Francesco Gazzillo

Assessing personality change in psychotherapy with the SWAP-200: A case study

Many studies document the efficacy of psychotherapy for acute syndromes such as depression, but less is known about personality change in patients treated for personality pathology. The Shedler–Westen Assessment Procedure (SWAP–200; Westen & Shedler, 1999a, 1999b) is an assessment tool that measures a broad spectrum of personality constructs and is designed to bridge the gap between the clinical and empirical traditions in personality assessment. In this article, we demonstrate the use of the SWAP–200 as a measure of change in a case study of a patient diagnosed with borderline personality disorder. We collected assessment data at the start of treatment and after 2 years of psychotherapy. The findings illustrate the personality processes targeted in intensive psychotherapy for borderline personality.

Personality subtypes in adolescents with anorexia nervosa

The aims of this study are to (1) empirically identify the personality subtypes of adolescents with anorexic disorders and (2) investigate the personality disorders, identity disturbances, and affective features associated with the different subtypes. We assessed 102 adolescent patients with Eating Disorders (anorexia nervosa and eating disorder not otherwise specified) using three clinical instruments: the Shedler-Westen Assessment Procedure for Adolescents (SWAP-200-A) (Westen D, Shedler J, Durrett C, Glass S, Martens A. Personality diagnoses in adolescence: DSM-IV Axis II diagnoses and an empirically derived alternative. Am J Psychiatry 2003;160:952-966), the Affective Regulation and Experience Questionnaire (AREQ) (Zittel Conklin C, Bradley R, Westen D. Affect regulation in borderline personality disorder. J Nerv Ment Dis 2006;194:69-77), and the Identity Disorder Questionnaire (IDQ) (Wilkinson-Ryan T, Westen D. Identity disturbance in borderline personality disorder: An empirical investigation. Am J Psychiatry 2000;157:528-541). We performed a Q factor analysis of the SWAP-200-A descriptions of our sample to identify personality subtypes. We correlated these personality styles with AREQ and IDQ factors and explored the personality differences among individuals with the different types of ED. The Q factor analysis identified three personality subtypes: high-functioning/perfectionist, emotionally dysregulated, and overcontrolled/constricted. Each subtype showed specific identity and affective features, comorbidities with different personality disorders, and clinical implications. These results contribute to the understanding of adolescents with ED and seem to be relevant for treatment planning.

The Psychodynamic Diagnostic Manual (PDM) and the PDM-2: Opportunities to Significantly Affect the Profession

In this article, we discuss the development of the Psychodynamic Diagnostic Manual (PDM) and its upcoming revision, the PDM-2. We describe the processes by which the PDM-2 is being developed and highlight important differences across both editions. At the same time, we emphasize the value of assessing internalized experience and how that can be of use toward the diagnostic assessment process.

Do the Processes of Psychoanalytic Work Lead to Benefit? Studies by the APS Research Group and the Psychoanalytic Research Consortium

There is a need for careful study of the relationships between the psychoanalytic/psychodynamic processes and their outcomes, yet the raw data to accomplish this study (i.e., psychoanalyses and psychoanalytic psychotherapies fully recorded and transcribed, and empirical instruments for assessing from an analytic perspective both the processes and results of these treatments) have been limited. Two related strategies to solve this deficit have been developed over the past 30 years by the Psychoanalytic Research Consortium (PRC): (1) the collection of an increasing database currently holding 31 fully recorded psychoanalyses and a number of long-term psychoanalytic psychotherapies safeguarded, confidentialized, and made available to the field; and (2) the development of new measures for assessing processes and outcomes of treatments from an analytic point of view, such as the Analytic Process Scales (APS), the Dynamic Interaction Scales (DIS), and the Personality Health Index (PHI) with RADIO categories. This article summarizes the history of the PRC and some of the findings of the research conducted with the APS, DIS, and PHI on the PRC cases.

Mentalization as a Predictor of Psychoanalytic Outcome: An Empirical Study of Transcribed Psychoanalytic Sessions Through the Lenses of a Computerized Text Analysis Measure of Reflective Functioning.

The Reflective Functioning Scale (Fonagy, Target, Steele, & Steele, 1998) was developed to empirically assess the capacity to mentalize thoughts, intentions, feelings and beliefs of oneself and others in the context of attachment relationships (Jurist & Meehan, 2009). To overcome the complexity of the RF scale scoring, the Computerized Text Analysis measure of Reflective Functioning (CRF) was created by Fertuck, Mergenthaler, Target, Levy, and Clarkin (2012). We report the results of a preliminary study applying the CRF to a sample of 540 sessions comprising 27 psychoanalytic treatments. Results show that patients’ reflective functioning (RF), as measured at the beginning of treatment, was positively correlated with two global measures of healthy personality functioning—the Global Assessment of Functioning (GAF; American Psychiatric Association, 2000) and the Personality Health Index (PHI; Waldron et al., 2011)—as measured at the end of treatment. Even when the PHI and GAF levels at the beginning of treatment, the length of the treatments, and the average number of sessions per week were controlled for, these correlations remained significant. At the same time, the RF of patients did not increase throughout treatment. The implications of these results and the validity of CRF as an outcome predictor of long-term psychoanalytic treatment are discussed.

Effectiveness is the gold standard of clinical research

[page 153] Psychological treatments have been shown to be at least as effective (and sometime even more effective) than psychotropic medications for many psychiatric disorders, in particular anxiety disorders, depressive disorders, and personality disorders (American Psychological Association, 2013; Cuijpers, 2017). Effective psychological treatments are also cost-effective: their implementation in public mental health services is convenient in financial terms, with decades of studies consistently demonstrating a reduction in public spending for psychological health (Abbass, Kisely, Rasic, Town & Johansson, 2015). Therefore, it could be critical that psychological treatments whose efficacy is supported by strong empirical evidence can be delivered as a primary choice in public mental health services. We hope and believe that the time when a psychologist or a psychiatrist (especially if paid by the public mental health system) could provide any treatment he or she thought fit, even in the absence of any scientific evidence of its efficacy, is coming to an end. However, a recommendation should be made to be very careful in not equating the empirical support of a given treatment with the sole presence of randomized controlled trials (RCTs) that show its efficacy. This would be a mistake from both an empirical and a theoretical perspective, as it runs the risk of throwing out the baby with the bathwater. In other words, endorsing a perspective according to which a specific treatment should be promoted or rejected on the sole basis of findings from RCT studies runs the risk of putting clinical science back almost twenty years from the current more advanced understanding of the efficacy, effectiveness, and usefulness of psychotherapy (Dazzi, 2006; Dazzi, Lingiardi, & Colli, 2006; Leichsenring et al., 2016; Silberschatz, 2017). This would be a Pyrrhic victory: absolutizing RCT as the only method to evaluate psychotherapy might favor its social legitimacy in the short time, as a result of the assimilation of psychological treatments to medical treatments (i.e., to the kinds of treatment for which RCT represents the gold standard); yet, in the long run such an assimilation would involve the negation of the scientific specificity of psychological treatments, thus hampering rather than promoting the scientific development of effective psychological treatments. From this standpoint, the document Psychotherapies for Anxiety and Depression: benefits and costs deserves appreciation for its political and cultural value, as an instrument to be used for dealing with institutional agencies – first of all, with public and private health agencies. However, several reflections are required in order to broaden its scope, and to establish a good enough platform for debating the topic with the wider community of scientists and practitioners interested in the development and validation of psychological and psychotherapeutic treatments. The first comment we want to make is that clients and patients do not need to receive evidence-based treatments per se. Actually, what they need to receive are effective treatments. In other words, the effectiveness of a treatment must be differentiated from the method used to empirically support it. On the scientific and logical levels, it is a serious error to confuse how to prove something with Effectiveness is the gold standard of clinical research

Patients’ crying experiences in psychotherapy: Relationship with the patient level of personality organization, clinician approach, and therapeutic alliance.

The present study sought to further understand patients’ crying experiences in psychotherapy. We asked 64 clinicians to randomly request one patient in their practice to complete a survey concerning crying in psychotherapy as well as a measure of therapeutic alliance. All clinicians provided information regarding their practice and patient diagnostic information. Fifty-five (85.93%) patients cried at least once, and 18 (28.1%) had cried during their most recent session. Patients’ frequency of crying episodes in therapy was negatively related with psychotic level of personality organization, while patients’ tendency to feel more negative feelings after crying was positively related to lower levels of personality organization. Patients’ feeling more in control after crying was positively related with an interpersonal therapeutic approach, while patients’ perception of therapists as more supportive after crying was positively related to a psychodynamic approach. Patients’ tendency to experience more negative feelings after crying was significantly related with both lower levels of personality organization and patients’ perception of the therapeutic alliance as weak. In regard to their most recent crying event in treatment, therapeutic alliance was related to gaining a new understanding of experience not previously recognized by the patient. Further, patients’ experiences of having never told anyone about their experience related to a crying episode, as well as their realization of new ideas and feeling of having communicated something that words could not express was positively related to the goal dimension of alliance. Patients’ perception of crying as a moment of genuine vulnerability, greater feelings of self-confidence and self-disclosure as well as having had a therapist response that was compassionate and supportive, was positively related with the bond dimension of alliance. Clinical implications and future research directions regarding patient crying experiences in psychotherapy are discussed.

The Components of Psychoanalysis: Factor Analyses of Process Measures of 27 Fully Recorded Psychoanalyses.

In an empirical study of psychoanalytic processes, the authors identify therapist, patient, and interaction factors from 2 instruments totaling 31 items based on clinicians’ evaluation of 540 sessions from 27 completely recorded psychoanalyses. The 2 instruments, developed over 30 years studying recorded psychoanalyses, are the Analytic Process Scales (APS; Waldron, Scharf, Hurst, Firestein, & Burton, 2004b) and the Dynamic Interaction Scales (DIS; Waldron, Gazzillo, Genova, & Lingiardi, 2013). This article reports the authors’ simplification of the complex patterns produced by the items via factor analysis. Guided by past process-outcome literature (Lambert, 2013), therapist, patient, and interaction items were factor analyzed in 3 separate analyses. Three patient factors emerged: the patient’s experience of the world, the patient’s experience of the analyst, and a factor the authors call patient dynamic competence. Components contributed by the therapist reduced to therapist’s relational competence and therapist’s dynamic competence. Interaction items produced just 1 factor, interaction quality. The authors describe the items contributing to each of these 6 factors and the correlations among these factors to permit the reader to better understand how they interact. Moreover, 2 second-order factors emerged which show what the authors describe as a parallel process between patient and analyst, allowing for a conceptualization of the intricate process of analyst and patient working together, with differing foci, in a potentially mutually enriching way.