Three-week inpatient Cognitive Evolutionary Therapy (CET) for patients with personality disorders: evidence of effectiveness in symptoms reduction and improved treatment adherence

Four years comparative follow-up evaluation of community-based, step-down, and residential specialist psychodynamic programmes for personality disorders

Although the fulcrum of service provision for personality disorder (PD) has shifted from hospital-based to psychodynamically- and cognitively-oriented outpatient programmes, very few studies have attempted to compare specialist moderate intensity outpatient programmes with specialist high-intensity residential models, or to explore whether a period of inpatient treatment may be necessary to improve outcome and prognosis. In this article, we prospectively compare changes over a 4-year period in 3 groups of patients with personality disorders (N = 162) treated in a specialist community-based (CBP, N = 30), a step-down (RT-CBP, N = 87), and a specialist residential programme (RT, N = 45) in psychiatric distress, deliberate self-injury, and suicide attempt using multilevel modelling and multivariate logistic regression analyses. The results showed that percentages of early-dropout were significantly different (p = .0001) for the 3 programmes (CBP = 13.4%, RT-CBP = 10.2%, and RT = 41.4%). A significant interaction between treatment model and time was found for psychiatric distress (p = .001), with CBP and RT-CBP achieving more marked changes (g = 1.20 and g = 0.68, respectively) compared to RT (g = 0.30) at 48-month follow-up. CBP and RT-CBP were found to significantly reduce impulsive behaviour (deliberate self-injury and suicide attempt) compared to RT. Severity of presentation was not found to be a significant predictor of outcome. Long-term RT showed no advantage over long-term CBP, either as stand-alone or as step-down treatment. Replication may be needed to confirm generalizability of results, and a number of limitations in the study design may moderate the inferences that can be drawn from the results.

Unresolved attachment and agency in women victims of intimate partner violence: A case-control study

OBJECTIVES

Women victims of IPV are more likely insecurely attached and have experienced childhood abuse, which according to the attachment theory is deeply related to disorganized attachment. This case-control study was performed with the aim to compare the attachment status and the defensive processing patterns of women victims of IPV (cases) with women with no experiences of IPV (controls).

METHODS

Cases were 16 women with an age range from 26 years to 51 years. The control group included 16 women with an age range from 26 years to 59 years. Women's states of mind in regard to attachment were evaluated with the Adult Attachment Projective Picture System, which allows classifying attachment status and defensive mechanisms.

RESULTS

Compared with control group, most IPV women resulted having an unresolved attachment status and describing characters less capable to draw upon internal resources, that is, internalized secure base, and less capable to act than controls. Women victims of IPV used significantly more words referring danger and failed protection than controls.

CONCLUSIONS

The results evidenced the strong effectiveness of the AAP on analysing the psychological attitudes of women victims of IPV. The dramatic events lived by the women victims of IPV are so dominant in their minds that they invade their stories. This could represent a clue of emotional dysregulation.

PRACTITIONER POINTS

The use of AAP improves the understanding of the agency of self and of the specific levels of trauma experienced by IPV victims, on clarifying their frightening/frightened dynamic, typical of the disorganized attachment relationship, which undermines their activity of mentalization. The therapist will assume the stance of a secure base and then both promoting exploration and contrasting impotence, humiliation, and subordination that IPV women have experienced. This therapeutic interpersonal context will be functional to reach two different but related therapeutic goals: (1) to facilitate the rebuilding of agency (through an activation of subject to explore concrete strategies for exiting from IPV), (2) to explore attachment-related segregated systems from awareness, and to integrate them in memory.