicable to their practice. We examined differences in learning experience by postgraduate year and by program, and conducted a qualitative analysis in a convergent parallel mixed-methods design to elucidate barriers encountered by residents upon using SBIRT techniques in clinical practice. RESULTS: Residents remained highly satisfied with the training at 4-month follow-up, with 80.1% reporting that they had used SBIRT skills in their clinical work. Use of SBIRT techniques was high at 6-month follow-up as well, with 85.9% of residents reporting that they regularly screened their patients for substance use, 74.4% reporting that they had applied brief intervention techniques, and 78.2% indicating that SBIRT training had made them overall more effective in helping patients with substance use issues. Differences in application rates and satisfaction were found by specialty. Qualitative analyses indicated that residents encountered patient readiness and specific contextual factors, such as time constraints, externally imposed values, and clinical norms, as barriers to implementation. CONCLUSIONS: Despite encountering obstacles such as time constraints and patient readiness, residents utilized many of the skills they had learned during SBIRT training in clinical practice and reported finding these skills useful in their management of patients with substance use issues.

Multispecialty screening, brief intervention, and referral to treatment (SBIRT) training in an academic medical center: Resident training experience across specialties.

BACKGROUND: The Substance Abuse and Mental Health Services Administration (SAMHSA) has recently begun to fund programs that train medical residents on how to utilize an evidence-based validated system known as screening, brief intervention, and referral to treatment (SBIRT) for providing early detection and brief treatment of unhealthy substance use. This paper investigates training outcomes of multispecialty SBIRT training at one such program at Albany Medical Center (AMC), one of the initial SAMHSA grantees. METHODS: Training outcomes were measured across 3 domains of learning: trainee satisfaction, acquired knowledge, and perceived usefulness. The authors explored differences in learning experience by postgraduate year and by specialty. RESULTS: Overall, residents were highly satisfied with the training, and learning outcomes met objectives. Residents' ratings of usefulness did not vary by program year. However, the results indicate that relative to residents in other programs, residents in psychiatry and pediatrics found the training components significantly more useful, whereas emergency medicine residents found training components to have less utility. Residents who found the training relevant to their daily work were more satisfied and more receptive to SBIRT training overall, which may help explain difference scores by program. CONCLUSIONS: Residents were highly satisfied with SBIRT skills training, although ratings of usefulness varied by residency program. Specialization by program and on-site modeling by senior faculty may enhance trainee satisfaction and perceived usefulness.

Impairments in Object Relations and Chronicity of Suicidal Behavior in Individuals With Borderline Personality Disorder.

While studies have demonstrated connections between impairments in object relations and self-destructive behaviors in individuals with borderline personality disorder (BPD), few have investigated whether these impairments relate to actual suicidal behaviors. The current study utilized the Social Cognition and Object Relations Scale-Global Method to investigate object relational functioning and suicidal behaviors in 131 residential treatment patients. Cognitive but not affective aspects of internalized representations predicted past suicidal behavior in BPD subjects; no relationships were found between quality of object representations and suicide in other-PD subjects. Implications of these findings for research, theory, and treatment of suicidal individuals are discussed.

Microprocess examination of therapeutic immediacy during a dynamic research interview.

This study examines the interviewer's use of immediacy during a dynamic interview to enhance the patient's ability to process affective material and deepen personal exploration. Using a microprocess design, immediacy events were identified and rated using the Consensual Qualitative Rating method. Moment-to-moment in-session activity was rated by trained observers with a focus on measuring patient process using the Therapist-Patient Interaction Rating Scale and interviewer process using the Therapeutic Environment Scale. Five immediacy events were identified and were found to range in depth from mundane exchanges to more active exchanges with affective depth. Mundane events were characterized by little attention to the affective component of the here-and-now relationship, dismissive and unsupportive comments, and had either no effect, or a negative effect on patient process. In contrast, immediacy events characterized by even limited affect and acknowledging engagement between patient and interviewer were followed by greater patient disclosure and increased capacity to process emotional information. Thus, attention to the quality of the immediacy intervention in future research appears warranted.

Mixed methods research design for pragmatic psychoanalytic studies.

Calls for more rigorous psychoanalytic studies have increased over the past decade. The field has been divided by those who assert that psychoanalysis is properly a hermeneutic endeavor and those who see it as a science. A comparable debate is found in research methodology, where qualitative and quantitative methods have often been seen as occupying orthogonal positions. Recently, Mixed Methods Research (MMR) has emerged as a viable "third community" of research, pursuing a pragmatic approach to research endeavors through integrating qualitative and quantitative procedures in a single study design. Mixed Methods Research designs and the terminology associated with this emerging approach are explained, after which the methodology is explored as a potential integrative approach to a psychoanalytic human science. Both qualitative and quantitative research methods are reviewed, as well as how they may be used in Mixed Methods Research to study complex human phenomena.

Improvement and recovery from suicidal and self-destructive phenomena in treatment-refractory disorders.

Long-term data about recovery from suicidal and self-destructive phenomena are limited. We examined these phenomena in a naturalistic, follow-along study of 226 adults with treatment-refractory disorders admitted at the Austen Riggs Center. Follow-along interviews systematically rated suicidal ideation, suicide attempts, self-mutilation, and other self-destructive phenomena. We identified vital status in 98.7%, finding 1 death by suicide. Among 79 who made at least 1 suicide attempt in the 6 months before admission, 61 (77.2%) were estimated to be free of suicidal acts by a median of 7.18 years. Self-mutilation and other self-destructive phenomena showed slightly longer times to recovery. Among 156 individuals with suicidal ideation, 79 (50.6%) attained sustained recovery at a median of 8.69 years. On average 2.9 to 5.2 years were required from the last observed self-destructive event to attain sustained recovery. Most participants showed significant improvement in suicidal phenomena, whereas between 50.6% and 77.2% attained sustained recoveries.