Mentalization-based treatment of female patients with severe personality disorder and substance use disorder

Personality disorder (PD) and substance use disorder (SUD) are frequently co-occurring conditions which severely affect individuals in different domains of their life. Around half of patients with SUD also suffer from a PD. Clinical research indicates that each of these conditions separately are difficult to treat and many obstacles to successful outcomes can be found. When these conditions occur together, consequences for treatment are even graver. Furthermore, these patients are often excluded from specialised psychiatric treatments for PD and are left to random treatment programmes in the SUD field where competence and knowledge on PD are often lacking. This dissertation sought to explore, through different methodological approaches, the experiences and changes in mentalization-based treatment (MBT) of 18 female patients with comorbid PD/SUD. Do they achieve beneficial results from the treatment, and do they accept and endure this long-term combination treatment which is tailored to patients with borderline PD? The dissertation consists of three papers. The first paper was a single-case study which investigates the treatment process of a patient suffering from SUD and schizotypal PD, which is considered difficult to treat and that could enlighten the process of working with transference and handling countertransference. The methodology was a hermeneutical single case efficacy design (HSCED) and vignettes from the treatment process together with abundant data collection were used in the analysis. The research question for paper 1 was: What are the effects of disorganised attachment on personality functioning and substance abuse, and how is it transformed through MBT? What are the central mechanisms of change? In paper 2, thirteen patients were interviewed qualitatively on their experiences of MBT and their view on own pathology approximately 2 years after terminating MBT. A thematic analysis within a hermeneutical-phenomenological epistemology was the methodological approach chosen for the analyses of transcribed semi-structured qualitative interviews. The research questions of paper 2 was: How do female patients with clinical significant borderline traits and comorbid SUD experience their own central change processes after participating in a MBT programme? When these patients experience change in psychotherapy, what central change processes do they highlight? Do they experience changes in their ability to mentalize when looking back at the therapy process? In paper 3, longitudinal quantitative data were collected from 18 patients at baseline, every 6 months in treatment, at the end of treatment and at follow-up two years after treatment. The assessment protocol had measures on PD, SUD, interpersonal functioning, symptomatic distress, general functioning and self-esteem. Furthermore paper 3 aimed to evaluate the feasibility aspects of the pilot project. Linear mixed models were utilised for the analyses of the quantitative data. The research questions of paper 3 were: What is the feasibility of MBT with female patients with severe PD and SUD? Does MBT have any positive effect on PD/SUD patients’ substance use and personality structure (primary outcome)? Does MBT have any positive effect on symptom distress, interpersonal and social functioning (secondary outcome)? In paper 1 we found that: 1) that the patient had changed in a clinically significant way, 2) that MBT was the main causative process for her change, 3) that the main mechanisms of change were reparations of ruptures in the alliance, handling countertransference and working in the transference through constant efforts a mentalizing the relationship, and 4) that treatment gains made it possible for her to maintain her mentalizing abilities even in close relationships that formerly would activate profound mental confusion. In paper 2 we found that patients experienced meaningful psychological change after participating in MBT and that by gaining the ability to reflect on their own feelings and thinking processes, interpersonal encounters became more flexible and ultimately patients experienced an increased sense of an agentic self. The themes that described their change processes were “by feeling the feeling”, “by thinking things through”, “by walking in your shoes to see myself”, and “by stepping outside of own bad feeling in seeing you”. In paper 3, we found that preliminary data on changes in several outcome measures indicated that MBT treatment gave both clinically and statistically significant changes in primary and secondary outcome measures. Furthermore, in evaluation of the feasibility aspects of the study we concluded that embarking on a randomized controlled trial (RCT) with this study protocol and treatment programme is “feasible with close monitoring”. Treatment adherence and routines for frequent and coherent assessment are important to implement and monitor. The findings in this dissertation indicate that MBT could be a potential beneficial treatment approach for female patients suffering from PD/SUD. Furthermore, different hypotheses on what are important mechanisms of change in MBT have been found. These include working in the transference, managing countertransference and mentalizing as a central change process. These suggestions for mechanisms of change should be further investigated in psychotherapy process studies. The lack of a control group and the limited number of participants suggest that conclusions must be made with caution. The feasibility aspects seem promising and larger studies on MBT with PD/SUD are recommended

Individual and Organizational Well-being when Workplace Conflicts are on the Agenda: A Mixed-methods Study

Previous studies have shown that direct involvement in workplace conflicts may have a significant impact on individual well-being. We used survey and interview data from a large nongovernmental organization (NGO) to analyze both the relationships between direct and indirect involvement in workplace conflicts and individual and organizational well-being. Results show that unaddressed conflicts and nonresponsive or conflict-involved managers are problematic because they fuel already existing conflicts, and also pave the way for new ones. If conflicts are not handled at an early enough stage, they seem to “paralyze” the organization and serve as an interlocking mechanism that contributes to hindering the necessary action from management. In our case, one-fifth of the employees were directly involved in the conflicts, and two-thirds felt that their local working environment had been influenced negatively by the conflicts. The prevalence of mental health problems in the NGO was almost twice as high as in the general Norwegian population, and slightly more than one out of 10 reported reduced work ability. We conclude that individuals directly involved in the conflicts experience negative health consequences, and that this fact, in combination with organizational issues and a very high share of employees indirectly involved in the conflicts, affected the well-being of the whole organization

Workplace Inclusion Competence and Employer Engagement

Existing active labor market policy (ALMP) measures have been unsuccessful in establishing long- term employment for vulnerable groups.This paper contributes to further development of the role of the employer engagement perspective in ALMP. We introduce the term workplace inclusion competence and explore its association to two distinct work-organizational categories: participa tion- and control-oriented management. We operationalize workplace inclusion competence as inclusion opportunity and inclusion capability. We argue that such competence is dynamic and processual, and find that organizational management-orientation, as well as work pace, employees’ developmental opportunities, financial situation and OSH, have an impact on workplace inclusion competence. Survey data among a sample of managers is analyzed regarding workplaces’ capabilities and opportunities in work inclusion processes. We present two sets of indexes to measure organizational management-orientation and inclusion skills competence. As such, we contribute to the research field by providing new and more specific concepts with adherent question indexes, and by connecting them to a work-organizational perspective

Antisocial personality disorder in group therapy, kindling pro-sociality and mentalizing

Patients with antisocial personality disorder (ASPD) are known for being difficult to treat. Treatment for ASPD is debated and lacking evidence. Among several reasons for treatment difficulties concerning ASPD, negative countertransference in health personnel is one central topic. Mentalization based treatment (MBT) is a reasonable candidate treatment for ASPD. From an ongoing pilot-study on MBT with substance using ASPD patients, we explore therapist experiences. Four experienced MBT therapists together with the principal investigator performed a focus group together. The therapists were themselves involved in performing this study and analyses are made as an autoethnographic study, with thematic analyses as methodological approach. As this study involved a qualitative investigation of own practice, reflexivity of the processes was performed. The aim was to explore in depth: therapist experiences and therapist wellbeing in MBT-ASPD. We found four main themes on therapist experiences: i) gaining safety by getting to know them better; ii) gaining cooperation through clear boundaries and a non-judgmental stance; iii) shifting inner boundaries; and iv) timing interventions in a high-speed culture. These four themes point to different therapist experiences one can have in MBT-ASPD. Our findings resonate well with the clinical literature on ASPD, the findings imply that clinical teams should have a focus on therapist countertransference and burnout, ensure that therapists uphold boundaries and open-mindedness in treatment of ASPD and that therapists experience vitalizing feelings in this line of work.publishedVersio

Workplace Barriers to Return-to-Work Processes

This study identified workplace barriers to return-to-work (RTW) processes through a multiple case study consisting of 38 cases. Sixty-four interviews with employees with mild traumatic brain injury (TBI) and 45 interviews with their managers were conducted in 2017–2020 at T1 (1–3 months after the employees returned to work) and T2 (12–16 months after T1). Workplace barriers were associated with the organizational and psychosocial work environments, TBI knowledge, and char- acteristics of the employee. The role of management was a key aspect across all barriers. Workplace barriers often co-occurred and became increasingly important at T2. At T2, most employees increased their workload, but some still experienced unsupportive management, workplace conflicts, and a low degree of job control. The psychosocial work environment is a main area for workplace barriers. The managers’ knowledge of RTW processes and TBI-related challenges potentially reduce barriers and thereby contribute to balance the needs of the organization and the individual

Combined cognitive and vocational interventions after mild to moderate traumatic brain injury: study protocol for a randomized controlled trial

Background A considerable proportion of patients with mild to moderate traumatic brain injury (TBI) experience long-lasting somatic, cognitive, and emotional symptoms that may hamper their capacity to return to work (RTW). Although several studies have described medical, psychological, and work-related factors that predict RTW after TBI, well-controlled intervention studies regarding RTW are scarce. Furthermore, there has traditionally been weak collaboration among health-related rehabilitation services, the labor and welfare sector, and workplaces. Methods/design This study protocol describes an innovative randomized controlled trial in which we will explore the effect of combining manualized cognitive rehabilitation (Compensatory Cognitive Training [CCT]) and supported employment (SE) on RTW and related outcomes for patients with mild to moderate TBI in real-life competitive work settings. The study will be carried out in the southeastern region of Norway and thereby be performed within the Norwegian welfare system. Patients aged 18–60 years with mild to moderate TBI who are employed in a minimum 50% position at the time of injury and sick-listed 50% or more for postconcussive symptoms 2 months postinjury will be included in the study. A comprehensive assessment of neurocognitive function, self-reported symptoms, emotional distress, coping style, and quality of life will be performed at baseline, immediately after CCT (3 months after inclusion), following the end of SE (6 months after inclusion), and 12 months following study inclusion. The primary outcome measures are the proportion of participants who have returned to work at 12-month follow-up and length of time until RTW, in addition to work stability as well as work productivity over the first year following the intervention. Secondary outcomes include changes in self-reported symptoms, emotional and cognitive function, and quality of life. Additionally, a qualitative RTW process evaluation focused on organizational challenges at the workplace will be performed. Discussion The proposed study will combine cognitive and vocational rehabilitation and explore the efficacy of increased cross-sectoral collaboration between specialized health care services and the labor and welfare system. If the intervention proves effective, the project will describe the cost-effectiveness and utility of the program and thereby provide important information for policy makers. In addition, knowledge about the RTW process for persons with TBI and their workplaces will be provided. Trial registration ClinicalTrials.gov, NCT03092713. Registered on 10 March 2017

Improvement of personality functioning among people treated within personality disorder mental health services. A longitudinal, observational study

Objective: Evidence-based personality disorder (PD) treatments are dominated by interventions targeting Borderline PD, although clinical populations characteristically include different PD features and severity. Personality functioning is a new concept intended to capture common features across PDs. This study aimed to investigate longitudinal improvement of personality functioning in a clinical sample assigned to PD treatment. Method: An observational, large, longitudinal study of patients in PD treatments on specialist mental health service levels (N = 1,051). DSM-5 PDs were systematically assessed on referral. Personality functioning was repeatedly assessed (LPFS-BF-2.0), supplemented by symptom distress (anxiety: PHQ-GAD-7, depression: PHQ-9), and social/occupational activity (WSAS, work/study activity). Statistics were linear mixed models. Results: Thirty per cent had personality difficulties below PD threshold. Among PDs, 31% had Borderline (BPD), 39% Avoidant (AvPD), 15% not otherwise specified, 15% other PDs, and 24% > one PD. More severe initial LPFS-BF was associated with younger age, presence of PD and increasing number of total PD criteria. Across PD conditions, LPFS-BF, PHQ-9 and GAD-7 improved significantly (overall effect size 0.9). Mean duration of PD treatment was 15 (SD 9) months. Drop-out rates were low (12%). LPFS-BF improvement-rates were higher for BPD. Younger age was moderately associated with slower PHQ-9 improvement. Work/study activity was initially poor, poorer levels associated with AvPD and younger age, and improvement was non-significant across PD conditions. AvPD was associated with slower WSAS improvement-rates. Conclusion: Personality functioning improved across PD conditions. The results highlight BPD improvements. The study points to challenges concerning AvPD treatment, poor occupational activity and age-related differences

The effects of patient-professional partnerships on the self-management and health outcomes for patients with chronic back pain: a quasi-experimental study

Background: Self-management may be a lifelong task for patients with chronic back pain. Research suggests that chronic pain self-management programmes have beneficial effects on patients’ health outcome. Contemporary pain management theories and models also suggest that a good patient-professional partnership enhances patients’ ability to self-manage their condition. Objectives: 1) To investigate whether there is a reciprocal relationship between self-management of chronic back pain and health-related quality of life (HRQoL); 2) to examine the impact of a good patient-professional partnership on HRQoL, either directly, or indirectly via change in the ability to self-manage pain. Design and setting: This quasi-experimental study was designed to take place during routine service appointments and conducted in a community-based pain management service in the United Kingdom. A patient-professional partnership was established in which patients were actively involved in setting up goals and developing individualised care plans. Through this, health professionals undertook patients’ health needs assessment, collaborated with patients to identify specific problems, provided written materials and delivered individualised exercise based on patients’ life situation. Patients were recruited following initial consultation and followed up three months later. Participants: A total of 147 patients (65% female) with a mean age of 48 years (SD: 14 years) were enrolled in the study. Of these, 103 subjects completed the study. Patients were included if they were aged 18 and over, suffered from chronic back pain, had opted in to the clinic and had sufficient ability to read and understand English. Patients were excluded if they opted out this service after the initial assessment, suffered from malignant pain or required acute medical interventions for their pain relief. Methods: Self-reported measures of HRQoL, patient-professional partnerships and self- management ability were collected at baseline and three months later. Pathways proposed were depicted using structural equation modelling. Results: There was no association between patients’ self-management ability and HRQoL at baseline. However, a positive direct effect was detected at three months (-0.38, p<0.01). A patient-professional partnership was not found to be beneficial for patients’ HRQoL through a direct pathway, but via an indirect pathway where self-management was a mediator (- 19.09, p<0.01). Conclusions: This study suggests that the increase in patients’ self-management ability may lead to improvement in HRQoL after pain management support provided in a partnership with health professionals. A good patient-professional partnership appears to be beneficial as an augmentation to self-management practice for patients with chronic back pain