Therapy For Personality Disorders Research Articles

Secure patient-therapist attachment following therapy for personality disorder in a forensic mental health setting

ABSTRACT Therapy for personality disorder can be understood as a process of enhancing attachment security. This study tests the theory that individuals in a secure forensic mental health setting with a diagnosis of personality disorder who have undertaken psychological therapy will report secure patterns of attachment in their relationship with their therapist. It uses a novel pattern matching approach that assesses the behavioural, cognitive and affective markers of attachment security in a group of patients undergoing therapy. Eight behavioural, cognitive and affective characteristics of secure attachment were identified. Ten patients completed a semi-structured interview about their experiences in therapy and key relationships, and their responses were reviewed for evidence of these eight characteristics. Nine out of ten participants were judged to have demonstrated a pattern of six or more of the eight characteristics of secure attachment. This study supports the theory that treatment for this group of patients works by developing patient-therapist attachments. A focus on attachment issues should, therefore, be a core aspect of therapy.

G-FORCE: the effectiveness of group psychotherapy for Cluster-C personality disorders: protocol of a pragmatic RCT comparing psychodynamic and two forms of schema group therapy

BackgroundCluster-C personality disorders (PDs), characterized by a high level of fear and anxiety, are related to high levels of distress, societal dysfunctioning and chronicity of various mental health disorders. Evidence for the optimal treatment is extremely scarce. Nevertheless, the need to treat these patients is eminent. In clinical practice, group therapy is one of the frequently offered approaches, with two important frameworks: schema therapy and psychodynamic therapy. These two frameworks suggest different mechanisms of change, but until now, this has not yet been explored. The purpose of the present G-FORCE trial is to find evidence on the differential (cost)effectiveness of two forms of schema group therapy and psychodynamic group therapy in the routine clinical setting of an outpatient clinic and to investigate the underlying working mechanisms and predictors of outcome of these therapies.MethodsIn this mono-centre pragmatic randomized clinical trial, 290 patients with Cluster-C PDs or other specified PD with predominantly Cluster-C traits, will be randomized to one of three treatment conditions: group schema therapy for Cluster-C (GST-C, 1 year), schema-focused group therapy (SFGT, 1.5 year) or psychodynamic group therapy (PG, 2 years). Randomization will be pre-stratified on the type of PD. Change in severity of PD (APD-IV) over 24 months will be the primary outcome measure. Secondary outcome measures are personality functioning, psychiatric symptoms and quality of life. Potential predictors and mediators are selected and measured repeatedly. Also, a cost-effectiveness study will be performed, primarily based on a societal perspective, using both clinical effects and quality-adjusted life years. The time-points of assessment are at baseline, start of treatment and after 1, 3, 6, 9, 12, 18, 24 and 36 months.DiscussionThis study is designed to evaluate the effectiveness and cost-effectiveness of three formats of group psychotherapy for Cluster-C PDs. Additionally, predictors, procedure and process variables are analysed to investigate the working mechanisms of the therapies. This is the first large RCT on group therapy for Cluster-C PDs and will contribute improving the care of this neglected patient group. The absence of a control group can be considered as a limitation.Trial registrationCCMO, NL72826.029.20. Registered on 31 August 2020, first participant included on 18 October 2020.

Individual psychotherapy for cluster-C personality disorders: protocol of a pragmatic RCT comparing short-term psychodynamic supportive psychotherapy, affect phobia therapy and schema therapy (I-FORCE)

BackgroundCluster-C personality disorders (PDs) are highly prevalent in clinical practice and are associated with unfavourable outcome and chronicity of all common mental health disorders (e.g. depression and anxiety disorders). Although several forms of individual psychotherapy are commonly offered in clinical practice for this population, evidence for differential effectiveness of different forms of psychotherapy is lacking. Also, very little is known about the underlying working mechanisms of these psychotherapies. Finding evidence on the differential (cost)-effectiveness for this group of patients and the working mechanisms of change is important to improve the quality of care for this vulnerable group of patients.ObjectiveIn this study, we will compare the differential (cost)-effectiveness of three individual psychotherapies: short-term psychodynamic supportive psychotherapy (SPSP), affect phobia therapy (APT) and schema therapy (ST). Although these psychotherapies are commonly used in clinical practice, evidence for the Cluster-C PDs is limited. Additionally, we will investigate predictive factors, non-specific and therapy-specific mediators.MethodsThis is a mono-centre randomized clinical trial with three parallel groups: (1) SPSP, (2) APT, (3) ST. Randomization on patient level will be pre-stratified according to type of PD. The total study population to be included consists of 264 patients with Cluster-C PDs or other specified PD with mainly Cluster-C traits, aged 18–65 years, seeking treatment at NPI, a Dutch mental health care institute specialized in PDs. SPSP, APT and ST (50 sessions per treatment) are offered twice a week in sessions of 50 min for the first 4 to 5 months. After that, session frequency decreases to once a week. All treatments have a maximum duration of 1 year. Change in the severity of the PD (ADP-IV) will be the primary outcome measure. Secondary outcome measures are personality functioning, psychiatric symptoms and quality of life. Several potential mediators, predictors and moderators of outcome are also assessed. The effectiveness study is complemented with a cost-effectiveness/utility study, using both clinical effects and quality-adjusted life-years, and primarily based on a societal approach. Assessments will take place at baseline, start of treatment and at 1, 3, 6, 9, 12, 18, 24 and 36 months.DiscussionThis is the first study comparing psychodynamic treatment to schema therapy for Cluster-C PDs. The naturalistic design enhances the clinical validity of the outcome. A limitation is the lack of a control group for ethical reasons.Trial registrationNL72823.029.20 [Registry ID: CCMO]. Registered on 31 August 2020. First participant included on 23 October 2020.

A schema mode model of repetitive negative thinking

BackgroundSchema Therapy mode formulations have recently been extended to a range of chronic, treatment‐resistant psychological disorders.AimThe aim of this study was to examine whether two forms of repetitive negative thinking (rumination and worry) can be conceptualised as a maladaptive coping mode, we term the “over‐analysing” mode, consistent with Young's schema mode model, which serves to distance individuals from distressing emotional states.MethodologyTwo online survey studies were conducted in community populations: study one (n = 109) investigated the relationship between schema modes, worry, and experiential avoidance. Study two (n = 129) extended the findings to include, in addition to schema modes and experiential avoidance, rumination and repetitive negative thinking.ResultsCorrelational analyses supported all hypothesised relationships across both studies. Mediation analyses across both studies identified a model in which the relationship between angry and vulnerable child modes, and worry, rumination, and repetitive negative thinking, respectively, was mediated by experiential avoidance.ConclusionThese findings conceptually support the addition of a new “over‐analysing” coping mode, which serves an avoidant function through repetitive negative thinking (a central component of mood and anxiety disorders) to the schema mode model. Generalisability of results is limited through the use of a cross‐sectional design and a heterogeneous, nonclinical sample. Further examination of the “over‐analysing” mode may enhance Schema Therapy conceptualisations, particularly in the treatment of mood and anxiety disorders. Moreover, emotion‐focused techniques found to be successful in Schema Therapy for personality disorders (e.g., imagery rescripting, chair‐techniques) may be relevant to modifying maladaptive schemas thoughts to underlie repetitive negative thinking processes such as worry and rumination.

The influence of depressive symptoms on the effectiveness of a short-term group form of Schema Cognitive Behavioural Therapy for personality disorders: a naturalistic study

BackgroundThis naturalistic study examined the outcomes of Short-Term Schema Cognitive Behavioural Therapy in groups with personality disorders, and with high and low severity of depressive symptoms.MethodsAssessments were made at baseline, at mid-treatment (week 10), at treatment termination (week 20) and at three-month follow-up (week 32) of 225 patients with personality disorders and high severity of depressive symptoms (PD-Hi) and patients with low severity of depressive symptoms (PD-Lo). The assessments focused on symptom (Symptom Checklist-90) and schema severity (Young Schema Questionnaire) and coping styles (Utrecht Coping List). We also measured the rate of symptom remission. The data obtained were subjected to multilevel analysis.ResultsPsychiatric symptoms and maladaptive schemas improved in both patient groups. Effect sizes were moderate, and even small for the coping styles. Symptom remission was achieved in the minority of the total sample. Remission in psychiatric symptomatology was seen in more PD-Lo patients at treatment termination. However, the difference in levels of remission between the two patient groups was no longer apparent at follow-up.ConclusionA short-term form of schema therapy in groups proved to be an effective approach for a broad group of patients with personality disorders. However, the majority of patients did not achieve symptom remission.Trial registrationNot applicable.

How do high-risk young adult prisoners with emerging personality disorders describe the process of change in therapy?

PurposeThe purpose of this paper is to investigate the views of young adult prisoners with emerging personality disorders (PDs), who were assessed as posing a high risk of causing serious harm to others, on the process of therapeutic change in a non-residential treatment service in a UK young offender institute. The treatment model utilises an integrated approach, specifically adapted for the developmental needs of young adults and combining therapies for PD with offence focussed interventions and regular keywork.Design/methodology/approachIn total, 13 participants, who had completed at least one year of therapy, were interviewed about their perspectives about what, if any, change had occurred and how any reported change had taken place. The interviews were transcribed verbatim and analysed via thematic analysis.FindingsAll participants described having made positive therapeutic change. Three overarching change themes were identified: mentalisation of others, self-knowledge and adaptive coping. Relationships with staff were described as the key mechanism through which change was achieved. Specific treatment interventions were mentioned infrequently, although keywork and generic individual therapy and groupwork sessions were also described as drivers to change.Originality/valueThe findings suggest the possibility of positive therapeutic outcomes for this complex service user group. They also suggest that the domains of change and associated mechanisms may be similar to those reported for other service user groups and in other settings.

Supplemental Material for The Effect of Alliance-Focused Training on a Cognitive-Behavioral Therapy for Personality Disorders

Supplemental Material for The Effect of Alliance-Focused Training on a Cognitive-Behavioral Therapy for Personality Disorders

Frontiers in Cognitive Behaviour Therapy for Personality Disorders

Clinicians generally find individuals with personality disorders to be challenging to treat, especially compared to clients who have only a straightforward depression or anxiety disorder. In this article we will summarise research on the efficacy of cognitive behaviour therapy (CBT) for personality disorders. Then we will focus on the conceptualisation and treatment of CBT for personality disorders that is based on the work of Aaron Beck and colleagues; that is, it is predicated upon the cognitive model of psychopathology. Next, we will describe two other forms of treatment with cognitive behavioural roots: schema therapy and dialectical behaviour therapy. A final section will suggest future directions.

A Study on the Courage Understanding and Courage Establishment of Christian Counseling for Avoidant Personality Disorder Therapy

A Study on the Courage Understanding and Courage Establishment of Christian Counseling for Avoidant Personality Disorder Therapy

The importance of integrated therapies for personality disorder in forensic populations: attending to content and structure of delivery

Purpose – The purpose of this paper is to provide some practice considerations for working with personality disorder, focusing on the application of assessment, formulation and therapy to complex populations such as forensic clients. In addressing this it outlines the concept of a Multi-Modal Integrated Therapy (MMIT) and how this is applied to personality disorder intervention. Design/methodology/approach – The core elements to consider in the provision of an integrated approach are outlined, informed by a review of the relevant literature. The paper does not aim to provide evaluation data but is intended to be a clinical practice document. Findings – The value of integrating the effective components of therapy to address all aspects of working with forensic populations is evidenced. It is argued that appropriate approaches will capture cognitive components (including Early Maladaptive Schemas and also adaptive schemas), Cognitive Analytic Therapeutic approaches and Dialectical Behaviour Therapy components to produce an effective framework to capture the complexities of personality disorder in forensic populations. Practical implications – The paper outlines how a move away from focusing on a single approach to understanding and intervening with personality disorder is key with complex populations, such as those found within forensic settings. The authors argue that practitioners should focus routinely on the importance of integration of principles relevant to personality disorder work. Originality/value – The paper argues for: Adopting a truly multi-modal integrated approach to interventions with personality disorder, highlighting the importance of MMIT. The importance of accounting for complexity in personality presentation in forensic populations and capturing positive as well as negative functioning. The value in identifying what is effective within existing therapies and applying these components as part of a wider package. The core elements of an effective approach are indicated.

The views of male forensic inpatients on how treatment for personality disorder works

Although there are now a number of psychological therapies for personality disorder, there has been relatively little research into the processes by which these therapies work. One way to explore this is to seek patients’ views on the process of change. This study explores the process of change among male forensic inpatients with primary diagnoses of personality disorder. Twelve patients in a high secure personality disorder service completed a semi-structured interview about their experiences of personal change. Thematic analysis of participants’ responses indicated that participants observed change in a variety of domains: core beliefs, awareness and behaviour. Consistent with previous psychotherapy research, interactions with therapists were seen as very important, but so was the wider interpersonal environment, while specific therapeutic techniques were cited relatively rarely. These results suggest that more attention should be paid to the effects of the wider interpersonal environment on therapeutic change processes with this population.

Impact of Treatment Intensity on Suicidal Behavior and Depression in Borderline Personality Disorder: A Critical Review

The effectiveness of less versus more intensive psychological therapies in reducing suicidal behavior and depression in suicidal patients with borderline personality disorder (BPD) was examined. Electronic databases were searched. Trials were separated into less versus more intensive therapies. Suicidal acts and depression outcome data were assessed. Six trials met search criteria (cognitive-behavioral therapy for personality disorder, mentalization-based therapy, dialectical behavior therapy). Seven measures of suicidal acts and two measures of depression were used in studies. Both less and more intensive therapies report significant decreases in suicidal behaviors. Apart from one small trial, both less and more intensive therapies report decreases in depression with no differences between therapies and control conditions. Two follow-up studies showed that reductions in suicidal behavior and depression are maintained over time. The authors conclude that both less and more intensive therapies are effective in treating depression and suicidal behaviors in patients with BPD. Clinicians should deliver the least intensive interventions that will provide these significant health gains.

Cost–effectiveness of psychotherapy for personality disorders: treatment recommendations and implementation

This article reviews the current evidence on the cost–effectiveness of psychotherapy for personality disorders (PDs). Although the evidence is still scarce, several well-designed cost–effectiveness studies provide insight into the question – how cost effective is it to reimburse therapies for PDs? This article further argues that the implementation costs and effects should be an integral part of cost–effectiveness analyses to enhance the dissemination of treatment recommendations. Moreover, cost–effectiveness analyses are important in working towards a more patient-centered approach in psychotherapy research that could potentially help accelerate the implementation and adoption of cost-effective care for PDs.

Integrative therapy for personality disorders: Experiences in developing integrative approaches for treatment-refractory personality-disordered clients

Personality Disordered (herein referred to as PD) clients are challenging to statutory mental healthcare programmes. They can be difficult to diagnose: their disorders can be obscured by second-order problems such as anxiety and depression, caused by PD cognitive processes. Treatment-as-usual (the predominant model of psychiatric intervention) for PD clients in crisis tends to focus on these second-order presentations, but provide no means of identifying underlying PD. The purpose of this paper is to describe how heuristic methods of diagnosis can be used to reframe the client’s distress in the context of personality disorders (according to DSM-IV criteria), and how subsequent application of integrative therapies can break their cycle of recidivism. Method: Two case studies of treatment-refractory individuals with cyclical patterns of crisis-point service engagement for self-harm or psychotic depression where heuristic/ integrative therapies were used. Results: The use of integrative therapies in the case studies presented resulted in a marked change in recidivism and quality of life for each client, as measured by a significant reduction in presentation of symptoms and hypervigilance. Discussion: By understanding the maladaptive cognitive-behavioural processes of PD clients, they can be modified to reduce the client’s self-defeating behavioural patterns, breaking the cycle of recidivism. However, a new diagnostic strategy must first be formulated that looks at the clients past use of mental health services to detect underlying PD.

Supportive psychoanalytic therapy for personality disorders.

Theoretical rationale, research, and clinical process from supportive psychoanalytic therapy for personality disorder patients are presented, with detailed discussion of clinical examples. Elements of the supportive therapy used in the Weill Cornell randomized controlled trial for borderline patients are described, including monitoring the frame of therapy and the emergency priorities of suicidal or treatment-threatening behavior; development and management of the therapeutic relationship; enhancing awareness, tolerance, and management of affect; facilitating growth of identity through support and modeling by the therapist; and avoiding explicit verbal interpretation of unconscious transference fantasy. Awareness of transference is used by the therapist to avoid injury to the patient's self esteem and to maximize tact in addressing the patient's defenses and maladaptive behaviors.

Art therapy for personality disorder: 2012 UK professional consensus guidelines, development process and outcome

This article outlines the development process of a UK professional consensus guideline for art therapy with service users who have the condition of personality disorder undertaken by the special interest group of the British Association of Art Therapists. The process involved the use of National Institute for Clinical Excellence guidance, a three-round Delphi Cycle and a final consensus check. It resulted in a 10-point guide for art therapists based on the first UK consensus on practice in this clinical area. This was then circulated for a final consensus check within the special interest group and achieved 100% consensus with signatories to the guidelines' total clinical experience amounting to 446 years of experience. The aim of publishing the guidance is to stimulate debate so that the guidelines may be further developed.

An exploration of group compassion‐focused therapy for personality disorder

People with personality disorders, especially those who also experience high self-criticism and shame, are known to be a therapeutic challenge and there is a high dropout rate from therapy. Compassion-focused therapy (CFT) was designed to address shame and self-criticism specifically, and to develop people's ability to be self-reassuring and more compassionate to themselves and others. This study explored how CFT affected self-criticism and self-attacking thoughts, feelings, and behaviours, as well as the general symptoms of anxiety, stress, and depression of a personality disordered group within an outpatient group setting, and evaluated the extent of maintenance at a 1-year follow-up. A secondary objective was to identify some of the key characteristics that such an intervention would require. This was a pilot study exploring the feasibility, acceptability, and potential value of CFT in treating this difficult population and, as such, was designed as a pre-randomized controlled trial (RCT) to provide evidence to support applications for funding for an RCT. This study utilized a mixed method combining qualitative and quantitative methods to support a programme evaluation. Eight participants were introduced to the evolutionary-based CFT model and taken through explorations of the nature of self-criticism and shame. In subsequent sessions, participants were taught the main compassion-focused exercises, and any difficulties were addressed. The group was asked to share their personal stories and experiences of practicing self-compassion and to develop compassionate encouragement for each other. Self-report measures were administered at the beginning, end, and at a 1-year follow-up. This 16-week group therapy was associated with significant reductions in shame measured by the Others as Shamer Scale (OAS), social comparison on the Social Comparison Scale (SCS) feelings of hating oneself, and an increase in abilities to be self-reassuring on the Self-Attacking and Self-Reassuring Scale (FSCRS), depression and stress measured by the Depression Anxiety and Stress Scale (DASS). There were significant changes on all CORE variables, well-being, risk, functioning, and problems. Also interesting was that all variables showed a trend for continued improvement at 1-year follow-up, albeit statistically non-significant. A content analysis revealed that patients had found it a moving and very significant process in their efforts to develop emotional regulation and self-understanding. CFT, delivered in a routine psychotherapy department for personality disorders, revealed a beneficial impact on a range of outcome measures. These improvements were maintained and further changes noted at 1-year follow-up. Further research is needed to explore the benefits of CFT using more detailed analysis and RCTs.

Navigating Therapeutic Alliance Ruptures in Cognitive Therapy for Avoidant and Obsessive-Compulsive Personality Disorders and Comorbid Axis I Disorders

Cluster C personality disorders are prevalent in outpatient samples, highly comorbid with Axis I disorders, and can worsen the course of Axis I pathology and treatment outcomes. Cognitive therapy for personality disorders (CT-PD) can be a potent treatment, but establishing and navigating the therapeutic alliance can be especially difficult with this population. Successful negotiation of alliance ruptures is important to prevent dropout, maintain patient engagement, and provide corrective feedback that can enhance treatment outcomes. We present examples of alliance ruptures from a clinical trial of CT-PD for Avoidant and Obsessive-Compulsive personality disorders, as well as strategies to address common challenges that therapists encounter. The issues highlighted also apply more broadly to cognitive therapy for other disorders.

A rational model for maximizing the effects of therapeutic relationship regulation in personality disorders with poor metacognition and over-regulation of affects.

The therapeutic relationship plays a key role in personality disorder (PD) psychotherapy. Some aspects of therapeutic relationship regulation appear important for treatment of PD clients, including those with constricted relational schemas, poor metacognition, and over-regulation of affects described here. AIM.: To propose a rational model for how and when to work on the therapeutic relationship by treating the underlying personality pathology. Formalize a step-by-step procedure for performing operations such as validation of clients' experiences, creating a sense of sharedness, assessing the quality of the therapeutic relationship in order to prevent and repair ruptures in the alliance, self-disclosing by the therapist, and metacommunication on the basis of clients' responses to treatment. We discuss the implications of this model for further research into the PD therapy process.

CBT for violent men with antisocial personality disorder. Reflections on the experience of carrying out therapy in MASCOT, a pilot randomized controlled trial

AbstractCognitive therapy for personality disorders (CBTpd) has been developed and assessed in borderline and antisocial personality disorders (ASPD) using a variety of research methodologies from single cases to randomized controlled trials. An exploratory randomized controlled trial of CBTpd compared with the usual treatment for men with ASPD in the community allowed insights into how to carry out therapy with this group of patients who are traditionally thought of as being difficult to manage. CBTpd for ASPD is time‐limited, is problem‐focused and aims to develop new ways of thinking and behaving that would reduce anger and acts of violence and improve interpersonal relationships. Men with ASPD often held beliefs that could interfere with the development of a therapeutic relationship. The beliefs were hypothesized to have arisen from experiences of being humiliated in childhood and adolescence as well as having experienced neglect and abuse. Equally, therapists needed to be aware that in developing a compassionate formulation of the patient's problems, they should not minimize the potential for violence. Supervision of both process and content had a greater importance than in other CBT models, and supervision required recordings of clinical sessions to enable this to happen. Copyright © 2009 John Wiley & Sons, Ltd.