Psychological mindedness and symptom reduction after psychotherapy in a heterogeneous psychiatric sample

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 (F_8,73 < 1.0; P > .20; partial η² < 0.10). However, PM increased over the course of the intervention (F_2,84 = 43.54; P < .001; η² = 0.51) and larger increases in the insight component of PM were associated with larger decreases on 6 of 8 symptom scores (F_8,70 = 3.55; P < .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.

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 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], [9], [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 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], [13], [14], [15]. Indeed, PM has been reported to be associated with a more adaptive cognitive style [12], and a higher level of well-being 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], [18], [19], [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.