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Kramer U, Golam M. Cognitive heuristics in borderline personality disorder across treatment: A longitudinal non-parametric analysis. J Clin Psychol 2019; 75:1320-1331. [PMID: 30887510 DOI: 10.1002/jclp.22775] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Revised: 02/21/2019] [Accepted: 02/24/2019] [Indexed: 02/06/2023]
Abstract
OBJECTIVE The development of a constructive therapeutic alliance may represent an important feature of interpersonal adaptation in clients with Borderline Personality Disorder (BPD). The present study explores cognitive heuristics as dynamic features of change in relationship with the therapeutic alliance in the treatment of BPD. METHOD In total, N = 60 clients with BPD, are included in the present study. In the context of brief therapy, the therapeutic alliance (WAI) is assessed from the client and the therapist perspectives after each therapy session; cognitive heuristics are assessed three times (CERS). The data analyses are on the basis of non-parametric clusters (kml3d) linked with the therapeutic alliance. RESULTS The results showed that clusters of cognitive heuristics trajectories are linked with the client's therapeutic alliance (t(55) = 2.30, p = .03), but they remained unrelated with the evolution of the therapist's alliance. CONCLUSIONS These results are discussed with regard to the interpersonal adaptiveness of cognitive heuristics in the context of BPD undergoing treatment.
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Affiliation(s)
- Ueli Kramer
- Department of Psychiatry, Institute of Psychotherapy and General Psychiatry Service, University of Lausanne, Switzerland
| | - Mehdi Golam
- Department of Psychiatry, University of Lausanne, Switzerland
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Antunes-Alves S, Vukovic B, Milyavskaya M, Kramer U, Dobson K, Drapeau M. Investigating the effects of therapist accuracy in cognitive behavioural therapy for depression. BRITISH JOURNAL OF GUIDANCE & COUNSELLING 2018. [DOI: 10.1080/03069885.2018.1453048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Affiliation(s)
- Sara Antunes-Alves
- Educational and Counselling Psychology, McGill University, Montreal, Canada
| | - Boris Vukovic
- Educational and Counselling Psychology, McGill University, Montreal, Canada
| | - Marina Milyavskaya
- Educational and Counselling Psychology, McGill University, Montreal, Canada
- Department of Psychology, Carleton University, Ottawa, Canada
| | - Ueli Kramer
- Département de Psychiatrie, Institut Universitaire de Psychothérapie et Service de Psychiatrie Générale, University of Lausanne, HUV Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Keith Dobson
- Department of Psychology, University of Calgary, Calgary, Canada
| | - Martin Drapeau
- Educational and Counselling Psychology, McGill University, Montreal, Canada
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Kramer U, Ortega D, Ambresin G, Despland JN, de Roten Y. The role of cognitive biases in short-term psychodynamic psychotherapy. Psychol Psychother 2018; 91:143-156. [PMID: 28901694 DOI: 10.1111/papt.12152] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Revised: 08/21/2017] [Indexed: 12/30/2022]
Abstract
UNLABELLED The concept of biased thinking - or cognitive biases - is relevant to psychotherapy research and clinical conceptualization, beyond cognitive theories. The present naturalistic study aimed to examine the changes in biased thinking over the course of a short-term dynamic psychotherapy (STDP) and to discover potential links between these changes and symptomatic improvement. This study focuses on 32 self-referred patients consulting for Adjustment Disorder according to DSM-IV-TR. The therapists were experienced psychodynamically oriented psychiatrists and psychotherapists. Coding of cognitive biases (using the Cognitive Errors Rating Scale; CERS) was made by external raters based on transcripts of interviews of psychotherapy; the reliability of these ratings on a randomly chosen 24% of all sessions was established. Based on the Symptom Check List SCL-90-R given before and after, the Reliable Change Index (RCI) was used. The assessment of cognitive errors was done at three time points: early (session 4-7), mid-treatment (session 12-17), and close to the end (after session 20) of the treatment. The results showed that the total frequency of cognitive biases was stable over time (p = .20), which was true both for positive and for negative cognitive biases. In exploring the three main subscales of the CERS, we found a decrease in selective abstraction (p = .02) and an increase in personalization (p = .05). A significant link between RCI scores (outcome) and frequency of positive cognitive biases was found, suggesting that biases towards the positive might have a protective function in psychotherapy. PRACTITIONER POINTS Therapists may be attentive to changes in biased thinking across short-term dynamic psychotherapy for adjustment disorder. Therapists may foster the emergence of positive cognitive biases at mid-treatment for adjustment disorder.
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Affiliation(s)
- Ueli Kramer
- Department of Psychiatry, Institute of Psychotherapy and General Psychiatry, University Hospital Center and University of Lausanne, Switzerland
| | | | - Gilles Ambresin
- Department of Psychiatry, Institute of Psychotherapy, University Hospital Center and University of Lausanne, Switzerland
| | - Jean-Nicolas Despland
- Department of Psychiatry, Institute of Psychotherapy, University Hospital Center and University of Lausanne, Switzerland
| | - Yves de Roten
- Department of Psychiatry, Institute of Psychotherapy, University Hospital Center and University of Lausanne, Switzerland
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Keller S, Stelmaszczyk K, Kolly S, de Roten Y, Despland JN, Caspar F, Drapeau M, Kramer U. Change in Biased Thinking in a Treatment Based on the Motive-Oriented Therapeutic Relationship for Borderline Personality Disorder. J Pers Disord 2018; 32:75-92. [PMID: 29388899 DOI: 10.1521/pedi.2018.32.supp.75] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Biased thinking is a common feature of patients presenting with borderline personality disorder (BPD). For the treatment of BPD, it was shown that the individualizing of the treatment, by using the motive-oriented therapeutic relationship (MOTR), had a beneficial short-term effect on process and outcome. So far, it remains unclear what the role of early change in biased thinking is in these treatments. The present study aims to assess whether there is a link between the MOTR, change in biased thinking, and outcome. The sample (N = 60) is based on a randomized controlled trial with two conditions: (a) 30 patients in a 10-session version of psychiatric management, and (b) 30 patients in a 10-session version of psychiatric management augmented with the MOTR. For each patient, three sessions (intake, middle, late) were selected, transcribed, and rated using the Cognitive Errors Rating Scale (CERS). An overall decrease of negative cognitive errors during 10 sessions of treatment was observed, independently of the treatment condition. No specific effect related to change in biased thinking may be attributed to the individualizing of the treatment. These results are discussed with regard to mechanisms of change in treatments for BPD, in particular with regard to the central role that biased thinking, as well as the MOTR, might play early in treatment.
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Affiliation(s)
- Sabine Keller
- University Institute of Psychotherapy, Department of Psychiatry-CHUV, University of Lausanne, Lausanne, Switzerland
| | - Kelly Stelmaszczyk
- Department of Counselling Psychology and Psychiatry, McGill University, Montreal, Quebec, Canada
| | - Stéphane Kolly
- General Psychiatry Service, Department of Psychiatry-CHUV, University of Lausanne, Lausanne, Switzerland
| | - Yves de Roten
- University Institute of Psychotherapy, Department of Psychiatry-CHUV, University of Lausanne, Lausanne, Switzerland
| | - Jean-Nicolas Despland
- University Institute of Psychotherapy, Department of Psychiatry-CHUV, University of Lausanne, Lausanne, Switzerland
| | - Franz Caspar
- Department of Clinical Psychology and Psychotherapy, University of Bern, Bern, Germany
| | - Martin Drapeau
- Department of Counselling Psychology and Psychiatry, McGill University, Montreal, Quebec, Canada
| | - Ueli Kramer
- University Institute of Psychotherapy, Department of Psychiatry-CHUV, University of Lausanne, Lausanne, Switzerland.,General Psychiatry Service, Department of Psychiatry-CHUV, University of Lausanne, Lausanne, Switzerland.,University of Windsor, Windsor, Ontario, Canada
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Kramer U. The Role of Coping Change in Borderline Personality Disorder: A Process-Outcome Analysis on Dialectical-Behaviour Skills Training. Clin Psychol Psychother 2016; 24:302-311. [PMID: 27098296 DOI: 10.1002/cpp.2017] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2015] [Revised: 03/11/2016] [Accepted: 03/22/2016] [Indexed: 11/06/2022]
Abstract
Difficulty in emotion regulation is a hallmark feature of patients with borderline personality disorder (BPD). Skills training concepts based on dialectical-behaviour therapy (DBT) are common and effective treatment options for specifically addressing lacking skills in emotion regulation. However, so far it is unclear which aspects of coping change over the course of DBT skills training and if these coping strategies predict symptom change. The present process-outcome analysis, based on a randomized controlled study, aims at investigating these questions, by referring to a general conception of coping and by using an observer-rated approach to assess coping strategies directly in the therapy sessions. In total, n = 31 patients with BPD underwent two individual clinical interview assessments (pre- and post-study intervention; half of the patients underwent DBT skills training, half were in a wait-list control). All individual assessment sessions were transcribed and analysed using the Coping Action Pattern Rating Scale. Outcome was assessed pre- and post-intervention using the Outcome Questionnaire-45.2 and the Borderline Symptom List 23. The results showed increase in overall coping functioning in patients who underwent the DBT skills training, compared with the controls, and specific increases in relatedness coping where the stress is appraised as challenge, along with specific decreases in autonomy coping where the stress is appraised as threat. These changes predicted changes in general distress and borderline symptomatology. The results are interpreted within a general framework aiming at understanding the psychological effects of treatments for BPD, in particular effects related to coping. Effective emotion regulation strategies may therefore be important candidates as potential change mechanisms in treatments for BPD. Copyright © 2016 John Wiley & Sons, Ltd. KEY PRACTITIONER MESSAGE It seems important for clinicians to assess the quality of coping strategies as they occur within the session facing a patient with borderline personality disorder. Clinicians may foster the emergence of support-seeking and self-reliance coping strategies in order to increase the effectiveness of therapy. Clinicians may monitor closely the patient's use of ineffective emotion regulation strategies, in particular opposition and submission, with the aim of reducing them early in therapy.
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Affiliation(s)
- Ueli Kramer
- Institute of Psychotherapy, Department of Psychiatry-CHUV, University of Lausanne, Lausanne, Switzerland.,General Psychiatry Service, Department of Psychiatry-CHUV, University of Lausanne, Lausanne, Switzerland.,Department of Psychology, University of Windsor, Windsor, Canada
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Kramer U, Caspar F, Drapeau M. Change in biased thinking in a 10-session treatment for borderline personality disorder: Further evidence of the motive-oriented therapeutic relationship. Psychother Res 2013; 23:633-45. [DOI: 10.1080/10503307.2013.791404] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
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Kramer U, Vaudroz C, Ruggeri O, Drapeau M. Biased thinking assessed by external observers in borderline personality disorder. Psychol Psychother 2013; 86:183-96. [PMID: 23674468 DOI: 10.1111/j.2044-8341.2011.02056.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Biased thinking (to some extent overlapping with the concepts of cognitive distortions and cognitive errors) is a key concept in cognitive therapy of borderline personality disorder (BPD). Specific contents and cognitive processes related to BPD functioning are known. However, most studies are based on self-report measures which present a number of important limitations, in particular the difficulty in assessing non-conscious processes infused by affect. So far, no studies were conducted using valid observer-rated methodology addressing the question of biased thinking in BPD as it unfolds spontaneously in session. DESIGN This is a controlled interview study comparing two matched groups, BPD patients and healthy controls. METHODS A total of N= 25 clinical dynamic interviews with patients presenting with BPD were transcribed and rated using the Cognitive Errors Rating Scale (Drapeau, Perry, & Dunkley, 2008); their cognitive profiles were compared to those of N= 25 healthy controls who underwent the same procedure. RESULTS Overall, results indicated that no between-group difference in the frequency of specific biases was found. However, heightened levels of negative cognitive biases, in particular over-generalizing and fortune-telling, were associated with BPD. Furthermore, negative over-generalizing was associated with the number of BPD symptoms. CONCLUSIONS These results have high levels of ecological validity and are promising for the refinement of cognitive theory of BPD. Clinical implications for assessment and intervention are discussed.
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Affiliation(s)
- Ueli Kramer
- Institute of Psychotherapy, Department of Psychiatry-CHUV, University of Lausanne, Switzerland.
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Antunes-Alves S, Thompson K, Kramer U, Drapeau M. The relationship between cognitive errors, coping strategies, and clients' experiences in session: An exploratory study. COUNSELLING & PSYCHOTHERAPY RESEARCH 2013. [DOI: 10.1080/14733145.2013.770894] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Kramer U. Observer-rated coping associated with borderline personality disorder: an exploratory study. Clin Psychol Psychother 2012; 21:242-51. [PMID: 23281000 DOI: 10.1002/cpp.1832] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2011] [Revised: 11/14/2012] [Accepted: 11/14/2012] [Indexed: 11/10/2022]
Abstract
BACKGROUND Little is known about coping specificities, as operationalization of the concept of affect regulation, in borderline personality disorder (BPD). It is most important to take into account methodological criticisms addressed to the self-report questionnaire approach and to compare BPD coping specificities to the ones of neighbouring diagnostic categories, such as bipolar disorder (BD). SAMPLING AND METHODS The present exploratory study compared the coping profiles of N = 25 patients presenting BPD to those of N = 25 patients presenting BD and to those of N = 25 healthy controls. All participants underwent a clinical interview that was transcribed and rated using the Coping Patterns observer-rater system. RESULTS Results partially confirmed study hypotheses and showed differences between BPD patients and healthy controls in all coping domains (competence, resources and autonomy), whereas the only coping domain presenting a BPD-specific lack of skills, compared with the BD patients, was autonomy, a set of coping strategies facing stress appraised as challenge. These coping processes were linked to general and BPD symptomatology. CONCLUSIONS These results extend conclusions of earlier studies on affect regulation processes in BPD and bear important clinical implications, in the context of dialectical behavior therapy and other therapeutic approaches. Limitations of this exploratory study, such as the small sample size, are acknowledged. KEY PRACTITIONER MESSAGE Coping can be reliably assessed in the narrative process in an non-structured interview frame. Patients with borderline personality disorder present with a specific lack of skills in affect regulation related to autonomy issues, compared to patients with bipolar disorder and healthy controls. Lack of skills in accommodation to distressing emotions in borderline personality disorder is related to symptom gravity and may be treated using radical acceptance strategies.
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Affiliation(s)
- Ueli Kramer
- Institute of Psychotherapy and Section K. Jaspers, Department of Psychiatry-CHUV, University of Lausanne, Switzerland
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Kramer U, de Roten Y, Drapeau M, Despland JN. Change in Cognitive Errors and Coping Over the Course of Brief Psychodynamic Intervention. J Clin Psychol 2012; 69:727-36. [DOI: 10.1002/jclp.21931] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Ueli Kramer
- Institute of Psychotherapy, Department of Psychiatry-CHUV; University of Lausanne; Switzerland
| | | | - Martin Drapeau
- Departments of Counselling Psychology and Psychiatry; McGill University; Canada
| | - Jean-Nicolas Despland
- Institute of Psychotherapy, Department of Psychiatry-CHUV; University of Lausanne; Switzerland
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