Do high-risk couples profit more or less from couple relationship education programs than low-risk couples? Room for improvement and vulnerability effects.

In recent years it has been discussed whether high-risk couples benefit more from Couple Relationship Education programs (CREs) than low-risk couples due to larger room for improvement, or profit less due to greater vulnerability. Pertinent response prediction studies yielded inconclusive results. Careful review suggests this may be due to: statistical handling (not disentangling room for improvement and vulnerability effects), time frame analyzed (not disentangling opposing effects during intervention and follow-up), sampling, and selection of risk factors. We used an analytic strategy that maximized odds for replicability and tested two hypotheses: (1) room for improvement: pre-intervention relationship dissatisfaction predicts gain in satisfaction during intervention, and decline during follow up, and (2) vulnerability: when adjusted for room for improvement (pre-intervention relationship dissatisfaction), risk factors show negative or negligible, but no positive associations with gain in satisfaction. Actor-Partner Interdependence Modeling (APIM) was employed in 79 self-referred (SR) couples and 50 clinician-referred (CR) couples who had completed the 'Hold me Tight' program, a CRE based on Emotionally Focused Couple Therapy. Our findings supported both the room for improvement hypothesis, with pre-intervention dissatisfaction predicting more gain during intervention (both samples) and decline during follow-up (SR sample, for the CR sample the effect was negligible), and the vulnerability hypothesis, as several negative, but no positive effects of risk factors were observed during intervention and follow-up. Specific risk factors did not replicate between samples. To promote replicable results in future research, we advocate disentangling room for improvement and vulnerability effects, separately testing effects during intervention and follow-up, purposeful sampling, and studying a large set of risk factors including partner variables.

Day hospital versus intensive outpatient mentalization-based treatment: 3-year follow-up of patients treated for borderline personality disorder in a multicentre randomized clinical trial.

BACKGROUND: Two types of mentalization-based treatment (MBT), day hospital MBT (MBT-DH) and intensive outpatient MBT (MBT-IOP), have been shown to be effective in treating patients with borderline personality disorder (BPD). This study evaluated trajectories of change in a multi-site trial of MBT-DH and MBT-IOP at 36 months after the start of treatment. METHODS: All 114 patients (MBT-DH n = 70, MBT-IOP n = 44) from the original multicentre trial were assessed at 24, 30 and 36 months after the start of treatment. The primary outcome was symptom severity measured with the Brief Symptom Inventory. Secondary outcome measures included borderline symptomatology, personality and interpersonal functioning, quality of life and self-harm. Data were analysed using multilevel modelling and the intention-to-treat principle. RESULTS: Patients in both MBT-DH and MBT-IOP maintained the substantial improvements made during the intensive treatment phase and showed further gains during follow-up. Across both conditions, 83% of patients improved in terms of symptom severity, and 97% improved on borderline symptomatology. No significant differences were found between MBT-DH and MBT-IOP at 36 months after the start of treatment. However, trajectories of change were different. Whereas patients in MBT-DH showed greater improvement during the intensive treatment phase, patients in MBT-IOP showed greater continuing improvement during follow-up. CONCLUSIONS: Patients in both conditions showed similar large improvements over the course of 36 months, despite large differences in treatment intensity. MBT-DH and MBT-IOP were associated with different trajectories of change. Cost-effectiveness considerations and predictors of differential treatment outcome may further inform optimal treatment selection.

Towards optimal treatment selection for borderline personality disorder patients (BOOTS): a study protocol for a multicenter randomized clinical trial comparing schema therapy and dialectical behavior therapy.

BACKGROUND: Specialized evidence-based treatments have been developed and evaluated for borderline personality disorder (BPD), including Dialectical Behavior Therapy (DBT) and Schema Therapy (ST). Individual differences in treatment response to both ST and DBT have been observed across studies, but the factors driving these differences are largely unknown. Understanding which treatment works best for whom and why remain central issues in psychotherapy research. The aim of the present study is to improve treatment response of DBT and ST for BPD patients by a) identifying patient characteristics that predict (differential) treatment response (i.e., treatment selection) and b) understanding how both treatments lead to change (i.e., mechanisms of change). Moreover, the clinical effectiveness and cost-effectiveness of DBT and ST will be evaluated. METHODS: The BOOTS trial is a multicenter randomized clinical trial conducted in a routine clinical setting in several outpatient clinics in the Netherlands. We aim to recruit 200 participants, to be randomized to DBT or ST. Patients receive a combined program of individual and group sessions for a maximum duration of 25 months. Data are collected at baseline until three-year follow-up. Candidate predictors of (differential) treatment response have been selected based on the literature, a patient representative of the Borderline Foundation of the Netherlands, and semi-structured interviews among 18 expert clinicians. In addition, BPD-treatment-specific (ST: beliefs and schema modes; DBT: emotion regulation and skills use), BPD-treatment-generic (therapeutic environment characterized by genuineness, safety, and equality), and non-specific (attachment and therapeutic alliance) mechanisms of change are assessed. The primary outcome measure is change in BPD manifestations. Secondary outcome measures include functioning, additional self-reported symptoms, and well-being. DISCUSSION: The current study contributes to the optimization of treatments for BPD patients by extending our knowledge on "Which treatment - DBT or ST - works the best for which BPD patient, and why?", which is likely to yield important benefits for both BPD patients (e.g., prevention of overtreatment and potential harm of treatments) and society (e.g., increased economic productivity of patients and efficient use of treatments). TRIAL REGISTRATION: Netherlands Trial Register, NL7699 , registered 25/04/2019 - retrospectively registered.

Do We Hold Males and Females to the Same Standard? A Measurement Invariance Study on the Psychopathy Checklist-Revised.

Psychopathy in females has been understudied. Extant data on gender comparisons using the predominant measure of assessment in clinical practice, the Psychopathy Checklist Revised (PCL-R), points to a potential lack of measurement invariance (MI). If indeed the instrument does not perform equally (well) in both genders, straightforward comparison of psychopathy scores in males and females is unwarranted. Using a sample of female and male forensic patients (N = 110 and N = 147 respectively), we formally tested for MI in a structural equation modeling framework. We found that the PCL-R in its current form does not attain full MI. Four items showed threshold-biases and particularly Factor 2 (the Social Deviance Factor) is gender biased. Based on our findings, it seems reasonable to expect that specific scoring adjustments might go a long way in bringing about more equivalent assessment of psychopathic features in men and women. Only then can we begin to meaningfully compare the genders on the prevalence, structure, and external correlates of psychopathy.

Client and Clinical Utility of the Assessment of Personality Disorders.

ABSTRACT: Clinical utility and client utility are important desirable properties when developing and evaluating a new classification system for mental disorders. This study reports on four focus groups followed up by a Delphi study among clinicians working with clients with personality disorders (PD) and clients with PD themselves to harness both user groups' perspectives on the utility of PD diagnosis. Our findings show that the client and clinician views of the concept of utility were closely aligned and include aspects of transparency of communication and the ability of an assessment to enhance hope, curiosity, motivation, and insight into a client's personality patterns. Unique to clinicians' appraisal was the ability of an assessment to capture both vulnerabilities and resilience of clients and to give information about the prognosis in treatment. Unique to clients' appraisal was the ability of an assessment to be destigmatizing and collaborative. These findings may serve to expand our definition and measurement of clinical utility, in that collaborative and nonstigmatizing procedures likely promote client acceptability. To capture both aspects, we offer two preliminary questionnaires (i.e., item sets open to further empirical testing) based on the data derived from the Delphi procedure.

Therapeutic Assessment in Personality Disorders: Toward the Restoration of Epistemic Trust.

Research evidence suggests Therapeutic Assessment positively affects clients with problems in living, including clients with personality disorders, who are typically quite resistant to change. Importantly, this change takes place quickly, in relatively few sessions. This article draws on a relatively new evolutionary-based theory of epistemic trust (ET) and epistemic hypervigilance (EH) as a lens to plausibly explain the efficacy of TA, and especially its influence on PD clients' alliance and motivation for subsequent psychotherapy (Fonagy, Luyten, & Alison, 2015). ET is the willingness to take in relevant interpersonally transmited information and it is essential to the immediate success of psychotherapy and its long-term impact. The collaborative, intersubjective framework of TA and many of its specific techniques might be understood as highly relevant to restoring ET in clients, especially those with PD. We close by discussing implications for psychological assessment, psychotherapy, and research.

Effectiveness of the 'Hold me Tight' Relationship Enhancement Program in a Self-referred and a Clinician-referred Sample: An Emotionally Focused Couples Therapy-Based Approach.

While evidence-based couple therapies are available, only a minority of troubled couples seek help and they often do this too late. To reach more couples earlier, the couple relationship education (CRE) group program "Hold me Tight" (HmT) based on Emotionally Focused Couples Therapy (EFCT) was developed. This study is the first to examine the effectiveness of HmT. Using a three-wave (waiting period, treatment, and follow-up) within-subject design, HmT was delivered to 79 self-referred couples and 50 clinician-referred couples. We applied a comprehensive outcome measure battery. Our main findings were that (1) self-referred couples significantly improved during HmT on all measures, that is relationship satisfaction, security of partner-bond, forgiveness, daily coordination, maintenance behavior, and psychological complaints, with a moderate-to-large mean effect size (d = .63), which was maintained (d = .57) during the 3.5 month follow-up; (2) in clinician-referred couples, who were vulnerable in terms of insecure attachment status and psychopathology, the improvement during HmT was moderate (d = .42), but this was reduced during the 3.5-month follow-up to a small effect (d = .22); (3) emotional functioning (typical HmT target) as well as behavioral functioning (typical Behavioral Couples Therapy-based CRE target) improved during HmT; and (4) individual psychological complaints, although not specifically targeted, were reduced during HmT. These findings suggest that HmT is a promising intervention for enhancement of relationship functioning. Clinical implications are discussed.

Treatment responsiveness of replicated psychopathy profiles.

Theory and accumulating data suggest systematic heterogeneity among offenders with psychopathic traits. Several empirical investigations converge on the nature of subtypes, but little is known about differences in treatment responsivity. We have used the 4-facet model of the Psychopathy Checklist-Revised (PCL-R) to provide a framework for detecting subtypes. The present study used the full range of PCL-R scores in a sample of male violent offenders (N = 190) to replicate subtypes found in a partly overlapping sample by Neumann, Vitacco, and Mokros (2016), using Latent Profile Analysis (LPA), and subsequently to examine potential differences in treatment responsivity. Four subtypes emerged. Within the prototypical psychopathic group, the distinction between intent-to-treat and completers was crucial. Prototypical psychopathic offenders were significantly more likely to drop out, but completers appeared to proceed through the different phases of treatment in much the same way as the other groups. Clearly, more research is needed to elucidate treatment interfering mechanisms and their associated patient characteristics, particularly for the prototypical psychopathic group. Developing therapeutic strategies to improve treatment compliance is a necessary step in the development of specialized treatment programs for these difficult patients. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Using MMPI-2-RF Correlates to Elucidate the PCL-R and Its Four Facets in a Sample of Male Forensic Psychiatric Patients.

This study documents the associations between the MMPI-2-RF (Ben-Porath & Tellegen, 2008 ) scale scores and the Psychopathy Checklist Revised (PCL-R; Hare, 2003 ) facet scores in a forensic psychiatric sample. Objectives were to determine how the MMPI-2-RF scales might enhance substantive understanding of the nature of the 4 PCL-R facets and to discern possible implications for the treatment of psychopathic patients. A sample of 127 male forensic psychiatric offenders admitted to a Dutch forensic psychiatric hospital completed the PCL-R and the MMPI-2. Exploratory stepwise regression analyses assessed the prediction of the PCL-R total and its facet scores from MMPI-2-RF scales at its 3 hierarchical levels. Conceptually meaningful results emerged at each level of the MMPI-2-RF hierarchy, including several consistent differences between predictor sets across the facets. Interestingly, ideas of persecution (RC6) was a specific predictor of PCL-R Facet 2, a facet noted for its association with treatment failure. Results are compared and contrasted to the extant body of empirical work to date, and some tentative clinical implications are offered.

Memorable Experiences in Therapeutic Assessment: Inviting the Patient's Perspective Following a Pretreatment Randomized Controlled Trial.

Accumulating evidence documents the efficacy of Therapeutic Assessment (TA) in terms of symptom reduction and other outcomes, but only minimal data speak to the patient's perspective of what is memorable, or potentially important, about this intervention. In line with the humanistic and phenomenological philosophy of TA, we solicited patient input by asking personality disorder (PD) patients who participated in a recent randomized controlled trial (De Saeger et al., 2014 ) about their experiences. We report on 10 PD patients who were administered semistructured interviews designed to assess an in-depth perspective of undergoing TA. Our methodological approach can be described as phenomenological and integrative, approximating guidelines provided by the Consensual Qualitative Research paradigm (Hill, 2012 ). Four core content domains emerged from the transcribed and coded interview protocols: (a) relationship aspects, (b) new insight into personal dynamics, (c) sense of empowerment, and (d) validation of self. Novel experiences were mostly of a relational nature, and pertained to feeling of being treated like an equal and essential partner in a highly individualized venture. Research and clinical implications of these patient reports of TA participation are discussed.

A Quasi-Experimental Evaluation of High-Intensity Inpatient Sex Offender Treatment in the Netherlands.

The current study quasi-experimentally assessed the outcome of high-intensity inpatient sex offender treatment in the Netherlands in terms of sexual and violent (including sexual) recidivism. It was hypothesized that treated sex offenders would show lower recidivism rates than untreated sex offenders of the same risk level. In line with the risk principle of the Risk, Need, Responsivity (RNR) model, we predicted that this would especially hold true for offenders of higher risk levels. The study sample consisted of 25% of all convicted Dutch sex offenders not referred to any form of treatment and discharged from prison between 1996 and 2002, and all convicted Dutch sex offenders referred to inpatient treatment who were discharged between 1996 and 2002. Static-99R risk levels of these 266 offenders were retrospectively assessed and survival curves regarding sexual and violent (including sexual) recidivism were compared between treated and untreated offenders, controlling for level of risk. Mean follow-up was 148.0 months (SD = 29.6) and the base rate of sexual recidivism was 15.0% and 38.4% for violent (including sexual) recidivism. Cox regression survival analyses showed marginally significant lower failure rates regarding sexual recidivism for treated high-risk offenders only, and significantly lower failure rates regarding violent (including sexual recidivism) for treated sex offenders of moderate-high and high-risk levels. No treatment effects for low and low-moderate risk offenders were found. Results underscore the risk principle of the RNR model: Treatment is more effective when its dosage is attuned to risk level.

Sleep-Related Safety Behaviors and Dysfunctional Beliefs Mediate the Efficacy of Online CBT for Insomnia: A Randomized Controlled Trial.

Several trials have demonstrated the efficacy of online cognitive behavioral therapy (CBT) for insomnia. However, few studies have examined putative mechanisms of change based on the cognitive model of insomnia. Identification of modifiable mechanisms by which the treatment works may guide efforts to further improve the efficacy of insomnia treatment. The current study therefore has two aims: (1) to replicate the finding that online CBT is effective for insomnia and (2) to test putative mechanism of change (i.e., safety behaviors and dysfunctional beliefs). Accordingly, we conducted a randomized controlled trial in which individuals with insomnia were randomized to either online CBT for insomnia (n = 36) or a waiting-list control group (n = 27). Baseline and posttest assessments included questionnaires assessing insomnia severity, safety behaviors, dysfunctional beliefs, anxiety and depression, and a sleep diary. Three- and six-month assessments were administered to the CBT group only. Results show moderate to large statistically significant effects of the online treatment compared to the waiting list on insomnia severity, sleep measures, sleep safety behaviors, and dysfunctional beliefs. Furthermore, dysfunctional beliefs and safety behaviors mediated the effects of treatment on insomnia severity and sleep efficiency. Together, these findings corroborate the efficacy of online CBT for insomnia, and suggest that these effects were produced by changing maladaptive beliefs, as well as safety behaviors. Treatment protocols for insomnia may specifically be enhanced by more focused attention on the comprehensive fading of sleep safety behaviors, for instance through behavioral experiments.

Effectiveness of Day Hospital Mentalization-Based Treatment for Patients with Severe Borderline Personality Disorder: A Matched Control Study.

The present study extends the body of evidence regarding the effectiveness of day hospital Mentalization-Based Treatment (MBT) by documenting the treatment outcome of a highly inclusive group of severe borderline personality disorder (BPD) patients, benchmarked by a carefully matched group who received other specialized psychotherapeutic treatments (OPT). Structured diagnostic interviews were conducted to assess diagnostic status at baseline. Baseline, 18-month treatment outcome and 36-month treatment outcome (after the maintenance phase) on psychiatric symptoms (Brief Symptom Inventory) and personality functioning (118-item Severity Indices of Personality Problems) were available for 29 BPD patients assigned to MBT, and an initial set of 175 BPD patients assigned to OPT. Propensity scores were used to determine the best matches for the MBT patients within the larger OPT group, yielding 29 MBT and 29 OPT patients for direct comparison. Treatment outcome was analysed using multilevel modelling. Pre to post effect sizes were consistently (very) large for MBT, with a Cohen's d of -1.06 and -1.42 for 18 and 36 months, respectively, for the reduction in psychiatric symptoms, and ds ranging from 0.81 to 2.08 for improvement in domains of personality functioning. OPT also yielded improvement across domains but generally of moderate magnitude. In conclusion, the present matched control study, executed by an independent research institute outside the UK, demonstrated the effectiveness of day hospital MBT in a highly inclusive and severe group of BPD patients, beyond the benchmark provided by a mix of specialized psychotherapy programmes. Interpretation of the (large) between condition effects warrants cautionary caveats given the non-randomized design, as well as variation in treatment dosages.

Specific personality traits and general personality dysfunction as predictors of the presence and severity of personality disorders in a clinical sample.

This study examined the associations of specific personality traits and general personality dysfunction in relation to the presence and severity of Diagnostic and Statistical Manual of Mental Disorders (4th ed. [DSM-IV]; American Psychiatric Association, 1994) personality disorders in a Dutch clinical sample. Two widely used measures of specific personality traits were selected, the Revised NEO Personality Inventory as a measure of normal personality traits, and the Dimensional Assessment of Personality Pathology-Basic Questionnaire as a measure of pathological traits. In addition, 2 promising measures of personality dysfunction were selected, the General Assessment of Personality Disorder and the Severity Indices of Personality Problems. Theoretically predicted associations were found between the measures, and all measures predicted the presence and severity of DSM-IV personality disorders. The combination of general personality dysfunction models and personality traits models provided incremental information about the presence and severity of personality disorders, suggesting that an integrative approach of multiple perspectives might serve comprehensive assessment of personality disorders.

Mapping the Personality Psychopathology Five domains onto DSM-IV personality disorders in Dutch clinical and forensic samples: implications for DSM-5.

The Personality Psychopathology Five (PSY-5) model represents 5 broadband dimensional personality domains that align with the originally proposed DSM-5 personality trait system, which was eventually placed in Section III for further study. The main objective of this study was to examine the associations between the PSY-5 model and personality disorder criteria. More specifically, we aimed to determine if the PSY-5 domain scales converged with the alternative DSM-5 Section III model for personality disorders, with a particular emphasis on the personality trait profiles proposed for each of the specific personality disorder types. Two samples from The Netherlands consisting of clinical patients from a personality disorder treatment program (n = 190) and forensic psychiatric hospital (n = 162) were used. All patients had been administered the MMPI-2 (from which MMPI-2-RF PSY-5 scales were scored) and structured clinical interviews to assess personality disorder criteria. Results based on Poisson or negative binomial regression models showed statistically significant and meaningful associations for the hypothesized PSY-5 domains for each of the 6 personality disorders, with a few minor exceptions that are discussed in detail. Implications for these findings are also discussed.

Head-to-head comparison of the alternative model for personality disorders and Section II personality disorder model in terms of predicting patient outcomes 1 year later.

The present study investigated the predictive validity of Criterion A and B of the Alternative Model for Personality Disorders (AMPD) compared to the DSM-5 Section II personality disorder (PD) model in predicting patient outcomes 1 year after initial assessment, in a hetero-method longitudinal design. A clinical sample of 84 participants were administered both traditional Section II and AMPD interviews by two independent interviewers. One year after assessment, disability (World Health Organization Disability Assessment Schedule 2.0) and symptom severity (Brief Symptom Inventory) were assessed. The Section II PD model did not predict disability (R² = .01) nor symptom severity (R² = .03). The AMPD model, on the other hand, predicted both disability (R² = .23) and symptom severity (R² = .29) 1-year postinitial assessment. Both Criterion A and B were significant predictors, but when jointly combined only Criterion A remained significantly predictive of both disability and symptom severity while Criterion B did not. Criterion A thus appears to capture core vulnerabilities of personality-disordered patients that are related to future functioning and symptom severity. Implications for clinical practice are discussed. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Comparing the clinical utility of the alternative model for personality disorders to the Section II personality disorder model: A randomized controlled trial.

The alternative model for personality disorders (AMPD) has been extensively studied over the past decade, but to date there is no direct comparison of the clinical utility of the AMPD model relative to the Section II personality disorder (PD) model in an ecologically valid design. The current study examined the clinical utility of an AMPD-informed assessment procedure and Section II PD assessment procedure as assessed by both patients and clinicians in a randomized controlled trial. A sample of 119 patients were randomly assigned to either an AMPD or a Section II PD assessment procedure. At the end of the assessment, patients filled out questionnaires pertaining to clinical utility, satisfaction, motivation for treatment, and general experience of the assessment. Clinicians who subsequently started treatment with these patients also completed two clinical utility questionnaires. There were no significant differences between the AMPD and Section II PD assessment procedure on patients' reported clinical utility, motivation for treatment, satisfaction, and general experience of the assessment nor were there significant differences between the models on clinician reported clinical utility. Explorative analyses revealed that, for patients, a positive relationship with the assessor was predictive of experienced utility. This study shows no superiority of the AMPD in terms of clinical utility but suggests that the alliance with the assessor is a particularly salient factor in clinical utility. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Impact of clinical severity on treatment response in a randomized controlled trial comparing day hospital and intensive outpatient mentalization-based treatment for borderline personality disorder.

This study examined the impact of clinical severity on treatment outcome in two programs that differ markedly in treatment intensity: day hospital mentalization-based treatment (MBT-DH) and intensive outpatient mentalization-based treatment (MBT-IOP) for borderline personality disorder (BPD). A multicenter randomized controlled trial was conducted. Participants include the full intention-to-treat sample of the original trial of N = 114 randomized BPD patients (MBT-DH n = 70, MBT-IOP n = 44), who were assessed at baseline and subsequently every 6 up to 36 months after start of treatment. Outcomes were general symptom severity, borderline features, and interpersonal functioning. Clinical severity was examined in terms of severity of BPD, general symptom severity, comorbid symptom disorders, comorbid personality disorders, and cluster C personality features. None of the severity measures was related to treatment outcome or differentially predicted treatment outcome in MBT-DH and MBT-IOP, with the exception of a single moderating effect of co morbid symptom disorders on outcome in terms of BPD features, indicating less improvement in MBT-DH for patients with more symptom disorders. Overall, patients with varying levels of clinical severity benefited equally from MBT-DH and MBT-IOP, indicating that clinical severity may not be a useful criterion to differentiate in treatment intensity.

Writing therapy for posttraumatic stress: a meta-analysis.

BACKGROUND: Face-to-face psychological treatments have difficulty meeting today's growing mental health needs. For the highly prevalent posttraumatic stress (PTS) conditions, accumulating evidence suggests that writing therapy may constitute an efficient treatment modality, especially when administered through the Internet. We therefore conducted a meta-analysis to investigate the efficacy of writing therapies for PTS and comorbid depressive symptoms. METHODS: The literature was searched using several structured and unstructured strategies, including key word searches of the PubMed, Web of Science, PsycINFO, and PILOTS databases. Six studies met eligibility criteria and were included in the analyses. These studies included a total of 633 participants, of which 304 were assigned to writing therapy. RESULTS: Across 5 direct comparisons of writing therapy to waiting-list control, writing therapy resulted in significant and substantial short-term reductions in PTS and comorbid depressive symptoms. There was no difference in efficacy between writing therapy and trauma-focused cognitive behavioral therapy, but we caution that this finding was based on only 2 direct comparisons. CONCLUSIONS: Writing therapy is an evidence-based treatment for PTS, and constitutes a useful treatment alternative for patients who do not respond to other evidence-based treatments. Internet adaptations of writing therapy for PTS may be especially useful for reaching trauma survivors in need of evidence-based mental health care who live in remote areas or who prefer to retain their anonymity.