Effects of motive-oriented therapeutic relationship in a ten-session general psychiatric treatment of borderline personality disorder: a randomized controlled trial

Fluctuations in therapist responsiveness facing clients with borderline personality disorder: Starting therapy on the right foot

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.

Good-Enough Therapy: A Review of the Empirical Basis of Good Psychiatric Management

In this review, the question of whether good psychiatric management (GPM) has a sufficient, or good-enough, evidence base is examined from two complementary perspectives. First, the author reviews research that has investigated whether GPM reduces symptoms of borderline personality disorder. Analyses at the group and individual levels have indicated that symptoms may decrease among patients receiving GPM. Second, the author reviews research that has investigated the processes through which change occurs in GPM. Studies that have shown process changes toward emotional balance, interpersonally effective functioning, and a more coherent and reality-based autobiographical narrative are discussed. To fully answer the question of whether GPM is good enough, more controlled trials are needed to demonstrate effectiveness, mechanisms of change, and broad implementation in culturally diverse populations.

A longitudinal view of an approach to responsiveness: Principles followed and lessons learned

AbstractResponsiveness is currently a hot topic in the psychotherapy literature with a large variation in what the term means to colleagues of various orientations. This adds to its popularity but limits the scope of whatever is written or said about responsiveness. The fact that the meaning of responsiveness has developed over time within the approaches adds also to the variation, while an understanding of development has the potential of deepening the understanding of each approach. As a fair description and comparison of even just the most important approaches is by far out of reach for a page-limited article, the development of one approach, which may be termed the "Bernese" approach is described here, along with lessons learnt and general comments. The approach includes Plan Analysis case formulations, the concept of complementary or Motive-Oriented Relationship, a description of a combined qualitative and quantitative assessment, and many methodological and conceptual considerations. Personal development is woven in. Overall, it seems fair to say that this approach, at its core developed long before responsiveness became popular, has turned out to still be useful, with a gain in depth as far as concepts and assessment are concerned.

Predictors of Effects in Brief Psychiatric Treatment for Borderline Personality Disorder

If evidence points to the equal efficacy of all bona fide treatments for borderline personality disorder (BPD) in general, it may not necessarily be true for a specific individual, nor do such general conclusions help in the triage of clients in clinical services. We investigated potential therapy outcome predictors for participants with a BPD diagnosis (N = 99). They were assessed on scales including the Outcome Questionnaire-45.2 (OQ-45), the Inventory of Interpersonal Problems-64, and the Borderline Symptom List. Our analyses revealed that individuals with low levels of symptom distress at intake had the smallest change in total OQ-45 score over the course of brief treatment, while the individuals with high levels of symptom distress had a mean large change in total score (-23). We observed that individuals with high symptom loads AND low levels of interpersonal problems at intake seemed to have the best progress.

Effectiveness of outpatient and community treatments for people with a diagnosis of 'personality disorder': systematic review and meta-analysis

BACKGROUND

Quality of care and access to effective interventions have been widely criticised as limited for people diagnosed with 'personality disorder' or who have comparable needs (described in some recent papers as "Complex Emotional Needs" (CEN). It is important to identify effective interventions and the optimal context and mode of delivery for people with CEN. We aimed to investigate the effectiveness of psychosocial interventions delivered in community and outpatient settings in treating symptoms associated with 'personality disorder', and the moderating effects of treatment-related variables.

METHODS

We systematically searched MEDLINE, EMBASE, PsycINFO, CINAHL, HMIC, ASSIA for articles published in English, from inception to November 23, 2020. We included randomized controlled trials examining interventions provided in community or outpatient settings for CEN. The primary outcome was 'personality disorder' symptoms, while secondary outcomes included anxiety symptoms, depressive symptoms, and global psychiatric symptoms. Random-effects meta-analysis was conducted for each outcome, and meta-regression analysis was performed to assess the moderating effects of treatment characteristics. The quality of the studies and the degree of publication bias was assessed.

RESULTS

We included 54 trials (n = 3716 participants) in the meta-analysis. We found a large effect size (g = 0.78, 95% CI: 0.56 to 1.01, p < 0.0001) favoring interventions for 'borderline personality disorder' (BPD) symptoms over Treatment as Usual or Waitlist (TAU/WL), and the efficacy was maintained at follow-up (g = 1.01, 95% CI: 0.37 to 1.65, p = 0.002). Interventions effectively reduced anxiety symptoms (g = 0.58, 95% CI: 0.21 to 0.95, p = 0.002), depressive symptoms (g = 0.57, 95% CI: 0.32 to 0.83, p < 0.0001), and global psychiatric symptoms (g = 0.50, 95% CI: 0.35 to 0.66, p < 0.0001) compared to TAU/WL. The intervention types were equally effective in treating all symptom categories assessed. Treatment duration and treatment intensity did not moderate the effectiveness of the interventions for any outcome.

CONCLUSIONS

People with a 'personality disorder' diagnosis benefited from psychological and psychosocial interventions delivered in community or outpatient settings, with all therapeutic approaches showing similar effectiveness. Mental health services should provide people with CEN with specialised treatments in accordance with the availability and the patients' preferences.

The first session matters: Therapist responsiveness and the therapeutic alliance in the treatment of borderline personality disorder

OBJECTIVES

The focus of the present research is to investigate the impact of therapist responsiveness at the very first session of therapy on the evaluation of therapeutic alliance from the therapist's perspective and from patient's perspective in the context of guideline-based treatment for borderline personality disorder.

DESIGN

The study has a correlational and longitudinal design applied to a 10-session therapy in a naturalistic setting.

METHODS

A total of four trained raters evaluated therapist responsiveness during the first session of therapy. After each therapy session, therapists and patients filled out the short form of the Working Alliance Inventory measuring working alliance; the sample included 13 therapists and 47 patients. Correlational analysis as well as hierarchical linear modelling exploring the relationship between first session therapist responsiveness and working alliance were performed.

RESULTS

The global evaluation of responsiveness revealed a significant relationship with the temporal evolution of the alliance rated from the therapists' perspective.

DISCUSSION

There is the necessity to further explore therapist appropriate responsiveness which could potentially explain several psychotherapy research results. Moreover, it could help in finding alternatives in order to facilitate patients' early engagement in therapy as well as facilitating the building process of therapeutic alliance. Finally, an effort should be made in order to study more individualized operationalization of responsiveness.

Current state of the evidence on community treatments for people with complex emotional needs: a scoping review

BACKGROUND

Improving the quality of care in community settings for people with 'Complex Emotional Needs' (CEN-our preferred working term for services for people with a "personality disorder" diagnosis or comparable needs) is recognised internationally as a priority. Plans to improve care should be rooted as far as possible in evidence. We aimed to take stock of the current state of such evidence, and identify significant gaps through a scoping review of published investigations of outcomes of community-based psychosocial interventions designed for CEN.

METHODS

We conducted a scoping review with systematic searches. We searched six bibliographic databases, including forward and backward citation searching, and reference searching of relevant systematic reviews. We included studies using quantitative methods to test for effects on any clinical, social, and functioning outcomes from community-based interventions for people with CEN. The final search was conducted in November 2020.

RESULTS

We included 226 papers in all (210 studies). Little relevant literature was published before 2000. Since then, publications per year and sample sizes have gradually increased, but most studies are relatively small, including many pilot or uncontrolled studies. Most studies focus on symptom and self-harm outcomes of various forms of specialist psychotherapy: most result in outcomes better than from inactive controls and similar to other specialist psychotherapies. We found large evidence gaps. Adaptation and testing of therapies for significant groups (e.g. people with comorbid psychosis, bipolar disorder, post-traumatic stress disorder, or substance misuse; older and younger groups; parents) have for the most part only reached a feasibility testing stage. We found little evidence regarding interventions to improve social aspects of people's lives, peer support, or ways of designing effective services.

CONCLUSIONS

Compared with other longer term mental health problems that significantly impair functioning, the evidence base on how to provide high quality care for people with CEN is very limited. There is good evidence that people with CEN can be helped when specialist therapies are available and when they are able to engage with them. However, a much more methodologically robust and substantial literature addressing a much wider range of research questions is urgently needed to optimise treatment and support across this group.

Addressing interpersonal patterns in patients with personality disorders partially explains psychotherapy outcome via changes in interaction patterns: A mediation analysis

OBJECTIVE

Many patients with personality disorders (PDs) present with problematic interaction patterns. These may also manifest in the therapeutic relationship. For successful treatment, therapists must therefore find effective ways to address such problematic interaction patterns.

METHODS

A total of 382 patients with PDs were recruited within a naturalistic setting and received integrative cognitive-behavioral therapy (CBT). Two subscales of the observer-rated Process-Content-Relationship Scale were applied to sessions 15, 20, and 25 of treatment: one on patient interaction patterns and the other on therapist addressing these. Symptom severity was assessed at intake and discharge. Mediation analysis was applied.

RESULTS

We found significant main effects of (1) therapists' addressing problematic interaction patterns in session 15 on patients' changes in such patterns from session 15 to 25 and (2) patients' changes in problematic interaction patterns on symptom severity at treatment termination. Further, the effect of therapists' addressing problematic interaction patterns on outcome was mediated by changes in patients' interaction patterns.

CONCLUSION

The results indicate that therapists' addressing of PD patients' problematic interaction patterns may be particularly important to improve such patterns and thereby treatment outcome. Future research should identify in which patients the mechanism of addressing interaction patterns works best.

How Plan Analysis can inform the construction of a therapeutic relationship

The construction of a positive therapeutic relationship was shown to be related with outcome in psychotherapy, but there are only a few prescriptive concepts helping the therapist to contribute to such a process. The present case illustrates the use of Plan Analysis (PA) and the motive-oriented therapeutic relationship (MOTR) in the explanation of the construction of a positive therapeutic relationship. We analyze the case of Sharon, a 22-year-old student presenting with major depressive disorder. We present the case formulation according to PA and select Session 7 from the therapeutic process to illustrate three moments of the therapist focus on the underlying motives: (a) a first moment when the therapist presents with nonoptimal features of responding to the patient's profile, (b) a second moment when the therapist intervenes optimally, and (c) a third moment when the therapist intervenes excellently. We discuss this case from the perspective of personalizing psychotherapy.

Lessening of the pervasiveness of interpersonal patterns in borderline personality disorder explains symptom decrease after treatment: A process analysis

Background

Problematic interpersonal patterns, as defined by the core conflictual relationship theme (CCRT) method, are part of the clinical presentation of clients with borderline personality disorder (BPD). So far, we do not know whether the pervasiveness of interpersonal patterns changes and if this change explains therapy outcome.

Methods

In a secondary analysis of a randomized controlled trial on a brief version of psychiatric treatment for BPD, a treatment with a psychodynamic focus, the present study included N = 39 clients. One early session and one late session of the treatment were transcribed and analyzed using the CCRT method.

Results

It appeared that pervasiveness of the predominant CCRT decreased over the course of the brief treatment; this effect was robust across treatment conditions. Change in pervasiveness in any CCRT component explained a small portion of variance of the decrease in borderline symptoms observed at the end of treatment.

Discussion

Lessening of pervasiveness of problematic in‐session interpersonal patterns may be hypothesized as potential mechanism of effective treatment for BPD which should be tested in controlled designs.

Psychotherapeutic case formulation: Plan analysis for narcissistic personality disorder

BACKGROUND

One of the relevant case formulation methods for personality difficulties is plan analysis. The present study aimed at delivering a prototypical plan analysis for clients presenting with a diagnosis of narcissistic personality disorder (NPD). The sample consisted of 14 participants diagnosed with an NPD. Based on audio clinical material, we developed 14 individual plan analyses that we then merged into a single prototypical plan analysis. For explorative purposes, we ran an ordinary least squares regression model to predict the narcissistic symptoms severity (NAR) measured on a scale of 1-7 of the 14 clients by the presence (respectively absence) of certain plans in their individual plan analysis. The synthesis revealed that clients with pathological narcissism share common basic motives. Results of the regression model reveal that the presence of the plan 'be strong' reduces the NAR scale by 1.52 points (p = 0.011).

DISCUSSION

In the treatment of psychological disorders, precise case formulations allow therapists for making clinically appropriate decision, personalizing the intervention and gaining insight into the client's subjective experience. In the prototypical plan structure we developed for NPD, clients strive to strengthen their self-esteem and avoid loss of control, criticism and confrontation as well as to get support, understanding and solidarity. When beginning psychotherapy with a client presenting with NPD, the therapist can use these plans as valuable information to help writing tailored, and therefore more efficient, case formulations for their patients presenting with an NPD.

Differentielle Beziehungsgestaltung in der Verhaltenstherapie: Auf dem Weg zu einer evidenzbasierten individualisierten Beziehungsgestaltung

Im Zuge der Anfänge der Verhaltenstherapie (VT) und der “kognitiven Wende” wurde der aktiven Beziehungsgestaltung und damit verbundenen Faktoren zunächst nur zweitrangig Beachtung geschenkt, obwohl die Bedeutung der Beziehung zwischen Therapeut und Patient auch in der VT bereits relativ früh erkannt wurde. Seitdem hat sich die VT substanziell weiterentwickelt. Insbesondere die aktive Gestaltung der therapeutischen Beziehung in Abhängigkeit verschiedener Variablen ist mittlerweile fester Bestandteil einer jeden VT. In dieser Übersichtsarbeit werden Konzepte der Beziehungsgestaltung dargestellt, welche der VT zugerechnet und im Rahmen der Ausbildung im deutschsprachigen Raum gelehrt werden. Fokussiert wird auf folgende drei Ansatzpunkte: Die Ausrichtung der Beziehung an (1) Therapiephasen, (2) Bedürfnissen, Motiven und Erwartungen sowie (3) frühen traumatisierenden Bezie­hungserfahrungen. Die aktuelle Studienlage legt nahe, dass pauschalisierte Handlungsempfehlungen zur aktiven Gestaltung der therapeutischen Beziehung zu kurz greifen. Ausgehend von der individuellen Problematik des einzelnen Patienten wird die Realisierung der therapeutischen Beziehung im Sinne einer differentiellen Beziehungsgestaltung beschrieben und diskutiert.

Self-Contempt, the Working Alliance and Outcome in Treatments for Borderline Personality Disorder: An Exploratory Study

Objective. We examined the role of expressed self-contempt in therapy for borderline personality disorder (BPD). Based on previous literature on BPD, we assumed an association between the self-contempt and the core symptoms of BPD. We also studied the progression of expressed self-contempt during the treatment and its effect on the alliance and the outcomes of treatment.Method. We rated the expressed self-contempt in 148 tape-recorded sessions with patients with BPD (N = 50), during a brief psychiatric treatment. We rated self-contempt at three time-points, using an observer-rate scale. Self-reported questionnaires were used to assess symptoms and the working alliance.Results. There are some associations between self-contempt and BPD symptoms. Expressed self-contempt did not change during the treatment. One measure of self-contempt was associated with a weaker alliance rated by the patients and with a stronger alliance rated by the therapists. The expression of high self-contempt was not predictive of outcomes when the initial level of problems was controlled for.Conclusions. The results highlight the importance to examine the complex effects of self-contempt in BPD undergoing treatment in a differentiated manner and suggest to clinicians and researchers to be attentive to this specific emotional state, and change therein, in psychotherapy.Keywords: Self-contempt; Borderline Personality Disorder; Brief Treatment; Therapeutic Alliance; EmotionTrial registration: ClinicalTrials.gov identifier: NCT01896024.

Social interaction patterns, therapist responsiveness, and outcome in treatments for borderline personality disorder

OBJECTIVES

Inflexible social interaction patterns are defining features of borderline personality disorder (BPD). Specific beliefs about the self and others may be activated across interaction situations, often leading to instable relationships. It may be pivotal to address these difficulties in early treatment phases, through appropriate therapist responsiveness, which means an adaptation of therapist's activity to their client's behaviours using emerging information in the process (Stiles, 2009, Clinical Psychology: Science and Practice, 16, 86).

DESIGN

In this process-outcome study, responsiveness is operationalized by the motive-oriented therapeutic relationship (Caspar, 2007, Handbook of psychotherapeutic case formulations, 2nd ed., 251-289, Guilford), based on the Plan analysis case formulation. The present study assesses the interplay between social interaction problems and therapist responsiveness, explaining symptoms at discharge and the therapeutic alliance.

METHOD

In total, N = 50 clients with BPD entered the study, and standard and responsive treatments were compared. Social interaction patterns were assessed by the newly developed Borderline Interaction Patterns Scale (BIPS), applied to recorded material of three sessions per therapy. Outcome was measured by general symptoms (OQ-45), borderline symptoms (BSL-23), interpersonal problems (IIP), and the therapeutic alliance (WAI).

RESULTS

Results suggest that in standard treatment, social interaction patterns are neither related to outcome nor the therapeutic alliance. In responsive treatment, more activation of social interaction patterns predicted better outcome on IIP and lower therapist ratings of the alliance.

CONCLUSIONS

The conclusions seem promising for specific effectiveness of responsive treatments in particular in the interpersonal problem area of BPD. Identifying social interaction patterns early in treatment may be a crucial pathway to change for BPD.

PRACTITIONER POINTS

Responsive therapy activating social interaction patterns may be crucial for better outcome. Future research should focus on mechanisms of change in early treatment phases for BPD. New scale for assessing social interaction patterns specific to borderline personality disorder.

CBT at the Crossroads: The Rise of Transdiagnostic Treatments

Transdiagnostic treatments span a heterogeneous group of interventions that target a wider range of disorders and can be applied to treat several disorders simultaneously. Several meta-analyses have highlighted the evidence base of these novel therapies. However, these meta-analyses adopt different definitions of transdiagnostic treatments, and the growing field of transdiagnostic therapies has become increasingly difficult to grasp. The current narrative review proposes a distinction of “one size fits all” unified and “my size fits me” individualized approaches within transdiagnostic therapies. Unified treatments are applied as “broadband” interventions to a range of disorders without tailoring to the individual, while individualized treatments are tailored to the specific problem presentation of the individual, e.g., by selecting modules within modular treatments. The underlying theoretical foundation and relevant empirical evidence for these different transdiagnostic approaches are examined. Advantages and limitations of the transdiagnostic treatments as well as future developments are discussed.

Brief psychological interventions for borderline personality disorder. A systematic review and meta-analysis of randomised controlled trials

BACKGROUND

People with Borderline Personality Disorder (BPD) have limited access to long term psychological therapies. Briefer interventions have been developed but trial evidence to support their use has not been reviewed.

AIMS

To examine whether psychological interventions for adults with BPD of six months duration or less improve symptoms, mood, self-harm, suicidal behaviour, and service use.

METHODS

The protocol was prospectively registered (PROSPERO CRD42017063777). Database searches were conducted up to April 2020. Inclusion, data extraction and risk of bias were assessed in duplicate. We identified 27 randomised controlled trials. We conducted random-effects meta-analyses sub-grouping data into delivery method, additional support, and comparison type.

RESULTS

High levels of bias were found for attrition and reporting. Heterogeneity was high in some pooled data. Borderline symptom reductions were greatest for interventions including additional support (SMD. -1.23, 95% C.I. -2.13, -0.33). Planned generic support may be as effective as specialist interventions for borderline symptoms (SMD = -0.11, 95% C.I. -0.51, 0.29) and social functioning (SMD = -0.16., 95% C.I. -0.65, 0.33). Follow-up was limited and direct comparison with post-intervention results was unreliable.

CONCLUSIONS

Short-term interventions may be effective. Access to additional support has an impact on outcomes. It is unclear if symptomatic change is sustained.

Impact of Psychotherapy on Psychosocial Functioning in Borderline Personality Disorder Patients

Borderline Personality Disorder (BPD) significantly impairs functioning. Fortunately, effective treatments are available for borderline symptoms but their effect on functioning should be assessed. The objective of this meta-analysis is to assess the effect of specifically-designed versus non-specifically designed psychotherapies on function in adult patients with BPD. The reference list of Cristea et al. 2017 was used to identify the randomized controlled trials (RCTs) assessing the BPD-specifically-designed psychotherapy versus non-specific psychotherapies in adult BPD patients. Among those, RCTs assessing post-treatment functioning using the Global Assessment of Functioning, Social Adjustment Scale-Self-Report and Inventory of Interpersonal Problems were included. Ten trials (880 participants) were included. Summary effect size was calculated using the measured Hedge's g. The results indicate the BPD patients in the intervention group had a significantly higher (g = 0.41; 95% CI, 0.09-0.73) level of psychosocial functioning after receiving the specifically-designed psychotherapies in comparison with BPD patients in control groups after receiving non-specific psychotherapies. Specifically-designed psychotherapies can improve psychosocial functioning although improvement in measurement of function (i.e., more objective and universal tools) and improvement in psychotherapies (i.e., more focused on general functioning) will be helpful.

How Personality Disorders Change in Psychotherapy: a Concise Review of Process

PURPOSE OF REVIEW

The present review summarizes the current state of the art in psychotherapy processes during treatments for clients with personality disorders. We outline some methodological challenges in the discipline of process research, give a brief historical account on process research, and then focus on specific processes studied from an empirical perspective.

RECENT FINDINGS

The current review acknowledges the centrality of the therapeutic relationship, in particular the therapeutic alliance, therapist empathy, and responsiveness in explaining outcome across treatment modalities for personality disorders. The review describes evidence from three overall and overlapping lines of inquiry that have garnered scientific interest in the past years. For emotional change (regulation, awareness, and transformation), socio-cognitive change (mentalizing, meta-cognition, and interpersonal patterns), and increase in insight and change in defense mechanisms, evidence is moderate to strong for these processes to contribute to healthy change in treatments for personality disorders, in particular borderline personality disorder. Avenues of future studies are outlined.

Metacognitive improvement and symptom change in a 3-month treatment for borderline personality disorder

OBJECTIVES

Recognizing and reflecting on one's own and other people's mental states represent a major difficulty for patients with borderline personality disorder (BPD). Only recently have studies begun exploring whether these capacities increase with successful therapies and if such an improvement is linked with outcome. The present study investigated whether metacognition would improve and if its improvement was related with symptom change in BPD patients.

DESIGN

The transcripts from the first and the penultimate session of a ten-session version of good psychiatric management were analysed with the MAS-R scale in a N = 37 BPD sample. Patients, selected from a previously published RCT (Kramer et al., 2014), were assigned either to the good psychiatric management treatment or to the same treatment with the addition of the Motive-Oriented Therapeutic Relationship (Caspar, 2007), a form of therapeutic relationship based on an individualized case formulation. Symptoms were assessed with the OQ-45.

RESULTS

Findings partially support the hypotheses. First, improvement in capacities to understand others' mind, to take a critical distance from one's own rigid and maladaptive beliefs, and to use behavioural and attentional strategies to face adversities is found in both treatment groups. Controlling for marital status, only the ability to differentiate between reality and representations remains significant. Second, no link between metacognitive change and symptom change during treatment is found. However, a link is observed between the increase in metacognition and symptom reduction at 6-month follow-up.

CONCLUSIONS

Results invite to further investigate the role of metacognition in therapy change through different modalities and in longer-term treatments.

PRACTITIONER POINTS

The development of metacognitive processes and their links with symptom change were examined during a short-term treatment in 37 borderline patients Improvement was found in capacities to understand others' mind, to take a critical distance from own rigid and maladaptive beliefs, and to use behavioural and attentional strategies even in a short-term treatment Controlling for marital status, only the ability to take a critical distance from representations remained significant A link was observed between increase in metacognition and symptom reduction at 6-month follow-up Understanding and tailoring interventions to specific metacognitive difficulties could be associated with symptom change during treatment for BPD patients.

Psychological therapies for people with borderline personality disorder

BACKGROUND

Over the decades, a variety of psychological interventions for borderline personality disorder (BPD) have been developed. This review updates and replaces an earlier review (Stoffers-Winterling 2012).

OBJECTIVES

To assess the beneficial and harmful effects of psychological therapies for people with BPD.

SEARCH METHODS

In March 2019, we searched CENTRAL, MEDLINE, Embase, 14 other databases and four trials registers. We contacted researchers working in the field to ask for additional data from published and unpublished trials, and handsearched relevant journals. We did not restrict the search by year of publication, language or type of publication.

SELECTION CRITERIA

Randomised controlled trials comparing different psychotherapeutic interventions with treatment-as-usual (TAU; which included various kinds of psychotherapy), waiting list, no treatment or active treatments in samples of all ages, in any setting, with a formal diagnosis of BPD. The primary outcomes were BPD symptom severity, self-harm, suicide-related outcomes, and psychosocial functioning. There were 11 secondary outcomes, including individual BPD symptoms, as well as attrition and adverse effects.

DATA COLLECTION AND ANALYSIS

At least two review authors independently selected trials, extracted data, assessed risk of bias using Cochrane's 'Risk of bias' tool and assessed the certainty of the evidence using the GRADE approach. We performed data analysis using Review Manager 5 and quantified the statistical reliability of the data using Trial Sequential Analysis.

MAIN RESULTS

We included 75 randomised controlled trials (4507 participants), predominantly involving females with mean ages ranging from 14.8 to 45.7 years. More than 16 different kinds of psychotherapy were included, mostly dialectical behaviour therapy (DBT) and mentalisation-based treatment (MBT). The comparator interventions included treatment-as-usual (TAU), waiting list, and other active treatments. Treatment duration ranged from one to 36 months. Psychotherapy versus TAU Psychotherapy reduced BPD symptom severity, compared to TAU; standardised mean difference (SMD) -0.52, 95% confidence interval (CI) -0.70 to -0.33; 22 trials, 1244 participants; moderate-quality evidence. This corresponds to a mean difference (MD) of -3.6 (95% CI -4.4 to -2.08) on the Zanarini Rating Scale for BPD (range 0 to 36), a clinically relevant reduction in BPD symptom severity (minimal clinical relevant difference (MIREDIF) on this scale is -3.0 points). Psychotherapy may be more effective at reducing self-harm compared to TAU (SMD -0.32, 95% CI -0.49 to -0.14; 13 trials, 616 participants; low-quality evidence), corresponding to a MD of -0.82 (95% CI -1.25 to 0.35) on the Deliberate Self-Harm Inventory Scale (range 0 to 34). The MIREDIF of -1.25 points was not reached. Suicide-related outcomes improved compared to TAU (SMD -0.34, 95% CI -0.57 to -0.11; 13 trials, 666 participants; low-quality evidence), corresponding to a MD of -0.11 (95% CI -0.19 to -0.034) on the Suicidal Attempt Self Injury Interview. The MIREDIF of -0.17 points was not reached. Compared to TAU, psychotherapy may result in an improvement in psychosocial functioning (SMD -0.45, 95% CI -0.68 to -0.22; 22 trials, 1314 participants; low-quality evidence), corresponding to a MD of -2.8 (95% CI -4.25 to -1.38), on the Global Assessment of Functioning Scale (range 0 to 100). The MIREDIF of -4.0 points was not reached. Our additional Trial Sequential Analysis on all primary outcomes reaching significance found that the required information size was reached in all cases. A subgroup analysis comparing the different types of psychotherapy compared to TAU showed no clear evidence of a difference for BPD severity and psychosocial functioning. Psychotherapy may reduce depressive symptoms compared to TAU but the evidence is very uncertain (SMD -0.39, 95% CI -0.61 to -0.17; 22 trials, 1568 participants; very low-quality evidence), corresponding to a MD of -2.45 points on the Hamilton Depression Scale (range 0 to 50). The MIREDIF of -3.0 points was not reached. BPD-specific psychotherapy did not reduce attrition compared with TAU. Adverse effects were unclear due to too few data. Psychotherapy versus waiting list or no treatment Greater improvements in BPD symptom severity (SMD -0.49, 95% CI -0.93 to -0.05; 3 trials, 161 participants), psychosocial functioning (SMD -0.56, 95% CI -1.01 to -0.11; 5 trials, 219 participants), and depression (SMD -1.28, 95% CI -2.21 to -0.34, 6 trials, 239 participants) were observed in participants receiving psychotherapy versus waiting list or no treatment (all low-quality evidence). No evidence of a difference was found for self-harm and suicide-related outcomes. Individual treatment approaches DBT and MBT have the highest numbers of primary trials, with DBT as subject of one-third of all included trials, followed by MBT with seven RCTs. Compared to TAU, DBT was more effective at reducing BPD severity (SMD -0.60, 95% CI -1.05 to -0.14; 3 trials, 149 participants), self-harm (SMD -0.28, 95% CI -0.48 to -0.07; 7 trials, 376 participants) and improving psychosocial functioning (SMD -0.36, 95% CI -0.69 to -0.03; 6 trials, 225 participants). MBT appears to be more effective than TAU at reducing self-harm (RR 0.62, 95% CI 0.49 to 0.80; 3 trials, 252 participants), suicidality (RR 0.10, 95% CI 0.04, 0.30, 3 trials, 218 participants) and depression (SMD -0.58, 95% CI -1.22 to 0.05, 4 trials, 333 participants). All findings are based on low-quality evidence. For secondary outcomes see review text.

AUTHORS' CONCLUSIONS

Our assessments showed beneficial effects on all primary outcomes in favour of BPD-tailored psychotherapy compared with TAU. However, only the outcome of BPD severity reached the MIREDIF-defined cut-off for a clinically meaningful improvement. Subgroup analyses found no evidence of a difference in effect estimates between the different types of therapies (compared to TAU) . The pooled analysis of psychotherapy versus waiting list or no treatment found significant improvement on BPD severity, psychosocial functioning and depression at end of treatment, but these findings were based on low-quality evidence, and the true magnitude of these effects is uncertain. No clear evidence of difference was found for self-harm and suicide-related outcomes. However, compared to TAU, we observed effects in favour of DBT for BPD severity, self-harm and psychosocial functioning and, for MBT, on self-harm and suicidality at end of treatment, but these were all based on low-quality evidence. Therefore, we are unsure whether these effects would alter with the addition of more data.

Structured Psychological Support for people with personality disorder: feasibility randomised controlled trial of a low-intensity intervention

BACKGROUND

National guidance cautions against low-intensity interventions for people with personality disorder, but evidence from trials is lacking.

AIMS

To test the feasibility of conducting a randomised trial of a low-intensity intervention for people with personality disorder.

METHOD

Single-blind, feasibility trial (trial registration: ISRCTN14994755). We recruited people aged 18 or over with a clinical diagnosis of personality disorder from mental health services, excluding those with a coexisting organic or psychotic mental disorder. We randomly allocated participants via a remote system on a 1:1 ratio to six to ten sessions of Structured Psychological Support (SPS) or to treatment as usual. We assessed social functioning, mental health, health-related quality of life, satisfaction with care and resource use and costs at baseline and 24 weeks after randomisation.

RESULTS

A total of 63 participants were randomly assigned to either SPS (n = 33) or treatment as usual (n = 30). Twenty-nine (88%) of those in the active arm of the trial received one or more session (median 7). Among 46 (73%) who were followed up at 24 weeks, social dysfunction was lower (-6.3, 95% CI -12.0 to -0.6, P = 0.03) and satisfaction with care was higher (6.5, 95% CI 2.5 to 10.4; P = 0.002) in those allocated to SPS. Statistically significant differences were not found in other outcomes. The cost of the intervention was low and total costs over 24 weeks were similar in both groups.

CONCLUSIONS

SPS may provide an effective low-intensity intervention for people with personality disorder and should be tested in fully powered clinical trials.

The Therapeutic Alliance Over 10 Sessions of Therapy for Borderline Personality Disorder: Agreement and Congruence Analysis and Relation to Outcome

The authors examined whether alliance dynamics are affected by tailoring the therapeutic relationship to the individual patient in brief psychotherapy of borderline personality disorder. Sixty patients were randomized to 10-session Good Psychiatric Management (GPM-BV) or GPM combined with Motive-Oriented Therapeutic Relationship techniques (MOTR+GPM-BV). Patient- and therapist-rated alliance was assessed weekly. Self-reported symptomatic distress was assessed pre-, mid-, and posttreatment. In MOTR+GPM-BV, stronger therapist-rated alliance predicted lower symptomatic distress in the same timepoint, but not in a lag, whereas symptomatic distress predicted therapist-rated alliance in a lag. Therapist-rated alliance was lower than patient-rated alliance in GPM-BV but not in MOTR+GPM-BV. In MOTR+GPM-BV, higher agreement on strong alliance tended to predict lower symptomatic distress. Patient- and therapist-rated alliances were temporally congruent, but congruence did not predict outcome. Addressing the relationship needs of patients may partly exert its salutary effect by increasing agreement between patients' and therapists' experience of the alliance.

The Role of Interactional Agreeableness in Responsive Treatments for Patients With Borderline Personality Disorder

It has been shown that agreeableness of patients with borderline personality disorder (BPD) had an impact on therapy process and outcome (Hirsh, Quilty, Bagby, & McMain, 2012). The goal of our study was to test whether agreeableness affects the therapeutic alliance and outcome assessed after brief treatment for BPD, and whether this link is moderated by therapist responsiveness. We compared two types of interventions (N = 60) in 10-session treatments (Kramer et al., 2014): a general psychiatric management (GPM)-based treatment and the same treatment supplemented with motive-oriented therapeutic relationship (MOTR), based on plan analysis case conceptualizations (PA; Caspar, 1995), as operationalization of therapist responsiveness. The results showed that there was a significant link between agreeableness and outcome for the GPM, but not for the MOTR. No links between agreeableness and the therapeutic alliance were found in both conditions. MOTR enables suppression of the influences of the patient's initial characteristics on the therapeutic results.

Metacognitive Interpersonal Therapy in group (MIT-G) for young adults with personality disorders: A pilot randomized controlled trial

Young adults with personality disorders (PD) other than borderline are in urgent need of validated treatments to help them in managing important life transitions. Therapeutic interventions focused upon social and interpersonal difficulties may facilitate these individuals in maximizing opportunities for employment, forming stable romantic relationships, and belong to social groups. It is also important that they are offered evidence-based, first-line time-limited treatments in order to maximize effectiveness and reduce costs. We developed a 16-session programme of group-based Metacognitive Interpersonal Therapy (MIT-G) including psychoeducation on the main interpersonal motives, an experiential component enabling practice of awareness of mental states; and use of mentalistic knowledge for purposeful problem-solving. We report a feasibility, acceptability, and clinical significance randomized clinical trial. Participants meeting inclusion criteria were randomized to receive MIT-G (n = 10) or waiting list+TAU (n = 10). Dropout rate was low and session attendance high (92.19%). Participants in the MIT-G arm had symptomatic and functional improvements consistent with large effect sizes. In the MIT-G arm similarly large effects were noted for increased capacity to understand mental states and regulate social interactions using mentalistic knowledge. Results were sustained at follow-up. Our findings suggest potential for applying MIT-G in larger samples to further test its effectiveness in reducing PD-related symptoms and problematic social functioning.

Treatment of Borderline Personality Disorder: Is Supply Adequate to Meet Public Health Needs?

OBJECTIVES

This study aimed to assess the supply of and demand for treatment of borderline personality disorder (BPD) to inform current standards of care and training in the context of available resources worldwide.

METHODS

The total supply of mental health professionals and mental health professionals certified in specialist evidence-based treatments for BPD was estimated for 22 countries by using data from publicly available sources and training programs. BPD prevalence and treatment-seeking rates were drawn from large-scale national epidemiological studies. Ratios of treatment-seeking patients to available providers were computed to assess whether current systems are able to meet demand. Training and certification requirements were summarized.

RESULTS

The ratio of treatment-seeking patients with BPD to mental health professionals (irrespective of professionals' interest or training in treating BPD) ranged from approximately 4:1 in Australia, the Netherlands, and Norway to 192:1 in Singapore. The ratio of treatment-seeking patients to clinicians certified in providing evidence-based care ranged from 49:1 in Norway to 148,215:1 in Mexico. Certification requirements differed by treatment and by country.

CONCLUSIONS

Shortages of both providers available to treat BPD and providers certified in specialist treatments of BPD exist in most of the 22 countries studied. In well-resourced countries, training clinicians to provide generalist or abbreviated treatments for BPD, in addition to specialist treatments, could help address the current implementation gap. More resource-efficient alternatives must be considered in countries with insufficient staff to implement even generalist treatments. Consideration of realistic allocation of care may shape future guidelines and standards of BPD treatments, beyond intensive evidence-based psychotherapies.

Cognitive heuristics in borderline personality disorder across treatment: A longitudinal non-parametric analysis

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.

Effects of Therapeutic Alliance and Metacognition on Outcome in a Brief Psychological Treatment for Borderline Personality Disorder

Objective: The therapeutic alliance is possibly a crucial factor in treatment for borderline personality disorder (BPD). Among predictors of therapeutic alliance, aspects that have not yet been considered are metacognition or the patient's capacity to be aware of mental states. We therefore explored whether metacognition predicted alliance and if metacognition and therapeutic alliance together predicted outcome in brief treatment for BPD. Method: In a secondary analysis of a randomized controlled trial, we included N = 36 patients with BPD in the current study. The original trial assessed the effects of a 10 session psychiatric standard treatment with or without the added the Plan Analysis and the Motive Oriented Therapeutic Relationship. We assessed the therapeutic alliance session by session (Working Alliance Inventory), metacognition at session 1 (using the Metacognitive Assessment Scale-Revised) and outcome (using residual gains on the Outcome Questionnaire-45.2 between sessions 1 and 10). Results: A more differentiated capacity to understand the mind of the others at treatment onset predicted an increase of therapist-rated alliance over time. Therapist rated alliance was the only significant outcome predictor (B = -0.85, R Squared = .12). Conclusions: More differentiated metacognition predicted therapeutic alliance which in turn affected outcome, thus making metacognition a relevant therapy target early in therapy for BPD. Future studies should expand this investigation to patients with better functioning, treated with different modalities and with longer treatments.

Change in Emotional and Theory of Mind Processing in Borderline Personality Disorder: A Pilot Study

Changes in emotional processing (EP) and in theory of mind (TOM) are central across treatment approaches for patients with borderline personality disorder (BPD). Although the assessment of EP relies on the observation of a patient's self-criticism in a two-chair dialogue, an individual's TOM assessments is made based on responses to humorous stimuli based on false beliefs. For this pilot study, we assessed eight patients with BPD before and after a 3-month-long psychiatric treatment, using functional magnetic resonance imaging and behavioral tasks. We observed arousal increase within the session of the two-chair dialogue (d = 0.36), paralleled by arousal decrease between sessions (d = 0.80). We found treatment-associated trends for neural activity reduction in brain areas central for EP and TOM. Our exploratory findings using an integrative assessment procedure of changes in EP and TOM point toward evidence for treatment effects at the brain systems level related to behavioral modulation.

Impact of confrontations by therapists on impairment and utilization of the therapeutic alliance

OBJECTIVE

Striking the balance between creating challenge through confrontation (drawing attention to discrepancies) to encourage change and offering support through the therapeutic relationship to ensure safety for patients represents a central issue for psychotherapists. The aim of the present study was to assess immediate effects of confrontations by therapists on the therapeutic alliance.

METHOD

We rated video recordings of 77 therapies to measure incidences of alliance ruptures/resolution attempts as well as confrontations by therapists. Change in the therapeutic alliance and therapy outcome were measured through questionnaires filled out by patients.

RESULTS

Confrontations were significantly associated with ruptures/resolution attempts on the micro level. Changes in the therapeutic alliance moderated the association between confrontations and alliance ruptures on the macro level: The bigger the fraction of a session containing confrontations, the larger the fraction containing ruptures, given a prior positive change in the therapeutic alliance. Therapists' use of confrontation during a resolution attempt was associated with significantly better therapy outcomes than no use of confrontation during or no resolution attempt.

CONCLUSIONS

Confrontations by therapists may temporarily impair the therapeutic alliance, but might also lead to better therapy outcomes when used to make an alliance rupture explicit as part of a resolution attempt. Clinical or methodological significance: This study provides quantitative explorations of therapists' fears and hopes regarding the use of confrontations (defined as focus on a discrepancy by the therapist). Results point to associations between confrontations and alliance ruptures, especially in the context of a secure alliance. Furthermore, resolution attempts might profit from initial confrontations regarding the relevant alliance rupture.

Maintaining Delusional Beliefs to Satisfy and Protect Psychological Needs

Abstract. Affiliation, control, and self-esteem are psychological needs that human beings attempt to satisfy and protect ( Epstein, 2003 ; Grawe, 2004 ). From a motivational perspective, behaviors, attentional and cognitive biases as well as symptoms can have an instrumental function for need satisfaction and protection ( Caspar, 2011 ). In this opinion paper, we elaborate the idea that the maintenance of delusions could be a motivated process. This approach helps to view the maintenance of delusional beliefs as a purposeful, yet mostly nonconscious, and not completely adaptive attempt to satisfy and protect psychological needs. Conclusions for case formulations, therapy planning, and therapeutic relationship building are drawn within the framework of cognitive-behavioral therapy for psychosis. In addition, limitations of the approach and future research avenues are discussed.

Adverse Effects of Outcome Monitoring Feedback in Patients With Personality Disorders: A Randomized Controlled Trial in Day Treatment and Inpatient Settings

This study aimed to evaluate the differential effect of outcome monitoring feedback to therapists and to patients on outcomes in cluster B, cluster C, and personality disorder not otherwise specified (PD-NOS) patients. Day treatment patients (n = 112) and inpatients (n = 94) were randomly assigned to a feedback to therapist (FbT), feedback to therapist and patient (FbTP), or no feedback (NFb) condition. Feedback was based on weekly administrations of the Outcome Questionnaire-45 (OQ-45). In cluster B and PD-NOS patients FbTP resulted in increased OQ-45 scores during the first 6 months of therapy for not on track (NOT) patients. In cluster C patients, no adverse effects of feedback were found. These results suggest that for certain personality disorder patient groups, providing feedback during treatment may not always be beneficial, although more research is needed to further assess these effects.

Effects of substance use disorder on treatment process and outcome in a ten-session psychiatric treatment for borderline personality disorder

BACKGROUND

Dual diagnosis is common in Borderline Personality Disorder (BPD), one of the most common being Substance Use Disorder (SUD). Previous studies have shown that general psychiatric management (GPM) was effective in reducing borderline symptoms. In the present study, we tested whether the short GPM was as effective in the BPD + SUD as in the BPD group.

METHODS

We analysed a group of 99 patients presenting a BPD. 51 of these patients presented a SUD. The BPD group and the BPD + SUD group received a manual-based short variant of the GPM treatment. Previous studies have shown that a 10-session version of GPM was effective in reducing borderline symptoms at the end of the treatment (Psychother Psychosom 83:176-86, 2014).

RESULTS

We found no significant difference in the reduction of general symptoms, which diminished in both groups. The specific borderline symptoms were also reduced in both groups, but there was a slightly higher reduction of the borderline symptoms in the SUD group. The therapeutic alliance progressed positively in all groups. Moreover, the alliance increased more over time in the SUD group.

CONCLUSION

The short variant of GPM seems to be effective in BPD treatment independently from the presence of SUD. Therefore, this treatment could be an effective entry-level treatment for patients with dual diagnosis as well as patients with BPD only. Further studies are needed to confirm efficacy and long-term outcome.

TRIAL REGISTRATION

The trial was registered at ClinicalTrial.gov (identifier NCT01896024 ).

Good psychiatric management: a review

Borderline personality disorder (BPD) has moved from being an untreatable disorder to a disorder with multiple evidence-based psychotherapies. When a second generation of research showed that less intensive, easier-to-learn therapies could be nearly as effective, they offered an approach that would be responsive to the persisting unmet needs of these patients. This paper describes good psychiatric management (GPM), a once-weekly, generalist model that medicalizes the disorder, emphasizes psychoeducation, and focuses on social adaptation. It is proposed that this approach be the primary intervention for BPD; more intensive evidence-based psychotherapies thereby reserved for those who fail to respond. It is also suggested that whether GPM's focus on social adaptation yields significant effects that improve outcome in this domain deserves testing.

Change in Biased Thinking in a Treatment Based on the Motive-Oriented Therapeutic Relationship for Borderline Personality Disorder

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.

Studying Effects and Process in Psychotherapy for Personality Disorders

This presentation gives an overview of the methods used for research on the process and outcome of psychotherapy. Possibilities as well as difficulties will be discussed, such as the conflict between internal and external validity and standardized versus individualized procedures as some of the issues deserving particular attention for research on psychotherapy for personality disorder patients. It is argued that good psychotherapy research is also good psychotherapy research for personality disorders, with heterogeneity, ego-syntony, and ambivalent motivation needing special attention. Adaptations of and alternatives for randomized clinical trials will be discussed.

Personality, personality disorders, and the process of change

OBJECTIVE

The present paper elaborates a process perspective of change in psychotherapy for personality disorders (PDs). Firstly, the paper reviews the literature of mechanisms of change in treatments of PD, with the main focus on emotional processing and socio-cognitive processing. Secondly, it proposes an illustrative case-series analysis of eight cases, drawn from a mediation analysis conducted within the context of a randomized controlled trial for borderline personality disorder (BPD).

METHOD

As such, cases with good and poor outcomes are compared, as are cases with poor and good intake features and cases with poor and good process markers across treatment.

RESULTS

The results illustrate possible pathways to healthy change over the course of four months of treatment, and possible pathways of the absence of change.

CONCLUSIONS

These results are discussed with regard to three main research perspectives: the combination of qualitative and quantitative methodology in psychotherapy research may be applied to case study research, a neurobehavioral perspective on change may incorporate the individualized experience in the laboratory and therapist responsiveness to patient characteristics may be a core feature of fostering change. Clinical or methodological significance of this article: The present paper illustrates individual pathways to change in personality disorders. It illustrates how coping capacities influence the process of psychotherapy and outcome in personality disorders. It demonstrates the relevance of individualizing treatments for personality disorders. It demonstrates several integrative features of psychotherapy research, in particular the use of neurobehavioral paradigms and the integration of single-case research within randomized controlled trials.

Leaving Distress Behind: A Randomized Controlled Study on Change in Emotional Processing in Borderline Personality Disorder

OBJECTIVE

The marked impulsivity and instability of clients suffering from borderline personality disorder (BPD) greatly challenge therapists' understanding and responsiveness. This may hinder the development of a constructive therapeutic relationship despite it being of particular importance in their treatment. Recent studies have shown that using motive-oriented therapeutic relationship (MOTR), a possible operationalization of appropriate therapist responsiveness, can enhance treatment outcome for BPD. The overall objective of this study is to examine change in emotional processing in BPD clients following the therapist's use of MOTR.

METHOD

The present paper focuses on N = 50 cases, n = 25 taken from each of two conditions of a randomized controlled add-on effectiveness design. Clients were either allocated to a manual-based psychiatric-psychodynamic 10-session version of general psychiatric management (GPM), a borderline-specific treatment, or to a 10-session version of GPM augmented with MOTR. Emotional states were assessed using the Classification of Affective-Meaning States (Pascual-Leone & Greenberg, 2005) at intake, midtreatment, and in the penultimate session.

RESULTS

Across treatment, early expressions of distress, especially the emotion state of global distress, were shown to significantly decrease (p = .00), and adaptive emotions were found to emerge (p < .05). Between-condition differences of change were found, including a significant increase in emotional variability and stronger outcome predictors in the MOTR condition.

CONCLUSIONS

The findings indicate initial emotional change in BPD clients in a relatively short time frame and suggest the addition of MOTR to psychotherapeutic treatments as promising. Clinical implications are discussed.

Therapist Adherence to Good Psychiatric Practice in a Short-Term Treatment for Borderline Personality Disorder

Therapist adherence describes the quality of interventions according to the imperatives of a treatment model. We examined the relationship between therapist adherence and symptom change in the context of a short-term treatment with respect good psychiatric management (GPM) principles. Based on a parent trial, borderline personality disorder patients (N = 40) benefited from a 10-session intervention. Adherence to GPM was assessed using a GPM Adherence Scale (GPMAS). The psychometric properties of the GPMAS were excellent, and the adherence to GPM explained 16% of the general symptom improvement (t(1) = 2.38, β = 0.40, p = 0.02) and 23% of the borderline symptom improvement (t(1) = 2.46, β = 0.48, p = 0.02). Because GPM adherence predicts the outcome after only 10 sessions, GPMAS is a valuable measure early on in psychiatric practice as part of an initial step to longer-term treatment, to quickly detect problems and correct them.

Developing Emotion-Based Case Formulations: A Research-Informed Method

OBJECTIVES

New research-informed methods for case conceptualization that cut across traditional therapy approaches are increasingly popular. This paper presents a trans-theoretical approach to case formulation based on the research observations of emotion.

METHODS

The sequential model of emotional processing (Pascual-Leone & Greenberg, 2007) is a process research model that provides concrete markers for therapists to observe the emerging emotional development of their clients. We illustrate how this model can be used by clinicians to track change and provides a 'clinical map,' by which therapist may orient themselves in-session and plan treatment interventions.

RESULTS

Emotional processing offers as a trans-theoretical framework for therapists who wish to conduct emotion-based case formulations. First, we present criteria for why this research model translates well into practice. Second, two contrasting case studies are presented to demonstrate the method.

CONCLUSIONS

The model bridges research with practice by using client emotion as an axis of integration. Key Practitioner Message Process research on emotion can offer a template for therapists to make case formulations while using a range of treatment approaches. The sequential model of emotional processing provides a 'process map' of concrete markers for therapists to (1) observe the emerging emotional development of their clients, and (2) help therapists develop a treatment plan. Copyright © 2016 John Wiley & Sons, Ltd.

The shorter the better? A follow-up analysis of 10-session psychiatric treatment including the motive-oriented therapeutic relationship for borderline personality disorder

OBJECTIVE

There is little research on short-term treatments for borderline personality disorder (BPD). While the core changes may occur only in long-term treatments, short-term treatments may enable the study of early generic processes of engagement in therapy and thus inform about effective treatment components. It was shown that a 10-session version of a psychiatric treatment was effective in reducing borderline symptoms at the end of this treatment [Kramer, U., Kolly, S., Berthoud, L., Keller, S., Preisig, M., Caspar, F., … Despland, J.-N. (2014). Effects of motive-oriented therapeutic relationship in a ten-session general psychiatric treatment for borderline personality disorder: A randomized controlled trial. Psychotherapy and Psychosomatics, 83, 176-186.]. Also, it was demonstrated in a randomized design that adding the motive-oriented therapeutic relationship (MOTR), following an individualized case formulation based on Plan Analysis, further increased general outcome after session 10 and had a positive effect on the early changes in self-esteem and alliance.

METHOD

The present study focuses on the follow-up period after this initial treatment, examining treatment density and outcomes after 6 months and service utilization after 12 months. Outcome was measured using the OQ-45.

RESULTS

Results on a sub-sample of N = 40 patients with available OQ-45 data at follow-up (n = 21 for MOTR-treatment, n = 19 for comparison treatment) showed maintenance of gains over the follow-up period, which did not differ between both conditions. It appeared for this sample that MOTR treatments, while using the same number of sessions, lasted more weeks (i.e., lower treatment density, defined as the number of sessions per week), when compared to the treatments without MOTR. Density marginally predicted symptom reduction at follow-up. Patients in MOTR treatments had a greater likelihood of entering structured psychotherapy after the initial sessions than patients in the comparison group.

CONCLUSIONS

These results are overall consistent with earlier studies on short-term treatments for BPD and underline the importance of individualizing interventions, by using case formulations that rely on idiographic methods and integrative concepts.

Are Suicide Attempters Wired Differently?: A Comparison With Nonsuicidal Depressed Individuals Using Plan Analysis

Limited research exists on internal risk processes in suicide attempters and factors that distinguish them from nonsuicidal depressive individuals. In this qualitative study, we investigated Plans, motives, and underlying self-regulatory processes of the two groups and conducted a comparative analysis. We analyzed narrative interviews of 17 suicide attempters and intake interviews of 17 nonsuicidal depressive patients using Plan Analysis. Then, we developed a prototypical Plan structure for both groups. Suicidal behavior serves various Plans found only in suicide attempters. Plans of this group are especially related to social perfectionism and withdrawal to protect their self-esteem. Depressive patients use several interpersonal control and coping strategies, which might help prevent suicidal behavior. The prototypical Plan structure of suicide attempters may be a valuable tool for clinicians to detect critical Plans and motives in their interaction with patients, which are related to suicide risk.