Sidney J. Blatt

Interpersonal relatedness and self-definition: Two prototypes for depression

Abstract This paper reviews recent research that indicates the importance of differentiating subtypes of depression based on two types of experiences that lead individuals to become depressed: (a) disruptions of interpersonal relations and (b) threats to self-integrity and self-esteem. We review research with clinical and nonclinical samples that investigated the relationships of these distinctions to the quality of current interpersonal relationships and to differential sensitivity to various types of stressful life events, as well as to aspects of early life experiences, especially the quality of the parent-child relationship. We also evaluate research evidence that considers the role of these two dimensions in clinical depression. In addition to proposing an etiologic model about aspects of the onset and recurrence of depression based on the interaction between personality predispositions and types of stressful life events, we place these observations about depression in a broad theoretical context of contemporary personality theory which defines two primary dimensions of personality development and psychopathology.

Experiences of depression : theoretical, clinical, and research perspectives

Recognizing these fundamentally different depressive experiences has spurred a remarkably wide range of research, the development of assessment tools, and impressive strides in understanding the nature, etiology, and treatment of this far-reaching disorder. With clarity he traces the extensive systematic investigation of these two types of depression and the role of disturbances in mental representations. A closing chapter considers the implications of these theoretical formulations and research findings for understanding the nature of therapeutic process with depressed patients.

Impact of perfectionism and need for approval on the brief treatment of depression: The National Institute of Mental Health Treatment of Depression Collaborative Research Program revisited.

Patients in the National Institute of Mental Health Treatment of Depression Collaborative Research Program (TDCRP) were administered at intake with the Dysfunctional Attitude Scale (DAS; A. N. Weissman & A. T. Beck, 1978). Factor analyses of the DAS in the TDCRP data as well as in several independent samples reveal two primary factors: an interpersonal factor, Need for Approval, and a self-critical factor, Perfectionism. This study explored the hypotheses that these factors, assessed prior to treatment, would have differential interactions with the two forms of psychotherapy evaluated in the TDCRP as well as differential relationships to various outcome measures (depression, clinical functioning, and social adjustment). DAS Perfectionism had consistently significant negative relationships with all the outcome measures in all four treatment conditions. Contrary to expectations, however, there were no significant interactions between the two DAS factors and the four types of brief treatment (cognitive-behavioral therapy, interpersonal therapy, imipramine, and placebo).

When and how perfectionism impedes the brief Treatment of depression : Further analyses of the national institute of Mental Health Treatment of Depression Collaborative Research Program

Perfectionism has previously been identified as having a significant negative impact on therapeutic outcome at termination in the brief (16-week) treatment of depression (S. J. Blatt, D. M. Quinlan, P. A. Pilkonis, & T. Shea, 1995) as measured by the 5 primary outcome measures used in the National Institute of Mental Health Treatment of Depression Collaborative Research Program (TDCRP). The present analyses of other data from the TDCRP indicated that this impact of perfectionism on therapeutic outcome was also found in ratings by therapists, independent clinical evaluators, and the patients and that this effect persisted 18 months after termination. In addition, analyses of comprehensive, independent assessments made during the treatment process indicated that perfectionism began to impede therapeutic gain in approximately 2/3 of the sample, in the latter half of treatment, between the 9th and 12th sessions. Implications of these findings are discussed, including the possibility that more perfectionistic patients may be negatively impacted by anticipation of an arbitrary, externally imposed termination date.

The Therapeutic Relationship in the Brief Treatment of Depression: Contributions to Clinical Improvement and Enhanced Adaptive Capacities.

Using data from the National Institute of Mental Health Treatment for Depression Collaborative Research Program, the authors examined the impact on treatment outcome of the patients perception of the quality of the therapeutic relationship and contribution to the therapeutic alliance. Shared variance with early clinical improvement was removed from these relationship measures. Multilevel modeling demonstrated that a perceived positive therapeutic relationship early in treatment predicted more rapid decline in maladjustment subsequent to the relationship assessment. This effect occurred equally across all 4 treatment conditions. A positive early therapeutic relationship also predicted better adjustment throughout the 18-month follow-up as well as development of greater enhanced adaptive capacities (EAC). Controlling a wide range of patient characteristics did not eliminate the effects of the therapeutic relationship on rate of improvement during treatment and on EAC. Thus, independent of type of treatment and early clinical improvement, the therapeutic relationship contributes directly to positive therapeutic outcome.

The Differential Effect of Psychotherapy and Psychoanalysis with Anaclitic and Introjective Patients: The Menninger Psychotherapy Research Project Revisited

Analyses of the data from the Menninger Psychotherapy Research Project (MPRP) have consistently indicated little difference in the therapeutic outcome between patients seen in psychoanalysis and those seen in psychotherapy. Reanalysis of the data from the MPRP, utilizing a distinction between two broad configurations of psychopathology (Blatt, 1974, 1990a; Blatt and Shichman, 1983), however, indicates that patients whose pathology focuses primarily on disruptions of interpersonal relatedness and who use primarily avoidant defenses (anaclitic patients), and patients whose pathology focuses primarily on issues of self-definition, autonomy, and self-worth and who use primarily counteractive defenses (introjective patients) differ in their responsiveness to psychotherapy and psychoanalysis. Based on recently developed procedures for systematically evaluating the quality of object representation on the Rorschach, reanalysis of the Menninger data reveals that anaclitic patients have significantly greater positive change in psychotherapy, while introjective patients have significantly greater positive change in psychoanalysis. These statistically significant patient-by-treatment interactions are discussed in terms of their clinical implications as well as the importance of differentiating among types of patients in studies of therapeutic outcome and of therapeutic process.

Attachment and separateness: A dialectic model of the products and processes of development throughout the life-cycle

Various theories of psychological development can be characterized according to whether they are primarily separation or attachment theories and whether they emphasize primarily the processes or the products of development. A full understanding of psychological development requires an integration of theories of attachment and separation and of what is attained in the course of psychological development (the products), as well as the mechanisms (or processes) by which these products are attained. Discussion of a revised model of Eriksons eight stages of psychosocial development illustrates the importance of formulating a dialectical developmental model that describes the interaction between attachment and separation and between product and process.

A cognitive morphology of psychopathology

In contrast to contemporary approaches to psychopathology that establish diagnostictaxonomies derived primarily from differences in manifest symptoms, this paper, based on an integration of cognitive and psychoanalytic developmental theory, proposes a structural cognitive morphology for understanding and assessing differences among various forms of psychopathology, from schizophrenia to the neuroses. A theoretical model based on the development of cognitive schema, consistent with clinical and research data, considers schizophrenia and paranoid schizophrenia as involving fundamental disturbances in boundary articulation and recognition constancy, and considers borderline personality disorders as involving disturbances in evocative constancy. Also, a lack of integration of object and selfschema, expressed in either a distorted and exaggerated preoccupation with interpersonal relatedness or self-definition, defines two primary personality configurations that have implications for understanding the neuroses and subtypes of depression, as well as differential response to various types of psychotherapeutic intervention.

Integrating theory-driven and empirically-derived models of personality development and psychopathology: a proposal for DSM V.

Although there is growing consensus that the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) should replace the categorical view of mental disorders with a dimensional approach rooted in personality theory, no consensus has emerged about the dimensions that should be the basis of the new classification system. Moreover, recent attempts to bridge the gap between psychiatric nosology and personality theories have primarily relied on empirically-derived dimensional personality models. While this focus on empirically-derived personality theories may result in a psychometrically valid classification system, it may create a classification system that lacks theoretical and empirical comprehensiveness and has limited clinical utility. In this paper, we first argue that research findings increasingly suggest that an integration of theory-driven and empirically-derived models of personality development is not only possible, but also has the potential to provide a more comprehensive and clinically-relevant approach to classification and diagnosis than either approach alone. Next, we propose a comprehensive model of personality development and psychopathology based on an integration of contemporary theory-driven and empirically-derived models of personality. Finally, we outline the implications of this approach for the future development of DSM, and especially its potential for developing research that addresses the interactions between psychosocial and neurobiological processes implicated in personality development and psychopathology.

Contributions of Psychoanalysis To the Understanding and Treatment of Depression

Psychoanalysis continues to make important contributions to basic clinical understanding of adaptive and maladaptive psychological development, and particularly to the understanding of depression and its treatment. This paper demonstrates that a basic theoretical conceptualization, central to many of Freuds fundamental contributions, has provided the basis for a wide range of contemporary psychoanalytic and nonpsychoanalytic formulations of personality development and organization; for understanding various forms of psychopathology in adults as deriving from disruptions of normal developmental processes, especially personality disorders and depression; and for conducting research on psychotherapeutic process and outcome in both brief and long-term intensive treatment.