Ole André Solbakken

Affect integration and reflective function: clarification of central conceptual issues.

Abstract The importance of affect regulation, modulation or integration for higher-order reflection and adequate functioning is increasingly emphasized across different therapeutic approaches and theories of change. These processes are probably central to any psychotherapeutic endeavor, whether explicitly conceptualized or not, and in recent years a number of therapeutic approaches have been developed that explicitly target them as a primary area of change. However, there still is important lack of clarity in the field regarding the understanding and operationalization of affect integration, particularly when it comes to specifying underlying mechanisms, the significance of different affect states, and the establishment of operational criteria for measurement. The conceptual relationship between affect integration and reflective function thus remains ambiguous. The present article addresses these topics, indicating ways in which a more complex and exhaustive understanding of integration of affect, cognition and behavior can be attained.

Assessment of Affect Integration: Validation of the Affect Consciousness Construct

Affect integration, or the capacity to utilize the motivational and signal properties of affect for personal adjustment, is assumed to be an important aspect of psychological health and functioning. Affect integration has been operationalized through the affect consciousness (AC) construct as degrees of awareness, tolerance, nonverbal expression, and conceptual expression of nine discrete affects. A semistructured Affect Consciousness Interview (ACI) and separate Affect Consciousness Scales (ACSs) have been developed to specifically assess these aspects of affect integration. This study explored the construct validity of AC in a Norwegian clinical sample including estimates of reliability and assessment of structure by factor analyses. External validity issues were addressed by examining the relationships between scores on the ACSs and self-rated symptom- and interpersonal problem measures as well as independent, observer-based ratings of personality disorder criteria and the Global Assessment of Functioning (GAF) scale from the Diagnostic and Statistical Manual of Mental Disorders (4th ed. [DSM–IV]; American Psychiatric Association, 1994).

Psychometric properties of the outcome questionnaire-45.2: the Norwegian version in an international context.

Abstract Objective: Monitoring of ongoing psychotherapy is of crucial importance in improving the quality of mental health care by detecting therapies being off track, which requires that the instrument used is psychometrically sound. This study investigates the psychometric properties of the Norwegian version of the Outcome Questionnaire 45.2 (OQ-45) and situates the results in an international context.Method: Data from one non-clinical sample (N = 338) and one clinical sample (N = 560) were compared to international samples investigating reliability, cut-offs, and factor structure. Results: The results show adequate reliability and concurrent validity. Conclusions: The means, clinical cut-offs, and the reliable change index vary across countries. However, the means of the OQ-45 for nonclinical samples correlate highly with external values of national well-being, indicating that the OQ-45 is a valid instrument internationally. The factor analyses in the present study do not confirm the hypothesized factor structure of the OQ-45, but are similar to the results internationally.

Affect integration as a predictor of change: Affect consciousness and treatment response in open-ended psychotherapy

Abstract The present study investigated the relationship between baseline levels of affect integration and the magnitude of change during and after open-ended psychotherapy. Affect integration reflects the capacity for accessing and utilizing the adaptive properties of affects for personal adjustment, along with the more general capability of tolerating and regulating affective activation. It is thus a capacity with relevance for the postulated mechanisms of change in various treatment modalities. Overall, the results indicated that patients with more severe problems in affect integration had larger improvements in symptoms, interpersonal and personality problems in open-ended treatment than those with less severe problems. This was also the case when examining the predictive effects of the integration of specific affects on changes in interpersonal relatedness. It was indicated that increasing problems with the integration of discrete affects were associated with distinct patterns of change in different interpersonal problem domains.

Implementation of an intensive short-term dynamic treatment program for patients with treatment-resistant disorders in residential care

BackgroundThis protocol presents a systematic residential treatment- and research program aimed at patients who have not responded adequately to previous treatment attempts. Patients included in the program primarily suffer from anxiety and/or depressive disorders and usually from one or more comorbid personality disorders. The treatment program is time-limited (eight weeks) and has its basis in treatment principles specified in intensive short-term dynamic psychotherapy (ISTDP). This treatment modality is theoretically well-suited for the handling of various forms of treatment resistance presumably central to these patients’ previous non-response to psychological and psychiatric interventions.Methods/DesignThe research component of the project entails a naturalistic longitudinal research design which aims at systematic evaluation of the effectiveness of the program. To our knowledge, this is one of the first treatment programs and corresponding research projects that systematically select patients with previous non- or negative response to treatment and subjects them to a broad and comprehensive, but theoretically unified and consistent treatment system.DiscussionThe present paper introduces the project, describes its theoretical and methodological underpinnings, and discusses possible future implications and contributions of the project. It thereby serves as a comprehensive background reference to future publications from the project.

Intensive short-term dynamic residential treatment program for patients with treatment-resistant disorders

BACKGROUND The study investigated the effectiveness of an Intensive Short-Term Dynamic (ISTDP) residential treatment program for patients with treatment resistant anxiety- and/or depressive disorders, with and without comorbid personality disorders. METHOD A non-randomized controlled trial examined the effects of an eight week intensive residential treatment program based on principles from ISTDP. Patients (N=60), who had repeated prior treatment failure for current mental disorder, sufficient dysfunction to warrant hospitalization, and evidencing capacity to take an intrapsychic perspective on own problems, were included. Outcome variables included measures of target complaints (depression/anxiety, social role dysfunction, and interpersonal distress), general symptom distress, and interpersonal functioning. Measures were administered throughout and after treatment. Change was assessed by multilevel growth curve modeling. Changes during and after treatment were compared to those reported by a sub-sample of wait-list controls taking treatment as usual (N=30). RESULTS The treatment group evidenced significant improvements on all measures. By contrast, receiving treatment as usual while on the wait-list did not yield significant changes. Effect sizes in the treatment group were consistently large at both termination and follow-up. Fourteen months after treatment 50.0% of patients had recovered in terms of target complaints. Approximately 53.3% and 48.3%, respectively, had recovered in terms of general symptom distress and interpersonal functioning. LIMITATIONS Limitations included a relatively small sample size, inability to discern the effectiveness of separate components of the treatment program, and lack of randomization of patients to wait-list and treatment. CONCLUSION ISTDP-based residential treatment with an eight-week time-limit appears to be effective for alleviating common and severe, treatment resistant mental disorders. The treatment program was superior to receiving treatment as usual while on the wait-list. Participation in the program quickly reduced target complaints, symptoms and interpersonal problems for patients who, based on previous treatment experiences, were expected to fare poorly in treatment. Gains were consistently maintained or improved further at follow-up. Results are promising for patients with chronic debilitating problems who often do not profit from traditional psychiatric treatment.

Effective Care of Treatment-Resistant Patients in an ISTDP-Based In-Patient Treatment Program

Overall, few studies reported in the literature have focused specifically on non-respond ers to psychotherapy. Even fewer have specifically selected patients based on previous non-response to treatment and attempted systematic, customized psychological interventions to address their needs. Such studies could yield important information about strategies for overcoming the unfortunate fact that so many do not benefit from psychological treatments. The current study, and the treatment program it examines, was designed and implemented as an attempt to remedy this state of affairs. With the aim of relieving the suffering of patients with repeated non-response to treatment, an intensive, time-limited, residential treatment program was devised. Using criteria for clinically signifi cant change in symptoms, 1 the average recovery rate for formal psychotherapeutic treatments delivered in welldesigned trials is approximately 50%. 2 Accordingly, approximately half the patients leave treatment with significant clinical symptoms or deteriorate during or after the intervention. In routine care (treatment as delivered outside of organized psychotherapy trials), the rates of recovery are substantially smaller. 3 Thus, a large percentage of patients in mental health care can be classified as “treatment-resistant” to psychotherapy. Given this, the development of new approaches specifically designed to aid these patients is of prime importance. Due to lack of research, it remains unknown whether modifications in treatment format, setting, dose, or con

Affect Consciousness in children with internalizing problems: Assessment of affect integration.

Affect integration was operationalized through the Affect Consciousness (AC) construct as degrees of awareness, tolerance, nonverbal expression and conceptual expression of 11 affects. These aspects are assessed through a semi-structured Affect Consciousness Interview (ACI) and separate rating scales (Affect Consciousness Scales (ACSs)) developed for use in research and clinical work with adults with psychopathological disorders. Age-adjusted changes were made in the interview and rating system. This study explored the applicability of the adjusted ACI to a sample of 11-year-old children with internalizing problems through examining inter-rater reliability of the adjusted ACI, along with relationships between the AC aspects and aspects of mental health as symptoms of depression, symptoms of anxiety, social competence, besides general intelligence. Satisfactory inter-rater reliability was found, as well as consistent relationships between the AC aspects and the various aspects of mental health, a finding which coincides with previous research. The finding indicates that the attainment of the capacity to deal adaptively with affect is probably an important contributor to the development of adequate social competence and maybe in the prevention of psychopathology in children. The results indicate that the adjusted ACI and rating scales are useful tools in treatment planning with children at least from the age of 11 years.

Are There Specific Relationships Between Symptom Patterns and Interpersonal Problems Among Psychiatric Outpatients

Associations between symptoms and interpersonal problems, assessed with the Symptom Checklist–90 (SCL–90–R) and the Inventory of Interpersonal Problems–64-item version (IIP–64), are examined in a large psychiatric outpatient sample. On the basis of the IIP–64 scores, the sample was divided into 8 subgroups, made up of different types of predominant interpersonal problems. These octant groups were used as independent variables in analyses testing hypothesized associations with symptom subscales of the SCL–90–R. In general, strong associations between symptoms and interpersonal problems were found. In addition, hostile and paranoid ideation symptoms displayed significant differences among octant groups, and were associated with interpersonal problems of the vindictive/self-centered kind. Phobic anxiety was associated with interpersonal problems of the socially inhibited kind. Assessing specific combinations of symptoms and interpersonal problems might be useful in treatment planning and evaluation.

Symptom- and personality disorder changes in intensive short-term dynamic residential treatment for treatment-resistant anxiety and depressive disorders

Objective The study investigated the effectiveness of an 8-week intensive residential treatment programme based on principles from intensive short-term dynamic psychotherapy for patients with known treatment-resistant anxiety- and/or depressive disorders (mainly with comorbid personality disorders). Methods Patients (N=95) with prior repeated treatment failure were included. Changes in self-reported target complaints, symptom severity, and overall interpersonal problems have been presented for these patients in two previous articles. We now expand upon the existing knowledge by presenting novel data from a number of important observer-based and self-reported outcome domains (diagnostic changes on Axis I and II, changes in overall personality dysfunction, disorder complexity, medication use, health care utilisation, and occupational activity). Results There were pervasive and significant improvements on all measures during treatment, which were maintained or further improved during follow-up. Fourteen months after the end of treatment, 46.26% of patients had recovered in terms of Axis I pathology, 63.79% had recovered in terms of Axis II pathology, 71.18% had returned to work, and there was a 28.62% reduction in regular use of psychotropic medications. Health care utilisation was reduced by 65.55%, and there were large improvements in disorder complexity and levels of personality dysfunction. Conclusion The treatment programme was highly effective for patients with common and complex treatment-resistant mental disorders. Results are encouraging for the relatively large number of patients who tend not to benefit from standard formats of treatment for debilitating psychological problems.