Drew Westen

The Empirical Status of Empirically Supported Psychotherapies: Assumptions, Findings, and Reporting in Controlled Clinical Trials.

This article provides a critical review of the assumptions and findings of studies used to establish psychotherapies as empirically supported. The attempt to identify empirically supported therapies (ESTs) imposes particular assumptions on the use of randomized controlled trial (RCT) methodology that appear to be valid for some disorders and treatments (notably exposure-based treatments of specific anxiety symptoms) but substantially violated for others. Meta-analytic studies support a more nuanced view of treatment efficacy than implied by a dichotomous judgment of supported versus unsupported. The authors recommend changes in reporting practices to maximize the clinical utility of RCTs, describe alternative methodologies that may be useful when the assumptions underlying EST methodology are violated, and suggest a shift from validating treatment packages to testing intervention strategies and theories of change that clinicians can integrate into empirically informed therapies.

Neural Bases of Motivated Reasoning: An fMRI Study of Emotional Constraints on Partisan Political Judgment in the 2004 U.S. Presidential Election

Research on political judgment and decision-making has converged with decades of research in clinical and social psychology suggesting the ubiquity of emotion-biased motivated reasoning. Motivated reasoning is a form of implicit emotion regulation in which the brain converges on judgments that minimize negative and maximize positive affect states associated with threat to or attainment of motives. To what extent motivated reasoning engages neural circuits involved in cold reasoning and conscious emotion regulation (e.g., suppression) is, however, unknown. We used functional neuroimaging to study the neural responses of 30 committed partisans during the U.S. Presidential election of 2004. We presented subjects with reasoning tasks involving judgments about information threatening to their own candidate, the opposing candidate, or neutral control targets. Motivated reasoning was associated with activations of the ventromedial prefrontal cortex, anterior cingulate cortex, posterior cingulate cortex, insular cortex, and lateral orbital cortex. As predicted, motivated reasoning was not associated with neural activity in regions previously linked to cold reasoning tasks and conscious (explicit) emotion regulation. The findings provide the first neuroimaging evidence for phenomena variously described as motivated reasoning, implicit emotion regulation, and psychological defense. They suggest that motivated reasoning is qualitatively distinct from reasoning when people do not have a strong emotional stake in the conclusions reached.

Quantifying Construct Validity: Two Simple Measures

Construct validity is one of the most central concepts in psychology. Researchers generally establish the construct validity of a measure by correlating it with a number of other measures and arguing from the pattern of correlations that the measure is associated with these variables in theoretically predictable ways. This article presents 2 simple metrics for quantifying construct validity that provide effect size estimates indicating the extent to which the observed pattern of correlations in a convergent-discriminant validity matrix matches the theoretically predicted pattern of correlations. Both measures, based on contrast analysis, provide simple estimates of validity that can be compared across studies, constructs, and measures meta-analytically, and can be implemented without the use of complex statistical procedures that may limit their accessibility.

Rethinking therapeutic action

Like other core psychoanalytic constructs, the theory of therapeutic action is currently in flux, as theorists of differing persuasions propose different mechanisms. In this article, the authors attempt to integrate developments within and without psychoanalysis to provide a working model of the multifaceted processes involved in producing change in psychoanalysis and psychoanalytic psychotherapy. A theory of therapeutic action must describe both what changes (the aims of treatment) and what strategies are likely to be useful in facilitating those changes (technique). The authors believe that single‐mechanism theories of therapeutic action, no matter how complex, are unlikely to prove useful at this point because of the variety of targets of change and the variety of methods useful in effecting change in those targets (such as techniques aimed at altering different kinds of conscious and unconscious processes). Interventions that facilitate change may be classified into one of three categories: those that foster insight, those that make use of various mutative aspects of the treatment relationship and a variety of secondary strategies that can be of tremendous importance. They propose that, in all forms of psychoanalytic treatment, we would be more accurate to speak of the therapeutic actions, rather than action.

When clinical description becomes statistical prediction.

This article reconsiders the issue of clinical versus statistical prediction. The term clinical is widely used to denote 1 pole of 2 independent axes: the observer whose data are being aggregated (clinician/expert vs. lay) and the method of aggregating those data (impressionistic vs. statistical). Fifty years of research suggests that when formulas are available, statistical aggregation outperforms informal, subjective aggregation much of the time. However, these data have little bearing on the question of whether, or under what conditions, clinicians can make reliable and valid observations and inferences at a level of generality relevant to practice or useful as data to be aggregated statistically. An emerging body of research suggests that clinical observations, just like lay observations, can be quantified using standard psychometric procedures, so that clinical description becomes statistical prediction.

Refining the Construct of Narcissistic Personality Disorder: Diagnostic Criteria and Subtypes

OBJECTIVE Narcissistic personality disorder has received relatively little empirical attention. This study was designed to provide an empirically valid and clinically rich portrait of narcissistic personality disorder and to identify subtypes of the disorder. METHOD A random national sample of psychiatrists and clinical psychologists (N=1,201) described a randomly selected current patient with personality pathology. Clinicians provided detailed psychological descriptions of the patients using the Shedler-Westen Assessment Procedure-II (SWAP-II), completed a checklist of axis II diagnostic criteria, and provided construct ratings for each axis II personality disorder. Descriptions of narcissistic patients based on both raw and standardized SWAP-II item scores were aggregated to identify, respectively, the most characteristic and the most distinctive features of narcissistic personality disorder. RESULTS A total of 255 patients met DSM-IV criteria for narcissistic personality disorder based on the checklist and 122 based on the construct ratings; 101 patients met criteria by both methods. Q-factor analysis identified three subtypes of narcissistic personality disorder, which the authors labeled grandiose/malignant, fragile, and high-functioning/exhibitionistic. Core features of the disorder included interpersonal vulnerability and underlying emotional distress, along with anger, difficulty in regulating affect, and interpersonal competitiveness, features that are absent from the DSM-IV description of narcissistic personality disorder. CONCLUSIONS These findings suggest that DSM-IV criteria for narcissistic personality disorder are too narrow, underemphasizing aspects of personality and inner experience that are empirically central to the disorder. The richer and more differentiated view of narcissistic personality disorder suggested by this study may have treatment implications and may help bridge the gap between empirically and clinically derived concepts of the disorder.

Affect regulation in borderline personality disorder.

Although difficulty with affect regulation is generally considered a core component of borderline personality disorder (BPD), surprisingly little research has focused on the nature of affect regulation and dysregulation in BPD. A random national sample of 117 experienced clinicians provided data on a randomly selected patient with BPD (N = 90) or dysthymic disorder (DD; N = 27). Clinicians described their patients using the Affect Regulation and Experience Q-sort-Questionnaire Version, a psychometric instrument designed for expert informants to assess affect and affect regulation. BPD and DD patients appear to differ in both the emotions they experience and the ways they regulate or fail to regulate them. Whereas DD patients are characterized by negative affect, BPD patients are characterized by both negative affect and affect dysregulation, which appear to be distinct constructs. BPD patients also show distinct patterns of affect regulation, and subtypes of BPD patients show distinct affect regulation profiles of potential relevance to treatment.

Relationship Between Attachment Patterns and Personality Pathology in Adolescents

OBJECTIVE To explore the relationship between attachment status and personality pathology in a large clinical sample of adolescents. METHOD Two hundred ninety-four randomly selected psychiatrists and psychologists were each asked to provide data on a patient (aged 14-18 years) in treatment for maladaptive personality patterns. Clinicians completed several measures including a clinician-report attachment questionnaire, several measures of personality pathology, and a clinician-report version of the Child Behavior Checklist. RESULTS In both dimensional and categorical analyses, secure attachment was negatively correlated with personality pathology and positively correlated with healthy functioning, whereas disorganized/unresolved attachment was strongly associated with multiple forms of personality pathology. Anxious/ambivalent attachment tended to be associated with measures of withdrawal, internalization, and introversion. Avoidant attachment style was not associated with any single form of personality pathology. CONCLUSION The marked association between unresolved attachment and more severe psychopathology in adolescents, the lack of construct validity of avoidant personality disorder in adolescents, and the broader relations among attachment, personality, and psychopathology are discussed.

The Shedler–Westen Assessment Procedure (SWAP): Making Personality Diagnosis Clinically Meaningful

There is a schism between science and practice in understanding and assessing personality. Approaches derived from the research laboratory often strike clinical practitioners as clinically naíve and of dubious clinical relevance. Approaches derived from clinical observation and theory often strike empirical researchers as fanciful speculation. In this article, we describe an approach to personality designed to bridge the science–practice divide. The Shedler–Westen Assessment Procedure (SWAP; Shedler & Westen, 2004a, 2004b; Westen & Shedler, 1999a, 1999b) is an empirically rigorous diagnostic method that preserves the richness and complexity of clinical case description. In this article, we describe its use in diagnosis, case conceptualization, and treatment planning. We review evidence for reliability, validity, and clinical utility. Finally, in the article, we present a system for personality diagnosis, as an alternative to Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; American Psychiatric Association, 2000) Axis II, that is empirically grounded, clinically relevant, and practical for routine use in both clinical and research contexts.

Etiology of Borderline Personality Disorder: Disentangling the Contributions of Intercorrelated Antecedents

A substantial body of research points to several variables relevant to the etiology of borderline personality disorder (BPD), notably childhood physical and sexual abuse, childhood family environment, and familial aggregation of both internalizing and externalizing disorders. However, these variables tend to be correlated, and few studies have examined them simultaneously. A national sample of randomly selected psychologists and psychiatrists described 524 adult patients with personality disorders. Family environment, parental psychopathology, and history of abuse all independently predicted BPD symptoms in multiple regression analyses. Sexual abuse contributed to the prediction of BPD symptoms over and above family environment, although family environmental factors such as instability partially mediated the effect. The results converge with recent studies using very different samples and methodologies.