Gambling disorder presents complex clinical challenges that often extend beyond the reach of single-model psychotherapeutic approaches. This case study illustrates a sequentially integrated treatment combining cognitive-behavioral therapy and time-limited dynamic psychotherapy for a middle-aged man with severe gambling disorder and a history of substance use disorders in sustained remission. Cognitive-behavioral therapy was initially implemented as a first-line, empirically validated intervention targeting gambling-related cognitions, behavioral reinforcement patterns, and self-efficacy. Despite high engagement and skill acquisition, the client demonstrated escalating relapse severity and persistent difficulty sustaining abstinence. A collaborative clinical reassessment led to a transition toward time-limited dynamic psychotherapy, informed by object relations theory, to address relational vulnerabilities and the function of gambling as a substitute attachment object. Through identification and disruption of cyclical maladaptive patterns within the therapeutic relationship, the client achieved sustained abstinence, significant reductions in gambling-related distortions, marked increases in self-efficacy, and improvements in mood and relational functioning maintained at follow-up. This case highlights the value of mechanism-sensitive sequential integration and underscores the importance of flexibility, reflexivity, and theoretical pluralism in the treatment of behavioral addictions.
Although psychotherapy research increasingly recognizes patients as active contributors to change, less attention has been given to patients' subjective experience of influencing the therapeutic process. Informed by control mastery theory, this cross-sectional survey examined patients' perceived capacity to influence psychotherapy and its associations with relational, process, and outcome variables. Participants were 364 adults (65.9% female; M-age = 34.7, SD = 11.2) who had received more than one session of psychotherapy through the U.K. National Health Service. Participants completed an online questionnaire assessing perceived patient influence (using the Client Influence Scale), therapeutic alliance, therapist responsiveness, therapeutic agency, psychological distress, and subjective evaluations of treatment. Greater perceived patient influence was moderately associated with stronger therapeutic alliance (r = .45), higher perceived therapist responsiveness (r = .44), greater therapeutic agency (r = .47), higher satisfaction (r = .38), greater perceived productivity (r = .39), and greater estimated change (r = .33), all p < .001. Regression analyses showed that perceived patient influence remained a significant independent predictor of all variables after controlling for psychological distress and the recency and duration of therapy, accounting for substantial incremental variance in core process variables (Delta R-2 = .12-.15) and smaller but robust variance in outcome evaluations (Delta R-2 = .05-.10). Overall, the findings indicate that patients' perceived capacity to influence psychotherapy represents a clinically meaningful, process-level dimension of engagement. Consistent with control mastery theory, perceived patient influence is closely linked to therapist responsiveness, the therapeutic alliance, and patient agency, underscoring its relevance for collaborative and attuned therapeutic processes despite the cross-sectional design.
The notion of common factors in psychotherapy emerged from observations that these processes are evidenced across diverse forms of healing, yet little research has examined how far they apply beyond psychotherapy. This study tests the applicability of common factors in help-seeking from 4 diverse helper groups: psychologists, medical practitioners, friends, and psychic practitioners. A sample of 734 adults (M age = 40.87 years) who sought help for stress or emotional problems completed measures of common factors and perceived outcomes after consulting a psychologist (n = 206), psychic (n = 131), medical practitioner (n = 212), or friend (n = 185). The emotional bond between participant and helper, expectancy of improvement, perceived credibility of the help, and engagement in therapeutic rituals each predicted perceived outcome across all helper groups. Furthermore, bond and ritual were unique predictors of perceived outcome within each group. A model of necessary and sufficient conditions for change showed that these factors were sufficient for positive outcome (i.e., the presence of all factors predicted better outcomes), but not necessary, with 41.7% of those not meeting all common-factor criteria reporting improvement nonetheless. Results suggest that common factors identified in psychotherapy research also operate in informal and nontraditional help-seeking contexts. These findings strengthen evidence for the core role of common factors in psychotherapy and expand our understanding of their broader applicability. Their apparent universality may offer opportunities for psychotherapists to apply these principles beyond the therapy room, informing community-based interventions to enhance public mental health.
Identifying personality disorder have historically relied on readily observable symptoms, often encouraging a top-down approach that prioritizes symptoms labeled as "problematic behaviors" over the internal struggles that give rise to them. This commentary explores a fundamental shift in the field: The move from static diagnostic description toward a more dynamic understanding of personality functioning. Drawing on contributions from this special issue, the authors argues that dimensional models of personality disorder provide a needed kinetic framework for clinical thinking. Within this framework, attention is redirected toward impairments of core capacities for self- and interpersonal functioning, commonly referred to as Criterion A. By focusing on identity, emotional coherence, and relational capacity, dimensional models bring diagnostic language closer to lived experience and to the processes targeted in psychotherapy. Rather than emphasizing behavioral control alone, this approach foregrounds the restoration of internal coherence and meaningful direction in life. Centering personality functioning in this way helps ensure that clinical practice remains focused on what ultimately matters most: The person behind the diagnosis.
This study uses Benjamin's structural analysis of social behavior (SASB) model to demonstrate ways in which a dimensional model of interpersonal and intrapsychic relating can be used in the diagnosis of diverse forms of personality disorder (PD). A clinical interview is used to elicit descriptions of relationship patterns with the self and others and is oriented to detect links between close attachment relationships and presenting problems. Benjamin (1996) offered a set of interpersonal prototypes for the PDs defined by the Diagnostic and Statistical Manual of Mental Disorders, noting that their comorbidity could be explained in large part by overlapping interpersonal features. Our investigation follows up on two related questions: (a) Can Benjamin's conceptualization of PDs be further operationalized and tested using SASB? and (b) Can SASB-defined copy process repetitions be used to identify common prototypes in patient narratives apart from the criteria used in the Diagnostic and Statistical Manual of Mental Disorders? Data from 93 adults from an inpatient psychiatric hospital, all of whom were diagnosed with PDs, were interviewed using Benjamin's case formulation method and coded for their interpersonal patterns. A method for comparing individual cases to each of Benjamin's prototypes was developed, and a Mantel test showed strong correspondence between expected and observed patterns of overlap. Separately, hierarchical cluster analysis identified clinically coherent groupings based on interpersonal and intrapersonal features. Results provide support for the coherence and validity of the SASB model as a dimensional method for defining and testing PD prototypes. The approach is distinct from other approaches in part by employing constructs with direct implications for clinical intervention.
While the clinical utility of the Alternative Diagnostic and Statistical Manual of Mental Disorders, fifth edition, Model for Personality Disorders (AMPD) is increasingly well established, research on how AMPD constructs change during psychotherapy remains limited. This study examines changes in personality dysfunction (Criterion A), pathological traits (Criterion B), and psychological symptoms over the course of 1 year of ongoing psychotherapy, using naturalistic data collected from private practice clinics. Data from 91 clients (72.5% women) across 34 therapists were collected at intake and 1 year later. Significant changes with small effect sizes were observed in global personality dysfunction and identity (Criterion A); negative affectivity, detachment, disinhibition, and psychoticism (Criterion B); and psychological symptoms. However, interpersonal pathology (Criterion A) did not significantly improve. Gender-moderated outcomes were found for participants with more severe baseline levels of personality dysfunction, with men showing more improvement than women. Criterion A and B contributed equally to predicting changes in psychological symptoms (Delta R-2 = .10), with improvements in identity and detachment as significant individual predictors. Some findings, most notably the differences in prognostic value across Criterion A elements and the malleability found for pathological traits, challenge widely accepted AMPD assumptions. Results are discussed bearing in mind the strengths and limitations of the study's naturalistic design. Public Health Significance Statement This article provides much-needed data on how dimensional personality constructs from the Alternative Diagnostic and Statistical Manual of Mental Disorders, fifth edition, Model for Personality Disorders change after 1 year of ongoing psychotherapy in an eclectic sample of private practice clients. The results shed light on some current debates regarding the Alternative Diagnostic and Statistical Manual of Mental Disorders, fifth edition, Model for Personality Disorders. They also demonstrate the feasibility of implementing dimensional assessment of personality pathology within the naturalistic framework of psychotherapy in private practice.
This commentary analyzes the contributions of the special issue on dimensional constructs of personality disorders, with a focus on their relevance for the integration of psychotherapeutic approaches. Dimensional constructs as targets of change, interpersonal processes in treatment, and implementation aspects are discussed. The articles illustrate how dimensional models inform prognosis, predict treatment response, and elucidate therapeutic mechanisms in different psychotherapeutic approaches. The commentary also discusses significance for the Brazilian context, where cross-cultural validation supports the applicability of dimensional instruments. Despite this, ongoing gaps in treatment access and variability in the clinical workforce may limit the broad adoption of these models in practice. Future research priorities include clinical trials that use dimensional outcome measures, longitudinal studies of patient trajectories, and cross-cultural investigations of implementation within diverse health care systems.
Routine outcome monitoring (ROM) is an important common factor in psychotherapy that can increase the effectiveness of psychotherapy and personalize patient-therapist matching. An International Consortium for Health Outcomes Measurement workgroup proposed a set of questionnaires for annual ROM for patients suffering personality disorders (PD). This data set was not validated. In addition, this set is extensive and time-consuming and therefore less applicable for frequent ROM. Therefore, the psychometric properties of the original item set was investigated in a sample of Dutch students earning course credits, and a brief version of the PD ROM set was developed, which was in line with the current views on PD's of the Alternative model of PD and the World Health Organization. The psychometric properties of this brief PD ROM questionnaire were investigated in a sample of students. The results showed that the psychometric properties of the original long International Consortium for Health Outcomes Measurement questionnaire set were poor, a six-factor structure instead of the purposed four-factor structure with a bad fit was found. The brief PD ROM questionnaire showed good psychometric properties and appears to be a reliable and valid instrument within this analog population. Further research in diverse clinical populations is needed to validate the brief PD ROM and ensure its reliability and usability in clinical practice. It demonstrated acceptable to good internal consistency and promising construct validity. A short ROM questionnaire that covers important health domains might ultimately provide a possibility for frequent monitoring of PD treatments, thereby increasing the effectiveness and efficiency of PD treatment.
Personality dimensions are not only enduring characteristics that distinguish clients from one another, they are also dynamic constructs that vary during psychotherapy sessions in ways that are informative for diagnosis, case formulation, and supervision. The interpersonal circumplex is an established personality assessment framework structured by dominance and warmth that can be used to distinguish personality disorder phenotypes from another and capture the dynamics of interpersonal processes, including psychotherapy. The Continuous Assessment of Interpersonal Dynamics (CAID) is an assessment method that records the client's and therapist's dominance and warmth every half second, creating time series that can be used to better understand therapeutic processes, including those known to be associated with certain orientations, therapeutic ruptures, alliance, and positive outcomes. In this article, we coded six psychotherapy sessions with three well-known therapists using CAID to demonstrate a three-level approach to understanding therapeutic processes. The first approach uses empirical parameters from CAID data to examine interpersonal processes quantitatively and compare sessions to normative interpersonal processes. The second approach uses graphical representations of therapy processes to identify clinically important moments and help clinicians and supervisors quickly identify the parts of sessions that are most important to reflect upon and discuss. The third and most common approach to discussions about therapy sessions involves the subjective narrative about what happened between the client and therapist. We discuss the potential of CAID to better understand therapy processes in challenging cases and in supervision, training, and research.
A discussion on eight papers is provided which explore the changeability of Criterion A and Criterion B of the Alternative Model of Personality Disorders according to the Diagnostic and Statistical Manual of Mental Disorders (Fifth edition; DSM-5). Data suggest that psychotherapy can produce meaningful change of both criteria and can serve as predictors of change. A dimensional case formulation based on the Alternative Model of Personality Disorders provides a suitable framework to guide selection of intervention modules and monitor therapy process. To deepen our understanding of change mechanisms multimethod approaches with frequent reassessments and experimental designs are required.
Objectives: The current project compares the effectiveness of cognitive reappraisal and needs identification interventions for working through lingering anger, bitterness, or resentment in response to interpersonal grievances. Method: Using an experimental, single therapy session design, 197 undergraduate participants (Study 1) completed a brief, self-guided online intervention involving either anger rumination (comparison condition), cognitive reappraisal, or the identification of unmet psychological needs. This design was replicated in a clinical sample of 31 adult participants (Study 2), who were recruited from local mental health clinics, utilizing in-person interventions. Outcomes consisted of changes in self-reported anger intensity, unfinished business, and unforgiveness. Results: Anger rumination produced little change in outcomes in the subclinical sample, whereas rumination exacerbated anger-related difficulties in the clinical sample. In both subclinical and clinical samples, cognitive reappraisal was associated with improvements in self-reported anger intensity, resolution, and unforgiveness. Needs identification was associated with reductions in unforgiveness in the subclinical sample but not in the clinical sample. Conclusions: The current project replicates and extends previous research by suggesting that cognitive reappraisal is more than just an emotion-regulation strategy-it is also a meaning-making strategy that reduces lingering feelings of anger toward intrapersonal resolution or forgiveness of interpersonal grievances. The expression of unmet psychological needs is a process of change that facilitates productive experiences of anger and should also be targeted by interventions across treatment approaches.
Despite its centrality in psychotherapy, state anxiety as a moment-to-moment dynamic phenomenon remains poorly operationalized, with no unified, validated framework for understanding and assessing it. Therapists still often rely on intuition or clients' subjective reports to infer momentary anxiety intensity, increasing the risk of misattunement and therapeutic rupture. To address this gap, we introduce a transtheoretical model that reconceptualizes in-session state anxiety as a graded continuum of dysregulation across neurovisceral, cognitive, clinical, and somatic domains. The model synthesizes the neurovisceral integration model (Thayer & Lane [2000, Journal of Affective Disorders, 61(3), 201-216]), Gross's process model of emotion regulation (Gross [1998, Review of General Psychology, 2(3), 271-299; 2015, Psychological Inquiry, 26(1), 130-137]; Gross & Ford [2023, Handbook of Emotion Regulation, Guilford Press]), and the somatic framework from intensive short-term dynamic psychotherapy (Frederickson [2013, Co-Creating Change: Effective Dynamic Therapy Techniques, Bch Fulfillment & Distribution]). This article reviews the theoretical background of state anxiety in psychotherapy, presents the three foundational frameworks and their unique contributions, elaborates on the model's five levels across multiple dimensions, and outlines potential applications alongside future directions for validation and clinical implementation.
This article explores how integrating predictive processing framework and control-mastery theory offers a novel account of how psychotherapy works. Predictive processing proposes that the brain continually generates predictions about sensory inputs based on prior experiences to anticipate and respond effectively to its environment. When actual experiences differ, prediction errors prompt updates to the brain's internal model of the world, thereby improving future predictions and supporting adaptive behavior. In cases of psychopathology, however, entrenched negative predictions may persist, offering temporary reduction in uncertainty despite being ultimately harmful. This short-term predictability and stability may outweigh change processes, leading to persistent distress. Yet, predictive processing leaves open the question of why some individuals seek therapy to challenge such beliefs, despite their bringing a semblance of security. Control-mastery theory complements predictive processing by emphasizing the patient's intrinsic motivation and active role in challenging and revising pathogenic beliefs through patient testing in psychotherapy. We argue that effective psychotherapy depends not only on the therapist's provision of experiences that generate salient prediction errors, but also on the patient's motivation and readiness to engage in revising deeply ingrained beliefs. Drawing on a clinical case of a woman in her 30s, we illustrate how early trauma shapes maladaptive generative models, constraining relational expectations. In therapy, attuned responses generate salient prediction errors, disconfirming maladaptive priors and updating generative models. Through implicit testing and integration of disconfirmatory experiences, the patient revises her internal predictive model, reducing maladaptive prediction errors and fostering therapeutic change.
Detached mindfulness (DM) is helpful for reducing maladaptive regulatory strategies such as worry. We investigated whether the effect of DM could be further enhanced by integrating an embodied attitude of detaching from one's experience. In a community sample, 161 participants were exposed to a worry induction paradigm and randomized to one of three conditions: DM alone (DM-C) or DM combined with either a "lazy" body position (DM + L) or a "stoic" body position (DM + S). Outcomes were state worry, anxiety, and decentering. Our primary hypothesis was not supported in that neither the "lazy" nor the "stoic" positions enhanced the effect of DM. Post hoc comparisons showed significantly more state worry and anxiety in the DM + L condition than the DM-C condition with small-to-medium effects. In comparing participants above and below the median on depressive and anxiety symptoms, those with higher symptom levels had worse outcomes when assuming the body positions. Especially the "lazy" body position resulted in more negative outcomes. Our results, albeit in contrast to our hypothesis, align with meta-analyses showing that contractive (e.g., slumped) positions are associated with more negative affect. Caution should therefore be taken in a clinical setting when asking participants to assume certain body positions while engaging in DM in response to worry.
