Individualisation in Psychotherapy Research: Personality Disorders Spearheading the Way

Decades of research could find no conclusive evidence that “mental disorders” exist as natural separated entities. Not only have epidemiological studies pointed out excessively high rates of comorbidity as well as short-term diagnostic instability, but the current nosology has also demonstrated its inability to clearly delimit “normal” from “abnormal” — or to use its vocabulary — “sane” from “sick”. As a result, the biomedical paradigm and its ensuing categorical classification have proven unfit to investigate, comprehend and accurately describe psychological distress. Since issues with the current categorical taxonomy considerably affect research and treatment development, it is paramount to move beyond categorical models and improve the conceptualisation, studying and classification of psychological distress. In this regard, personality disorders (PDs) provide a great opportunity since the very nature of the concept makes shortcomings of a categorical paradigm arguably even more salient: either someone’s personality is inherently ill (disordered) or it is healthy. Yet, research has demonstrated the superior validity of a dimensional approach where individual differences in personality are continuously distributed and do not consist of two discrete categories (ill vs. healthy). As a result, the field of PDs is taking a leading role in the integration of alternative approaches to provide fully accurate descriptions of people’s difficulties rather than forcing individuals into imprecise categories. In psychotherapy research, the field follows a similar rationale and draws from the dimensional paradigm to focus on the individualisation of methods. The aim of the present doctoral dissertation is to demonstrate the theoretical and methodological potential of said individualised and integrated approaches on the basis of three articles in the field of PDs. The first article illustrates how the individualisation of stimuli and the integration of the field of research in psychotherapy with neuroimaging can enhance our understanding of changes during psychotherapy for Borderline Personality Disorder (BPD). The second article presents the elaboration of a prototypical Plan Analysis of Narcissistic Personality Disorder (NPD) from individual case formulations and its implications for treatment. Finally, the third article is a study investigating the differences in emotional arousal between participants with a BPD and controls during an individualised experiential task focusing on self-criticism. The discussion reviews and analyses the findings of each article and addresses the limits as well as the broader theoretical and practical implications of their designs for psychotherapy research. The thesis concludes with a summary and an outline of future directions of the field of PDs and mental health.In jahrzehntelanger Forschung konnte kein schlüssiger Beweis dafür gefunden werden, dass "psychische Störungen" als natürliche, voneinander getrennte Einheiten existieren. Epidemiologische Studien haben nicht nur auf übermässig hohe Komorbiditätsraten und kurzfristige diagnostische Instabilität hingewiesen, sondern auch gezeigt, dass die derzeitige Nosologie nicht in der Lage ist, eine klare Abgrenzung zwischen "normal" und "abnormal" vorzunehmen — oder, um ihr Vokabular zu verwenden — , zwischen "gesund" und "krank" zu unterscheiden. Infolgedessen erweisen sich das biomedizinische Paradigma und die daraus resultierende kategorische Klassifizierung als ungeeignet, um psychisches Leid zu beschreiben, zu verstehen und zu untersuchen. Da die Mängel der derzeitigen kategorialen Taxonomie die Forschung und die Entwicklung von therapeutischen Behandlungen erheblich beeinträchtigen, ist es von grösster Bedeutung, unsere Konzeptualisierung, Untersuchung und Klassifizierung von psychischem Leid zu verbessern. Persönlichkeitsstörungen (PS) bieten eine grosse Chance zur Überwindung des kategorialen Paradigmas, da durch die Natur ihres Untersuchungsobjekts die Unzulänglichkeiten biomedizinischer Ansätze besonders hervortreten: Entweder ist die Persönlichkeit einer Person von Natur aus krank (gestört) oder sie ist gesund. Denn in Forschung zu PS gilt die Überlegenheit eines dimensionalen Ansatzes, bei dem die individuellen Unterschiede in der Persönlichkeit kontinuierlich verteilt sind und nicht aus zwei diskreten Kategorien (krank vs. gesund) bestehen, als fest etabliert. Damit nimmt das Fachgebiet der PS eine führende Rolle bei der Integration alternativer Ansätze ein, um psychische Schwierigkeiten von Menschen genau zu beschreiben, anstatt sie in ungenaue Kategorien zu zwingen die keine vollständig akkuraten Beschreibungen liefern. In der Psychotherapieforschung folgt das Feld einer ähnlichen Logik und stützt sich auf das dimensionale Paradigma, indem sie sich auf die Individualisierung ihrer Methoden konzentriert. Ziel dieser Dissertation ist es, anhand von drei Artikeln im Bereich der PS, die theoretischen und methodischen Potenziale individualisierter und integrierter Ansätze aufzuzeigen. Der erste Artikel veranschaulicht, wie die Individualisierung von Stimuli und die Integration des Forschungsfeldes der Psychotherapie mit dem Neuroimaging unser Verständnis der Veränderungen während der Psychotherapie der Borderline-Persönlichkeitsstörung (BPS) verbessern kann. Der zweite Artikel stellt die Ausarbeitung einer prototypischen Plananalyse (Fallkonzeption) der narzisstischen Persönlichkeitsstörung (NPS) anhand von Einzelfallkonzeptionen und deren Auswirkungen auf die Behandlung vor. Der dritte Artikel präsentiert eine Studie, in der die Unterschiede in der emotionalen Aktivierung zwischen TeilnehmerInnen mit einer BPS und Kontrollpersonen während einer individualisierten Erfahrungsaufgabe mit Schwerpunkt auf Selbstkritik untersucht wurden. In der Diskussion werden die Ergebnisse der einzelnen Artikel kritisch durchleutet sowie die Grenzen und die breiteren theoretischen und praktischen Implikationen der vorgestellten Designs für die Psychotherapieforschung thematisiert. Die Dissertation schliesst mit einer Zusammenfassung und Überlegungen zu zukünftigen Forschungsperspektiven im Bereich der PS und der psychischen Gesundheit

Change in emotional processing in daily life: relationship with in-session self-esteem

In-session emotional processing is a central component of psychotherapy, but little is known about the types and the quality of emotional processing individuals engage in daily life. An ecological momentary assessment (EMA) schedule has been validated to assess distinct emotional experiences as they emerge in daily life. It remains an open question whether changes observed in distinct emotional experiences over a week of assessment are related to in-session self-esteem. In total, N = 42 university students participated in a one-week assessment of emotions using ecological momentary assessment, as well as in a one-session experiential task of resolving self-criticism (using a two-chair dialogue from emotion-focused therapy). The emotions in daily life were self-reported by the participants on a regular basis, and self-esteem was assessed three times during the two-chair dialogue. Two-level hierarchical linear models reveal emotional changes in daily life, and in-session self-esteem is introduced as predictor at level 2. In-session self-esteem was correlated with symptom levels. The results showed that changes in primary maladaptive emotions in the one-week assessment were predicted by state and trait components of in-session self-esteem, which took place at the outset of the EMA. Trait-components of self-esteem were linked with the level of symptoms, whereas state-components of self-esteem were not. The present study underscores the importance of extending research from within-session observations of emotional processing towards daily life

Integrating Core Conflictual Relationship Themes in neurobiological assessment of interpersonal processes in psychotherapy

Interpersonal processes are a key target in counselling and psychotherapy. It is of paramount importance to sharpen their assessment using integrated methods. Hence, this methodological paper describes how fields of research in psychotherapy and neuroimaging can be integrated into one novel complementary neurobehavioural paradigm that can be applied to enhance our understanding of interpersonal processes in psychotherapy. To illustrate this integration, we present selected data from a pre–post pilot study where the authors assessed interpersonal processes in brief treatment for borderline personality disorder using the core conflictual relationship theme, functional magnetic resonance imaging (fMRI) and outcome questionnaires. To do so, they measured individual changes in neural activity using an fMRI task pre‐ and post‐treatment where clients gave feedback on the emotional valence of sentences extracted from their own Relationship Anecdotes Paradigm interviews mixed with neutral ones. In this paper, using data from two participants of said study, we discuss how to implement this methodology and what can be achieved in terms of results

Mechanisms of change in brief treatments for borderline personality disorder: a protocol of a randomized controlled trial

Borderline personality disorder (BPD) is one of the most frequent, most debilitating and lethal mental conditions and is associated with a serious burden of disease. Treatment for patients with BPD involves structured psychotherapy, and may involve brief psychiatric treatment as first-line intervention. No controlled study has assessed the effectiveness of such brief intervention. Whereas most psychotherapy studies in patients with BPD focus on the effectiveness of the intervention, we still lack an understanding of how and why these effects are produced from a patient process perspective. It is therefore of utmost importance to study the treatment-underlying mechanisms of change. The present study plans to apply novel measurement methods for assessing change in two central psychobiological processes in BPD: emotion and socio-cognitive processing. The study uses theory-driven and ecologically valid experimental tasks, which take the patient's individual experience as the anchor, by integrating methodology from psychotherapy process and neurofunctional imagery research. The aim of this two-arm, randomized controlled study is to test the effects (i.e., symptom reduction) and the underlying mechanisms of change associated with a brief psychiatric treatment (10 sessions over 4 months), compared with treatment as usual. Participants (N = 80 patients with BPD) undergo assessments at four points (intake, 2 months, discharge, and 12-month follow up). In addition to symptom measures, individuals undergo a 2-step assessment for the potential mechanisms of change (i.e., emotion and socio-cognitive processing): (1) behavioral and (2) (for a sub-sample) neurofunctional. We hypothesize that change in the mechanisms explains the treatment effects. This study uses an easy-to-implement treatment of BPD, and a sophisticated assessment procedure to demonstrate the critical role of psychobiological change in emotion and socio-cognitive processing in brief treatments. It will help increase the effectiveness of brief treatment for BPD and help diminish the societal burden of disease related to BPD, in these early stages of treatment. TRIAL REGISTRATION {2}: ClinicalTrials.gov: NCT03717818. Registered on 24 October 2018). Protocol version {3} number 2 from 9 February 2018

Ecological momentary assessment of emotional processing: An exploratory analysis comparing daily life and a psychotherapy analogue session

Background: Emotional processing has been studied in psychotherapy as a state-dependent, sequential process of change. So far, no studies have applied this conceptualisation of emotional processing to the assessments of emotion in daily life. This is particularly important in the light of the pertinence of day-by-day fluctuations of emotions for understanding mental health and for monitoring the impact of prevention and psychotherapy programmes. This study examined the internal and ecological validity of a state-dependent conceptualisation of emotional processing in daily life, in comparison with an experiential-psychodynamic psychotherapy analogue session. Methods: In total, N = 42 university students participated in an experiential-psychodynamic session, completed symptom measures and responded to a one-week period of ecological momentary assessment (EMA) using a smartphone. Emotional processing in the session was assessed using the valid observer-rated measure Classification of Affective Meaning States (CAMS), and emotional responses in daily life were assessed using newly developed theory-consistent items self-rated via an interactive smartphone program. Results: Internal validity was generally satisfactory across the subscales used in EMA. Correspondence between EMA and in-session emotional processing was generally low, but specific relationships were found between self-rated fear, rejecting anger, hurt/grief or loneliness and the observer-rated productive emotions in the psychotherapy analogue session. Relationships between maladaptive emotional processing and intensity in symptoms were found. Conclusions: This is the first study to have examined the validity of a state-dependent conception of emotional processing in daily life, in direct comparison with a psychological session. We recommend using this assessment schedule to develop or complement integrative prevention or intervention programmes