Transference-focused psychotherapy (TFP) is a modified form of psychoanalytic psychotherapy grounded in object relations theory. It was developed to treat borderline personality disorder but has been used with a broader range of personality pathology. Notable adaptations include establishing an explicit treatment contract; a grounding in the domains of work, intimacy, and creativity rather than strict free association; a more formalized structure for training and supervising therapists; and a staged approach to interpretation that focuses sequentially on the elucidation of dominant object relations dyads, role reversals, and in later stages insight into dyadic layering and unconscious motivations. This article suggests that, whereas the existing literature on transference-focused group psychotherapy (TFP-G) emphasizes the use of group-as-a-whole interpretations, the clinical application of TFP principles in group psychotherapy for personality pathology could draw from TFP's approach to interpretation in individual therapy to elaborate a range of interventions that could be deployed according to patient needs and abilities. This flexible approach could remain compatible with the object relations model of borderline personality organization elucidated by Kernberg, while drawing upon the strategies, techniques, and tactics of individual TFP to equip group therapists with a broader array of tools than have been proposed thus far. Doing so would improve the model's ease of application, enhance flexibility, and mitigate potential drawbacks of group approaches emphasizing whole-group interpretations. Such adaptations could be useful to TFP-G therapists per se and group therapists with an integrative approach.

Patients with a personality disorder are frequently encountered in clinical settings, and their treatment often poses unique clinical dilemmas given specific features of the illness and treatment landscapes that are commonly austere. The past few decades have seen the emergence of new models for conceptualizing personality disorders and several new evidence-based treatments. However, the question of which patient should be matched to which treatment, and when, is a significantly under-investigated topic. We propose that one important component of answering this question is considering readiness for treatment, which has not received the same degree of attention as it has in other areas of mental health treatment. While there are currently no empirically validated tools to reliably quantify readiness for treatment, here we argue that it is still an important topic to consider when working with this patient population. We present 3 different case-based discussions where different features of personality disorders and different features of readiness are highlighted, along with several potential elements that could be included in clinical education curricula. In addition to benefiting patients, a more direct consideration of readiness for treatment may also benefit providers by reducing moral distress and the health care system more broadly by improving resource allocation.

Loneliness has been linked to negative self-evaluations, yet its association with severe, hateful forms of selfcriticism remains unclear. The present study examined the relationship between loneliness and self-criticism, accounting for neuroticism, and tested whether age and adverse childhood experiences (ACEs) moderated this link. Participants were 343 adults (ages 18-75) recruited online who completed self-report measures of loneliness, self-criticism, neuroticism, and ACEs. Analyses indicated that loneliness was significantly associated with self-criticism beyond the effects of neuroticism, accounting for 7% additional variance. A significant interaction effect was observed between loneliness and age, indicating loneliness to be most strongly related to self-criticism among younger adults. Exploratory analysis also revealed this interaction to be significant only among individuals with multiple types of childhood adversity. Findings suggest that loneliness is associated with selfcriticism beyond general negative affectivity, particularly for young adults with histories of adversity. These results highlight the potential value of targeting loneliness and self-critical thinking in interventions for traumaexposed youth.

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.

Narcissistic personality disorder (NPD) and pathological narcissism (PN) urgently need empirically supported treatment options. Mohajerin et al. randomized controlled trial yielded promise in addressing this gap. However, in this commentary, an international group of personality disorder experts identify a number of issues with the trial methodology, reporting and interpretation: (i) the unlikeliness that consecutive sample recruitment would result in almost equal number of participants in grandiose vs. vulnerable subgroups; (ii) the unlikeliness that consecutive sample recruitment would result in almost equal number of participating men and women; (iii) the unlikely possibility that grandiose and vulnerable narcissism would appear as uncorrelated subtypes; (iv) dissimilar treatment responses to schema-focused therapy vs. Unified Protocol; (v) absence of dropouts; (vi) unclear randomization procedure; (vii) poor screening and recruitment procedures and limited transparency in trial registration; (viii) exclusive reliance on self-report measures; (ix) limited transparency in supervision and treatment fidelity procedures; (x) nonequivalence of treatment dose and duration; and (xi) lack of clarity on how the disclosure of NPD diagnosis to participants was handled in the trial. In light of these concerns, it is difficult to reconcile the results of this trial with the inherent challenges of treating NPD and PN. We therefore warrant against considering it a benchmark in NPD treatment innovation.

Although many forms of the Conformity to Masculine Norms Inventory (CMNI) are widely used in international literature, there is yet to be a Turkish version. The CMNI-30 is an instrument consisting of 30 statements developed to measure masculinity ideologies, with statements representing different behaviors associated with masculinity. The CMNI-30 has proven reliable and valid across different languages and cultures. This study evaluated the psychometric properties of the Turkish version of the CMNI-30. Tested with 1,091 Turkish men, data were collected after content validation with the 10-factor model of the CMNI-30, indicating good construct validity. Also, convergent validity, Cronbach's alpha coefficient, item-total score analysis, and test-retest analyses were applied. Confirmatory factor analysis showed that the CMNI-30 was similar to its original structure, and all factor loadings were above 0.30. The fit indices were >0.85, and the root mean square error of approximation value was <0.05. Cronbach's alpha value was calculated as 0.871. Item-total correlations ranged between .253 and .541, and the test-retest correlation was found to be r = .344 (p < .001). Convergent validity analysis showed a significant positive relationship between CMNI-30 and Male Role Norms Scale. These findings provide preliminary evidence for the validity and reliability of the Turkish version of the CMNI-30.

OBJECTIVES:Loneliness has been established as a threat to health and well-being, and may be particularly problematic for men due to masculinity norms that emphasize self-reliance. Given the importance of understanding loneliness and its threat to well-being among men, the present study was designed to examine a dispositional risk factor, pathological narcissism, on men's experience of loneliness and reduced satisfaction with life. DESIGN:An online prospective cohort design was used to examine relations between pathological narcissism, including narcissistic vulnerability and grandiosity, loneliness and life satisfaction. METHODS:A sample of men seeking online mental health help was recruited to complete self-report measures regarding pathological narcissism, loneliness and life satisfaction across a six-month period. Linear regression analyses were used to examine men's (N = 319, Mage = 38.85 + 14.39) narcissistic vulnerability and grandiosity in relation to loneliness and to test mediation models whereby loneliness (at 3 months) would mediate the relationship between narcissistic vulnerability (baseline) and life satisfaction (at six months), including variability in the latter by controlling for baseline life satisfaction. RESULTS:When examined together, only narcissistic vulnerability and not grandiosity was significant in predicting loneliness. Mediation models indicated significant indirect effects of baseline narcissistic vulnerability on life satisfaction at six months-and change in life satisfaction over six months-through the mediating effect of interim loneliness. CONCLUSIONS:Findings indicate narcissistic vulnerability as a significant dispositional factor in men's loneliness, and that such loneliness in turn diminishes men's general well-being.

Narcissism is a hot topic in popular media, which often emphasizes harmful aspects and behaviours of individuals with narcissistic features. Such media likely contributes to negative perspectives that could further stigmatize narcissism and those who may suffer from narcissistic difficulties. However, limited research has investigated perspectives about narcissism among the general public. The present study surveyed 815 US-based adults to explore public perspectives regarding the prevalence of narcissism, attitudes related to stigma, perspectives on suffering and hope, therapeutic issues and experiences of harm associated with narcissism. Findings indicate that a majority view narcissism as a prevalent and undesirable personality feature and warrant considerable clinical intervention. Individuals who endorsed having experienced harm by someone with narcissistic features were more likely to express negative perspectives. The mixture of public perspectives regarding narcissism seems to indicate a potential role for public education in order to reduce stigma and promote help-seeking and treatment efforts.

Background Dissociation, a complex construct characterized by disruptions across multiple domains of mental functioning, is closely intertwined with psychopathology, emotion dysregulation, and early adverse experiences. Interpersonal guilt, a form of guilt rooted in relational experiences, is a factor that may contribute to dissociative processes, particularly under overwhelming circumstances. Yet, the interplay between interpersonal guilt and dissociation remains underexplored, alongside the roles of early adverse parenting experiences and the influence of intense emotions such as anger in shaping this relationship. Objective To investigate the association between interpersonal guilt and dissociation. We further examined the indirect effect of early adverse parenting experiences on dissociation through the mediating role of interpersonal guilt, with this mediation moderated by anger. Methods An online sample of 275 participants completed validated self-report measures assessing interpersonal guilt, dissociation, anger and early adverse parenting experiences. Hypothesized relationships were tested using correlation and regression analyses, including mediation and moderated mediation. Results Burdening guilt and self-hate were the interpersonal guilt types most strongly associated with dissociation, with burdening guilt showing a unique association when controlling for the other forms of guilt. Furthermore, burdening guilt mediated the relationship between early adverse parenting experiences and dissociation, and this pathway was amplified under moderate to high levels of anger, underlying anger's moderating role. Conclusions Findings highlight the central role of burdening guilt in shaping vulnerability to dissociation. Early adverse parenting experiences may foster the development of burdening-guilt-related pathogenic beliefs, which in turn could increase susceptibility to dissociation. This vulnerability may be further exacerbated under conditions of heightened anger, emphasizing the moderating role of intense emotions. Clinically, assessing and addressing interpersonal guilt and anger regulation may inform interventions for individuals with dissociative tendencies, particularly those with histories of adverse parenting.

Mental health difficulties typically develop during adolescence, yet service utilization rates among youth are low. We sought to understand perspectives among Canadian youth accessing mental health services at an integrated youth services centre called Foundry. Forty-one semi-structured qualitative interviews were conducted with youth aged 15-24 years. A grounded theory framework was developed. Youth described emotional experiences of distress as catalysts to seeking mental health services. They also discussed challenges in understanding their own emotions as barriers to accessing mental health services. Gender identity and norms influenced participants' experiences of accessing services. Anxious emotions were predominantly associated with youths' experiences with seeking mental health services. Conversely, once at Foundry, over half the youth experienced positive emotions about help-seeking, with more than half of these youth continuing to access services post interview. Providing Integrated Youth Services like Foundry can increase service engagement and support adaptive emotional development for youth of all genders.

OBJECTIVE:Patient coaching refers to patient-initiated communication that helps therapists understand therapy goals, maladaptive beliefs, personal challenges, and preferred therapeutic approaches. Despite its theoretical significance, empirical research remains limited, with a few recent studies relying on labor-intensive methods involving extensive training of raters and detailed case analysis. To support broader empirical research, this study introduces the Patient Coaching Rating System (PCRS) to assess two dimensions of patient coaching: information coaching (what and why) and direction coaching (how). METHODS:Seven raters used the PCRS to rate 22 segments from an early psychotherapy session. Each segment was rated on two dimensions-information coaching and direction coaching-with a 0-4 scale. RESULTS:The raters achieved interrater reliability scores of 0.86 for information coaching and 0.68 for direction coaching. Whereas information coaching demonstrated excellent reliability, direction coaching showed moderate to good reliability, highlighting the need for further refinement of the coding manual. CONCLUSIONS:This pilot study provides a structured method for assessing patient coaching and represents an initial step toward facilitating empirical investigation within therapy sessions.

Patients in psychotherapy may inform, orient, and redirect their therapist according to their particular problems, goals, and needs--conceptualized by Control-Mastery Theory as the patient coaching the therapist. Yet there has been limited research on patients' subjective experiences of engaging in coaching communication. This study used an online survey to obtain patients' perspectives on the degree to which they coached their therapist and the effects and implications of having done so. Of 248 participants who had received psychotherapy, 123 provided text responses for qualitative analysis regarding their experience of coaching communication. Thematic analysis was employed to extract themes from these narratives. Major themes included the use of coaching to orient the therapist to desired goals and preferred intervention approaches, and to redirect the therapist when necessary. Themes regarding the impact of coaching included positive experiences when coaching was well received and negative experiences when therapists ignored the patient's coaching. Findings from this preliminary investigation suggest that coaching communication may be an important feature of the therapeutic process for many patients, with implications for therapist responsiveness and therapy outcomes. Moreover, the findings indicate that patients' coaching communication is a worthy subject for future psychotherapy research.

OBJECTIVE:Although negative experiences in psychotherapy are commonly reported by patients, these phenomena are understudied. The present study introduces the Problematic Impressions of Therapy Scale (PITS), a new measure designed to assess distressing in-session experiences. METHODS:In two large samples of psychotherapy patients (N = 541 and N = 545), we conducted exploratory factor analysis followed by exploratory structural equation modeling to determine the underlying factor structure and psychometric properties of the PITS. RESULTS:Results supported a 21-item, two-factor model reflecting therapist "errors of commission" (e.g., pressuring disclosure, expressing judgment) and "errors of omission" (e.g., failing to provide support or direction). Both subscales demonstrated acceptable internal consistency and good model fit across U.K.- and U.S.-based samples. In tests of concurrent validity, higher PITS scores showed moderate-to-strong negative associations with measures of the working alliance (Working Alliance Inventory) and perceived therapist responsiveness (Patient's Experience of Attunement and Responsiveness), suggesting that more frequent or distressing negative experiences correlate with weaker alliances. Further, errors of omission uniquely predicted poorer ratings of both bond and task dimensions of the alliance. CONCLUSION:These findings support the reliability and construct validity of the PITS as a tool for identifying and quantifying negative or hindering experiences in psychotherapy.

Understanding treatment failures is important for improving therapist responsiveness and mitigating negative outcomes in psychotherapy. One factor that may increase the risk for treatment failure is the therapist's determination to adhere to a particular treatment model. While therapist adherence has mostly been discussed in reference to manualized treatments, the concept can also be applied to therapies guided by case formulations, in that the formulation can serve as an individualized model of therapy for a given patient. Adherence to an accurate formulation has been shown to have a positive impact on the process and outcome of a therapy. However, failure to test and reevaluate a formulation across the course of a therapy-in light of a patient's emerging needs and concerns-can result in a failed treatment. Clinical material is presented from a failed 16-session psychotherapy to illustrate the negative effects of a therapist's rigid formulation adherence, despite communications from the patient signaling potential modifications to the case formulation. By remaining open to new information and reevaluating the case formulation throughout the course of treatment, therapists may improve their responsiveness and decrease the likelihood of negative outcomes in psychotherapy.

Yalom (1985) believed that working in the here-and-now of the group is essential to facilitating the "therapeutic factors" necessary for a successful outcome. Yet, we currently lack research examining whether a here-and-now in-session focus predicts the therapeutic factors, as theorized. This study used Linguistic Inquiry and Word Count (LIWC) analysis to assess group member and leader in-session here-and-now focus by analyzing words spoken in a session. The results suggest that when group leaders use more here-and-now words in a speaking turn, group members use more here-and-now words in the subsequent speaking turn. However, contrary to expectation, group leaders and group members "matching" on here-and-now language in a session did not predict more therapeutic factors in between sessions, but rather less social learning. Instead, how consistent or variable group members or leaders were in their here-and-now focus generally predicted more therapeutic factors. These results suggest that LIWC may be a promising vehicle to assess here-and-now language in group therapy sessions and that a here-and-now in-session focus has a complex relationship with the therapeutic factors.

Childhood emotional abuse is a recognized factor for long-term psychological and physical health problems, including persistent somatic symptoms. Negative self-beliefs, such as self-hate-related beliefs, may explain how emotional mistreatment contributes to physical distress in adulthood beyond general emotional difficulties. A longitudinal study was conducted with 298 help-seeking adults. At baseline, participants completed measures of childhood emotional abuse, self-hate, and general negative affectivity. Somatic symptoms were assessed two months later. Mediation analyses tested whether self-hate mediated the relationship between childhood emotional abuse and somatic symptoms while accounting for the influence of general negative affectivity, which reflects a general tendency to experience negative emotional states. Participants (Mage = 33.7, SD = 11.8) were predominantly female (63.3%) and Caucasian (84.2%). Childhood emotional abuse (M = 11.24, SD = 6.60) was significantly associated with self-hate (M = 10.35, SD = 6.13, r = 0.33, p < 0.001) and somatic symptoms (M = 13.99, SD = 6.76, r = 0.27, p < 0.001). Self-hate strongly correlated with somatic symptoms (r = 0.45, p < 0.001). Mediation analyses showed that self-hate significantly mediated the link between emotional abuse and somatic symptoms, even after accounting for general negative affectivity as a covariate (indirect effect = 0.07, 99% CI [0.03, 0.13]). These findings highlight self-hate as a key mechanism linking childhood emotional abuse to somatic symptoms. Even when controlling for broader emotional instability, self-hate remained central. Addressing these negative self-beliefs through targeted interventions may help reduce both emotional suffering and associated physical manifestations.

OBJECTIVE:Young adulthood is a unique period when most men's romantic relationships are in nascent stages. The current study aimed to explore the impact of romantic relationship challenges on young men's mental health in a national sample of undergraduate Canadian-based university students. PARTICIPANTS:A reference group from the 2022 National College Health Assessment was analyzed (N = 2,036), comprising young men (18-24 years) who were enrolled in full-time undergraduate studies in Canada. METHODS:Multivariate analysis of covariance (MANCOVA) was used to examine differences in psychological distress, loneliness, suicide risk, and positive mental health based on relationship distress. RESULT:Overall, 816 respondents (40.1%) reported experiencing a romantic relationship challenge in the last 12 months. Young men who experienced a distressed relationship reported higher levels of psychological distress (partial η2 = .043), loneliness (partial η2 = .050), and suicidal behavior (partial η2 = .034), and lower levels of positive mental health (partial η2 = .011). CONCLUSIONS:The findings reflect significant mental health concerns for young men who experience relationship challenges, underscoring the need to provide tailored services to young men in navigating their romantic relationships, including a relationship breakdown.