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Existential dynamic therapy (“VITA”) for treatment-resistant depression with Cluster C disorder: Matchedcomparison to treatment as usualGry Stålsett a , Tore Gude a , M. Helge Rønnestad b & Jon T. Monsen ba Modum Bad Clinic, Research Institute, Vikersund, Norwayb Psychology, University of Oslo, Oslo, NorwayPublished online: 12 Jun 2012.

To cite this article: Gry Stålsett , Tore Gude , M. Helge Rønnestad & Jon T. Monsen (2012) Existential dynamic therapy(“VITA”) for treatment-resistant depression with Cluster C disorder: Matched comparison to treatment as usual,Psychotherapy Research, 22:5, 579-591, DOI: 10.1080/10503307.2012.692214

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Existential dynamic therapy (‘‘VITA’’) for treatment-resistantdepression with Cluster C disorder: Matched comparisonto treatment as usual

GRY STALSETT1*, TORE GUDE1, M. HELGE RØNNESTAD2, & JON T. MONSEN2

1Modum Bad Clinic, Research Institute, Vikersund, Norway & 2Psychology, University of Oslo, Oslo, Norway

(Received 12 May 2011; revised 24 April 2012; accepted 25 April 2012)

AbstractExistential suffering may contribute to treatment-resistant depression. The ‘‘VITA’’ treatment model was designed for suchpatients with long-standing depression accompanied by existential and/or religious concerns. This naturalistic effectivenessstudy compared the VITA model (n �50) with a ‘‘treatment as usual’’ comparison group (TAU; n �50) of patients withtreatment-resistant depression and Cluster C comorbidity. The TAU patients were matched on several characteristicswith the VITA patients. The VITA model included existential, dynamic, narrative and affect-focused components. TheVITA group had significantly greater improvement on symptom distress and relational problems during treatment andfrom pre-treatment to 1-year follow-up. Patients in the VITA, at follow-up, were more likely to be employed and less likelybe using psychotropic medications.

Keywords: depression; spirituality and religion and psychotherapy; experiential/existential/humanistic psychotherapy;

psychoanalytic/psychodynamic therapy

Depression has become an epidemic disease of our

time (Honneth, 1995; Murray & Lopez, 1996;

WHO, 2010), affecting about 121 million people

worldwide, making it among the leading causes of

disability. Disturbingly, fewer than 25% of those

affected by depression have access to effective

treatment (WHO, 2010). Some of the barriers to

effective care include lack of trained providers, lack

of treatment options, and social stigma (American

Psychiatric Association Practice Guidelines for the

Treatment of Psychiatric Disorders, 2006). There is

also a lack of treatments matched to different types

of patients, different types of depression, and to

patients with comorbidity (e.g., Fava & Davidson,

1996; Fava & Rush, 2006; Guscott & Grof,

1991; Thase, 1996). Treatment-resistant depression

(TRD), often defined as no clear remission despite

more than three treatments, is a common clinical

presentation responsible for much of the burden of

major depressive disorder. TRD is estimated to

characterize more than one-third of depressed pa-

tients (Fava, 2003; Fava & Rush, 2006; National

Institue for Clinical Excellence, 2004). Clearly

there is a need for clinically relevant research on

treatment-resistant depression (Rush, Thase, &

Dube, 2003; Thase, 2001).

Many individuals with TRD have comorbid Clus-

ter C personality disorders, which might explain why

TRD is difficult to treat successfully (Driessen et al.

2010; Keitner, Ryan, Miller, Kohn, & Epstein, 1991;

Kornstein & Schneider, 2001; Petersen et al., 2002).

Cluster C personality disorders, which are character-

ized as anxious and fearful personality disorders, are

the most common personality disorders (American

Psychiatric Association, 2006) and complicate the

treatment of Axis I disorders; that is to say, patients

with Axis I disorders comorbid with Cluster C

personality disorders have poorer prognoses than

those without Cluster C comorbidity (Hardy et al.,

1995; Reich & Vasile, 1993; Shea et al., 1990). This

population of individuals*those with treatment-

resistant depression comorbid with Cluster C per-

sonality disorders (TRD/CCC)*do not function

well in society, as they are likely to be unemployed

or underemployed, have poor social relations

(e.g., being in dysfunctional relationships), rely on

government assistance, and entail high healthcare

costs. Clearly, this group of patients are personally

distressed and a burden to society in terms of cost,

Correspondence concerning this article should be sent to Gry Stalsett, Modum Bad Psychiatric Center, Badeveien Vikersund, 3370

Norway. Email: Gry.Stalsett@modum-bad.no

Psychotherapy Research, September 2012; 22(5): 579�591

ISSN 1050-3307 print/ISSN 1468-4381 online # 2012 Society for Psychotherapy Research

http://dx.doi.org/10.1080/10503307.2012.692214

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making it imperative that effective treatments be

identified and developed (Eaton et al., 2008; Moran,

2004; Murray & Lopez, 1996).

Individuals with TRD, whether or not comorbid

with Cluster C personality disorders, have by defini-

tion received prior courses of therapy for depression,

most likely antidepressant treatments as well as

evidence-based psychotherapies (e.g., CBT). Thus

these individuals have failed to respond to what are

considered first-line treatments for depression.

Although antidepressants and evidence-based pysh-

cotherapy have been shown to be effective treat-

ments for depression, it is clear that they are not

sufficiently effective for all individuals, as evidenced

by the prevalence of TRD. Consequently it is

necessary to employ other treatments and to develop

new treatments for this population.

In our clinical experience with TRD/CCC at

Modum Bad Clinic in Vikersund, Norway, we found

that many of these individuals expressed existential

issues involving religion, loneliness, meaningless-

ness, death, lack of freedom, fear of freedom, guilt

and shame. The existential orientation to psy-

chotherapy is grounded in the notion that pathology,

particularly anxiety and depression, is due to the

core issue of angst about the meaning of life and

death (Becker, 1973; Boss, 1979; May, Angel, &

Ellenberger, 1958; Schneider, 2007; Yalom, 1980).

The psychological function of a religious belief

system may serve as a primary means to ease

existential angst and manage the anxiety related to

the awareness of one’s mortality (see e.g., Vail et al.,

2011). Indeed, an intrinsic religious orientation,

which refers to an authentic internally motivated

faith and practice, is positively related to mental well-

being (e.g., Maltby & Day, 2000; Vail et al., 2011).

However, an extrinsic orientation to religion, which

refers to religious practices motivated by external

rewards (e.g., social status) or because it is required

for group membership, is related to neuroticism and

depression, racial prejudice and other indications of

psychological rigidity, and mitigates the adaptive

function of religion as a buffer to an existential fear

of death (Jonas & Fisher, 2006; Maltby & Day, 2004;

Vail et al., 2011). This is consistent with the

literature that suggests existential, spiritual or reli-

gious suffering can have a significant impact on

maintenance of depression and severe psychopathol-

ogy (e.g., Meissner, 1996; McConnel, Pargament,

Ellison, & Flanelly, 2006; Rizzuto, 1979).

Therefore it is worth considering treatments that

deliberately address religious and/or spiritual issues.

A recent meta-analysis by Worthington, Hook,

Davis, and McDaniel (2011) concluded that patients

receiving psychotherapies that accommodated the

patient’s religious and spiritual beliefs were efficacious

(i.e., superior to controls) on both psychological and

spiritual outcomes (e.g., being more like Jesus

Christ, spiritual well-being). However, this meta-

analysis also found that adding a spiritual and/or

religious component to already existing treatment

was not sufficient, as this addition had no effect on

psychological variables (although it did have an

effect on spiritual variables). Moreover, psychothera-

pies that are currently offered rarely directly address

existential issues (Ghaemi, 2001), and the concept of

God is often neglected as a topic in psychotherapy

(e.g., Bergin, 1991; Shafranske, 1996; Sperry &

Shafranske, 2005).

Based on our experience with TRD/CCC patients

at Modum Bad and the literature on psychological

issues related to religious/spiritual issues, we sought

to develop a treatment that integrated what is known

about treatment of depression and Cluster C per-

sonality disorders with a psychological focus on

existential and religious issues. The aim was to

integrate insights from the field of clinical psychology

of religion and existential psychotherapy (see Jones,

2010; Malitzky, 2010; Meissner, 1996; Richards,

2010; Rizzuto, 1979; Shafranske, 1992, 1996;

Stalsett, Engedal & Austad, 2010a; Yalom, 1980,

2007) rather than adding religious components (e.g.,

prayer, text from the Bible) to an already existing

treatment. The resulting treatment, which we called

VITA (so named because vita is Latin for life) is an

existential short-term dynamic group-oriented ther-

apy focused on the interweaving of affect, object

relations, narrative, and existential issues in a highly

structured inpatient program (see Stalsett et al.,

2010a).

In the first naturalistic effectiveness study of VITA

we determined that this new treatment approach was

safe, tolerated and effective (Stalsett, Austad, Gude,

& Martinsen, 2010). In this study, 40 patients*mostly suffering from depressive disorders with

additional anxiety and/or Cluster C personality

disorders*completed 12 weeks of the VITA treat-

ment. These patients experienced significant reduc-

tion in depressive symptoms and a reduction in

personality disorder symptoms at treatment termi-

nation and at 1-year follow-up, and had improved

occupational functioning at 1-year follow-up. The

patients’ relational patterns moved towards in-

creased self-representation (e.g., self-confidence,

self-worth, being active in the world) and reduced

submissiveness and over-conscientiousness. This

naturalistic study was inconclusive because it lacked

controls to rule out threats such as natural history,

regression toward the mean, etc. For example, it

might well have been that the 12-week stay in a

residential program provided sufficient respite from

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the stress of everyday life for these patients to show

remarkable improvement.

Before designing a randomized clinical trial of

VITA, we wanted to collect additional evidence

that VITA was effective. Therefore, we designed a

matched-comparison study in which patients treated

in VITA were compared to matched controls treated

at Modum Bad in a similar residential context, which

we termed treatment as usual (TAU). This study

addressed the following research question: Will

patients in VITA demonstrate greater improvement

on symptoms, interpersonal functioning, employ-

ment and medication use than matched comparison

TAU patients at post-treatment and at follow-up?

Methods

Design

The present study used a matched-comparative

study in a naturalistic setting to examine how

patients who experienced the VITA treatment model

performed at termination and 1-year follow-up

compared to patients who received treatment as

usual (TAU) in an earlier period at the hospital

before VITA was an option.

Participants

The study samples for the VITA and TAU groups

were recruited from patients admitted to Modum

Bad Clinic, Norway, a national hospital for non-

psychotic patients, often considered the ‘‘end-of-the-

line’’ for patients unresponsive to prior treatments.

Modum Bad offers specialized programs for a

variety of long-standing disorders including chronic

depression, typically with Axis II comorbidity, the

treatment for which involves a 3-month residential

program. At intake all patients were assessed, given a

diagnosis (either ICD or DSM), and completed

various screening instruments, including the Beck

Depression Inventory, the Symptom Checklist 90,

and the Inventory of Interpersonal Problems.

Patients participating in both treatments were

recruited from patients seeking treatment at Modum

Bad but who were not referred for specialized care

(e.g., referred to an eating disorder, panic, or

agoraphobia unit). Patients were exluded if they

exhibited or had recent history of destructive im-

pulsivity (i.e., were dangerous to self or others),

recent psychotic episodes, or recent suicide at-

tempts, as Modum Bad is not an acute clinic but

offers psychotherapy as a third line of the Norwegian

mental healthcare system. All patients who were

screened had prior unsuccessful combinations of

inpatient, outpatient, and medication treatment.

About 8% of persons applying for treatment at

Modum Bad met the inclusion criteria for TAU

and for VITA.

VITA Treatment Participants

Out of that pool of candidates who expressed

existential issues, 188 were referred for evaluation

for the VITA project on the basis of having indicated

in their application that religious or existential issues

were a long-lasting part of their mental distress. The

188 applicants were assessed during a two-day pre-

examination in which their ‘‘affect consciousness’’

for nine specific affects was assessed by the semi-

structured Affect Consciousness Interview (Monsen,

Eilertsen, Melgard, & Ødegard, 1996) to determine

whether their affective experience or affective orga-

nization was related to a representation of God. The

inclusion criteria were that the patients expressed

specific emotions (e.g., shame, fear, anger) related to

God, whether or not they believed in God, reported

existential issues related to psychological distress,

were depressed, were diagnosed with Cluster C

personality disorder, did not have other specific

diagnoses (e.g., eating disorders), were willing to

receive group therapy, and agreed to focus in therapy

on their existential and religious issues from a

psychological perspective.

In all, 72 patients met the criteria for the VITA

treatment and received the treatment. As described

below, 50 of these patients were included in the

present study based on being matched with patients

in the TAU group (i.e., only 50 patients could be

matched at the proper levels of the matching

variables with particular TAU patients). The Axis I

and Axis II diagnoses of the 50 patients in this

condition are presented in Table I. All of the patients

were diagnosed with depressive disorders (major

depressive disorder, dysthymic disorder, or depres-

sive scores above the clinical cutoff for depression on

the Beck Depression Inventory, i.e., above 15, mild

Table I. Axis I and II diagnoses at pre-treatment in matched

samples of VITA and TAU

VITA TAU

n % N %

Axis I

Major depressive disorder 40 80 30 60

Dysthymic disorder 15 30 16 32

Agoraphobia 6 12 1 2

Panic disorder 12 24 9 18

Social phobia 3 6 6 12

Generalized anxiety disorder 9 18 9 18

Axis II

Single Cluster C diagnosis 31 62 32 64

Multiple Cluster C diagnoses 19 38 18 36

VITA existential dynamic therapy 581

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depression) based on referral information and Mod-

um Bad clinical assessment. All patients received one

Cluster C diagnosis (n�31) or multiple Cluster C

diagnoses (n�19).

Treatment-as-usual participants. The com-

parison group (TAU) patients received treatment as

usual, a group-oriented therapy at Modum Bad

Psychiatric Center that was offered before the VITA

program was established. These patients completed

the outcome measues as part of a study of Cluster C

patients (Gude & Vaglum, 2001). The inclusion

criteria for these TAU patients were the same as for

the VITA group, except that the patients did not need

to reveal specific emotions (e.g., shame, fear, anger)

related to God although they may well have revealed

emotions related to God. The exclusion criteria were

identical to those for the VITA group (e.g., no

destructive impulsivity, recent psychotic episodes, or

recent suicide attempts, other specific disorders, etc.).

To develop a comparison group, 50 VITA patients

were successfully matched with 50 patients receiving

treatment as usual. Matching criteria were based on

diagnoses and on level of severity of pathology at

intake. Patients selected for the TAU group had to

have a depressive diagnosis (either major depressive

disorder, dysthymia, or depressive scores above the

clinical cutoff for depression on the Beck Depression

Inventory). Patients were also matched to VITA

patients based on their scores on the Beck Depres-

sion Inventory, the Symptom Checklist-90-R, and

the Inventory of Interpersonal Problems (see below

for description of the inventories).

Patient characteristics and demographics.

The diagnoses of the patients and the initial scores

on the inventories are presented in Table I and

Table II. The four TAU patients who did not meet

criteria for a DSM depression diagnosis had high

depression scores on the BDI. To ensure compar-

ability of the diagnoses in the two groups, two

psychiatrists, blind to treatment condition and not

involved in the treatment, independently reviewed

the pre-treatment charts and confirmed the depres-

sion diagnoses and Cluster C diagnoses for all

patients in VITA and TAU. The 50 VITA subjects

(29 women, 21 men) ranged in age from 28 to

62 years (m�43) and the 50 TAU subjects (28

women, 22 men) ranged in age from 23 to 57 years

(m�41). Both VITA and TAU patients reported an

average of three prior unsuccessful treatments. To

allay concerns that the 50 VITA patients who were

able to be matched with TAU patients differed from

the other 22 VITA patients, pretest scores on the

three outcome measures, as well as age and gender,

were compared. There were no significant differ-

ences on any variable (all p values �.28).

Assessment Measures

The following outcome battery was used for both

treatment conditions, at pre-treatment (T1), at post-

treatment (T2), and at 1-year follow-up (T3).

The Symptom Checklist-90. The Symptom

Checklist -90-R (SCL-90-R) has been widely used

in both clinical and research settings to evaluate

general psychopathology (Derogatis, 1977; Derogatis,

Lipman, & Covi, 1973; Smitz, Hartkamp, & Franke,

2000). The SCL-90-R is a 90-item self-report

symptom inventory for the assessment of psycholo-

gical symptoms and psychological distress scored

on a 0 (not at all) to 4 (extremely) scale. The Global

Severity Index (GSI), which is the mean score of

all items and is a global measure of psychological

symptoms and distress, was used in this study. The

test-retest reliability and internal consistency of

Table II. Means, standard deviations, effect sizes, and test statistics for outcome measures

Pre-treatment

(T1)

Post-treatment

(T2)

One-year

follow-up

(T3) Effect

size

Effect

size

Effect

size F time F treatment F T�T

Treatment condition Mean SD Mean SD Mean SD T1�T2 T2�T3 T1�T3

SCL-90-R

VITA 1.27 .54 .75 .49 .57 .41 1.01 .40 1.47

TAU 1.28 .51 1.01 .56 1.08 .60 .51 .12 .36 42.1*** 9.0** 11.3***

BDI

VITA 22.32 7.78 10.44 7.40 8.64 7.24 1.57 .25 1.80

TAU 20.06 8.50 14.94 9.11 16.74 10.82 .58 .18 .34 56.0*** 6.6* 16.1***

IIP

VITA 1.67 .63 1.30 .67 .99 .61 .57 .49 1.11

TAU 1.62 .51 1.46 .62 1.47 .59 .28 .02 .27 36.7*** 3.4 14.6***

Note. Effect size �Cohens d: (pretest mean � posttest mean)/SDpooled..

* pB.05, ** pB.01, *** pB.001.

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SCL-90-R have been found acceptable (Derogatis,

1977).

The Beck Depression Index. The Beck Depres-

sion Inventory (BDI: Beck, Steer, & Garbin, 1988) is

a widely used 21-item measure self-report instru-

ment for assessing severity of depression. Each item

is scored from zero (symptom not present) to three

(symptom experienced extremely); scores between

10 and 19 indicate mild depression, 20 to 29 indicate

moderate depression, and above 30 indicate major

depression.

The Inventory of Interpersonal Problems.

The Inventory of Interpersonal Problems (IIP;

Horowitz, Rosenberg, Baer, Ureno, & Villasenor,

1988) is a self-report instrument developed to assess

interpersonal problems. The present study used the

48-item version of the IIP, which was derived from

the original 127 items (Horowitz et al., 1988). This

48-item version has demonstrated adequate validity,

reliability, and internal consistency (Gude, Moum,

Kaldestad, & Friis, 2000). IIP is scored on a scale of

0 to 4. There are six subscales but only the mean

score of all items is reported in this study. The mean

total score for a non-clinical population was .53

(SD�.31; Pedersen, 2002).

Medication use and employment status. The

use of tranquilizers and anti-depressants as well

as employment status were assessed dichoto-

mously (0�not medicated/employed, 1�medicated/

employed) at pre-treatment and at follow-up. At pre-

treatment, medication use and employment status

were established by the referring physician and at

follow-up by a Modum Bad psychiatrist, based on

patient self-report.

Description of Treatments

VITA program. The VITA program’s main

components, as shown in Figure 1, involve an

Figure 1. VITA program components and strategies.

VITA existential dynamic therapy 583

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intensive study of affective connections in social

relationships among belief systems and ultimate

concerns (e.g., death, meaning, isolation, etc.) (see

Kernberg, 1988, 2000; Malan, 1979; Monsen &

Monsen, 1999; Rizzuto, 1979). Each existential

issue is addressed in relation to time (past, present,

and future), narrative construction (e.g., a broken

life or unlived life), relational space (e.g., alone, in

dyads, etc.), relational history, and defenses and

affects (Yalom, 1980, 2007; see also Spence,1982;

White & Epston, 1990).

The VITA program is designed to teach patients to

be mindful of affect by registering affects as events in

a non-judging way: ‘‘being aware in a ‘being mode’’’

(Kabat-Zinn, 1990; Segal, Williams, & Teasdale.

2002). Patients are encouraged to mentalize by

differentiating between one’s own affects and others’

(quite similar to Bateman and Fonagy, 2006, and

Fonagy, Gergely, Jurist and Target, 2002), and to

meta-reflect to obtain a broader and flexible per-

spective or ‘‘bird’s eye view’’ (some similarties to

metacognitive insight in Teasdale et al., 2002, and

Semerari et al., 2003). These strategies are hypothe-

sized as crucial to deal with patients’ existential

suffering and to address and loosen the grip of rigid

belief systems, often referred to as extrinsic orienta-

tion toward religion, that are embedded in their life

stories by acquiring a coherent understanding of how

existential suffering and rigid beliefs contribute to

their problems. As opposed to many treatments,

VITA directly addresses religious beliefs and their

dynamic origins.

VITA treatment activities (Figure 2) were carefully

designed to implement VITA strategies and achieve

the VITA goals. For example, art therapy develops

emotional awareness, integration and mentalization

by repeated painting of oneself, mother, father, and

God. Narrative groups share and transform percep-

tion and affect-related memories of key life stories.

Daily diaries process daily issues and enhance affect

processing and mindfulness. The End of Week

Reflection Group encourages ‘‘meta-reflection’’ on

universal concerns. The Daily Meditation (Mind-

fulness) Group trains patients in mindfulness to find

‘‘the quiet eye in the storm.’’ Physical exercise groups

are used to promote health and social activity.

Evaluation Groups assessed monthly treatment pro-

gress. Psychoeducation teaches the purpose and

importance of each program component. A more

complete description of VITA, including theoretical

bases, treatment integration, and case example, as

well as critiques, are found elsewhere (Jones, 2010;

Malitzky, 2010; Richards, 2010; Stalsett et al.,

2010a, 2010b).

Adherence to the VITA protocol was ensured in

several ways. First, two of the therapists in theVITA

program were developers of the treatment. Treat-

ment personnel had an agreement on treatment

principles and strategies, specific and detailed in-

structions for group activities existed and were

followed, and treatment developers (therapist as

well as non-therapist developers) and supervisiors

observed therapy live (through one-way mirrors) and

with videotapes. The treatment team and developers

met twice daily to discuss treatment adherence and

ensure that therapist actions were consistent with

VITA principles.

Figure 2. Comparison of treatment components in TAU and VITA.

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Treatment As Usual (TAU). The TAU group

was drawn from the regular Modum Bad inpatient

treatment programs. The treatment was, generally

speaking, psychodynamically based residential treat-

ment programs, with eclectically chosen cognitive

strategies, offered in group format augmented by

individual treatment once per week. The TAU

program was similar to VITA in its number of

activities and structure (see Figure 2), although

there was no psychoeducation for TAU as there

was for VITA. Instead, the TAU patients worked on

goal-setting with the nursing staff. The TAU group

received the same amount of dynamic group therapy

(twice a week), with staff behind a one-way mirror,

and individual therapy (once a week), but without

the deliberately intensive focus on object relations

(including God) and affects. Patients in the TAU

worked on dynamic issues often in a here-and-now

context, exploring feelings towards toward staff

members and other patients in different group

settings. Religious and existential issues were occa-

sionally reflected upon, but were not an intentional

treatment focus.

The TAU weekly activities are listed in Figure 2.

The TAU program activities were designed to

explore issues arising in group and individual ther-

apy. As in VITA, TAU dynamic group therapy

focused on interaction within the group; for exam-

ple, relational patterns were addressed to increase

patients’ awareness of their impact on behavior. Art

Therapy, as in traditional occupational therapy,

involved painting, crafts, woodworking, and collage

making, to elicit group issues and creative expres-

sion. Movement therapy encouraged bodily expression

of personal and relational topics, and Physical exercise

groups were designed to promote health and social

activity.

VITA and TAU differences and similarities.

VITA patients identified existential distress, isola-

tion, lack of meaning, shame and guilt, which were

often related to inner objects, whereas TAU patients

had not been screened in those terms. VITA and

TAU patients received in-depth examination of

affects through the Affect Consciousness Interview

(ACI; Monson et al., 1996), although VITA focused

on religious and spiritual/existential concerns in each

component of the program, whereas the TAU group

did not give systematic attention to existential issues.

Both VITA and TAU involved the standard

Modum Bad 3-month inpatient residential treat-

ment, with therapeutic interventions delivered dur-

ing the day. There were nursing staff on duty if TAU

patients wanted to talk during the night, but it was

optional. VITA patients did not have night staff

although there were general hospital staff members

on duty for emergencies. The night time differences

were due to different philosophies of care and not

because one group of patients was perceived as more

impaired than the other. The developers of VITA

believed that night staff facilitated dependency and

regression. Therefore the VITA program taught

patients to deal with suffering by writing in diaries,

excercising ‘‘mindfulness,’’ and working on ‘‘the

capacity to be alone’’ until they were able to speak

with staff during the day. The focus on autonomy at

night was a part of the VITA philosophy (noted in

Figure 2).

Medication in both conditions was managed by

the psychiatrist and nurse on staff. The personnel in

both groups attempted to reduce reliance on med-

ications to control symptoms, although this perspec-

tive was explicitly explained to the patients in VITA.

VITA and TAU Therapists

Both TAU and VITA utilized one psychologist, one

psychiatrist, one psychiatric nurse and one art

therapist. In the TAU condition, the personnel

occasionally changed between cohorts of patients.

The original VITA personnel had all been TAU

therapists, although when changes were made the

new personnel added to VITA had not been TAU

therapists. In TAU, one additional nurse served

during evenings and nights.

Statistical Analyses

To test whether the two treatment groups changed

differently on the SCL-90-R, BDI and IIP across

time, pre-treatment (T1), post-treatment (T2), and

1-year follow-up (T3), a repeated measures (pre-,

post-, follow-up) MANOVA was employed, with

particular attention to the treatment by time inter-

action. If the MANOVA yielded a significant

(p B.05) interaction term, the scores of each instru-

ment were analyzed separately with repeated-mea-

sures ANOVAs. To understand changes in each

phase, effect sizes were computed by taking the

difference of the means of the measures for the

respective phases and dividing by the pooled stan-

dard deviations (i.e., Cohen’s d; Cohen, 1977). Chi-

square tests were used for categorical data on

employment status and medication use.

Results

The means and standard deviations at pre-test, post-

test, and follow-up for the SCL-90-R, BDI, and IIP

are presented in Table II and illustrated in Figure 3.

The repeated measures MANOVA performed on the

SCL-90-R, BDI and IIP revealed a significant time

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Figure 3. Means scores for VITA and TAU at pretreatment, posttreatment, and follow-up.

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effect (F(6,93) �25.53, pB.001), a significant

treatment effect (F(3,96) �3.13, pB.029), and

a significant time by treatment interaction,

(F(6,93) �6.33, pB.001). Thus it appears that

patients in both groups improved but that the

VITA treatment was clearly superior to the TAU.

The significant effects in MANOVA led to the

following univariate analyses.

The univariate analyses yielded significant differ-

ences in scores on all three measures for effects of

time (SCL-90-R, F�42.1, pB.001; BDI, F�56.0,

pB.001; IIP, F�36.7, pB.001). The effects for

treatment were significant for the SCL-90-R and the

BDI (SCL-90-R, F�9.0, p�.003; BDI, F�6.6,

p�.01) but not for IIP (F�3.4, p�.67). Impor-

tantly, the time-by-treatment interactions were

highly significant for all three measures (SCL-

90-R, F�11.3, pB.001; BDI, F�16.1, pB.001;

IIP, F�14.6, pB.001).1

The pattern of change for VITA and TAU can be

understood by examining Figure 3 and Table II.

From pre- to post-treatment (T1-T2), VITA de-

monstrated medium to large effect sizes (viz., 1.01,

1.57, .57 for the SCL-90-R, BDI, and IIP, respec-

tively), while TAU showed small to medium effect

sizes (viz., .51, .58, .28 for the SCL-90-R, BDI, and

IIP, respectively). From post-treatment to follow-up

(T2-T3), VITA demonstrated small to moderate

effect sizes (viz., .40, .25, .49 for the SCL-90-R,

BDI, and IIP, respectively), while TAU showed small

effect sizes (viz., .12, .18, .02 for the SCL-90-R,

BDI, and IIP, respectively). The differences between

VITA and TAU are most apparent when the overall

change from pre-treatment to 1-year follow-up

(T1-T3) is examined. The effect sizes for VITA

improvement were very large (viz., 1.47, 1.80, 1.11

for the SCL-90-R, BDI, and IIP, respectively),

whereas TAU effects were small (viz., .36, .34, .27

for the SCL-90-R, BDI, and IIP, respectively). The

superiority of VITA at post-treatment was amplified

at follow-up because the VITA patients continued to

make progress after the treatment was terminated.

With regard to employment and medication, Table

III shows the proportions of employed, anti-depressant

use, and tranquilizer use at pre-treatment (T1) and

1-year follow-up (T3) for the VITA and TAU. The

increase in employment from pre-treatment to 1-year

follow-up was significantly higher in VITA than in

TAU (x2�9.49, p�.004); the decrease in medication

use from pre-treatment to follow-up was signficinatly

greater in VITA than for TAU (x2�32.00, pB.001

for antidepressants x2�25.00, pB.001 for tranquili-

zers). The reduction of medication use to 8% for the

VITA patients is quite remarkable given the initial use

of medication in this group was roughly twice as great

for these patients as it was for the TAU group before

treatment (44% v 20%).

Discussion

This naturalistic effectiveness study compared the

VITA model (n �50) with a matched ‘‘treatment as

usual’’ comparison group (TAU; n �50) for patients

with treatment-resistant depression and Cluster C

comorbidity (TRD/CCC) with existential and reli-

gious issues. The primary result is that patients who

received VITA showed remarkable improvement

relative to their initial level of functioning as well as

to TAU. First, there was significant improvement in

depression, general symptoms, and interpersonal

functioning in both the VITA and TAU groups

from pre- to post-treatment, although the effects

for VITA were roughly twice the size of the effects for

TAU. Second, VITA patients made significant gains

after completion of the treatment (i.e., from post-

treatment to 1-year follow-up) whereas the TAU

group maintained their gains but did not continue to

improve. TAU effects from pre-treatment to post-

treatment and follow-up were small to modest; that

is to say, improvement for the TAU patients was not

remarkable, whereas it appears that VITA patients

experienced relatively large benefits from the treat-

ment. Third, 1 year after treatment, patients in the

VITA group were much more likely to be employed

and less likely to be using psychotropic medication

relative to pre-test and relative to the TAU patients

at follow-up. That the VITA patients did not relapse

after termination but instead continued to improve,

a relatively rare event in the treatment of chronic

mental health disorders, should be noted. Consider-

ing the functional impairment of this population and

the associated costs to society, the promising results

of the VITA treatment should be noted.

Table III. Employment and use of medication at pre-treatment and 1 year follow-up

VITA TAU

Pre-treatment 1-year follow-up Pre-treatment 1-year follow-up Between treatment x2 at follow-up

Employed 8 (16%) 48 (96%)* 8 (16%) 37 (74%)* 9.49 pB.01

Antidepressant 22 (44%) 4 (8%)** 10 (20%) 31 (62%)** 32.00 pB.001

Tranquilizers 13 (26%) 0 (0%)*** 6 (12%) 20 (40%)*** 25.00 pB.001

*p B .05, **p B .01, ***p B .001.

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It appears that VITA is a viable and effective

treatment for patients with treatment-resistant

depression comorbid with Cluster C personality

disorder and who have expressed existential and

religious issues as a significant part of their suffering.

It appears that VITA’s in-depth focus on blocked

affects (i.e., anger blocked by shame and guilt; see

Kernberg, 1988, 2000; Malan, 1979; Monsen &

Monsen, 1999; McCullough-Vaillant, 1994, 1997;

Rizzuto, 1979; Yalom, 1995) might have contributed

to the positive outcome in this study. Furthermore,

VITA’s development of affect integration (Monsen &

Monsen, 1999), regulation of affects through mind-

fulness (Kabat-Zinn,1990; Segal et al., 2002), men-

talization exercises (e.g., Fonagy et al., 2002;

Malitzky, 2010; Stalsett et al., 2010a), and emphasis

on meta-reflection might have built the capacity to

tolerate ambiguity in life and withstand the ups and

downs in living that often lead to relapse (e.g.,

Hanna & Ottens, 1995; Teasdale et al., 2002).

However, the present study is not sufficient to

identify active ingredients and consequently we

have started intensive process research to better

examine the process of change.

The major limitation of this study is that it is not a

randomized clinical trial. VITA patients may have

differed from TAU patients in openness and will-

ingness to address psychologically existential and

religious concerns, since only the VITA patients were

screened for that purpose to be included in a new

treatment approach. The VITA patients’ knowledge

that they were part of a new and special venture

within the hospital may have created expectancy

effects. As well, the VITA therapists, some of whom

were involved in the development of VITA, may have

been more enthusiastic, been more involved in the

treatment, had greater allegiance, and been more

confident that the treatment would be successful

than they were when they delivered the TAU.

Moreover, matching can never ensure comparability

in the way that randomization does and there could

be unobserved differences that account for the

obtained results.

There is an important limitation related to the unit

of analysis. The treatment was delivered in groups as

well as individual format, which creates a partially

nested structure*patients within therapists and

within groups. As is typical of such treatment

studies, the nested structure was not modeled, given

the small number of upper-level units and the

complex partial nesting (e.g., some members of a

group had different individual therapists). The issues

with expectancy and nesting might interact in that

the enthusiasm for the VITA treatment might have

created a more therapeutic interaction in the groups.

In this way, the enthusiasm of a single patient might

have affected the others in the groups.

There are a number of other methodological

limitations. The patient diagnostic method was not

constant, as some patients were diagnosed with

structured interviews and others were not; however,

the retrospective chart reviews were applied consis-

tently with all patients. All outcome measures were

self-report and there were no independent clinician

or assessor ratings. Outcome measures, although

varied (viz., symptoms, interpersonal functioning,

depression, medication use, and employment), did

not assess personality directly, which is a limitation

because the patients exhibited cluster C features.

Patients, when discharged, were referred to their

community outpatient services, but no information

was available for either group about type or intensity

of follow-up treatment, other than self-reported

medication use. The present study involved intensive

residential treatment and it would be important to

adapt and test the VITA treatment for outpatient

use.

Despite the limitations, particularly around the

issues of using a non-randomized control group, it is

important to note that the patients in the matched

comparison group (i.e., TAU) were selected based

on diagnoses, psychological symptoms, and inter-

personal functioning, and were treated in the same

institution, with a viable and accepted treatment,

with a comparable intensity of therapy. This study

met Leichsenring’s (2004) criteria for the highest

level of naturalistic studies and provides strong,

although preliminary, evidence for the effectiveness

of VITA. It is now appropriate for VITA to be tested

with a randomized clinical trial for treatment-resis-

tant depression comorbid with Cluster C patients

who express existential issues.

This treatment-resistant population may have

responded as well as they did to the VITA treatment

because they received what they came for, namely

to address their existential suffering and religous

ambivalence. Clinicians treating treatment-resistant

depression should consider addressing the psycholo-

gical functioning of patients’ internal representations

of God and their related adaptive or maladaptive

affect integration and relationships. The integrated

existential and psychodynamic focus on facilitating

a transformation of patients’ rigid inner representa-

tions of self and others tailored to individual

patients’ treatment needs has been shown to be

safe and well-tolerated. For more than three decades

Allen Bergin (1980, 1991; Bergin & Richards, 2000)

has challenged the psychotherapy community to

embrace and address religious issues and values

as important and potentially helpful aspects of

therapy.

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Acknowledgments

We are grateful for the contributions of Leigh

McCullough, John Roosevelt Boettiger, and Bruce

Wampold in conducting the research and preparing

the manuscript.

Note1 A potential threat to the validity of this study is that the 50 VITA

patients who were matched to the 50 TAU patients were not

representative of the 72 VITA patients. That is, the 50 patients

may be a biased sample of VITA patients. To examine this

threat, we also conducted the same analyses reported herein

with all 72 patients in the VITA conditions versus the 50 TAU

patients. For all three variables (viz., SCL-90-R, BDI and IIP)

the treatment (VITA vs. TAU) by time (pre, post, follow-up)

interaction were statisically significant (all psB.001).

References

American Psychiatric Association, APA. (1994). Diagnostic and

Statictical Manual of Mental Disorders: DSM IV. Washington

DC: American Psychiatric Association.

American Psychiatric Association Practice Guidelines for the

Treatment of Psychiatric Disorders. (2006). Washington DC:

American Psychiatric Association.

Bateman, A., & Fonagy, P. (2006). Mentalization-based treatment

for borderline personality disorder: A practical guide. Oxford:

Oxford University Press.

Beck, A.T., Steer, R.A., & Garbin, M.G. (1988). Psychometric

properties of the Beck Depression Inventory: Twenty-five years

of evaluation. Clinical Psychology Review, 8, 77�100.

Becker, E. (1973). The denial of death. New York: The Free Press.

Bergin, A.E. (1980). Psychotherapy and religious values. Journal

of Consulting and Clinical Psychology, 48, 95�105.

Bergin, A.E. (1991). Values and religious issues in psychotherapy

and mental health. American Psychologist, 46, 394�403.

Bergin, A.E., & Richards, S. (2000). Handbook of psychotherapy

and religious diversity. Washington DC: American Psychological

Association.

Boss, M. (1971/1979). Existential foundations of medicine and

psychology. New York: Jason Aaronson.

Cohen, J. (1977). Statistical power analysis for the behavioral

sciences. New York: Academic Press.

Derogatis, L.R. (1977). The SCL-90-R: Administration, scoring and

procedures. Manual I. Baltimore, MD: Clinical Psychometric

Research.

Derogatis, L.R., Lipmann, R., & Covi, L. (1973). SCL-90:An

outpatient psychiatric rating scale-preliminary report.

Psychopharmacology Bulletin, 19, 13�28.

Driessen, E., Cuijpers, P., de Maat, S.C., Abbass, A.A., de

Jonghe, F., & Dekker, J. (2010). The efficacy of short-term

psychodynamic psychotherapy for depression: A meta-analysis.

Clinical Psychology Review, 30, 25�36.

Eaton, W.W., Martina, S.S., Nestadt, G., Bienvene, O.J.,

Clarke, D., & Alexandre, P. (2008). The burden of mental

disorders. Epidemiological Review, 30, 1�14.

Fava, M. (2003). Diagnosis and definition of treatment�resistant

depression. Biological Psychiatry, 53, 649�659.

Fava, M., & Davidson, K.G. (1996). Definition and epidemiology

of treatment�resistant depression. Psychiatric Clinics of North

America, 19, 179�200.

Fava, M., & Rush, A.J. (2006). Current status of augmentation

and combination treatments for major disorder: A literature

review and a proposal for a novel approach to improve practice.

Psychotherapy and Psychosomatics, 75, 139�153.

Fonagy, P., Gergely, G., Jurist, G.L., & Target, M. (2002). Affect

regulation, mentalization and the development of the self. New

York: Other Press.

Ghaemi, N.S. (2001). Rediscovering existential psychotherapy:

The contribution of Ludwig Binswanger. American Journal of

Psychotherapy, 55, 51�64.

Gude, T., Moum, T., Kaldestad, E., & Friis, S. (2000). Inventory

of interpersonal problems: A three-dimensional balanced and

scalable 48-item version. Journal of Personality Assessment, 74,

296�310.

Gude, T., & Vaglum, P. (2001). One-year follow-up of patients

with cluster C personality disorders: a prospective study

comparing patients with ‘‘pure’’ and comorbid conditions

within cluster C, and ‘‘pure’’ C with ‘‘pure’’ cluster A or B

conditions. Journal of Personality Disorders, 15, 216�228.

Guscott, R., & Grof, P. (1991). The clinical meaning of refractory

depression: a review for the clinician. American Journal of

Psychiatry, 148, 695�704.

Hanna, F.J., & Ottens, A.J. (1995). The role of wisdom in

psychotherapy. Journal of Psychotherapy Integration, 5, 195�217.

Hardy, G.E., Barkham, M., Shapiro, D.A., Rees, A., Reynolds, S.,

& Stiles, W.B. (1995). Impact of Cluster C personality

disorders (Avoident, Dependent, Obsessive-Compulsive) on

outcomes of contrasting brief psychotherapies for depression.

Journal of Consulting and Clinical Psychology, 63, 997�1004.

Honneth, A. (1995). The struggle for recognition, the moral grammar

of social conflicts. Cambridge, MA: Polity Press.

Horowitz, L.M., Rosenberg, S.E., Baer, B.A., Ureno, G., &

Villasenor, V.S. (1988). Inventory of interpersonal problems:

Psychometric properties and clinical applications. Journal of

Consulting and Clinical Psychology, 56, 885�892.

Jonas, E., & Fischer, P. (2006). Terror management and religion.

Evidence that intrinsic religiousness mitigates worldview de-

fense following mortality salience. Journal of Personality and

Social Psychology, 91, 553�567.

Jones, J.W. (2010).Commentary on the persecuting God and the

crucified self: The case of Olav and the transformation of his

pathological self-image. Psychotherapeutic change and spiritual

transformation: The interaction effect. Pragmatic Case Studies in

Psychotherapy 6, 109�111. http://pcsp.libraries.rutgers.edu.

Kabat-Zinn, J. (1990). Full catastophe living.Using the wisdom of

your body and mind to face stress, pain, and illness. New York:

Dealcorte.

Keitner, G.I., Ryan, C.E., Miller, I.W., Kohn, R., & Epstein, N.B.

(1991). 12-month outcome of patients with major depression

and comorbid psychiatric or medical illness (compound

depression). American Journal of Psychiatry, 148, 345�350.

Kernberg, O.F. (1988). Object relations theory in clinical practice.

Psychoanal Quarterly, 57, 481�504.

Kernberg, O.F. (2000). Psychoanalytic perspectives on the

religious experience. Journal of Psychotherapy, 54, 452�476.

Kornstein, S.G., & Schneider, R.K. (2001). Clinical features of

treatment resistant depression. Journal of Clinical Psychiatry, 6,

18�25.

Leichsenring, F. (2004). Randomized controlled versus naturalis-

tic studies: A new research agenda. Bulletin of the Menninger

Clinic, 68, 137�151.

Malan, D. (1979). Individual psychotherapy and the science of

psychodynamics. London: Butterworth Press.

Malitzky, M.S. (2010). Commentary on the persecuting God and

the crucified self: The case of Olav and the transformation of

his pathological self-image. Dissolution of ‘‘The Committee’’:

mentalization and psychic transformation in the case of Olav.

Pragmatic Case Studies in Psychotherapy, 6, 118�125. http://

pcsp.libraries.rutgers.edu.

VITA existential dynamic therapy 589

Dow

nloa

ded

by [

Uni

vers

ite D

e Pa

ris

1] a

t 12:

24 0

5 Se

ptem

ber

2013

Maltby, J., & Day, L. (2000). Depressive symptoms and religious

orientation: examining the relationship between religiousity

and depression within the context of other correlates of

depression. Personality and Individual Differences, 28, 383�393.

Maltby, J., & Day, K. (2004). Should never the twain meet?

Integrating models of religious personality and religious

mental health. Personality and Individual Differences, 36, 1275�1290.

May, R., Angel, E., & Ellenberger, H.F. (Eds.). (1958). Existence:

A new dimension in psychiatry and psychology. New York: Basic

Books.

McConnel, K.M., Pargament, K.I., Ellison, C.G., & Flanelly, K.J.

(2006). Examining the links between spiritual struggles and

symptoms of psychopathology in a national sample. Journal of

Clinical Psychology, 62, 1469�1484.

McCullough-Vaillant, L. (1994). The next step in short term

dynamic psychotherapy. Psychotherapy, 67, 134�144.

McCullough-Vaillant, L. (1997). Changing character: An anxiety

regulating model of short term dynamic psychotherapy. New York:

Perseus Books.

Meissner, W.W. (1996). The pathology of beliefs and the beliefs of

pathology. In E.P. Shafranske (Ed.), Religion and the clinical

practice of psychology (pp. 241�267). Washington DC: American

Psychological Association.

Monsen, J.T., Eilertsen, D.E., Melgard, T., & Ødegard, P. (1996).

Affects and affect consciousness. Initial experience with the

assessment of affect integration. Journal of Psychotherapy

Practice and Research, 5, 238�249.

Monsen, J.T., & Monsen, K. (1999). Affects and affect

consciousness: A psychotherapy model integrating Silvan

Tomkins’s affect- and script theory within the framework of

self psychology. In A. Goldberg (Ed.), Pluralism in self

psychology: Progress in self psychology. Hillsdale, NJ: The Analytic

Press.

Moran, M. (2004). More workers getting treatment for depres-

sion, but it’s inadequate. Health Care Economics. Psychiatric

News, 39(6), 9�14.

Murray, C.J.L., & Lopez, A.D. (Eds.). (1996). The global burden of

disease. A comprehensive assessment of mortality and disability from

diseases, injuries, and risk factors in 1990 and projected to 2020.

Cambridge, MA: Harvard School of Public Health.

National Institute for Clinical Excellence. (2004) Depression:

Management of depression in primary and secondary Care. Clinical

Guideline 23. http://www.nice.org.uk/CG023NICEguideline.

Pedersen, G. (2002). Norsk revidert versjon av Inventory of

Interpersonal Problems-Circumplex (IIP-C). Tidsskrift for

Norsk Psykologforening, 39, 25�34.

Petersen, T., Hughes, M., Papakostas, G.I., Kant, A., Fava, M.,

Rosenbaum, J.F., & Nierenberg, A.A. (2002). Treatment-

resistant depression and Axis II comorbidity. Psychotherapy

and Psychosomatics, 71, 269�274.

Reich, J.H., & Vasile, R.G. (1993). Effects of personality disorders

on the outcome of axis I conditions. Journal of Nervous and

Mental Disorders, 181, 475�484.

Richards, P.S. (2010). Commentary on the persecuting God and

the crucified self: The case of Olav and the transformation of

his pathological self-image. The role of religion and spirituality

in Olav’s treatment and recovery: Commentary on an exemp-

lary case report. Pragmatic Case Studies in Psychotherapy, 6,

101�108. http://pcsp.libraries.rutgers.edu.

Rizzuto, A.M. (1979). The birth of the living God. Chicago: The

University of Chicago Press.

Rush, A.J., Thase, M.E., & Dube, S. (2003). Research issues in

the study of difficult-to-treat depression. Biological Psychiatry,

53, 743�753.

Schneider, K.J. (2007). Existential-integrative psychotherapy:

Guideposts to the core of practice. New York: Routeledge.

Schore, A.N. (1994). Affect regulation and the origin of the self. The

neurobiology of emotional development. Hillsdale, NJ: Lawrence

Erlbaum Associates.

Segal, Z.V., Williams, J.M.G., & Teasdale, J.D. (2002).

Mindfulness-based cognitive therapy for depression. A new approach

to preventing relapse. New York: Guilford.

Semerari, A., Carcione, A., Dimaggio, G., Falcone, M., Nicolo,

G., Procacci, M., & Alleva, G. (2003). Assessment. How to

evaluate metacognitive functioning assessment scale and its

applications. Clinical Psychology and Psychotherapy, 10, 238�261.

Shafranske, E. (1992). God-representation as the transforma-

tional object. In M. Finn & J. Gartner (Eds.), Object relation

theory and religion. Clinical applications (pp. 57�72). Westport,

CT: Praeger.

Shafranske, E.P. (Ed.). (1996). Religion and the clinical practice of

psychology. Washington DC: American Psychological Associa-

tion.

Shaap-Jonker, H., Eureling-Bontekoe, E., Verhagen, P.J., & Zock,

H. (2002). Image of God and personality pathology: An

exploratory study among psychiatric patients. Mental Health,

Religion and Culture, 5, 55�71.

Shea, M.T., Pilkonis, P.A., Beckham, E., Collins, J.F., Elkin, I.,

Sotsky, S.M., & Docherty, J.P. (1990). Personality disorders

and treatment outcome in the NIMH treatment of Depression

Collaborative Research Program. American Journal of

Psychiatry, 147, 711�718.

Smitz, N., Hartkamp, N., & Franke, G.H. (2000). Assessing

clinically significant change: application to the SCL-90-R.

Psychological Reports, 86, 263�274.

Spence, D. (1982). Narrative truth and historical truth: Meaning

and interpretation in psychoanalysis. New York: Norton.

Sperry, L., & Shafranske, E.P. (2005). Spiritually oriented

psychotherapy. Washington DC: American Psychological Asso-

ciation Press.

Stalsett, G., Austad, A., Gude, T., & Martinsen, E. (2010).

Existential issues and representation of god in psychotherapy:

A naturalistic study of 40 patients in the VITA treatment

model. Psyche & Geloof, 21, 76�91.

Stalsett, G., Engedal, L.G., & Austad, A. (2010a). The persecut-

ing God and the crucified self: The case of Olav and the

transformation of his pathological self�image. Pragmatic Case

Studies in Psychotherapy, 6, 49�100.

Stalsett, G., Engedal, L.G., & Austad, A. (2010b). Response to

commentaries on the persecuting God and the crucified self:

The case of Olav and the transformation of his pathological

self-image. Reflections on Olav’s therapy: The roles of religious

experience, self psychology, and metalization. Pragmatic Case

Studies in Psychotherapy, 6, 126�133.

Teasdale, J.D., More, R.G., Hayhurst, H., Pope, M., Williams, S.,

& Segal, Z.V. (2002). Metacognitive awareness and prevention

of relapse in depression: Empirical evidence. Journal of Con-

sulting and Clinical Psychology, 70, 275�287.

Thase, M.E. (1996). The role of Axis II comorbidity in the

management of patients with treatment-resistant depression.

The Psychiatric Clinics of North America, 19, 287�309.

Thase, M.E. (2001). The need for clinically relevant research on

treatment-resistant depression. Journal of Clinical Psychiatry,

62, 221�224.

Vail, K.E., Rothschild, Z.K., Wise, D.R., Solomon, S., Pyszcyns-

ki, T., & Greenberg, J. (2011). A terror management analysis of

psychological functions of religion. Personality and Social

Psychology Review, 14, 84�94.

Wampold, B.E. (2001). The great psychotherapy debate: Models,

methods and findings. Mahwah, NJ: Lawrence Erlbaum.

White, M., & Epston, D. (1990). Narrative means to therapeutic

ends. New York: Norton.

590 G. Stalsett et al.

Dow

nloa

ded

by [

Uni

vers

ite D

e Pa

ris

1] a

t 12:

24 0

5 Se

ptem

ber

2013

WHO. (2010). World Health Organization-WHO.int. http://www.

who.int/mental_health/management/depression.

Worthington, E.L. Jr., Hook, J.N., Davis, D.E., & McDaniel,

M.A. (2011). Religion and spirituality. Journal of Clinical

Psychology: In Session, 67, 204�214.

Yalom, I. (1980). Existential psychotherapy. New York: Basic Books.

Yalom, I.D. (1995). The theory and practice of group psychotherapy

(4th ed). New York: Basic Books.

Yalom, I.D. (2007). Staring at the sun. Overcoming the terror of

death. San Fransisco, CA: Jossey-Bass.

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