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Diamond D, Keefe JR, Hörz-Sagstetter S, Fischer-Kern M, Doering S, Buchheim A. Changes in Attachment Representation and Personality Organization in Transference-Focused Psychotherapy. Am J Psychother 2023; 76:31-38. [PMID: 36695536 DOI: 10.1176/appi.psychotherapy.20220018] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
OBJECTIVE The aim of this article was to construct an empirical bridge between object relations theory and attachment theory by investigating how researchers in both traditions have contributed to understanding and assessing identity diffusion (a keystone of personality pathology) and object relations in patients with borderline personality disorder during 1 year of transference-focused psychotherapy (TFP). METHODS The Adult Attachment Interview (AAI) and the Structured Interview of Personality Organization (STIPO) were administered to patients (N=104, all women) before and after 1 year of treatment. This study was part of a randomized controlled trial in which 104 patients with borderline personality disorder were randomly assigned to receive either TFP (a manualized, structured psychodynamic treatment approach) or treatment by experienced community psychotherapists. Changes on the AAI in attachment representations, narrative coherence, and reflective function were examined for their associations with changes on the STIPO in identity, object relations, and aggression. RESULTS Patients who shifted from disorganized (unresolved) to organized attachment on the AAI after 1 year of TFP (but not treatment by experienced community psychotherapists) showed hypothesized improvements in domains of personality organization on the STIPO, including identity, object relations, and aggression. Those who did not change from disorganized (unresolved) to organized attachment improved only in the domain of aggression. CONCLUSIONS These findings highlight the centrality of identity diffusion to borderline personality disorder pathology and the importance of targeting it in treatment. Furthermore, the results suggest that identity may be indexed by measures of attachment security, narrative coherence, and personality organization.
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Affiliation(s)
- Diana Diamond
- Department of Psychiatry, Weill Cornell Medical College, New York City (Diamond); Department of Psychology, City University of New York, New York City (Diamond); Department of Psychiatry and Behavioral Sciences, Albert Einstein College of Medicine, New York City (Keefe); Department of Clinical Psychology and Psychotherapy, Psychologische Hochschule Berlin, Berlin (Hörz-Sagstetter); Department of Psychoanalysis and Psychotherapy, Medical University of Vienna, Vienna (Fischer-Kern, Doering); Institute of Psychology, University of Innsbruck, Innsbruck, Austria (Buchheim)
| | - John R Keefe
- Department of Psychiatry, Weill Cornell Medical College, New York City (Diamond); Department of Psychology, City University of New York, New York City (Diamond); Department of Psychiatry and Behavioral Sciences, Albert Einstein College of Medicine, New York City (Keefe); Department of Clinical Psychology and Psychotherapy, Psychologische Hochschule Berlin, Berlin (Hörz-Sagstetter); Department of Psychoanalysis and Psychotherapy, Medical University of Vienna, Vienna (Fischer-Kern, Doering); Institute of Psychology, University of Innsbruck, Innsbruck, Austria (Buchheim)
| | - Susanne Hörz-Sagstetter
- Department of Psychiatry, Weill Cornell Medical College, New York City (Diamond); Department of Psychology, City University of New York, New York City (Diamond); Department of Psychiatry and Behavioral Sciences, Albert Einstein College of Medicine, New York City (Keefe); Department of Clinical Psychology and Psychotherapy, Psychologische Hochschule Berlin, Berlin (Hörz-Sagstetter); Department of Psychoanalysis and Psychotherapy, Medical University of Vienna, Vienna (Fischer-Kern, Doering); Institute of Psychology, University of Innsbruck, Innsbruck, Austria (Buchheim)
| | - Melitta Fischer-Kern
- Department of Psychiatry, Weill Cornell Medical College, New York City (Diamond); Department of Psychology, City University of New York, New York City (Diamond); Department of Psychiatry and Behavioral Sciences, Albert Einstein College of Medicine, New York City (Keefe); Department of Clinical Psychology and Psychotherapy, Psychologische Hochschule Berlin, Berlin (Hörz-Sagstetter); Department of Psychoanalysis and Psychotherapy, Medical University of Vienna, Vienna (Fischer-Kern, Doering); Institute of Psychology, University of Innsbruck, Innsbruck, Austria (Buchheim)
| | - Stephan Doering
- Department of Psychiatry, Weill Cornell Medical College, New York City (Diamond); Department of Psychology, City University of New York, New York City (Diamond); Department of Psychiatry and Behavioral Sciences, Albert Einstein College of Medicine, New York City (Keefe); Department of Clinical Psychology and Psychotherapy, Psychologische Hochschule Berlin, Berlin (Hörz-Sagstetter); Department of Psychoanalysis and Psychotherapy, Medical University of Vienna, Vienna (Fischer-Kern, Doering); Institute of Psychology, University of Innsbruck, Innsbruck, Austria (Buchheim)
| | - Anna Buchheim
- Department of Psychiatry, Weill Cornell Medical College, New York City (Diamond); Department of Psychology, City University of New York, New York City (Diamond); Department of Psychiatry and Behavioral Sciences, Albert Einstein College of Medicine, New York City (Keefe); Department of Clinical Psychology and Psychotherapy, Psychologische Hochschule Berlin, Berlin (Hörz-Sagstetter); Department of Psychoanalysis and Psychotherapy, Medical University of Vienna, Vienna (Fischer-Kern, Doering); Institute of Psychology, University of Innsbruck, Innsbruck, Austria (Buchheim)
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2
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Volkert J, Taubner S, Barkauskiene R, Mestre JM, Sales CMD, Thiele V, Saliba A, Protić S, Adler A, Conejo-Cerón S, Di Giacomo D, Ioannou Y, Moreno-Peral P, Vieira FM, Mota CP, Raleva M, Rangel Santos Henriques MI, Røssberg JI, Schmidt SJ, Perdih TS, Ulberg R, Heinonen E. Mediators and Theories of Change in Psychotherapy for Young People With Personality Disorders: A Systematic Review Protocol. Front Psychol 2021; 12:703095. [PMID: 34616334 PMCID: PMC8488151 DOI: 10.3389/fpsyg.2021.703095] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 08/18/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Personality disorders (PDs) are a severe health issue already prevalent among adolescents and young adults. Early detection and intervention offer the opportunity to reduce disease burden and chronicity of symptoms and to enhance long-term functional outcomes. While psychological treatments for PDs have been shown to be effective for young people, the mediators and specific change mechanisms of treatment are still unclear. Aim: As part of the “European Network of Individualized Psychotherapy Treatment of Young People with Mental Disorders” (TREATme), funded by the European Cooperation in Science and Technology (COST), we will conduct a systematic review to summarize the existing knowledge on mediators of treatment outcome and theories of change in psychotherapy for young people with personality disorders. In particular, we will evaluate whether mediators appear to be common or specific to particular age groups, treatment models, or outcome domains (e.g., psychosocial functioning, life quality, and adverse treatment effects). Method: We will follow the reporting guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement recommendations. Electronic databases (PubMed and PsycINFO) have been systematically searched for prospective, longitudinal, and case–control designs of psychological treatment studies, which examine mediators published in English. Participants will be young people between 10 and 30years of age who suffer from subclinical personality symptoms or have a personality disorder diagnosis and receive an intervention that aims at preventing, ameliorating, and/or treating psychological problems. Results: The results will be published in a peer-reviewed journal and at conference presentations and will be shared with relevant stakeholder groups. The data set will be made available to other research groups following recommendations of the open science initiative. Databases with the systematic search will be made openly available following open science initiatives. The review has been registered in PROSPERO (evaluation is pending, registration number ID 248959). Implications: This review will deliver a comprehensive overview on the empirical basis to contribute to the further development of psychological treatments for young people with personality disorders.
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Affiliation(s)
- Jana Volkert
- Department of Psychology, MSB Medical School Berlin, Berlin, Germany.,Institute of Psychosocial Prevention, University of Heidelberg, Heidelberg, Germany
| | - Svenja Taubner
- Institute of Psychosocial Prevention, University of Heidelberg, Heidelberg, Germany
| | | | - Jose M Mestre
- Department of Psychology, University of Cádiz, Cádiz, Spain
| | - Célia M D Sales
- Faculty of Psychology and Education Science, University of Porto, Porto, Portugal.,Center for Psychology, University of Porto, Porto, Portugal
| | - Vanessa Thiele
- Institute of Psychology, University of Kassel, Kassel, Germany
| | - Andrea Saliba
- Mental Health Services Malta, University of Malta, Msida, Malta
| | - Sonja Protić
- Institute of Criminological and Sociological Research Belgrade, Belgrade, Serbia
| | - Asta Adler
- Institute of Psychology, Vilnius University, Vilnius, Lithuania
| | | | - Dina Di Giacomo
- Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - Yianna Ioannou
- Department of Social Sciences, University of Nicosia, Nicosia, Cyprus
| | | | - Filipa Mucha Vieira
- Faculty of Psychology and Education Science, University of Porto, Porto, Portugal.,Center for Psychology, University of Porto, Porto, Portugal
| | - Catarina Pinheiro Mota
- Center for Psychology, University of Porto, Porto, Portugal.,Center for Psychology, University of Trás-os-Montes and Alto Douro, Vila Real, Portugal
| | - Marija Raleva
- Department of Child and Adolescent Psychiatry, University Clinic Skopje, Skopje, North Macedonia
| | | | | | - Stefanie J Schmidt
- Department of Clinical Psychology and Psychotherapy, University of Bern, Bern, Switzerland
| | | | - Randi Ulberg
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Department of Psychiatry, Diakonhjemmet Hospital, Oslo, Norway
| | - Erkki Heinonen
- National Institute for Health and Welfare, Helsinki, Finland.,Department of Psychology, University of Oslo, Oslo, Norway
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3
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Keefe JR, Kim TT, DeRubeis RJ, Streiner DL, Links PS, McMain SF. Treatment selection in borderline personality disorder between dialectical behavior therapy and psychodynamic psychiatric management. Psychol Med 2021; 51:1829-1837. [PMID: 32204742 DOI: 10.1017/s0033291720000550] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND No evidence-based therapy for borderline personality disorder (BPD) exhibits a clear superiority. However, BPD is highly heterogeneous, and different patients may specifically benefit from the interventions of a particular treatment. METHODS From a randomized trial comparing a year of dialectical behavior therapy (DBT) to general psychiatric management (GPM) for BPD, long-term (2-year-post) outcome data and patient baseline variables (n = 156) were used to examine individual and combined patient-level moderators of differential treatment response. A two-step bootstrapped and partially cross-validated moderator identification process was employed for 20 baseline variables. For identified moderators, 10-fold bootstrapped cross-validated models estimated response to each therapy, and long-term outcomes were compared for patients randomized to their model-predicted optimal v. non-optimal treatment. RESULTS Significant moderators surviving the two-step process included psychiatric symptom severity, BPD impulsivity symptoms (both GPM > DBT), dependent personality traits, childhood emotional abuse, and social adjustment (all DBT > GPM). Patients randomized to their model-predicted optimal treatment had significantly better long-term outcomes (d = 0.36, p = 0.028), especially if the model had a relatively stronger (top 60%) prediction for that patient (d = 0.61, p = 0.004). Among patients with a stronger prediction, this advantage held even when applying a conservative statistical check (d = 0.46, p = 0.043). CONCLUSIONS Patient characteristics influence the degree to which they respond to two treatments for BPD. Combining information from multiple moderators may help inform providers and patients as to which treatment is the most likely to lead to long-term symptom relief. Further research on personalized medicine in BPD is needed.
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Affiliation(s)
- John R Keefe
- Department of Psychiatry, Weill Medical College of Cornell University, New York, NY, USA
| | - Thomas T Kim
- Department of Psychology, University of Pennsylvania, Philadelphia, PA, USA
| | - Robert J DeRubeis
- Department of Psychology, University of Pennsylvania, Philadelphia, PA, USA
| | - David L Streiner
- Department of Psychiatry & Behavioural Neurosciences, McMaster University, Hamilton, Ontario, Canada
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Paul S Links
- Department of Psychiatry & Behavioural Neurosciences, McMaster University, Hamilton, Ontario, Canada
| | - Shelley F McMain
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
- Borderline Personality Disorder Clinic, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
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4
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Hayden MC, Müllauer PK, Beyer KJP, Gaugeler R, Senft B, Dehoust MC, Andreas S. Increasing Mentalization to Reduce Maladaptive Defense in Patients With Mental Disorders. Front Psychiatry 2021; 12:637915. [PMID: 33776819 PMCID: PMC7991294 DOI: 10.3389/fpsyt.2021.637915] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 02/16/2021] [Indexed: 01/22/2023] Open
Abstract
Background: There are indications of associations between the ability to mentalize and psychological defense mechanisms. However, only a few studies have focused on these associations, and even fewer have included empirical analyses. In the present study, we aimed to fill this research gap by analyzing the link between the ability to mentalize and psychological defense mechanisms in patients with mental disorders. We examined whether changes in defense mechanisms are predicted by an increase in mentalization or whether such changes are only related to reductions in psychopathology and interpersonal problems. Methods: A clinical sample of N = 89 patients was studied during and after inpatient psychiatric rehabilitation. Repeated-measures analyses of variance were performed to determine changes in mentalization, psychological defense, psychopathology, and interpersonal problems over the course of therapy and post-treatment. Linear regression analyses were used to predict the change in defense patterns based on an increase in mentalization. Results: Maladaptive defense mechanisms were significantly reduced during inpatient therapy and remained low until follow-up, whereas neurotic and adaptive defense mechanisms did not change significantly. The results of the regression analyses indicated that mentalization played an important role in the reduction in maladaptive defense during and after inpatient rehabilitation for mental disorders, whereas reductions in psychopathology and interpersonal distress were only partially associated with a reduction in maladaptive defense. Conclusion: We conclude that mentalization is vital for reducing maladaptive defense mechanisms, which are commonly associated with mental disorders. In therapy, an increase in patients' capacity to mentalize may be a practicable approach to diminish maladaptive defense mechanisms.
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Affiliation(s)
- Markus C Hayden
- Institut für Psychologie, Alpen-Adria-Universität Klagenfurt, Klagenfurt, Austria.,Klinik Bad Reichenhall der Deutschen Rentenversicherung Bayern-Süd, Bad Reichenhall, Germany
| | - Pia K Müllauer
- Institut für Psychologie, Alpen-Adria-Universität Klagenfurt, Klagenfurt, Austria
| | - Klea J P Beyer
- Institut für Psychologie, Alpen-Adria-Universität Klagenfurt, Klagenfurt, Austria
| | - Richard Gaugeler
- Öffentliches Krankenhaus Waiern, Feldkirchen in Kärnten, Austria
| | - Birgit Senft
- Reha-Klinik für Seelische Gesundheit und Prävention, Klagenfurt, Austria
| | | | - Sylke Andreas
- Institut für Psychologie, Alpen-Adria-Universität Klagenfurt, Klagenfurt, Austria
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Keefe JR, Solomonov N, Derubeis RJ, Phillips AC, Busch FN, Barber JP, Chambless DL, Milrod BL. Focus is key: Panic-focused interpretations are associated with symptomatic improvement in panic-focused psychodynamic psychotherapy. Psychother Res 2018; 29:1033-1044. [DOI: 10.1080/10503307.2018.1464682] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
Affiliation(s)
- John R. Keefe
- Department of Psychology, University of Pennsylvania, Philadelphia, PA, USA
| | - Nili Solomonov
- Derner School of Psychology, Adelphi University, Garden City, NY, USA
| | - Robert J. Derubeis
- Department of Psychology, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Fredric N. Busch
- Department of Psychiatry, Weill Cornell Medical College, New York, NY, USA
| | - Jacques P. Barber
- Derner School of Psychology, Adelphi University, Garden City, NY, USA
| | | | - Barbara L. Milrod
- Department of Psychiatry, Weill Cornell Medical College, New York, NY, USA
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