Group Treatment in Psychotherapy by Robert G. Hinckley and Lydia Hermann

A recently completed clinical trial that investigated the effectiveness of a group-oriented, day treatment program provided an opportunity to pursue a multidimensional approach to the prediction of treatment outcome. The sample consisted of 99 psychiatric outpatients, most of whom had received diagnoses of affective and personality disorders. The predictor variables included a patient personality characteristic (psychological mindedness), a group process variable (patient work), and their interaction. Univariate analyses revealed significant direct relationships between psychological mindedness and both work and favorable outcome, and between work and favorable outcome. Multivariate analyses indicated that psychological mindedness and work had independent significant relationships (additive or interactive) with several of the outcome variables. In combination they accounted for up to a quarter of the outcome variance. The results demonstrate the benefit of using a theoretically consistent multidimensional approach. The time-efficient nature of the predictor measures used in the study make them particularly amenable for use by clinicians and researchers.     

The antecedents of aggressive behavior among men with schizophrenia: a prospective investigation of patients in community treatment

The association between psychotic symptoms and violence is unclear, due in part to methodological features of investigations that have examined this question, and in part to the fact that the association likely differs by disorder and treatment conditions. Using data from The Comparative Study of the Prevention of Crime and Violence by Mentally Ill Persons, we examined 128 men with schizophrenia or schizoaffective disorder discharged from general and forensic psychiatric hospitals in Canada, Finland, Germany, and Sweden. The association between symptoms and aggressive behavior was studied during two 6 month periods when the patients lived in the community. Severe positive and negative symptoms of psychosis, depression, and anxiety were measured at the beginning of each of the 6 month periods. In addition, at the beginning of the second 6 month period changes in symptoms in the previous period were indexed. Aggressive behavior was measured in each 6 month period by reports from patients and from collaterals. During the first 6 months post-discharge, after controlling for the presence of antisocial personality disorder or PCL score and past diagnoses of alcohol/drug abuse/dependence, the presence of a severe positive symptom significantly increased the risk of aggressive behavior. During the second 6 month period, after controlling for antisocial personality disorder or PCL score and self-reported alcohol/drug use, the presence of a severe positive symptom, a TCO symptom, and an increase in TCO symptoms significantly increased the risk of aggressive behavior. Neither depot medications nor obligatory community treatment reduced the risk of aggressive behavior after controlling for the presence of a severe positive symptom and/or TCO symptoms. These findings suggest that, among men with schizophrenia being treated in the community, the presence of severe psychotic symptoms and the development of TCO symptoms are antecedents of aggressive behavior.     

Personality, birth order and attachment styles as related to various types of jealousy

The relationships between jealousy, personality, attachment styles and birth order were examined in a sample of 100 Dutch men and 100 Dutch women. Three types of jealousy were examined: reactive jealousy (a negative response to the emotional or sexual involvement of the partner with someone else), preventive jealousy (efforts to prevent intimate contact of the partner with a third person), and anxious jealousy (obsessive anxiety, upset, and worrying about the possibility of infidelity of the partner). The three types of jealousy were not at all related to egoism and dominance, but significantly correlated with neuroticism, social anxiety, rigidity and hostility. Only among women was a low self-esteem correlated with jealousy. On all three jealousy measures, those with an anxious-ambivalent attachment style were more jealous than those with an avoidant style, with those with a secure attachment style being the least jealous. Attachment style was strongly related to most personality dimensions, but the effects of attachment style upon jealousy stayed virtually the same when controlling for personality factors. The most important finding in the present study was that laterborns were more jealous according to all three measures than firstborns, a finding that was not due to personality differences between first- and laterborns, nor to differences in attachment style, gender or occupational level of the father. Because some evidence was found that only borns were slightly less jealous than firstborns, it is suggested that the experience of exclusive love and attention in one's childhood, leads to a lower level of jealousy among firstborns.     

Gender differences in alcohol dependence: personality variables, psychopathological profile and personality disorders

In this paper, gender differences in personality, psychopathology and personality disorders of alcohol-dependent patients are described. The sample consisted of 158 alcohol-dependent patients attending a psychiatric outpatient clinic (105 men and 55 women). All participants were assessed with various assessment tools related to personality (Impulsiveness Scale, Sensation Seeking Scale and STAI), psychopathology (SCL-90-R, BDI and Inadaptation Scale) and personality disorders (IPDE). There were no differences in personality variables, but the women had more anxiety and depressive symptoms and also more problems to adapt to everyday life than did the men. Personality disorders were not as prevalent as in the case of men, and the most frequent among women were obsessive-compulsive, dependent and histrionic personality disorders. Implications of this study for further research are commented on.     

Sex-specific clinical correlates of hoarding in obsessive-compulsive disorder

Little is known about whether the clinical correlates of hoarding behavior are different in men and women with obsessive-compulsive disorder (OCD). In the current study, we evaluated the association of hoarding with categories of obsessions and compulsions, psychiatric disorders, personality dimensions, and other clinical characteristics separately in 151 men and 358 women with OCD who were examined during the OCD Collaborative Genetics Study. We found that, among men but not women, hoarding was associated with aggressive, sexual, and religious obsessions and checking compulsions. In men, hoarding was associated with generalized anxiety disorder and tics whereas, among women, hoarding was associated with social phobia, post-traumatic stress disorder, body dysmorphic disorder, nail biting, and skin picking. In women but not men, hoarding was associated with schizotypal and dependent personality disorder dimensions, and with low conscientiousness. These findings indicate that specific clinical correlates of hoarding in OCD are different in men and women and may reflect sex-specific differences in the course, expression, and/or etiology of hoarding behavior in OCD.     

Gender differences in comorbid disorders among offenders in prison substance abuse treatment programs

This study examined gender differences in a range of lifetime psychiatric disorders in a sample of 272 offenders newly admitted to a prison substance abuse program. Although these men and women did not differ in severity of substance use in the six months prior to incarceration, women were significantly more likely than men to report a lifetime psychiatric disorder and a lifetime severe disorder. Furthermore, gender differences emerged in the pattern of lifetime psychiatric comorbidity. Women reported greater lifetime major depression, posttraumatic stress disorder, eating disorder, and borderline personality disorder; men were more likely than women to meet criteria for antisocial personality disorder. Additionally, female offenders were found to have a higher degree of internalizing disorders than male offenders, but there were no gender differences in degree of externalizing disorders. The study concluded that women offenders newly admitted to a prison substance abuse program present with a greater psychiatric vulnerability and a different pattern of psychiatric comorbidity than their male counterparts.     

Bayesian Diagnostics of Hidden Markov Structural Equation Models with Missing Data

Cocaine is a type of drug that functions to increase the availability of the neurotransmitter dopamine in the brain. However, cocaine dependence or abuse is highly related to an increased risk of psychiatric disorders and deficits in cognitive performance, attention, and decision-making abilities. Given the chronic and persistent features of drug addiction, the progression of abstaining from cocaine often evolves across several states, such as addiction to, moderate dependence on, and swearing off cocaine. Hidden Markov models (HMMs) are well suited to the characterization of longitudinal data in terms of a set of unobservable states, and have increasingly been used to uncover the dynamic heterogeneity in progressive diseases or activities. However, the existence of outliers or influential points may misidentify the hidden states and distort the associated inference. In this study, we develop a Bayesian local influence procedure for HMMs with latent variables in the presence of missing data. The proposed model enables us to investigate the dynamic heterogeneity of multivariate longitudinal data, reveal how the interrelationships among latent variables change from one state to another, and simultaneously conduct statistical diagnosis for the given data, model assumptions, and prior inputs. We apply the proposed procedure to analyze a dataset collected by the UCLA center for advancing longitudinal drug abuse research. Several outliers or influential points that seriously influence estimation results are identified and removed. The proposed procedure also discovers the effects of treatment and individuals’ psychological problems on cocaine use behavior and delineates their dynamic changes across the cocaine-addiction states.     

Youth dating violence

Adolescents' responses to the Youth Dating Violence Survey have previously been documented by the Centers for Disease Control and Prevention (1996). The present study on dating violence examined the responses of thirty-seven adolescents enrolled in an alternative high school program. Many reported psychological victimization in a dating relationship: their partners did something to make them feel jealous, damaged their possessions, said things to hurt their feelings, insulted them in front of others, tried to control them, threatened them, blamed them for bad things the dating partners did, and brought up something from the past to hurt them. In terms of perpetrating psychological abuse in a dating relationship, over half of the adolescents reported that they hurt their dating partners' feelings, insulted them in front of others, did something just to make them jealous, tried to control them, and damaged their possessions. Many of the adolescents had also been victims of physical violence in their dating relationships; they reported being scratched, slapped, slammed or held against a wall, kicked, bitten, forced to have sex, choked, and pushed, grabbed, or shoved, as well as having their arms twisted and fingers bent. Some perpetrated physical violence in dating situations, such as scratching their dating partners, hitting them with a fist or something hard, throwing something that hit their dating partners, kicking them, slapping them, physically twisting their arms, slamming or holding them against a wall, bending their fingers, biting them, choking them, and pushing, grabbing, or shoving them. The findings confirm that dating violence among adolescents is a serious health problem that needs to be addressed.     

Change in adolescent boys at teen ranch: a five-year study

A five-year study was undertaken to assess the effectiveness of the Teen Ranch 70-bed residential treatment program for adolescent boys. To date, no long-term study of treatment effectiveness has been conducted; research has concentrated on recidivism, and while this provides some meaningful information, it provides little or no data to treatment directors, therapists, and administrators concerning in-process therapy or client change issues. The present study compared 120 full psychological test and retest batteries of boys who were in the program for at least one year. Through test-retest analysis, 27 intellectual and personality variables were compared to describe changes that took place. Nine intellectual and academic change variables and nine personality change variables were found to be significant. These changes were utilized to examine the overall effectiveness of the Teen Ranch residential treatment program and the possibility of integrating evaluation and treatment processes.     

Dangerous and severe personality disorders: a new personality concept from the United Kingdom

In 1998, we in England were shocked by the apparently motiveless murders of a mother and two of her children when they were traveling home from school in a rural area. Subsequently a patient with personality disorder, being monitored by the forensic psychiatric services, was convicted of their murders. The government was determined to prevent this type of offense from recurring and in 1999 introduced a new concept, dangerous and severe personality disorder (DSPD). This subsequently became a treatment and assessment program for individuals who satisfy three requirements: (1) have a severe disorder of personality, (2) present a significant risk of causing serious physical or psychological harm from which the victim would find it difficult or impossible to recover, and (3) the risk of offending should be functionally linked to the personality disorder. The implications of this program are discussed with regard to international systems of classification and service provision. We also attempt to place DSPD in the wider context of psychiatric participation in the management of personality disordered offenders.     

Intimate partner aggression reporting concordance and correlates of agreement among men with alcohol use disorders and their female partners

This study examined relationship aggression reporting concordance among 303 men with alcohol use disorders and their female partners enrolled in couples-based alcohol abuse treatment. Agreement for physical and psychological aggression was generally consistent with, or higher than, concordance rates reported among other populations. Men's antisocial personality disorder characteristics were the strongest predictor of higher concordance for male- and female-perpetrated aggression. Higher alcohol problem severity, poorer relationship adjustment, and higher psychopathic personality features were associated with better concordance in some analyses. Women reported experiencing more physical aggression than men reported perpetrating, and women reported perpetrating more psychological aggression than men reported experiencing. Findings highlight the importance of obtaining aggression reports from both partners and the need for research investigating methods for improving concordance.     

Predicting treatment outcome and recidivism among patients in a maximum security token economy

The relationship between program performance and outcome for patients in maximum security token economy programs has not been previously studied. We examined variables related to success in a token economy program and to postrelease failure for 92 men in a maximum security psychiatric hospital. Point earnings later in the program were best predicted by earlier point earnings. Variables that best predicted postrelease failure, defined in various ways, were similar to those found in other studies; youthfulness, having spent more time in institutions, a diagnosis of personality disorder or retardation rather than psychosis, not having been found not guilty by reason of insanity or unfit to stand trial, and having been referred from another psychiatric hospital. That program variables were generally unrelated to later outcome suggests that treatment programs for patients in maximum security settings must emphasize skills that are relevant to postrelease success.     

Moral variables before and after a court‐mandated psychological treatment of men convicted of violence against their partners: Evolution and relationship with sexist attitudes

Assuming that some moral variables can play a role in explaining intimate partner violence (IPV) and its treatment, this study explores the evolution of the relationship between some moral variables, which have recently been connected to IPV, and sexist attitudes in 160 men convicted of violence against the partner. The general hypothesis is that the moral variables can change during psychological treatments, and therefore be intervention targets, because they are related to more traditional variables in the field of IPV, such as sexist attitudes. To test this idea, we took pretreatment and posttreatment measures on moral variables (moral absolutism and moral foundations) and sexist attitudes (benevolent and hostile sexism) and analyzed their relationships and their changes after the completion of a prescribed psychological treatment. The results showed that (a) the moral variables were significantly correlated with the sexist attitudes before and after the treatment; (b) the men convicted of violence against the partner held with less certainty their general beliefs about morality and their particular beliefs about the binding moral foundations (in‐group, authority, and purity) after the unspecific psychological treatment; and (c) their moral absolutism before the treatment predicted the remaining sexist attitudes after the treatment. Practical implications can be drawn to better understand this kind of prevalent violence and eventually to improve the psychological treatments.     

Men’s Gendered Constructions of Intimate Partner Violence as Predictors of Court-Mandated Batterer Treatment Drop Out

The purpose of this study was to explore the meaning men make of their violence toward intimate partners and to examine if and how these meanings and constructions of violence predicted who drops out of batterer treatment prior to program completion. We used both qualitative and quantitative data collected from 154 men court-mandated to participate in a batterer intervention program. The qualitative findings indicated that the men in this sample minimized and denied responsibility for the violence they used towards their intimate partners while simultaneously rationalizing and justifying their violent behavior. Such findings provide insight into how denial and minimization and, more broadly, men’s constructions of masculinity might predict their tendency to drop out of batterer treatment. Furthermore, building upon our qualitative findings, logistic regression analysis revealed that men who were lower income, no longer intimately involved with the women they abused, and who reported lower levels of physical violence and higher levels of hostility were more likely to drop out of the batterer treatment program.     

Childhood antecedents of serious violence in adult male offenders

Prospective longitudinal studies have shown strong predictions from conduct disorders (CDs) in childhood to antisocial personality disorder (ASPD) and violence in adults. However, little is known of the childhood antecedents of serious violence nor whether these may vary depending on the context in which the violence occurs. In this study, 54 men aged 21-40 years serving prison sentences for violent crime were assessed. Standardized interviews of ASPD and violence were conducted independently of interviews covering retrospective recall of childhood psychiatric disorders and adverse experiences. Analyses of the predictors of overall violence suggested a pathway involving childhood CD and adult ASPD associated with interparental discord, and an additional pathway associated with experiencing interparental violence in childhood. Different results were however obtained when account was taken of the context of the violence. The CD-ASPD pathway was associated with social violence, but not with partner violence. Partner violence was predicted by retrospective reports of having been exposed to interparental violence during childhood but not by reports of childhood CD or adult ASPD. Thus developmental pathways to serious violence may be different depending on the social domain in which the violence occurs.     

Spontaneous and Reflexive Cognitions Related to Spousal Abuse: The Role of Experiences of Violence

The aim of this study was to investigate the recognition of violent behaviors, assessment of their severity, and reaction time in recognizing violent behaviors among individuals (91 men, 122 women) who have been exposed to spousal abuse, either as victim or aggressor, and those who have not reported such experiences. Results indicate a relation between the rapidity with which participants recognized a behavior, number of behaviors recognized, and assessment of the severity of such behaviors. Moreover, participants recognized physical violence more readily than psychological violence, and rated physical violence more severely. Finally, the experience of violence in a couple, as perpetrator or as victim, was linked to reaction time for each type of violence.     

The Dark Side of Heterosexual Romance: Endorsement of Romantic Beliefs Relates to Intimate Partner Violence

Romance and control are often conflated by the media, and individuals may believe that certain controlling or jealous behaviors by men toward women are romantic and can be a sign of love and commitment in heterosexual relationships. The current study explored three types of romantic beliefs among women: endorsement of the ideology of romanticism, highly valuing romantic relationships, and the belief that jealousy is good. The goal was to determine whether these beliefs would be related to finding controlling behaviors romantic as well as to reported experiences of both physical and psychological intimate partner violence (IPV). We surveyed 275 heterosexual-identified women, aged 18 to 50, and measured their endorsement of romantic beliefs, the extent to which they romanticized controlling behavior, and experiences of physical and psychological abuse within their current or most recent romantic relationship. Romantic beliefs were related to romanticizing controlling behaviors, which, in turn, was related to experiences of IPV. There was also a significant indirect relationship between romantic beliefs and experiences of IPV. The data indicate that seemingly positive romantic ideologies can have insidious negative effects. Findings may be useful for clinicians and those who advocate for prevention of IPV as they illustrate a need to refocus traditional ideas of healthy relationships at the societal level.     

The relationship between childhood violence and alcohol problems among men who batter: An empirical review and synthesis

The available literature indicates that: (a) experiences of childhood violence are associated with mediator variables, including antisocial behaviors and depressive symptomatology, that are themselves associated with development of alcohol problems and perpetration of partner violence for men in adulthood; (b) experiences of childhood violence and, more strongly, observation of interparental violence during childhood predict perpetration of partner violence in adulthood for males; (c) presence of partner violence is associated with certain types of alcohol problems for men; and (d) both partner violence and alcohol problems are associated with marital conflict. However, available research has often excluded important moderator variables, such as history of familial and parental alcohol problems and history of parental psychiatric disorders. Based on the available research, two indirect pathways between childhood violence and adulthood problems (i.e., alcohol problems and partner violence) are proposed as guides for future research in the areas of family violence and alcohol problems for men. Further, bidirectional associations between alcohol problems and partner violence are proposed. Finally, inclusion of important moderator and mediator variables in multivariate research designs is suggested.     

Personality and situational correlates of self-reported reasons for intimate partner violence among women versus men referred for batterers' intervention

This study examines personality and situational correlates of self-reported reasons for intimate partner violence (IPV) among women and men court-ordered to batterers' intervention as IPV offenders. Women endorsed self-defense and men retaliation as their primary reasons for IPV. Both also endorsed emotion dysregulation as a reason for much of their violence. Women's partner violence was largely, but not exclusively, situationally motivated. Women's reasons for violence also related significantly to self-reported borderline personality symptomology. Men's reasons for IPV related primarily to their self-reported antisocial and borderline personality traits, not to situational factors. Thus, the IPV of some women and some men may be considered "characterological," in that it reflects something about the individual's character or personality. Control or domination of one's partner was not a primary reason for violence among women or men, despite the assumption on which many batterer intervention programs are based, that IPV is primarily a power and control tactic. Clinical implications and recommendations for future research are provided.     

Violent and disruptive behavior among drug-involved prisoners: relationship with psychiatric symptoms

This study examines the relationship between psychiatric symptoms and violent/disruptive behavior among 192 inmates who participated in prison-based substance abuse treatment. Participants came from two sites able to provide narrative reports of disciplinary actions in the Criminal Justice Drug Abuse Treatment Studies' Co-Occurring Disorders Screening Instrument study. In multivariate logistic models, a lifetime history of thought insertion/control ideation (OR, 11.6; 95% CI, 1.8-75.2), antisocial personality disorder (OR, 3.3; 95% CI, 1.2-8.9), and disciplinary action related to possession of controlled substances or contraband (OR, 4.9; 95% CI, 1.9-12.3) were associated with increased risk for violent or disruptive behavior while in prison, whereas lifetime phobic symptoms (OR, 0.2; 95% CI, 0.1-0.54) and high school graduation (OR, 0.4; 95% CI, 0.2-1.0) were associated with a decreased risk of violence and disruptive behavior in general. We conclude that, among inmates in substance abuse treatment, symptoms that increase risk for violence or disruptive behavior include thought control/insertion ideation and disciplinary infractions related to controlled substances, contraband, or failure to participate in assigned programs, as well a history of antisocial personality disorder.