Understanding "patient deterioration" in psychotherapy from depressed patients' perspectives: A mixed methods multiple case study.

OBJECTIVE: This study scrutinizes the meaning of deterioration in psychotherapy beyond the widely used statistical definition of reliable symptom increase pre-to-post treatment. METHOD: An explanatory sequential mixed-methods multiple case study was conducted, combining quantitative pre-post outcome evaluation of self-reported depression symptoms and qualitative analysis of patients' interviews. In a Randomized Controlled Study on the treatment of Major Depression, three patients showing reliable increase in symptom severity on the BDI-II pre-to-post therapy were selected. An interpretative phenomenological analysis (IPA) was performed on individual interviews conducted pre-, peri- and post-treatment. RESULTS: Cross-case outcome experiences were: (1) uncontrollable complaints; (2) remaining questions and uninternalized insights and (3) persisting interpersonal difficulties. Within-case idiosyncratic differences revealed that the statistical classification of "deterioration" not necessarily corresponds to a "deteriorated experience," nor univocally indicates unwanted therapy effects. Our findings point at the influences of the patient's (lack of) agency in the process, a discrepancy between patients' expectations and the therapy offer, the therapeutic relationship, interpersonal difficulties, and contextual influences. CONCLUSION: The meaning of symptomatic deterioration should be interpreted within a patient's idiosyncratic context. The multi-faceted nature of deterioration requires further research to rely on multiple perspectives and mixed methods.

The Ghent Psychotherapy Study: A Pragmatic, Stratified, Randomized Parallel Trial into the Differential Efficacy of Psychodynamic and Cognitive-Behavioral Interventions in Dependent and Self-Critical Depressive Patients.

INTRODUCTION: Different types of psychotherapy are effective for treating major depressive disorder across groups yet show large within-group differences. Patient personality style is considered a potentially useful variable for treatment matching. OBJECTIVE: This study is the first experimental test of the interaction between therapeutic approach and patients' dependent versus self-critical personality styles. METHODS: A pragmatic stratified parallel trial was carried out with 100 adult patients diagnosed with DSM-IV-TR major depressive disorder. They were randomly assigned to short-term (16-20 sessions) cognitive behavioral therapy (CBT) or short-term psychodynamic psychotherapy (STPP). Patients were assessed at baseline, during therapy, post-therapy, and at 3- and 6-month follow-up. Primary outcome is depression severity measured by the Hamilton Rating Scale for Depression posttreatment. Primary analysis was by intention to treat. This trial is registered with the ISRCTN registry (www.isrctn.com), number ISRCTN17130982. RESULTS: The intention-to-treat sample consisted of 100 participants; 40 with self-critical and 60 with dependent personality styles were randomized to either CBT (n = 50) or STPP (n = 50). We observed no interaction effect (-0.34 [-6.14, 5.46]) between therapy and personality style and found no evidence for a difference in effectiveness between the treatments in general in terms of symptom reduction and maintained benefits at 6-month follow-up. CONCLUSION: We found no evidence that dependent versus self-critical personality styles moderate the relation between treatment and outcome in depression. Research using individual patient data could gain further insight into why specific therapeutic approaches work better for specific patients.

What too strict a method obscures about the validity of outcome measures.

Objective: To assess the outcome of psychotherapeutic treatments, psychotherapy researchers often compare pre- and post-treatment scores on self-report outcome measures. In this paper, the common assumption is challenged that pre-to-post decreasing and increasing outcome scores are indicative of successful and failed therapies, respectively.Method: The outcome of 29 psychotherapeutic treatments was evaluated by means of quantitative analysis of pre- and post-treatment scores on commonly used outcome measures (such as the Symptom Checklist-90-R, the Inventory of Interpersonal Problems, and the General Health Questionnaire-12), as well as through consensual qualitative research.Results: Overall, a moderate to low convergence between qualitative and quantitative evaluations of outcome was observed. Detailed analyses of six cases are presented in which pre-to-post comparisons of outcome measures proved misleading.Conclusions: It is concluded that psychotherapy outcome research might benefit from assessment strategies that are sensitive to the singularities of individual treatments and to the complexity of the phenomenon of therapeutic outcome. Furthermore, classical psychometric evaluations of the validity of outcome measures might be supplemented with less-systematic evaluations that take any contingent source of information on outcome into account.

Lived experiences: a focus group pilot study within the MentALLY project of mental healthcare among European users.

BACKGROUND: Mental healthcare is an important component in societies' response to mental health problems. Although the World Health Organization highlights availability, accessibility, acceptability and quality of healthcare as important cornerstones, many Europeans lack access to mental healthcare of high quality. Qualitative studies exploring mental healthcare from the perspective of people with lived experiences would add to previous research and knowledge by enabling in-depth understanding of mental healthcare users, which may be of significance for the development of mental healthcare. Therefore, the aim of the current study was to describe experiences of mental healthcare among adult Europeans with mental health problems. METHOD: In total, 50 participants with experiences of various mental health problems were recruited for separate focus group interviews in each country. They had experiences from both the private and public sectors, and with in- and outpatient mental healthcare. The focus group interviews (N = 7) were audio recorded, transcribed verbatim and analysed through thematic analysis. The analysis yielded five themes and 13 subthemes. RESULTS: The theme Seeking and trying to find help contained three subthemes describing personal thresholds for seeking professional help, not knowing where to get help, and the importance of receiving help promptly. The theme Awaiting assessment and treatment contained two subthemes including feelings of being prioritized or not and feelings of being abandoned during the often-lengthy referral process. The theme Treatment: a plan with individual parts contained three subthemes consisting of demands for tailored treatment plans in combination with medications and human resources and agreement on treatment. The theme Continuous and respectful care relationship contained two subthemes describing the importance of continuous care relationships characterised by empathy and respect. The theme Suggestions for improvements contained three subthemes highlighting an urge to facilitate care contacts and to increase awareness of mental health problems and a wish to be seen as an individual with potential. CONCLUSION: Facilitating contacts with mental healthcare, a steady contact during the referral process, tailored treatment and empathy and respect are important aspects in efforts to improve mental healthcare. Recommendations included development of collaborative practices between stakeholders in order to increase general societal awareness of mental health problems.

What "good outcome" means to patients: Understanding recovery and improvement in psychotherapy for major depression from a mixed-methods perspective.

This study explored the meaning of "good outcome" within and beyond the much-used statistical indices of clinical significance in standard outcome research as developed by Jacobson and Truax (1991). Specifically, we examined the experiences of patients marked as "recovered" and "improved" following cognitive-behavioral therapy and psychodynamic therapy for major depression. A mixed-methods study was conducted using data gathered in an RCT, including patients' pre-post outcome scores on the Beck Depression Inventory-II and posttreatment client change interviews. We selected 28 patients who showed recovery and 19 patients who showed improvement in self-reported depression symptoms. A grounded theory analysis was performed on patients' interviews, ultimately resulting in a conceptual model of "good outcome." From patients' perspectives, good outcome can be understood as feeling empowered, finding personal balance and encountering ongoing struggle, indicating an ongoing process and variation in experience. The Jacobson-Truax classification of "good outcome" could not account for the (more pessimistic) nuances in outcome experiences, especially for "improved" patients, and did not grasp the multidimensional nature of outcome as experienced by patients. It is recommended that statistical indications of clinical meaningfulness are interpreted warily and ideally contextualized within personal narratives. Further research on the phenomenon of change and good outcome is required, aiming at integrating multiple perspectives and methods accordingly the multidimensional phenomenon under study. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

A Critical Perspective on Mental Health News in Six European Countries: How Are "Mental Health/Illness" and "Mental Health Literacy" Rhetorically Constructed?

In this study, we aim to contribute to the field of critical health communication research by examining how notions of mental health and illness are discursively constructed in newspapers and magazines in six European countries and how these constructions relate to specific understandings of mental health literacy. Using the method of cluster-agon analysis, we identified four terminological clusters in our data, in which mental health/illness is conceptualized as "dangerous," "a matter of lifestyle," "a unique story and experience," and "socially situated." We furthermore found that we cannot unambiguously assume that biopsychiatric discourses or discourses aimed at empathy and understanding are either exclusively stigmatizing or exclusively empowering and normalizing. We consequently call for a critical conception of mental health literacy arguing that all mental health news socializes its audience in specific understandings of and attitudes toward mental health (knowledge) and that discourses on mental health/illness can work differently in varying contexts.

A quest for self-soothing: A systematic case study into emotion-focused therapy with an emotionally avoidant client who committed sexual offenses.

OBJECTIVE: The current study is part of a multiple case study that investigated the emotional change in individuals who have committed sexual offenses (ISOs). This case study highlights how one client used sex as a maladaptive coping strategy to suppress negative emotions. METHOD: A mixed-methods design was used to track changes in the client's affect regulation (AR) during four phases, including a baseline (Phase A), treatment as usual (Phase B), treatment with an emotion-focused therapy (EFT) component added (Phase C), and follow up (Phase A). RESULTS: The qualitative description with verbatim clinical vignettes, revealed deeper insight into some important steps and hindrances and the impact of specific EFT-interventions. Quantitative analysis of self-report and observational measures showed a significant improvement in the client's AR across different phases of treatment. CONCLUSIONS: The study improves our knowledge of the emotional change in ISOs during treatment and illustrates some key interventions, steps, and hindrances.

Change processes underlying "good outcome": A qualitative study on recovered and improved patients' experiences in psychotherapy for major depression.

Aim: Exploring change processes underlying "good outcome" in psychotherapy for major depression. We examined the perspectives of patients who "recovered" and "improved" (Jacobson & Truax) following time-limited CBT and PDT. Method: In the context of an RCT on the treatment of major depression, patients were selected based on their pre-post outcome scores on the BDI-II: we selected 28 patients who recovered and 19 who improved in terms of depressive symptoms. A grounded theory analysis was conducted on post-therapy client change interviews, resulting in an integrative conceptual model. Results: According to recovered and improved patients, change follows from an interaction between therapy, therapist, patient, and extra-therapeutic context. Both helping and hindering influences were mentioned within all four influencing factors. Differences between recovered and improved patients point at the role of patients' agency and patients' internal and external obstacles. However, patients marked as "improved" described heterogeneous experiences. CBT- and PDT-specific experiences were also observed, although our findings suggest the possible role of therapist-related influences. Conclusion: From patients' perspectives, various change processes underlie "good outcome" that do not necessarily imply an "all good process". This supports a holistic, multidimensional conceptualization of change processes in psychotherapy and calls for more fine-grained mixed-methods process-outcome research.

[Psychoanalytic single case studies of children and adolescents: characterisation with the "Inventory of Basic Information in Single Cases"]. / Psychoanalytische Einzelfallstudien von Kindern und Jugendlichen: Charakterisierung mit dem "Inventory of Basic Information in Single Cases".

Right from its beginning single case studies on children and adolescents have been an highly esteemed means of communication in psychoanalysis; from the view of treatment research time and again critical arguments are brought forward. As single case studies may provide relevant answers for detailed process aspects, in this study we present a methodology for systematizing the reporting culture.

Impact of personality style changes on CBT and PDT treatment responses in major depression.

This study examines the influence of depressive personality styles on treatment responses in patients with major depression receiving cognitive behavioural therapy and psychodynamic therapy. We assessed changes in personality styles, including dependency, self-criticism, sociotropy, and autonomy, and their association with treatment response. Both treatment modalities led to significant reductions in self-criticism and sociotropy scores. Depressive symptom severity decreased overall, with a more pronounced reduction observed in the cognitive behavioural therapy group. Notably, reduced self-criticism and sociotropy were associated with better treatment outcomes in the cognitive behavioural therapy group. Our findings highlight the role of personality styles in influencing treatment outcomes for major depression. The study suggests an association between changes in personality styles and the reduction of symptoms. Our results support the idea that unique pathways of change are activated depending on the therapeutic intervention. These insights are critical in tailoring treatments to individual needs, addressing the central question of 'what works for whom'.

Depressive personality traits and temperament and character personality traits in a clinical sample: Results from regression and network analyses.

Personality and psychopathology are highly relevant and easily relatable constructs. The current study investigated the relationships between dependency and self-criticism, sociotropy and autonomy depressive personality traits, and Cloninger's temperament and character personality traits postulated as vulnerability factors for depression, in relation to depressive and general psychopathology symptoms in a clinical sample of 100 patients diagnosed with major depressive disorder. The results showed that self-directedness, a character trait of the temperament and character model, was positively associated with dependency, self-criticism, sociotropy, and autonomy. Applying more in-depth analyses with regression models revealed associations between self-directedness and depressive personality styles dependency and sociotropy, and general psychopathology symptoms was a significant clinical indicator in these relationships. Going beyond the regression models, network analysis showed that self-directedness is associated with self-criticism, sociotropy, autonomy, and general psychopathology symptoms. The relationship between self-directedness and sociotropy, self-criticism and autonomy suggests that these depressive personality traits may be attributable to aspects of self-determination, maturity, responsibility, discipline, and self-acceptance. General psychopathology research informed by literature incorporating personality traits has far-reaching implications for understanding individual differences as well as increasing efforts to contribute to the amelioration of disabling psychological disorders like major depressive disorders.

Interpersonal problems and cognitive characteristics of interpersonal representations in alexithymia: a study using a self-report and interview-based measure of alexithymia.

In this study, associations between alexithymia, interpersonal problems, and cognitive-structural aspects of internal interpersonal representations were examined. Alexithymia was measured using the Toronto Structured Interview for Alexithymia (TSIA) and the 20-item Toronto Alexithymia Scale (TAS-20). To measure interpersonal problems, the dominance and affiliation dimension scores of the Inventory of Interpersonal Problems were used, and cognitive-structural characteristics of interpersonal representations were measured using the Social Cognition and Object Relations Scale (SCORS). As hypothesized, alexithymia was related to cold and withdrawn, but not to dominant or submissive, interpersonal functioning. In terms of the SCORS, alexithymia was negatively related to complexity of interpersonal representations, both in TAT and in interview narratives, indicating a link between alexithymia and mentalization. However, alexithymia was related only to the dimension of social causality when this dimension was scored on TAT narratives. Overall, the TSIA provides the most consistent and stable results after controlling for negative affectivity.

The assessment of the social cognition and object relations scale on TAT and interview data.

This study examines the reliability and convergent validity of 2 versions of the Social Cognition and Object Relations Scale (SCORS), one for use with Thematic Apperception Test narratives (SCORS-TAT; Westen, 1990) and one for use with clinical interview data (SCORS-CDI; Westen, Barends, Leigh, Mendel, & Silbert, 1990 ). Four SCORS dimensions were evaluated. Data were collected in a psychiatric sample (N = 74). Results show that although interrater reliability was good for all dimensions, internal consistency was low, especially for the affective dimensions. Structural equation modeling, in which a model with 2 factors (i.e., SCORS-TAT and SCORS-CDI) and 4 dimensions each was tested, indicated low convergence between corresponding dimensions of SCORS-TAT and SCORS-CDI. Correlational analyses suggested that this was due to a strong method factor. Regression analyses, however, revealed that the presence of a personality disorder operated as a moderator for convergence between corresponding cognitive-structural dimensions.

The single case archive: Review of a multitheoretical online database of published peer-reviewed single-case studies.

Case study methods are increasingly recognized as crucial methods to enhance understanding of the complexity of psychotherapy processes and as way to bridge the science-practice gap. The Single Case Archive (SCA) was constructed to facilitate access to the existing field of case study research for academic, clinical, and educational purposes. Cases were selected through systematic screening of relevant peer-reviewed journals in the field of psychotherapy research and rigorous snowball sampling. All cases meeting inclusion criteria were inventoried using the Inventory for Basic Information in Single Cases that maps study, patient, therapist, and therapy characteristics. About 3,471 cases from 175 peer-reviewed journals published between 1955 and 2019 were included in the SCA database. The SCA comprises cases from different theoretical backgrounds, discussing patients from different age categories, with different presenting problems going through a diversity of psychotherapeutic treatments that are studied using a range of methods. Cases differ strongly with respect to the amount of information that is present in the case study, and the field should pay more attention to ethical considerations like informed consent and providing relevant basic descriptive information. An online platform makes the SCA database searchable by researchers, clinicians, and students. In conclusion, the SCA is a unique resource that makes case studies more easily accessible, facilitates meta-studies and reviews of case studies, and stimulates methodological developments in the field of case study research. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Alexithymia, social detachment and cognitive processing.

Using lexical content analysis (linguistic inquiry and word count), the hypotheses that social detachment and impaired cognitive processing are typical for alexithymia are investigated. Based on clinical interviews with 32 outpatients (mixed diagnoses), we found support for the hypotheses for the externally oriented thinking facet of alexithymia only.

Extending Blatt's two-polarity model of personality development to dissociative identity disorder: a theory-building case study.

In this theory-building case study, we investigate Blatt's two-polarity model of personality development according to which psychopathology is a consequence of an unbalance between the two developmental lines of interpersonal relatedness and self-definition. Anaclitic psychopathology, such as schizophrenia, histrionic, dependent, and borderline personality disorders, is associated with an excessive and rigid emphasis on interpersonal relatedness. In this theory-building case study, we examine whether this model can be extended to dissociative identity disorder (DID). The patient is a 23-year old Caucasian man who suffers from periodic episodes of dissociation. Consensual qualitative research for case studies is used to quantitatively and qualitatively describe the interplay between symptomatic and interpersonal evolutions throughout 41 sessions of supportive-expressive psychoanalytic psychotherapy. In line with the two-polarity model of personality development, close associations between symptoms of dissociation and dependent interpersonal dynamics were observed. Psychoanalytic interventions focusing on elaboration of the subjective meanings of (past and anticipated) dissociations, and on working through core interpersonal conflicts, are followed by transformations in the patient's interpersonal stances and subjective well-being. No new dissociative episodes were reported during the follow-up assessment three and a half years after the completion of treatment. This case study demonstrates that DID is a form of anaclitic psychopathology as it is associated with a predominant tendency to interpersonal relatedness.

The Observer Alexithymia Scale: a reliable and valid alternative for alexithymia measurement?

In this study, we evaluated the reliability and validity of the Dutch version of the Observer Alexithymia Scale (OAS; Haviland, Warren, & Riggs, 2000) while addressing shortcomings of earlier research. Internal consistency and test-retest reliability were found to be adequate, whereas interrater reliability was insufficient. The original five-factor model (Distant, Uninsightful, Somatizing, Humorless, Rigid) with item parcels showed excellent fit, indicating adequate translation. Alternative models were tested to overcome problems with the parcel method, and all showed poor fit. OAS total scores correlated .23 with the 20-item Toronto Alexithymia Scale (Bagby, Parker, & Taylor, 1994; Bagby, Taylor, & Parker, 1994) and .50 with the Toronto Structured Interview for Alexithymia (Bagby, Taylor, Parker, & Dickens, 2006). These problematic results on validity compromise the use of the OAS as an alexithymia measure.

Reconstruction and validation of the Personal Style Inventory in a Flemish clinical and student sample.

The Personal Style Inventory-II (Robins, Ladd, Welkowitz, Blaney, Diaz, & Kutcher, 1994) was constructed to assess sociotropy and autonomy; two personality dimensions associated with increased susceptibility to depression. In the present study, the authors used a confirmatory factor analysis to evaluate the fit of the theoretical model of the Personal Style Inventory-II in a heterogeneous clinical sample (N=266) and in a student sample (N=799); construct validity was evaluated by correlating the Personal Style Inventory-II scales with the scales of the Inventory of Interpersonal Problems-64 and the Symptom Checklist-90-R. Poor fit of the original Personal Style Inventory-II model was observed in both samples. Yet, after progressive elimination of 18 items, a good fit was obtained in the clinical sample and replicated in the student sample. This brief version demonstrated better construct validity than the long version, especially in a depressed clinical sample: sociotropy was associated with nonassertive, overly accommodating, and self-sacrificing interpersonal behaviour, depressive symptoms, phobic complaints, and anxiety and somatic symptoms; autonomy was associated with cold and vindictive interpersonal behaviour, obsessive-compulsive symptoms, and aggressive urges. In contrast to the long version, scores on the shortened version showed the predicted sex differences.

Reformulating and Mirroring in Psychotherapy: A Conversation Analytic Perspective.

The conversational actions of reformulating and mirroring constitute some of the core intervention techniques of psychotherapy. The purpose of the present study was to investigate the way in which therapists in cognitive-behavioral (CBT) and psychodynamic therapy (PDT) use reformulating and mirroring strategies to return patients' prior talk and how their differential usage can be viewed in light of the respective manualized recommendations. A mixed methods approach was applied using qualitative data that derived from a RCT. The data collection consisted of 200 excerpts assembled from both treatment conditions. The method of Conversation Analysis was used to determine the practices that accomplished instances of reformulating and mirroring, and to examine their distinct implications for subsequent talk. The quantitative analysis revealed that cognitive-behavioral therapists are significantly more likely to use reformulations, which is in harmony with what is suggested in CBT's treatment manuals. Psychodynamic therapists' frequent use of transformative formulations is, by contrast, unexpected in regard to the suggestions of the treatment protocol, as these interventions steer toward topical closure. Compared to the CBT condition, psychodynamic therapists were still significantly more likely to rely on mirroring strategies, which are in line with PDT's theoretical preference. Our findings raise the question whether alleged differences in treatment styles, as they are imposed by RCT methodology, are actually tangible in manual-guided clinical practice.

Working through childhood trauma-related interpersonal patterns in psychodynamic treatment: An evidence-based case study.

OBJECTIVE: Adult interpersonal difficulties are considered 1 of the core consequences of childhood trauma exposure. However, research concerning the nature of interpersonal patterns associated with childhood trauma is scarce. The aim of this case study of a supportive-expressive psychodynamic therapy with a woman with a traumatic background, is to provide a detailed understanding of the nature of interpersonal patterns at the beginning and throughout therapy, and to provide an in-depth investigation of the therapeutic process. METHOD: The Core Conflictual Relationship Theme method (Luborsky & Crits-Christoph, 1998) and the Penn Adherence/Competence Scale for Supportive Expressive Dynamic Psychotherapy (Barber & Critis-Christoph, 1996) were applied to study dominant interpersonal patterns and therapeutic interventions, respectively. RESULTS: At the beginning of therapy, the patient was unable to safely express herself because others were perceived as critical and rejecting. This relationship pattern originated in her primary (traumatic) childhood relationships and was repeated in her adult relationships. As treatment progresses, the patient aspired more proactively to assert herself and felt more self-confident in interactions, although she consistently perceived the reactions of others in a negative way. The neutral, acknowledging and empowering attitude of the therapist created a new relational experience, through which change (on the interpersonal level) appears to be achieved. CONCLUSIONS: We conclude that to adequately address interpersonal difficulties in therapy, it is fundamental to recognize dominant interpersonal patterns and to apprehend their dynamics within the broader context of the case. (PsycINFO Database Record (c) 2020 APA, all rights reserved).