Perfectionism and therapeutic alliance: a review of the clinical research

In this review, we synthesize findings regarding the relationship between perfectionism and therapeutic alliance, most of which come from analyses by Blatt and colleagues. Results suggest what follows. First, patients’ initial level of perfectionism negatively affects patients’ bond with therapists and perception of therapists’ Rogerian attributes (empathy, congruence, and regard) early in treatment and engagement in therapy later in treatment. Second, therapists’ contribution to alliance is not seemingly affected by patients’ initial perfectionism level. Third, individual patients of therapists who are perceived on average by their patients to be higher on Rogerian attributes experience greater decreases in perfectionism and symptoms. Fourth, more positive perceptions of therapists’ Rogerian attributes early in treatment lead to greater symptom decrease for patients with moderate perfectionism. Fifth, greater early patient engagement in therapy is related to greater decrease in perfectionism, but a strong relationship with the therapist may be necessary for an accompanied greater decrease in symptoms. The relationship between pre-treatment perfectionism and alliance is partially explained by higher levels of hostility and lower levels of positive affect. Sixth, the relationship between pre-treatment perfectionism and outcome is almost entirely explained by level of patient contribution to alliance and satisfaction with social network, highlighting the importance of focusing on social functioning for patients with high perfectionism (both in and outside of the session). Limitations include that most of the findings are from analyses of one large data set and a range of measurement issues. Future research should utilize different measures, perspectives, and populations and examine specific session process

Biases in research: risk factors for non-replicability in psychotherapy and pharmacotherapy research

Replicability of findings is an essential prerequisite of research. For both basic and clinical research, however, low replicability of findings has recently been reported. Replicability may be affected by research biases not sufficiently controlled for by the existing research standards. Several biases such as researcher allegiance or selective reporting are well-known for affecting results. For psychotherapy and pharmacotherapy research, specific additional biases may affect outcome (e.g. therapist allegiance, therapist effects or impairments in treatment implementation). For meta-analyses further specific biases are relevant. In psychotherapy and pharmacotherapy research these biases have not yet been systematically discussed in the context of replicability. Using a list of 13 biases as a starting point, we discuss each bias's impact on replicability. We illustrate each bias by selective findings of recent research, showing that (1) several biases are not yet sufficiently controlled for by the presently applied research standards, (2) these biases have a pernicious effect on replicability of findings. For the sake of research credibility, it is critical to avoid these biases in future research. To control for biases and to improve replicability, we propose to systematically implement several measures in psychotherapy and pharmacotherapy research, such as adversarial collaboration (inviting academic rivals to collaborate), reviewing study design prior to knowing the results, triple-blind data analysis (including subjects, investigators and data managers/statisticians), data analysis by other research teams (crowdsourcing), and, last not least, updating reporting standards such as CONSORT or the Template for Intervention Description and Replication (TIDieR)

Prototype personality diagnosis in clinical practice: A viable alternative for DSM–5 and ICD–11

Several studies suggest that a prototype-matching approach yields diagnoses of comparable validity to the more complex diagnostic algorithms outlined in the Diagnostic and Statistical Manual of Mental Disorders (4th ed.). Furthermore, clinicians prefer prototype diagnosis of personality disorders to the current categorical diagnostic system or alternative dimensional methods. An important extension of this work was to investigate the degree to which clinicians are able to make prototype diagnoses reliably. The aim of this study was to assess the interrater reliability of a prototype-matching approach to personality diagnosis in clinical practice. Using prototypes derived empirically in prior research, outpatient clinicians diagnosed patients' personality after an initial evaluation period. External evaluators independently diagnosed the same patients after watching videotapes of the same clinical hours. Interrater reliability for prototype diagnosis was high, with a median r ϭ .72. Cross-correlations between disorders were low, with a median r ϭ .01. Clinicians and clinically trained independent observers can assess complex personality constellations with high reliability using a simple prototype-matching procedure, even with prototypes that are relatively unfamiliar to them. In light of its demonstrated reliability, efficiency, and versatility, prototype diagnosis appears to be a viable system for the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders and the 11th edition of the International Classification of Diseases, with exceptional utility for research and clinical practice

Is psychotherapy effective? A re-analysis of treatments for depression

Aims The aim of this study was to reanalyse the data from Cuijpers et al.'s (2018) meta-analysis, to examine Eysenck's claim that psychotherapy is not effective. Cuijpers et al.after correcting for bias, concluded that the effect of psychotherapy for depression was small (standardised mean difference, SMD, between 0.20 and 0.30), providing evidence that psychotherapy is not as effective as generally accepted.MethodsThe data for this study were the effect sizes included in Cuijpers et al. (2018). We removed outliers from the data set of effects, corrected for publication bias and segregated psychotherapy from other interventions. In our study, we considered wait-list (WL) controls as the most appropriate estimate of the natural history of depression without intervention.ResultsThe SMD for all interventions and for psychotherapy compared to WL controls was approximately 0.70, a value consistent with past estimates of the effectiveness of psychotherapy. Psychotherapy was also more effective than care-as-usual (SMD = 0.31) and other control groups (SMD = 0.43).ConclusionsThe re-analysis reveals that psychotherapy for adult patients diagnosed with depression is effective

Minding the gaps : using narrative account to explore people’s experiences of using a voluntary sector mental health counselling service

Introduction: In the UK almost 50% of illness diagnosed among working age adults is mental distress, with depression and chronic anxiety cited as the two most prevalent psychological illnesses. However, only 24% of those who experience anxiety and depression, consistent with diagnoses, receive National Health Service (NHS) interventions. Effective mental health care is predicated on understanding the lived experiences of those using services in order to provide sensitively-attuned therapy. An understanding of the process of counselling and what makes it effective will only be achieved through hearing the voices of service users. However, with regard to counselling, the literature foregrounding the perspectives of those using services remains sparse. Method: This paper reports on a qualitative research project, adopting a case study approach, the aim of which was to explore detailed narratives of the experiences of people who had used a voluntary sector mental health counselling service in order to elicit the strengths and/or opportunities for improvement of the service. Twelve participants, five males and seven females, were interviewed on a one to one basis and six themes were identified; Mindful of the Gap; Easing like Sunday Morning; Magic Moments; Love is in the Air; Lighting up a Future and Following up the Changes: Spreading the Word. Results: Findings suggest the service is beneficial, with therapeutic interventions being tailor-made to meet the person’s needs and one which ensures a safe environment and compassionate care for those in distress

Evaluating outcomes of therapies offered by occupational therapists in adult mental health

Background: Attitudes towards the use of outcome measures by professionals working in mental health have been shown to be variable. Occupational therapists appear to have difficulty specifying goals and measuring the outcomes of interventions. Aims: To measure the outcomes of therapies offered by occupational therapists and to assess concurrent validity of the Van du Toit Model of Creative Ability (VdT MoCA) assessment. Method: The Global Assessment of Functioning (GAF), VdT MoCA assessment and Canadian Occupational Performance Measure (COPM) were used. Changes in mean scores on the measures were assessed using appropriate tests. Correlations between measures were assessed using Spearman's non-parametric test. Results: Mean post-therapy scores were significantly higher than pre-therapy scores on all three measures. VdT MoCA assessment scores pre- and post-therapy were highly correlated with GAF scores. The COPM outcome scores were uncorrelated with VdT MoCA assessment and GAF scores. Conclusions: The results offer a promising indication that occupational therapy interventions may increase functioning and thus aid clients' recovery. The VdT MoCA assessment is promising as a measure of improvement in functioning. Further research is needed to confirm these results and to further explore issues around occupational therapists' use of outcome measures

Pragmatic randomized controlled trial of long-term psychoanalytic psychotherapy for treatment-resistant depression: the Tavistock Adult Depression Study (TADS)

This pragmatic randomized controlled trial tested the effectiveness of long-term psychoanalytic psychotherapy (LTPP) as an adjunct to treatment-as-usual according to UK national guidelines (TAU), compared to TAU alone, in patients with long-standing major depression who had failed at least two different treatments and were considered to have treatment-resistant depression. Patients (N=129) were recruited from primary care and randomly allocated to the two treatment conditions. They were assessed at 6-monthly intervals during the 18 months of treatment and at 24, 30 and 42 months during follow-up. The primary outcome measure was the 17-item version of the Hamilton Depression Rating Scale (HDRS-17), with complete remission defined as a HDRS-17 score ?8, and partial remission defined as a HDRS-17 score ?12. Secondary outcome measures included self-reported depression as assessed by the Beck Depression Inventory - II, social functioning as evaluated by the Global Assessment of Functioning, subjective wellbeing as rated by the Clinical Outcomes in Routine Evaluation - Outcome Measure, and satisfaction with general activities as assessed by the Quality of Life Enjoyment and Satisfaction Questionnaire. Complete remission was infrequent in both groups at the end of treatment (9.4% in the LTPP group vs. 6.5% in the control group) as well as at 42-month follow-up (14.9% vs. 4.4%). Partial remission was not significantly more likely in the LTPP than in the control group at the end of treatment (32.1% vs. 23.9%, p=0.37), but significant differences emerged during follow-up (24 months: 38.8% vs. 19.2%, p=0.03; 30 months: 34.7% vs. 12.2%, p=0.008; 42 months: 30.0% vs. 4.4%, p=0.001). Both observer-based and self-reported depression scores showed steeper declines in the LTPP group, alongside greater improvements on measures of social adjustment. These data suggest that LTPP can be useful in improving the long-term outcome of treatment-resistant depression. End-of-treatment evaluations or short follow-ups may miss the emergence of delayed therapeutic benefit

Relationship between the Social Cognition and Object Relations Scale (SCORS) and attachment style in a clinical sample

This present study examined the relationship between the Social Cognition and Object Relations Scale (SCORS) and two measures of adult attachment: the Relationship Questionnaire (RQ) and the Experiences in Close Relationships Questionnaire‐Revised (ECR‐R). Forty‐five patients (76% female) at a university‐based outpatient treatment clinic participated in this study. We hypothesized that higher levels of attachment security would be associated with higher, more adaptive ratings on the SCORS variables. Results indicated that the SCORS Self‐Esteem (SE) variable was significantly positively related to the RQ's Secure Attachment ratings and negatively related with the ECR‐R's Anxious Attachment scale. Additionally, negative trends were noted between SE and the RQ's Fearful and Preoccupied Attachment scores. The SCORS Emotional Investments in Relationships and Affective Quality of Representations variables were associated with higher Secure scores and lower, more maladaptive Preoccupied scores on the RQ. It was also associated with greater attachment anxiety as measured by the ECR‐R. Using both clinician (SCORS) and participant‐rated measures (ECR‐R and RQ), this study provides further understanding on how object representations and attachment style relate within a clinical sample. Results are discussed in light of prior research examining relationships between object relations and adult attachments, and clinical implications are also reviewed. Copyright © 2010 John Wiley & Sons, Ltd. Key Practitioner Message: • Individuals with higher levels of attachment anxiety may enter therapy with more self‐image problems. • Individuals with higher levels of attachment anxiety may enter therapy with more maladaptive expectations about relationships. • Patients who endorse high levels of attachment anxiety (e.g., fearful and preoccupied) may be more likely to present with Axis II complaints. • Examining a patient's attachment style and object relations using different measures of assessment (e.g., explicit and implicit) can help gain a deeper and more comprehensive understanding of a patient.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/88074/1/721_ftp.pd