Can Personaiity

Traits Predict Outcome?

Psychotherapy

Hope R. Conte, Robert Plutchik, Susan Picard, and T. Byram Karasu Ninety-six new admissions to a psychiatric outpatient clinic who attended a median of 14 therapy sessions completed a self-report Personality Profile Index prior to their first session. This index provides scores on eight dimensions of personality, a conflict measure, and a measure of social desirability. Scores were correlated with number of sessions and outcome as measured by a Symptom Checklist and by a Global Assessment Scale (GAS). Improvement was significantly related to number of sessions attended. Patients scoring high on being rejecting of others (rejection) were significantly less likely to show improvement after therapy. Rejection, aggression, passivity, and conflict were significantly related to the extent of symptoms and problems with which patients presented at the clinic. Copyright 0 1991 by W.B. Saunders Company

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LINICIANS ARE regularly faced with making decisions regarding a patient’s suitability for and probable response to individual psychotherapy. Thus, the search for pretherapy patient characteristics to predict psychotherapy outcome continues, in spite of evidence that such attempts have had only limited success. For example, in an extensive study, Weber et al.’ found that once a suitable candidate for psychoanalysis or psychotherapy has been chosen, the eventual outcome of treatment is only marginally predictable. This finding is consistent with those of Gottschalk et al.,’ Malan3 Garfield and Bergin and Luborsky et a1.5 Nevertheless, some previous empirical studies do provide limited evidence that interpersonal personality variables can be predictive of outcome. As an example, a major conclusion of Kernberg et al6 was that when patients presented with a history of poor interpersonal relations, their prognosis for dynamically oriented forms of therapy was also poor. In contrast, Tyson and Sandier’ found object relatedness in general and “basic trust” in particular to have a prognostically favorable relationship to good outcome of psychoanalysis. In much the same vein, Moras and Strupp’ found that clinicians’ pretherapy ratings of clients’ interpersonal relations, particularly lack of mistrust and hostility, were highly predictive of the clients’ ability to form a good therapeutic alliance, which in turn predicted successful psychotherapy. However, with the exception of a significant correlation between the Minnesota Multiphasic Personality Inventory (MMPI) Depression Scale and a measure of outcome, the direct correlations between clinical judgments of clients’ interpersonal functioning and patients’ and therapists’ ratings of outcome were not significant. Using only self-report ratings but not clinical judgments, Filak et a1.9 also explored the extent to which clients’ pretherapy interpersonal attitudes were

From the Department of Psychiatry, Albert Einstein College of MedicinelMontefiore Medical Center, Bronx, NY. Address reprint requests to Hope R. Conte, Ph.D., Department of Psychiatry, Bronx Municipal Hospital Center, Nurses Residence-SS2.5, Bronx, NylO461. Copyright 0 1991 by W.B. Saunders Company 0010440X/91/3201-0009$03.00l0 66

Comprehensive

Psychiatry, Vol. 32, No. 1 (January/February),

1991: pp 66-72

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related to outcome of relatively short-term individual psychotherapy. Their results support Moras and Strupp’s’ findings of the importance of clients’ premorbid interpersonal functioning for successful psychotherapy. They found that patients considered to have a successful treatment outcome were significantly more affiliative and less hostile both before and after therapy than patients labeled only moderately successful or unsuccessful. No significant differences were found on a dominance-submission dimension. More recently, Horowitz et al.,” also using a self-report inventory for measuring interpersonal relations, found that in a group of patients who received brief dynamic psychotherapy, patients with problems of assertiveness improved to a significant degree, whereas those with problems of intimacy did not. Conte et al. “.I2 also have reported significant relations between personality traits and outcome of therapy. Histrionic, obsessive-compulsive, and paranoid personality traits as measured by self-report scales were shown to be negatively related to outcome,” as were depression, rejection, and conflict. In contrast, sociability was predictive of good outcome.12 One possible reason for the limited findings about personality variables as predictors of outcome may be that the range of personality measures used in individual studies has been too narrow. Recent research on circumplex models of personality suggests that a larger number of interrelated personality dimensions should be simultaneously studied in any given investigation. Using a personality test based on a circumplex model of interpersonal behavior that concomitantly explores eight personality dimensions, the present study represents a further attempt to explore the extent to which pretherapy personality traits are related to psychotherapy outcome. METHOD

Patients For approximately 12 months, new admissions to a large outpatient clinic affiliated with a medical school were asked to complete a self-report personality questionnaire during the time period between registration at the clinic and seeing their evaluators. One hundred eighty patients were willing to sign a consent form and had sufficient time to complete the questionnaire. This number represents 52% of the 349 patients admitted during this period. The clinical records of 50 randomly selected patients who were admitted to the clinic during the same time period, but who chose not to participate, were reviewed in order to determine the representativeness of the participating patients. No significant differences were found between the randomly selected sample and the participants in terms of sex distribution, age, education, marital status, discharge diagnosis, or number of therapy sessions attended. All patients came from a largely lower middle class to lower class population, with a varied ethnic distribution. Thus, the sample of 180 patients may be considered to be representative of clinic admissions on demographic and diagnostic variables. Of these 180 patients, 10 (6%) were referred to other facilities after their evaluation and thus received no therapy at the clinic. Thirty patients (17%) had not as yet been discharged at the time of data analysis. An additional 44 patients (24%) dropped out of treatment before their fourth therapy session. Since four therapy sessions were considered to be the minimum number required for inclusion in the study, there remained 96 patients who attended a mean of 20 (SD 18.68) and a median of 13.5 sessions (range, four to 126). The sample of patients consisted of 39 men and 57 women. Their mean age was 34.76 (SD 11.41) years. Fifty-three percent were single, 23% married, and 23% were either divorced, widowed, or separated. Patients were diagnosed by the clinic therapists under the supervision of senior faculty on the basis of DSM-III-R criteria as follows: 26% affective disorder, 22% personality disorder, 17% adjustment disorder, 11% schizophrenia, 11% anxiety disorder, 5% substance use disorder, and 8%

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other, which included such varied diagnoses as schizoaffective and V codes. Thirty-one (32%) of the patient sample were not prescribed psychotropic drugs, while 65 (68%) received anxiolytics, antidepressants, and in some cases, major tranquilizers.

Psychotherapeutic Treatments The clinic provides a variety of psychotherapies. Overall, the orientation of the supervisors at the clinic is broadly psychodynamic, and all therapists are exposed to this general orientation. When individual therapy, the predominant mode of treatment, is provided, therapists and their supervisors flexibly adapt their primarily psychodynamic approach to the specific condition of the patient. In this study, the majority (77%) of the patients were in individual therapy, 10% were in both individual and group, 12% were in group, and 1% was in couples therapy.

Psychotherapists Seventy-four percent of the 96 patients were evaluated and/or treated by third-year psychiatric residents under the supervision of senior faculty members. Sixteen percent and lo%, respectively, were treated by social workers and psychology interns under supervision. The treating clinicians were unaware that the patients’ clinical records would serve as a basis for a retrospective study.

Test Instruments The Personality Profile Index (PPI) is a test instrument that is based on the notion that a circumplex model is the most parsimonious and appropriate one to represent the structure of interpersonal personality traits. “-” This means that traits may be considered to exist around a hypothetical circle, with those nearest one another being most similar, while those 180” from one another being opposites. However, although the PPI is theoretically based, the actual items chosen for the test have their origins in the empirically derived circular ordering of trait terms reported by Conte and Plutchik.‘3,‘4 As developed by these authors,‘* eight dimensions of personality are rated: acceptance, submission, passivity, depression, rejection, aggression, assertion, and sociability. The PPI also provides a conflict measure and a measure of social desirability, which provides data on the extent to which an individual is attempting to appear in an especially good or poor light. Good internal consistency and measures of discriminative validity have been demonstrated.‘s,‘9 The PPI consists of 89 items in a self-report format, with 10 to 13 items for each of the eight dimensions, each answered on a five-point scale ranging from “never” to “very often.” There are two equivalent forms, form A and form B. Previous research” has shown that scores on all dimensions and on the conflict and social desirability measures of PPI-A and PPI-B are highly and significantly correlated in all cases, indicating that the forms may be used interchangeably. The items of PPI-A are adjectival in nature. The items of PPI-B, the one used in the present study, are in the form of descriptive phrases. Thus, the dimensions of aggression, sociability, and submission are tapped, respectively, by such items as “I let people know what is wrong with their opinions,” “I am a warm and caring person,” and “I avoid taking risks.” Coefficients (Y,based on an N of 50, ranged from .66 to .91 with a mean of .76, indicating that PPI-B has good internal consistency. Individuals taking the test receive a total score for each of the eight dimensions, as well as total conflict and social desirability scores. These scores are then converted into percentile scores based on normative data obtained from 318 individuals, mostly college students, characterized by a lack of overt pathology or psychiatric hospitalization. These scores may then be plotted on a circular diagram to illustrate graphically the configuration of personality traits for any given individual or sample of individuals. For the purpose of correlating PPI-B scores with the outcome measures and with number of sessions, they were transformed tot scores.

Psychiatric Outpatient Rating Scale This 21-item rating scale, which has demonstrated good internal consistency and interjudge reliability, as well as a measure of concurrent validity,m provided data regarding symptom and problem changes. Each of the 21 symptoms is rated on a five-point scale ranging from “0” (not present), through “1” (minimal problem), “2” (moderate problem), “3” (severe problem), to “4” (very severe problem). A total score is obtained. The higher the score, the more symptoms the patient has. Patients were rated on the Psychiatric Outpatient Rating Scale (PORS) by the evaluating clinician at intake and again by the treating therapist at discharge. The difference between the two total scores represented the degree of symptom change over the course of therapy. The initial rating is subtracted from the discharge

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rating. Therefore, the change score is usually negative. The PORS discharge ratings with the effect of initial ratings partialled out and PORS residual change scores served as outcome measures. The Global Assessment Scale (GAS)2’ was used to determine the degree of change in level of functioning over the course of treatment. The GAS is an instrument consisting of 10 categories that describe different levels of psychosocial functioning on a continuum of mental health. Satisfactory interrater agreement was established for this population (r = .78), based on the average of three pairs of independent raters. One rater then assigned initial GAS scores on the basis of intake evaluations and discharge GAS scores on the basis of discharge summaries from the patients’ charts. Scores may range from 1 to 100. The higher the score, the better the patient’s level of functioning. A difference score, which served as a measure of change, was then derived by calculating the differences between these pretherapy and posttherapy scores. Residual difference scores and discharge GAS scores, with the effect of initial ratings partialled out, were used as outcome measures.

RESULTS

The 39 men and 57 women in the group of 96 patients who attended four or more therapy sessions were compared on age, education, GAS and PORS initial, discharge, and residual change scores, and on the personality variables. With the exception of initial GAS and PORS ratings, they were comparable on all variables. The females scored significantly higher than the males on initial GAS ratings (mean + SD, 50.47 + 12.38 v 44.74 + 11.34; r = 2.30, P < .02) and lower on the initial PORS ratings (18.98 5 6.18 v 21.90 + 8.50; t = 1.96, P < .05), indicating that they were better functioning and had fewer symptoms than the males. However, since there were no significant differences between the two groups on discharge or change ratings, the decision was made to combine them for further data analysis. The most striking finding of this study is that, with the exception of rejection, the personality traits of the patients as assessed before attending four or more therapy sessions were not significantly correlated with any of the outcome measures. Scores on the GAS residual change measure correlated -.21 (P < .05) with rejection. This means that the more a patient reported being rejecting of other people prior to therapy, the less likely was he or she to show an improvement in symptoms or problems. In contrast, improvement was significantly related to number of therapy sessions attended. For those patients who attended four or more sessions (N = 96) the correlation between GAS residual change and number of sessions was .20 (P < .05), and that between GAS discharge ratings and number of sessions was .24 (P < .Ol). However, while these correlations are statistically significant, the actual magnitude of the mean GAS change, 3.73 points on a scale that ranges from 1 to 100, is clinically rather meager. What these data suggest is that an average of 14 sessions of psychotherapy for these 96 patients produced very little improvement and that what improvement did occur was essentially unrelated to pretherapy personality characteristics. Figure 1 presents a personality profile, based on percentile scores, of the 96 patients as they described themselves prior to therapy. What is evident is that, as a group, they are much more submissive, passive, and depressed than the normative group. They are also considerably less assertive. Their social desirability and conflict scores put them in the 31st and 77th percentile, respectively, indicating both that they are highly conflicted and that they were making no attempt to present themselves in a favorable light. One other interesting finding is the correlation between personality measures

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Fig 1. Personality Profile Index, form B, psychiatric outpatients (N = 96).

and initial symptom and problem scores. Even though there is little evidence for change as the result of psychotherapy, there is a relation between the personality of the patients and the extent of the symptoms and problems with which they present at the outpatient clinic. As indicated by the correlations with initial PORS scores, patients presenting high on rejection, aggression, conflict, and passivity also have the greatest number of symptoms and problems (r’s = .25, P < .Ol, .24, .22, and .21, P < .05, respectively). DISCUSSION

The findings of the present study are, in general, consistent with those of other investigators who have found few significant predictors of outcome. Further, even when significant levels of prediction are found, the correlations usually fall in the .2 to .3 range, indicating very limited prediction of outcome variance. For example, Luborsky et al.’ found that out of 84 pretreatment predictive measures, the best of the few predictors was emotional freedom, which correlated .30 (P < .Ol) with rated benefits. The fact that patients in this study who scored high on rejection prior to therapy were significantly less likely to show improvement on the GAS residual change measure is also consistent with the findings of others.“” Most investigators who have found some connection between the quality of interpersonal relations and outcome have found that the poorer the initial quality of these relations, the poorer the prognosis for dynamically oriented therapy. Poor interpersonal relations are characterized by mistrust and hostility as well as by lack of affiliation and “basic trust,“6 all of which are elements of the personality trait of rejection. Those variables that have been shown in previous literature to be predictive of positive change relate to the patient’s ability to develop a positive attitude toward the therapist and to the extent to which he or she is committed to work at changing. Neither of these attributes is characteristic of an individual who is typically rejecting of others.

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Improvement on two of the outcome measures, the GAS residual change score and the GAS discharge rating, was significantly related to the number of sessions attended by the patients. The literature is inconsistent on the effect of this variable. For example, Malan3 found a positive relation between number of sessions and outcome. More recently, Schramski et al.u identified total sessions at a psychotherapy clinic as predictors of positive change in status at both termination and follow-up. In contrast, in a study designed to measure the extent to which progress in therapy can be predicted from the interpersonal styles of therapists and clients, it was found that number of sessions was unrelated either to client-rated progress or to symptom reduction. Yet another type of result is reported by Strassberg et al.% Through 20 sessions there was a strong positive relationship between treatment length and counselor-assessed outcome. After 20 sessions, additional counseling was no longer associated with further increases in improvement. Nevertheless, the preponderance of the evidence indicates that the more therapy patients receive, the more they benefit from it.25,26However, few studies comment on the clinical significance of their findings or specify what is meant by “outcome” or on what evidence conclusions are based. These factors undoubtedly contribute to the lack of consistency of findings in this area. What the present study has shown is that personality variables are significantly related to the extent of symptoms and problems with which patients enter therapy. This group of 96 patients was less assertive and more submissive, passive, depressed, and conflicted than a normative sample. In addition, the higher their scores on rejection, aggression, conflict, and passivity, the more symptoms and problems in living they exhibited. These traits are highly at variance with the characteristics considered important for the selection of appropriate patients for brief psychodynamic therapy. The clinical writing on brief psychotherapy,” indeed on psychodynamic therapy in general,% stresses the importance of good previous adjustment, good ability to relate, high motivation, and the absence of dependency and tendencies towards acting out. It is obvious that criteria such as these would exclude a large proportion of patients presenting at outpatient psychotherapy clinics, where it has been estimated that most patients either drop out or are terminated before the eighth session.29 The patients in the present sample, who attended a median of 14 sessions, can be considered a part of that sizable patient pool who would be deemed poor candidates for short-term therapy. Whether or not personality traits of patients having the characteristics described above would be predictive of outcome of relatively short-term therapy is an issue that needs to be studied. With the present sample of patients and therapists, all that can be concluded is that personality traits account for little of the outcome variance. REFERENCES 1. Weber JJ, Bachrach HM, Solomon M: Factors associated with the outcome of psychoanalysis: Report of the Columbia Psychoanalytic Center Research Project (HI). Int Rev Psycho-Anal 12:251-262,1985 2. Gottschalk LA, Fox RA, Bates DE: A study of prediction in outcome in a mental health crisis clinic. Am J Psychiatry 130:1107-1111,1973 3. Malan DH: The Frontier of Brief Psychotherapy. New York, NY, Plenum, 1976 4. Garfield SL, Bergin AE (eds): Handbook of Psychotherapy and Behavior Change: An Empirical Analysis (ed 3). New York, NY, Wiley, 1986

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5. Luborsky L, Crits-Christoph P, Mintz J, et al: Who Will Benefit From Psychotherapy: Predicting Therapeutic Outcomes. New York, NY, Basic Books, 1988 6. Kernberg OF, Burstein ED, Coyne L, et al: Psychotherapy and psychoanalysis: Final report of the Menninger Foundation’s Psychotherapy Research Project. Bull Menninger Clin 36:1-275,1972 7. Tyson R, Sandler J: Problems in the selection of patients for psychoanalysis: Comments on the application of the concepts “indications,” “suitability,” and “analyzability.” Br J Med Psycho1 44:211-228,197l 8. Moras K, Strupp HH: Pretherapy interpersonal relations, patients’ alliance, and outcome in brief therapy. Arch Gen Psychiatry 39:405-409, 1982 9. Filak J, Abeles N, Norquist S: Clients’ pretherapy interpersonal attitudes and psychotherapy outcome. Prof Psycho1 Res Prac 17:217-222,1986 10. Horowitz LM, Rosenberg SE, Baer BA, et al: Inventory of interpersonal problems: Psychometric properties and clinical applications. J Consult Clin Psycho1 56:885-892,198s 11. Conte HR, Plutchik R, Picard S, et al: Self-report measures as predictors of psychotherapy outcome. Compr Psychiatry 29:355-360, 1988 12. Conte HR, Plutchik R, Buck L, et al: Interrelations among ego functions and personality traits: Their relation to psychotherapy outcome. Am J Psychother ~01451991 13. Conte, HR: A circumplex model for personality traits (Doctoral dissertation, NYU). Dissertation Abstracts International 36,3569 B (University Microfilms No. 7601731), 1975 14. Conte HR, Plutchik R: A circumplex model for interpersonal personality traits. J Pers Sot Psycho1 40:701-711, 1981 15. Wiggins JS: Circumplex models of interpersonal behavior in clinical psychology, in Kendell PC, Butcher JN (eds): Handbook of Research Methods in Clinical Psychology. New York, NY, Wiley, 1982, pp 183-221 16. Wiggins JS, Broughton R: The interpersonal circle: A structural model for the integration of personality research, in Hogan, R, Jones WH (eds): Perspectives in Personality, vol 1. Greenwich, CT, JAI, 1985, pp l-47 17. Fisher GA, Heise DR, Bohrnstedt GW, et al: Evidence for extending the circumplex model of personality trait language to self-reported moods. J Pers Sot Psycho1 49233-242, 1985 18. Plutchik R, Conte HR: Measuring emotions and their derivatives: Personality traits, ego defenses, and coping styles, in Wetzler S, Katz M (eds): Contemporary Approaches to Psychological Assessment. New York, NY, BrunneriMazel, 1989, pp 239-269 19. Conte HR, Plutchik R, Picard S, et al: Sex differences in personality traits and coping styles of hospitalized alcoholics. J Stud Alcohol, Jan 1991 20. Plutchik R, Conte HR, Spence W, et al: Development of a scale for the measurement of symptom change in an outpatient clinic. Compr Psychiatry 31:134-139,199O 21. Endicott J, Spitzer RL, Fleiss JL, et al: The Global Assessment Scale: A procedure for measuring severity of psychiatric disturbance. Arch Gen Psychiatry 33:766-771,1976 22. Schramski TG, Beutler LE, Lauver PJ, et al: Factors that contribute to posttherapy persistence of therapeutic change. J Clin Psycho1 40:78-85,1984 23. Rudy JP, McLemore CW, Gorsuch RL: Interpersonal behavior and therapeutic progress: Therapists and clients rate themselves and each other. Psychiatry 48:264-281,198.5 24. Strassberg DS, Anchor KN, Cunningham J, et al: Successful outcome and number of sessions: When do counselors think enough is enough? J Counsel Psycho1 24:477-480,1977 25. Howard KI, Kopta SM, Krause MS, et al: The dose-effect relationship in psychotherapy. Am Psycho1 41:159-164,1986 26. Orlinsky DE, Howard KI: Process and outcome in psychotherapy, in Garfield SL, Bergin AE (eds): Handbook of Psychotherapy and Behavior Change. New York, NY, Wiley, 1986, pp 311-381 27. Koss MP, Butcher JN: Research on brief psychotherapy, in Garfield SL, Bergin AE (eds): Handbook of Psychotherapy and Behavior Change. New York, NY, Wiley, 1986, pp 627-670 28. Strupp HH: Psychotherapy research: Reflections on my career and the state of the art. J Sot Clin Psycho1 2:3-24,1984 29. Garfield SL: Research on client variables in psychotherapy, in Garfield SL, Bergin AE (eds): Handbook of Psychotherapy and Behavior Change. New York, NY, Wiley, 1986, pp 213-256

Can personality traits predict psychotherapy outcome?

Ninety-six new admissions to a psychiatric outpatient clinic who attended a median of 14 therapy sessions completed a self-report Personality Profile ...
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