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Beyond symptom reduction: Development and validation of the Complementary Measure of Psychotherapy Outcome (COMPO)

Chui, Harold; Chong, Eddie S K; Atzil-Slonim, Dana; Sahin, Zeynep; Solomonov, Nili; Minges, Mary V; Kuprian, Nadia; Barber, Jacques P
Most measures of psychotherapy outcome focus on symptomatic change. However, clients often report other changes through therapy, such as increased self-acceptance. This study reports on the development and validation of the Complementary Measure of Psychotherapy Outcome (COMPO) that assesses different areas of psychological functioning deemed important by clients and therapists. Items were written based on a literature review of client-reported change and feedback from experienced therapists. Exploratory factor analysis was conducted on the initial 42-item COMPO administered to 264 psychotherapy clients. Iterative item reduction resulted in the final 12-item, four-factor solution, with factors named self-acceptance, self-knowledge, relationship quality, and consideration of others. This factor structure, along with a bifactor model that contains a general factor and the four domain-specific factors, was replicated on a sample of 571 adults in the community. The 12-item COMPO exhibits convergent validity with measures of self-esteem, insight, social support, and empathy; demonstrates 2-week test-retest reliability; and predicts life satisfaction. The 12-item COMPO was further administered to 28 clients in short-term psychodynamic therapy for depression. Except for consideration of others, COMPO subscales and total scale scores improved from pre- to posttherapy. Posttherapy COMPO scores were also higher among clients who experienced clinically significant change compared to those who did not. The COMPO was negatively associated with depressive symptoms and impairments in functioning across the three samples. The brevity of the COMPO makes it a convenient tool to supplement symptom-based measures for a more comprehensive assessment of outcome in psychotherapy. (PsycInfo Database Record (c) 2020 APA, all rights reserved).
PMID: 33090871
ISSN: 0022-0167
CID: 4642862

Patient, therapist, and relational antecedents of hostile resistance in cognitive-behavioral therapy for panic disorder: A qualitative investigation

Schwartz, Rachel A; Chambless, Dianne L; Milrod, Barbara; Barber, Jacques P
Hostile resistance (clients' openly combative behavior directed at therapists) predicts poor outcomes in cognitive-behavioral therapy (CBT) for panic disorder, but its origins are poorly understood. It is important to have a holistic understanding of the etiology of hostile resistance that incorporates the therapeutic context if these behaviors-and their negative consequences-are to be prevented and effectively addressed. Of the 71 adults who received CBT for panic disorder as part of larger trial, 8 exhibited hostile resistance. Grounded theory methodology was used to develop a theoretical framework to understand why these patients became hostile in session. The 10 minutes of session preceding instances of hostile resistance and matched portions of sessions from five never hostile controls were coded. Two pathways to hostile resistance emerged-one in which patient characteristics were primary and one wherein therapist failures (particularly of empathy) were primary. Being a challenging patient (i.e., narcissistic, obsessive, angry, resistant) moderated which pathway was followed. However, even among challenging patients, rarely was hostile resistance attributable to patients' dispositions alone. Most often, patient factors interacted with therapist (e.g., displays of frustration) and treatment (e.g., directiveness, degree of structure) factors to produce such resistance. Contrary to the view of hostile resistance as simply a product of a hostile patient, the picture is more complex. Findings indicate that greater attention to common factors in CBT and more flexible applications of treatment protocols is warranted. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
PMID: 33539140
ISSN: 1939-1536
CID: 4802182

Comparing the interpersonal profiles of obsessive-compulsive personality disorder and avoidant personality disorder: Are there homogeneous profiles or interpersonal subtypes?

Solomonov, Nili; Kuprian, Nadia; Zilcha-Mano, Sigal; Muran, J Christopher; Barber, Jacques P
Previous studies have shown that individuals with personality disorder (PD) suffer from significant interpersonal distress. Some PDs, such as avoidant personality disorder (AvPD), have been characterized with a clear homogeneous interpersonal profile. Other PDs, such as obsessive-compulsive personality disorder (OCPD), have shown significant heterogeneity rather than a distinct profile. Our study aimed to compare these two PDs and determine their interpersonal profiles. Analyses included 43 patients with OCPD and 64 with AvPD recruited in 2 clinical trials. They completed the Inventory of Interpersonal Problems at baseline (Alden, Wiggins, & Pincus, 1990). Structural summary and circular statistic methods were used to examine group interpersonal profile. Cluster analysis was used to identify subtypes within the OCPD and AvPD samples. The AvPD sample demonstrated a homogeneous interpersonal profile placed in the socially avoidant octant of the circumplex. In contrast, the OCPD group exhibited a heterogeneous interpersonal profile, with two subtypes on opposite sides of the circumplex: (a) "aggressive" (i.e., vindictive-domineering) and (b) "pleasing" (i.e., submissive-exploitable). Both clusters demonstrated homogeneous, prototypical, and distinct interpersonal profiles. Our findings show that individuals with either OCPD or AvPD exhibit significant interpersonal distress. Although AvPD may be inherently an interpersonal PD, OCPD cannot classified into one homogenous profile, but rather two distinct interpersonal subgroups. The heterogeneity may be explained by the presence of interpersonal subtypes. Detection of subtypes can inform future research on treatment targets as well as personalized interventions, tailored to patients' specific interpersonal difficulties. (PsycINFO Database Record (c) 2020 APA, all rights reserved).
PMID: 31944791
ISSN: 1949-2723
CID: 4485812

A meta-analysis of psychodynamic treatments for borderline and cluster C personality disorders

Keefe, John R; McMain, Shelley F; McCarthy, Kevin S; Zilcha-Mano, Sigal; Dinger, Ulrike; Sahin, Zeynep; Graham, Kathryn; Barber, Jacques P
Personality disorders (PD) carry high psychosocial dysfunction and are associated with treatment resistance in nonspecialized care. Psychodynamic therapies (PDT) are often used to treat PDs, but there has never been a systematic meta-analysis of PDT trials for PD. To evaluate the evidence base for PDTs for PDs across multiple outcome domain, a systematic search for PDT for PD trials was conducted through PubMed and PsycINFO. Sixteen trials were identified, comprising 19 dynamic, 8 active, and 9 control groups predominantly reflecting treatment of borderline and mixed Cluster C PDs, and a random effects meta-analysis was undertaken. PDTs were superior to controls in improving core PD symptoms (g = -0.63; 95% confidence interval [CI; -0.87, -0.41]), suicidality (g = -0.79, p = .02; 95% CI [-1.38, -0.20]), general psychiatric symptoms (g = -0.47; 95% CI [-0.69, -0.25]), and functioning (g = -0.66; 95% CI [-1.01, -0.32]), but not for interpersonal problems due to heterogeneity (g = -1.25; 95% CI [-3.22, 0.71]). Outcomes for PDTs were not different from other active treatments in core PD (g = 0.05; 95% CI [-0.25, 0.35]) or other symptoms. This pattern continued into posttreatment follow-up (average 14 months). Study quality was generally rated as adequate and was unrelated to outcomes. Compared with other treatments, PDTs do not have different acute effects and are superior to controls, although only trials treating BPD employed active controls and non-BPD trials were of lower quality. Underresearched areas include narcissistic PD, specific Cluster C disorders, and personality pathology as a continuous construct. (PsycInfo Database Record (c) 2020 APA, all rights reserved).
PMID: 31804128
ISSN: 1949-2723
CID: 4485732

Processes of therapeutic change: Results from the Cornell-Penn Study of Psychotherapies for Panic Disorder

Barber, Jacques P; Milrod, Barbara; Gallop, Robert; Solomonov, Nili; Rudden, Marie G; McCarthy, Kevin S; Chambless, Dianne L
To examine process of changes in two distinct psychotherapies-cognitive-behavioral therapy (CBT) and Panic-Focused Psychodynamic Psychotherapy (PFPP). Two hypothesized processes of change-misinterpretation of bodily sensations and Panic Specific Reflective Function (PSRF)-were tested in the CBT and PFPP arms of the Cornell-Penn Study of Psychotherapies for Panic Disorder. The Brief Bodily Sensations Interpretation Questionnaire (BBSIQ) measures misinterpretation of bodily sensations-a focus of CBT interventions. PSRF, a target of PFPP, assesses the capacity to reflect on the underlying meaning of panic symptoms. A sample of 138 patients (37.7% men, 72.56% Whites, and 16.7% Latinx) with primary Diagnostic and Statistical Manual for Mental Disorders-Fourth Edition (DSM-IV) panic disorder were included in the present analyses. Mixed effects models tested the effects of early change in BBSIQ and PSRF (intake through Week 5) on subsequent change in the Panic Disorder Severity Scale (PDSS; Week 5 through termination). Early change on both PSRF and BBSIQ predicted subsequent change in panic severity across the two treatments. As predicted, PSRF changed more in PFPP than in CBT, but, contrary to expectation, BBSIQ showed comparable changes in both groups. Counterintuitively, CBT patients benefited more in terms of panic symptom improvement when their PSRF improved than did PFPP patients. This is the first demonstration of general processes of change (PSRF and BBSIQ) across psychotherapies for panic disorder, suggesting that to the extent patients change their beliefs about the meaning of panic, their panic symptoms improve in time-limited, panic-focused psychotherapies. (PsycINFO Database Record (c) 2020 APA, all rights reserved).
PMID: 32105128
ISSN: 0022-0167
CID: 4485862

Therapists' interventions as a predictor of clients' emotional experience, self-understanding, and treatment outcomes

Fisher, Hadar; Rafaeli, Eshkol; Bar-Kalifa, Eran; Barber, Jacques P; Solomonov, Nili; Peri, Tuvia; Atzil-Slonim, Dana
Clients' emotional experience (EE) and self-understanding (SU) are two clients' processes thought to play a key role in many therapeutic approaches, especially psychodynamic (PD) psychotherapy. Previous studies exploring client processes and the interventions assumed to promote them have found that both processes and interventions are related to a reduction in symptoms. However, the complex associations between the use of specific interventions, clients' processes and symptomatic outcomes have rarely been investigated. Using data collected on a session-by-session basis, we explored (a) the temporal associations between clients' processes (EE and SU) and treatment outcomes (clients' level of functioning), (b) the associations between therapists' AF and PD interventions and clients' processes, and (c) the direct and indirect associations among therapists' interventions, clients' processes, and clients' functioning. Clients (N = 115) undergoing PD psychotherapy reported their general functioning presession using the Outcome Rating Scale, and their EE and SU postsession using the Emotional Experience Self-Report and Self-Understanding Scale, respectively. Therapists reported their use of interventions postsession using the Multitheoretical List of Interventions. Longitudinal multilevel models indicated that higher EE and SU scores predicted subsequent change in functioning. Moderate (vs. high or low) use of AF interventions predicted an increase in clients' EE. Greater use of PD interventions predicted an increase in clients' SU, which also mediated improvement in functioning. These findings highlight the importance of adjusting therapists' use of interventions to promote clients' therapeutic processes and outcomes. (PsycINFO Database Record (c) 2019 APA, all rights reserved).
PMID: 31414878
ISSN: 0022-0167
CID: 4485632

In-session emotional expression predicts symptomatic and panic-specific reflective functioning improvements in panic-focused psychodynamic psychotherapy

Keefe, John R; Huque, Zeeshan M; DeRubeis, Robert J; Barber, Jacques P; Milrod, Barbara L; Chambless, Dianne L
In panic-focused psychodynamic psychotherapy (PFPP), exploration and interpretation of avoided and conflicted emotions and fantasies surrounding anxiety are thought to promote panic-specific reflective functioning (PSRF), which drives panic disorder improvements. Patient emotional expression within a session may be a marker of engaged processing and experiencing of affectively charged material. Degree of in-session expressed emotion, indicating both verbal and nonverbal emotions, was examined across three early therapy sessions for prediction of subsequent outcomes. We further investigated whether personality disorder traits, theorized to relate to constricted (obsessive-compulsive) or heightened (borderline) emotions, moderated this relationship. Emotional expression in Sessions 2, 5, and 10 of a 24-session PFPP protocol was assessed by blinded observers in 44 patients randomized to PFPP in a two-site randomized controlled trial of psychotherapies for panic disorder. Robust regressions were conducted to examine the relationship between average emotional expression across the measured sessions and symptom and PSRF changes subsequent to the sampled sessions, as well as moderation by personality disorder criteria, controlling for early outcomes. Higher levels of emotional expression across the early sessions predicted greater subsequent symptom and PSRF improvement. Elevations in expression of grief/sadness drove the symptomatic finding. Patients meeting more borderline criteria experienced a smaller and potentially negative relationship between emotional expression and symptom improvement. Emotional expression in PFPP may be an indicator of positive therapy process for patients without comorbid borderline personality traits, predicting prospective improvements in both a key mediator (PSRF) and symptoms. (PsycINFO Database Record (c) 2019 APA, all rights reserved).
PMID: 30869969
ISSN: 1939-1536
CID: 4802032

Clinical severity as a moderator of outcome in psychodynamic and dialectical behavior therapies for borderline personality disorder

Sahin, Zeynep; Vinnars, Bo; Gorman, Bernard S; Wilczek, Alexander; Ã…sberg, Marie; Barber, Jacques P
The aim of the present study was to assess the effect of initial level of psychiatric severity on treatment outcome in psychodynamic therapy and dialectical behavior therapy (DBT) for borderline personality disorder (BPD). It was hypothesized that DBT would lead to better outcome for patients with high psychiatric severity, whereas dynamic treatment would lead to better outcome for patients with lower psychiatric severity. Data from the 5th-year follow-up of the Stockholm City Council's and the Karolinska Institute's Psychotherapy Project were used in the present study. A total of 106 female patients diagnosed with BPD with at least 2 past suicide attempts were randomized into object-relational psychotherapy (ORP; based on transference-focused psychotherapy), DBT, and treatment as usual. Patients' baseline global severity index was used as a moderator. Global Assessment of Functioning (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition [American Psychiatric Association, 1994]) was used to examine outcome. There was a significant 3-way interaction of Time × Treatment × Severity. Post hoc analyses suggested that patients with lower levels of severity had significantly better outcomes in object-relational psychotherapy. For patients with higher severity, the 3 treatments resulted in similar outcomes in terms of level of functioning. Outcome of treatment for BPD might differ significantly for patients depending on their initial levels of overall psychiatric severity. If our findings are replicated for patients with low severity and supported for a high-severity sample, psychiatric severity can be used as a low-cost and effective tool to match patients with BPD to optimal treatments. (PsycINFO Database Record
PMID: 29239627
ISSN: 1949-2723
CID: 4802022

Psychotherapy with American Indians: An exploration of therapist-rated techniques in three urban clinics

Beitel, Mark; Myhra, Laurelle L; Gone, Joseph P; Barber, Jacques P; Miller, Alyssa; Rasband, Aaron; Cutter, Christopher J; Schottenfeld, Richard S; Barry, Declan T
The aim of the project was to conduct psychotherapy research in American Indian mental health clinics. To date, very little psychotherapy research has been conducted in this area. We report the findings from a multisite investigation of psychotherapy techniques used with American Indians. Psychotherapists, working in three American Indian clinics, were asked to self-report the therapeutic interventions that they used in sessions with 93 separate adult American Indian outpatients. Each therapist rated each client exactly once, and thus data on 93 sessions were collected. Therapists' self-reported technique use with the Multitheoretical List of Therapist Interventions (McCarthy & Barber, 2009). Ratings were made immediately following the delivery of a session. The common factors approach was the most reported approach, followed by person-centered and interpersonal approaches. However, the therapists reported using techniques from all of the main therapeutic approaches. Technique use was affected by client- (demographic and diagnostic), therapist-, and therapy-related variables. This project represents a promising start to systematic psychotherapy research in busy, urban American Indian clinics. Many psychotherapeutic techniques are utilized, and there are many avenues for future research. A replication with client and observer ratings will be an important next step. (PsycINFO Database Record
PMID: 29565621
ISSN: 1939-1536
CID: 4567482

Fluctuations in alliance and use of techniques over time: A bidirectional relation between use of "common factors" techniques and the development of the working alliance

Solomonov, Nili; McCarthy, Kevin S; Keefe, John R; Gorman, Bernard S; Blanchard, Mark; Barber, Jacques P
OBJECTIVE:The aim of this study was twofold: (a) Investigate whether therapists are consistent in their use of therapeutic techniques throughout supportive-expressive therapy (SET) and (b) Examine the bi-directional relation between therapists' use of therapeutic techniques and the working alliance over the course of SET. METHOD/METHODS:Thirty-seven depressed patients were assigned to 16 weeks of SET as part of a larger randomized clinical trial (Barber, Barrett, Gallop, Rynn, & Rickels, ). Working Alliance Inventory-Short Form (WAI-SF) was collected at Weeks 2, 4, and 8. Use of therapeutic interventions was rated by independent observers using the Multitheoretical List of Therapeutic Interventions (MULTI). Intraclass correlation coefficients assessed therapists' consistency in use of techniques. A cross-lagged path analysis estimated the working alliance inventory- Multitheoretical List of Therapeutic Interventions bidirectional relation across time. RESULTS:Therapists were moderately consistent in their use of prescribed techniques (psychodynamic, process-experiential, and person-centred). However, they were inconsistent, or more flexible, in their use of "common factors" techniques (e.g., empathy, active listening, hope, and encouragements). A positive bidirectional relation was found between use of common factors techniques and the working alliance, such that initial high levels of common factors (but not prescribed) techniques predicted higher alliance later on and vice versa. CONCLUSION/CONCLUSIONS:Therapists tend to modulate their use of common factors techniques across treatment. Additionally, when a strong working alliance is developed early in treatment, therapists tend to use more common factors later on. Moreover, high use of common factors techniques is predictive of later improvement in the alliance.
PMID: 28960657
ISSN: 1099-0879
CID: 2945742