Faculty Bibliography

We examine the complex relations among therapeutic alliance, adherence to Supportive-Expressive Therapy (SET), therapist competence, and their interactions in predicting change in drug use. Experts rated early therapy sessions of cocaine dependent patients (n = 108) randomized to SET as part of the Collaborative Cocaine Treatment Study. Moderate adherence to SET and competent delivery of SET were separately associated with poorer outcome. Further, strong alliance combined with low levels of SET adherence was associated with a better outcome than moderate or high levels. Moreover, the usage of nonprescribed techniques (i.e., Individual Drug Counseling [IDC]) by SET therapists predicted better outcome in a subsample (n = 36), and SET patients receiving high levels of IDC adherence had less predicted drug use compared with those with high levels of SET techniques. Overall results may suggest that decreasing cocaine use through straightforward drug counseling techniques instead of trying to help patients understand the reasons for their use is a better initial road to recovery.

Using data from the National Institute on Drug Abuse Collaborative Cocaine Treatment Study, this article focuses on the outcomes of patients who received supportive-expressive (SE) psychodynamically-oriented psychotherapy (plus group drug counseling; GDC). Short-term SE for cocaine dependent individuals, while not the most efficacious treatment examined in the study (individual drug counseling [IDC] plus GDC was), produced large improvements in cocaine use. In addition, there was evidence that SE was superior to IDC on change in family/social problems at the 12 month follow-up assessment, particularly for those patients with relatively more severe difficulties in this domain at baseline. For patients who achieved abstinence early in treatment, SE produced comparable drug use outcomes to IDC, with mean drug use scores numerically lower for SE at all of the follow-up assessments (9, 12, 15, and 18 months). SE patients who achieved initial abstinence decreased cocaine use from a mean 10.1 days per month at baseline to a mean of 1.3 days at 12 months.

Abstract Eighteen patients diagnosed with burnout-related depression and receiving short-term psychodynamic group psychotherapy were included in this study. The participants completed the group version of the California Psychotherapy Alliance Scales (CALPAS) five times during treatment and evaluated the relationship positively. Alliance increased significantly as treatment progressed; however, the amount of change was small. Level of alliance to the group-as-a-whole, averaged over time, was predictive of two out of three outcome measures, whereas growth in alliance during the early phase of therapy was not predictive of outcome. Exploratory examination of the alliance at different time points showed that alliance to the group-as-a-whole at mid-phase of treatment was substantially correlated with outcome. Personality features such as dismissing attachment style and being overly nurturant or exploitable were predictive of early growth in alliance.

Supportive-expressive psychotherapy (SEP) has generated some empirical evidence supporting its effectiveness for treating a variety of Axis I disorder; however, no evidence supporting its use for patients with severe personality disorders has been published. This article describes a patient suffering from several personality disorders-avoidant, obsessive-compulsive, paranoid, narcissistic, and antisocial--using the core conflictual relationship theme (CCRT) method. Supportive-expressive psychotherapy focuses on connecting the CCRT with symptoms and maladaptive personality traits, with the goal of resolving these conflicts. Most maladaptive traits for such a complex patient are ego-syntonic, not experienced as internal conflicts, and therefore not easily accessible to therapeutic exploration. Such a patient is likely to experience the external environment as hostile once his ego-syntonic wishes are not automatically granted and thus the therapeutic alliance may suffer. This article will show the interpersonal processes that are activated when a patient is treated with time-limited, manualized psychotherapy.

The belief that rigidity across relationships is related to greater symptoms and poorer functioning commonly informs the practice of many psychodynamic and interpersonal therapists. Using a profile correlation approach, we tested this hypothesis in a sample of 250 clients and 90 undergraduate control participants. Symptoms and functioning were assessed with the Inventory of Interpersonal Problems (IIP), Global Assessment of Functioning scale, and Brief Symptom Inventory. A revised version of the empirically-derived Central Relationship Questionnaire (CRQ) was used to measure interpersonal patterns. Revisions were made to the CRQ to increase the interpersonal dimensions it captured, reduce its length, and model a higher-order factor structure. The psychometric properties of the revised CRQ were found to be adequate. Rigidity as measured with the CRQ was not related to rigidity measured with the IIP (amplitude) and did not differ significantly among individuals with different interpersonal problems or DSM-IV diagnoses. Contrary to theory, however, greater rigidity across relationships was related to fewer symptoms and interpersonal problems. These relations did not appear due to the valence or the extremeness of the interpersonal patterns used in the estimation of rigidity.

The assessment of intervention competence possesses an obvious relevance for practitioners and clinical scientists alike. It is often assessed as part of the evaluation of treatment integrity in clinical research in general, and in randomized clinical trials (RCTs) in particular. The authors first attempt to add clarity to the concept and better differentiate intervention competence from closely related constructs. Next, the authors review and evaluate the main measures of therapist competence used in RCTs, relying on this conceptual foundation to provide suggestions for future measures. The empirical literature on the relation between therapist competence and clinical outcome is then reviewed. The relation, while positive, is weaker than expected, and factors having a potential bearing on this are discussed. The authors then recommend that new measures be created and that the assessment of limited-domain competence be supplemented by explorations of global competence. Due to the potential ramifications for the field, the authors also recommend that caution be exercised in the task of operationally defining competence.

Reviews the book, Ambivalence in psychotherapy: Facilitating readiness to change by David E. Engle and Hal Arkowitz (see record 2006-02766-000). This book is devoted to the understanding, diagnosis, and resolution of ambivalence in our clients to help them move toward change. Our current understanding of ambivalence is as conflicted as our clients sometimes feel. Often when we speak of ambivalence we mean resistance, or any behavior that interferes with treatment. The authors set the framework of their book by clearly defining the phenomenon of resistant ambivalence as a subset of resistance that includes both movements toward change and movements away from change. The authors then review how different theoretical orientations conceptualize resistant ambivalence. Engle and Arkowitz then consider the current methods of assessing resistant ambivalence. Their review is comprehensive and covers qualitative, clinical interview, and self-report methods. Many of the measures were not initially meant to capture ambivalence, but the authors give convincing arguments on why and how they should be adapted. The book discusses the interventions that the authors believe are likely to bring about change in ambivalent clients.

Using data from the National Institute of Drug Abuse Collaborative Cocaine Treatment Study, the authors examined 24 patient pretreatment variables as predictors of outcome. The most clinically meaningful outcome in the treatment of substance dependence--degree of sustained abstinence--was used. Predictor variables included demographic features, aspects of the disorder and the recovery environment, expectations about treatment, and beliefs about addiction, relapse, and the 12-step philosophy. Four of the 24 examined variables--craving, acuity of biomedical problems, belief in the 12-step philosophy, and expectations for improvement--were significantly predictive of degree of sustained abstinence using a Bonferroni-corrected alpha level. No significant interactions with treatment condition were noted. The joint effect of the 4 predictor variables had a clinically meaningful impact on outcome.

Introduction: This study examined whether measures of Personality Disorder (PD) from the Diagnostic and Statistical Manual of Mental Disorder IV, psychodynamic character, psychological mindedness, interpersonal patterns and personality traits predicted treatment outcome for PD patients. Method: Consecutive PD patients were randomly assigned to manualized time-limited supportive-expressive psychotherapy (SEP; n = 76) or non-manualized open-ended community delivered psychodynamic treatment (CDPT; n = 80). Significant predictors were tested together in order to examine whether they moderated or predicted the reduction of psychiatric symptoms (Symptom Check List-90). Results: In the entire sample, patients with more severe levels of PD disorderness (number of positive PD criteria) had slower rates of improvement, but patients with more severe levels of vindictiveness (assessed by the Inventory of Interpersonal Problems [IIP]) had higher rates of improvement. High levels of IIP dominance were significantly related to higher rate of improvement in the CDPT treatment compared with SEP. Conclusion: Due to the fact that more severe PD patients had slower rates of improvement, longer treatment may be needed for this population. Specific interpersonal problems may impact whether patients should receive manualized or non-manualized treatment.