Interpersonal problems as predictors of therapeutic alliance and symptom improvement in cognitive therapy for depression

Department of Clinical Psychological Science, Maastricht University, The Netherlands.
Journal of Affective Disorders (Impact Factor: 3.38). 02/2012; 138(3):458-67. DOI: 10.1016/j.jad.2011.12.044
Source: PubMed


The degree to which interpersonal problems of depressed patients improve over the course of cognitive therapy (CT) and relate to the quality of the therapeutic alliance and to symptom improvement, remains unclear.
We analyzed data of adult outpatients (N=523) with major depressive disorder participating in a clinical trial to determine the factor structure of the Inventory of Interpersonal Problems-Circumplex (IIP-C) and to relate the observed factor scores to the quality of the therapeutic alliance and symptom improvement over the course of CT. Patients received 16-20 sessions protocol (50-60 min each) of individual CT according to the treatment manual by Beck et al. (1979).
We found a three-factor structure (interpersonal distress, agency, and communion) of interpersonal problems. Interpersonal distress decreased (d=.90), but interpersonal style did not change substantively during CT (communion d=.03; agency d=.14). High initial agency scores related negatively to the therapeutic alliance (β=-.12), whereas high initial communion scores related positively to the therapeutic alliance (β=.15). Elevated pre-treatment interpersonal distress scores were related to both weaker therapeutic alliances (β=.13) and higher symptom levels throughout treatment (β=.10).
All patients in this study had recurrent MDD and it is therefore uncertain whether the results would generalize to patients with other psychiatric disorders.
This study supports the use of the IIP-C as a comprehensive measure of patients' interpersonal style and interpersonal distress. The IIP-C measured before CT showed some predictive validity with respect to therapeutic alliance measured at the midpoint and therapy outcome. The clinical importance of these findings is discussed.

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    • "Previous research examining the influence of interpersonal distress on outcome has failed to provide definitive answers. For example, Renner et al. (2012) showed that high distress negatively influenced symptomatic improvement in cognitive therapy for depression. In non-depressed or mixed samples, overall interpersonal distress predicted negative outcome in some, but not all studies (e.g. "
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    ABSTRACT: Previous studies reported inconsistent findings regarding the association of interpersonal problems with therapy outcome. The current study investigates if interpersonal problems predict process and outcome of three different treatments for depression. The data originate from a randomized clinical trial comparing supportive-expressive psychotherapy, antidepressant medication and pill-placebo for treatment of depression. Interpersonal problems were used as predictors of alliance, symptomatic improvement and premature termination of treatment. Interpersonal problems related to communion predicted better alliances, but slower symptomatic improvement. Low agency predicted slower symptomatic improvement in supportive-expressive psychotherapy, but not in the medication or placebo condition. Lower interpersonal distress was associated with an increased likelihood to terminate treatment prematurely. The sample size did not allow the detection of small effects within the treatment groups. Interpersonal problems are influential for the treatment of depression, but parts of their effects depend on the type of treatment.
    Journal of Affective Disorders 08/2013; 151(2). DOI:10.1016/j.jad.2013.07.003 · 3.38 Impact Factor
    • "Depressed clients are characterized by an interpersonal style that can best be described as a blend between social avoidance and nonassertiveness (Barrett & Barber, 2007; Renner, Lobbestael, et al., 2012). This depressogenic interpersonal style remains stable after cognitive therapy (CT) for depression (Renner, Jarrett, et al., 2012). Studies relating interpersonal problems to depression chronicity are rare. "
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    ABSTRACT: Schema therapy (ST) is an integrative treatment approach to chronic lifelong problems with an established effectiveness for treating personality disorders. This article describes the adaptation of ST to chronic depression by reviewing the literature on the underlying risk factors to chronic depression. A model of chronic depression is presented, describing the interplay between empirically supported risk factors to chronic depression (early adversity, cognitive factors, personality pathology, interpersonal factors). We provide a treatment protocol of ST for chronic depression describing techniques that can be used in ST to target these underlying risk factors. Based on the current body of empirical evidence for the underlying risk factors to chronic depression, ST appears to be a promising new treatment approach to chronic depression, as it directly targets these underlying risk factors.
    Clinical Psychology Science and Practice 06/2013; 20(2):166-180. DOI:10.1111/cpsp.12032 · 2.92 Impact Factor
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    • "Interpersonal problems may influence treatment response via the therapeutic alliance. Renner et al. (2012) reported a positive relation between pre-treatment communal problems and alliance, and a negative relation between both agentic problems and alliance and interpersonal distress and alliance, over and above depressive severity. Further, in an earlier investigation of depressed patients with multiple sclerosis, results provided support for the mediating role of early working alliance in the association between overall interpersonal problems and treatment outcome (Howard et al., 2006). "
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    ABSTRACT: INTRODUCTION: Empirical research has converged to support the concurrent association between social difficulties and psychiatric symptoms; yet, longitudinal associations between interpersonal problems and treatment outcome require clarification. The current investigation evaluated the influence of interpersonal problems assessed prior to treatment on interpersonal impacts assessed during treatment as well as on treatment outcome in outpatients with major depressive disorder (MDD). METHOD: 125 participants with a primary diagnosis of MDD were randomized to receive cognitive behavioural therapy or interpersonal therapy. Participants completed the Beck Depression Inventory-II, Hamilton Depression Rating Scale, and Inventory of Interpersonal Problems Circumplex before and after treatment. Therapists completed the Impact Message Inventory during and after treatment. RESULTS: Interpersonal distress improved over the course of treatment; all other interpersonal changes were non-significant when distress was taken into account. Pre-treatment rigidity and agentic problems predicted less reduction in depressive symptoms, whereas agentic and communal impacts upon therapists during treatment predicted greater symptom change. Overall interpersonal distress was only indirectly associated with treatment response later in treatment, through its association with agentic style. Results did not differ across therapy type, and were replicated across self-report and interviewer-rated measures of depression severity. LIMITATIONS: Limitations include the brief duration of treatment, lack of medication arm, and potentially restricted generalizability of patients in a randomized control trial to those in routine practice. CONCLUSIONS: Interpersonal style demonstrated a trait-like stability over treatment, and appears to fluctuate due to co-occurring distress. Yet, specific interpersonal styles were negative prognostic indicators, even within therapy specifically targeting interpersonal functioning.
    Journal of Affective Disorders 05/2013; 150(2). DOI:10.1016/j.jad.2013.04.030 · 3.38 Impact Factor
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