This thesis portfolio comprises of three parts: Part one: a systematic literature review, in which the available research into personality disorders during the perinatal period is reviewed. A systematic search identified 11 studies for inclusion, the findings of which are reviewed in a narrative synthesis incorporating methodological critique. Conclusions are drawn and related to the wider literature, and implications for research and practice are highlighted. Part two: a qualitative study, in which the views of perinatal mental health staff were gathered to provide an insight into understanding of perinatal mental health problems and care. Three staff teams were interviewed using focus groups and thematic analysis was used to analyse the data, from which six themes emerged. These themes are discussed in relation to implications for practice and the wider research into perinatal mental health problems. Part three: appendices supporting the systematic literature review and qualitative study, including an epistemological statement and a reflective statement.

This study sought to investigate the construct of Relational Spirituality through: 1) identifying its correlates among demographic, spiritual, and parenting variables in a large, religiously and ethnically diverse sample of adolescents, and 2) investigating its associations with highly prevalent forms of psychopathology in adolescents. Participants were 615 adolescents representing a broad range of ethnicities (Caucasian, African-American, Asian-American, Latino, and multiracial, and other) and religious denominations (Catholic, Protestant, Jewish, Atheist, Agnostic, Buddhist, and other). The Brief-Multidimensional Measure of Spirituality/Religiosity, the Mysticism Scale, the Beck Depression Inventory and the Beck Anxiety Inventory were used to measure spirituality, depression, and anxiety, respectively, while frequency of alcohol use was ascertained with a single item. Parental relationship quality was measured using the Parental Bonding Instrument and the Parental Transparency Scale. Given that rates of depression, anxiety and spirituality have been demonstrated to be higher in girls than boys, gender differences in patterns of association were examined with respect to each type of psychopathology. Results of stepwise regression analyses revealed that exclusively in females, Relational Spirituality accounted for a significant portion of the variance in depressive symptomatology above and beyond demographic, parenting, and religious variables. Stepwise regression analyses also showed that Relational Spirituality contributed to a significant portion of variance in alcohol use above and beyond other correlated variables in both boys and girls. In contrast, Relational Spirituality did not contribute to the variance in anxiety; rather, the quality of religious social support was protective against anxious symptomatology. Findings suggest that Relational Spirituality is differentially associated with widespread forms of psychopathology in adolescents, and our understanding of these disorders may be enhanced through a spiritual perspective.

Posttraumatic growth (PTG) is a prolific construct under study within both trauma and positive psychology literature alike. Many of these studies rely predominantly on cross-sectional, retrospective self-report data. Recent studies have attempted to subject PTG to more rigorous scientific standards of measurement. In this study, we examined posttraumatic growth measured longitudinally among survivors of the September 11th, 2001 terrorist attack, in order to explore whether participants' reports of posttraumatic growth were associated with, supported or contradicted by friend ratings of improvement. In this context, participant-reported posttraumatic growth was consistently linked with friend ratings of deteriorating functioning, providing evidence that posttraumatic growth is undermined by friend ratings. These findings suggest that self-reported PTG may inadequately predict functioning as rated by alternative, more objective measures, and that PTG may reflect negative psychological adjustment.

The primary goal of this study was to investigate how psychotherapists in training develop a professional identity. Specifically, the aims were 1) to generate a theory that could guide thinking about this subject; and 2) to apply the knowledge gained to formulate ideas about the education of future psychotherapists. Twenty-nine doctoral students, recruited primarily in New York and California, were interviewed about their professional development. Qualitative analyses of the transcribed interviews (utilizing multiple methodologies, including the Listening Guide method) revealed normative aspects of, as well as individual differences with respect to, identity formation. Specifically, within a professional and cultural context that poses specific challenges and demands, psychotherapist trainees continuously recreate their identities through the performance of four identity tasks: exploring, committing, feeling, and reflecting. Through engagement in these tasks, trainees develop a distinctive set of skills, ideas, ways of working, and professional attitudes, and a subjective sense of themselves as psychotherapists with a unique therapeutic style and presence. Conceptualized as a dialectical process of differentiation and psychological separation, this process appears to characterize the identity formation of all trainees. Differences in identity formation are conceptualized in terms of trainees' ability to flexibly shift among identity tasks in response to changing contextual demands and circumstances; this quality is termed fluidity and is seen as the result of the specific and changing interactions between trainees and the professional context within which they develop. Six different approaches to identity formation, termed identity configurations, were identified, reflecting varying levels of engagement in identity tasks. Specifically, two "dialectical identity configurations" were identified, representing the fluidity of identity that arises from shifts in engaging and coping with changing contextual demands. These dialectical identity configurations also promote the development of a therapeutic repertoire that is unique, reflective of trainees' abilities and interests, and deeply meaningful. In contrast, four "non-dialectical identity configurations" were identified, representing coping with contextual challenges via a narrow range of relatively invariant responses. As such, these identity configurations are likely to interfere with the development of a therapeutic repertoire that is personal and emotionally resonant. Six case illustrations are presented to exemplify these ideas. Findings are explored in relation to other theories and models in the areas of identity and psychotherapists' development. In addition, implications of these ideas for training, including specific recommendations, are discussed.

The primary objective of this study was to examine clinicians' fidelity to a promising new clinical intervention known as Listen-Empathize-Agree-Partner (LEAP) that addresses issues of poor insight, therapeutic alliance, and treatment adherence prevalent in the schizophrenia population. A secondary purpose of this study was to assess the factor structure of a measure developed to examine the core principles of the LEAP method. Forty-eight mental health clinicians working in Assertive Community Treatment (ACT) programs randomized into intervention and control groups were assessed for fidelity to the LEAP method via the LEAP Fidelity Measure (LFM), a self-report instrument. Results revealed a three-factor structure of this measure which were labeled "Reflective Listening, Delaying and Opining," "Partnering on Shared Goals," and "Client-Centered Listening and Empathizing." Multivariate Analyses of Variance indicated that clinicians who were trained in LEAP had significantly higher levels of fidelity to the "Reflective Listening, Delaying and Opining" and "Partnering on Shared Goals" components than clinicians who were not trained in this method. There were no significant differences between the groups on the "Client-Centered Listening and Empathizing" component. Analyses did not reveal significant gender differences or effects based on years of general and specific ACT clinical experience between the two groups. However, in a post hoc analysis, a modest correlation between gender and fidelity to the "Client-Centered Listening and Empathizing" component showed that male clinicians tended to report higher fidelity to this specific set of interventions when compared to their female counterparts. These results are discussed within the context of feasibility in training and implementing LEAP in real-world community mental health clinical settings. Additionally, limitations of this study and implications for future research are discussed.

The primary aim of this study was to explore affective manifestations of cultural countertransference toward English-speaking Asian American clients in psychotherapy and to investigate the roles of therapist race and therapist racial attitudes. Fifty-six therapist participants completed measures of affective cultural countertransference toward and clinical assessments of a current client who is either White or Asian American. Participants also completed measures of racial attitudes toward Asian Americans as well as demographic questionnaires about themselves and their client. For the qualitative portion of data collection, five White psychologists were interviewed to further understand the relationship of these variables in White therapist-Asian American client dyads, the primary cross-cultural therapeutic relationship of interest. Thematic Analysis was used to explore qualitative data. Statistical results failed to show moderate or larger effect sizes for overall differences in cultural affective countertransference based on therapist-client race combination. Results suggest that White therapists experience similar levels of both positive and negative countertransference toward clients, regardless of race. Although qualitative data on White therapists reflected themes of racial biases consistent with Asian stereotypes of high competence and lack of sociability, quantitative comparisons distinguished that White therapists do not experience any more racial bias toward Asian clients than do Asian therapists. In fact, there was a trend suggesting the latter may experience more. For Asian therapists, countertransference in intraethnic dyads was strongly associated with Asian racial biases. There were a couple trends reflected in the quantitative data that should be interpreted conservatively given this study's methodological limitations, but, nevertheless, warrant further investigation: Compared to Asian therapists, White therapists experience more negative countertransference toward both White and Asian clients. White therapists' negative countertransference also showed small to medium associations with their racial bias against Asians. Qualitative evidence supported and expanded upon these trends: There was a dominant countertransferential theme among White therapist participants to counter Asian clients' culturally-syntonic drives for achievement and performance. Independent of therapist-client race, negative countertransference showed significant negative relationships to GAF, prognosis, and working alliance, while positive countertransference was positively related to prognosis and working alliance, as expected. Countertransference was also found to be related to client diagnosis, but not therapist theoretical orientation. The clinical, research, and theoretical implications of these findings are explored and limitations discussed.

The current study examined the role of context sensitive emotional responding in normal and pathological adjustment to loss among conjugally bereaved persons later in bereavement. We specifically focused on investigating how participants with complicated grief (CG) emotionally responded in comparison to a non-pathological bereaved group. We comprehensively measured the emotional responding behaviors (i.e., facial displays of emotion and head movements) of participants as they watched an evocatively sad or neutral film and also examined their emotion experience via self-report. We anticipated that CG participants would show and report less emotional context-sensitivity (i.e., less sadness and more negative emotions other than sadness) than non-pathological bereaved participants in the sad condition. Our findings demonstrate differences in both the emotional expression and emotional experience of the CG group compared with the non-pathological bereaved group in the context of a sad film. Our findings both support and extend our predictions. While overall participants more commonly expressed the prototypical sadness expressions in the sad condition than the neutral condition, a number of notable interaction effects emerged. Specifically, non-pathological bereaved participants were significantly more likely to express sadness expressions that involved the orbicular oculi muscles (i.e., AU 6 or the "cheek raiser"), the outer muscles that orbit the eyes, than CG participants in the sad condition. Research evidences how the orbicular oculi muscles are associated with "genuine" or more intense expressions of happiness and the current study suggests that the orbicular oculi muscles also distinguish between sadness expressions. In addition, while both groups were more likely to report feeling greater sadness in the sad condition than the neutral condition, CG participants were more likely to feel disgust and anger than non-pathological bereaved participants in the sad condition, pointing to unique pattern of context insensitive emotional responding. We found that CG is "complicated" in part due to its high co-morbidity rates with Major Depressive Disorder (MDD) and Post-traumatic Stress Disorder (PTSD). While controlling for the effects of MDD and PTSD did not significantly change our results, the high co-morbidity rate of CG with MDD (74%) and PTSD (68%) begs us to consider the pan-diagnostic nature of chronic grief-related pathology. In sum, the current study highlights grief-related pathology as a distinct clinical problem and points to how emotion context-insensitivity importantly plays a role in the maintenance of grief-related problems.

The present research is a prospective follow-up study which investigates the neuropsychological test performance of children with Attention Deficit/Hyperactivity Disorder (ADHD) and examines whether test performance and severity of childhood disruptive behaviors predict adult psychiatric status and functioning in major domains (educational, social, and occupational). Participants were 100 middle-class, White boys (mean age = 9) of average intelligence diagnosed with ADHD without comorbid conduct disorder (CD) diagnoses. Childhood predictors were teacher behavioral ratings and performance on a variety of neuropsychological tests. Participants were later assessed at mean age 25 by clinicians blind to childhood status. Linear and logistic regression analyses were used to determine the impact of childhood predictor variables on adult outcome. Results showed no significant impairment on measures of neuropsychological functioning, nor was neuropsychological test performance generally correlated with severity of disruptive behaviors. ADHD boys with low ratings of conduct disorder behaviors (not at all, just a little) demonstrated lower verbal ability than those without CD behaviors. Severity of childhood CD behaviors emerged as the most consistent predictor of adult functioning and prevalence of psychiatric disorders. Measures of working memory and attention (Working Memory Index and Freedom from Distractibility Factor of the WISC-R) inconsistently predicted functioning in some areas, although this may reflect the well-known relationship between childhood IQ and later adult functioning. Taken together, the findings suggest that in boys with ADHD who are of average intelligence and have intact neuropsychological functioning, even low levels of CD behaviors are associated with poor prognosis in adulthood.

Subthreshold symptoms of depression (defined as symptoms that do not meet full criteria for the disorder) are a significant concern, associated with a range of behavioral and emotional problems, raising the risk of adolescents developing more severe depression later. Yet research on subthreshold depression is lacking, and the relationship between affective and somatic symptom improvement has not been adequately studied. Prior research with adult samples lend credence to the hypothesis that symptoms of mood/motivation respond faster to psychotherapy (Rush, Beck, Kovacs, Weissenburger, and Hollon, 1982) than pharmacotherapy with the opposite response for vegetative symptoms such as sleep and appetite (DiMascio, Weissman, Prusoff, and Neu 1979). The current study was built upon prior research that found Interpersonal Psychotherapy Adolescent Skills Training (IPT-AST) to be an efficacious prevention intervention for adolescents with subthreshold depression, as compared to school counseling (Young, Mufson and Gallop, 2010). In this investigation, we sought to compare the trends in symptomatic improvement among 32 participants treated with IPT-AST over eight weeks. Clusters of mood/ motivation and vegetative symptoms were followed from baseline to the end of treatment. The results suggest that mood symptoms improved significantly before vegetative symptoms, within the first four weeks of preventive treatment. Significant improvement in vegetative symptoms was found to occur later between weeks 6 and 8. Thus adolescents receiving IPT-AST preventive treatment demonstrated faster reduction in mood/motivation symptoms than vegetative symptoms. Analyses revealed that fewer participants were identified as having not improved on the mood/motivation cluster than on the vegetative cluster indicating a better response for adolescents with mood symptoms than vegetative symptoms. Although, no relationships in improvements in mood/motivation and vegetative clusters were found controlling for baseline mood/motivation and vegetative symptoms; positive associations were found between cluster variables (mood, vegetative and total depression) over time. Gender was also not found to moderate the relationship between improvement on mood and vegetative symptoms over time indicating no significant differences in the improvement between males and females. Overall, findings from the current investigation strengthen the results from previous studies regarding the timeline of symptom improvement with IPT-AST.

The current study examined the relationships between parental depression, offspring depression, and offspring temperament among 203 offspring at high or low-risk for depression. Offspring were followed over a 20-year study period. Two primary study aims were addressed. First, we sought to confirm that parental depression predicts offspring lifetime depression and offspring difficult temperament, and that offspring difficult temperament predicts offspring major depression, while adjusting for family effect. Second, we sought to examine the pathoplasty model of the relationship between temperament and psychopathology by examining how offspring difficult temperament affects qualitative features of major depression - specifically, frequency, severity, and duration. Results indicate that high-risk offspring have more difficult temperament and are four times more likely to have lifetime major depressive disorder (MDD) than low-risk offspring. In addition, offspring with a difficult temperament are twice as likely to have lifetime MDD than low-risk offspring. Results from aim 2 revealed that difficult temperament predicts greater frequency of lifetime MDEs, but not severity or duration. Finally, individual dimensions of temperament were uniquely associated with frequency, severity, and duration of major depressive episodes differentially across risk groups. Implications and future research directions are discussed.