Conflict begets conflict: Executive control,mental state vacillations,and the therapeutic alliance in treatment of borderline personality disorder

This study evaluated the psychometric properties of the 4 scales of the Behavioral Health Questionnaire-20 (BHQ-20): Global Mental Health, Well-Being, Symptoms, and Life Functioning. Four samples were used: community adults, college students, college students in counseling, and adults in outpatient psychotherapy. Support was found for internal consistency and 2-week test-retest reliability. For construct validity, the BHQ-20 scales distinguished levels of pathology among the samples and were sensitive to improvement across 3 psychotherapy sessions. Concurrent validity correlations with the scales of established measures were at least moderately high. Higher correlations were also found between the BHQ-20 scales and the nonanalogous scales of the established measures. These results, along with high correlations among the BHQ-20 scales, indicated the presence of 1 primary mental health dimension accounting for the variance. The BHQ-20 was proven to be a generally reliable, valid questionnaire that is distinguished by the efficiency with which it assesses mental health.     

Psychotherapists' response to borderline personality disorder: A core conflictual relationship theme analysis

Abstract

This study examined therapists' emotional and cognitive responses to patients with borderline personality disorder (BPD) versus patients with major depressive disorder (MDD). Therapists' narratives (N=80) were elicited using the Relationship Anecdotes Paradigm interview method and then scored according to the core conflictual relationship theme–Leipzig/Ulm method (CCRT-LU; Albani et al., 2002). The emotional valences of therapists' responses were significantly more negative toward patients with BPD. Therapists differentially experienced patients with BPD as typically withdrawing and patients with MDD as attending within sessions. Therapists felt less satisfied in their therapeutic role with BPD despite a consistent wish to help patients. Findings support the utility of the CCRT-LU method in investigating therapist relational experiences and underscore the challenges for BPD treatment.     

The developmental profile: Validation of a theory-driven instrument for personality assessment

Abstract

The Developmental Profile is an instrument for personality assessment. It covers both maladaptive and adaptive characteristics. The current study examined its internal consistency and construct validity in a Dutch sample of 763 participants from various clinical and nonclinical settings. The internal consistency reliability estimates were good for the clusters of levels (adaptive, neurotic, and primitive), although not for all separate levels. Confirmatory factor analysis showed an overall good fit, with the exception of the level of primary narcissism. Furthermore, empirical evidence was found for the interpretation of a patient's Developmental Profile according to increasing levels of aggregation, with as a highest level a single maladaptivity–adaptivity scale score. This scale significantly distinguished among different patient groups.     

Mentalization-based therapy adherence and competence stimulates in-session mentalization in psychotherapy for borderline personality disorder with co-morbid substance dependence

Objective: To test whether adherence to mentalization-based treatment (MBT) principles predict better patient in-session mentalizing. Methods: Two sessions for each of 15 patients with borderline personality disorder and comorbid substance abuse disorder were rated for MBT adherence and competence. Individual patient statements were rated for Reflective Functioning (RF), therapist statements were rated as demanding RF or not. Data were analysed using multilevel modelling. Results: MBT adherence and competence predicted higher session RF (β?=?.58–.75), even while controlling for pre-treatment RF. In addition, therapist interventions directed toward exploring mental states predicted higher RF of subsequent patient responses (β?=?.11–.12). Conclusions: MBT adherence and competence were significantly related to patient in-session mentalizing, supporting the validity of MBT principles. Results point to the importance of supervision for therapists to become adherent to MBT principles. The small number of patients and sessions limits generalizability of results.     

An individual differences perspective on change in psychotherapy: The case of health care utilization

Abstract

The purpose of this study was to explore systematic interindividual variation in change of a number of health care utilization variables (HCUVs) during psychotherapy and identify patient characteristics associated with this variation. Three-wave panel data from 420 patients were analyzed with nonparametric latent class regression followed by chi-square interaction analyses among patient variables. For the various HCUVs, three to six classes were identified, with widely different patterns of change during treatment. Axis I diagnosis, chronicity, functional impairment, gender, and level of education were among the patient characteristics that differentiated the classes. It was concluded that main effects analyses seriously distort heterogeneity of change and that health care utilization, unless it is a specific therapeutic aim, may be irrelevant as an indication of outcome of psychotherapy.     

Changing character: A narrative review of personality change in psychotherapies for personality disorder

Objective: Personality disorder (PD) is a negative prognostic indicator for treatment, and absolute improvements in functioning among these patients are often modest. This may be because personality features that give rise to dysfunction in PD are not targeted optimally during most treatments. Method: Attachment, mentalization, core beliefs, and personality organization/defense use were identified as personality constructs that have been pursued in treatment studies and that are proposed to underlie PD. Results: All constructs correlate with psychiatric symptoms, PD diagnosis, and functioning. Defense mechanisms and core beliefs further distinguish specific PDs, whereas personality organization separates more versus less severe PDs. Evidence from treatment and naturalistic studies indicate that maturation of defense mechanisms temporally precedes improvements in symptoms and functioning. Changes in attachment and mentalization correlate with some outcomes, but mediation of improvement has not been established. In psychodynamic therapy, transference interpretations may promote amelioration of personality dysfunction. With the exception of attachment, the experimental literature is lacking that could explicate the mechanisms by which these personality constructs maintain psychosocial dysfunction. Conclusions: Future research should aim to identify changes in these mechanisms that mediate positive outcomes in PD, as well as the specific therapeutic procedures that best promote positive change in PD.     

Development and criterion validity of a computerized text analysis measure of reflective functioning

Abstract

The Reflective Functioning scale (RF) is a narrative-based assessment of the capacity to coherently conceptualize one's own and others' subjective motivations, emotions, beliefs, and desires. We report the preliminary results of an effort to develop a computerized text analysis version (CRF) of the RF assessment system. A sample of 113 clinical and non-clinical Adult Attachment Interviews (AAI) were utilized to develop the CRF measure. Using the Marker Approach (Mergenthaler & Bucci, 1999), 54 linguistic markers of high RF language were identified. The associations between CRF and RF were significant in both a clinical sample of patients diagnosed with Borderline Personality Disorder (BPD) (Spearman rho=.57, p<.0001) and a non-clinical sample of adults (Spearman rho=.57, p=.002). These results suggest that a CRF rating scale is feasible, has preliminary criterion validity, and, therefore, has potential to facilitate the efficient assessment of RF.     

Transference,countertransference, emotional expression,and session quality over the course of supportive expressive therapy: The raters' perspective

Abstract

Independent judges rated transference, countertransference, therapist emotional expression, and session quality, in videotaped sessions of Supportive Expressive Psychotherapy for Depression over time. Based on 44 patients and four therapists, HLM analyses suggested that negative transference predicted therapist expression of negative affect. While negative transference predicted a rough session, positive transference predicted a deep session. Positive countertransference and positive affect predicted a smooth but superficial session, with positive transference sometimes acting as a moderator. Sessions became less deep and smoother over time, with therapist emotional expression moderating the relationship between treatment phase and depth. The results suggest that positive countertransference behaviors and feelings have a particularly negative impact on a session and that transference contributes to a deep and rough session.     

Art therapy for patients diagnosed with personality disorders cluster B/C: A thematic analysis of emotion regulation from patient and art therapist perspectives

ABSTRACT

This study examined the explanation for the found causal relationship between art therapy and positive therapeutic effects, in a previously conducted randomised controlled trial (RCT) with personality disorders cluster B/C. In-depth interviews were used to collect the data, in order to examine the experience without preconceived notions or expectations. Thematic analysis was used to analyse the data to generate and interpret themes. Eight patients who participated in the RCT intervention were asked to evaluate their experiences with art media highlighting emotion regulation and Expressive Therapies Continuum (ETC) levels. Also three art therapists were asked to evaluate the artwork made by these participants. Thematic analysis resulted in five themes. These results suggested that through the targeted use of art assignments, material handling, and preferred approaches to art process and ETC levels, patients experienced, shaped and shared emotions not previously wilfully encountered. The therapeutic effects were explained by combined specific art therapy factors linked to the art media. These factors were reported by participants as evoking and helping them understand and regulate internal images and emotions. Results suggested that art therapy encourages a present-focused awareness and stimulates emotional processes evoked by material interaction.     

Development of an art-therapy intervention for patients with personality disorders: an intervention mapping study

Art therapy for people diagnosed with personality disorders (PD) cluster B/C seems valuable to explore dysfunctional patterns in managing emotions. Current art therapy interventions are based on practical beliefs or commonsense approaches, without a sound basis in research results. To increase the effectiveness of art therapy for this target group, a planned, systematic and theory-based approach is needed. The principles of Intervention Mapping were applied to guide the development, implementation, and planned evaluation of the art therapy intervention. Empirical findings, theoretical models, and clinical practice experience were combined to construct a programme tailored to the needs of the target group. A structured 10-session art therapy intervention programme for patients was developed, aimed at: experiencing a (more) stable and positive sense of self, being able to express and regulate emotions, understanding emotions, thoughts and behaviours, using improved social and problem solving skills. Implementation took place and evaluation of the intervention is being carried out. The systematically developed art therapy intervention seems to be promising for PD patients in learning to deal with their problems. The results of the evaluation study may contribute to the knowledge about the use of art therapy for PD problems.     

The role of sex and autonomy-connectedness in internalizing and externalizing personality pathology,coping and axis-I pathology: among psychiatric and healthy elderly

Objectives: In the current study we investigated the relationship of sex and autonomy-connectedness with internalizing and externalizing personality disorder symptoms (PDS), coping and axis-I pathology in older age.

Method: A path model was tested which was based on neo-analytical object relation, attachment- and primary-personality theory, among 100 clinical and 106 non-clinical elderly.

Results: In line with our model, autonomy-connectedness (self-awareness and capacity of managing new situations) was strongly associated to internalizing PDS in both groups. In both groups, neither sex nor autonomy-connectedness predicted externalizing PDS. Sex, internalizing as well as externalizing PDS and reactive defensive coping were associated to axis-I psychopathology.

Conclusions: We conclude that sex and autonomy-connectedness were, similarly as in adult populations, associated to internalizing PDS and axis-I pathology. Treatment of elderly with internalizing PDS and axis-I psychopathology should therefore focus on enhancing autonomy-connectedness.     

Goldilocks on the couch: Moderate levels of psychodynamic and process-experiential technique predict outcome in psychodynamic therapy

Objectives: Greater symptom change is often assumed to follow greater technique use, a “more is better” approach. We tested whether psychodynamic techniques, as well as common factors and techniques from other orientations, had a curvilinear relation to outcome (i.e., whether moderate or “just right” intervention levels predict better outcome than lower or higher levels). Methods: For 33 patients receiving supportive-expressive psychodynamic psychotherapy for depression, interventions were assessed at Week 4 using the multitheoretical list of therapeutic interventions and symptoms were rated with the Hamilton Rating Scale for Depression. Results: Moderate psychodynamic and experiential techniques predicted greater symptom change compared to lower or higher levels. Conclusion: This “Goldilocks effect” suggests a more complex relation of intervention use to outcome might exist.     

Out-patient behaviour therapy in alcoholism: impact of personality disorders and cognitive impairments

OBJECTIVE: We investigated whether alcoholic patients with comorbid personality disorders and those with cognitive impairments would benefit in a different way from different behaviour therapy strategies. METHOD: After detoxification, 120 alcoholics were assigned randomly to one of three out-patient treatment programmes comprising 'coping skills training', 'cognitive behaviour therapy' or unspecific supportive control therapy. Personality disorders and cognitive impairments were assessed at the beginning of the 6-month treatment period. RESULTS: The impact of concomitant personality disorders or cognitive impairments was generally only moderate and mainly independent from treatment condition. However, alcoholic patients relapsing within 6 months after detoxification showed a higher rate of personality disorders (especially antisocial and borderline) and slightly more cognitive deficits (especially in verbal memory and visuomotor functions) than abstainers even before therapy. CONCLUSION: The high amount of early relapses and drop-outs probably hindered larger differentiated treatment effects. Hypotheses will be retested in treatment completers using forthcoming follow-up data.     

Reliability and validity of the DBT-VLCS: A measure to code validation strategies in dialectical behavior therapy sessions

Objective: There are six strategies or validation levels in dialectical behavior therapy (DBT), yet there are no measures designed to code for them. This absence limits our understanding of the relationship between validation strategies and treatment outcome. The DBT-Validation Level Coding Scale (DBT-VLCS) was developed to overcome this limitation. Method: This research reports on the interrater reliability and content validity for the DBT-VLCS. Results: Overall, interrater reliability was excellent for all items, with the exception of two items that demonstrated good reliability. Good content validity was demonstrated for six of the seven items. Conclusions: This preliminary study suggests that the DBT-VLCS is a reliable and valid measure to code the presence of validation in DBT. This measure creates the opportunity for research that has not previously been possible.     

Self-Image as a Moderator of Change in Psychotherapy1 Margrethe S. Halvorsen and Jon T. Monsen,Department of Psychology,University of Oslo,Oslo, Norway.

Abstract

This study used the Structural Analysis of Social Behavior (SASB) introject model to investigate the relationship between patients’ self-image at pretreatment and change during psychotherapy. Data were obtained from the Norwegian Multisite Study of Process and Outcome in Psychotherapy, including 233 completed therapies. The patients were classified into four self-image profile groups (i.e., self-attack, self-control, intermediate attack–control, and self-love) based on their initial SASB pattern coefficients. Overall, the results indicated that response to treatment was contingent on self-image at pretreatment. Patients with a self-attacking self-image showed larger reductions in symptoms and sum criteria on Axis II during psychotherapy than those with less pathological self-images. As expected, the primary change in self-image was along the affiliation dimension, although patients with elevated pretreatment levels of self-control revealed substantial changes along the interdependence dimension as well.     

Beyond the tip of the iceberg: Exploring the potential of the meaning extraction method and aftercare e-mail themes

Abstract

The objectives were to examine the relationships among clients' affect regulation capacities, in-session emotional processing, outcome, and the working alliance in 66 clients who received either cognitive–behavioral therapy or process-experiential emotion-focused therapy for depression. Clients’ initial level of affect regulation predicted their level of emotional processing during early and working phases of therapy. Clients’ peak emotional processing in the working phase of therapy mediated the relationship between their initial level of affect regulation and their level of affect regulation at the end of therapy; and clients' level of affect regulation at the end of therapy mediated the relationship between their peak level of emotional processing in the working phase of therapy and outcome. Clients’ affect regulation at the end of therapy predicted outcome independently of the working alliance. The findings suggest that clients' level of affect regulation early in therapy has a significant impact on the quality of their in-session processing and outcome in short-term therapy. Limitations of the study and future directions for research are discussed.