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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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Kramer U. Good-Enough Therapy: A Review of the Empirical Basis of Good Psychiatric Management. Am J Psychother 2024:appipsychotherapy20230041. [PMID: 38853525 DOI: 10.1176/appi.psychotherapy.20230041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2024]
Abstract
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.
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Affiliation(s)
- Ueli Kramer
- Department of Psychiatry, University of Lausanne, Lausanne, Switzerland; Department of Psychology, University of Windsor, Windsor, Ontario, Canada
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Rodriguez TR, Rufino KA, Patriquin MA, Anestis JC. An Examination of the Treatment Utility of the MMPI-2-RF: Prediction of Post-Treatment Depressive Symptoms and Increased Understanding of the Therapeutic Alliance in an Inpatient Mood Disorder Treatment. J Pers Assess 2023; 105:667-678. [PMID: 36352739 DOI: 10.1080/00223891.2022.2137029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 10/04/2022] [Indexed: 11/11/2022]
Abstract
The study examined the ability of Minnesota Multiphasic Personality Inventory-2-Restructured Form (MMPI-2-RF) substantive scales to predict depressive symptoms in a psychiatric inpatient setting. The indirect effect of patient-rated alliance with their treatment team on these relationships was also investigated. Participants included 678 (52.5% female, 97.1% White) inpatients diagnosed with a mood disorder. MMPI-2-RF scales, Patient Health Questionnaire (PHQ-9) at intake and discharge, and Working Alliance Inventory-Short at discharge were used to test study hypotheses regarding MMPI-2-RF predictive utility and the influence of alliance. Jacobson and Truax's (1991) reliable change index (RCI) was calculated to identify those who did (74% of the sample) and did not (24%) make reliable and clinically significant depressive symptom change, and the predictive utility of MMPI-2-RF scores in distinguishing these groups was examined. MMPI-2-RF scales assessing internalizing and somatic dysfunction accounted for an additional 2% to 8% of the variance in depressive symptoms reported at discharge, above and beyond depressive symptoms reported at intake. Somatic scales were also able to differentiate groups based on clinically significant change on the PHQ-9 (small-sized effect). The relationship between MMPI-2-RF scales and depressive symptoms at discharge was indirect through alliance in 64% of models. Clinical implications are discussed.
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Affiliation(s)
- Taylor R Rodriguez
- Department of Psychology, School of Arts & Sciences, Rutgers, The State University of New Jersey, New Brunswick, New Jersey
| | - Katrina A Rufino
- The Menninger Clinic, Houston, Texas
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, Texas
- The University of Houston Downtown, Houston, Texas
| | - Michelle A Patriquin
- The Menninger Clinic, Houston, Texas
- Michael E. DeBakey VA Medical Center, Houston, Texas
| | - Joye C Anestis
- Department of Health Behavior, Society, & Policy, School of Public Health, Rutgers, The State University of New Jersey, New Brunswick, New Jersey
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Jeong S, Aymerich-Franch L, Arias K, Alghowinem S, Lapedriza A, Picard R, Park HW, Breazeal C. Deploying a robotic positive psychology coach to improve college students' psychological well-being. USER MODELING AND USER-ADAPTED INTERACTION 2023; 33:571-615. [PMID: 38737788 PMCID: PMC11086679 DOI: 10.1007/s11257-022-09337-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 04/22/2022] [Indexed: 05/14/2024]
Abstract
Despite the increase in awareness and support for mental health, college students' mental health is reported to decline every year in many countries. Several interactive technologies for mental health have been proposed and are aiming to make therapeutic service more accessible, but most of them only provide one-way passive contents for their users, such as psycho-education, health monitoring, and clinical assessment. We present a robotic coach that not only delivers interactive positive psychology interventions but also provides other useful skills to build rapport with college students. Results from our on-campus housing deployment feasibility study showed that the robotic intervention showed significant association with increases in students' psychological well-being, mood, and motivation to change. We further found that students' personality traits were associated with the intervention outcomes as well as their working alliance with the robot and their satisfaction with the interventions. Also, students' working alliance with the robot was shown to be associated with their pre-to-post change in motivation for better well-being. Analyses on students' behavioral cues showed that several verbal and nonverbal behaviors were associated with the change in self-reported intervention outcomes. The qualitative analyses on the post-study interview suggest that the robotic coach's companionship made a positive impression on students, but also revealed areas for improvement in the design of the robotic coach. Results from our feasibility study give insight into how learning users' traits and recognizing behavioral cues can help an AI agent provide personalized intervention experiences for better mental health outcomes.
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Affiliation(s)
| | | | | | - Sharifa Alghowinem
- MIT Media Lab, Cambridge, MA, USA
- Computer and Information Sciences College at Prince Sultan University, Riyadh, Saudi Arabia
| | - Agata Lapedriza
- MIT Media Lab, Cambridge, MA, USA
- Estudis d’Informàtica, Multimèdia i Telecomunicacióat Universitat Oberta de Catalunya, Barcelona, Spain
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Tanzilli A, Boldrini T, Carone N, Gualco I, Lingiardi V, Williams R. Patient personality dimensions, relational patterns and therapeutic alliance in clinical practice: An empirical investigation. Clin Psychol Psychother 2023; 30:97-111. [PMID: 35981709 DOI: 10.1002/cpp.2779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Revised: 07/03/2022] [Accepted: 08/15/2022] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Transference (meant in this context, as the patient relational patterns expressed towards the clinician) and therapeutic alliance play a crucial role in the treatment of personality pathology. To date, no empirical study examined the association between these two dimensions of the clinical relationship and patients' personality maladaptive traits in psychotherapy. METHODS A national sample of therapists (N = 100) of different theoretical orientations assessed dysfunctional personality features of a patient in their care using a comprehensive and empirically grounded dimensional diagnostic approach from the Shedler-Westen Assessment Procedure-200 (SWAP-200). Moreover, they filled in the Psychotherapy Relationship Questionnaire (PRQ) to identify interpersonal patterns expressed early in treatment by the patients and the Working Alliance Inventory (WAI-T) to evaluate quality of therapeutic alliance. RESULTS Overall, the most severe and maladaptive dimensions of patients' personality were associated with more negative clinician-patient dynamics and poorer levels of therapeutic alliance in statistically significant and clinically relevant ways. Notably, the hostile transference was predicted by both SWAP Hostility and Psychopathy, whereas the SWAP Narcissism was the strongest predictor of the special/entitled transference. The latter was also predicted by SWAP Emotional Dysregulation; conversely, the SWAP Dysphoria was the most robust predictor of anxious/preoccupied pattern. The SWAP Schizoid Orientation and Psychopathy predicted avoidant/dismissing attachment pattern; moreover, they were strongly and negatively related to the SWAP Psychological Health that was the best predictor of positive transference and alliance. CONCLUSIONS Findings support that therapists' careful understanding of patients' interpersonal ways during early treatment stages may meaningfully inform diagnostic and therapeutic processes.
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Affiliation(s)
- Annalisa Tanzilli
- Department of Dynamic and Clinical Psychology, and Health Studies, Faculty of Medicine and Psychology, Sapienza University of Rome, Rome, Italy
| | - Tommaso Boldrini
- Department of Developmental Psychology and Socialization, University of Padua, Padua, Italy
| | - Nicola Carone
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
| | - Ivan Gualco
- Center for Individual and Couple Therapy, Genoa, Italy
| | - Vittorio Lingiardi
- Department of Dynamic and Clinical Psychology, and Health Studies, Faculty of Medicine and Psychology, Sapienza University of Rome, Rome, Italy
| | - Riccardo Williams
- Department of Dynamic and Clinical Psychology, and Health Studies, Faculty of Medicine and Psychology, Sapienza University of Rome, Rome, Italy
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Culina I, Fiscalini E, Martin-Soelch C, Kramer U. The first session matters: Therapist responsiveness and the therapeutic alliance in the treatment of borderline personality disorder. Clin Psychol Psychother 2023; 30:131-140. [PMID: 36066208 DOI: 10.1002/cpp.2783] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 08/17/2022] [Accepted: 08/31/2022] [Indexed: 02/03/2023]
Abstract
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.
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Affiliation(s)
- Ines Culina
- General Psychiatry Service, Department of Psychiatry, University Hospital Center and University of Lausanne, Lausanne, Switzerland.,Unit of Clinical and Health Psychology, Department of Psychology, University Fribourg, Fribourg, Switzerland
| | - Elsa Fiscalini
- Department of Health and Social Affairs, Medical and Psychological Service Lugano, Republic and Canton of Ticino, Switzerland
| | - Chantal Martin-Soelch
- Unit of Clinical and Health Psychology, Department of Psychology, University Fribourg, Fribourg, Switzerland
| | - Ueli Kramer
- General Psychiatry Service, Department of Psychiatry, University Hospital Center and University of Lausanne, Lausanne, Switzerland.,Institute of Psychotherapy and General Psychiatry, Department of Psychiatry, University Hospital Center and University of Lausanne, Lausanne, Switzerland.,Department of Psychology, University of Winsdor, Winsdor, Ontario, Canada
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7
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Aafjes-van Doorn K, Kealy D, Ehrenthal JC, Ogrodniczuk JS, Joyce AS, Weber R. The Relationship Between Patients' Personality Traits, the Alliance, and Change in Interpersonal Distress in Intensive Group Treatment for Personality Dysfunction. J Pers Disord 2022; 36:731-748. [PMID: 36454157 DOI: 10.1521/pedi.2022.36.6.731] [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] [Indexed: 12/05/2022]
Abstract
This study examined patients' personality traits as operationalized by the five-factor model in relation to early alliance and reduction of interpersonal distress through an intensive group treatment program for personality dysfunction. A sample of 79 consecutively admitted psychiatric outpatients with personality dysfunction who attended an 18-week intensive group treatment program completed the NEO Five-Factor Inventory at pretreatment, the Inventory of Interpersonal Problems at pre- and posttreatment, and the Edmonton Therapeutic Alliance Scale, a measure of the therapeutic alliance with the program therapist, at Session 5. Results indicated that patients who were relatively extraverted tended to rate the alliance with their program therapist higher and subsequently reported more improvement of interpersonal distress. The presence of a personality disorder did not moderate this mediation. Patients' extraversion likely promotes a bonding with the therapist and facilitates the interpersonal group work necessary for improvement. Assessing patients' level of extraversion before starting intensive group treatment might indicate which intervention strategies could be useful with that patient within the program frame.
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Affiliation(s)
| | - David Kealy
- Department of Psychiatry, University of British Columbia, Vancouver, Canada
| | | | - John S Ogrodniczuk
- Department of Psychiatry, University of British Columbia, Vancouver, Canada
| | - Anthony S Joyce
- Department of Psychiatry, University of Alberta, Edmonton, Canada
| | - Rainer Weber
- Clinic for Psychosomatics and Psychotherapy, University of Cologne, Germany
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Heinonen E, Knekt P, Lindfors O. What Works for Whom: Patients' Psychological Resources and Vulnerabilities as Common and Specific Predictors of Working Alliance in Different Psychotherapies. Front Psychiatry 2022; 13:848408. [PMID: 35865305 PMCID: PMC9294449 DOI: 10.3389/fpsyt.2022.848408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 06/07/2022] [Indexed: 11/13/2022] Open
Abstract
Background Across different types of psychotherapy, one of the most robust predictors of better therapeutic outcomes is a good working alliance between patient and therapist. Yet there is little comparative research on whether particular patients more likely achieve a better alliance in certain treatments which represent particular therapeutic approaches or durations. Methods 326 patients suffering from depressive and/or anxiety disorder were randomized into two short-term (solution-focused or psychodynamic) and one long-term (psychodynamic) therapy models. Treatments lasted ~7 and 36 months, respectively. Before randomization, patients were assessed with the interview-based Suitability for Psychotherapy Scale and filled Childhood Family Atmosphere and Life Orientation Test questionnaires. Patients filled Working Alliance Inventory after 3rd therapy session and at end of treatment; the long-term therapy patients, additionally, at 7 months' time point. Linear regression models were used. Results Greater psychological resources (e.g., capacity for self-reflection, affect regulation, flexible interaction) had little effect on alliance during the course of the short-term therapies. However, they did predict better working alliances at end of long-term as opposed to short-term therapy. Childhood adversities impacted alliances already at 7 months. Conclusions Although patients with certain qualities achieve better alliances in long-term as opposed to short-term therapies, apparently the theoretical orientation of therapy makes little difference. For patients with childhood adversities, differences between long-term (psychodynamic) treatment vs. various brief therapy models may be particularly salient.
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Affiliation(s)
- Erkki Heinonen
- Department of Psychology, University of Oslo, Oslo, Norway
- Department of Public Health and Welfare, Finnish Institute for Health and Welfare, Helsinki, Finland
- Department of Psychology and Logopedics, University of Helsinki, Helsinki, Finland
| | - Paul Knekt
- Department of Public Health and Welfare, Finnish Institute for Health and Welfare, Helsinki, Finland
| | - Olavi Lindfors
- Department of Public Health and Welfare, Finnish Institute for Health and Welfare, Helsinki, Finland
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Huggett C, Gooding P, Haddock G, Quigley J, Pratt D. The relationship between the therapeutic alliance in psychotherapy and suicidal experiences: A systematic review. Clin Psychol Psychother 2022; 29:1203-1235. [PMID: 35168297 PMCID: PMC9546023 DOI: 10.1002/cpp.2726] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 01/10/2022] [Accepted: 02/10/2022] [Indexed: 11/10/2022]
Abstract
It is well established that there is a fundamental need to develop a robust therapeutic alliance to achieve positive outcomes in psychotherapy. However, little is known as to how this applies to psychotherapies which reduce suicidal experiences. The current narrative review summarizes the literature which investigates the relationship between the therapeutic alliance in psychotherapy and a range of suicidal experiences prior to, during and following psychotherapy. Systematic searches of MEDLINE, PsycINFO, Web of Science, EMBASE and British Nursing Index were conducted. The search returned 6472 studies, of which 19 studies were eligible for the present review. Findings failed to demonstrate a clear link between suicidal experiences prior to or during psychotherapy and the subsequent development and maintenance of the therapeutic alliance during psychotherapy. However, a robust therapeutic alliance reported early on in psychotherapy was related to a subsequent reduction in suicidal ideation and attempts. Study heterogeneity, varied sample sizes and inconsistent reporting may limit the generalizability of review findings. Several recommendations are made for future psychotherapy research studies. Training and supervision of therapists should not only highlight the importance of developing and maintaining the therapeutic alliance in psychotherapy when working with people with suicidal experiences but also attune to client perceptions of relationships and concerns about discussing suicidal experiences during therapy.
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Affiliation(s)
- Charlotte Huggett
- Division of Psychology and Mental Health, School of Health Sciences, Manchester Academic Health Science CentreUniversity of ManchesterManchesterUK
- Greater Manchester Mental Health NHS Foundation Trust, Manchester Academic Health Science CentreManchesterUK
| | - Patricia Gooding
- Division of Psychology and Mental Health, School of Health Sciences, Manchester Academic Health Science CentreUniversity of ManchesterManchesterUK
- Greater Manchester Mental Health NHS Foundation Trust, Manchester Academic Health Science CentreManchesterUK
| | - Gillian Haddock
- Division of Psychology and Mental Health, School of Health Sciences, Manchester Academic Health Science CentreUniversity of ManchesterManchesterUK
- Greater Manchester Mental Health NHS Foundation Trust, Manchester Academic Health Science CentreManchesterUK
| | - Jody Quigley
- Division of Psychology and Mental Health, School of Health Sciences, Manchester Academic Health Science CentreUniversity of ManchesterManchesterUK
- Pennine Care NHS Foundation TrustAshton‐under‐LyneUK
| | - Daniel Pratt
- Division of Psychology and Mental Health, School of Health Sciences, Manchester Academic Health Science CentreUniversity of ManchesterManchesterUK
- Greater Manchester Mental Health NHS Foundation Trust, Manchester Academic Health Science CentreManchesterUK
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10
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Fletcher AC, Delgadillo J. Psychotherapists' personality traits and their influence on treatment processes and outcomes: A scoping review. J Clin Psychol 2022; 78:1267-1287. [PMID: 34993964 DOI: 10.1002/jclp.23310] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 11/06/2021] [Accepted: 12/21/2021] [Indexed: 11/09/2022]
Abstract
BACKGROUND Prior research indicates that patients' personality traits are associated with psychotherapy processes and outcomes. However, the potential relevance of therapists' personality traits is less understood. METHODS This is a scoping review of studies investigating associations between therapists' personality traits with treatment processes and outcomes. Three databases (Scopus, PsycINFO, and Web of Science) were searched, identifying 27 eligible studies synthesized using a narrative review of key findings. RESULTS The influence of therapists' personality traits was studied in relation to therapeutic orientation, interpersonal skills, therapist competence and skill, model fidelity, treatment outcomes, therapeutic alliance, and therapist well-being. Findings indicate that therapists' personality traits are associated with the choice of therapeutic orientation and with interpersonal skills, but there is mixed evidence about associations with clinical outcomes. CONCLUSION Therapists' personality traits are associated with therapeutic orientation and interpersonal skills. However, it remains unclear whether therapists' personality traits influence other aspects of therapeutic processes or outcomes.
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Affiliation(s)
| | - Jaime Delgadillo
- Clinical Psychology Unit, Department of Psychology, University of Sheffield, Sheffield, UK
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11
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The role of personality traits in inpatient pulmonary rehabilitation response in patients with chronic obstructive pulmonary disease. Respir Med 2021; 190:106680. [PMID: 34768075 DOI: 10.1016/j.rmed.2021.106680] [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: 07/08/2021] [Revised: 10/04/2021] [Accepted: 10/30/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND The effectiveness of pulmonary rehabilitation (PR) is a critical issue for chronic obstructive pulmonary disease (COPD) patients. However, PR response is marked by a strong heterogeneity, partially unexplained to date. We hypothesized that personality traits defined by the Five-Factor Model could modulate the effect of inpatient-PR. OBJECTIVE The aim was to assess the associations between these five personality traits and PR outcomes. METHODS 74 persons with COPD admitted for a 5-week inpatient PR program had a personality assessment at the start of the program (T1). Exercise capacity, quality of life, sensory and affective dyspnea dimensions were assessed at T1 and at the end of the program (T2). Their evolution was evaluated using the delta score between T2 and T1. PR response was defined using the minimal clinically important change score for each of them. A composite response was established distinguishing the poor responders' group, made of patients who responded to 0, 1 or 2 parameters and the good responders' group, with patients who responded on 3 or 4 indicators. RESULTS Logistic regressions analyses highlighted that those with a high level of openness [OR = 0.36, 95% CI = 0.15-0.74, p < 0.01] were less likely to respond on quality of life, controlling for socio-demographic factors and the severity of the disease. CONCLUSION This study shows that the investigation of the personality constitutes an interesting perspective for better understanding the interindividual differences observed between patients in the PR response. Tailoring clinical intervention to the patient's personality could be a promising prospect for optimizing PR effectiveness.
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12
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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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Pong LHE, Cheung R, Yu CKC. Predicting therapeutic alliance with client characteristics and expectations in Hong Kong. ASIA PACIFIC JOURNAL OF COUNSELLING AND PSYCHOTHERAPY 2021. [DOI: 10.1080/21507686.2021.1960575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Lek Hon Edmond Pong
- Department of Counselling and Psychology, Hong Kong Shue Yan University, Hong Kong, Hong Kong
| | - Raysen Cheung
- Department of Counselling and Psychology, Hong Kong Shue Yan University, Hong Kong, Hong Kong
| | - Calvin Kai-Ching Yu
- Counselling and Psychology, Hong Kong Shue Yan University, Hong Kong, Hong Kong
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Cersosimo BH, Hilsenroth MJ, Bornstein RF, Gold JR. Personality Assessment Inventory Clinical Scales in Relation to Patient and Therapist Rated Alliance Early in Treatment. Assessment 2021; 29:806-816. [PMID: 33559486 DOI: 10.1177/1073191121990092] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
We examined relationships between the Personality Assessment Inventory (PAI) clinical scales (e.g., Somatic Complaints [SOM]) and subscales (e.g., Conversion [SOM-C]) with patient- and therapist-rated alliance early in treatment (third or fourth session). We also replicated and extended findings from a previous study examining PAI treatment scales (Treatment Rejection, Treatment Process Index) and early session therapist-rated alliance. We used PAI protocols from a clinical outpatient sample (N = 84). Data were analyzed using stepwise linear regressions. Results suggest that patients who report lower early session alliance also report more antisocial features (β = -.219, p = .050, f2 = 0.05) specifically more antisocial behaviors (β = -.315, p = .004, f2 = 0.11). Additionally, therapists report higher early session alliance with patients who report more anxiety-related disorders (β = .274, p = .012, f2 = 0.08), specifically traumatic stress (β = .325, p = .003, f2 = 0.12). No significant relationships were found between patient- or therapist-rated alliance and Treatment Rejection and Treatment Process Index, consistent with prior findings. Clinical implications are discussed.
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Affiliation(s)
- Bianca H Cersosimo
- Gordon F. Derner School of Psychology, Adelphi University, Garden City, NY, USA
| | - Mark J Hilsenroth
- Gordon F. Derner School of Psychology, Adelphi University, Garden City, NY, USA
| | - Robert F Bornstein
- Gordon F. Derner School of Psychology, Adelphi University, Garden City, NY, USA
| | - Jerold R Gold
- Gordon F. Derner School of Psychology, Adelphi University, Garden City, NY, USA
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Masland SR, Schnell SE, Shah TV. Trust Beliefs, Biases, and Behaviors in Borderline Personality Disorder: Empirical Findings and Relevance to Epistemic Trust. Curr Behav Neurosci Rep 2020. [DOI: 10.1007/s40473-020-00220-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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16
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Baier AL, Kline AC, Feeny NC. Therapeutic alliance as a mediator of change: A systematic review and evaluation of research. Clin Psychol Rev 2020; 82:101921. [DOI: 10.1016/j.cpr.2020.101921] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 08/06/2020] [Accepted: 09/14/2020] [Indexed: 02/07/2023]
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17
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Kramer U, Beuchat H, Grandjean L, Pascual-Leone A. How Personality Disorders Change in Psychotherapy: a Concise Review of Process. Curr Psychiatry Rep 2020; 22:41. [PMID: 32519017 DOI: 10.1007/s11920-020-01162-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
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.
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Affiliation(s)
- Ueli Kramer
- Department of Psychiatry-CHUV, Institute of Psychotherapy, University of Lausanne, Place Chauderon 18, CH-1003, Lausanne, Switzerland. .,General Psychiatry Service, Department of Psychiatry-CHUV, University of Lausanne, Lausanne, Switzerland. .,Department of Psychology, University of Windsor, Windsor, Canada.
| | - Hélène Beuchat
- Department of Psychiatry-CHUV, Institute of Psychotherapy, University of Lausanne, Place Chauderon 18, CH-1003, Lausanne, Switzerland
| | - Loris Grandjean
- Department of Psychiatry-CHUV, Institute of Psychotherapy, University of Lausanne, Place Chauderon 18, CH-1003, Lausanne, Switzerland
| | - Antonio Pascual-Leone
- Department of Psychiatry-CHUV, Institute of Psychotherapy, University of Lausanne, Place Chauderon 18, CH-1003, Lausanne, Switzerland.,Department of Psychology, University of Windsor, Windsor, Canada
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18
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Fahlgren MK, Berman ME, McCloskey MS. The role of therapeutic alliance in therapy for adults with problematic aggression and associated disorders. Clin Psychol Psychother 2020; 27:858-886. [PMID: 32410318 DOI: 10.1002/cpp.2475] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Revised: 05/11/2020] [Accepted: 05/12/2020] [Indexed: 11/06/2022]
Abstract
The nature and quality of the relationship between therapist and client in psychotherapy, known as therapeutic alliance, have been proposed as one of the most important factors for successful treatment outcome, which has been has robustly supported across many types of treatment, populations, raters of alliance (i.e., client, therapist, or observer), and alliance measures. However, most research on alliance and treatment outcome has been conducted in children and adults with internalizing problems (e.g., mood and anxiety disorders) or children with externalizing problems (e.g., conduct disorder), despite the fact that alliance may be particularly important for adults with externalizing problems such as problematic aggression, who may have high levels of resistance, blaming, and interpersonal problems. Very limited research has examined the role of alliance in individuals who present to treatment due to high levels of aggressive behaviour specifically (e.g., those convicted of a violent offence). The current systematic review examined the extant research on the relationship between alliance and outcome in treatment of highly aggressive individuals, as well as those who are diagnosed with a disorder for which aggression is a primary symptom (i.e., post-traumatic stress disorder, antisocial personality disorder, and borderline personality disorder). Overall, it was shown that alliance has a positive impact on treatment outcome among those engaging in or at risk for problematic aggression. Additionally, the alliance-outcome relationship may be affected by therapy modality, alliance rater perspective, and potential mechanisms of alliance. Implications for future research, including utilizing more primarily aggressive samples, are discussed.
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Affiliation(s)
- Martha K Fahlgren
- Department of Psychology, Temple University, Philadelphia, Pennsylvania, USA
| | - Mitchell E Berman
- Department of Psychology, Mississippi State University, Starkville, Mississippi, USA
| | - Michael S McCloskey
- Department of Psychology, Temple University, Philadelphia, Pennsylvania, USA
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19
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Stratton N, Mendoza Alvarez M, Labrish C, Barnhart R, McMain S. Predictors of Dropout From a 20-Week Dialectical Behavior Therapy Skills Group for Suicidal Behaviors and Borderline Personality Disorder. J Pers Disord 2020; 34:216-230. [PMID: 30179573 DOI: 10.1521/pedi_2018_32_391] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Treatment dropout among individuals with borderline personality disorder (BPD) is associated with negative psychosocial outcomes. Identifying predictors of dropout among this population is critical to understanding how to improve treatment retention. The present study extends the current literature by examining both static and dynamic predictors of dropout. Chronically suicidal outpatients diagnosed with BPD (N = 42) were randomly assigned to a 20-week dialectical behavior therapy (DBT) skills training group. Static and dynamic predictors were assessed at baseline, 5, 10, 15, 20 weeks, and 3 months post-intervention. A post-hoc two-stage logistic regression analysis was conducted to predict dropout propensity. Receiving disability benefits at baseline and decreases in mindfulness were associated with significantly increased probability of dropout. Clinicians working with chronically self-harming outpatients diagnosed with BPD would benefit from prioritizing clinical interventions that enhance mindfulness in order to decrease dropout propensity.
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Affiliation(s)
- Natalie Stratton
- Department of Psychology, Ryerson University, Toronto, Ontario, Canada
| | | | | | | | - Shelley McMain
- Centre for Addiction and Mental Health, Toronto.,Department of Psychiatry, University of Toronto
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20
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Ruggero CJ, Kotov R, Hopwood CJ, First M, Clark LA, Skodol AE, Mullins-Sweatt SN, Patrick CJ, Bach B, Cicero DC, Docherty A, Simms LJ, Bagby RM, Krueger RF, Callahan JL, Chmielewski M, Conway CC, De Clercq B, Dornbach-Bender A, Eaton NR, Forbes MK, Forbush KT, Haltigan JD, Miller JD, Morey LC, Patalay P, Regier DA, Reininghaus U, Shackman AJ, Waszczuk MA, Watson D, Wright AGC, Zimmermann J. Integrating the Hierarchical Taxonomy of Psychopathology (HiTOP) into clinical practice. J Consult Clin Psychol 2020; 87:1069-1084. [PMID: 31724426 DOI: 10.1037/ccp0000452] [Citation(s) in RCA: 127] [Impact Index Per Article: 31.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVE Diagnosis is a cornerstone of clinical practice for mental health care providers, yet traditional diagnostic systems have well-known shortcomings, including inadequate reliability, high comorbidity, and marked within-diagnosis heterogeneity. The Hierarchical Taxonomy of Psychopathology (HiTOP) is a data-driven, hierarchically based alternative to traditional classifications that conceptualizes psychopathology as a set of dimensions organized into increasingly broad, transdiagnostic spectra. Prior work has shown that using a dimensional approach improves reliability and validity, but translating a model like HiTOP into a workable system that is useful for health care providers remains a major challenge. METHOD The present work outlines the HiTOP model and describes the core principles to guide its integration into clinical practice. RESULTS Potential advantages and limitations of the HiTOP model for clinical utility are reviewed, including with respect to case conceptualization and treatment planning. A HiTOP approach to practice is illustrated and contrasted with an approach based on traditional nosology. Common barriers to using HiTOP in real-world health care settings and solutions to these barriers are discussed. CONCLUSIONS HiTOP represents a viable alternative to classifying mental illness that can be integrated into practice today, although research is needed to further establish its utility. (PsycINFO Database Record (c) 2019 APA, all rights reserved).
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Affiliation(s)
| | - Roman Kotov
- Department of Psychiatry, Stony Brook University
| | | | - Michael First
- Department of Psychiatry, New York State Psychiatric Institute, Columbia University
| | | | | | | | | | - Bo Bach
- Psychiatric Research Unit, Slagelse Psychiatric Hospital
| | | | | | - Leonard J Simms
- Department of Psychology, University at Buffalo, The State University of New York
| | - R Michael Bagby
- Departments of Psychology and Psychiatry, University of Toronto
| | | | | | | | | | - Barbara De Clercq
- Department of Developmental, Personality, and Social Psychology, Ghent University
| | | | | | - Miriam K Forbes
- Centre for Emotional Health, Department of Psychology, Macquarie University
| | | | | | | | | | - Praveetha Patalay
- Centre for Longitudinal Studies and MRC Unit for Lifelong Health and Ageing, University College London
| | - Darrel A Regier
- Department of Psychiatry, Center for the Study of Traumatic Stress, Uniformed Services University
| | | | | | | | - David Watson
- Department of Psychology, University of Notre Dame
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21
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Doorn KAV, Kamsteeg C, Portier K, Chitre G. A Dialectical Behavior Therapy Skills Group in a Psychoanalytic Community Service: A Pilot Study. J Cogn Psychother 2020; 34:21-46. [PMID: 32701474 DOI: 10.1891/0889-8391.34.1.21] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
This exploratory study reports on the implementation and effectiveness of a 20-week Dialectical Behavior Therapy (DBT) skills group provided to 8 outpatients (7 women, average age 33 years old) within a psychoanalytic community clinic. We report on the practical implementation of this DBT skills group, and describe how the theoretical/technical differences between DBT and psychoanalysis were negotiated by the two co-therapists. The effectiveness of the skills group was evaluated on standardized measures of borderline personality symptoms, depression, anxiety, interpersonal problems, quality of life, and mindfulness skills that patients completed before and after treatment. At post-treatment, patients evaluated the DBT skills group on a satisfaction questionnaire and therapists completed a countertransference measure. Pre-post outcome data indicated reduced symptom levels of anxiety, depression, and improved quality of life. Both therapists reported moderate therapist responses typically associated with borderline personality disorder psychopathology. Their therapist responses were not associated with symptom levels or change but were related to patient satisfaction. Accumulative pilot studies like these add to the practice-based evidence of DBT components offered within psychoanalytically-oriented community clinics. However, given the exploratory nature of this study, strong conclusions are precluded until further effectiveness research is conducted.
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Affiliation(s)
| | | | | | - Geetali Chitre
- Access Institute for Psychological Services, San Francisco, California
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22
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Zufferey P, Caspar F, Kramer U. The Role of Interactional Agreeableness in Responsive Treatments for Patients With Borderline Personality Disorder. J Pers Disord 2019; 33:691-706. [PMID: 30650009 DOI: 10.1521/pedi_2019_33_367] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
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.
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Affiliation(s)
- Pauline Zufferey
- Department of Psychiatry and Psychotherapy, Centre Hospitalier du Valais Romand, Monthey, Switzerland
| | - Franz Caspar
- Department of Clinical Psychology and Psychotherapy, University of Bern, Bern, Switzerland
| | - Ueli Kramer
- Lausanne University Hospital, and Institute of Psychotherapy, Department of Psychiatry-CHUV, and University of Lausanne, Lausanne, Switzerland
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23
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Koppers D, Kool M, Van H, Driessen E, Peen J, Dekker J. The effect of comorbid personality disorder on depression outcome after short-term psychotherapy in a randomised clinical trial. BJPsych Open 2019; 5:e61. [PMID: 31530296 PMCID: PMC6646965 DOI: 10.1192/bjo.2019.47] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Revised: 05/15/2019] [Accepted: 06/04/2019] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Time-limited psychotherapy for depression is effective. However, comorbid personality disorders affect therapy outcomes negatively. Studies of follow-up effects and results relating to the influence of comorbid personality disorder and treatment modality are scarce. AIMS To determine the influence of comorbid personality disorder and treatment modality on outcomes after cognitive-behavioural therapy (CBT) or short-term psychodynamic supportive psychotherapy (SPSP) for depression. METHOD This study draws on data from a previously published randomised clinical trial contrasting SPSP and CBT for depression (both 16 sessions). We compared the effectiveness of these psychotherapies for patients with and without personality disorder (n = 196). The primary measure was depression outcome; the secondary measurements were interpersonal functioning and quality of life. Collected data were analysed using multilevel analysis. Trial registration: ISRCTN31263312 (http://www.controlled-trials.com). RESULTS Although participants with and without comorbid personality disorder improved at treatment termination (d = 1.04, 95% CI 0.77-1.31 and d = 1.36, 95% CI 0.97-1.76, respectively) and at follow-up (d = 1.15, 95% CI 0.87-1.43 and d = 2.12, 95% CI 1.65-2.59 respectively), personality disorder had a negative effect on depression outcome at both measurement points (P < 0.05). A similar negative effect on interpersonal functioning was no longer apparent at follow-up. Comorbid personality disorder had no influence on social functioning or quality of life outcomes, irrespective of treatment modality. CONCLUSIONS CBT and SPSP contribute to the improvement of depressive symptoms and interpersonal problems in depressed patients with and without comorbid personality disorder. Both treatments are an effective first step in a stepped care approach, but - given remaining levels of depression in patients with personality disorder - they are probably inadequate for large numbers of patients with this comorbidity. DECLARATION OF INTEREST None.
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Affiliation(s)
- David Koppers
- Clinical Psychologist and Researcher, Department of Research and Quality of Care, ARKIN Mental Health Institute, the Netherlands
| | - Marit Kool
- Clinical Psychologist and Researcher, Department of Personality Disorders, ARKIN Mental Health Institute, the Netherlands
| | - Henricus Van
- Psychiatrist, and Researcher, Department of Personality Disorders, ARKIN Mental Health Institute, NPI, the Netherlands
| | - Ellen Driessen
- Researcher, Department of Research and Quality of Care, ARKIN Mental Health Institute, the Netherlands
| | - Jaap Peen
- Methodologist, Department of Research and Quality of Care, ARKIN Mental Health Institute, the Netherlands
| | - Jack Dekker
- Head, Department of Research and Quality of Care, ARKIN Mental Health Institute; and Faculty of Behavioural and Movement Sciences, Section Clinical Psychology, Vrije Universiteit, the Netherlands
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24
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A meta-analytic review of personality traits and their associations with mental health treatment outcomes. Clin Psychol Rev 2019; 70:51-63. [DOI: 10.1016/j.cpr.2019.04.002] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Revised: 03/23/2019] [Accepted: 04/03/2019] [Indexed: 12/14/2022]
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25
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Dimaggio G, Maillard P, MacBeth A, Kramer U. Effects of Therapeutic Alliance and Metacognition on Outcome in a Brief Psychological Treatment for Borderline Personality Disorder. Psychiatry 2019; 82:143-157. [PMID: 31112457 DOI: 10.1080/00332747.2019.1610295] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
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.
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26
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Pasquali CE, Ybrandt H, Armelius K. Client self-image, therapist acting, and the establishment of the therapeutic alliance in a training context. EUROPEAN JOURNAL OF PSYCHOTHERAPY & COUNSELLING 2018. [DOI: 10.1080/13642537.2018.1529687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
| | - H. Ybrandt
- Department of Psychology, Umeå University, Umeå, Sweden
| | - K. Armelius
- Department of Psychology, Umeå University, Umeå, Sweden
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27
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Dunster-Page CA, Berry K, Wainwright L, Haddock G. An exploratory study into therapeutic alliance, defeat, entrapment and suicidality on mental health wards. J Psychiatr Ment Health Nurs 2018; 25:119-130. [PMID: 29166548 DOI: 10.1111/jpm.12444] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/17/2017] [Indexed: 11/29/2022]
Abstract
UNLABELLED WHAT IS KNOWN ON THE SUBJECT?: The strength of a relationship between people with mental health difficulties and professionals has been linked to patients feeling suicidal. A relationship has been found between how defeated and trapped people with mental health difficulties feel and how suicidal they feel. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: This study explored the relationship between alliance, suicidality, defeat and entrapment in people admitted to mental health wards as previous research has focused on people in the community. Patient-rated defeat, entrapment and suicidality are related in this sample of people admitted to mental health wards. A relationship was found between how well nurses said they bonded with their named patient and how trapped the patients felt by their environment. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Nurses should consider if patients are feeling defeated or trapped when helping people with mental health difficulties to feel less suicidal. ABSTRACT Introduction Suicidality is prevalent worldwide, particularly in people who access mental health services. The quality of therapeutic alliance between people with mental health difficulties and staff has been associated with suicidality but only in community settings. Defeat and entrapment are correlated with suicidality and may mediate any relationship between alliance and suicidality. Therefore, this exploratory study explored these relationships in people admitted to mental health wards. Aim To explore defeat, entrapment, suicidality and alliance between nurses and people admitted to mental health wards. Method Fifty inpatient nurse-patient dyads completed questionnaires regarding demographics, defeat, entrapment, suicidality and alliance with their named nurse. Nurses completed questionnaires on demographics, alliance with their patient and the patients' suicidality. Results Defeat, entrapment and suicidality were correlated. A correlation between nurse-rated bond and external entrapment was found, but no other correlations between alliance, defeat, entrapment and suicidality were statistically significant. Discussion and clinical implications Ward-based nurses should consider the relationship between defeat, entrapment and suicidality when developing interventions to improve suicidality. Although there was no evidence of a relationship between total alliance and suicidality, developing closer bonds with patients may reduce patients' feelings of being trapped by their environment.
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Affiliation(s)
- C A Dunster-Page
- School of Health Sciences, University of Manchester, Manchester, UK
| | - K Berry
- School of Health Sciences, University of Manchester, Manchester, UK
| | - L Wainwright
- School of Health Sciences, University of Manchester, Manchester, UK
| | - G Haddock
- School of Health Sciences, University of Manchester, Manchester, UK
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28
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The relationship between therapeutic alliance and patient's suicidal thoughts, self-harming behaviours and suicide attempts: A systematic review. J Affect Disord 2017; 223:165-174. [PMID: 28755624 DOI: 10.1016/j.jad.2017.07.040] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Revised: 07/18/2017] [Accepted: 07/19/2017] [Indexed: 11/21/2022]
Abstract
BACKGROUND Suicidality is a common concern for people with mental health problems. The interpersonal nature of suicidality suggests that therapeutic alliance may be important when working clinically with suicidal patients. This paper is a systematic review of studies investigating the association between alliance and treatment outcome relating to suicidal ideation and behaviours. METHODS Systematic searches of PsychINFO, MEDLINE, AMED, EMBASE, Web of Science and CINAHL were completed using words that captured the concepts of alliance and suicidality. Eligible studies: involved participants aged 18-years-old or over; used a validated measure of therapeutic alliance; and reported associations between alliance and suicidality. Abstracts, qualitative studies and articles not written in English were excluded. RESULTS Twelve studies were included. Findings indicated that alliance is associated with suicidality. Alliance was related to suicidality in eleven of the papers. Self-harming behaviours had the strongest association with patient-rated alliance. Suicide attempts had the weakest association, possibly due to the infrequency of suicide attempts in the studies reviewed. LIMITATIONS The twelve studies were heterogeneous in terms of the measure of alliance used, method of assessing suicidality, clinical setting and professional-type. This variability limited the degree to which findings could be synthesised. CONCLUSION Therapists, care-coordinators and mental health teams should recognise the importance of building a strong therapeutic alliance with suicidal patients. Researchers should use consistent methods of measuring alliance and assessing suicidality in future studies. Clinicians and researchers should note that suicidal thoughts, self-harm and suicide attempts may be related to alliance in different ways and therefore should be assessed as separate constructs.
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29
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The relationship between clients’ personality traits, working alliance and therapy outcome in a training context. CURRENT ISSUES IN PERSONALITY PSYCHOLOGY 2017. [DOI: 10.5114/cipp.2017.65244] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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30
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Bagby RM, Gralnick TM, Al‐Dajani N, Uliaszek AA. The role of the five‐factor model in personality assessment and treatment planning. CLINICAL PSYCHOLOGY-SCIENCE AND PRACTICE 2016. [DOI: 10.1111/cpsp.12175] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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31
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Vroling MS, Wiersma FE, Lammers MW, Noorthoorn EO. Predicting Dropout from Intensive Outpatient Cognitive Behavioural Therapy for Binge Eating Disorder Using Pre-treatment Characteristics: A Naturalistic Study. EUROPEAN EATING DISORDERS REVIEW 2016; 24:494-502. [PMID: 27594180 DOI: 10.1002/erv.2474] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Revised: 07/19/2016] [Accepted: 08/01/2016] [Indexed: 12/14/2022]
Abstract
BACKGROUND Dropout rates in binge eating disorder (BED) treatment are high (17-30%), and predictors of dropout are unknown. METHOD Participants were 376 patients following an intensive outpatient cognitive behavioural therapy programme for BED, 82 of whom (21.8%) dropped out of treatment. An exploratory logistic regression was performed using eating disorder variables, general psychopathology, personality and demographics to identify predictors of dropout. RESULTS Binge eating pathology, preoccupations with eating, shape and weight, social adjustment, agreeableness, and social embedding appeared to be significant predictors of dropout. Also, education showed an association to dropout. DISCUSSION This is one of the first studies investigating pre-treatment predictors for dropout in BED treatment. The total explained variance of the prediction model was low, yet the model correctly classified 80.6% of cases, which is comparable to other dropout studies in eating disorders. Copyright © 2016 John Wiley & Sons, Ltd and Eating Disorders Association.
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Affiliation(s)
- Maartje S Vroling
- GGNet Amarum, Expert Centre for Eating Disorders, Zutphen/Nijmegen, the Netherlands. .,NijCare, Radboud University Nijmegen, Nijmegen, the Netherlands. .,Department of Clinical Psychology, Radboud University Nijmegen, Behavioral Science Institute, Nijmegen, the Netherlands.
| | - Femke E Wiersma
- GGNet Amarum, Expert Centre for Eating Disorders, Zutphen/Nijmegen, the Netherlands.,Department of Personality Disorders, Pro Persona Mental Health Care, Arnhem, the Netherlands
| | - Mirjam W Lammers
- GGNet Amarum, Expert Centre for Eating Disorders, Zutphen/Nijmegen, the Netherlands.,Department of Clinical Psychology, Radboud University Nijmegen, Behavioral Science Institute, Nijmegen, the Netherlands
| | - Eric O Noorthoorn
- GGNet, Training Centre for Psychiatrists Warnsveld, Warnsveld, the Netherlands.,Dutch Information Centre for Coercive Measures, Stichting Benchmark GGZ, Bilthoven, the Netherlands
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32
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Kushner SC, Quilty LC, Uliaszek AA, McBride C, Bagby RM. Therapeutic alliance mediates the association between personality and treatment outcome in patients with major depressive disorder. J Affect Disord 2016; 201:137-44. [PMID: 27219531 DOI: 10.1016/j.jad.2016.05.016] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Revised: 04/30/2016] [Accepted: 05/13/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND Patient personality traits have been shown to influence treatment outcome in those with major depressive disorder (MDD). The trait agreeableness, which reflects an interpersonal orientation, may affect treatment outcome via its role in the formation of therapeutic alliance. No published studies have tested this hypothesis in patients with MDD. METHOD Participants were 209 outpatients with MDD who were treated in a randomized control trial. Mediation analyses were conducted to examine the role of therapeutic alliance in the association between pretreatment personality and the reduction of depression symptom severity during treatment. Separate models were estimated for patient- versus therapist-rated therapeutic alliance. RESULTS We found a significant indirect effect of agreeableness on the reduction of depression severity via patient-rated therapeutic alliance. Results were replicated across two well-validated measures of depression symptom severity. Results also partially supported indirect effects for extraversion and openness. Therapist ratings of alliance did not mediate the association between personality and treatment outcomes. LIMITATIONS Patients were recruited as part of a randomized control trial, which may limit the generalizability of results to practice-based clinical settings. Due to constraints on statistical power, intervention-specific mediation results were not examined. CONCLUSIONS These results highlight the importance of personality and the role it plays in treatment process as well as outcome.
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Affiliation(s)
| | - Lena C Quilty
- University of Toronto, Canada; Centre for Addiction and Mental Health, Canada
| | - Amanda A Uliaszek
- University of Toronto, Canada; Centre for Addiction and Mental Health, Canada
| | - Carolina McBride
- University of Toronto, Canada; Centre for Addiction and Mental Health, Canada
| | - R Michael Bagby
- University of Toronto, Canada; Centre for Addiction and Mental Health, Canada.
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McMain S, Newman MG, Segal ZV, DeRubeis RJ. Cognitive behavioral therapy: Current status and future research directions. Psychother Res 2015; 25:321-9. [DOI: 10.1080/10503307.2014.1002440] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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Thielmann I, Hilbig BE, Niedtfeld I. Willing to give but not to forgive: borderline personality features and cooperative behavior. J Pers Disord 2014; 28:778-95. [PMID: 24689764 DOI: 10.1521/pedi_2014_28_135] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Impaired cooperation has been proposed to contribute to social dysfunctioning in borderline personality disorder (BPD). However, prior research has not distinguished active from reactive cooperation (i.e., nonexploitation versus non-retaliation)--two aspects of cooperative behavior associated with different basic personality traits (viz. Honesty-Humility and Agreeableness). The authors hypothesized that, due to low levels of Agreeableness, but normal levels of Honesty-Humility, borderline personality (BP) features are related to impaired reactive cooperation, but unrelated to active cooperation. Participants (N = 559) hypothetically played both the allocator in the dictator game and the recipient in the ultimatum game. High levels of BP features predicted impaired reactive cooperation in the ultimatum game, which was mediated through low Agreeableness. In contrast, BP features did not predict active cooperation in the dictator game-mirroring the nonassociation between BP features and Honesty-Humility. The findings highlight the importance of focusing on aspects of forgiveness in interventions aiming to improve cooperativeness in BPD.
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Abstract
OBJECTIVE This paper reviews the construct of the working alliance, beginning with its historical development and moving into its modern pantheoretical conceptualization. METHOD Major research efforts on the topic are reviewed. The review includes both theoretical and empirical literature on the working alliance and related constructs, such as alliance ruptures and repair, and therapeutic negotiation. Existing measures of the working alliance are also reviewed. RESULTS The working alliance is critiqued on both theoretical and empirical grounds, including the strengths and limitations of current approaches and assessments. Recent theoretical developments are reviewed, among them work on alliance rupture and repair and the reconceptualization of the alliance as a process of therapeutic negotiation. Emerging applications of advanced statistical techniques to measure the working alliance are also considered. CONCLUSION The review concludes by supporting recent efforts that have attempted to increase the sophistication of measurement tools and statistical approaches, and encouraging future research in these areas.
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Affiliation(s)
- Jennifer M Doran
- a Department of Psychology , The New School for Social Research , New York , NY , USA
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Johansen R, Melle I, Iversen VC, Hestad K. Personality traits, interpersonal problems and therapeutic alliance in early schizophrenia spectrum disorders. Compr Psychiatry 2013; 54:1169-76. [PMID: 23856387 DOI: 10.1016/j.comppsych.2013.05.016] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2013] [Revised: 05/16/2013] [Accepted: 05/22/2013] [Indexed: 10/26/2022] Open
Abstract
BACKGROUND The quality of the therapeutic alliance is associated with engagement in- and thus important to the outcome of- treatment in schizophrenia. In non-psychotic disorders, general personality traits and individual patterns of interpersonal problems have been linked to the formation and quality of the therapeutic alliance. The role of these factors in relation to therapeutic alliance has not previously been explored in schizophrenia spectrum disorders. AIM To investigate associations between personality traits, interpersonal problems and the quality of the therapeutic alliance in early schizophrenia spectrum disorders. METHODS Demographic and clinical characteristics including Positive and Negative Syndrome Scale (PANSS) scores were assessed in 42 patients. Personality traits and interpersonal problems were assessed with the NEO Five factor Inventory (NEO-FFI) and the circumplex model of the Inventory of Interpersonal Problems (IIP-64C). Therapeutic alliance was measured with the Working Alliance Inventory - short form (WAI-S). RESULTS Patient WAI-S scores were predicted by IIP-64C Submissive/Hostile interpersonal problems, age and PANSS excitative symptoms. Therapist WAI-S scores were predicted by NEO-FFI Agreeableness and the PANSS insight item. CONCLUSION Core traits of personality and dimensions of interpersonal problems are associated with both patients' and therapists' perceptions of the quality of the working alliance.
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Affiliation(s)
- Ragnhild Johansen
- St. Olav's Hospital, Trondheim University Hospital, Forensic department Brøset Centre for Research and Education in Forensic Psychiatry, 7440 Trondheim, Norway; Dept of Psychology, The Norwegian University of Science and Technology, 7491 Trondheim, Norway.
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Quilty LC, Mainland BJ, McBride C, Bagby RM. Interpersonal problems and impacts: further evidence for the role of interpersonal functioning in treatment outcome in major depressive disorder. J Affect Disord 2013; 150:393-400. [PMID: 23726776 DOI: 10.1016/j.jad.2013.04.030] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2013] [Accepted: 04/19/2013] [Indexed: 12/31/2022]
Abstract
INTRODUCTION Empirical research has converged to support the concurrent association between social difficulties and psychiatric symptoms; yet, longitudinal associations between interpersonal problems and treatment outcome require clarification. The current investigation evaluated the influence of interpersonal problems assessed prior to treatment on interpersonal impacts assessed during treatment as well as on treatment outcome in outpatients with major depressive disorder (MDD). METHOD 125 participants with a primary diagnosis of MDD were randomized to receive cognitive behavioural therapy or interpersonal therapy. Participants completed the Beck Depression Inventory-II, Hamilton Depression Rating Scale, and Inventory of Interpersonal Problems Circumplex before and after treatment. Therapists completed the Impact Message Inventory during and after treatment. RESULTS Interpersonal distress improved over the course of treatment; all other interpersonal changes were non-significant when distress was taken into account. Pre-treatment rigidity and agentic problems predicted less reduction in depressive symptoms, whereas agentic and communal impacts upon therapists during treatment predicted greater symptom change. Overall interpersonal distress was only indirectly associated with treatment response later in treatment, through its association with agentic style. Results did not differ across therapy type, and were replicated across self-report and interviewer-rated measures of depression severity. LIMITATIONS Limitations include the brief duration of treatment, lack of medication arm, and potentially restricted generalizability of patients in a randomized control trial to those in routine practice. CONCLUSIONS Interpersonal style demonstrated a trait-like stability over treatment, and appears to fluctuate due to co-occurring distress. Yet, specific interpersonal styles were negative prognostic indicators, even within therapy specifically targeting interpersonal functioning.
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Affiliation(s)
- Lena C Quilty
- Centre for Addiction and Mental Health, Toronto, ON, Canada.
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