Faculty Bibliography

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.

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.

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.

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.

The longitudinal course of cocaine dependence is characterized by alternating periods of abstinence and relapse. Although gender has emerged as an important predictor of relapse, previous studies have examined mean differences in use by gender. Focusing strictly on differences in averages between men and women does not address potential gender differences in transitions between use and abstinence. Transition rates for men and women were compared using data from the National Institute on Drug Abuse Collaborative Cocaine Treatment Study. Abstinence and nonabstinence for each of the 6 months of active treatment was determined by using a composite measure of use that incorporated information from weekly and monthly self-reports and urine toxicology screenings. Random effects were introduced to describe intersubject heterogeneity in transition rates. In this sample of 454 patients, rates of transition between abstinence and use were significantly different between men and women, with men showing twice the rate of transition between states despite similar average levels of use. These data may have important implications for both treatment planning and the types of outcomes considered in clinical practice and research.

Although patients with mood disorders report interpersonal difficulties in addition to depression or anxiety, few studies have examined interpersonal patterns in those patients. Here the authors' goals were to (a) identify the interpersonal pattern in patients with major depressive disorder (MDD), (b) determine interpersonal differences between subgroups of MDD patients, and (c) examine the interpersonal patterns of comorbid MDD patients. One- hundred forty-one MDD adults participated in an ongoing randomized clinical trial of treatments for depression. Interpersonal profiles revealed that MDD patients were significantly more distressed by interpersonal problems than normative samples. Furthermore, MDD patients with depressive personality disorder reported more interpersonal distress than MDD-only patients report and were more likely to have interpersonal problems related to dominance and control than submissiveness.

The study is aimed at investigating the impact of a personality disorder (PD) diagnosis, in terms of functional impairment and subjective distress, in order to better understand the burden of this diagnosis and its implications. Among the 462 consecutive psychiatric patients diagnosed with the DSM structured interview for Axis I, II and V diagnoses, almost 60% had PD. Patients with PD displayed considerable vulnerability and suffering in many domains, including finances and interpersonal relationships. Despite the educational and occupational similarities of PD patients and non-PD patients, the PD patients had more problems maintaining permanent job positions. They also had more symptomatic suffering and concerns about health than non-PD patients. Generally, the results were in line with findings in the literature but more thoroughly captured the challenges that PD patients face in various areas of life. Awareness of the frequent comorbidity of PD with Axis I disorders seems crucial in developing future treatment plans with an emphasis on psychosocial rehabilitation, vocational training and social support.

Understanding the predictors that are responsible for the range of patient outcome in specific treatments may enable us to recognize the most suitable treatment for each patient. This special section is devoted to studies that have furthered our understanding of this crucial and varied relation between predictors and outcomes in specific therapeutic contexts. The studies included in this special section have investigated primarily patient-based predictors of outcome. Nevertheless, a study that investigates therapist-based predictors of outcome and a study of process-based predictors of outcome were also included. One of the strengths of many of the articles included in this special section is a large sample size. Therefore, both positive and negative results from some of these studies are of great importance.

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.

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