Change processes in psychotherapy for patients presenting with histrionic personality disorder.

OBJECTIVE: Histrionic personality disorder (HPD) with a lifetime prevalence rate of 1.8% is an under-researched psychiatric diagnosis. The present study therefore aimed to investigate both the processes and outcomes of psychotherapy for HPD in a non-controlled study. METHODS: A total of 159 patients diagnosed with HPD were recruited and received clarification-oriented psychotherapy. Sessions 15, 20, and 25 were video-recorded and analysed using the Process-Content-Relationship Scale. Therapy outcome was assessed with symptom measures at intake and discharge. Hierarchical linear modelling was applied to estimate the changes in the psychotherapeutic outcome and associations with patient and therapist process developments. RESULTS: Improvements in relationship processes of patients and therapists were systematically related to outcome while only partial relationships were found on the levels of process and content. CONCLUSION: The present study represents the first systematic insight into core changes in patients with HPD undergoing psychotherapy.

[Evaluation of the Effectiveness of the Clarification-Oriented Psychotherapy in Persons with a Narcissistic Personality Disorder According to DSM-IV - A Naturalistic Longitudinal Study with Pre-Post Design]. / Evaluation der Wirksamkeit der klärungsorientierten Psychotherapie bei Personen mit einer narzisstischen Persönlichkeitsstörung nach DSM-IV ­ eine naturalistische Längsschnittstudie mit prä-post Design.

BACKGROUND: The treatment of patients diagnosed with a narcissistic personality disorder (NPS) is considered to be extra challenging. Well-controlled studies on the effectiveness of psychotherapy in NPS patients are not available; so many interventions are based on theoretical constructs. The clarification-oriented psychotherapy (COP) is a psychotherapeutic approach, which emerged from concepts of the cognitive behavioral therapy, client-centered psychotherapy and various process-oriented procedures. The present ambulatory therapy-evaluation of COP aimed to evaluate the effectiveness of a psychotherapeutic treatment for patients suffering from NPS. METHODS AND RESULTS: Retrospective cohort-study including 173 treatment-seeking NPS-patients. Via pre-post per-protocol-analysis, significant improvements mostly with medium effect sizes were found in all relevant parameters after completion of the COP (58.6±10.5 sessions). In particular, the ambitious/narcissistic personality style in the "Personality Style and Disorders Inventory (PSSI)" (primary outcome) was improved (medium effect size: d=-0.49 [-0.67; -0.31], p<0.001). Analyses revealed even high effect sizes in terms of the improvement of depressive "states" and "traits", neuroticism as well as self-acceptance. The lowest effect sizes however were found for improvements in self-regulation (d=0.2 [0.03; 0.36], p=0.02). DISCUSSION: As no intention-to-treat analysis has been carried out, the effect sizes of COP in the treatment of NPS might be overestimated. Nevertheless, our findings support the use of COP for the treatment of NPS. In light of evidence-based medicine, the present so far most comprehensive study on this topic warranted an increase of the evidence of COP in the treatment of NPS from level IV to level III.

Addressing interpersonal patterns in patients with personality disorders partially explains psychotherapy outcome via changes in interaction patterns: A mediation analysis.

Objective Many patients with personality disorders (PDs) present with problematic interaction patterns. These may also manifest in the therapeutic relationship. For successful treatment, therapists must therefore find effective ways to address such problematic interaction patterns. Methods: A total of 382 patients with PDs were recruited within a naturalistic setting and received integrative cognitive-behavioral therapy (CBT). Two subscales of the observer-rated Process-Content-Relationship Scale were applied to sessions 15, 20, and 25 of treatment: one on patient interaction patterns and the other on therapist addressing these. Symptom severity was assessed at intake and discharge. Mediation analysis was applied. Results: We found significant main effects of (1) therapists' addressing problematic interaction patterns in session 15 on patients' changes in such patterns from session 15 to 25 and (2) patients' changes in problematic interaction patterns on symptom severity at treatment termination. Further, the effect of therapists' addressing problematic interaction patterns on outcome was mediated by changes in patients' interaction patterns. Conclusion: The results indicate that therapists' addressing of PD patients' problematic interaction patterns may be particularly important to improve such patterns and thereby treatment outcome. Future research should identify in which patients the mechanism of addressing interaction patterns works best.

Psychotherapeutic case formulation: Plan analysis for narcissistic personality disorder.

BACKGROUND: One of the relevant case formulation methods for personality difficulties is plan analysis. The present study aimed at delivering a prototypical plan analysis for clients presenting with a diagnosis of narcissistic personality disorder (NPD). The sample consisted of 14 participants diagnosed with an NPD. Based on audio clinical material, we developed 14 individual plan analyses that we then merged into a single prototypical plan analysis. For explorative purposes, we ran an ordinary least squares regression model to predict the narcissistic symptoms severity (NAR) measured on a scale of 1-7 of the 14 clients by the presence (respectively absence) of certain plans in their individual plan analysis. The synthesis revealed that clients with pathological narcissism share common basic motives. Results of the regression model reveal that the presence of the plan 'be strong' reduces the NAR scale by 1.52 points (p = 0.011). DISCUSSION: In the treatment of psychological disorders, precise case formulations allow therapists for making clinically appropriate decision, personalizing the intervention and gaining insight into the client's subjective experience. In the prototypical plan structure we developed for NPD, clients strive to strengthen their self-esteem and avoid loss of control, criticism and confrontation as well as to get support, understanding and solidarity. When beginning psychotherapy with a client presenting with NPD, the therapist can use these plans as valuable information to help writing tailored, and therefore more efficient, case formulations for their patients presenting with an NPD.

Subtypes of narcissistic personality disorder based on psychotherapy process: A longitudinal nonparametric analysis.

The present study aims at empirically exploring subtypes of narcissistic personality disorder (NPD), based on patient descriptors of the psychotherapeutic process. Subtype identification and characterization of NPD is central, in particular, to increase diagnostic precision, linking categorical and dimensional conceptualizations of psychopathology, and to individualize treatments. A total of N = 161 patients diagnosed with NPD undergoing clarification-oriented psychotherapy were included in the present reanalysis of a naturalistic pre-post process-outcome study. At three crucial time-points of the therapy (Sessions 15, 20, and 25), the patient's in-session quality of content, process, and relationship are assessed using intensive video- and audio analyses. Levels of psychopathology were assessed using self-reported questionnaires. Data were analyzed using longitudinal nonparametric analysis. Based on in-session processes across three time-points, a two-subtype solution was retained (optimal vs. suboptimal process qualities). Optimal process quality of time was linked with the intensity of narcissistic symptoms; suboptimal process quality was linked with a variety of general symptom loads and problematic personality traits. The two empirical subtypes were predicted by the quality of real-life functioning with an accuracy of more than 92% and were partially associated with outcome. NPD may be empirically differentiated between patients engaging in optimal psychotherapy process versus those who engage in suboptimal psychotherapy process. This differentiation has reliable clinical predictors at the outset of treatment. The present study has implications in terms of personalizing psychotherapy for patients presenting NPD, or pathological narcissism. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Processes of Change in Psychotherapy for Narcissistic Personality Disorder.

The present study aims at determining the role for outcome of potential processes of change in psychotherapy for narcissistic personality disorder (NPD). They were examined on three levels: the content, the process, and the relationship. A total of 161 patients suffering with NPD were recruited in a naturalistic setting as part of the present study. They underwent a long- term clarification-oriented psychotherapy. Sessions 15, 20, and 25 were video- or audio-recorded and analyzed with an observer-rated instrument that measures the quality of the interaction processes from the patient's and therapist's perspectives. Different self-report measures were used to assess therapy outcomes. In-session improvement was observed in both patient and therapist processes across sessions. Patient improvement in the three levels of processes was systematically related with outcome. Only partial relationships were found between therapist improvement and outcome. The present study represents the first systematic insight into core changes in patients with NPD undergoing psychotherapy.

Social interaction patterns, therapist responsiveness, and outcome in treatments for borderline personality disorder.

OBJECTIVES: Inflexible social interaction patterns are defining features of borderline personality disorder (BPD). Specific beliefs about the self and others may be activated across interaction situations, often leading to instable relationships. It may be pivotal to address these difficulties in early treatment phases, through appropriate therapist responsiveness, which means an adaptation of therapist's activity to their client's behaviours using emerging information in the process (Stiles, 2009, Clinical Psychology: Science and Practice, 16, 86). DESIGN: In this process-outcome study, responsiveness is operationalized by the motive-oriented therapeutic relationship (Caspar, 2007, Handbook of psychotherapeutic case formulations, 2nd ed., 251-289, Guilford), based on the Plan analysis case formulation. The present study assesses the interplay between social interaction problems and therapist responsiveness, explaining symptoms at discharge and the therapeutic alliance. METHOD: In total, N = 50 clients with BPD entered the study, and standard and responsive treatments were compared. Social interaction patterns were assessed by the newly developed Borderline Interaction Patterns Scale (BIPS), applied to recorded material of three sessions per therapy. Outcome was measured by general symptoms (OQ-45), borderline symptoms (BSL-23), interpersonal problems (IIP), and the therapeutic alliance (WAI). RESULTS: Results suggest that in standard treatment, social interaction patterns are neither related to outcome nor the therapeutic alliance. In responsive treatment, more activation of social interaction patterns predicted better outcome on IIP and lower therapist ratings of the alliance. CONCLUSIONS: The conclusions seem promising for specific effectiveness of responsive treatments in particular in the interpersonal problem area of BPD. Identifying social interaction patterns early in treatment may be a crucial pathway to change for BPD. PRACTITIONER POINTS: Responsive therapy activating social interaction patterns may be crucial for better outcome. Future research should focus on mechanisms of change in early treatment phases for BPD. New scale for assessing social interaction patterns specific to borderline personality disorder.

Psychotherapy of Dependent Personality Disorder: The Relationship of Patient-Therapist Interactions to Outcome.

OBJECTIVE: So far, only a few studies have focused on psychotherapy for Dependent Personality Disorder (DPD). DPD is marked by a repetitive pattern of efforts aiming at maintaining close relationships, which may present as a lack of assertiveness and as a difficulty in making routine decisions. The present study aims at exploring processes of change taking place during the working phase of a clarification-oriented psychotherapy (COP) by focusing on the in-session patient-therapist interaction, as it changes during treatment and their links with treatment outcome. Methods: N = 74 patients with DPD were recruited in a naturalistic setting; they underwent long-term COP. Sessions 15, 20 and 25 were video- or audio-recorded and analyzed using the Process-Content-Relationship Scale, an observer-rated instrument that measures the quality of the interaction processes from patient's and therapist's perspectives. Therapy outcomes were assessed with the Personality Inventory - Dependency Subscale, Beck Depression Inventory, Inventory of Interpersonal Problems and Self-efficacy Scale at intake and discharge of therapy. Three-level Hierarchical Linear Modeling was applied to test the hypotheses. Results: Improvement in interaction processes was observed in all patient's and therapist's variables over the sessions 15, 20, 25. Overall, this increase in quality of interaction process was unrelated with outcome, but decrease in dependency traits was predicted by increase in therapist's quality of relationship offer, understanding of content and directivity over the course of the working phase of COP. Conclusions: Studying interaction processes in DPD provides an initial understanding of differential roles of potential mechanisms of change in effective treatment.

The role of shame and self-compassion in psychotherapy for narcissistic personality disorder: An exploratory study.

This process-outcome study aims at exploring the role of shame, self-compassion, and specific therapeutic interventions in psychotherapy for patients with narcissistic personality disorder (NPD). This exploratory study included a total of N = 17 patients with NPD undergoing long-term clarification-oriented psychotherapy. Their mean age was 39 years, and 10 were male. On average, treatments were 64 sessions long (range between 45 and 99). Sessions 25 and 36 were rated using the Classification of Affective Meaning States and the Process-Content-Relationship Scale. Outcome was assessed using the Symptom Check List-90 and Beck Depression Inventory-II. Between Sessions 25 and 36, a small decrease in the frequency of shame was found (d = .30). In Session 36, the presence of self-compassion was linked with a set of specific therapist interventions (process-guidance and treatment of behaviour-underlying assumptions; 51% of variance explained and adjusted). This study points to the possible central role of shame in the therapeutic process of patients with NPD. Hypothetically, one way of resolving shame is, for the patient, to access underlying self-compassion.

Emotional Processing, Interaction Process, and Outcome in Clarification-Oriented Psychotherapy for Personality Disorders: A Process-Outcome Analysis.

It is important to understand the change processes involved in psychotherapies for patients with personality disorders (PDs). One patient process that promises to be useful in relation to the outcome of psychotherapy is emotional processing. In the present process-outcome analysis, we examine this question by using a sequential model of emotional processing and by additionally taking into account a therapist's appropriate responsiveness to a patient's presentation in clarification-oriented psychotherapy (COP), a humanistic-experiential form of therapy. The present study involved 39 patients with a range of PDs undergoing COP. Session 25 was assessed as part of the working phase of each therapy by external raters in terms of emotional processing using the Classification of Affective-Meaning States (CAMS) and in terms of the overall quality of therapist-patient interaction using the Process-Content-Relationship Scale (BIBS). Treatment outcome was assessed pre- and post-therapy using the Global Severity Index (GSI) of the SCL-90-R and the BDI. Results indicate that the good outcome cases showed more self-compassion, more rejecting anger, and a higher quality of therapist-patient interaction compared to poorer outcome cases. For good outcome cases, emotional processing predicted 18% of symptom change at the end of treatment, which was not found for poor outcome cases. These results are discussed within the framework of an integrative understanding of emotional processing as an underlying mechanism of change in COP, and perhaps in other effective therapy approaches for PDs.