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Culina I, Ranjbar S, Nadel I, Kramer U. Fluctuations in therapist responsiveness facing clients with borderline personality disorder: Starting therapy on the right foot. Psychother Res 2024:1-10. [PMID: 38943681 DOI: 10.1080/10503307.2024.2368784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 06/10/2024] [Indexed: 07/01/2024] Open
Abstract
OBJECTIVE The present paper focuses on therapist responsiveness during the initial therapy session with clients with borderline personality disorder (BPD), aiming to analyze therapist responsiveness at short intervals during the initial session and determine if it can predict therapeutic alliance from both therapist and client viewpoints. METHOD A sample of 47 clients participated in the study for 10 sessions of therapy. Therapeutic alliance from therapists' and clients' perspectives was rated after each session; external raters assessed therapist responsiveness during the initial session. Multiple linear regression models and linear mixed models with backward variable selection based on AIC were run to analyze whether specific therapist behaviors during session one predicted therapeutic alliance rated from therapists' and clients' perspectives. RESULTS The results indicate that therapists normalizing and validating clients' experiences during the first session are crucial for establishing therapeutic alliance for BPD clients; however, for therapists, the increase in variability of emotions verbalized by clients during the initial session negatively impacts therapeutic alliance. CONCLUSION The study contributes to further understand the impact of therapists' behavior at the beginning of therapy with BPD clients. Therapist responsiveness is crucial for therapy outcome but is methodologically challenging; therefore, efforts in this direction should be pursued.
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Affiliation(s)
- Ines Culina
- General Psychiatry Service, Department of Psychiatry, University Hospital Center and University of Lausanne, Lausanne, Switzerland
| | - Setareh Ranjbar
- Psychiatric Epidemiology and Psychopathology Research Center, Department of Psychiatry, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Isabella Nadel
- Department of Psychiatry, Williams College, Williamstown, MA, USA
| | - Ueli Kramer
- General Psychiatry Service, Department of Psychiatry, University Hospital Center and University of Lausanne, Lausanne, Switzerland
- Institute of Psychotherapy, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
- Department of Psychology, University of Windsor, Windsor, Canada
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Marconi E, Monti L, Fredda G, Kotzalidis GD, Janiri D, Zani V, Vitaletti D, Simone MV, Piciollo S, Moriconi F, Di Pietro E, Popolo R, Dimaggio G, Veredice C, Sani G, Chieffo DPR. Outpatient care for adolescents' and young adults' mental health: promoting self- and others' understanding through a metacognitive interpersonal therapy-informed psychological intervention. Front Psychiatry 2023; 14:1221158. [PMID: 38025443 PMCID: PMC10651761 DOI: 10.3389/fpsyt.2023.1221158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 10/02/2023] [Indexed: 12/01/2023] Open
Abstract
Introduction Psychological distress may result in impairment and difficulty understanding oneself and others. Thus, addressing metacognitive issues in psychotherapy may improve psychopathology in adolescents and young adults (AYAs). We aimed to compare metacognitive interpersonal therapy (MIT)-informed psychotherapy with other treatment-as-usual (TAU) therapies. Methods We administered the Global Assessment of Functioning (GAF) scale, the Clinical Global Impressions-Severity (CGI-S) scale, and the Brief Psychiatric Rating Scale (BPRS) at baseline (BL) and at treatment termination (the endpoint was at 6 months and any last results obtained before that term were carried forward in analyzes). Patients received concomitant psychiatric and psychological treatment. Results Sixty AYAs were involved in the study. There was a significant reduction in symptomatology after the intervention. Twelve patients (17%) dropped out; treatment adherence was 83%. In the MIT group, 2 patients dropped out (11%), and in the TAU group, 9 patients dropped out (19%). All scales showed a significant reduction in symptoms between baseline (BL) and the 6-month endpoint: GAF (χ2 = 6.61, p < 0.001), BPRS (χ2 = 6.77, p < 0.001), and CGI (χ2 = 7.20, p < 0.001). There was a greater efficacy for the MIT group in terms of symptom reduction on the BPRS (t = 2.31; p < 0.05). Conclusion The study confirmed the efficacy of early and integrated care in adolescence and suggested greater symptom reduction for a psychotherapeutic intervention focused on stimulating mentalization skills. The study indicates the usefulness of this type of approach in the treatment of adolescent psychopathology. Due to the small sample size, the results need replication.
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Affiliation(s)
- Elisa Marconi
- Clinical Psychology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Laura Monti
- Clinical Psychology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Giulia Fredda
- Clinical Psychology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Georgios D. Kotzalidis
- Department of Psychiatry, Department of Neuroscience, Head, Neck and Thorax, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
- NESMOS Department (Neurosciences, Mental Health, and Sensory Organs), University of Rome “La Sapienza”, Rome, Italy
| | - Delfina Janiri
- Department of Psychiatry, Department of Neuroscience, Head, Neck and Thorax, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Valentina Zani
- Catholic University of the Sacred Heart–Rome, Rome, Italy
| | | | | | | | - Federica Moriconi
- Clinical Psychology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | | | - Raffaele Popolo
- Center for Metacognitive Interpersonal Therapy, Rome, Italy
- Department of Mental Health, Rome, Italy
| | | | - Chiara Veredice
- Pediatric Neuropsychiatry Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Gabriele Sani
- Department of Psychiatry, Department of Neuroscience, Head, Neck and Thorax, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
- Institute of Psychiatry, Department of Neuroscience, Catholic University of the Sacred Heart–Rome, Rome, Italy
| | - Daniela Pia Rosaria Chieffo
- Clinical Psychology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
- Department of Life Sciences and Public Health Department, Catholic University of Sacred Heart, Rome, Italy
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Martin S. Why using “consciousness” in psychotherapy? Insight, metacognition and self-consciousness. NEW IDEAS IN PSYCHOLOGY 2023. [DOI: 10.1016/j.newideapsych.2023.101015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/31/2023]
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Kvarstein EH, Zahl KE, Stänicke LI, Pettersen MS, Baltzersen ÅL, Johansen MS, Eikenaes IUM, Arnevik EA, Hummelen B, Wilberg T, Pedersen G. Vulnerability of personality disorder during the Covid-19 crises - a multicenter survey of treatment experiences among patients referred to treatment. Nord J Psychiatry 2022; 76:52-63. [PMID: 34126854 DOI: 10.1080/08039488.2021.1934110] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND The societal shutdown due to the Covid-19 pandemic involved mental health services for personality disorder (PD) and was introduced from 12 March 2020 in Norway. Rapid implementation of treatment modifications was required for patients typically characterized by insecure attachment and vulnerability to separation. AIM To investigate immediate reactions to the shutdown of services; alternative treatment received; and differences related to age in a clinical sample of patients with PD. DESIGN A survey performed from June to October 2020 (after the first Covid-19 wave) among 1120 patients from 12 units offering comprehensive group-based PD programs. RESULTS The response-rate was 12% (N = 133). Negative feelings of anxiety, sadness, and helplessness were noteworthy immediate reactions, but the dominating attitude was accommodation. Younger patients (<26 years) reported more skepticism and less relief. Modified treatment was mainly telephone therapy. Digital therapy was less available, but was more frequent among younger patients. A minority received digital group therapy. Most patients rated the frequency and quality of modified treatments as satisfactory in the given situation, but also worried about own treatment progress, lack of group therapy, and 47% missed seeing the therapist when having telephone consultations. CONCLUSION The survey confirms a radical modification from comprehensive group-based PD programs to telephone consultations, low availability of digital consultations and group treatments. Taking a short-term, first wave perspective, the survey indicates a noteworthy capacity among poorly functioning patients for accommodating to a clearly challenging situation, as well as considerable concern about treatment progress.
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Affiliation(s)
- Elfrida Hartveit Kvarstein
- Department for National and Regional Functions, Division of Mental Health and Addiction, Section for Personality Psychiatry and Specialized Treatments, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Kjell-Einar Zahl
- Group Therapy Section, Follo District Psychiatric Centre, Akershus University Hospital, Nordbyhagen, Norway
| | - Line Indrevoll Stänicke
- Department of Psychology, University of Oslo, Oslo, Norway.,Nic Waals Institute, Lovisenberg Deacon Hospital, Oslo, Norway
| | - Mona Skjeklesaether Pettersen
- Department of Substance Abuse, Clinic for Mental Health and Addiction Treatment, University Hospital of North Norway, Tromsø, Norway.,Department for National and Regional Functions, Division of Mental Health and Addiction, Network for Personality Disorders, Section for Personality Psychiatry and Specialized Treatments, Oslo University Hospital, Oslo, Norway
| | - Åse-Line Baltzersen
- Department for National and Regional Functions, Division of Mental Health and Addiction, National Advisory Unit for Personality Psychiatry, Section for Personality Psychiatry and Specialized Treatments, Oslo University Hospital, Oslo, Norway.,Department of Interdisciplinary Health Sciences, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Merete Selsbakk Johansen
- Department for National and Regional Functions, Division of Mental Health and Addiction, Outpatient Clinic for Specialized Treatment of Personality Disorders, Section for Personality Psychiatry and Specialized Treatments, Oslo University Hospital, Oslo, Norway
| | - Ingeborg Ulltveit-Moe Eikenaes
- Department for National and Regional Functions, Division of Mental Health and Addiction, National Advisory Unit for Personality Psychiatry, Section for Personality Psychiatry and Specialized Treatments, Oslo University Hospital, Oslo, Norway
| | - Espen Ajo Arnevik
- Department for Research and Innovation, Division of Mental Health and Addiction, Section for Clinical Addiction Research, Oslo University Hospital, Oslo, Norway
| | - Benjamin Hummelen
- Department for Research and Innovation, Division of Mental Health and Addiction, Section for Treatment Research, Oslo University Hospital, Oslo, Norway
| | - Theresa Wilberg
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Department for Research and Innovation, Division of Mental Health and Addiction, Section for Clinical Addiction Research, Oslo University Hospital, Oslo, Norway
| | - Geir Pedersen
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Department for National and Regional Functions, Division of Mental Health and Addiction, Network for Personality Disorders, Section for Personality Psychiatry and Specialized Treatments, Oslo University Hospital, Oslo, Norway
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How does level of personality functioning inform clinical management and treatment? Implications for ICD-11 classification of personality disorder severity. Curr Opin Psychiatry 2021; 34:54-63. [PMID: 33252430 DOI: 10.1097/yco.0000000000000658] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE OF REVIEW The International Classification of Diseases, 11th Edition (ICD-11) classifies personality disturbance according to levels of severity. This article reviews the literature on levels of personality functioning in relation to clinical management and treatment, and proposes how these findings apply to the ICD-11 classification of personality disorders. RECENT FINDINGS Findings were primarily derived from studies using the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) Level of Personality Functioning Scale (LPFS), Kernberg's Level of Personality Organization, and the general P-factor of personality disorder. Severity of personality dysfunction is related to treatment outcome, risk of dropout, therapeutic alliance, readiness for treatment, risk of harm to self or others, risk of dissociation and psychotic-like breaks, coherence in narrative identity, reflective functioning, and epistemic trust. SUMMARY The overall level of personality disorder severity indicates risk of negative outcomes and may be used as decision tool for 'personalized medicine' and required treatment intensity (e.g., strength of alliance and the need for establishing epistemic trust). Beyond the ICD-11 guidelines for determining personality disorder severity, these implications also apply to practitioners using comparable frameworks such as the DSM-5 LPFS and Kernberg's Level of Personality Organization. Future research should focus on the interaction of severity with trait qualifiers in relation to clinical management.
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Leutritz AL, Colic L, Borchardt V, Cheng X, Zhang B, Lison S, Frommer J, Buchheim A, Strauss B, Fonagy P, Nolte T, Walter M. Attachment-specific speech patterns induce dysphoric mood changes in the listener as a function of individual differences in attachment characteristics and psychopathology. Psychol Psychother 2020; 93:754-776. [PMID: 31746134 DOI: 10.1111/papt.12258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Revised: 10/21/2019] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Early childhood experiences influence cognitive-emotional development, with insecure attachment predisposing to potential psychopathologies. We investigated whether narratives containing attachment-specific speech patterns shape listeners' emotional responses and social intentions. DESIGN First, 149 healthy participants listened to three narratives characteristic for secure, insecure-preoccupied, and insecure-dismissing attachment. Following each narrative, the well-being and interpersonal reactivity as a particular aspect of emotional reactivity of the listener were assessed. Likewise, psychopathological aspects of personality were evaluated. A follow-up study compared 10 psychosomatic patients with a current depressive episode and/or personality disorder with distinct depressive symptoms and 10 age- and gender-matched healthy controls. METHODS Effects of narratives on listeners' mental state were tested with repeated-measures AN(C)OVA. Mediating effects in the listener (attachment characteristics in the context of personality traits) were explored. Narrative effects were compared between patients and controls. RESULTS Listening to insecure attachment narratives reduced well-being in controls. Nevertheless, tendency for social interaction was highest following the insecure-preoccupied narrative. Importantly, listeners' individual attachment characteristics mediated the relationship between well-being/interpersonal reactivity following the insecure-preoccupied narrative and levels of psychopathology. Furthermore, compared with healthy participants, patients showed higher emotional reactivity following exposure to the insecure-preoccupied narrative, represented by lower well-being and lower estimation of friendliness towards the narrator. CONCLUSIONS Exposure to attachment-specific speech patterns can result in dysphoric mood changes. Specifically, the insecure-preoccupied narrative influenced the listeners' emotional state, which was further mediated by the individual attachment patterns and psychopathological personality characteristics. This deepens the understanding of interpersonal processes, especially in psychotherapeutic settings. PRACTITIONER POINTS In clinical populations, insecure-preoccupied attachment has a high prevalence. In this study, listening to a narrative characteristic of insecure-preoccupied speech patterns resulted in reduced well-being in healthy listeners. Patients with depressive symptoms showed a higher emotional reactivity towards the insecure-preoccupied narrative compared to healthy controls. While working on (childhood) traumata, for example, in group therapy or inpatient settings, therapists should raise awareness to possible mood changes through discourse-conveyed attachment characteristics in listeners as a 'side effect'.
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Affiliation(s)
- Anna Linda Leutritz
- Clinical Affective Neuroimaging Laboratory, Magdeburg, Germany.,Department of Psychiatry and Psychotherapy, Otto von Guericke University, Magdeburg, Germany
| | - Lejla Colic
- Clinical Affective Neuroimaging Laboratory, Magdeburg, Germany.,Leibniz Institute for Neurobiology, Magdeburg, Germany
| | - Viola Borchardt
- Clinical Affective Neuroimaging Laboratory, Magdeburg, Germany
| | - Xuemei Cheng
- Department of Mechanical and Electrical Engineering, Beijing Polytechnic College, China
| | - Bin Zhang
- The Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, China
| | - Sarah Lison
- Department of Psychosomatics and Psychotherapy, Otto von Guericke University, Magdeburg, Germany
| | - Jörg Frommer
- Department of Psychosomatics and Psychotherapy, Otto von Guericke University, Magdeburg, Germany
| | - Anna Buchheim
- Institute of Psychology, University of Innsbruck, Austria
| | - Bernhard Strauss
- Institute of Psychosocial Medicine and Psychotherapy, University Hospital Jena, Germany
| | - Peter Fonagy
- Research Department of Clinical, Educational and Health Psychology, University College London, UK.,Anna Freud National Centre for Children and Families, London, UK
| | - Tobias Nolte
- Anna Freud National Centre for Children and Families, London, UK.,Wellcome Trust Centre for Neuroimaging, University College London, UK
| | - Martin Walter
- Clinical Affective Neuroimaging Laboratory, Magdeburg, Germany.,Leibniz Institute for Neurobiology, Magdeburg, Germany.,Max Planck Institute for Biological Cybernetics, Tübingen, Germany.,Center for Behavioral Brain Sciences, Magdeburg, Germany.,Department of Psychiatry and Psychotherapy, University Hospital Jena, Germany
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Borderline personality disorder, metacognition and psychotherapy. J Affect Disord 2020; 276:1095-1101. [PMID: 32777647 DOI: 10.1016/j.jad.2020.07.117] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 07/08/2020] [Accepted: 07/22/2020] [Indexed: 11/21/2022]
Abstract
BACKGROUND Deficits in the ability to think about own mental states and that of others (mindreading) are seen as key aspects of borderline personality disorder (BPD), which could sustain BPD symptoms. Interestingly, some studies showed that in BPD patients metacognition is selectively compromised and could improve during treatments. However, empirical findings are inconsistent, and it is debatable whether BPD presents a specific profile of mindreading impairments that could improve during treatments. METHODS We performed a bibliographic research on PubMed , Google Scholar and Scopus of all studies investigating a) the metacognitive functioning in the BPD patients and b) the link between psychotherapy, metacognition improvement and BPD symptomatology. A total of 11 studies met our inclusion criteria and considered metacognition following the definition proposed by Semerari. RESULTS Overall, the results suggest that BPD metacognitive profile mainly includes difficulties in metacognitive sub-domains of integration, differentiation and mastery. The type of treatment most appropriate to improve metacognitive abilities and reduce symptoms seemed to be a long term treatment and specifically focused on metacognitive deficits. LIMITATIONS Lack of a control group, small sample sizes and heterogeneity in terms of gender, age, comorbidities and other ongoing treatments are the key limits of the original studies reviewed. CONCLUSIONS The results sustain the hypothesis of a selective and specific metacognitive impairment in BPD patients that could improve during treatments together with their symptomatology. However, more studies are needed to further investigate the role of metacognition in the effectiveness of treatments.
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Folmo EJ, Stänicke E, Johansen MS, Pedersen G, Kvarstein EH. Development of therapeutic alliance in mentalization-based treatment—Goals, Bonds, and Tasks in a specialized treatment for borderline personality disorder. Psychother Res 2020; 31:604-618. [DOI: 10.1080/10503307.2020.1831097] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Affiliation(s)
- E. J. Folmo
- Norwegian National Advisory Unit on Personality Psychiatry, Section for Personality Psychiatry & Specialized Treatments, Division of Mental Health & Addiction, Oslo University Hospital, Oslo, Norway
- Department of Psychology, University of Oslo, Oslo, Norway
| | - E. Stänicke
- Department of Psychology, University of Oslo, Oslo, Norway
| | - M. S. Johansen
- Section for Personality Psychiatry & Specialized Treatments, Division of Mental Health & Addiction, Oslo University Hospital, Oslo, Norway
| | - G. Pedersen
- Section for Personality Psychiatry & Specialized Treatments, Division of Mental Health & Addiction, Oslo University Hospital, Oslo, Norway
- NORMENT, KG Jebsen Center for Psychosis Research, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - E. H. Kvarstein
- Section for Personality Psychiatry & Specialized Treatments, Division of Mental Health & Addiction, Oslo University Hospital, Oslo, Norway
- Adult Psychiatry Unit, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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The identification of a risk profile for young people with borderline personality pathology: a review of recent literature. Curr Opin Psychol 2020; 37:13-20. [PMID: 32653538 DOI: 10.1016/j.copsyc.2020.06.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 05/25/2020] [Accepted: 06/07/2020] [Indexed: 12/28/2022]
Abstract
The shift towards early intervention in borderline personality disorder (BPD) has introduced a clinical staging approach in the treatment for young persons with BPD. Complementary to staging is profiling: the identification of psychological, social and biological risk variables that may predict prognosis. The aim of this paper is to provide a risk profile for BPD by systematically reviewing literature on potential risk markers for poor prognosis for BPD. An extensive literature search revealed evidence for seven categories of risk factors: adverse childhood experiences, BPD symptom profile, associated mental disorders, personality impairments and traits, current interpersonal context, biological disposition and socio-demographics. Including these markers within the current staging approach, to compose individual risk profiles for poor BPD prognosis, may assist in personalizing treatment for young people with BPD and in refining research protocols for treatment outcome studies.
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