Changes in Attachment Representation and Personality Organization in Transference-Focused Psychotherapy

Clinical Pearls: Good Psychiatric Management for Borderline Personality Disorder and Transference-Focused Psychotherapy

Good psychiatric management (GPM) for borderline personality disorder is a generalist strategic case management approach used by helping professionals of different training backgrounds to work with patients with borderline personality disorder. GPM includes a flexibly administered once-weekly psychotherapy for which a brief introductory course in GPM alone is considered sufficient preparation. GPM integrates concepts from specialized evidence-based treatments for borderline personality disorder, including transference-focused psychotherapy (TFP). This article describes the TFP elements that John Gunderson acknowledged as influential to his development of GPM. A basic introduction to TFP is provided, and elements in GPM that interweave with TFP's theoretical foundation are elucidated and then illustrated in a clinical vignette that captures the GPM clinician's interventions influenced by these ideas. The vignette is then used to illustrate clinical tools informed by TFP principles and common to both GPM and TFP.

Culture and ICD-11 personality disorder: Implications for clinical practice across diverse ethnic groups

BACKGROUND

Personality disorder (PD) in ICD-11 is defined primarily by self and interpersonal dysfunction and optionally by other qualifiers. This definition is inseparable from relativism of cultural determinants.

AIMS

This review aimed to synthesize the relevant aspects of the influence of culture on clinical practice and health management for this condition, aligning them to the ICD-11 PD model.

METHOD

In Scopus, we systematically searched for studies that included the text strings: cultur* | personality AND (disorder* OR patholog*) without any restrictions on publication date or language or other exclusion criteria, up to November 2022.

RESULTS

Evidence suggests that cultural variables in ethnic groups (Western and non-Western) such as the individualist/collectivist philosophy, historical/generational trauma, immigration, acculturation, religion, and gender influence the etiology, semiology, epidemiology, evaluation, diagnosis, treatment, and management of health services for ICD-11 PD. We discuss the limitations and propose future lines of research on this topic based on our knowledge and experience. In this review, we provide the scientific community and clinicians with relevant cultural information to guide their practice and propose strategies to manage PD from the ICD-11 model.

CONCLUSIONS

More research is needed using mixed study methodologies on stigma, the experiences of patients, clinicians, and health agencies, to reduce the care gaps and achieve a culturally comprehensive, inclusive, and competent use of this new model.

A Novel Approach to Examining Working Alliance Instability During Psychotherapy for Borderline Personality Disorder

OBJECTIVE

This study aimed to quantify the instability of psychotherapy process variables by using a novel data-analytic approach. The study explored instability of the working alliance over 10 treatment sessions and its relationship with self-esteem.

METHODS

Data were extracted from a randomized controlled trial, conducted in Switzerland, of a short-term intervention for borderline personality disorder. Sixty clients diagnosed as having borderline personality disorder were randomly assigned to receive either 10 sessions of good psychiatric management-brief version (GPM-BV) or GPM-BV combined with a relational principle called motive-oriented therapeutic relationship. Square successive differences were calculated for client and therapist ratings of alliance instability. Multilevel models were used to test within- and between-person associations of alliance instability with self-esteem.

RESULTS

Although some preliminary analyses showed an association between a more stable alliance and higher self-esteem at the start of psychotherapy, the alliance did not become more stable over time. Alliance instability was not associated with self-esteem at either the within- or between-person level.

CONCLUSIONS

This study highlights the advantages, procedures, and challenges of applying square successive differences to psychotherapy research data. The results suggest that the working alliance develops in complex ways and indicate the importance of continuing to use novel methods to capture dynamic psychotherapy processes.

Unravelling inter-relations within and between psychodynamic constructs and psychopathology using network analysis

Psychodynamic constructs and psychopathology are closely inter-related, but more detailed insight is needed. We investigated these complex inter-relations using network analysis. A Gaussian graphical model in a sample of N = 2232 psychotherapeutic inpatients was estimated. Self-administered questionnaires to assess interpersonal relations (Inventory of Interpersonal Problems-32), psychodynamic conflicts (Operationalized Psychodynamic Diagnosis-Conflict Questionnaire), personality functioning (Operationalized Psychodynamic Diagnosis-Structure Questionnaire-Short Form, Inventory of Personality Organization-Short Form), and psychopathology (Brief Symptom Inventory) were utilized. We investigated the network structure, identified the most inter-related psychodynamic constructs and the psychodynamic constructs with the strongest inter-relations to psychopathology, and explored the clustering of all included constructs. Active and passive conflict processing modes were negatively inter-related in most conflicts. Passive conflict processing modes were more strongly related to psychopathology than active ones in all conflicts, apart from the care versus autarky conflict. Identity diffusion shared the strongest inter-relations within psychodynamic constructs. The psychodynamic constructs that were most strongly related to psychopathology were impairments in self-perception and the passive self-worth conflict. Psychopathology and psychodynamic constructs formed distinct clusters. Our results emphasize the relevance of personality functioning within psychodynamic constructs and in relation to psychopathology.

Can Patients With Narcissistic Personality Disorder Change? A Case Series

ABSTRACT

The study was set out to establish the potential for psychotherapy to effect improvements in patients with narcissistic personality disorder (NPD). Eight patients with NPD who improved in treatment were identified. Consensus clinician/investigator diagnostic scores from before and after the psychotherapies were retroactively established on the Diagnostic Interview for Narcissism (DIN) and the Diagnostic Statistic Manual for Psychiatric Disorders, 5th Edition (DSM-5) Personality Disorder Section II criteria. Psychosocial functioning (work or school, romantic relationships) before and after the psychotherapies was retroactively evaluated as well. At the completion of the therapies after 2.5 to 5 years, all patients had improved, no longer met DIN or DSM-5 criteria for NPD, and showed better psychosocial functioning. Symptomatic improvements were associated with large effect sizes. In conclusion, changes in NPD can occur in treatment after 2.5 to 5 years. Future research should identify patient characteristics, interventions, and common processes in such improved cases that could help with development of treatments.

Transference interpretation and psychotherapy outcome: a systematic review of a no-consensus relationship

Despite its well-established importance in psychoanalytic theory, there is a scarcity of empirical evidence on the relationship between a therapist's transference interpretation (TI) and therapeutic outcome. The current scientific literature shows no consensus on the existence and nature of such an association. Therefore, the present study aimed to systematically review the literature on the link between TI and outcomes in psychodynamic psychotherapies. The American Psychological Association PsycInfo, MEDLINE, and the Web of Science Core Collection were selected as the primary databases for the literature search. Studies were included if they measured the frequency/ concentration of TI in psychodynamic psychotherapy [e.g., transference focused psychotherapy (TFP), supportive-expressive therapy] or compared a treatment group (e.g., high in TI and TFP) with a control group (e.g., low in TI supportive therapy) in an adult population with psychiatric symptoms. Out of 825 retrieved abstracts, 25 articles (21 studies) were included in the final synthesis. 13 out of 21 (62%) studies showed a significant improvement in at least one therapy outcome measure following the use of TI. The present systematic review also revealed high heterogeneity across studies in terms of TI measurement, outcome assessment (e.g., psychiatric symptoms, dynamic change, interpersonal functioning, therapeutic alliance), study design (e.g., experimental, quasi-experimental, naturalistic), patient population (e.g., anxiety disorders, personality disorders), and types of treatment (e.g., TFP, supportive-expressive therapy), preventing researchers from asserting solid conclusions. The results strongly highlight the urgent need for highquality research to understand which types of patients, how, and when TIs could be effective throughout the therapy process.

All the Same? Different Measures of Personality Functioning Are Similar but Distinct. A Comparative Study from a Psychodynamic Perspective Using Exploratory Graph Analysis

Personality functioning (PF) is a central construct in many theories of personality pathology. Based on psychodynamic theories, two screening questionnaires to assess PF are widely used: The Inventory of Personality Organization-16 item version and the Operationalized Psychodynamic Diagnosis-Structure Questionnaire Short Form. This study aimed to explore the similarities and differences of the two questionnaires in a large clinical sample of N = 1636 psychotherapeutic inpatients. Correlation analyses were conducted to examine the associations between the global scores and between the subscales. The study further used Exploratory Graph Analysis (EGA) to explore the dimensionality of the items. The stability of estimates was evaluated using a bootstrap version of EGA (bootEGA). The results indicated that the two questionnaires are highly correlated, yet not multicollinear, and moderate to large correlations were found between their subscales. EGA revealed six dimensions that fairly represented the original subscales. BootEGA showed that the dimensions and items were stable, except for one item that did not load sufficiently on any dimension. The findings suggest that although the questionnaires are highly correlated, their subscales tap into distinct domains of PF. We discuss implications stemming from these findings for clinical and scientific practice.

The role of mentalizing in psychological interventions in adults: Systematic review and recommendations for future research

Mentalizing is the human capacity to understand actions of others and one's own behavior in terms of intentional mental states, such as feelings, wishes, goals and desires. Mentalizing is a transtheoretical and transdiagnostic concept that has been applied to understanding vulnerability to psychopathology and has attracted considerable research attention over the past decades. This paper reports on a pre-registered systematic review of evidence concerning the role of mentalizing as a moderator and mediator in psychological interventions in adults. Studies in adults were reviewed that address the following questions: (a) does pre-treatment mentalizing predict treatment outcome; (b) do changes in mentalizing across treatment predict outcome; (c) does adherence to the principles or protocol of mentalization-based treatment predict outcome; and (d) does strengthening in-session mentalizing impact the therapeutic process via improved alliance, alleviated symptoms, or improved interpersonal functioning? Results suggest that mentalizing might be a mediator of change in psychotherapy and may moderate treatment outcome. However, the relatively small number of studies (n = 33 papers based on 29 studies, totaling 3124 participants) that could be included in this review, and the heterogeneity of studies in terms of design, measures used, disorders included, and treatment modalities, precluded a formal meta-analysis and limited the ability to draw strong conclusions. Therefore, theoretical and methodological recommendations for future research to improve the quality of existing research in this area are formulated.

Changes in attachment dimensions during the treatment of acute post-traumatic stress disorder in sexually assaulted Brazilian women

Introduction

Attachment patterns are established during early childhood; however, extreme experiences throughout life may change this structure, either toward attachment security or insecurity. We analyzed changes in attachment dimensions in women with acute post-traumatic stress disorder (PTSD) following sexual assault, that were randomized to a 14-week treatment with either the medication sertraline or Interpersonal Psychotherapy.

Methods

Seventy-four adult women who presented significant reduction in PTSD symptoms across the trial responded to the Revised Adult Attachment Scale at baseline, on week 8 of treatment, and at the end of the trial, on week 14. We fitted a generalized linear model to explain the attachment anxiety and avoidance scores at baseline. A generalized linear mixed model investigated how attachment dimensions changed over time. Socioeconomic data, treatment type, history of childhood trauma, and PTSD severity over the 14-week period were the considered covariates.

Results

At baseline, attachment anxiety was associated with a history of early trauma. Attachment anxiety remained stable during the follow-up. Attachment avoidance, on the other hand, significantly increased from baseline to week 14. Higher avoidance was observed in patients with higher total PTSD scores and on the cluster of hyperarousal symptoms. Races other than White (black, mixed-race, or Asian) and younger age were associated with higher attachment avoidance.

Discussion

Contrary to our expectations, attachment avoidance increased during follow-up, indicating changes in the interpersonal realm beyond the symptoms of PTSD.

Central psychological symptoms from a network analysis of patients with anxiety, somatoform or personality disorders before psychotherapy

BACKGROUND

Cross-sectional network analysis examines the relationships between symptoms to explain how they constitute disorders. Up to now, research focuses mostly on depression, posttraumatic stress disorder, and rarely assesses larger networks of various symptoms measured with instruments independent of classifications. Studies on large groups of psychotherapy patients are also rare.

METHODS

Analyzing triangulated maximally filtered graph (TMFG) networks of 62 psychological symptoms reported by 4616 consecutive nonpsychotic adults in 1980-2015.

RESULTS

Case-dropping and nonparametric bootstrap proved the accuracy, stability and reliability of networks in patients' sex-, age-, and time of visit divided subgroups. Feeling that others are prejudiced against the patient was the most central symptom, followed by catastrophic fears, feeling inferior and underestimated. Sadness, panic, and sex-related complaints were less central than we expected. All analysed symptoms were connected, and we found only small sex-related differences between subsamples' networks. No differences were observed for time of visit and age of patients.

LIMITATION

Analyses were cross-sectional and retrospective, not allowing examination of directionality or causality. Further, data are at the between-person level; thus, it is unknown whether the network remains constant for any person over time. One self-report checklist and building binary network method may bias results. Our results indicate how symptoms co-occured before psychotherapy, not longitudinally. Our sample included public university hospital patients, all White-Europeans, predominantly females and university students.

CONCLUSIONS

Hostile projection, catastrophic fears, feeling inferior and underestimated were the most important psychological phenomena reported before psychotherapy. Exploring these symptoms would possibly lead to enhancement of treatments.