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Psychological mindedness and symptom reduction after psychotherapy in a heterogeneous psychiatric sample
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Comprehensive Psychiatry 51 (2010) 492 – 496 www.elsevier.com/locate/comppsych
Psychological mindedness and symptom reduction after psychotherapy in a heterogeneous psychiatric sample Ivan Nyklíčeka,⁎, Daphne Majoora , Pierre A.A.M. Schalkenb a
Center of Research on Psychology in Somatic disease (CoRPS), Department of Medical Psychology, Tilburg University, Postbox 90153, 5000 LE Tilburg, Netherlands b Center for Psychological Recovery, Berlicumseweg 8, 5248 NT Rosmalen, Netherlands
Abstract Background: Psychological mindedness (PM) has been claimed to be beneficial for outcome of various forms of psychotherapy. The purpose of this study was to investigate the influence of PM on the therapy results of a psychiatric patient sample with heterogeneous psychological symptoms. Methods: Participants were 110 patients with different diagnoses who were hospitalized at the Center for Psychological Recovery (Rosmalen, Netherlands). Before and after treatment, they were asked to complete the Balanced Index of Psychological Mindedness and the Symptom Checklist-90. Results: Baseline PM was not associated with a decrease in symptom scores (F8,73 b 1.0; P N .20; partial η2 b 0.10). However, PM increased over the course of the intervention (F2,84 = 43.54; P b .001; η2 = 0.51) and larger increases in the insight component of PM were associated with larger decreases on 6 of 8 symptom scores (F8,70 = 3.55; P b .005; partial η2 = 0.29). Conclusions: These results suggest that although a high PM is not a prerequisite for successful cognitive behavioral therapy, an increase in insight is associated with better outcome. © 2010 Elsevier Inc. All rights reserved.
1. Introduction Appelbaum [1] was one of the first who used the term psychological mindedness (PM). Appelbaum [1] stated that PM is “a person's insight to see relationships among thoughts, feelings, and actions, with the goal of learning the meaning and causes of his experiences and behavior” (p. 36). Other definitions have also been provided by several other authors, broadening the definition according to the specific views and contexts of the authors (eg, by Conte et al [2] and McCallum and Piper [3]). In line with the attempt by Hall [4] to extract the core dimensions of PM, we define the core of PM as the “interest and ability to be in touch with and reflect upon one's psychological states and processes” [5]. It has been claimed that PM is a prerequisite for positive outcome of psychotherapy. For instance, PM has been stated ⁎ Corresponding author. Department of Medical Psychology, Tilburg University, PO Box 90153, 5000 LE Tilburg, The Netherlands. Tel.: +31 13 4662391; fax: +31 13 4662370. E-mail address: [email protected] (I. Nyklíček). 0010-440X/$ – see front matter © 2010 Elsevier Inc. All rights reserved. doi:10.1016/j.comppsych.2010.02.004
to imply a willingness to commit oneself to the therapeutic alliance and to a basic agreement with the values and norms implicit of psychotherapy [6]. It has been shown that PM is related with a higher commitment to psychotherapy, as reflected in a higher number of attended sessions and stronger involvement in the therapy process [3,6,7]. Some of the few empirical studies report a beneficial effect of baseline PM on improvement after several forms of psychotherapy [8-10]. For instance, Piper et al (1998) [8] revealed a direct positive association between baseline PM and therapy outcome for interpretative and supporting therapy in individuals with different diagnoses. However, some studies did not obtain relationships between PM and therapy outcome. McCallum and Piper (1997) [11] reported that PM had a positive influence on the amount of work invested in the therapy sessions for three different personality disorders, but only the amount of work, not PM, was related to outcome [3]. The discrepancy between studies finding positive results and those not obtaining a significant effect of PM may be due to several methodological issues, such as the different patient samples and different measurement instruments used
I. Nyklíček et al. / Comprehensive Psychiatry 51 (2010) 492–496
to assess PM. Most of the previous instruments used to measure PM have psychometric shortcomings, mainly unclear content validity or poor factorial validity [5]. In addition, previous studies have approached PM as a unitary construct, whereas it has been argued that PM is multidimensional [4]. Various aspects of PM, such as the interest in one's inner psychological states and processes and the ability to gain insight into these phenomena may be differentially related to outcome of psychotherapy [4,5], precluding clear associations when PM is approached in a unidimensional way. More generally, PM is conceptualized as a crucial factor in the development of adaptive emotion regulation, which in its turn is essential for a person's well-being [12-15]. Indeed, PM has been reported to be associated with a more adaptive cognitive style [12], and a higher level of wellbeing in a sample of healthy students [16], as well as in a sample of psychiatric patients [5]. In addition, one may expect psychotherapy to have a positive influence on PM, especially an enhancement of insight into psychological states and processes as a result of the emphasis in most if not all forms of psychotherapy on the importance of introspection and self-monitoring for adequate emotion regulation [13,14]. Extrapolating this line of thought, one may expect an increase in PM, as a result of psychotherapy, to be associated with a decrease of psychological symptoms and an increase in psychological well-being. However, up to date, neither effects of psychotherapy on levels of PM nor the association of a putative change in PM with change in symptoms have been investigated, although previous work has been conducted on the inversely related concept of alexithymia. The results of those studies tend to show a decrease of alexithymia over the treatment period [17-20], whereas three studies reported an association between decrease in alexithymia and decrease in symptoms in psychiatric patients [17,18,20]. Therefore, the aims of the present study were (1) to examine if PM increases during psychotherapy, (2) to determine whether both pretherapy scores of PM and the putative increase in PM during therapy are associated with a decrease in symptom levels from pretreatment to posttreatment, and (3) to investigate the potentially differential effects regarding the aforementioned relations of the two core dimensions of PM: interest and ability to reflect upon one's psychological states and processes.
2. Methods 2.1. Participants Participants were patients who were admitted to the Center for Psychological Recovery (CPR) at Rosmalen, the Netherlands, for a period of 6 to 12 weeks. The weekends were spent at home. The length of the treatment was determined by the diagnosis, the course of the treatment, and
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the possibility of hospitalization (patients often prefer to stay for some time after inpatient treatment). The CPR offers assistance to adults with a variety of personal problems that may be associated with the home or work situation. Most patients have symptoms of depression, anxiety, or burnout. Patients having addiction problems, severe psychiatric, or personality disorders are not admitted. All 110 patients who had their intake between August 2005 and June 2006 agreed to participate in this study: 27 men (24.2%) and 83 women (75.8%) in the age between 23 and 71 years (mean age, 45.3 years; SD, 9.8). Of these patients, 86 (78.2%) completed both baseline and posttreatment questionnaires and were included in the analyses. Main reasons for not completing were leaving the center to another institution after a crisis (n = 8) and reluctance to complete the posttreatment questionnaires. Of the 86 completers, 67 (77.9%) were women, 51 (59.3%) had a partner, 59 (68.6%) had at least midlevel vocational education or higher, 41 (47.7%) had a paid job, 55 (64.0%) were using psychotropic medication (all antidepressants or tranquillizers), and 81 (95.3%) have had some form of mental health care previously. Mean age was 45.1 years (SD, 9.9). Patients received the following Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, diagnoses: mood disorder (45.3%), anxiety disorders (9.3%), adjustment disorder (18.6%), and other diagnoses (26.8%). All patients received cognitive behavioral therapy techniques for their problems and participated in the study after providing a written informed consent. The study was approved by the Review Committee of the participating institute (Center for Psychological Recovery at Rosmalen, the Netherlands). 2.2. Measurements Psychological symptoms were measured by the Symptom Check List-90 (SCL-90; [21]). It estimates the present psychopathologic symptoms in 8 dimensions: anxiety, phobic anxiety, depression, somatization, paranoid ideation and interpersonal sensitivity, insufficiency of thinking and behavior, sleeping problems, and hostility. The SCL-90 is a self-report scale consisting of 90 items, which are answered on a 5-point Likert scale from “not at all” (score 1) to “very much” (score 5). The Dutch version of the SCL-90 has a good to excellent internal consistency with the most Cronbach α values above .80. The test-retest reliability is between 0.73 and 0.97, and also, the content validity and criterion validity are satisfactory [22]. Psychological mindedness was assessed using the Balanced Index of Psychological Mindedness ([5]). It is a self-report questionnaire consisting of 14 items, which are answered on a 5-point Likert scale raging from “strongly disagree” (score 1) to “strongly agree” (score 5). The scale has 2 subscales of 7 items: interest in one's internal psychological phenomena and insight in these phenomena, according to the theoretical model by Hall (1992) [4]. Internal consistency of the subscales is adequate (Cronbach
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α = .85 for interest and .76 for insight), as well as the testretest reliability (r = 0.63 for interest and r = 0.71 for insight for a period of 6-7 weeks). Convergent and discriminant validity has been established by substantial correlations with related constructs such as self-consciousness, emotional intelligence, and alexithymia (negative) and low correlations with the basic personality traits of neuroticism and extraversion [5]. 2.3. Procedure On the third day of the admission at the CPR, the patients were personally approached by the second author for participation in the study. They were provided with information, and an informed consent form was signed, before the Balanced Index of Psychological Mindedness was completed. The SCL-90 was already completed before admission, as it was sent to the patients' homes with the request to fill them out and bring them to the intake at admission. The same questionnaires were completed at the day of discharge. 3. Results Of the 110 participants at baseline, 5 did not complete the baseline questionnaires. Mean length of treatment was 10.61 weeks (SD, 2.23), which started on average 12.81 days (SD, 8.09) after intake. Psychological mindedness (both interest and insight) were not associated with length of treatment (P N .10). Eighty-six individuals of the 110 who were approached for participation completed questionnaires at both time points. The group of noncompleters included 8 patients who prematurely left the center for another institution because of a crisis. The completers did not differ from those not completing the questionnaires on any of the demographic and baseline clinical variables, including baseline SCL and PM scores (all P N .10). A repeated-measures multivariate analysis of variance revealed a significant decrease on all psychological symptom subscales (Table 1; omnibus F8,78 = 15.16; P b .001; η2 = Table 1 Pre- and posttreatment means and standard deviations of psychological symptoms (SCL-90) and PM (Balanced Index of Psychological Mindedness)
Phobic anxiety Anxiety Depression Somatization Insufficiency Paranoid ideation Hostility Sleeping problems PM interest PM insight ⁎⁎⁎ P b .001.
Pretreatment
Posttreatment Partial η
F statistic
13.68 (6.26) 27.83 (8.94) 53.08 (12.15) 30.20 (9.33) 26.24 (6.29) 43.11 (12.77) 11.89 (4.94) 10.56 (3.67) 16.44 (5.34) 13.13 (5.74)
10.70 (4.93) 19.05 (8.41) 34.18 (14.30) 21.58 (8.42) 18.79 (7.15) 32.05 (11.17) 8.55 (3.24) 7.51 (3.42) 19.32 (5.97) 18.51 (5.93)
24.96⁎⁎⁎ 73.82⁎⁎⁎ 125.13⁎⁎⁎ 69.52⁎⁎⁎ 78.81⁎⁎⁎ 54.38⁎⁎⁎ 43.41⁎⁎⁎ 53.81⁎⁎⁎ 21.09⁎⁎⁎ 80.47⁎⁎⁎
2
0.23 0.46 0.59 0.45 0.48 0.39 0.34 0.39 0.20 0.49
0.61). Psychological mindedness increased over the course of the intervention (Table 1; omnibus F2,84 = 43.54; P b .001; η2 = 0.51), which was the case for both interest (F1,85 = 21.09; P b .001; partial η2 = 0.20) and insight (F1,85 = 80.47; P b .001; partial η2 = 0.49). To diminish type I error, a multivariate analysis of covariance with change scores (post and pretreatment) of the 8 psychological symptoms scales as outcome variables was conducted to examine whether baseline PM may be associated with a decrease in psychological symptoms, including baseline psychological symptoms score—total SCL-90 score—as a covariate. As none of the variables sex, age, education (at least midlevel vocational vs. lower), job status (job vs no job), previous psychological treatment (yes vs no), use of psychotropics (yes vs no), diagnosis (mood disorder vs other, in view of the small n of the other groups), or length of treatment were associated with symptom change (all P N .20) in a preliminary analysis, they were omitted from the final analysis (inclusion did not change the results). The omnibus test revealed only one significant effect, of baseline psychological symptoms score (F8,73 = 4.93; P b .001; partial η2 = 0.35). Higher baseline scores were associated with a larger reduction in all 8 psychological domains (standardized β coefficient ranging from −.31 (P = .008) for sleeping problems to −.54 (P b .001) for paranoid ideation; Table 2). Interest and insight were not associated with symptom change (F b 1.0; P N .20; partial η2 b 0.10). An identical analysis was conducted with pre- to posttreatment change scores in PM (post minus pretreatment) instead of baseline scores as independent variables. Besides the same effect of baseline psychological symptoms (F8,70 = 4.80; P b .001; partial η2 = 0.35), an effect appeared of change in insight (F8,70 = 3.55; P b .005; partial η2 = 0.29) but not interest (F8,70 = 0.56; P N .20; partial η2 = 0.06). Univariate tests showed that a larger increase in insight was associated with a larger decrease in all but 2 psychological symptom scales (Table 2).
Table 2 Summary of standardized β coefficients predicting change in psychological symptoms scores Outcome variable
Baseline SCL-90
Baseline Baseline Increase of Increase of interest insight interest insight
Phobic anxiety Anxiety Depression Somatization Insufficiency Paranoid ideation Hostility Sleeping problems
−0.41⁎⁎⁎ −0.52⁎⁎⁎ −0.47⁎⁎⁎ −0.51⁎⁎⁎ −0.36⁎⁎ −0.54⁎⁎⁎
−0.20 – – – – –
−0.46⁎⁎⁎ – −0.31⁎⁎ –
– – – – – –
– – – – – –
−0.28⁎ −0.33⁎⁎ −0.31⁎⁎ −0.37⁎⁎⁎ −0.39⁎⁎⁎ –
– –
– –
– −0.30⁎⁎
Beta coefficients less than .20 are not shown. ⁎ P b .05. ⁎⁎ P b .01. ⁎⁎⁎ P b .001.
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4. Discussion The purpose of this study was to investigate if PM is associated with therapy outcomes in a psychiatric patient population with heterogeneous psychological symptoms. Although no significant effects were found for baseline PM, PM increased over the course of the therapy, and a larger increase in the insight component of PM was associated with a larger decrease in most psychological symptoms. This effect was present while taking into account baseline scores of psychological symptoms and while none of the other baseline demographic and clinical characteristics showed an association with symptom change. To the best of our knowledge, this is the first study to examine and show such association between PM enhancement and therapy outcome. Several studies have been performed on the inversely related construct of alexithymia, the person characteristic consisting of a poor insight into ones emotions, a poor verbal ability in expressing feelings, and a cognitive style with a focus on environmental details rather than psychological processes [23]. A decrease in alexithymia has been reported in several studies on diverse patient groups, including depression [18,20], bulimia nervosa [17], and obsessivecompulsive disorder [24], although in 2 other studies, no change was observed [19,25]. In 3 of 4 studies reporting a decrease in alexithymia, this decrease was associated with a decrease in symptoms [17,18,20]. This is in line with the first results on the role of change in PM in therapy outcome presented here. That the association between increase in PM and decrease in symptoms was found for the insight facet of PM, not interest, might be explained by the higher scores on the latter facet at baseline and a smaller change over the course of the intervention. This might be due to the possibility that participants of a psychotherapy program, especially in an inpatient setting, are already at baseline interested to work on their psychological problems, implying a readiness for introspection. The associations between change in insight and decrease in symptoms were found for most SCL subscales, except paranoid ideation and hostility. We do not know the reason for absence of associations with these subscales. We can only speculate that perhaps this might be related with the fact that the focus of these subscales is largely on cognitions regarding other people not cognitions about one's own states and processes. The other subscales are more focused on the latter, which is also true for the instrument used to measure insight in the present study. The association found between increase in insight and decrease in symptoms may be due to the former causing the latter, which however cannot be inferred from the present data assessing both variables at only two identical time points. For such a conclusion, a randomized trial is needed, explicitly changing insight in one group of clients but not in the other, control, group. A causal role of PM in relieving psychological symptoms is plausible though, both from a theoretical point of view and from the few indirect empirical
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findings. Theoretically, because PM is associated with enhanced awareness of internal psychological states, processes, and needs, it contributes to adequate affect regulation and thus psychological well-being [5,14]. Correlational support is provided in the form of evidence showing that a higher PM is associated with lower psychological symptoms scores in a student sample [16] as well as a psychiatric patient sample [5]. In addition, therapy based on the enhancement of PM (there called mentalization) has beneficial effects in certain patient groups, such as patients with a borderline personality disorder [26]. The present results also provide evidence that PM is not a fixed personality characteristic but can be changed in the course of significant events, such as psychotherapy. We must note that because of the lack of a control group we cannot attribute the change in PM to psychotherapy. A controlled study is needed. Nevertheless, the finding that an increase in insight is associated with a decrease in symptoms is intriguing and calls for further study. Regarding baseline PM, no effects were found, which was not expected and which is not in line with some earlier findings [8-10]. Our findings might have been due to a floor effect in this particular group of patients of whom 95% have had psychological treatment before, which possibly had advanced their level of PM to a degree sufficient to profit from the current program, involving mainly cognitive behavioral therapy. Earlier studies finding positive effects of PM were largely based on more insight-oriented therapy, for which higher levels of PM may be required [6]. Our respondents did have significantly lower PM scores on both subscales compared to people from the general population [5]. At least in the present context, the data suggest that a relatively low baseline PM may not hinder cognitive behavioral therapy. However, also earlier studies have not unequivocally shown that baseline PM has a positive effect on therapy results, some studies reporting no associations with outcome [3,11]. Discrepancies may have been due to (1) different patient groups studied; (2) different measuring instruments used to assess PM, most of which had psychometric shortcomings such as unclear factor structure [27] and unclear content validity [5,27]; and (3) assessing PM as a unidimensional construct. In the present study, 2 PM dimensions were assessed that clearly showed differential relations with therapy outcome. This is in line with our finding that baseline PM was also not associated with the length of treatment, which was found in some of the earlier studies focused on insight-oriented psychodynamic therapy [3,6]. 4.1. Limitations of the present study The lack of a control group is a clear limitation of the present study, preventing conclusions regarding the effectiveness of the therapies applied in this setting, despite that effect sizes in the treatment group were large. However,
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testing the effectiveness was not the aim of the present investigation, the aim being the examination of associations between PM and change in symptoms in this group of psychiatric inpatients receiving psychotherapy. Some additional limitations may be identified. The sample consisted of patients with various diagnoses. Because the number of patients per diagnosis category was not large enough, we could not examine a potential moderating effect of diagnosis on the results obtained. Because the present sample was largely residential, using psychotropics, and having received some form of mental care before, the question of generalizability to other kinds of samples should be examined in future investigations. Regarding the associations found between increase in insight and decrease in symptoms, future investigations should use (a) more measurement time points to be able to monitor the dynamics of the relative changes in both PM and psychological symptoms, which will shed light on the question how the changes in both sets of variables relate to each other in the course of the therapy, and (b) a randomized design with a well-chosen control group, enhancing PM explicitly in one but not in the other group. This will make inferences regarding the potential causal role of change in insight possible. References [1] Appelbaum SA. Psychological-mindedness: word, concept and essence. Int J Psychoanal 1973;54:35-46. [2] Conte HR, Buckley P, Picard S, Karasu TB. Relationships between psychological mindedness and personality traits and ego functioning: validity studies. Compr Psychiatry 1995;36:11-7. [3] McCallum M, Piper WE. The Psychological Mindedness Assessment Procedure. Psychol Assess 1990;2:412. [4] Hall JA. Psychological-mindedness: a conceptual model. Am J Psychother 1992;46:131-40. [5] Nyklíček I, Denollet J. Development and evaluation of the Balanced Index of Psychological Mindedness (BIPM). Psychol Assess 2009;21: 32-44. [6] Conte HR, Plutchik R, Jung BB, Picard S, Karasu TB, Lotterman A. Psychological mindedness as a predictor of psychotherapy outcome: a preliminary report. Compr Psychiatry 1990;31:426-31. [7] McCallum M, Piper WE. Psychological mindedness: a contemporary understanding. Mahwah (NJ): Lawrence Erlbaum; 1997. [8] Piper WE, Joyce AS, McCallum M, Azim HF. Interpretive and supportive forms of psychotherapy and patient personality variables. J Consult Clin Psychol 1998;66:558-67.
[9] Piper WE, Joyce AS, Rosie JS, Azim HF. Psychological mindedness, work, and outcome in day treatment. Int J Group Psychother 1994;44: 291-311. [10] Piper WE, McCallum M, Joyce AS, Rosie JS, Ogrodniczuk JS. Patient personality and time-limited group psychotherapy for complicated grief. Int J Group Psychother 2001;51:525-52. [11] McCallum M, Piper WE, O'Kelly J. Predicting patient benefit from a group-oriented, evening treatment program. Int J Group Psychother 1997;47:291-314. [12] Beitel M, Ferrer E, Cecero JJ. Psychological mindedness and cognitive style. J Clin Psychol 2004;60:567-82. [13] Björgvinsson T, Hart J. Cognitive behavioral therapy promotes mentalizing. In: Allen JG, Fonagy P, editors. Handbook of mentalization-based treatment. Chichester, UK: Wiley; 2006. p. 157-70. [14] Fonagy P. The mentalization-focused approach to social development. In: Allen JG, Fonagy P, editors. Handbook of mentalization-based treatment. Chichester, UK: Wiley; 2006. p. 53-100. [15] Cecero JJ, Beitel M, Prout T. Exploring the relationships among early maladaptive schemas, psychological mindedness and self-reported college adjustment. Psychol Psychother 2008;81:105-18. [16] Trudeau KJ, Reich R. Correlates of psychological mindedness. Pers Individ Differ 1995;19:699-704. [17] de Groot JM, Rodin G, Olmsted MP. Alexithymia, depression, and treatment outcome in bulimia nervosa. Compr Psychiatry 1995;36: 53-60. [18] Ozsahin A, Uzun O, Cansever A, Gulcat Z. The effect of alexithymic features on response to antidepressant medication in patients with major depression. Depress Anxiety 2003;18:62-6. [19] Rufer M, Hand I, Braatz A, Alsleben H, Fricke S, Peter H. A prospective study of alexithymia in obsessive-compulsive patients treated with multimodal cognitive-behavioral therapy. Psychother Psychosom 2004;73:101-6. [20] Spek V, Nyklíček I, Cuijpers P, Pop V. Alexithymia and cognitive behaviour therapy outcome for subthreshold depression. Acta Psychiatr Scand 2008;118:164-7. [21] Derogatis LR, Lipman RS, Covi L. SCL-90: an outpatient psychiatric rating scale–preliminary report. Psychopharmacol Bull 1973;9:13-28. [22] Arrindell WA, Ettema JHM. Handleiding bij een multidimensionele psychopathologie-indicator (Manual of a multidimensional indicator of psychopathology). Lisse, Netherlands: Swets; 2003. [23] Taylor GJ, Bagby M, Parker J. Psychological-mindedness and the alexithymia construct. Br J Psychiatry 1989;154:731-2. [24] Rufer M, Ziegler A, Alsleben H, Fricke S, Ortmann J, Bruckner E, et al. A prospective long-term follow-up study of alexithymia in obsessive-compulsive disorder. Compr Psychiatry 2006;47:394-8. [25] Schmidt U, Jiwany A, Treasure J. A controlled study of alexithymia in eating disorders. Compr Psychiatry 1993;34:54-8. [26] Bateman AW, Fonagy P. Mentalization-based treatment of BPD. J Personal Disord 2004;18:36-51. [27] Shill MA, Lumley MA. The Psychological Mindedness Scale: factor structure, convergent validity and gender in a non-psychiatric sample. Psychol Psychother Theor Res Pract 2002;75:131-50.
Comprehensive Psychiatry 51 (2010) 492 – 496 www.elsevier.com/locate/comppsych
Psychological mindedness and symptom reduction after psychotherapy in a heterogeneous psychiatric sample Ivan Nyklíčeka,⁎, Daphne Majoora , Pierre A.A.M. Schalkenb a
Center of Research on Psychology in Somatic disease (CoRPS), Department of Medical Psychology, Tilburg University, Postbox 90153, 5000 LE Tilburg, Netherlands b Center for Psychological Recovery, Berlicumseweg 8, 5248 NT Rosmalen, Netherlands
Abstract Background: Psychological mindedness (PM) has been claimed to be beneficial for outcome of various forms of psychotherapy. The purpose of this study was to investigate the influence of PM on the therapy results of a psychiatric patient sample with heterogeneous psychological symptoms. Methods: Participants were 110 patients with different diagnoses who were hospitalized at the Center for Psychological Recovery (Rosmalen, Netherlands). Before and after treatment, they were asked to complete the Balanced Index of Psychological Mindedness and the Symptom Checklist-90. Results: Baseline PM was not associated with a decrease in symptom scores (F8,73 b 1.0; P N .20; partial η2 b 0.10). However, PM increased over the course of the intervention (F2,84 = 43.54; P b .001; η2 = 0.51) and larger increases in the insight component of PM were associated with larger decreases on 6 of 8 symptom scores (F8,70 = 3.55; P b .005; partial η2 = 0.29). Conclusions: These results suggest that although a high PM is not a prerequisite for successful cognitive behavioral therapy, an increase in insight is associated with better outcome. © 2010 Elsevier Inc. All rights reserved.
1. Introduction Appelbaum [1] was one of the first who used the term psychological mindedness (PM). Appelbaum [1] stated that PM is “a person's insight to see relationships among thoughts, feelings, and actions, with the goal of learning the meaning and causes of his experiences and behavior” (p. 36). Other definitions have also been provided by several other authors, broadening the definition according to the specific views and contexts of the authors (eg, by Conte et al [2] and McCallum and Piper [3]). In line with the attempt by Hall [4] to extract the core dimensions of PM, we define the core of PM as the “interest and ability to be in touch with and reflect upon one's psychological states and processes” [5]. It has been claimed that PM is a prerequisite for positive outcome of psychotherapy. For instance, PM has been stated ⁎ Corresponding author. Department of Medical Psychology, Tilburg University, PO Box 90153, 5000 LE Tilburg, The Netherlands. Tel.: +31 13 4662391; fax: +31 13 4662370. E-mail address: [email protected] (I. Nyklíček). 0010-440X/$ – see front matter © 2010 Elsevier Inc. All rights reserved. doi:10.1016/j.comppsych.2010.02.004
to imply a willingness to commit oneself to the therapeutic alliance and to a basic agreement with the values and norms implicit of psychotherapy [6]. It has been shown that PM is related with a higher commitment to psychotherapy, as reflected in a higher number of attended sessions and stronger involvement in the therapy process [3,6,7]. Some of the few empirical studies report a beneficial effect of baseline PM on improvement after several forms of psychotherapy [8-10]. For instance, Piper et al (1998) [8] revealed a direct positive association between baseline PM and therapy outcome for interpretative and supporting therapy in individuals with different diagnoses. However, some studies did not obtain relationships between PM and therapy outcome. McCallum and Piper (1997) [11] reported that PM had a positive influence on the amount of work invested in the therapy sessions for three different personality disorders, but only the amount of work, not PM, was related to outcome [3]. The discrepancy between studies finding positive results and those not obtaining a significant effect of PM may be due to several methodological issues, such as the different patient samples and different measurement instruments used
I. Nyklíček et al. / Comprehensive Psychiatry 51 (2010) 492–496
to assess PM. Most of the previous instruments used to measure PM have psychometric shortcomings, mainly unclear content validity or poor factorial validity [5]. In addition, previous studies have approached PM as a unitary construct, whereas it has been argued that PM is multidimensional [4]. Various aspects of PM, such as the interest in one's inner psychological states and processes and the ability to gain insight into these phenomena may be differentially related to outcome of psychotherapy [4,5], precluding clear associations when PM is approached in a unidimensional way. More generally, PM is conceptualized as a crucial factor in the development of adaptive emotion regulation, which in its turn is essential for a person's well-being [12-15]. Indeed, PM has been reported to be associated with a more adaptive cognitive style [12], and a higher level of wellbeing in a sample of healthy students [16], as well as in a sample of psychiatric patients [5]. In addition, one may expect psychotherapy to have a positive influence on PM, especially an enhancement of insight into psychological states and processes as a result of the emphasis in most if not all forms of psychotherapy on the importance of introspection and self-monitoring for adequate emotion regulation [13,14]. Extrapolating this line of thought, one may expect an increase in PM, as a result of psychotherapy, to be associated with a decrease of psychological symptoms and an increase in psychological well-being. However, up to date, neither effects of psychotherapy on levels of PM nor the association of a putative change in PM with change in symptoms have been investigated, although previous work has been conducted on the inversely related concept of alexithymia. The results of those studies tend to show a decrease of alexithymia over the treatment period [17-20], whereas three studies reported an association between decrease in alexithymia and decrease in symptoms in psychiatric patients [17,18,20]. Therefore, the aims of the present study were (1) to examine if PM increases during psychotherapy, (2) to determine whether both pretherapy scores of PM and the putative increase in PM during therapy are associated with a decrease in symptom levels from pretreatment to posttreatment, and (3) to investigate the potentially differential effects regarding the aforementioned relations of the two core dimensions of PM: interest and ability to reflect upon one's psychological states and processes.
2. Methods 2.1. Participants Participants were patients who were admitted to the Center for Psychological Recovery (CPR) at Rosmalen, the Netherlands, for a period of 6 to 12 weeks. The weekends were spent at home. The length of the treatment was determined by the diagnosis, the course of the treatment, and
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the possibility of hospitalization (patients often prefer to stay for some time after inpatient treatment). The CPR offers assistance to adults with a variety of personal problems that may be associated with the home or work situation. Most patients have symptoms of depression, anxiety, or burnout. Patients having addiction problems, severe psychiatric, or personality disorders are not admitted. All 110 patients who had their intake between August 2005 and June 2006 agreed to participate in this study: 27 men (24.2%) and 83 women (75.8%) in the age between 23 and 71 years (mean age, 45.3 years; SD, 9.8). Of these patients, 86 (78.2%) completed both baseline and posttreatment questionnaires and were included in the analyses. Main reasons for not completing were leaving the center to another institution after a crisis (n = 8) and reluctance to complete the posttreatment questionnaires. Of the 86 completers, 67 (77.9%) were women, 51 (59.3%) had a partner, 59 (68.6%) had at least midlevel vocational education or higher, 41 (47.7%) had a paid job, 55 (64.0%) were using psychotropic medication (all antidepressants or tranquillizers), and 81 (95.3%) have had some form of mental health care previously. Mean age was 45.1 years (SD, 9.9). Patients received the following Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, diagnoses: mood disorder (45.3%), anxiety disorders (9.3%), adjustment disorder (18.6%), and other diagnoses (26.8%). All patients received cognitive behavioral therapy techniques for their problems and participated in the study after providing a written informed consent. The study was approved by the Review Committee of the participating institute (Center for Psychological Recovery at Rosmalen, the Netherlands). 2.2. Measurements Psychological symptoms were measured by the Symptom Check List-90 (SCL-90; [21]). It estimates the present psychopathologic symptoms in 8 dimensions: anxiety, phobic anxiety, depression, somatization, paranoid ideation and interpersonal sensitivity, insufficiency of thinking and behavior, sleeping problems, and hostility. The SCL-90 is a self-report scale consisting of 90 items, which are answered on a 5-point Likert scale from “not at all” (score 1) to “very much” (score 5). The Dutch version of the SCL-90 has a good to excellent internal consistency with the most Cronbach α values above .80. The test-retest reliability is between 0.73 and 0.97, and also, the content validity and criterion validity are satisfactory [22]. Psychological mindedness was assessed using the Balanced Index of Psychological Mindedness ([5]). It is a self-report questionnaire consisting of 14 items, which are answered on a 5-point Likert scale raging from “strongly disagree” (score 1) to “strongly agree” (score 5). The scale has 2 subscales of 7 items: interest in one's internal psychological phenomena and insight in these phenomena, according to the theoretical model by Hall (1992) [4]. Internal consistency of the subscales is adequate (Cronbach
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α = .85 for interest and .76 for insight), as well as the testretest reliability (r = 0.63 for interest and r = 0.71 for insight for a period of 6-7 weeks). Convergent and discriminant validity has been established by substantial correlations with related constructs such as self-consciousness, emotional intelligence, and alexithymia (negative) and low correlations with the basic personality traits of neuroticism and extraversion [5]. 2.3. Procedure On the third day of the admission at the CPR, the patients were personally approached by the second author for participation in the study. They were provided with information, and an informed consent form was signed, before the Balanced Index of Psychological Mindedness was completed. The SCL-90 was already completed before admission, as it was sent to the patients' homes with the request to fill them out and bring them to the intake at admission. The same questionnaires were completed at the day of discharge. 3. Results Of the 110 participants at baseline, 5 did not complete the baseline questionnaires. Mean length of treatment was 10.61 weeks (SD, 2.23), which started on average 12.81 days (SD, 8.09) after intake. Psychological mindedness (both interest and insight) were not associated with length of treatment (P N .10). Eighty-six individuals of the 110 who were approached for participation completed questionnaires at both time points. The group of noncompleters included 8 patients who prematurely left the center for another institution because of a crisis. The completers did not differ from those not completing the questionnaires on any of the demographic and baseline clinical variables, including baseline SCL and PM scores (all P N .10). A repeated-measures multivariate analysis of variance revealed a significant decrease on all psychological symptom subscales (Table 1; omnibus F8,78 = 15.16; P b .001; η2 = Table 1 Pre- and posttreatment means and standard deviations of psychological symptoms (SCL-90) and PM (Balanced Index of Psychological Mindedness)
Phobic anxiety Anxiety Depression Somatization Insufficiency Paranoid ideation Hostility Sleeping problems PM interest PM insight ⁎⁎⁎ P b .001.
Pretreatment
Posttreatment Partial η
F statistic
13.68 (6.26) 27.83 (8.94) 53.08 (12.15) 30.20 (9.33) 26.24 (6.29) 43.11 (12.77) 11.89 (4.94) 10.56 (3.67) 16.44 (5.34) 13.13 (5.74)
10.70 (4.93) 19.05 (8.41) 34.18 (14.30) 21.58 (8.42) 18.79 (7.15) 32.05 (11.17) 8.55 (3.24) 7.51 (3.42) 19.32 (5.97) 18.51 (5.93)
24.96⁎⁎⁎ 73.82⁎⁎⁎ 125.13⁎⁎⁎ 69.52⁎⁎⁎ 78.81⁎⁎⁎ 54.38⁎⁎⁎ 43.41⁎⁎⁎ 53.81⁎⁎⁎ 21.09⁎⁎⁎ 80.47⁎⁎⁎
2
0.23 0.46 0.59 0.45 0.48 0.39 0.34 0.39 0.20 0.49
0.61). Psychological mindedness increased over the course of the intervention (Table 1; omnibus F2,84 = 43.54; P b .001; η2 = 0.51), which was the case for both interest (F1,85 = 21.09; P b .001; partial η2 = 0.20) and insight (F1,85 = 80.47; P b .001; partial η2 = 0.49). To diminish type I error, a multivariate analysis of covariance with change scores (post and pretreatment) of the 8 psychological symptoms scales as outcome variables was conducted to examine whether baseline PM may be associated with a decrease in psychological symptoms, including baseline psychological symptoms score—total SCL-90 score—as a covariate. As none of the variables sex, age, education (at least midlevel vocational vs. lower), job status (job vs no job), previous psychological treatment (yes vs no), use of psychotropics (yes vs no), diagnosis (mood disorder vs other, in view of the small n of the other groups), or length of treatment were associated with symptom change (all P N .20) in a preliminary analysis, they were omitted from the final analysis (inclusion did not change the results). The omnibus test revealed only one significant effect, of baseline psychological symptoms score (F8,73 = 4.93; P b .001; partial η2 = 0.35). Higher baseline scores were associated with a larger reduction in all 8 psychological domains (standardized β coefficient ranging from −.31 (P = .008) for sleeping problems to −.54 (P b .001) for paranoid ideation; Table 2). Interest and insight were not associated with symptom change (F b 1.0; P N .20; partial η2 b 0.10). An identical analysis was conducted with pre- to posttreatment change scores in PM (post minus pretreatment) instead of baseline scores as independent variables. Besides the same effect of baseline psychological symptoms (F8,70 = 4.80; P b .001; partial η2 = 0.35), an effect appeared of change in insight (F8,70 = 3.55; P b .005; partial η2 = 0.29) but not interest (F8,70 = 0.56; P N .20; partial η2 = 0.06). Univariate tests showed that a larger increase in insight was associated with a larger decrease in all but 2 psychological symptom scales (Table 2).
Table 2 Summary of standardized β coefficients predicting change in psychological symptoms scores Outcome variable
Baseline SCL-90
Baseline Baseline Increase of Increase of interest insight interest insight
Phobic anxiety Anxiety Depression Somatization Insufficiency Paranoid ideation Hostility Sleeping problems
−0.41⁎⁎⁎ −0.52⁎⁎⁎ −0.47⁎⁎⁎ −0.51⁎⁎⁎ −0.36⁎⁎ −0.54⁎⁎⁎
−0.20 – – – – –
−0.46⁎⁎⁎ – −0.31⁎⁎ –
– – – – – –
– – – – – –
−0.28⁎ −0.33⁎⁎ −0.31⁎⁎ −0.37⁎⁎⁎ −0.39⁎⁎⁎ –
– –
– –
– −0.30⁎⁎
Beta coefficients less than .20 are not shown. ⁎ P b .05. ⁎⁎ P b .01. ⁎⁎⁎ P b .001.
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4. Discussion The purpose of this study was to investigate if PM is associated with therapy outcomes in a psychiatric patient population with heterogeneous psychological symptoms. Although no significant effects were found for baseline PM, PM increased over the course of the therapy, and a larger increase in the insight component of PM was associated with a larger decrease in most psychological symptoms. This effect was present while taking into account baseline scores of psychological symptoms and while none of the other baseline demographic and clinical characteristics showed an association with symptom change. To the best of our knowledge, this is the first study to examine and show such association between PM enhancement and therapy outcome. Several studies have been performed on the inversely related construct of alexithymia, the person characteristic consisting of a poor insight into ones emotions, a poor verbal ability in expressing feelings, and a cognitive style with a focus on environmental details rather than psychological processes [23]. A decrease in alexithymia has been reported in several studies on diverse patient groups, including depression [18,20], bulimia nervosa [17], and obsessivecompulsive disorder [24], although in 2 other studies, no change was observed [19,25]. In 3 of 4 studies reporting a decrease in alexithymia, this decrease was associated with a decrease in symptoms [17,18,20]. This is in line with the first results on the role of change in PM in therapy outcome presented here. That the association between increase in PM and decrease in symptoms was found for the insight facet of PM, not interest, might be explained by the higher scores on the latter facet at baseline and a smaller change over the course of the intervention. This might be due to the possibility that participants of a psychotherapy program, especially in an inpatient setting, are already at baseline interested to work on their psychological problems, implying a readiness for introspection. The associations between change in insight and decrease in symptoms were found for most SCL subscales, except paranoid ideation and hostility. We do not know the reason for absence of associations with these subscales. We can only speculate that perhaps this might be related with the fact that the focus of these subscales is largely on cognitions regarding other people not cognitions about one's own states and processes. The other subscales are more focused on the latter, which is also true for the instrument used to measure insight in the present study. The association found between increase in insight and decrease in symptoms may be due to the former causing the latter, which however cannot be inferred from the present data assessing both variables at only two identical time points. For such a conclusion, a randomized trial is needed, explicitly changing insight in one group of clients but not in the other, control, group. A causal role of PM in relieving psychological symptoms is plausible though, both from a theoretical point of view and from the few indirect empirical
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findings. Theoretically, because PM is associated with enhanced awareness of internal psychological states, processes, and needs, it contributes to adequate affect regulation and thus psychological well-being [5,14]. Correlational support is provided in the form of evidence showing that a higher PM is associated with lower psychological symptoms scores in a student sample [16] as well as a psychiatric patient sample [5]. In addition, therapy based on the enhancement of PM (there called mentalization) has beneficial effects in certain patient groups, such as patients with a borderline personality disorder [26]. The present results also provide evidence that PM is not a fixed personality characteristic but can be changed in the course of significant events, such as psychotherapy. We must note that because of the lack of a control group we cannot attribute the change in PM to psychotherapy. A controlled study is needed. Nevertheless, the finding that an increase in insight is associated with a decrease in symptoms is intriguing and calls for further study. Regarding baseline PM, no effects were found, which was not expected and which is not in line with some earlier findings [8-10]. Our findings might have been due to a floor effect in this particular group of patients of whom 95% have had psychological treatment before, which possibly had advanced their level of PM to a degree sufficient to profit from the current program, involving mainly cognitive behavioral therapy. Earlier studies finding positive effects of PM were largely based on more insight-oriented therapy, for which higher levels of PM may be required [6]. Our respondents did have significantly lower PM scores on both subscales compared to people from the general population [5]. At least in the present context, the data suggest that a relatively low baseline PM may not hinder cognitive behavioral therapy. However, also earlier studies have not unequivocally shown that baseline PM has a positive effect on therapy results, some studies reporting no associations with outcome [3,11]. Discrepancies may have been due to (1) different patient groups studied; (2) different measuring instruments used to assess PM, most of which had psychometric shortcomings such as unclear factor structure [27] and unclear content validity [5,27]; and (3) assessing PM as a unidimensional construct. In the present study, 2 PM dimensions were assessed that clearly showed differential relations with therapy outcome. This is in line with our finding that baseline PM was also not associated with the length of treatment, which was found in some of the earlier studies focused on insight-oriented psychodynamic therapy [3,6]. 4.1. Limitations of the present study The lack of a control group is a clear limitation of the present study, preventing conclusions regarding the effectiveness of the therapies applied in this setting, despite that effect sizes in the treatment group were large. However,
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testing the effectiveness was not the aim of the present investigation, the aim being the examination of associations between PM and change in symptoms in this group of psychiatric inpatients receiving psychotherapy. Some additional limitations may be identified. The sample consisted of patients with various diagnoses. Because the number of patients per diagnosis category was not large enough, we could not examine a potential moderating effect of diagnosis on the results obtained. Because the present sample was largely residential, using psychotropics, and having received some form of mental care before, the question of generalizability to other kinds of samples should be examined in future investigations. Regarding the associations found between increase in insight and decrease in symptoms, future investigations should use (a) more measurement time points to be able to monitor the dynamics of the relative changes in both PM and psychological symptoms, which will shed light on the question how the changes in both sets of variables relate to each other in the course of the therapy, and (b) a randomized design with a well-chosen control group, enhancing PM explicitly in one but not in the other group. This will make inferences regarding the potential causal role of change in insight possible. References [1] Appelbaum SA. Psychological-mindedness: word, concept and essence. Int J Psychoanal 1973;54:35-46. [2] Conte HR, Buckley P, Picard S, Karasu TB. Relationships between psychological mindedness and personality traits and ego functioning: validity studies. Compr Psychiatry 1995;36:11-7. [3] McCallum M, Piper WE. The Psychological Mindedness Assessment Procedure. Psychol Assess 1990;2:412. [4] Hall JA. Psychological-mindedness: a conceptual model. Am J Psychother 1992;46:131-40. [5] Nyklíček I, Denollet J. Development and evaluation of the Balanced Index of Psychological Mindedness (BIPM). Psychol Assess 2009;21: 32-44. [6] Conte HR, Plutchik R, Jung BB, Picard S, Karasu TB, Lotterman A. Psychological mindedness as a predictor of psychotherapy outcome: a preliminary report. Compr Psychiatry 1990;31:426-31. [7] McCallum M, Piper WE. Psychological mindedness: a contemporary understanding. Mahwah (NJ): Lawrence Erlbaum; 1997. [8] Piper WE, Joyce AS, McCallum M, Azim HF. Interpretive and supportive forms of psychotherapy and patient personality variables. J Consult Clin Psychol 1998;66:558-67.
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