Faculty Bibliography

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.

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.

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.

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 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.

In this article, the authors address the rationale for and uses of treatment integrity measurement in psychotherapy research, focusing on therapists' adherence and competence in trauma and posttraumatic stress disorder treatment research. The following issues are examined: (a) distinctions between adherence monitoring, performed contemporaneously with ongoing study treatments, and adherence evaluation, and the implications for outcomes analysis; (b) simultaneous measurement of adherence and competence; (c) selection of sessions for adherence/competence assessment and the need for concurrent outcome measurement, and (d) the association between therapist adherence, competence, alliance and treatment outcome. Recommendations regarding common problems in the implementation of adherence and competence measurement are made throughout. The article concludes with a summary of steps and considerations in decision-making with regard to treatment integrity

OBJECTIVE: The American Psychiatric Association (APA) practice guideline for panic disorder recommends psychodynamic psychotherapy for panic disorder patients with comorbid personality disorders. No data underlie this recommendation. This exploratory study assessed the moderating effect of personality disorder on psychodynamic and non-psychodynamic psychotherapy outcome. METHOD: Forty-nine subjects with primary DSM-IV panic disorder were randomly assigned to 12 weeks of twice-weekly Panic-Focused Psychodynamic Psychotherapy or Applied Relaxation Training. The primary outcome measure was the Panic Disorder Severity Scale; the moderating effect of Axis II psychopathology on the Sheehan Disability Scale was also tested. The trial was conducted between February 2000 and January 2005. RESULTS: Twenty-four subjects (49%) met DSM-IV criteria for a Structured Clinical Interview for DSM-IV Axis II Disorders-diagnosed personality disorder, of whom 19 (79%) had a cluster C diagnosis. Presence of a cluster C diagnosis moderated treatment outcome. Such subjects experienced greater improvements in Panic-Focused Psychodynamic Psychotherapy than subjects without cluster C comorbidity. CONCLUSIONS: Despite its small sample size, this exploratory analysis provides initial preliminary evidence corroborating the APA practice guideline recommendation. Future panic disorder clinical trials should explore Axis II moderator effects. CLINICAL TRIALS REGISTRATION: ClinicalTrials.gov identifier NCT00128388.

OBJECTIVE: This study examined 6-month treatment outcomes among 428 cocaine-dependent outpatients with (n = 34) and without (n = 394) posttraumatic stress disorder (PTSD) in a randomized controlled multisite clinical trial of manual-based psychotherapies for substance use disorder (SUD). METHOD: Assessments were completed at baseline and monthly during the 6-month treatment. With longitudinal mixed-effects models, we compared outcomes between SUD-PTSD and SUD-only patients and also examined rates of within-group change. RESULTS: Results indicated a highly consistent pattern: the SUD-PTSD patients were more impaired to begin with and remained so across time compared with SUD-only patients (with the exception of substance use and addiction-related legal and employment problems, which did not differ between groups). Also, the SUD-PTSD patients improved less than SUD-only patients in alcohol use and the majority of addiction-related psychosocial problems. However, the two groups did not differ significantly in improvement over time on drug use or global psychological severity. CONCLUSIONS: The greater impairment and relative lack of improvement of SUD-PTSD patients, compared with those with SUD-only, suggest a need for dual-diagnosis treatments that more directly target their areas of difficulty.