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

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

IMPRoving Outcomes for children exposed to domestic ViolencE (IMPROVE): an evidence synthesis

BackgroundExposure to domestic violence and abuse (DVA) during childhood and adolescence increases the risk of negative outcomes across the lifespan.ObjectivesTo synthesise evidence on the clinical effectiveness, cost-effectiveness and acceptability of interventions for children exposed to DVA, with the aim of making recommendations for further research.Design(1) A systematic review of controlled trials of interventions; (2) a systematic review of qualitative studies of participant and professional experience of interventions; (3) a network meta-analysis (NMA) of controlled trials and cost-effectiveness analysis; (4) an overview of current UK provision of interventions; and (5) consultations with young people, parents, service providers and commissioners.SettingsNorth America (11), the Netherlands (1) and Israel (1) for the systematic review of controlled trials of interventions; the USA (4) and the UK (1) for the systematic review of qualitative studies of participant and professional experience of interventions; and the UK for the overview of current UK provision of interventions and consultations with young people, parents, service providers and commissioners.ParticipantsA total of 1345 children for the systematic review of controlled trials of interventions; 100 children, 202 parents and 39 professionals for the systematic review of qualitative studies of participant and professional experience of interventions; and 16 young people, six parents and 20 service providers and commissioners for the consultation with young people, parents, service providers and commissioners.InterventionsPsychotherapeutic, advocacy, parenting skills and advocacy, psychoeducation, psychoeducation and advocacy, guided self-help.Main outcome measuresInternalising symptoms and externalising behaviour, mood, depression symptoms and diagnosis, post-traumatic stress disorder symptoms and self-esteem for the systematic review of controlled trials of interventions and NMA; views about and experience of interventions for the systematic review of qualitative studies of participant and professional experience of interventions and consultations.Data sourcesMEDLINE, Cumulative Index to Nursing and Allied Health Literature, PsycINFO, EMBASE, Cochrane Central Register of Controlled Trials, Science Citation Index, Applied Social Sciences Index and Abstracts, International Bibliography of the Social Sciences, Social Services Abstracts, Social Care Online, Sociological Abstracts, Social Science Citation Index, World Health Organization trials portal and clinicaltrials.gov.Review methodsA narrative review; a NMA and incremental cost-effectiveness analysis; and a qualitative synthesis.ResultsThe evidence base on targeted interventions was small, with limited settings and types of interventions; children were mostly &lt; 14 years of age, and there was an absence of comparative studies. The interventions evaluated in trials were mostly psychotherapeutic and psychoeducational interventions delivered to the non-abusive parent and child, usually based on the child’s exposure to DVA (not specific clinical or broader social needs). Qualitative studies largely focused on psychoeducational interventions, some of which included the abusive parent. The evidence for clinical effectiveness was as follows: 11 trials reported improvements in behavioural or mental health outcomes, with modest effect sizes but significant heterogeneity and high or unclear risk of bias. Psychoeducational group-based interventions delivered to the child were found to be more effective for improving mental health outcomes than other types of intervention. Interventions delivered to (non-abusive) parents and to children were most likely to be effective for improving behavioural outcomes. However, there is a large degree of uncertainty around comparisons, particularly with regard to mental health outcomes. In terms of evidence of cost-effectiveness, there were no economic studies of interventions. Cost-effectiveness was modelled on the basis of the NMA, estimating differences between types of interventions. The outcomes measured in trials were largely confined to children’s mental health and behavioural symptoms and disorders, although stakeholders’ concepts of success were broader, suggesting that a broader range of outcomes should be measured in trials. Group-based psychoeducational interventions delivered to children and non-abusive parents in parallel were largely acceptable to all stakeholders. There is limited evidence for the acceptability of other types of intervention. In terms of the UK evidence base and service delivery landscape, there were no UK-based trials, few qualitative studies and little widespread service evaluation. Most programmes are group-based psychoeducational interventions. However, the funding crisis in the DVA sector is significantly undermining programme delivery.ConclusionsThe evidence base regarding the acceptability, clinical effectiveness and cost-effectiveness of interventions to improve outcomes for children exposed to DVA is underdeveloped. There is an urgent need for more high-quality studies, particularly trials, that are designed to produce actionable, generalisable findings that can be implemented in real-world settings and that can inform decisions about which interventions to commission and scale. We suggest that there is a need to pause the development of new interventions and to focus on the systematic evaluation of existing programmes. With regard to the UK, we have identified three types of programme that could be justifiably prioritised for further study: psycho-education delivered to mothers and children, or children alone; parent skills training in combination with advocacy: and interventions involving the abusive parent/caregiver. We also suggest that there is need for key stakeholders to come together to explicitly identify and address the structural, practical and cultural barriers that may have hampered the development of the UK evidence base to date.Future work recommendationsThere is a need for well-designed, well-conducted and well-reported UK-based randomised controlled trials with cost-effectiveness analyses and nested qualitative studies. Development of consensus in the field about core outcome data sets is required. There is a need for further exploration of the acceptability and effectiveness of interventions for specific groups of children and young people (i.e. based on ethnicity, age, trauma exposure and clinical profile). There is also a need for an investigation of the context in which interventions are delivered, including organisational setting and the broader community context, and the evaluation of qualities, qualifications and disciplines of personnel delivering interventions. We recommend prioritisation of psychoeducational interventions and parent skills training delivered in combination with advocacy in the next phase of trials, and exploratory trials of interventions that engage both the abusive and the non-abusive parent.Study registrationThis study is registered as PROSPERO CRD42013004348 and PROSPERO CRD420130043489.FundingThe National Institute for Health Research Public Health Research programme.</jats:sec

Psychotherapy research and the Psychodynamic Diagnostic Manual (PDM–2)

The new Psychodynamic Diagnostic Manual (PDM-2; Lingiardi & McWilliams, 2017) aspires to emphasize a holistic view of individuals, rather than focusing solely on the treatment of diagnoses or the amelioration of symptoms that constitute them. In this paper, we discuss the ways in which the PDM-2 differs from the Diagnostic and Statistical Manual of Mental Disorders, 5th ed. (DSM–5; American Psychiatric Association, 2013) and complements it as a tool. We discuss these topics in the context of studies within the field of psychotherapy research that seem to be relevant to PDM-2 syndromes and domains of functioning. We review some recent specific examples of psychotherapy research that help illustrate the role that different PDM-2 constructs play in treatment, as well as suggest ideas for future directions in research about the PDM-2. It is our hope that the PDM-2 diagnostic framework will aid in planning clinically sophisticated and methodologically robust research designs examining psychotherapy process and outcome

Assessment of Combat-Related Stress and Physical Symptoms of Gulf War Veterans: Criterion Validity of Selected Hand Test Variables

We examined the utility of selected Hand Test (Wagner, 1983) variables in relation to posttraumatic stress and physical symptoms in Gulf War (GW) veterans. In this study, we sought to replicate and expand on prior empirical findings that have demonstrated efficacy of the Hand Test in the assessment of posttraumatic stress disorder (PTSD; Walter, Hilsenroth, Arsenault, Sloan, & Harvill, 1998). Based on this previous research, Hand Test variables were selected a priori and examined across three groups of veterans: (a) a control group of participants who were in a reserve unit not deployed to the GW theater of operations, (b) a subclinical group of deployed GW veterans who reported 1 to 5 Diagnostic and Statistical Manual of Mental Disorders (4th ed. [DSM-IV]; American Psychiatric Association, 1994) criteria for PTSD, and (c) a group of deployed GW veterans who met DSM-IV criteria for PTSD. Analyses demonstrated significant differences across the three groups and significant relationships among selected Hand Test variables with the number of DSM-IV symptoms of PTSD reported in the interviews as well as with the number of physical problems reported by these veterans. We discuss these findings in relation to the assessment and treatment of posttraumatic stress symptomatology

Patient SWAP-200 personality dimensions and FFM Traits: do they predict therapist responses?

The main aim of this study was to examine the relationship between therapists' emotional responses and patients' personality evaluated by 3 dimensional diagnostic approaches empirically derived from the Shedler-Westen Assessment Procedure-200 (SWAP-200; Westen & Shedler, 1999a, 1999b): Two of these rely on the 5-factor model (FFM) domains, that were assessed with different SWAP-200 FFM versions developed by Shedler and Westen (SW-FFM scales; 2004) and McCrae, Löckenhoff, and Costa (MLC-FFM scales; 2005); the third approach is based on a multifaceted model of personality syndromes (SWAP personality dimension scales; see Shedler & Westen, 2004). A national sample of psychiatrists and psychologists (N = 166) of various theoretical orientations completed the Therapist Response Questionnaire (TRQ; Zittel Conklin & Westen, 2003) to identify patterns of therapist response, and the SWAP-200 to assess personality regarding a patient currently in their care. The findings showed good levels of construct validity between the SW-FFM and MLC-FFM scales, with the exception of the Openness trait. Moreover, specific SW-FFM and MLC-FFM scales were significantly associated with distinct SWAP personality dimension scales according in a conceptually meaningful nomological network. Although there were significant, theoretically coherent, and systematic relationships between therapists' responses and patients' personality features, overall the contribution of the SW-FFM and MLC-FFM traits in predicting therapists' responses was less sizable than the SWAP personality dimensions. These results seem to confirm the diagnostic and therapeutic value of countertransference as an essential tool in understanding psychological traits/dimensions that underlie the patients' psychopathology, both from within and outside of the FFM

Interpersonal clusters in a depressed outpatient sample

Background: Prior research suggests that DSM diagnostic classification alone does not provide a full clinical picture for psychotherapy patients. Interpersonal problems are a promising area of research to aid in understanding patient experience and functioning, as well as build upon our existing understanding of psychotherapy treatment processes and outcomes. Methods: 71 outpatients were enrolled in individual psychodynamic psychotherapy and received a DSM-IV diagnosis of a depressive spectrum disorder. Each patient's current major depressive episode symptoms, global assessment of functioning (GAF) score, and interpersonal functioning were assessed pre-treatment. Hierarchical cluster analysis was used to investigate whether interpersonal “types” could be identified. Results: Hierarchical cluster analysis produced a 3-cluster solution that indicated 3 distinct interpersonal subtypes: 1) Non-assertive; 2) Socially Avoidant; and 3) Overly Nurturant. The subtypes did not significantly differ in terms of depressive diagnosis, global symptomatology, current major depressive episode symptoms, or GAF score. However, the Socially Avoidant cluster demonstrated significantly more male patients than the Non-assertive or Overly Nurturant clusters (p = .014). Limitations: The current study utilizes a small sample size (N = 71), which limits statistical power. Findings must be interpreted with caution. Additionally, DSM-IV diagnostic classifications were used. Conclusions: This study suggests the existence of three interpersonal profiles in depressive disorders: non-assertive, socially avoidant, and overly nurturant. These presentations, independent of quantitative levels of distress, imply that DSM-V classifications are insufficient to understand a patient's clinical presentation. It may be important to assess a patient's interpersonal functioning early in order to improve psychotherapy process and depression outcomes

Use of the Mississippi Scale for Combat‐related PTSD in Detecting War‐related, Non‐combat Stress Symptomatology

This study investigated the effectiveness of the Mississippi Scale for Desert Storm War Zone Personnel (M‐PTSD‐DS), developed from the Mississippi Scale for Combat Related PTSD (M‐PTSD; Keane, Caddell, and Taylor, 1988), in the measurement of varying degrees of war‐related post‐traumatic stress (PTS) symptomatology of non‐combat Persian Gulf War veterans. Thirty Marines were administered the M‐PTSD‐DS after 3 months of active duty in Operation Desert Storm. The M‐PTSD‐DS scores of the Marines were related significantly to the number of PTS symptoms reported by the Marines. This scale appears to be quite effective in detecting varying degrees of war‐related stress in non‐combatants

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Assessment of Noncombat, War-Related Posttraumatic Stress Symptomatology: Validity of the PK, PS, and IES Scales

This study investigated effectiveness of MMPI-2 PK and PS scales and the Impact of Event (IES) scales in detecting posttraumatic stress symptomatology in 66 Marine reservists exposed to 3 months of war-related stress but no direct fighting in the Persian Gulf. The IES, MMPI-2, and War Stress Interview-Operation Desert Storm (WSI-ODS), administered 90 days later, revealed that 71% of participants experienced one or more symptoms of acute posttraumatic stress for at least 1 month after the Gulf War. PK, PS and IES scores were significantly related to number of symptoms reported and were moderately effective in detecting subclinical levels of war-related stress