Two-year follow-up and changes in reflective functioning in specialist and nonspecialist treatment models for personality disorder.

Abstract

There is a growing body of studies linking impairments in mentalizing or reflective functioning (RF) with childhood adversity, the development of personality disorder (PD), and psychiatric morbidity. Fewer studies have investigated the purported role of changes in RF in relation to clinical outcome in treatments focusing on this capacity. Moreover, it is as yet unclear whether specialist and nonspecialist treatment models are equally effective in bringing about change in RF in conjunction with symptomatic improvement. This study aimed to investigate the association between changes in RF in three samples of individuals with PD treated in two specialist psychosocial programs (a step-down model; RT-CBP, and a long-term residential model; RT) and in an outpatient general psychiatric service (GP) over a 2-year period after intake into treatment. RF was assessed using the Reflective Functioning Scale scored on the Adult Attachment Interview and clinical outcome was assessed in terms of psychiatric distress, social adjustment, and global functioning. Changes in RF were most marked in RT-CBP compared with RT and GP. Changes in RF explained differences between treatment models for social and global adjustment outcomes, but not for disparities in psychiatric distress. A medium-intensity treatment approach to PD such as RT-CBP was more effective in improving RF and provided a balance between psychotherapy input and efforts at social integration, by bringing patients into closer contact with their social world.

Personality trait domains predict psychiatric symptom and functional outcomes.

“…Thus, treatment trials of specific clinical syndromes such as depression make clear that personality pathology hampers response to standard depression treatment when personality pathology is not a focus, yet they do not tell the whole story. When personality pathology is the primary focus of treatment like those found in mentalization-based open effectiveness trials we find negligible or no negative impact on outcome (Bateman & Fonagy, 2008; Chiesa et al, 2020; Fowler, Clapp, et al, 2018; Smits et al, 2020; Vogt & Norman, 2019). It is only when we distill the latent factor of the most virulent aspects of personality pathology do we see a negative impact on treatment outcome (Constantinou et al, 2020).…”

“…This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. trials we find negligible or no negative impact on outcome Chiesa et al, 2020;Fowler, Clapp, et al, 2018;Smits et al, 2020;Vogt & Norman, 2019). It is only when we distill the latent factor of the most virulent aspects of personality pathology do we see a negative impact on treatment outcome (Constantinou et al, 2020).…”

“…Treatment approaches focusing on improving two broad features of personality impairment (emotion dysregulation and impaired mentalizing) are increasingly proving to be effective for individuals with Borderline Personality Disorder (Bateman & Fonagy, 2008; Chiesa et al, 2020; Fowler, Clapp, et al, 2018; Smits et al, 2020; Vogt & Norman, 2019), as well as for non-PD patients. In a series of studies from the index hospital from which the present sample was drawn, a MBT approach was associated with large effect size reductions in: Emotion dysregulation, with substantial improvements among adults with personality disorders (Fowler et al, 2016), depression and anxiety severity with no negative impact due to PDs (Fowler et al, 2017), somatic symptom reduction, again with no negative impact on slopes due to PD status (Madan et al, 2016), and shift to more adaptive interpersonal styles during treatment (Clapp et al, 2013).…”

Current state of the evidence on community treatments for people with complex emotional needs: a scoping review

“…Compared to controls, participants receiving psychodynamic therapy improved on most non-primary outcomes . Non-randomised experiments, observational studies, quasi experiment, and natural experiment with pre-post comparison ( n = 26) [ 48 , 177 – 201 ] Sample size: < 20 ( n = 1); 20–100 ( n = 18); > 100 ( n = 7). Date: 1990–1999 ( n = 6); 2000–2009 ( n = 12); 2010–2019 ( n = 7); 2020- ( n = 1).…”

The case for remote supervision

“…As the pressure to meet state regulations has mounted in the public sector, and insurance companies reduce the number of sessions they cover in a year, the emphasis on evidence‐based treatments (EBT), most often in the form of Cognitive Behavioral Therapy (CBT), continues unabated despite the fact that evidence collected and published over several years demonstrates that psychodynamic treatment is as effective and, in the long term, more effective than CBT, (See Chiesa et al., 2021, Shedler, 2010, Yonatan‐Lews et al., 2021, among many others). Most recently, a meta‐analysis (Cuijpers et al., 2023) examines whether CBT is superior to other therapies and finds weak to nonexistent evidence of such superiority.…”