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'.

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.

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.

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).

The Nature of Client Agency Prior to Therapy: A Qualitative Study on Clients' Narratives.

Client agency is considered a crucial contributor to good treatment outcome. Recent studies, however, differ strongly in how they conceptualise and investigate agency. The current study explores the nature of client agency in ten clients' pre-treatment interviews. Applying Consensual Qualitative Research, we constructed three overarching categories, subdivided into 14 sub-categories capturing both between- and within-person differences in agency before therapy. We found that all participants oscillated between the experience of a lack of grip on problems on the one hand and noticing their involvement in the problem and taking action on the other. These results present a dynamic conceptualisation of client agency. This allows us to ask pertinent questions for both future research and clinical practice.

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.

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.

Interpersonal dynamics and therapeutic relationship in patients with functional somatic syndromes: A metasynthesis of case studies.

Patients with functional somatic syndromes (FSS) often display troubled relationships with health care providers, psychotherapists, and significant others. Research shows that patients' history of trauma, attachment disturbances, and mentalization deficits may result in the emergence of maladaptive interpersonal patterns, which may later contribute to the onset and maintenance of FSS, "doctor hopping," and dropout in psychotherapy. As the nature and therapeutic consequences of such maladaptive interpersonal patterns in FSS cannot be understood sufficiently by quantitative methods alone, there is a need for in-depth qualitative research. To address this issue, we conducted a metasynthesis of 23 published case studies of patients with FSS from various psychotherapeutic orientations. Results show that patients with FSS from our sample perceived others as unreliable, that is, unavailable, overcontrolling, and overprotective. To adapt to such unreliable others, patients attempted to please and to control them. Patients also suppressed their emotional awareness and expression. Although alexithymia could also play a role, the primary reason for emotional avoidance seemed to be interpersonal in nature, that is, patients were avoiding negative emotions in order to please and control the unreliable others. The onset and worsening of FSS were associated with both interpersonal and physical triggers. Showing signs of physical or emotional distress led to more rejection, overcontrol, and overprotection from unreliable others, which could create a "vicious circle." Our results suggest that offering a more interpersonal perspective on emotion regulation difficulties would be beneficial for patients with FSS, counselors, psychotherapists, and other health care professionals. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

The Influence of Interpersonal Patterns on the Therapy Process in a Case of Childhood Trauma.

Research concerning the influence of core interpersonal patterns related to childhood trauma on the therapeutic process is scarce. We investigated interpersonal patterns at the start of treatment, changes in interpersonal patterns as treatment progressed, and the change process in a mixed-methods single case study of a supportive-expressive psychodynamic psychotherapy with a 33-year-old female with a history of childhood trauma. The patient showed a pervasive inability to open up towards others throughout the entire treatment, which is closely associated with others' actual or anticipated rejection, disrespect and disinterest. Excessive use of expressive interventions, which target interpersonal change, initially led to a worsening of the patient's condition. Via supportive and general interventions, symptom stabilization was achieved. The findings of this study suggest a thorough understanding of dominant interpersonal patterns is necessary to recognize their influence on the therapy process.

Countertransference Processes in Psychodynamic Therapy with Dependent (Anaclitic) Depressed Patients: A Qualitative Study Using Supervision Data.

Although Blatt's two-polarity model of depression has suggested that patients' interpersonal styles may shape countertransference phenomena in psychotherapy, empirical research on this topic has remained scarce. This article provides an in-depth study of countertransference processes in clinical work with dependent (anaclitic) depressed patients using a qualitative methodology. Thematic analysis of narrative material of psychodynamic therapists discussing patient cases during supervision (n = 7) resulted in four recurrent themes: "empathy, compassion, and support," "anxiety, feeling overwhelmed, and protection," "frustration, irritation, and confrontation," and "inadequacy, incompetence, and fatalism." We found that these countertransference processes mainly revolved around perceived adaptive and maladaptive aspects of patients' relational functioning. Regarding clinical practice, our study suggests that therapists can use countertransference to determine in which position they are maneuvered by patients, although we caution against the exclusive use of subjectively informed data as a benchmark in the diagnostic and treatment process. We conclude that further in-depth research on countertransference and personality styles is needed to identify pitfalls in the treatment of depression.

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 Differentiates Poor- and Good-Outcome Psychotherapy? A Statistical-Mechanics-Inspired Approach to Psychotherapy Research, Part Two: Network Analyses.

Statistical mechanics is the field of physics focusing on the prediction of the behavior of a given system by means of statistical properties of ensembles of its microscopic elements. The authors examined the possibility of applying such an approach to psychotherapy research with the aim of investigating (a) the possibility of predicting good and poor outcomes of psychotherapy on the sole basis of the correlation pattern among their descriptors and (b) the analogies and differences between the processes of good- and poor-outcome cases. This work extends the results reported in a previous paper and is based on higher-order statistics stemming from a complex network approach. Four good-outcome and four poor-outcome brief psychotherapies were recorded, and transcripts of the sessions were coded according to Mergenthaler's Therapeutic Cycle Model (TCM), i.e., in terms of abstract language, positive emotional language, and negative emotional language. The relative frequencies of the three vocabularies in each word-block of 150 words were investigated and compared in order to understand similarities and peculiarities between poor-outcome and good-outcome cases. Network analyses were performed by means of a cluster analysis over the sequence of TCM categories. The network analyses revealed that the linguistic patterns of the four good-outcome and four poor-outcome cases were grounded on a very similar dynamic process substantially dependent on the relative frequency of the states in which the transition started and ended ("random-walk-like behavior", adjusted R 2 = 0.729, p < 0.001). Furthermore, the psychotherapy processes revealed statistically significant changes in the relative occurrence of visited states between the beginning and the end of therapy, thus pointing to the non-stationarity of the analyzed processes. The present study showed not only how to quantitatively describe psychotherapy as a network, but also found out the main principles on which its evolution is based. The mind, from a linguistic perspective, seems to work-through psychotherapy sessions by passing from the most adjacent states and the most occurring ones. This finding can represent a fertile ground to rethink pivotal clinical concepts such as the timing of an interpretation or a comment, the clinical issue to address within a given session, and the general task of a psychotherapist: from someone who delivers a given technique toward a consultant promoting the flexibility of the clinical field and, thus, of the patient's mind.

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.

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.

Core Interpersonal Patterns in Complex Trauma and the Process of Change in Psychodynamic Therapy: A Case Comparison Study.

We performed a case comparison study to investigate the nature of interpersonal patterns in childhood trauma and the process of change therein. We analyzed three matching cases of childhood trauma that followed a psychodynamic treatment via a mixed-methods design. We found that (1) the core tendency to avoid negative reactions from others through passive behaviors emerged in all three cases, both in childhood and adulthood, (2) core interpersonal patterns transpired in the interaction between patient and therapist and thereby affected the therapeutic relationship, and (3) change ensued when a repetition of core interpersonal patterns was avoided and a new relational experience occurred. The accumulated findings across cases further resulted in several clinical implications and recommendations, such as the importance of the assessment of patients' (covert) conditions, responsiveness, supervision and facilitating patients' agency, and provided several avenues for further research.

Healthcare professionals' perspectives on mental health service provision: a pilot focus group study in six European countries.

BACKGROUND: The mental healthcare treatment gap (mhcGAP) in adult populations has been substantiated across Europe. This study formed part of MentALLY, a research project funded by the European Commission, which aimed to gather qualitative empirical evidence to support the provision of European mental healthcare that provides effective treatment to all adults who need it. METHODS: Seven focus groups were conducted with 49 health professionals (HPs), including psychologists, psychiatrists, social workers, general practitioners, and psychiatric nurses who worked in health services in Belgium, Cyprus, Greece, the Netherlands, Norway and Sweden. The focus group discussions centered on the barriers and facilitators to providing quality care to people with mild, medium, and severe mental health problems. Analyses included deductively and inductively driven coding procedures. Cross-country consensus was obtained by summarizing findings in the form of a fact sheet which was shared for triangulation by all the MentALLY partners. RESULTS: The results converged into two overarching themes: (1) Minding the treatment gap: the availability and accessibility of Mental Health Services (MHS). The mhcGAP gap identified is composed of different elements that constitute the barriers to care, including bridging divides in care provision, obstacles in facilitating access via referrals and creating a collaborative 'chain of care'. (2) Making therapeutic practice relevant by providing a broad-spectrum of integrated and comprehensive services that value person-centered care comprised of authenticity, flexibility and congruence. CONCLUSIONS: The mhcGAP is comprised of the following barriers: a lack of funding, insufficient capacity of human resources, inaccessibility to comprehensive services and a lack of availability of relevant treatments. The facilitators to the provision of MHC include using collaborative models of primary, secondary and prevention-oriented mental healthcare. Teamwork in providing care was considered to be a more effective and efficient use of resources. HPs believe that the use of e-mental health and emerging digital technologies can enhance care provision. Facilitating access to a relevant continuum of community-based care that is responsive coordinated and in line with people's needs throughout their lives is an essential aspect of optimal care provision.

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.

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).