Journal of Social and Clinical Psychology, Vol. 23, No. 2, 2004, pp.

140-154
SHAHAR ET AL. IMPEDES RELATIONS PERFECTIONISM

PERFECTIONISM IMPEDES SOCIAL RELATIONS AND RESPONSE TO BRIEF TREATMENT FOR DEPRESSION
GOLAN SHAHAR AND SIDNEY J. BLATT Yale University DAVID C. ZUROFF McGill University JANICE L. KRUPNICK Georgetown University School of Medicine STUART M. SOTSKY George Washington University Medical Center

Previous analyses of data from the National Institute of Mental Health (NIMH)-sponsored Treatment of Depression Collaborative Research Project (TDCRP) revealed that patients perfectionism had an adverse effect on treatment outcome (Blatt, Quinlan, Pilkonis, & Shea, 1995). Part of this adverse effect was accounted for by perfectionistic patients difficulties in relating constructively to their therapist (Zurof et al., 2000). However, even after taking into account this indirect effect, the remaining direct effect of perfectionism on outcome was statistically significant, suggesting the presence of other mediators. The present study identifies one of these other mediators: the quality of the patients social network. Specifically, patients pretreatment perfectionism predicted a less positive social network over time, which in turn predicted less reduction of symptoms at termination. The two mediating effects that involved the social network and the therapeutic alliance accounted for the statistically significant direct effect of pretreatment perfectionism on outcome. Results highlight the impact of personality on interpersonal processes in determining the outcome of brief treatment for depression.

Correspondence concerning this article should be addressed to Golan Shahar, Department of Psychiatry, Yale University School of Medicine, 25 Park St., New Haven, CT 06519. Electronic mail may be sent to golan.shahar@yale.edu . We would like to express our appreciation to the investigators in the Treatment for Depression Collaborative Research Program (TDCRP) for providing access to their data set.

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The National Institute of Mental Health (NIMH)-sponsored Treatment of Depression Collaborative Research Project (TDCRP) was a randomized clinical trial that compared three treatments for major depression: cognitive-behavioral therapy (CBT), interpersonal therapy (IPT), and imipramine plus clinical management (IMI-CM). The clinical trial also included an inactive placebo plus clinical management (PLA-CM) condition. Original analyses of the TDCRP data indicated few substantial differences in clinical outcome among the three active treatment groups (Elkin, 1994). In contrast to this lack of differential treatment effect, Blatt and colleagues (1995) found a robust effect of patients personality on outcome. Patients with elevated pretreatment perfectionism were less likely to exhibit symptomatic improvement at termination than their less perfectionistic counterparts. As further demonstrated by Zuroff and colleagues (2000), this adverse effect of patients perfectionism was mediated by the therapeutic alliance. Utilizing ratings by Krupnick, Sotsky, and colleagues (1996) of patients contribution to the therapeutic alliance, Zuroff and colleagues found that pretreatment perfectionism predicted patients difficulties in constructively participating in the therapeutic alliance, which in turn contributed to poorer therapeutic outcome. Although this mediating effect was statistically significant, a significant direct effect of pretreatment perfectionism on outcome remained after controlling for the mediator, suggesting that other mediators might be involved in the adverse effect of perfectionism. Our objective was to evaluate another potential mediator of the effect of pretreatment perfectionism on outcome, namely, patients social relations outside treatment. Our primary hypothesis was that part of the impediment to the therapeutic response of perfectionistic patients is impaired social relationship outside treatment. Extensive research demonstrated that patients who had satisfying interpersonal relations were more likely to recover from major depression than patients with less satisfying relations (e.g., Moos, 1990; Vallejo, Gasto, Catalan, Bulbena, & Menchon, 1991). Additionally, emerging theoretical conceptualizations and empirical research underscore individuals capacity to actively influence their social context (Coyne, 1976; Hammen, 1991; Shahar & Priel, 2003; Zuroff, 1992). In particular, individuals perfectionism, or self-criticism, is a salient factor in shaping social relations. Elevated perfectionism reduces participants perceived social support (Mongrain, 1998; Priel & Shahar, 2000), increases their interpersonal stress (Dunkley, Zuroff, & Blankstein, 2003; Priel & Shahar, 2000; Shahar & Priel, 2003), and elicits confrontations in close relationships (Zuroff & Duncan, 1999).

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Accordingly, we hypothesized that patients pretreatment perfectionism would adversely influence social relations, which would in turn impede response to brief treatment for depression. We also hypothesized that this mediating effect of social relations would complement the aforementioned mediating effect of the therapeutic alliance.

METHOD
PARTICIPANTS TDCRP participants were outpatients with nonbipolar, nonpsychotic major depressive disorder. Two hundred thirty-nine patients (75% female) began treatment, and 162 completed treatment, having participated in at least 12 treatment sessions over at least a 15-week period (see inclusion and exclusion criteria in Elkin, 1994). The average age of patients who began treatment was 35 years. The number of patients available for analysis varied at different points in the treatment process because of patients dropping out or being withdrawn from treatment. To maintain continuity with previous analyses (e.g., Zuroff et al., 2000), we focused on 144 treatment completers for whom complete data were available on all the measures described below.

MEASURES
Pretreatment Perfectionism. The Dysfunctional Attitudes Scale (DAS, Weissman & Beck, 1978) was used to measure pretreatment perfectionism. The DAS measures cognitive vulnerability to depression. A Principal Component Analysis of DAS data obtained in the TDCRP (Imber et al., 1990) yielded two factors: perfectionism and need for approval. The Perfectionism subscale measures the tendency to view the self in critical terms (e.g., If I fail at my work, than I am a failure as a person). The Need for Approval subscale measures the tendency to value other peoples judgment (e.g., What other people think of me is important). Blatt, Zuroff, Quinlan, and Pilkonis (1996) created residualized versions of these subscales in which they removed the shared variance from each subscale. Blatt et al. (1996) referred to these residualized versions as pure perfectionism and pure need of approval. Because previous analyses (e.g., Blatt et al., 1996) demonstrated that pure perfectionism, but not pure need of approval, predicted therapeutic outcome, and because such prediction is a prerequisite for examining the mediating effects hypothesized above (Baron & Kenny, 1986), we present here only results involving pure perfectionism.

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Patient Contribution to the Therapeutic Alliance. Krupnick et al. (1994) developed a modified form of the Vanderbilt Therapeutic Alliance Scale (VTAS; Hartley & Strupp, 1983), in which patient-therapist exchanges are videotaped and coded, to be applicable to the four treatment conditions in the TDCRP. Ratings of videotapes were made of sessions 3, 9, and 15 for patients who had completed treatment. Factor analysis of the modified VTAS revealed two factors (Krupnick et al., 1996): (1) the contribution of the patient to the therapeutic alliance, and (2) the contribution of the therapist to the therapeutic alliance. Krupnick et al. (1996) demonstrated that the patients contribution (but not the therapists contribution) to the therapeutic alliance early in treatment was significantly related to therapeutic outcome. Previous analyses (Zuroff et al., 2000) demonstrated the effects of perfectionism on the contribution of patients, but not therapists, to the therapeutic alliance. Because such an effect is a prerequisite for examining the mediating effects hypothesized above (Baron & Kenny, 1986), we focused only on the patient contribution to the therapeutic alliance. For economy of expression, we use the term therapeutic alliance in the reminder of this article to refer to the patients contribution to the alliance. To assess the therapeutic alliance construct as a latent variable, we derived two indicators of the Patient Contribution subscale. Krupnick et al. (1996) pointed out that this subscale included 13 items referring specifically to the patients contribution to the alliance (e.g., patient talks freely, openly, and honestly about himself), and 7 items referring to the patient-therapist interaction (e.g., patient and therapist share common viewpoint about the patients problems). We labeled the first set of items PATIENT and the second set PAT/THER, and computed means for each set of items. The PATIENT and PAT/THER means were treated as two indicators of the patient contribution to the therapeutic alliance. We constructed indicators for the therapeutic alliance in both the early (session 3) and late (session 15) treatment sessions. The Social Network Form. Elkin, Parloff, Hadley, and Autry (1985) developed the Social Network Form as part of the TDCRP. This form was completed by trained clinical evaluators (CEs) at intake, as well as several times during the treatment period and follow-up. CEs inquired about seven classes of potentially satisfying relationships: (1) a significant other living with a patient, (2) family members, (3) siblings, (4) an in-law, (5) neighbors, (6) a close friend in the work setting, and (7) any other close friend. The CEs recorded the number of people with whom the patient currently had regular contact and the number of hours per week spent interacting with these people, and rated the degree to which the patient appeared satisfied with those relationships. Satisfaction ratings were made on a 5-point scale (1 = very dissatisfied, 2 = somewhat dis-

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satisfied, 3 = equally satisfied and dissatisfied, 4 = somewhat satisfied, and 5 = very satisfied). Adequate predictive validity of the instrument was demonstrated by Zlotnick, Shea, Pilkonis, Elkin, and Ryan (1996), and by Zuroff and Blatt (2003). Zlotnick et al. (1996) found that the social network, measured both as the number of relationship domains that were assessed to be either somewhat satisfying (i.e., 4") or very satisfying (i.e., 5"), and by the number of persons with whom the patient had close and satisfying relations (i.e., number of confidants), was related to low levels of depressive symptoms during the follow-up period. Zuroff and Blatt (2003), in a more recent analysis of TDCRP data, used the number of persons with whom the patient had a satisfying relation in all domains and found that this variable had a stress-buffering effect during the follow-up period. Patients with more satisfactory social relations reported fewer depressive symptoms in response to stressful life events. In the present study, we were interested in assessing social network as a multi-indicator latent variable. Hence, we derived two indicators from that scale. The first was Zuroff and Blatts (2003) indicator of the number of persons with whom the patients had satisfying relations. Relations were defined as satisfying if they received a score of 4 or above on the satisfaction scale, reflecting the breadth of patients satisfying social relations; hence, the indicator was labeled BREADTH. The second indicator was the average number of hours per week during which patients interacted with people with whom they had satisfying interactions. This indicator was chosen because it reflects the intensity with which patients had satisfying interpersonal relations (i.e., INTENSE). BREADTH and INTENSE scores were computed for the intake and the termination sessions. Symptoms. Blatt et al. (1996) constructed a composite clinical outcome variable, based on the five primary outcome measures of the TDCRP: the Beck Depression Inventory (BDI; Beck, Ward, Mendelson, Mock, & Erbaugh, 1961), the total score on the Hopkins Symptoms Checklist-90 (SCL-90; Derogatis, Lipman, & Covi, 1973), the 17-item Hamilton Rating Depression Scale (HRDS; Hamilton, 1960), the Global Assessment Scale (GAS; Endicott, Spitzer, Fleiss, & Cohen, 1976), and the sum of the global ratings from the Social Adjustment Scale (SAS; Weissman & Paykel, 1974). The BDI and SCL-90 are self-report measures, and the HRDS, GAS, and SAS are interview-based measures completed by CEs. Blatt et al. (1996) regressed the termination score on each of these measures on the respective intake score, deriving five residual scores that measured clinical change. When these residual scores were factor-analyzed, they yielded a single factor accounting for 76% of the variance. Scores on this factor were used to construct a composite clinical outcome.

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We utilized a similar strategy for the measurement of treatment outcome, but introduced three modifications. First, because we were interested in directly controlling for pretreatment symptoms while examining the effects of pretreatment perfectionism on patients alliance and the social network, we did not assess change in symptoms using residual scores. Instead, we constructed symptom measures for both intake (Time 1) and termination (Time 2), and represented change in symptoms by controlling for Time 1 symptoms when examining the effects of other predictor variables on Time 2 symptoms. Secondly, instead of factor-analyzing the clinical scales, we treated them as indicators of a single latent variable in the context of structural equation modeling. Finally, we did not include the SAS as an indicator of this latent variable because we were concerned that the SAS would overlap in content with the social network indicators, which could inflate the indirect effect leading from perfectionism to clinical functioning via the social network.

RESULTS
ANALYTIC STRATEGY Our hypotheses were tested using Structural Equation Modeling (SEM; Hoyle & Smith, 1994) via the AMOS 4.01 program (Arbuckle, 1999), based on Maximum Likelihood (ML) estimation. Model fit was assessed via the 2/df index (Byrne, 1989; values below 2.0 represent acceptable model fit), the Bentler-Bonett Non Normed Fit Index (NNFI; Bentler & Bonett, 1980; values higher than .90 represent acceptable model fit), and the Root Mean Square of Approximation (RMSEA; Steiger, 1980; values of .05 and lower represent acceptable model fit). Our analyses were conducted in three stages. First, in adherence with the two-step approach (Anderson & Gerbing, 1988), we examined the measurement model of the latent variables: Symp0wk (i.e., symptoms during intake, measured by intake levels of BDI, HDRS, SCL-90, and GAS), Alliance 1 (measured by session 3 levels of PATIENT and PAT/THER), Alliance 2 (measured by session 15 levels of PATIENT and PAT/THER), Network 1 (measured by intake levels of BREADTH and INTENSITY), Network 2 (measured by termination levels of BREADTH and INTENSITY), and Symp16wk (i.e., symptoms at termination, measured by termination levels of BDI, HDRS, SCL-90, and GAS). Note that because pretreatment perfectionism was not measured as a latent variable, it was not included in this measurement model. The measurement model was examined via Confirmatory Factor Analysis (CFA). We expected adequate model fit and statistically significant loadings of the manifest indicators on their respective latent variables.

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In the second stage, we tested a preliminary structural model in which we estimated the effect of pretreatment perfectionism on Symp16wk, controlling for Symp0wk. As argued by Baron and Kenny (1986), a statistically significant effect of an independent variable (in our case, pretreatment perfectionism) on an outcome (i.e., Symp16wk), assessed while controlling for possible confounds (i.e., Symp0wk), is a prerequisite for assessing indirect effects such as those hypothesized here. In the third stage, we examined a, SEM model that included the therapeutic alliance and the social network as mediators. The outcome variable and the independent variables were the same as in the previous model. Alliance 1 and 2 and Network 1 and 2 served as mediators. To ensure measurement invariance across time, the loadings of each indicator on its respective latent variable were constrained to equality across time. Moreover, autocorrelations were specified between the unique variances of the indicators (i.e., variance that is unrelated to the latent constructs) across time (cf., Hoyle & Smith, 1994). Finally, to account for shared method variance, two additional correlated errors were introduced. For each measurement occasion, a correlation was specified between the unique variances of the self-report symptom measures (i.e., BDI and SCL-90) and the interview-based measures (i.e., HDRS and GAS). STAGE 1: ESTIMATING THE MEASUREMENT MODEL The means, standard deviations, and correlations among the study variables are presented in Table 1, which served as the basis for conducting the CFAs and SEMs. The CFA model demonstrated an adequate fit, 2(82) = 105.62, p = .04; 2/df = 1.28; NNFI = .96; RMSEA = .04. The loadings of the indicators on their respective latent variables were moderate to high (i.e., ranging from .42 to .89) and statistically significant (p < .001). The correlations between the latent variables are presented in Table 2. The pattern emerging from these correlations is largely expected, with the exception of the correlation between Alliance 1 and Network 2 (r = .31, p < .01). This correlation implies that patients who constructively participated in the therapeutic alliance earlier in treatment enjoyed a more positive social context at termination. STAGE 2: ESTIMATING A PRELIMINARY SEM MODEL The preliminary SEM model yielded an acceptable fit to the data, 2(20) = 25.57; 2df = 1.3; NNFI = .98; RMSEA = .044. Pretreatment perfection-

TABLE 1. Means, Standard Deviations, and Correlations among the Study Variables 17 1.00 70.4 10.7

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1. PFT 2. BDI0W 3. HAM0W 4. SCLT0W 5. GAS0W 6. PATIENT0W 7. PAT/THER0W 8. BREADTH0W 9. INTENSITY0W 10. PATIENT16W 11. PAT/THER16W 12. BREADTH16W 13. INTENSITY16W 14. BDI16W 15. HAM16W 16. SCLT16W 17. GAS16W M SD

1 1.00 .07 .13 .05 .02 .07 .06 .10 .06 .21 .18 .17 .28 .22 .26 .24 .31 .1 13.8

2 1.00 .34 .56 .32 .04 .03 .07 .08 .08 .05 .10 .06 .24 .05 .17 .05 26.9 7.9

3 1.00 .34 .45 .05 .14 .10 .00 .04 .01 .01 .15 .07 .14 .08 .10 19.0 4.1

4 1.00 .24 .04 .03 .02 .11 .03 .04 .14 .01 .15 .11 .30 .07 1.4 .5

5 1.00 .01 .11 .11 .10 .00 .04 .13 .06 .06 .02 .11 .05 52.5 6.9

6 1.00 .81 .14 .13 .21 .12 .13 .26 .22 .21 .24 .21 3.3 .5

7 1.00 .13 .09 .24 .17 .16 .27 .18 .20 .25 .22 3.5 .5

8 1.00 .60 .02 .06 .39 .27 .09 .05 .17 .13 3.3 3.0

9 1.00 .09 .00 .25 .30 .12 .11 .19 .17 35.9 44.1

10 1.00 .84 .17 .15 .37 .41 .32 .45 3.5 .5

11 1.00 .07 .04 .39 .38 .30 .38 3.6 .5

12 1.00 .51 .37 .20 .34 .36 5.6 3.4

13 1.00 .34 .26 .33 .34 61.3 59.3

14 1.00 .71 .82 .69 8.9 8.8

15 1.00 .71 .81 7.4 5.8

16 1.00 .66 .5 .5

Notes. N = 144. Correlations higher than |.16| are statistically significant (p < .05, twotail tests). PFT = pretreatment pure perfectionism; BDI = Beck Depression Inventory; HAM = Hamilton Depression Rating Scale; SCLT = Hopkins Symptoms Checklist, Total Scores; GAS = Global Assessment Scale; PATIENT = patients contribution to the therapeutic alliance; PAT/THER = patient and therapists joint contribution to the therapeutic alliance; BREADTH = number of satisfying relations; INTENSITY = hours of satisfying relations.

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ism had a statistically significant effect on symptoms at termination, controlling for pretreatment symptoms ( = .32, t = 3.2, p < .001).

STAGE 3: ESTIMATING THE MODEL THAT INCLUDED BOTH THE THERAPEUTIC ALLIANCE AND THE SOCIAL NETWORK The SEM in which both therapeutic alliance and the social network were considered as mediators demonstrated an acceptable fit to the data, 2(96) = 137.65, 2/df = 1.4, NNFI = .95, RMSEA = .05. As hypothesized, pretreatment perfectionism had a statistically significant effect on Network 2 = -.28, t = -2.6, p < .01), controlling for Network 1 and for Symp0wk. In turn, Network 2 had a significant effect on Symp16wk ( = -.41, t = -2.9, p < .001), controlling for the effect of the other predictor variables. Additionally, pretreatment perfectionism had a significant effect on Alliance 2 ( = -.22, t = -2.4, p < .05), controlling for Alliance 1 and for Symp0wk. In turn, Alliance 2 had a significant effect on Symp16wk ( = -.40, t = -4.4, p < .001), controlling for the effect of the other predictor variables. Utilizing the Bias-Corrected (BC) confidence interval procedure (Efron, 1987), we found that the indirect effect of pretreatment perfectionsim on Symp16wk, which includes the indirect path involving Alliance 2 and Network 2, was statistically significant (unstandardized estimate = .11, standard error = .044, p = .004). The remaining direct effect of pure perfectionism on Symp16wk, controlling for the mediators, was nonsignificant ( = .11, t = 1.2, p > .05), and fixing this effect to zero did not yield a significant reduction of model fit, 2(1) = 1.47, p > .05. This pattern suggests that Alliance 2 and Network 2 fully account for the statistically significant part of the effect of pretreatment perfectionism on Symp16wk. The Model Modification procedure in AMOS 4.01 indicated that the fit of the model examined in stage 4 could be significantly improved by specifying a path from Alliance 1 to Network 2, a path that is consistent with the correlations between Alliance 1 and Network 2 presented in Table 2. When the suggested path was specified, a statistically significant improvement of fit was obtained, 2(1) = 8.65, p < .05, and the path leading from Alliance 1 to Network 2 was statistically significant ( = .28, t = 2.37, p < .05). Hence, we deemed this model with the additional significant path coefficient as the final SEM model. In Figure 1, we present standardized coefficients of this model. To simplify the presentation, only statistically significant or nearly significant path coefficients are presented.

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TABLE 2. Correlations between the Latent Variables.

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Symp 0wk Symp16wk Alliance 1 Alliance 2 Network 1 Network 2

Symp 0wk Symp16wk Alliance 1 Alliance 2 Network 1 Network 2 1.00 ns .15 1.00 ns .11 .27** 1.00 ns .02 .48*** .22* 1.00 ns ns ns ns .03 .19 .14 .02 1.00 ns ns .03 .52** .31** .14 .45* 1.00

Note. Symp 0wk = Symptoms at intake; Symp16wk = Symptoms at termination; Alliance 1 = Patients contribution to the therapeutic alliance early in treatment; Alliance 2 = Patients contribution to the therapeutic alliance later in treatment; Network 1 = Social network at intake; Network 2 = Social netns work at termination. N = 144 . *p < .05; **p < .01; ***p < .001. Nonsignificant.

DISCUSSION
Two principal findings were obtained in this study. The first, expected finding was that the effect of patients pretreatment perfectionism on residual symptoms at treatment termination was mediated not only by the therapeutic alliance but also by social relations. The second, unexpected finding was that patients social relations late in treatment mediated the effect of their early constructive therapeutic alliance on symptoms at termination. We discuss these two findings and conclude by noting the studys limitations. PERFECTIONISM IMPEDES SOCIAL RELATIONS WITHIN AND OUTSIDE TREATMENT Research consistently indicated that perfectionistic individuals, who tend to set high standards and evaluate themselves harshly, experience a host of negative outcomes, including self-reported distress, clinical depression, and suicide (e.g., Blatt, 1995). These individuals, who appear to be in urgent need of treatment, have serious difficulties in benefiting from brief treatment for depression (Blatt et al., 1995). Findings (Zuroff et al., 2000) indicate that a part of these difficulties can be explained by perfectionisms interfering with these patients ability to establish and maintain a therapeutic alliance. Our findings suggest that another segment of this adverse effect is accounted for by the interference of pretreatment perfectionism with establishing and maintaining satisfying social relations outside of treatment. This finding is consistent with studies demonstrating that self-critical, perfectionist individuals tend to generate a maladaptive social context

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Netw ork 1

0.34

Netw ork 2

-0.30
0.19

-0.39 0.28

Symp0w k

Symp16w k

-0.40

PFT

-0.22

Alliance 1
0.22

Alliance 2

Note. Numbers are standardized path coefficients. Effects of pretreatment perfectionism on the therapeutic alliance and the social network are highlighted. The effect of Symp0wk on Symp16wk approaches significance (p = .06). PFT = pretreatment perfectionism.

(for review, see Shahar, 2001). Plausibly, perfectionistic individuals negative internal representations, or schemas, of self and significant others account for at least some of their impaired interpersonal relationships (Blatt, Wein, Chevron, & Quinlan, 1979; Mongrain, 1998). These representations seem to organize perfectionistic individuals social exchange, making it difficult for them to attend to positive interpersonal cues (Aube & Whiffen, 1996), and forcing them to avoid intimacy and self-disclosure (Zuroff & Fitzpatrick, 1995) and to act in a hostile manner in close relations (Zuroff & Duncan, 1999). Possibly, perfectionistic individuals project their own self-criticism onto others and therefore expect the condemnation from others that they inflict upon themselves. Ironically, such projections are likely to consolidate and even exacerbate these individuals negative representations of self and others, thus contributing to a vicious interpersonal cycle (Zuroff, 1992). On a more general level, this study is, to the best of our knowledge, one of the first to apply action perspectives of risk and resilience to psychotherapy research. By integrating a line of inquiry that highlights the role of patients social network in their recovery from depression during treatment (Moos, 1990; Vallejo, et al. 1991) with an independent line of inquiry that depicts individuals as actively shaping their social

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context and, indirectly, their distress (Shahar, 2001; Zuroff, 1992), we were able to demonstrate that patients, constrained by their personality, actively shape and mold the very social conditions that influence their recovery during brief treatment for depression. PATIENTS SOCIAL NETWORK LATE IN TREATMENT MEDIATED THE EFFECT OF CONSTRUCTIVE EARLY THERAPEUTIC ALLIANCE ON RESIDUAL SYMPTOMS AT TERMINATION We found that the previously reported effect of patients constructive early therapeutic alliance on outcome (Krupnick et al., 1996) is mediated by their social relations outside treatment. Specifically, constructive therapeutic alliance formed early in treatment predicted more satisfying relations at termination, in turn leading to better outcome. Most previous discussions of the mechanisms underlying the effects of early therapeutic alliance involved within-therapy processes, such as increased compliance with therapeutic or pharmacological regimes, or increased openness on the part of the patient (cf., Krupnick et al., 1996). Yet our findings suggest that patients ability to constructively engage in a relation with their therapist bolsters their social relations with friends, family members, and other significant others. Possibly, a constructive early therapeutic alliance primes positive relational schemas, which are then brought to bear on patients social relations in a manner similar to psychodynamic formulations of transference (see Andersen & Miranda, 2000, for empirical support of the occurrence of transference in everyday life using a social-cognitive perspective). LIMITATIONS This indirect effect from early therapeutic alliance to latter outcome through the mediating variable of satisfying social relations was not predicted. Consequently, interpretation of this effect should be made with caution. Yet, we believe that this finding holds the potential to deepen understanding of the ways by which the therapeutic alliance enhances patients response to treatment. Our analyses were based on 144 participants for whom all relevant data was available. To what extent did this analysis sample differ from the other patients who initially participated in the study? To address this question, we compared the analysis sample with the remaining participants. The analysis sample was somewhat more adaptive in that it manifested a more constructive early therapeutic alliance (t[223] = 4.03, t[223] = 3.67, p < .001; for PATIENT and PAT/THERAP, respectively), and less symptoms on the HRSD (t[237] = -2.21, p < .05) than the

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remaining cases. This sample reported fewer hours of satisfying social relations (t[229] = -2.78, p < .01), perhaps because it was less distressed and needed less social support. Finally, the analysis sample tended to report more perfectionism (t[237] = 1.94, p = .052). These findings do not lend themselves to a clear-cut conclusion as to how missing cases might have affected the results. Nevertheless, the fact that some differences were found highlights the need for replication of these and other findings obtained with the TDCRP data. Another limitation pertains to the measurement of patients perfectionism via the DAS. Perfectionism is a multidimensional construct (see Blatt, 1995, for review). Although the perfectionism factor of the DAS has been previously shown to correlate strongly with other measures of perfectionism, or self-criticism (Shahar & Priel, 2003; Zuroff & Duncan, 1999), it seems that the type of perfectionism assessed by the DAS reflects a particularly malignant aspect of this construct, namely, the tendency to adopt a critical stance toward the self (Shahar, 2001). The possibility that other dimensions of perfectionism might yield different patterns of results should be explored in future research. Finally, although the present results are consistent with a host of experimental and non-experimental studies demonstrating the effect of self-critical perfectionism on distress-related contextual factors (e.g., Mongrain et al. 1998; Zuroff & Duncan, 1999), our findings should not be taken to indicate a direct demonstration of causality. These analyses are consistent with the causal model specified in the present study, but other models might explain the data as well. Nevertheless, the mounting evidence of the detrimental effect of patients perfectionism within and outside treatment should encourage future investigations of ways this dimension of serious vulnerability might be prevented and/or treated.

REFERENCES
Andersen, S. M., & Miranda, R. (2000). Transference: How past relationships emerge in the present. Psychologist, 13, 608-609. Anderson, J. C., & Gerbing, D. W. (1988). Structural equation modeling in practice: A review and recommended two-step approach. Psychological Bulletin, 103, 411-323. Arbuckle, J. L., (1999). AMOS: A structural equation modeling software Chicago: SmallWaters Corporation. Aube, J., & Whiffen, V. E. (1996). Depressive styles and social acuity: Further evidence for distinct interpersonal correlates of dependency and self-criticism. Communication Research, 23, 407-424. Baron, R.M., & Kenny, D.A. (1986). The moderator-mediator variable distinction in social psychological research: Conceptual, strategic, and statistical considerations. Journal of Personality and Social Psychology, 51, 1173-1182.

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