Better personality functioning at the end of therapy is linked to long-term mental health

A recent study published in Comprehensive Psychiatry provides evidence that improving an individual’s underlying personality functioning during therapy helps sustain mental health gains long after the formal treatment ends. The research suggests that when patients experience improvements in their core ability to regulate emotions and relate to others, they are less likely to see a return of depression, anxiety, and physical symptoms a year later.

Personality functioning is a psychological concept that acts as a structural framework for mental health. “Clinicians in psychodynamic settings work on the assumption that symptoms often rest on something more basic, namely a person’s capacity to perceive themselves realistically, regulate emotion, and maintain contact with others, which is usually summarized as personality structure or, more commonly now, personality functioning,” said Jürgen Fuchshuber, a researcher at the Department of Psychoanalysis and Psychotherapy at the Medical University of Vienna.

When a person has impairments in this area, they often struggle to handle stress. These difficulties are frequently associated with a variety of psychiatric issues, including depression and anxiety.

In the context of psychotherapy, mental health professionals seek to understand how changes in these deep-seated personality traits influence more noticeable symptoms over time. Past research indicates that therapy can improve personality functioning. “Generally, I have been interested in applying quantitative empirical methods to psychodynamic theories for some time,” Fuchshuber said. “The data from the sample investigated in this study gave us the opportunity to take a real in depth look at some very interesting questions in this regard.”

Past studies have attempted to measure these changes, but they often struggled to pinpoint exact individual progress. “Earlier work with these data had shown that personality functioning and symptoms change together during treatment,” Fuchshuber noted. “While those results are valid and answer different questions from the ones we asked here, the methods used did not separate stable differences between patients from fluctuations within one patient over time, as the random intercept cross lagged panel model does.”

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This advanced statistical approach allowed the team to isolate temporary, dynamic changes from a person’s general baseline traits. The scientists were specifically interested in the transition out of care.

“We were also curious about what happens after discharge, when the supporting effect of the therapeutic relationship falls away and patients have to rely on their own regulatory capacities,” Fuchshuber explained. It is relatively easy for a patient to feel better while they are in a highly supportive hospital environment. The real test often comes after discharge, when the patient must rely on their own internal coping skills.

To explore these dynamics, the scientists analyzed data from an existing large project known as the Multicenter Effectiveness Study of Inpatient Psychosomatic Psychotherapeutic Treatment. The study included 2,094 participants receiving mental health care at 19 different university hospitals in Germany. The sample was 68 percent female, with an average age of nearly 40 years. The patients received either day hospital or full inpatient care. Treatment included various approaches like cognitive-behavioral therapy and psychodynamic therapy.

The researchers tracked the participants across three distinct time points. The first measurement took place at baseline, when the patients were admitted to the hospital. The second measurement occurred at discharge, after an average of about 50 days of treatment. Finally, the third measurement was taken at a one-year follow-up point.

At each time point, the participants filled out a series of standardized questionnaires. To measure personality functioning, the researchers used a 12-item self-report survey that assesses impairments in self-perception and relationship models. Higher scores on this survey indicated more severe impairments.

The team also measured three specific categories of psychopathology. They used a widely recognized nine-item questionnaire to gauge the severity of depressive symptoms. A similar seven-item survey was used to assess generalized anxiety. Finally, they measured somatic symptoms using a 15-item questionnaire. Somatic symptoms are physical issues, such as pain or fatigue, that cause significant distress and can be linked to psychological stress.

The researchers applied their complex statistical model to see how fluctuations in these variables influenced one another over time. They controlled for factors like age, sex, and the duration of the hospital stay. During the active treatment phase, from admission to discharge, the scientists did not find that changes in personality functioning predicted changes in symptoms.

“The treatment context turned out to matter a lot,” Fuchshuber told PsyPost. “During the inpatient or day clinic treatment itself, a patient’s personality functioning did not predict how their symptoms developed. Symptom change in that phase was instead strongly tied to depressive symptoms at admission.”

Patients with higher initial depression scores tended to show less improvement in personality functioning. High baseline depression also predicted worse physical symptoms and higher anxiety at the time of discharge.

The therapeutic environment itself seemed to provide the necessary support for the patients, reducing the immediate need for internal coping skills. “A plausible reading is that the clinic itself provides a good deal of external structure and regulation, so individual differences in self regulation matter less while the patient is in it, and considerably more once they are on their own,” Fuchshuber explained.

The most prominent pattern emerged in the period after treatment ended, from hospital discharge to the one-year follow-up. “After discharge, this changed,” Fuchshuber said. “In that period, where a patient’s personality functioning stood at the end of treatment predicted their depressive, anxious and physical symptoms a year later.”

If a patient’s personality functioning at discharge remained poorer than their personal average, they were significantly more likely to experience increased depression, anxiety, and physical symptoms a year later. On the other hand, patients who achieved better-than-average improvements in their personality functioning by the end of their hospital stay tended to maintain their symptom relief.

In addition, depression at the time of discharge strongly predicted an increase in both anxiety and somatic symptoms at the one-year mark. This indicates that lingering depressive symptoms can have a broad, negative impact on a person’s overall physical and mental health long after therapy concludes. Interestingly, higher anxiety at admission predicted a slight decrease in depression and physical symptoms by discharge. The authors suggest this might be a statistical anomaly caused by the overlapping nature of anxiety and depression, where a temporary spike in anxiety triggers compensatory coping mechanisms.

These interconnected findings provide specific guidance for mental health professionals. “For treatment that would suggest depressive symptoms deserve early attention, while personality functioning is more relevant to whether gains hold up over the following year,” Fuchshuber noted. “But of course, these are statistical patterns within a large clinical sample, not a guarantee about any individual course of therapy.”

Some limitations should be considered when interpreting these findings. A notable issue is the amount of missing data at the one-year follow-up mark. Nearly 40 percent of the original patients did not complete the final set of questionnaires. It is possible that patients whose mental health deteriorated after leaving the hospital were less likely to respond to the follow-up surveys, which could skew the long-term estimates.

The complex statistical models used in this research estimate many variables at once. Because of this complexity, some of the observed pathways were relatively modest in size. The authors suggest that these specific long-term predictions need to be replicated in independent studies before clinical guidelines are officially changed.

Future research might explore exactly which types of therapeutic interventions are most effective at improving personality functioning. Understanding these mechanisms could help mental health professionals tailor their treatments to build deeper, more enduring coping skills in their patients. Monitoring personality functioning throughout therapy could help clinicians identify individuals who might need more intensive aftercare.

The study, “How personality functioning shapes symptom development during and after treatment: A random intercept cross lagged panel analysis,” was authored by Jürgen Fuchshuber, Henrik Kessler, Aram Kehyayan, Magdalena Pape, Tobias Hofmann, Matthias Rose, Katrin Imbierowicz, Franziska Geiser, Ilona Croy, Kerstin Weidner, Jörg Rademacher, Silke Michalek, Eva Morawa, Yesim Erim, Martin Teufel, Alexander Bäuerle, Stanislav Heinzmann, Claas Lahmann, Eva Milena Johanne Peters, Johannes Kruse, Dirk von Boetticher, Christoph Herrmann-Lingen, Mariel Nöhre, Martina de Zwaan, Ulrike Dinger, Hans-Christoph Friederich, Alexander Niecke, Christian Albus, Rüdiger Zwerenz, Manfred Beutel, Casper Roenneberg, Peter Henningsen, Barbara Stein, Christiane Waller, Karsten Hake, Carsten Spitzer, Andreas Stengel, Stephan Zipfel, Katja Weimer, Harald Gündel, Stephan Herpertz, and Stephan Doering.