Countertransference in the treatment of patients with personality disorders: A longitudinal study.

OBJECTIVE: This study examines how therapist emotional response/countertransference (CT) develops during treatment for patients with personality disorders (PDs) and how pre-treatment patient factors (severity of personality pathology, PD category, level of symptom distress) predict CT responses. Secondly, we explored associations between patient clinical outcome and CT. METHOD: A longitudinal, observational study including 1956 patients with personality pathology treated at psychotherapy units within specialist mental health services. Therapists' emotional response was repeatedly assessed by the Feeling Word Checklist-Brief Version (FWC-BV) with three subscales-Inadequate, Confident, and Idealized. RESULTS: Levels of Inadequate CT were lowest and stable over time while Confident and Idealized increased over time. Greater severity of personality pathology and borderline PD predicted higher initial Inadequate, lower initial Confident and decreasing Inadequate over time. Antisocial PD predicted decreasing Confident. Number of PD criteria had higher impact on therapist CT than level of symptom distress. Clinical improvement was associated with decreasing Inadequate. CONCLUSION: Therapists reported predominantly Confident CT when working with PD patients. More severe personality pathology, and borderline PD, specifically, predicted more negative CT initially, but the negative CT decreased over time. Patients who did not improve were associated with increasing Inadequate.

How therapists in cognitive behavioral and psychodynamic therapy reflect upon the use of metaphors in therapy: a qualitative study.

BACKGROUND: Research suggests that metaphors are integral to psychotherapeutic practice. We wanted to explore how 10 therapists reflect upon the use of metaphors in therapy, and how they react to some metaphors expressed by patients treated for of major depressive disorder (MDD). METHODS: Five therapists practicing psychodynamic therapy (PDT) and five practicing cognitive behavioral therapy (CBT) were interviewed with a semi-structured qualitative interview. Transcripts were analyzed using a thematic analysis approach. RESULTS: Our analysis resulted in two main themes: the therapeutic use of metaphors, and conflicting feelings towards metaphors used by depressed patients. Most therapists said that they do not actively listen for metaphors in therapy and many said that they seldom use metaphors deliberately. While PDT-therapists appeared more attentive to patient-generated metaphors, CBT-therapists seemed more focused on therapist-generated metaphors. Most therapists did not try to alter the patient-generated metaphors they evaluated as unhelpful or harmful. Some therapists expressed strong negative feelings towards some of the metaphors used by patients. PDT-therapists were the most critical towards the metaphor of tools and the metaphor of depression as an opponent. CBT-therapists were the most critical towards the metaphor of surface-and-depth. CONCLUSIONS: These results remind us of the complexity of using metaphors in therapy, and can hopefully be an inspiration for therapists to reflect upon their own use of metaphors. Open therapeutic dialogue on the metaphor of tools, surface-depth and depression as an opponent may be necessary to avoid patient-therapist-conflicts. TRIAL REGISTRATION: Clinical Trial gov. Identifier: NCT03022071 . Date of registration: 16/01/2017.

Digging down or scratching the surface: how patients use metaphors to describe their experiences of psychotherapy.

BACKGROUND: In the present study, we wanted to explore which metaphors patients suffering from major depressive disorder (MDD) use to explain their experience of being in therapy and their improvement from depression. METHODS: Patients with MDD (N = 22) received either psychodynamic therapy (PDT) or cognitive behavioral therapy (CBT). They were interviewed with semi-structured qualitative interviews after ending therapy. The transcripts were analyzed using a method based on metaphor-led discourse analysis. RESULTS: Metaphors were organized into three different categories concerning the process of therapy, the therapeutic relationship and of improvement from depression. Most frequent were the metaphorical concepts of surface and depth, being open and closed, chemistry, tools, improvement as a journey from darkness to light and depression as a disease or opponent. CONCLUSIONS: Patient metaphors concerning the therapeutic experience may provide clinicians and researchers valuable information about the process of therapy. Metaphors offer an opportunity for patients to communicate nuances about their therapeutic experience that are difficult to express in literal language. However, if not sufficiently explored and understood, metaphors may be misinterpreted and become a barrier for therapeutic change. TRIAL REGISTRATION: Clinical Trial gov. Identifier: NCT03022071 . Date of registration: 16/01/2017.

Mechanisms of change and heterogeneous treatment effects in psychodynamic and cognitive behavioural therapy for patients with depressive disorder: a randomized controlled trial.

BACKGROUND: Major depressive disorder (MDD) is a prevalent psychiatric condition associated with significant disability, mortality and economic burden. Cognitive behavioral therapy (CBT) and psychodynamic psychotherapy (PDT) are found to be equally effective for patients with depression. However, many patients do not respond sufficiently to either treatment. To offer individualized treatment, we need to know if some patients benefit more from one of the two therapies. At present little is known about what patient characteristics (moderators) may be associated with differential outcomes of CBT and PDT, and through what therapeutic processes and mechanisms (mediators) improvements occur in each therapy mode. Presently only theoretical assumptions, sparsely supported by research findings, describe what potentially moderates and mediates the treatment effects of CBT and PDT. The overall aim of this study is to examine theoretically derived putative moderators and mediators in CBT and PDT and strengthen the evidence base about for whom and how these treatments works in a representative sample of patients with MDD. METHODS: One hundred patients with a diagnosis of MDD will be randomized to either CBT or PDT. Patients will be treated over 28 weeks with either CBT (one weekly session over 16 weeks and three monthly booster sessions) or PDT (one weekly session over 28 weeks). The patients will be evaluated at baseline, during the course of therapy, at the end of therapy, and at follow-up investigations 1 and 3 years post treatment. A large range of patient and observer rated questionnaires (specific preselected putative moderators and mediators) are included. DISCUSSION: The clinical outcome of this study may better guide clinicians when deciding what kind of treatment any individual patient should be offered. Moreover, the study aims to further our knowledge of what mechanisms lead to symptom improvement and increased psychosocial functioning. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03022071.

Countertransference feelings and personality disorders: a psychometric evaluation of a brief version of the Feeling Word Checklist (FWC-BV).

BACKGROUND: The Feeling Word Checklist (FWC) is a self-report questionnaire designed to assess therapists' countertransference (CT) feelings. The primary aim of the study was to evaluate the psychometric properties of a brief, 12-item version of the Feeling Word Checklist (FWC-BV). The second aim was to validate the factor structure by examining the associations between the FWC-BV factors, patients' personality pathology and therapeutic alliance (TA). METHODS: Therapists at 13 different outpatient units within the Norwegian Network of Personality Disorders participated, and the study includes therapies for a large sample of patients (N = 2425) with personality pathology. Over a period of 2.5 years, therapists completed the FWC-BV for each patient in therapy every 6 months. Statistical methods included exploratory (EFA) and confirmatory (CFA) factor analysis. Internal consistency was estimated using Mc Donald's coefficient Omega (ωt). The Structured Clinical Interview for DSM-IV - Axis II (SCID II) and Mini International Neuropsychiatric Interview (MINI) were used as diagnostic instruments, and patient-rated TA was assessed using the Working Alliance Inventory (WAI-SR). RESULTS: Factor analyses revealed three clinically meaningful factors: Inadequate, Idealised and Confident. These factors had acceptable psychometric properties. Most notably, a number of borderline PD criteria correlated positively with the factors Inadequate and Idealised, and negatively with the factor Confident. All the factors correlated significantly with at least one of the WAI-SR subscales. CONCLUSIONS: The FWC-BV measures three clinically meaningful aspects of therapists' CT feelings. This brief version of the FWC seems satisfactory for use in further research and in clinical contexts.

How do men with severe sexual and physical childhood traumatization experience trauma-stabilizing group treatment? A qualitative study.

Background: Exposure to potentially traumatizing events, defined as events involving actual or threatened death or serious injury, is associated with an elevated risk of developing enduring physical, psychological and social problems. Complex post-traumatic stress disorder (PTSD) is a disorder that can occur after prolonged and repeated trauma. At least 30% of the sexually abused population is male, but in spite of this fact, treatment research focusing on male victims is virtually non-existent in comparison to research on female victims. Objective: Trauma-stabilizing group treatment is an increasingly used treatment method for patients with complex PTSD. The aim of the present study was to explore how men participating in a gender-specific trauma-stabilizing intervention experience this treatment approach. Methods: Five men who participated in a trauma-stabilizing group treatment were interviewed with a semi-structured qualitative interview. The data were analysed using interpretative phenomenological analysis. Results: The analysis revealed five main themes. The themes highlight the experiences of the participants and describe positive and negative experiences: (1) Group atmosphere, comprising safety, community, emotional openness, anxiety and pressure; (2) Learning, categorized into knowledge and self-understanding; (3) Motivation, which describes both inner and outer motivation; (4) Structure, comprising structure of the meetings, group size and duration of the meetings; and (5) Gender, defined as the experiences of being in an all-male group with female group leaders. Conclusions: There seem to be a lot of advantages to inviting men to attend gender-specific groups for trauma-stabilizing treatment. The men emphasized the support they received and that participating in a mixed-gender group would have been more difficult. In the future, it may be important to arrange all-male stabilization groups with more focus on male-specific topics.

Antecedentes: La exposición a eventos potencialmente traumatizantes se asocia a un riesgo elevado de desarrollar problemas físicos, psicológicos y sociales duraderos. Al menos 30% de la población abusada son hombres, pero a pesar de este hecho, la investigación enfocada en víctimas de sexo masculino es virtualmente inexistente en comparación a la investigación en víctimas de sexo femenino.Objetivo: El tratamiento de grupo de estabilización del trauma es un método de tratamiento cada vez más usado para pacientes con TEPT complejo. El objetivo del presente estudio fue explorar cómo experimentan este enfoque de tratamiento los hombres que participan en una intervención de estabilización del trauma género-específica.Métodos: A cinco hombres que participaron en tratamiento de grupo de estabilización del trauma se les aplicó una entrevista cualitativa semi estructurada. Los datos fueron analizados usando Análisis Fenomenológico Interpretativo.Resultados: El análisis reveló cinco temas principales. Los temas destacan las experiencias de los participantes y describen experiencias positivas y negativas: i. Atmósfera grupal que comprende seguridad, comunidad, apertura y ansiedad, ii. Aprendizaje categorizado en conocimiento y auto-comprensión, iii. Motivación que describe tanto la motivación interna como externa. Iv. Estructura que comprende la estructura de las sesiones, tamaño del grupo y duración de las sesiones, v. Género definido como las experiencias de estar en un grupo compuesto sólo de hombres liderado por mujeres.Conclusiones: Parece haber muchas ventajas en invitar a hombres a un grupo género-específico para tratamiento de estabilización del trauma. Los hombres enfatizaron el apoyo que recibieron y que participar en un grupo de género mixto habría sido más difícil. En el futuro puede ser importante organizar grupos de estabilización sólo de hombres con mayor enfoque en temas específicos masculinos.

Metacognitive beliefs mediate the effect of emotional abuse on depressive and psychotic symptoms in severe mental disorders.

BACKGROUND: Early trauma is linked to higher symptom levels in bipolar and psychotic disorders, but the translating mechanisms are not well understood. This study examines whether the relationship between early emotional abuse and depressive symptoms is mediated by metacognitive beliefs about thoughts being uncontrollable/dangerous, and whether this pathway extends to influence positive symptoms. METHOD: Patients (N = 261) with psychotic or bipolar disorders were assessed for early trauma experiences, metacognitive beliefs, and current depression/anxiety and positive symptoms. Mediation path analyses using ordinary least-squares regressions tested if the effect of early emotional abuse on depression/anxiety was mediated by metacognitive beliefs, and if the effect of early emotional abuse on positive symptoms was mediated by metacognitive beliefs and depression/anxiety. RESULTS: Metacognitive beliefs about thoughts being uncontrollable/dangerous significantly mediated the relationship between early emotional abuse and depression/anxiety. Metacognitive beliefs and depression/anxiety significantly mediated the relationship between early emotional abuse and positive symptoms. The models explained a moderate amount of the variance in symptoms (R 2 = 0.21-0.29). CONCLUSION: Our results indicate that early emotional abuse is relevant to depression/anxiety and positive symptoms in bipolar and psychotic disorders, and suggest that metacognitive beliefs could play a role in an affective pathway to psychosis. Metacognitive beliefs could be relevant treatment targets with regards to depression/anxiety and positive symptoms in bipolar and psychotic disorders.

Cognitive milieu therapy and physical activity: experiences of mastery and learning among patients with dual diagnosis.

During the last decade, there has been a growing interest in implementing cognitive milieu therapy (CMT) in psychiatric institutions. However, there is a lack of systematic evaluations from patients' point of view. The aim of this study was to explore and describe patient perceptions of essential experiences of mastery, learning alternative ways of thinking, and acquiring new skills through CMT and physical activity in an inpatient setting. Qualitative interviews were carried out with 20 patients with dual diagnosis. A hermeneutic - phenomenological approach was used in the data collection and analysis. The results showed that the learning climate in the unit was important. This included a proactive attitude from the staff, focusing on cooperation on equal terms between patients and staff, and a professional methodological approach through CMT. The optimal balance between staff-induced activities and patient initiatives was not easy to obtain. Patients appreciated both the education provided by the staff and learning from other patients. The cognitive method was sometimes experienced as too theoretical and difficult to understand. Physical activity, however, was experienced as 'concrete' and providing practical knowledge. It motivated patients to establish new habits and provided opportunities for the development of mastery together with other patients.

TCF4 sequence variants and mRNA levels are associated with neurodevelopmental characteristics in psychotic disorders.

TCF4 is involved in neurodevelopment, and intergenic and intronic variants in or close to the TCF4 gene have been associated with susceptibility to schizophrenia. However, the functional role of TCF4 at the level of gene expression and relationship to severity of core psychotic phenotypes are not known. TCF4 mRNA expression level in peripheral blood was determined in a large sample of patients with psychosis spectrum disorders (n = 596) and healthy controls (n = 385). The previously identified TCF4 risk variants (rs12966547 (G), rs9960767 (C), rs4309482 (A), rs2958182 (T) and rs17512836 (C)) were tested for association with characteristic psychosis phenotypes, including neurocognitive traits, psychotic symptoms and structural magnetic resonance imaging brain morphometric measures, using a linear regression model. Further, we explored the association of additional 59 single nucleotide polymorphisms (SNPs) covering the TCF4 gene to these phenotypes. The rs12966547 and rs4309482 risk variants were associated with poorer verbal fluency in the total sample. There were significant associations of other TCF4 SNPs with negative symptoms, verbal learning, executive functioning and age at onset in psychotic patients and brain abnormalities in total sample. The TCF4 mRNA expression level was significantly increased in psychosis patients compared with controls and positively correlated with positive- and negative-symptom levels. The increase in TCF4 mRNA expression level in psychosis patients and the association of TCF4 SNPs with core psychotic phenotypes across clinical, cognitive and brain morphological domains support that common TCF4 variants are involved in psychosis pathology, probably related to abnormal neurodevelopment.

Early detection of psychosis: positive effects on 5-year outcome.

BACKGROUND: During the last decades we have seen a new focus on early treatment of psychosis. Several reviews have shown that duration of untreated psychosis (DUP) is correlated to better outcome. However, it is still unknown whether early treatment will lead to a better long-term outcome. This study reports the effects of reducing DUP on 5-year course and outcome. METHOD: During 1997-2000 a total of 281 consecutive patients aged >17 years with first episode non-affective psychosis were recruited, of which 192 participated in the 5-year follow-up. A comprehensive early detection (ED) programme with public information campaigns and low-threshold psychosis detection teams was established in one healthcare area (ED-area), but not in a comparable area (no-ED area). Both areas ran equivalent treatment programmes during the first 2 years and need-adapted treatment thereafter. RESULTS: At the start of treatment, ED-patients had shorter DUP and less symptoms than no-ED-patients. There were no significant differences in treatment (psychotherapy and medication) for the 5 years. Mixed-effects modelling showed better scores for the ED group on the Positive and Negative Syndrome Scale negative, depressive and cognitive factors and for global assessment of functioning for social functioning at 5-year follow-up. The ED group also had more contacts with friends. Regression analysis did not find that these differences could be explained by confounders. CONCLUSIONS: Early treatment had positive effects on clinical and functional status at 5-year follow-up in first episode psychosis.

Assessment of social anxiety in first episode psychosis using the Liebowitz Social Anxiety scale as a self-report measure.

OBJECTIVE: Social anxiety is a common problem in psychotic disorders. The Liebowitz Social Anxiety Scale, Self-Rating version (LSAS-SR) is a widely used instrument to capture different aspects of social anxiety, but its psychometric properties have not been tested in this patient group. The aims of the present study were to evaluate the psychometric properties of the LSAS-SR in patients with first episode psychosis, to investigate whether it differentiated between active and passive social withdrawal and to test which clinical factors contributed to current level of social anxiety. METHOD: A total of 144 first episode psychosis patients from the ongoing Thematically Organized Psychosis (TOP) study were included at the time of first treatment. Diagnoses were set according to the Structured Clinical Interview (SCID-1) for DSM-IV. A factor analysis was carried out and the relationship of social anxiety to psychotic and general symptomatology measured by the Positive and Negative Syndrome Scale (PANSS) was evaluated. Possible contributors to social anxiety were analyzed using multiple hierarchic regression analysis. RESULTS: The factor analysis identified three subscales: public performance, social interaction and observation. All three subscales showed satisfactory psychometric properties, acceptable convergent and discriminate properties, and confirmed previous findings in social anxiety samples. Self-esteem explained a significant amount of the variance in social anxiety, even after adjusting for the effects of delusions, suspiciousness and depression. CONCLUSION: The study shows that the LSAS-SR can be used in this patient group, that social anxiety is strongly related to both behavioral social avoidance and to self-esteem. The results support the use of this measure in assessment of social anxiety in both clinical settings and in research.

Early identification of non-remission in first-episode psychosis in a two-year outcome study.

OBJECTIVE: To identify predictors of non-remission in first-episode, non-affective psychosis. METHOD: During 4 years, we recruited 301 patients consecutively. Information about first remission at 3 months was available for 299 and at 2 years for 293 cases. Symptomatic and social outcomes were assessed at 3 months, 1 and 2 years. RESULTS: One hundred and twenty-nine patients (43%) remained psychotic at 3 months and 48 patients (16.4%) remained psychotic over 2 years. When we compared premorbid and baseline data for the three groups, the non-remitted (n = 48), remitted for <6 months (n = 38) and for more than 6 months (n = 207), duration of untreated psychosis (DUP) was the only variable that significantly differentiated the groups (median DUP: 25.5, 14.4 and 6.0 weeks, respectively). Three months univariate predictors of non-remission were being single, longer DUP, core schizophrenia, and less excitative and more negative symptoms at baseline. Two-year predictors were younger age, being single and male, deteriorating premorbid social functioning, longer DUP and core schizophrenia. In multivariate analyses DUP, negative and excitative symptoms predicted non-remission at 3 months, but only DUP predicted at 2 years. CONCLUSION: Long DUP predicted both 3 month and 2-year non-remission rates in first-episode psychosis.

A 2-year follow-up of involuntary admission's influence upon adherence and outcome in first-episode psychosis.

OBJECTIVE: To see, if voluntary admission for treatment in first-episode psychosis results in better adherence to treatment and more favourable outcome than involuntary admission. METHOD: We compared consecutively first-admitted, hospitalised patients from a voluntary (n = 91) with an involuntary (n = 126) group as to psychopathology and functioning using Positive and Negative Syndrome Scale and Global Assessment of Functioning Scales at baseline, after 3 months and at 2 year follow-up. Moreover, duration of supportive psychotherapy, medication and number of hospitalisations during the 2 years were measured. RESULTS: More women than men were admitted involuntarily. Voluntary patients had less psychopathology and better functioning than involuntary patients at baseline. No significant difference as to duration of psychotherapy and medication between groups was found. No significant difference was found as to psychopathology and functioning between voluntarily and involuntarily admitted patients at follow-up. CONCLUSION: Legal admission status per se did not seem to influence treatment adherence and outcome.

Patient satisfaction and treatment environment: a 20-year follow-up study from an acute psychiatric ward.

The aim of this study was to examine to what extent the different subscales of the Ward Atmosphere Scale (WAS) are related to patient satisfaction on wards for psychotic patients. We wanted to examine if it was possible to replicate previous findings from cross-sectional studies and improve the understanding of which of the WAS subscales that should be considered the most important for patient satisfaction. From 1981 through 2000, the ward atmosphere, in an acute psychiatric ward, was evaluated 11 times with the Ward Atmosphere Scale (WAS). A total of 129 patients completed the WAS as well as a General Satisfaction Index (GSI) comprising three items. Z-scores were calculated to describe the fluctuations in the GSI and the WAS subscales. Four of the WAS subscales, Involvement, Practical orientation, Angry and aggressive behavior and Staff control, strongly co-varied with patient satisfaction. Unexpectedly, the Support and Order and organization subscales correlated only moderately with patient satisfaction. The remaining five WAS subscales (Spontaneous behavior, Autonomy, Personal problem orientation, Program clarity and Staff attitude to expressed feelings) were only weakly correlated with patient satisfaction. This study confirms that four of the six assumedly most important WAS subscales are strongly related to patient satisfaction on wards for psychotic patients. Changes in these WAS subscales seems to be paralleled by changes in patient satisfaction in the expected direction.

Work environment and job satisfaction. A psychometric evaluation of the Working Environment Scale-10.

BACKGROUND: The working environment in mental health wards has been shown to have profound effects on the health and work stability of mental health workers. Despite an apparent need for regular measurement of work environment, development of short and reliable instruments for such measurements has been largely neglected. The aim of the present study was to evaluate the psychometric properties of the Working Environment Scale-10 (WES-10). METHODS: During the period 1990 through 2000, a total of 640 staff members on 42 wards for psychotic patients completed the WES-10. To establish the number of subscales, a factor analysis was carried out. The internal consistency of the subscales was calculated as Cronbach's alpha. We also collected data concerning satisfaction with the ward, its patients and staff, and for how long the respondents had worked and expected to continue to work at the ward. RESULTS: We identified four subscales named: Self Realization, Workload, Conflict and Nervousness. The psychometric properties of the subscales proved to be acceptable. All the subscales were significantly correlated with at least one satisfaction item, and/or the time the staff expected to continue at the ward. Most notably, the Self Realization subscale was strongly correlated to general satisfaction with the ward, and to the time the staff expected to work on the ward in the future, while Conflict was strongly negatively correlated with liking for staff. CONCLUSION: The WES-10 appears to measure four clinically meaningful subscales. It seems well suited for use in further research and for evaluation of clinical milieus.

A suggested revision of the Ward Atmosphere Scale.

OBJECTIVE: In a previous study, we have suggested a revision of the Anger/Aggression and the Spontaneity subscales. The main aim of this study was to re-evaluate the psychometric properties of the other eight subscales of the Ward Atmosphere Scale. METHOD: A total of 550 patients and 822 staff members on 54 psychiatric wards for psychotic patients completed the WAS and the Good Milieu Index (GMI). We calculated Cronbach's alpha, the Corrected Item Total subscale Correlation, subscale intercorrelations and the correlation between subscales and GMI. RESULTS: By removing a total of 16 items, the psychometric properties improved. The revised subscales had acceptable psychometrics and gave a clearer picture of the relationship between the perceived level of patient satisfaction and the WAS subscale scores. CONCLUSION: The revision suggested in this study 'modernized' several of the subscales. We suggest that this revision is implemented in the future use of the WAS.

Do the Spontaneity and Anger and Aggression subscales of the Ward Atmosphere Scale form homogeneous dimensions? A cross-sectional study of 54 wards for psychotic patients.

OBJECTIVE: The main aim of this study was to examine the psychometric properties of the two subscales of the Ward Atmosphere Scale (WAS), Spontaneity and Anger and Aggression, which measure the level of expressed emotion. We wanted to examine if the items measuring attitude and behavior form different dimensions. METHOD: A total of 550 patients in 54 different psychiatric wards for psychotic patients completed the WAS and the Good Milieu Index. RESULTS: Removing, respectively, four items from the Spontaneity subscale, three items from the Anger and Aggression subscale the psychometric properties improved. The two revised subscales were named Spontaneous Behavior (SB) and Angry, Aggressive Behavior (AAB). A new 'attitude' subscale, comprising three items, was named Staff Attitude to Expressed Feelings (SAEF). CONCLUSION: For patients the attitude and behavior items seem to form separate dimensions. The three subscales examined are probably of central importance for patient satisfaction.