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

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

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

Vold i nære relasjoner Konsekvenser av vold og behandling av voldsutsatte

This paper describes the dynamics of domestic violence and gives and outline for therapy with those exposed to domestic violence. The aim is to describe mechanism that are specific to this kind of trauma and some of the interventions that are important in therapy with this group of patients. The paper presents a thorough description of what violence is especially enlightening psychological violence. Based on research done in this field, the relationships of domestic violence is described. The psychological consequences of violence is described on a symptom and phenomenological level. Finally some conclusions about therapy will be drawn. Here the clinician's attitudes, cooperation with other instances, security, normalization of reactions and a focus on resources will be important

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

Mentalization-based treatment for female patients with comorbid personality disorder and substance use disorder: A pilot study

Objectives: In this study, we investigated the feasibility of mentalization-based treatment (MBT) for patients with comorbid substance use disorder (SUD) and borderline personality disorder (BPD). No published study has ever specifically looked at MBT for these patients. Such individuals are known to have a very poor prognosis and harbor much pain and misery. Moreover, few randomized controlled trials exist on psychotherapy efficiency for patients with comorbid substance use disorder and borderline personality disorder. There is an urgent need for more knowledge on treatment for this patient group. Design: A pilot project within a naturalistic clinical setting with longitudinal data collection during treatment and at follow-up. Eighteen female patients attended a pilot project and participated in up to 36 months of treatment, according to the manuals. Patients were measured on primary (pre/post) and secondary (longitudinal) outcome measures before treatment, every six months during treatment, at the end of treatment, and at follow-up approximately two years after treatment. Methods: Statistical analyses of repeated outcome measures (GSI, CIP, GAF, WSAS, and RSES) and of pre/post measures (Axis I and II diagnosis) were performed with linear mixed models, and Cohens d was calculated. Results: Significant improvements on primary and secondary outcome measures were demonstrated, with effect sizes ranging from moderate to large. With respect to primary outcome, these SUD/PD patients were almost fully recovered from their SUD at follow-up (a predicted score of 0.2 Axis I SUD diagnosis at follow-up in comparison with a score of 1.8 at baseline). Conclusion: MBT as performed in this pilot project indicates promising results for patients with (mostly borderline) PDs and comorbid SUDs. Performing RCT studies is warranted