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Background This article introduces a new treatment protocol for depression. Based on previous research which indicated the presence of cognitive conflicts in depression, this study created an intervention manual to address these conflicts. Method The therapy manual for depressive patients followed the guideline for inclusion in clinical trials (stage II), which has received high recognition. A preliminary version (stage I) of this manual was formulated based on other, more general dilemma-focused therapy publications, inspired by personal construct theory (PCT), and input from clinical experience. The resulting version was then applied during the 8-session format of a pilot study with patients diagnosed with major depressive disorder or dysthymia. Finally, feedback was requested from seasoned and highly respected therapists, some of whom were familiar with PCT. Results According to the mentioned guideline, the intervention manual selected the theoretical framework, in this case PCT, to include its conceptualization of depression and resolution of dilemmas (to foster clinical improvement) as a main treatment goal. The manual was then contrasted with psychoanalytic psychotherapy, cognitive-behavior therapy (CBT), motivational interviewing (MI), and other similar approaches such as cognitive-analytic therapy and coherence therapy. Following these conceptual clarifications, the specific interventions included in the manual were defined according to both categories: their unique and essential components and those conceived as common psychotherapeutic factors. Next, the general structure and content for each session were presented. The structure consisted of seven well-defined individual sessions with an additional session, which could complement any of the former sessions to address the patient’s issues in greater depth, if needed. Conclusions This Dilemma-Focused Intervention manual aimed to improve the treatment outcome for depression by offering an intervention that could be combined with other general approaches. At its present level of definition, it allows for inclusion in controlled trials (eg, the current RCT combining group CBT with this intervention). Thus, this manual added to the existing resources in psychotherapeutic research and practice for treatment of depression.

Background Cognitive behavioural therapy (CBT) is aimed to counteract cognitions and behaviours that are considered as dysfunctional. The aim of the study is to test whether the inclusion of a non-counteractive approach (dilemma-focused intervention, DFI) in combination with CBT group therapy will yield better short- and long-term outcomes than an intervention conducted entirely using CBT. Method A total of 128 patients with depression and at least one cognitive conflict, of six health community centres in Barcelona, participated from November of 2011 to December of 2014 in seven weekly group CBT sessions and were then randomly allocated to either DFI or CBT (eight individual sessions each) by an independent researcher. Depressive symptoms were assessed with the Beck Depression Inventory-II at baseline, at the end of therapy and three- and twelve-month follow-ups. Therapists did not participate in any of the assessments nor in the randomisation of patients and evaluators were masked to group assignment. Both intention to treat and complete case analyses were performed using linear mixed models with random effects. Findings According to intention-to-treat analysis (F2, 179 = 0.69) and complete case analysis (F2, 146 = 0.88), both conditions similarly reduced the severity of symptoms across posttreatment assessments. For the 77 participants (CBTgroup +CBTindividual = 40; CBTgroup+DFIindividual = 37) that completed allocated treatment and one-year follow-up assessment, response and remission rates were relative higher for the DFI condition, however no significant differences were found between treatment conditions. The relapse rates were similar between treatment conditions (CBTgroup +CBTindividual = 7/20; CBTgroup+DFIindividual = 8/22). Interpretation Although using a counteractive approach across all the treatment sessions is quite effective, it does not seem to be necessary to produce significant improvement. DFI may be considered as an alternative, which could be included in a wider treatment for depression.

Este estudio se basa en el análisis comparativo de la alianza terapéutica en dos casos de terapia de pareja para la depresión con distinto resultado terapéutico, en términos de cambio sintomático. El Sistema para la Observación de la Alianza Terapéutica en Intervención Familiar (SOFTA-o) se utilizó para evaluar cómo la pareja establecía la alianza terapéutica con el terapeuta y, por el otro, como el terapeuta construyó la alianza terapéutica con la pareja en el proceso de terapia, durante la primera, sexta y última sesión del tratamiento. Se valoró la construcción de la alianza terapéutica mediante un análisis de micro proceso para proporcionar una información más exhaustiva sobre el transcurso de la terapia. Se considera de gran relevancia que el terapeuta fomente la creación de un contexto de soporte mutuo entre la pareja para que ésta trabaje en la terapia de un modo colaborativo. Finalmente, se discutesobre la importancia de la alianza terapéutica en terapia de pareja para la depresión, con unamención a las implicaciones que tiene este estudio en la investigación y en la práctica clínica. This article reports an analysis of the therapeutic alliance in two contrasting couple therapy cases for depression with different outcome in terms of depressive symptoms. The System for Observing Family Therapy Alliances (SOFTA-o) was used to analyze the therapeutic alliance established by all the participants, including clients but also therapists, during the first, sixth and last sessions of the treatment. The alliance is best assessed using micro-process analysis, allowing it to provide valuable information to the therapist on what is happening in treatment when a partner is suffering from depression. A collaborative alliance between both members is necessary in order for the therapist to establish a context of mutual support in which the couple is seen working collaboratively. Finally, there is discussion of the importance that the therapeutic alliance can make in couple therapy for depression, with mention also of the implications for research and for clinical practice.

This article reports an analysis of the therapeutic alliance in two contrasting couple therapy cases for depression with different outcome in terms of depressive symptoms. The System for Observing Family Therapy Alliances (SOFTA-o) was used to analyze the therapeutic alliance established by all the participants, including clients but also therapists, during the first, sixth and last sessions of the treatment. The alliance is best assessed using micro-process analysis, allowing it to provide valuable information to the therapist on what is happening in treatment when a partner is suffering from depression. A collaborative alliance between both members is necessary in order for the therapist to establish a context of mutual support in which the couple is seen working collaboratively. Finally, there is discussion of the importance that the therapeutic alliance can make in couple therapy for depression, with mention also of the implications for research and for clinical practice. Este estudio se basa en el análisis comparativo de la alianza terapéutica en dos casos de terapia de pareja para la depresión con distinto resultado terapéutico, en términos de cambio sintomático. El Sistema para la Observación de la Alianza Terapéutica en Intervención Familiar (SOFTA-o) se utilizó para evaluar cómo la pareja establecía la alianza terapéutica con el terapeuta y, por el otro, como el terapeuta construyó la alianza terapéutica con la pareja en el proceso de terapia, durante la primera, sexta y última sesión del tratamiento. Se valoró la construcción de la alianza terapéutica mediante un análisis de micro proceso para proporcionar una información más exhaustiva sobre el transcurso de la terapia. Se considera de gran relevancia que el terapeuta fomente la creación de un contexto de soporte mutuo entre la pareja para que ésta trabaje en la terapia de un modo colaborativo. Finalmente, se discute sobre la importancia de la alianza terapéutica en terapia de pareja para la depresión, con una mención a las implicaciones que tiene este estudio en la investigación y en la práctica clínica.

Course of eating disorders (ED) in patients treated in Day Hospital is analyzed by evaluating 24 women at baseline and approximately 3 years after initial assessment, in several variables: personality factors, motivation, psychological symptoms, severity, self-esteem, self-construction, construction of parental figures and polarization. Clinical variables of the history of the disorder are also included. 70.8% of the patients completed treatment and, 3 years after intake, 47.06% relapsed. The following factors seem to be associated with negative course: severity of ED, high scores on relapse (Transtheoretical Model of Change) and opening to experience, long period between onset of symptoms and first treatment, self-perception of fatness body image? low self-esteem prior to ED, and negative perception of their mother.

Concurrent personality disorder (PD) and substance use disorder (SUD) are common in clinical practice. However, SUD is the main criterion for study exclusion in most psychotherapeutic studies of PD. As a result, data on treatment outcomes in patients with concurrent PD/SUD are scarce. The study sample consisted of 51 patients diagnosed with severe PD and admitted for psychotherapeutic treatment as a part of routine mental health care. All patients were diagnosed with PD according to the Structured Clinical Interview for PD. Patients were further assessed (DSM-IV diagnostic criteria) to check for the presence of concurrent SUD, with 28 patients diagnosed with both disorders (PD-SUD). These 28 cases were then compared to the 23 patients without SUD (PD-nSUD) in terms of psychiatric hospitalizations and psychiatric emergency room (ER) visits before and during the 6-month therapeutic intervention and every 6 months thereafter for a total of 36 months. The baseline clinical characteristics correspond to a sample of PD patients (78% met DSM-IV criteria for borderline PD) with poor general functioning and a high prevalence of suicide attempts and self-harm behaviors. Altogether, the five outcome variables - the proportion and the number of psychiatric inpatient admissions, the number of days hospitalized, and the proportion and the number of psychiatric ER visits - improved significantly during the treatment period, and this improvement was maintained throughout the follow-up period. Although PD-SUD patients had more psychiatric hospitalizations and ER visits than PD-nSUD patients during follow-up, the differences between these two groups remained stable over the study period indicating that the treatment was equally effective in both groups. Specialized psychotherapy for severe PD can be effectively applied in patients with concurrent PD-SUD under usual practice conditions. These findings suggest that exclusion of patients with dual disorders from specialized treatments is unjustified.

Background Depression is one of the more severe and serious health problems because of its morbidity, disabling effects and for its societal and economic burden. Despite the variety of existing pharmacological and psychological treatments, most of the cases evolve with only partial remission, relapse and recurrence. Cognitive models have contributed significantly to the understanding of unipolar depression and its psychological treatment. However, success is only partial and many authors affirm the need to improve those models and also the treatment programs derived from them. One of the issues that requires further elaboration is the difficulty these patients experience in responding to treatment and in maintaining therapeutic gains across time without relapse or recurrence. Our research group has been working on the notion of cognitive conflict viewed as personal dilemmas according to personal construct theory. We use a novel method for identifying those conflicts using the repertory grid technique (RGT). Preliminary results with depressive patients show that about 90% of them have one or more of those conflicts. This fact might explain the blockage and the difficult progress of these patients, especially the more severe and/or chronic. These results justify the need for specific interventions focused on the resolution of these internal conflicts. This study aims to empirically test the hypothesis that an intervention focused on the dilemma(s) specifically detected for each patient will enhance the efficacy of cognitive behavioral therapy (CBT) for depression. Design A therapy manual for a dilemma-focused intervention will be tested using a randomized clinical trial by comparing the outcome of two treatment conditions: combined group CBT (eight, 2-hour weekly sessions) plus individual dilemma-focused therapy (eight, 1-hour weekly sessions) and CBT alone (eight, 2-hour group weekly sessions plus eight, 1-hour individual weekly sessions). Method Participants are patients aged over 18 years meeting diagnostic criteria for major depressive disorder or dysthymic disorder, with a score of 19 or above on the Beck depression inventory, second edition (BDI-II) and presenting at least one cognitive conflict (implicative dilemma or dilemmatic construct) as assessed using the RGT. The BDI-II is the primary outcome measure, collected at baseline, at the end of therapy, and at 3- and 12-month follow-up; other secondary measures are also used. Discussion We expect that adding a dilemma-focused intervention to CBT will increase the efficacy of one of the more prestigious therapies for depression, thus resulting in a significant contribution to the psychological treatment of depression. Trial registration ISRCTN92443999 ; ClinicalTrials.gov Identifier: NCT01542957 .

The Multi-Center Dilemma Project is a collaborative research endeavour aimed at determining the role of dilemmas —a kind of cognitive conflict, detected by using an adaptation of Kelly's Repertory Grid Technique— in a variety of clinical conditions. Implicative dilemmas appear in one third of the non-clinical group (n = 321) and in about half of the clinical group (n = 286), the latter having a proportion of dilemmas that doubles that of the non-clinical sample. Within the clinical group, we studied 87 subjects, after completing a psychotherapy process, and found that therapy helps to dissolve those dilemmas. We also studied, independently, a group of subjects diagnosed with social phobia (n = 13) and a group diagnosed with irritable bowel syndrome (n = 13) in comparison to non-clinical groups. In both health related problems, dilemmas seem to be quite relevant. Altogether, these studies, though preliminary (and with a small group size in some cases), yield a promising perspective to the unexplored area of the role of cognitive conflicts as an issue to consider when trying to understand some clinical conditions, as well as a focus to be dealt with in psychotherapy when dilemmas are identified. El Proyecto Multi-Céntrico Dilema aúna los esfuerzos de distintos centros de investigación con el propósito de determinar el papel de los dilemas personales en una amplia gama de problemas de salud. Estos dilemas, identificados mediante una adaptación de la Técnica de Rejilla de Kelly, aparecen en un tercio de un grupo de población normal (n = 321) y en la mitad del grupo clínico (n = 286). Comparando los sujetos que presentan dilemas, los del grupo clínico doblan a los del grupo normal en proporción de dilemas. También revisamos dos estudios independientes con un grupo de pacientes diagnosticados con fobia social (n = 13) y otro con síndrome del intestino irritable (n = 13), ambos en comparación con grupos de población normal. En los dos casos se encuentran diferencias que apuntan en la dirección de la relevancia de los dilemas. Tomando en conjunto los datos disponibles, todo parece augurar unas buenas perspectivas con respecto al papel relevante (auque hasta el momento no explorado) de los conflictos cognitivos a la hora de comprender algunos problemas clínicos. También sugieren el interés de incluir en su tratamiento el trabajo con dilemas, al menos para los sujetos que los presenten.

El estudio de los conflictos cognitivos se ha llevado a cabo desde diversas aproximaciones teóricas. En el ámbito de la Psicología de los Constructos Personales, la técnica de la rejilla ha permitido operativizar un tipo de conflicto cognitivo denominado Dilema Implicativo (DI) y estudiar su papel en el campo de lasalud. En este trabajo se ha analizado la construcción del sí mismo, la estructura cognitiva y el malestar psicológico en personas con y sin DI pertenecientes a una muestra comunitaria. En la investigación participaron 115 sujetos (56.5% mujeres y 43.5% hombres). Las técnicas de evaluación utilizadas fueron la técnica de la rejilla, y las versiones españolas del Symptom Check List-90-R (SCL-90-R) y el Clinical Outcome in Routine Evaluation (CORE-OM). Los principales resultados revelan correlaciones positivas en las tres medidas del sí mismo, lo que suponeuna alta autoestima, aunque si se comparan los grupos con/sin DI, se observan correlaciones más bajas en las personas con dilemas. En cuanto a la complejidad cognitiva, las personas con dilemas muestran una estructura cognitiva más diferenciada. Por último, en relación con el malestar psicológico percibido, los dos grupos presentan puntuaciones dentro del rango de la normalidad aunque las personas sin DI se sienten en mayor sintonía consigo mismas/con los demás que las personas con dilemas, presentando estas últimas puntuaciones superiores en escalas de depresión y ansiedad del SCL-90, y en las medidas globales del CORE-OM.