Laurent Berthoud

Effects of Motive-Oriented Therapeutic Relationship in a Ten-Session General Psychiatric Treatment of Borderline Personality Disorder: A Randomized Controlled Trial

Background: Motive-oriented therapeutic relationship (MOTR) was postulated to be a particularly helpful therapeutic ingredient in the early treatment phase of patients with personality disorders, in particular with borderline personality disorder (BPD). The present randomized controlled study using an add-on design is the first study to test this assumption in a 10-session general psychiatric treatment with patients presenting with BPD on symptom reduction and therapeutic alliance. Methods: A total of 85 patients were randomized. They were either allocated to a manual-based short variant of the general psychiatric management (GPM) treatment (in 10 sessions) or to the same treatment where MOTR was deliberately added to the treatment. Treatment attrition and integrity analyses yielded satisfactory results. Results: The results of the intent-to-treat analyses suggested a global efficacy of MOTR, in the sense of an additional reduction of general problems, i.e. symptoms, interpersonal and social problems (F1, 73 = 7.25, p < 0.05). However, they also showed that MOTR did not yield an additional reduction of specific borderline symptoms. It was also shown that a stronger therapeutic alliance, as assessed by the therapist, developed in MOTR treatments compared to GPM (Z55 = 0.99, p < 0.04). Conclusions: These results suggest that adding MOTR to psychiatric and psychotherapeutic treatments of BPD is promising. Moreover, the findings shed additional light on the perspective of shortening treatments for patients presenting with BPD.

Motive-Oriented Psychotherapeutic Relationship Facing a Patient Presenting with Narcissistic Personality Disorder: A Case Study

Motive-oriented therapeutic relationship (MOTHER), a prescriptive concept based on an integrative form of case formulation, the Plan Analysis (PA) method (Caspar, in: Eells (ed.), Handbook of psychotherapy case formulations, 2007), has shown to be of particular relevance for the treatment of patients presenting with personality disorders, in particular contributing to better therapeutic outcome and to a more constructive development of the therapeutic alliance over time (Kramer et al., J Nerv Ment Dis 199:244–250, 2011). Several therapy models refer to MOTHER as intervention principle with regard to borderline and Narcissistic Personality Disorder (NPD) (Sachse et al., Clarification-oriented psychotherapy of narcissistic personality disorder, 2011; Caspar and Berger, in: Dulz et al. (eds.), Handbuch der Borderline-Störungen, 2011). The present case study discusses the case of Mark, a 40-year-old patient presenting with NPD, along with anxious, depressive and anger problems. This patient underwent a seven-session long pre-therapy process, based on psychiatric and psychotherapeutic principles complemented with PA and MOTHER, in preparation for further treatment. MOTHER will be illustrated with patient–therapist verbatim from session 4 and the links between MOTHER and confrontation techniques will be discussed in the context of process-outcome hypotheses, in particular the effect of MOTHER on symptom reduction.

Motive-oriented therapeutic relationship in brief psychodynamic intervention for patients with depression and personality disorders†

Motive-Oriented Therapeutic Relationship (MOTR, also called Complementary Therapeutic Relationship) has already shown itself to be related to therapeutic outcome in several studies. The present study aims to test MOTR in a 4-session Brief Psychodynamic Intervention for patients presenting with major depressive disorder (MDD) and comorbid personality disorder (PD). In total, N = 20 patients were selected; n = 10 had MDD, n = 10 had MDD with comorbid PD. The first therapy session was videotaped and analyzed by means of Plan Analysis and the MOTR scale. Results suggest a differential effect on outcome: only the nonverbal component of MOTR is related to symptomatic change in patients presenting with MDD and comorbid PD; no such effect was found for patients with MDD alone. These results are discussed in line with the generalization and refinement of the conclusions of previous findings on the MOTR.

Emotional processing in a ten-session general psychiatric treatment for borderline personality disorder: a case study

This study examines the effects of a borderline-specific treatment, called general psychiatric management, on emotional change, outcome and therapeutic alliance of an outpatient presenting with borderline personality disorder. Based on the sequential model of emotional processing, emotional states were assessed in a 10-session setting. The case showed an increase in expressions of distress and no change in therapeutic alliance and tended towards general deterioration. Results suggest emotional processing may play a lesser role in general psychiatric management in early phase treatment than previously hypothezised.

The shorter the better? A follow-up analysis of 10-session psychiatric treatment including the motive-oriented therapeutic relationship for borderline personality disorder

Abstract Objective: There is little research on short-term treatments for borderline personality disorder (BPD). While the core changes may occur only in long-term treatments, short-term treatments may enable the study of early generic processes of engagement in therapy and thus inform about effective treatment components. It was shown that a 10-session version of a psychiatric treatment was effective in reducing borderline symptoms at the end of this treatment [Kramer, U., Kolly, S., Berthoud, L., Keller, S., Preisig, M., Caspar, F., … Despland, J.-N. (2014). Effects of motive-oriented therapeutic relationship in a ten-session general psychiatric treatment for borderline personality disorder: A randomized controlled trial. Psychotherapy and Psychosomatics, 83, 176–186.]. Also, it was demonstrated in a randomized design that adding the motive-oriented therapeutic relationship (MOTR), following an individualized case formulation based on Plan Analysis, further increased general outcome after session 10 and had a positive effect on the early changes in self-esteem and alliance. Method: The present study focuses on the follow-up period after this initial treatment, examining treatment density and outcomes after 6 months and service utilization after 12 months. Outcome was measured using the OQ-45. Results: Results on a sub-sample of N = 40 patients with available OQ-45 data at follow-up (n = 21 for MOTR-treatment, n = 19 for comparison treatment) showed maintenance of gains over the follow-up period, which did not differ between both conditions. It appeared for this sample that MOTR treatments, while using the same number of sessions, lasted more weeks (i.e., lower treatment density, defined as the number of sessions per week), when compared to the treatments without MOTR. Density marginally predicted symptom reduction at follow-up. Patients in MOTR treatments had a greater likelihood of entering structured psychotherapy after the initial sessions than patients in the comparison group. Conclusions: These results are overall consistent with earlier studies on short-term treatments for BPD and underline the importance of individualizing interventions, by using case formulations that rely on idiographic methods and integrative concepts.

Leaving Distress Behind: A Randomized Controlled Study on Change in Emotional Processing in Borderline Personality Disorder

Objective: The marked impulsivity and instability of clients suffering from borderline personality disorder (BPD) greatly challenge therapists’ understanding and responsiveness. This may hinder the development of a constructive therapeutic relationship despite it being of particular importance in their treatment. Recent studies have shown that using motive-oriented therapeutic relationship (MOTR), a possible operationalization of appropriate therapist responsiveness, can enhance treatment outcome for BPD. The overall objective of this study is to examine change in emotional processing in BPD clients following the therapist’s use of MOTR. Method: The present paper focuses on N = 50 cases, n = 25 taken from each of two conditions of a randomized controlled add-on effectiveness design. Clients were either allocated to a manual-based psychiatric-psychodynamic 10-session version of general psychiatric management (GPM), a borderline-specific treatment, or to a 10-session version of GPM augmented with MOTR. Emotional states were assessed using the Classification of Affective-Meaning States (Pascual-Leone & Greenberg, 2005) at intake, midtreatment, and in the penultimate session. Results: Across treatment, early expressions of distress, especially the emotion state of global distress, were shown to significantly decrease (p = .00), and adaptive emotions were found to emerge (p < .05). Between-condition differences of change were found, including a significant increase in emotional variability and stronger outcome predictors in the MOTR condition. Conclusions: The findings indicate initial emotional change in BPD clients in a relatively short time frame and suggest the addition of MOTR to psychotherapeutic treatments as promising. Clinical implications are discussed.

Metacognition as a predictor of change in the treatment for borderline personality disorder: A preliminary pilot study.

There is evidence that a key feature in borderline personality disorder (BPD) is the difficulty to reflect on one’s own as well as on other people’s state of mind. So far, no study has examined the link between metacognition and symptom change presented by BPD patients across treatment. This preliminary pilot study represents a first step in describing impairments in different dimensions of metacognition and their connection with the symptoms presented by a N = 10 BPD sample. The transcripts from the first and the penultimate session of a 10-session version of Good Psychiatric Management were analyzed. The global score and the 3 subscales of the Metacognition Assessment Scale—Revised were used to assess metacognitive abilities: Understanding of one’s own mind, Understanding of other’s mind, and Mastery. Symptoms were assessed with the Outcome Questionnaire—45.2. Results show a general low level of metacognition. Therapy sessions with BPD patients seem to be characterized by impairments in metacognition, notably in the reflection on other’s states of mind and in the use of this information to solve conflicts and problems. Moreover, sessions highlighting a higher level of the Understanding of other’s mind at the onset of treatment were linked with better outcome compared to sessions showing poorer metacognitive abilities in this area. Implications for an integrated treatment for BPD and future research are discussed. La metacognición como predictor del cambio en el tratamiento del trastorno límite de la personalidad: un estudio piloto preliminar Hay evidencia de que una característica clave en el Trastorno Límite de la Personalidad (TLP) es la dificultad de reflexionar sobre el estado de ánimo propio y sobre el estado de ánimo de otras personas. Hasta el momento, ningún estudio ha examinado el vínculo entre la metacognición y el cambio de síntomas presentado por pacientes con TLP durante el tratamiento. Este estudio piloto preliminar representa un primer paso para describir los impedimentos en diferentes dimensiones de la metacognición y su conexión con los síntomas presentados por una muestra de N = 10 TLP. Se analizaron las transcripciones de la primera y la penúltima sesión de una versión de diez sesiones de Good Psychiatric Management. El puntaje global y las tres subescalas de la Escala de Evaluación de Metacognición-Revisada (MAS-R) se utilizaron para evaluar las habilidades metacognitivas: Comprensión de la propia Mente, Comprensión de la Mente de Otros y Dominio. Los síntomas se evaluaron con el OQ-45. Los resultados muestran un bajo nivel general de metacognición. Las sesiones de terapia con pacientes con DBP parecen estar caracterizadas por alteraciones en la metacognición, especialmente en la reflexión sobre los estados mentales de otros y en el uso de esta información para resolver conflictos y problemas. Por otra parte, las sesiones que destacan un nivel más alto de la comprensión de la mente del otro en el inicio del tratamiento se asociaron con mejores resultados en comparación con las sesiones que muestran habilidades metacognitivas más pobres en esta área. Se analizan las implicaciones de un tratamiento integrado para el TLP y futuras investigaciones.

Monitoring the effects of adult psychotherapy in routine practice in Switzerland: A feasibility trial

Abstract Background: Several studies have been published on the effects of psychotherapy in routine practice. Complementing traditional views summarised as ‘dose-effect models’, Stiles et al. put forward data consistent with the responsive regulation model underlining the importance of the clients active participant role in defining length of treatment. One may ask what level of change reached by a patient is considered to be the ‘good enough level’ (GEL) and if it is related to the duration of psychotherapy. Aims: The main objective of the present feasibility trial was to monitor the patients session-by-session evolution using a self-report questionnaire in order to define the GEL, i.e. the number of sessions necessary for the patient to reach significant change. Method: A total of N=13 patients undergoing psychotherapy in routine practice participated in the study, completing the Outcome Questionnaire – 45.2 (OQ-45), which assesses the symptom level, interpersonal relationships and social role after e...