KATHOLIEKE UNIVERSITEIT LEUVEN Faculteit Psychologie en ...inner+change.pdf · Onderzoeksgroep...

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KATHOLIEKE UNIVERSITEIT LEUVEN Faculteit Psychologie en Pedagogische Wetenschappen Onderzoeksgroep Psychodiagnostiek en Psychopathologie Onderzoeksgroep Psychotherapie en Dieptepsychologie TOUCHING INNER CHANGE Psychoanalytically Informed Hospitalization-Based Treatment of Personality Disorders. A Process-Outcome Study. Proefschrift aangeboden tot verkrijging van de graad van Doctor in de Psychologische Wetenschappen door Rudi Vermote onder leiding van Professor Dr. H. Vertommen, promotor Professor Dr. J. Corveleyn, co-promotor

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Touching Inner Change. Psychoanalytically Informed Hospitalization -Based Treatment of Personality Disorders. A Process-Outcome Study. Rudi Vermote Promotor: Prof. Dr. Hans Vertommen Co-promotor: Prof. Dr. Jozef Corveleyn

The RCT of Bateman & Fonagy (1999, 2001) showed the effectiveness of psychoanalytically informed hospitalization for borderline patients. Such a treatment is not symptom oriented but targets psychic changes, denoted as the psychoanalytic process.

Given the intensity and length of this treatment and the severity of the pathology, it is important to examine whether it is possible to measure these hypothesized psychic changes and their relation with outcome. Furthermore we wanted to examine whether we could discriminate different patterns of change and their relation with client variables, as this would permit to better adapt the treatment to the needs of the patients. For such a study a naturalistic design with model specific measures was most appropriate (Clarkin, 2004).However till now, there was no clear definition of the psychoanalytic process in Personality Disorders (P.D.), only few instruments to measure it exist and a link between process and outcome was shown to be weak or inexistent (Vaughan & Roose, 1995).

In the first part we define the specificity of the psychic changes in P.D. by way of a three dimensional model: a background experience of felt safety, the mental representations of self-other relationships and the mentalization of experiences.

In a second part we examined and constructed the instruments to study this process from three perspectives: an independent researcher's, a patient's and a therapist's perspective. For the independent researcher's perspective we operationalized the three dimensions to be measured on the Object Relations Inventory (Blatt & Auerbach, 2003) with a newly constructed Felt Safety Scale, with the Differentiation Relatedness Scale (Blatt & Auerbach,2003), with the Reflective Functioning Scale (Fonagy et al.,1998) and with a Bion Grid Scale. For the patient's perspective we constructed the Leuven Psychotherapy Scale with items based on statements of patients themselves and by factor analysing the answers of 492 patients in hospitalization based therapy. For the therapist's perspective we used the newly developed Psychoanalytic Process Rating Scale (Stoker and Zevalkink,2005). We studied the reliability and divergent and convergent validity of each of these scales.

In a third part we studied the outcome of 70 P.D. patients in a psychoanalytically informed hospitalization at the U.C. Kortenberg during a year treatment and a year follow-up. We found the same significant improvement as in the Bateman & Fonagy (1999, 2001) outcome study with a continuing improvement after discharge. Furthermore we could delineate outcome trajectories, which revealed an impact of personality style. This corroborates the findings of Blatt (1992). We further examined the early drop-out group in comparison with the therapy group and found differences in client variables on hostility and vindictiveness and no significant difference in symptom outcome one year after admission.

In a fourth part we studied the process and its relation with outcome from three perspectives (researcher, patient, therapist) on 47 consecutively admitted patients who stayed long enough to study the process. From the three perspectives, a peculiar but coherent change over time was revealed pointing at a regression from three to six months and an improvement of most parameters in the subsequent period. We found a significant relation between the change of most process measures and the change of symptom and personality related measures. From the three perspectives, this relation was highly significant for the basic dimension of felt safety. The relation with the dimension about the integration of the mental representations of object relations was significant as well, the dimension of mentalization was related with personality change but not with symptom change.

In a fifth part we studied patterns of psychic change and found that patients with a similar severity of borderline pathology showed a different pattern of inner change according to their personality style. We found a stable pattern of inner change with a considerable gain from the treatment as it is, starting late but continuing after treatment, to be related with an introjective, more controlled, withdrawn and narcissistic personality style. A fluctuating pattern, with an easy desintegration of mentalization and a vulnerability to separations was related with an anaclitic personality style. Clinical implications are discussed.

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Dankwoord

In de eerste plaats dank ik Professor Vertommen. Hij zal als promotor altijd een

voorbeeld voor mij blijven. Zelfs in de onmogelijkste momenten was hij steeds beschikbaar

en zag hij heldere wetenschappelijke oplossingen. Met zijn ruime onderzoekservaring hielp

hij het belangrijke van het onbelangrijke te onderscheiden, legde hij de juiste klemtonen

naargelang de fase van het onderzoek en hield hij een tijdslijn in de gaten voor het

proefschrift. Een betere en toegewijdere promotor kan ik me niet dromen. Professor

Corveleyn steunde me als copromotor, hij hielp me de brug maken tussen het empirische

onderzoek en het psychoanalytische werk, met geduld en precisie doorworstelde hij mijn

sneuvelteksten. Ik ben hem ook dankbaar de drijvende kracht te zijn van het onderzoek van

psychoanalytisch georiënteerde behandelingen. Yannic Verhaest complementeerde me op

veel terreinen. Als onderzoeksmedewerkster heeft ze zich op een uitzonderlijk nauwgezette en

vastberaden manier ingezet. Ze kon de grote groep patiënten die bereid waren mee te werken

gedurende twee jaar op een fijngevoelige manier motiveren en de gegevens van de meer dan

30 medewerkers bijhouden en mee verwerken. De inzet, nauwgezetheid en de

vooruitziendheid waarmee ze dit alles deed is bewonderenswaardig. Rob Stroobants was als

wetenschappelijk medewerker onvolprezen, hij zocht van in het begin mee naar de juiste

statistische verwerking van de vele gegevens, voerde tientallen analyses uit en met een bijna

oosterse onthechting trotseerde hij gedurende jaren mijn onwetendheid. Zonder hem zou dit

werk nooit tot stand zijn gekomen. Kristof Van Steelandt bood het nuchtere perspectief van

een pur sang onderzoeker.

Mijn grootste dank gaat naar de directie van het ziekenhuis, in het bijzonder naar

Professor Peuskens zonder wiens aanmoediging en daadwerkelijke ondersteuning dit projekt

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niet mogelijk was. Ik dank ook Professor Verhaest die de vader is van het behandelmodel en

dit tot bloei bracht.

Het voltooien van dit project en het maken van dit proefschrift waren een les in

nederigheid en vertrouwen. Meer dan dertig actieve medewerkers namen een deeltaak op

zich. Alleen al het uittikken en scoren van de 450 Object Relations Inventory, slechts een deel

van het onderzoek, nam meer dan 10.000 uur in beslag. Dank zij de onbaatzuchtige hulp,

steun en niet aflatend vertrouwen van deze groep kon dit werk voltooid worden..

Ik ben de collega's van de beide onderzoeksgroepen dankbaar in het bijzonder dr.Dirk

Smits, dr.Laurence Claes, drs.Greet Geenen en Professor Patrick Luyten voor hun steun en

medewerking.

Mijn speciale dank gaat uit naar dr. Martens, mijn collega op de dienst en de collega's

die tijdens het onderzoek in opleiding waren en die waar nodig een deel van het werk

overnamen: dr. Kathleen Michiels, dr. Claudia Devin en dr.Els De Baerdemaker, die

daarenboven alles nalas in de laatste dagen.

Aan de procesbeordeling door de therapeuten namen bijna alle stafleden deel, de

groep is te groot om iedereen op te noemen: Erica Bourgois, Ingrid Demuynck, Chris Druyts,

Ingrid Janssens, Greet Poot, Michel Probst, Ann Schiemsky, Eric Tibau, Brigitte Vanden

Berghe. Marcel Franssen en Lieve Janssens behoorden daarenboven tot de vaste groep

scoorders. Ik dank Jasper Scheir en Edith Maes voor de vervanging.

13 .studenten maakten hun thesis in het kader van dit onderzoek en hielpen de last

dragen, verschillende van hen traden op als onafhankelijke scoorder: Ellen Wos, Tine Van

Brant, Nele Sauviller, Frede Van Hemelrijck, Katy Lelièvre, Sylvia Desimone, Annelies

Hoydonckx, Jasper Scheir, Caroline Put, Evelyne Peeters, Astrid Van Raemdonck, Karen Van

Winckel, Liesbet Weverbergh. Het was een stimulerende en aangename samnwerking.

Ik dank dr. Fuhr voor de taalcorrectie.

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Mijn grootste dank en respect voor alle patiënten die op een of andere manier

meewerkten, aan een onderzoek dat voor hen los van hun individuele behandeling stond en

die de moeite bleven doen om achteraf en op eigen kosten te blijven meewerken aan het

follow-up onderzoek.

Last but not least dank ik voor de steun, de opleiding en het vertrouwen van

toponderzoekers als Professor. P. Fonagy (University College London), Professor S. Blatt

(Yale University), Professor J. Clarkin (Cornell University) die steeds met een inspirerende

geestdrift feed-back gaven en on-line beschikbaar bleven voor adviezen. De Research

Advisory Board van de International Psychoanalytical Association verleende een substantiele

beurs aan het project in 2001, die verlengd werd in 2002 en 2003. Dit werd aangevuld door

het bestuur van het U.C. en een bijdrage van de Lotto. Door de omvang en het tijdsintensief

werk was dit een kostelijk onderzoek en ik dank dan ook uitvoerig voor deze steun en dit

vertrouwen.

Het werk draag ik op aan Dominique. Zij was er altijd om met een warm hart bij te

springen: thuis, in het ziekenhuis en als een van de vaste scoorders en corrector bij de

eindtekst. Ik draag het ook op aan Lobke, Kasper, Zoe en Samuel. Voor hen was ik de laatste

twee jaar vaak maar een schim van wie ik had moeten zijn, ik heb te weinig gegeven en zeer

veel gekregen. Ik draag het ook op aan mijn moeder, die me heeft moeten missen en aan mijn

vader die fier zou geweest zijn over de prestatie.

Ik draag het werk ook op aan de medewerkers van de KLIPP in het UC te Kortenberg,

waar het project groeide, gedragen en uitgevoerd werd vanuit de gedeelde bezorgdheid een zo

goed mogelijk behandelmodel aan te bieden.

Het is onmogelijk om alle vrienden op te noemen die me hebben gesterkt met hun

interesse en steun. Ze weten dat ik hen in mijn hart draag en dankbaar ben. Ik dank tevens

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alle collega's, en de medeleden van de initiatieven en verenigingen waar ik deel van uit maak

om met een mededogen te verdragen dat ik niet altijd even beschikbaar was.

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Table of contents

Preface

Part 1: Psychic Change in Personality Disorders

Chapter 1: Three Dimensions in the Treatment of Personality Disorders on Psychoanalytic

Lines: Clinical and Theoretical Background and a design for Research 23

Chapter 2: Two Sides of Mentalization: Comparing the Bion and the Fonagy Approach 51

Part 2: Instruments to Measure Psychic Change in Personality Disorders

Chapter 3: Measuring the Psychoanalytic Process in Personality Disorders on the Object

Relations Inventory: the Perspective of the Independent Researcher 73

Chapter 4: Het Meten van Psychiche Verandering met de Leuvense Psychotherapie Schaal:

het Perspectief van de Patiënt 105

Chapter 5: Measuring the Psychoanalytic Process with the Psychoanalytic Process Rating

Scale: the Perspective of the Therapist 133

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Part 3: Outcome, Outcome Trajectories and Drop-out

Chapter 6: Outcome and Outcome Trajectories of Personality Disordered Patients During and

After a Hospitalization on Analytic Lines 151

Chapter 7: Patient Attrition in a Psychoanalytically Informed Hospitalization-Based

Treatment for Personality Disorders 183

Part 4: The Relation between Process and Outcome

Chapter 8: The Kortenberg - Leuven Process Outcome Study on Patients with Personality

Disorders in Psychoanalytically Oriented Hospitalization 203

Part 5: Patterns of Psychic Change

Chapter 9: Patterns of Inner Change and Their Relation with Patient Characteristics and

Outcome in a Psychoanalytically Informed Treatment of Patients with Personality Disorders

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Conclusion: Pointers in Psychoanalytically Informed Hospitalization-Based Treatment of

Personality Disorders 263

References 275

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List of Abbreviations

BDI Beck Depression Inventory

BGS Bion Grid Scale

DRS Differentiation Relatedness Scale

GPS Global Personality Score

GSS Global Symptom Score

IIP Inventory of Interpersonal Problems

LPS Leuven Psychotherapy Scale

ORI Object Relations Inventory

PPRS Psychoanalytic Process Rating Scale

RFS Reflective Functioning Scale

SCID II Structured Clinical Interview of the DSM-III-R axis II

SCL Symptom Checklist

SHI Self Harm Inventory

STAI Spielberger State and Trait Anxiety Inventory

STAXI Spielberger State and Trait Anger Inventory

TEQ Traumatic Experiences Questionnaire

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Preface

The psychoanalytically informed hospitalization-based treatment of personality

disorders at the University Centre St.-Joseph, Kortenberg exists since more than thirty years.

The programme was set up by Prof. Verhaest. It was the first such specialized centre for

personality disorders in Belgium, with the Viersprong (J.Jongerius) in Holland and the Cassel

Hospital (T.Main) in England as its counterparts. Since, thousands of patients have been

treated and hundreds of professionals have been trained at the setting. This was before the

DSM III, axis II (APA, 1980) category of personality disorders existed. The treatment focused

on neurotic and so-called pre-oedipal pathology, mostly patients with a borderline or a

neurotic condition in the psychoanalytic sense.

The program set up by Prof. Verhaest was a unique combination of therapeutic

community principles, psychoanalytic group therapy and a range of conjoint non-verbal

therapies within a highly structured frame. The underpinning concepts were mainly

Kernberg's (1975) ideas about split transference in borderline patients and Kohut's (1971)

ideas about the vulnerable self in narcissistic patients. Patients were seen as going through a

process in which holding (Winnicott, 1960), therapeutic alliance (Meissner, 1996) and the

working through of moments of separation-individuation (Mahler, 1968) played a great role.

Over the years, the teams of the wards were stable, staff carefully trained and a therapeutic

culture became firmly established. Convinced of the role of the therapeutic environment, a

first research project took place with the Ward Atmosphere Scale (Verhaest, 1982, 1983 a, b).

Gradually the focus of the treatment shifted towards an inner process in patients, which

is catalysed when they start to deal mentally with their experiences instead of acting them out.

We called this phenomenon ' interiorization' (verinnerlijking, Verinnerliching), based on the

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ideas of the importance of an inner mental space which is not evident in personality disorders

(Winnicott, 1971; Bion, 1955; Meltzer, 1975). In consequence, by the end of the eighties Prof.

Verhaest started to evaluate the patient's process according to three simple categories: whether

the patients were able to speak, to discuss or to reflect. As such he was a fore-runner of the

Reflective Functioning concepts (Fonagy et al, 2002), which became the base of the current

approach of personality disorders (Bateman & Fonagy, 2004). Our group further studied the

transformation of experiences into something psychic, relying on Bion's theories on

mentalization (Vermote, 1994, 1995, 1996b,c, 1997b,1998a,b,1999, 2000b,c, 2001,

2002a,b,c,e, 2003a,b, 2004a,b, Kinet & Vermote, 2005). Non-verbal therapies and

experiences at the ward play a great role in these transformations of protomental phenomena.

Mentalization is studied from two sides in Chapter 2.

In team discussions we were often impressed by the effects of these inner psychic

changes and the way they took place within the setting. Given the lengthy treatments, we

wanted to be sure that this was not wishful thinking and set up a study about the relation

between the outcome five years after therapy and the going through such a mental process.

The results showed a positive relation and were presented at the first European Conference of

Personality Disorders (Vermote & Callens, 1994). However the methodology of this study

was weak as it was a retrospective study and we were lacking a clear definition and

operationalization of the process of inner change.

Integrating experiences and theoretic concepts, a three dimensional model of this

process grew. This model became a practical tool in organising the treatment, and in the

evaluation of the patients (Vermote, 1996a, 1997a, 2000a,b, 2002 a,b; Vermote & Callens,

1994; Vermote & Van Sina, 1998; Pieters & Vermote, 2002). This model is discussed at

length in Chapter 1.

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Motivated by the research minded director of the hospital, Prof. Peuskens, we decided to

renew our empirical approach to the treatment. We were confronted again with the

considerable lack of instruments to measure a psychoanalytic process. As Spence (1993)

stated, psychoanalysis was situated where medicine was at the turn of the twentieth century,

with a lot of clinical wisdom in the soft clinical tissue of the practitioners, described in

innumerable publications but without a thorough empirical validation of it. Discontened with

the method of measuring the effects of our treatment with clinical symptom scales, we looked

for other ways of measuring what happens in the treatment. Prof. Vertommen of the Research

Group on Psychopathology and Psychodiagnostics of the Faculty of Psychology of the

Katholieke Universiteit Leuven, offered methodological advice. Finding no appropriate

instrument to measure the specificity of our treatment, we started constructing and validating

a scale that is specific for evaluation of the process in personality disordered patients in

psychoanalytically informed hospitalisation, the Leuven Psychotherapy Scale (see Chapter 4).

In 1999 the seminal paper of Bateman & Fonagy was published about an RCT on the

outcome of a psychodynamic oriented hospitalisation for borderlines, very much like ours.

The study demonstrated the effectiveness of such a treatment and resulted in a revaluation of

the psychoanalytic method in treating personality disorders (Sanderson, Swenson & Bohus,

2002). It was a proof that it was possible to study psychoanalytic treatment with standard

methods of current research. Contacting Prof. Fonagy resulted in taking part at the UCL-IPA

research training in 2000. In our trial to study the psychoanalytic process in personality

disorders, the idea grew of operationalizing the three-dimensional model on which we

anchored our treatment in the last years. Prof. Fonagy and Prof. Target (University College

London) and other renown researchers such as Prof. Blatt (Yale University) and Prof. Clarkin

(Cornell University) supported this idea and helped with this task which we imposed upon our

services. The operationalization of the treatment model is discussed in Chapter 3.

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Knowing that the psychoanalytic process is such a vague notion we wanted to study it

from several sides hoping that as Shapiro stated 'finally the elephant would become obvious

for the blind man....' (Bucci, 1996). We developed, translated and validated measures to score

the process from three perspectives: the independent researcher's, the patient's and the

therapist's point of view (Chapters 3, 4, 5).

Given the recent evidence of the effectiveness of psychodynamic treatments in general

(Sandell et al., 2000; Perry et al., 1999; Leichsenring and Leibing, 2003; Leuzinger-Bohleber,

2002) and of the hospitalisation based treatment on analytic lines of P.D. patients in particular

(Bateman & Fonagy, 1999, 2001), we were not so much interested in studying the

effectiveness but decided to focus on the questions of 'how it works and for whom'.

The IPA research advisory board (Chair: Prof. Wallerstein) granted the project in 2001,

2002 & 2003 which was a substantial support. The directory board of the hospital offered the

extra support necessary for research assistance by Y. Verhaest. Given the close collaboration

with the Faculty of Psychology for methodological, statistical and theoretical support, the idea

of making a doctoral dissertation about the project grew. Prof. Vertommen accepted to be the

promotor and prof. Corveleyn to be the co-promotor of this work.

We decided to study the following clinically relevant questions:

1. A formulation of psychic change in the treatment process in three-dimensional model

and its implementation in the treatment of personality disorders (Chapters 1,2).

2. The first question is of course whether it is possible to measure the inner changes

focused on in the treatment (Chapters 3,4,5).

3. Knowing that the outcome of the treatment is not homogeneous and is for a great deal

effected by pre-treatment client variables, we wanted to know whether we could discern

various outcome trajectories and whether these were indeed related to pre-treatment variables.

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In that case it would be possible to refine the indication for the treatment and to adapt the

treatment to the specificity of the patients, instead of offering an uniform treatment for all

(Chapter 6).

4. One of the major problems of psychotherapy with personality disorders is a high

drop-out rate. This is a real problem with figures in literature up to 60 % (Chiesa, 2000).

Therefore it is important to study this phenomenon and to look for variables which predict

such early stopping of the treatment (Chapter 7).

5. The main interest of the study is the process of inner change in the patients. Are we

right in basing our treatment on this inner change, or is it an illusion?

- Firstly, we want to study the change over time of all the process parameters. Is a

coherent process revealing itself from different perspectives? If so, does the results

corroborate some theories of inner change and falsify others? Is the three-dimensional model

of inner change in PD patients, on which the treatment is based, valid? Are there implications

for the technique of the treatment?

- Second, we want to know how changes in these process parameters are related with

changes in clinical symptoms, and more important with changes in personality related ways of

coping and relating. Which parameters of the process relate with these changes? Do we

enhance these facets of the process with our treatment or do we have to accentuate other

lines? It is for instance a debate since years in the psychotherapy of P.D. patients (Akthar,

1995), whether one should confront, interpret or rather be there in a supportive way, offering

corrective experiences. How much weight should one give to one approach or to another and

at what stage of the treatment? This is studied in chapter 8.

- Third, there are strong arguments, that not all patients have the same kind of

psychotherapeutic process. Is it possible to discern different patterns of the process of inner

change? If so, is this related to client variables? Are there different mechanisms of change for

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different groups of clients and what are the implications for treatment? This is studied in

chapter 9.

Preliminary results of the study have been presented at several conferences (Vermote,

2000e, 2002d; Vermote, Vertommen, Corveleyn & Peuskens, 2002; Vermote, Vertommen,

Corveleyn, Verhaest & Peuskens, 2003; Vermote, Vertommen, Verhaest & Peuskens, 2004;

Vermote, Vertommen, Corveleyn et al., 2004 April). To situate the method of this process

study compared with other process studies, a scheme of Hill and Lambert (2004) is used

(table 1).

Table 1

Categorisation of the Kortenberg-Leuven Process-Outcome Study on Personality Disordered

Patients in Psychoanalytically Informed Hospitalization

1.Focus of evaluation patient

2.Aspect of the process inner changes of the patient

(psychoanalytic process)

3.Theoretical basis psychodynamic

4. Perspective of evaluation - nonparticipant observer

- patient

- therapist

5. Unit studied macroprocess unit: whole treatment

6. Type of measurement interval scales and nominal categories

7. Level of inference required inferential

8. Stimulus material to make judgment participation and combination of tape and

transcript

according to Hill and Lambert (2004)

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Guide for the reader

Each chapter is written in a way that it can be read as an independent text. This causes

overlaps in the description of study groups, instruments, procedures and analysis of data. The

reader who intends reading the whole study, can easily skip parts that overlap. A short

indication of the content of each chapter follows for the reader who is interested in a part of

the study.

Chapter 1: The clinical and theoretical background of the psychoanalytically informed

hospitalization of personality disordered patients, with formulation of the research questions

and study design.

Chapter 2: A detailed psychoanalytical approach of one of the dimensions of the

treatment: mentalization.

Chapter 3 - 4- 5: The development and the examination of the reliability and validity of

model specific scales to measure intrapsychic changes. This might be of interest for

colleagues involved in the same kind of research.

Chapter 6-7: These chapters are about the outcome, outcome trajectories and drop-out of

psychoanalytically informed hospitalisation for personality disorders. It is of interest for

psychiatrists and psychotherapists, involved in treating personality disorders.

Chapter 8: This is the capital part of the study: the study of the relation of inner psychic

changes and changes in symptoms and personality related characteristics. The findings of this

chapter may have further clinical implications.

Chapter 9: This chapter is about patterns of inner change and their relation with patient's

characteristics.

Conclusion: This chapter is about the clinical implications of the findings of this study.

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PART 1

PSYCHIC CHANGE IN PERSONALITY DISORDERS

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Chapter 1

Three Dimensions in the Treatment of Personality Disorders on

Psychoanalytic Lines: Clinical and Theoretical Background and a

Design for Research

The Randomised Controlled Trial Outcome study of Bateman and Fonagy (1999, 2001),

showing the effectiveness of psychotherapy for borderline personality disorders on analytic

lines on different outcome measures, was an important argument to place psychoanalytic

oriented treatment of borderline personality disorders in the APA guidelines on the treatment

of borderline personality disorders (Sanderson et al., 2002). One of the most important

questions is, of course, whether, to what degree, and how these outcome changes correspond

with the inner changes at which a psychoanalytic informed treatment aims. As there is no

direct access to these inner changes of personality disordered patients, one has to rely on a

model to apprehend them. The aim of this article is to present the model the authors

operationalized to do so. The concrete clinical anchoring of this model will be described,

before entering into its empirical operationalization for a process-outcome study1.

1 Granted by the Research Advisory Board of the International Psychoanalytical

Association in 2001, 2002, 2003.

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Personality Disorders

The problematic reaction of Personality Disordered (PD) patients to the psychoanalytic

situation has been studied since the beginning of psychoanalysis. Often seemingly good

candidates for psychoanalysis during the intake sessions, these patients reveal a far more

primitive level of psychic functioning once they are in therapy. This is characterised by not

tolerating separations, having trouble with the as-if character of the transference, and an

acting out of their psychic pain instead of symbolizing it. At the worst this may be coupled

with a malignant regression and self-destructive and suicidal behaviour. Since the 30s, many

concepts and names were applied to these patients. In 1975, Kernberg hypothesized a

personality structure or organization for this group of patients, the borderline personality

structure.

Aiming for an atheoretical and descriptive vantage point, the DSM III Committee (APA,

1980), allotted a specific diagnostic axis, called Axis II, to the personality disorders (PD),

consisting of eleven categories. This categorical diagnostic approach and the psychodynamic

structural approach relate to one another in that all Axis II categories correspond to the

borderline personality structure, except for the obsessive-compulsive and depressive

categories which belong to a neurotic personality structure (Kernberg, 1996).

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Three Dimensions in the Psychoanalytic Approach of Personality Disorders

When applying the wide range of psychoanalytic theories to the clinical experience of

analytic treatment of personality disorders, three dimensions emerge as being of particular

importance: a background dimension of the experience of safety, a dimension of psychic

functioning or the mentalization of affects and experiences, and a dimension of object-

relational patterns. The first two dimensions are silent and non-problematic in neurotic

structures, which is not the case in personality disorders.

The background experience of safety is seen as a basic, generalized feeling of safety. It

is described by Sandler (1960) as 'a background feeling within the ego, a feeling which can be

referred to as one of safety or security. I want to stress the positive character of this feeling

(which need not, of course, be conscious). It is a feeling which bears the same relation to

anxiety as the positive body state of satiation and contentment bears to instinctual tension.

Genetically, this feeling must be a derivative of the earliest experiences of tension and

satisfaction. It is a feeling of well-being, a sort of ego-tone. It is more than the mere absence

of anxiety, and reflects, I believe, some fundamental quality of living matter which

distinguishes it from the inanimate. It is a quality of feeling which we can oppose to the affect

of anxiety, representing in a sense its polar opposite' (p. 352).

This inner feeling of safety is frail and often lacking in personality disorder patients,

hence their great sensitivity to even small changes in the therapeutic frame. It gives rise to a

subjective feeling of self, ‘a place within oneself to retreat and relax’ (Winnicott, 1963). It is

related to many other psychoanalytic concepts such as Sroufe’s ‘felt security’ (1996), Klein’s

‘good internal mother’ (1940), Kohut’s ‘primary mother’ (1971), Doi’s ‘amae’ (1989),

Balint’s ‘primary love’(1960), and Holmes’ ‘secure base’ (2001).

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Constitutional factors and environmental factors play a capital role in mediating inner

and outer stimuli to preserve this basic feeling. Winnicott (1967) and Bion (1962) talk of

seeing oneself in the eyes of the other as the basis of such self-regulating mechanisms. In PD,

this ‘felt safety’ is a necessary canvas or matrix upon which object-relational patterns can be

integrated and mentalization can take place. For PD this felt safety is not permanent, they are

constantly checking and searching for it. In doing psychotherapy and psychoanalysis, it is

important to keep the degree of Felt Safety in mind. At moments of regression one must

‘secure’ these patients; otherwise they fall back on non-mentalizing mechanisms.

The dimension of mentalization relates to the psychic transformation of affects,

perceptions, and experiences by a psychic apparatus for thinking (Bion, 1962), which may be

compared with a kind of mental processing ‘machinery’ (Damasio, 2000). More poetically,

one could term it ‘the dreamer who dreams the dream’ (Grotstein, 2000). This psychic

processing is now commonly referred to as mentalization, a term which originated in France

in the 60s. In contrast to neurotic patients, many PD patients are characterized by a failing of

this automatic psychic processing. Rather than transforming and elaborating their emotional

experiences, they tend to evacuate them from the psyche by an evocation of sensorial

experiences such as self-harm, substance use, sexual and physical excitement, or by evoking

and controlling these feelings in others by projective identification. A facet of mentalization,

the interpretation of interpersonal behaviour in terms of psychic states, is conceptualized and

operationalized for research by Fonagy and colleagues (1991, 1993, 1994, 1995, 2000, 2002)

as Reflective Functioning.

The dimension of the object relations is the most prominent dimension in the

psychoanalytic conceptualisation of PD. In fact, O. Kernberg (1975) based his paradigmatic

theory of personality organization for the greatest part on this dimension. Inner objects are

nowadays conceptualized as patterns of mental representations, originating in the experience

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of very early relationships and continuing to govern relationships with oneself and others.

These self-object-relational patterns are reflected in the transference and may show many

degrees of sophistication and integration. In PD there is a pathological splitting of the inner

objects. It is the aim of the psychoanalytic therapy to transform the inner objects in the

transference-countertransference toward greater differentiation and integration. Kernberg

(1975) advocates to do so by interpreting object-relational dyads in the transference in the

here and now of a session (Clarkin et al, 1999). A Kohutian approach, rather, aims at a

regression within the transference, offering corrective experiences in an attempt to create new

holding and soothing self-objects, which the patient was missing and so giving failed

development a new chance. Most theories and therapies about personality disorders, such as

Meissner (1988), Masterson (1993), Akthar (1992), Adler (1994), and Blatt and Behrends

(1987), integrate more or less both points of view and may be put on a spectrum ranging from

the Kernberg to the Kohut pole.

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The Multilevel Psychic Functioning Within the Three Dimensions

Keeping these three dimensions in mind, one may conceive in each dimension a

spectrum going form undifferentiation to differentiation, implicating that the mind

simultaneously functions at several levels or layers along this spectrum. Many psychoanalytic

theories refer to this phenomenon. Ferenczi’s ‘confusion of tongues’ (1949) deals with the

problem of understanding someone who is functioning at a developmentally earlier level,

while one is listening at a more developed level. Balint’s ‘basic fault’ (1968) describes a layer

in primitive mental disorders which is characterised by a two-person relationship with an

intense preoccupation with primary love and difficulty grasping conventional language and

meaning. Bion’s (1962) conceptualisation of a psychotic and non-psychotic part in each

personality reflects the same multilevel functioning. The same approach is found in Matte-

Blanco’s ‘unconscious as infinite sets’ (1988), with levels going form pure undifferentiation

characterized by an interchangeability of elements and symmetry, as in mathematical infinity,

and levels of a much greater differentiation. The equivalent and pretend mode of psychic

functioning as conceptualized by Target and Fonagy (1996) are referring to the same

phenomenon of multilevel mental functioning.

Neuroscientific models of the mind point in the same direction, demonstrating that the

mind functions at several levels without there being necessarily an interaction between these

various levels. Emotions are, for instance, dealt with simultaneously by cortical cognitive

processing systems and amygdala-thalamus systems (Damasio, 2000; Kandel, 1999; Ledoux,

1998). The same was noted with regard to perceptions (Ramachandran, 1998) as well as

procedural and explicit memory systems (Ledoux, 1998). There are only partial interactions

between the levels, and they are marked by a different set of characteristics. At the lower

levels, for instance, there is no naming, no differentiation, a determination and an immediacy.

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At higher levels the pace is slower, and a linking with verbal and autobiographical memory

elements takes place.

It is obviously too early and too complicated to link psychoanalytic concepts to such

neuroscientific findings, but we should at least question the widespread one-way

psychoanalytic model according to which somatic experiences and emotions are being

processed to still higher forms of symbolization. In any case, a multilevel approach makes it

easier to understand the clinical symptoms and the features of the inner psychic process in

PD. In treating PD, a permanent monitoring of the level of psychic functioning in the here and

now is fundamental to be sure to reach the patients at their level. It determines whether one

should intervene with securing, clarifying, containing, or with interpretation of meaning.

An Integrative Three Dimensional Model of Personality Disorders

In applying this multilevel approach to the three dimensions discussed, one may

distinguish a gradient from undifferentiation to differentiation in each dimension. At the basic

level, each of the three dimensions are undifferentiated and therefore also undifferentiated

from each other. This is what we see in regressive states and in primitive pathology:

borderline patients act in the here and now, without making a differentiation in the analytic

situation between past and present, between self and other, or between a real and a

transferential as-if relationship. Moreover, these patients have difficulty in naming and

differentiating affects, which are often experienced as a generalized and threatening feeling.

In the same vein, interventions at a symbolic level are experienced as real and concrete,

leading to confusion.

At a more differentiated level, the level at which people with neurotic structures are

typically functioning, the three dimensions are clearly separated. At this level, the dimension

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of felt safety corresponds to a working alliance, and the object-relational dimension is

characterized by an as-if transference in which inner conflicts are repeated and may be

interpreted. In the mentalization dimension, at the same time, affects are mentalized and their

meaning may be analysed at a symbolic level and the model of the mind of self and others is

taken into account.

While the basic undifferentiated layers are prominent in PD, this does not preclude that

PD patients could function to a certain degree at the more differentiated levels as well. This

frail upper layer may cause these patients to be misleadingly perceived as neurotic in a first

encounter. However, after starting psychoanalytic therapy and regression occuring, they easily

shift to a functioning at the basic, undifferentiated level.

The Specificity of the Therapeutic Process in Personality Disorders

In PD it is not only important to discern different levels of psychic functioning in the

present state but to differentiate as well the levels at which the therapeutic process takes place

(Balint, 1968; Godfrind, 1993; Vermote, Vertommen, Corveleyn & Peuskens, 2002).

At the more differentiated levels, whole-object relationships result in a working

alliance and in an as-if transference in the therapy, where intrapsychic conflicts may be

repeated, interpreted and worked through. This corresponds to what can be called the classic

psychoanalytic process (Vaughan & Roose, 1995).

At the undifferentiated level there is a confluence of the three dimensions. At this level

the therapy progresses in a total situation in the here and now. The boundaries between patient

and therapist are fragile due to projective identification. The therapist is seen as a real figure,

and actions speak louder than words.

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Figure 1. A three-dimensional Model of the Psychoanalytic Process in Personality Disordered

Patients.

1.Felt safety

working alliance

total situationfeeling of safety through

therapeutic frame and therapeutic relationshipin the here and now

3.Objectrelations

whole objectsas-if transference

part -objectsprojective identication

2.Mentalisation

symbolisationpretend mode

acting out ,evacuation

psychic equivalent mode

Mentalization of what is experienced is poor, resulting in a constant danger of acting

out. At this so-called basic level of the psychoanalytic process, the main therapeutic tools are

securing, support, containment of the intense emotions, and giving form to and naming the

undifferentiated mental experiences.

These two levels happen together and influence each other. Interpretations at the level of

the classic process may result in a greater anxiety and put the basic process again to the fore.

Then containment, support, and structure are vital before it is possible again to interpret at the

content level, or the level of differentiated transference phenomena.

Merging of the three dimensions with part-object relating in a total situation: Basic PA Process: growing feeling of safety, decrease of splitting and part-object relating and increase of mentalization

Classic PA Process: repetition, regression, working through of inner conflicts

diff

eren

tiatio

n

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Clinical vignette

The following example illustrates how the installation of a background feeling of safety

by being contained was basic to the integration of the excessive splitting of a patient's inner

representations and her capacity to deal with her inner world at a more differentiated level.

Jane is an 18-year-old girl. Her parents got divorced when she was 14. One sister

makes her way in life, but her brother is a psychiatric patient and on drugs. Jane

displayed behavioural problems such as physical and verbal aggression, suicide

attempts and parasuicidal behaviour, drug abuse, and promiscuity. There was no

background of safety, and an undifferentiation of feelings, which were not mentalized.

Her mother was terminally ill at the time of admission to our setting.

The same picture was manifest in the beginning of her therapy. She was very

provocative, shouting at fellow patients and staff, and was absent for a great deal of the

time during the therapies. In the pre-therapy group she told about her intense feelings of

hate towards her mother, whom she did not want to see. This showed how she was

overwhelmed by her feelings, could not differentiate them nor accept ambivalence. Her

mental representations of significant others were diffuse and split. Her only way to deal

with these intense affects was to run away a few times from the therapeutic setting and

finally to commit another suicide attempt, for which we had to transfer her to a secluded

ward. There she was visited and comforted by several staff members.

The staff decided to give her another chance and to admit her again to the clinical

psychotherapy ward. This was not self-evident, and she was very grateful for this. Her

confidence in the staff and her felt safety gradually increased, and she began to show

some of her psychic pain and talk about it. Though she needed a great deal of external

structure, she relinquished her disturbing behaviour. A transformational moment

occurred when a team member accompanied her on a visit to her severely ill mother for

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the first time after a long lapse. This was a new experience to her. The colleague helped

the mother and daughter in containing the very painful emotions, and contacts were

renewed before the mother died.

Gradually the patient got attached to the ward. She became reflective about her

inner world, developed a kind of empathy towards others, and started to talk and reflect

instead of getting lost in the acting-out and evacuation of her feelings. Her habitual way

of dressing with stiletto heels and transparent blouses became less provocative as she

became aware of the defensive side of her attitude and the effect it had on other patients.

In the non-verbal therapies she discovered an inner richness of which she had not been

aware.

At a more differentiated level she started to work through separation and loss. It

was hard for her to realize what she had been missing in her life so far. She could

integrate different aspects of the representations of her mother and mourn for her. She

was able to give in to her own vulnerability. She could relate this to her feelings towards

the therapist. Thinking about her transference towards the other members of the group

and their reactions towards her made her conscious about her identity as a young

woman. Sexuality had another meaning now than the evacuation of tension. At the end

of her therapy she behaved as a kind of senior patient, helping new patients in finding

out what the therapy was about. After dismissal she resumed her studies.

Structural Diagnosis and the Three Dimensional Approach of Psychic Functioning in


Personality disorders can be classified within this three-dimensional spectrum. From an

object-relational point of view, Kernberg (1996) made a distinction between high-level and

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low-level borderline personality organizations. In low-level borderline cases there is more

splitting and a greater infusion of aggression in their object-relations than in high-level

borderline cases. Similar relations between categorical and structural diagnoses have been

made by Gabbard (1994) and Akhtar (1992). This comparative approach from an object-

relational point of view can be complemented with the two other discussed dimensions: felt

safety and mentalization. It enables us to discern different structures behind identical

symptom clusters, each having different prognoses and therapeutic needs, a differentiation

which is lacking in the descriptive categorical DSM approach, as is evidenced by three

examples.

The symptom cluster of attention-seeking, dramatic behaviour, dependency, and sexual

dysfunction may point towards a neurotic (hysterical) or a histrionic (borderline) structure.

The hysterical PD has a neurotic structure with a well-established background feeling of

safety and a capacity of tolerating separations, which is not the case for the borderline

histrionic structure. As mentalization is functional in the hysterical neurotic structure,

symptoms may have a symbolic meaning, reflecting intrapsychic conflicts often sexual in

nature. In contrast, sexuality in histrionic borderline cases rather serves as a concrete

evacuation of tension. The object-relations in the hysterical neurotic structure most often

reflect a typical triangular nature, while histrionic patients are characterized by dyadic part-

object-relations with many projective identifications and a lack of boundaries.

Behind the symptom cluster of social detachment and lack of interpersonal and intimate

relationships, one can discern either an avoidant PD with a high-level borderline personality

structure or a schizoid PD with a low-level borderline personality structure. The first group

lacks felt safety and scans the environment for signs of safety but does, nevertheless, succeed

in mentalizing their feelings and perceptions. Also, their object-relations are basically of a

whole-object nature – tolerating ambivalence. The low-level schizoid PD is different. There is

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a basic distrust, a failing mentalization with a danger of micropsychosis, and an inner-

borderline world of split self-object-relations which is hidden behind the schizoid, detached

appearance.

The structural difference between the two kinds of narcissism is well known. There is a

difference between borderline narcissistic patients as described by Kernberg and narcissists as

described by Kohut (1966). This differentiation corresponds more or less to Rosenfeld’s

(1987) and Bateman’s (1998) distinction between thick- versus thin-skinned narcissists,

Masterson’s (1993) exhibitionistic versus closet narcissistic type, Gabbard’s (1989) oblivious

versus hypervigilant type, or Akthar’s (1992) overt versus covert type of narcissism. In all

these distinctions we again see a difference in the three dimensions. The second category of

narcissists has a high-level borderline personality structure and shows a lack of felt safety

which they try to repair by constantly looking for approval from others. They tend to have

whole-object-relational patterns and only slight problems in mentalization. In contrast, the

first group of narcissistic patients displays a false sense of safety in hiding behind a grandiose

self, with their object-relations being split and split parts being projected unto others with an

omnipotent control of others. Their failing mentalization easily results in narcissistic rage.

Malignant narcissism (Kernberg, 1984) is an even lower level of narcissistic borderline

organization close to antisocial personality disorders. In malignant narcissism, the background

feeling of safety is missing, resulting in the feeling of living in a dog-eat-dog world, with a

failing mentalization and an eager and dangerous acting-out of affects, rather than a

mentalization of these affects. The internal objects are split, resulting in an infusion of

aggression and a typical idealization of bad internal split objects – the internal mafia gang of

Rosenfeld (1987). When there is a failing Super-Ego as well, this malignant narcissism results

in an antisocial personality disorder.

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Clinical vignette

Jane is an obese young woman of 20. She is the only daughter from a poor family

and ashamed about this. She is very socially withdrawn and was referred to the

secluded ward because of repetitious and severe suicide attempts with strangulation and

self-mutilation. As a child she was often ridiculed in school. But being intelligent and

having good marks at school, she was idealised by both her parents. The referring

psychiatrist suspected an Asperger syndrome, given Jane’s severe problems in contact,

her difficulty to talk about emotions, and her frequent use of stopgaps in conversation.

In the beginning of treatment the suicidal thread remained, resulting in one

attempt with a phone cable. Intrapsychic dynamics became clearer by her works at art

therapy, which were full of aggressive content. Music therapy showed her difficulty with

rhythm and with letting herself go in improvisation. For a long time she tended to be

very withdrawn during group psychoanalytic sessions but finally became less anxious,

and her felt safety increased. She started to talk about her inner world, which was

characterized by fantasies about grandiosity. The group members dealt with these issues

in a delicate way. She revealed herself as a covert, hypervigilant narcissist with

avoidant traits corresponding to a high-level borderline personality structure.

Instead of acting out undifferentiated feelings of distress by self-destructive

behavior, she could gradually experience and differentiate her inner feelings and reflect

upon them. For the first time in his life she experienced an intimate relationship with a

man. During the group sessions she allowed herself to experience feelings of rivalry

with a female group member. All this was new to her. It may have corresponded to new

internal objects. Typical oedipal transferential themes became evident in the group

therapy. She started training in the running and fitness group. The suicidal thoughts

disappeared, she felt very attached to the setting and several patients, felt stronger, and

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decided to take up her studies again. She was very grateful for the changes she

experienced.

The Organization of an Inpatient Psychotherapy Setting of Personality Disorders Based on the

Three Dimensional Model of Intrapsychic Change in Personality Disorders

This three-dimensional model served as a mould in organizing the inpatient treatment of

personality disorders at the University Centre Kortenberg, Belgium (Vermote & Van Sina,

1998; Pieters & Vermote, 2002). The setting comprises two wards. One ward is organized as

a day hospital for two groups of eight patients, while the other offers inpatient psychotherapy

for four groups of eight patients. The stay is open-ended with one year as a maximum limit.

The two wards have a similar therapy programme consisting of one and a half hours of

psychoanalytic psychotherapy three times a week, three art therapy sessions a week, two

music therapy sessions a week, and three psychomotor therapy sessions a week. Moreover,

the wards offer sociotherapy, with community meetings and small group meetings, and

activities such as cooking and cleaning as well. On the whole, the setting does not differ all

that much from many others, except for the fact that our approach was tailored to the

psychodynamic three-dimensional model.

The Dimension of Felt Safety

The background experience of safety corresponds to the way patients ‘use’ (Winnicott,

1969) the security and the predictability of the therapeutic setting to feel secure. Ideally this

felt safety should be interiorized during therapy or enhance an already existing kernel of inner

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safety. The feeling of safety is mainly guaranteed by a strong psychoanalytic frame. All

therapies take place within a frame of fixed appointments, and absences are interpreted

meticulously. Additionally, there is a well-considered frame of rules and agreements as far as

the goings-on at the ward are concerned. The rules are not open to discussion and relate to

matters such as physical violence, sexual contact with fellow patients, substance use, self-

harm, and parasuicidality. The information about these rules and the making of a contract on

these matters are part of the regular intake procedure prior to the treatment. When there is a

tendency to offend the rules, mostly due to an evacuation of intolerable feelings by action

instead of mentalizing them, patients are offered alternatives and support mainly by looking

together for the meaning of this behaviour. It is very seldom that people have to leave the

setting because of breaking the rules. Apart from these set rules, there are a number of

agreements which remain open to discussion and can be adjusted after consideration at the

patient-staff meeting. They concern matters such as entrance times, the location of the

smoking area, changes in the therapeutic programme, and so forth.

Within this predictable system, there is a 24-hour staff coverage for both the partially

and fully hospitalised patients. A number of staff members are available at all times in case

the patients should feel the need to talk, while a need for protection can be mediated by a

graded system of guidance (phone calls, being accompanied by a fellow patient, family

member or nurse).

The therapeutic frame is seen as a dynamic structure, which is always under attack,

given the psychodynamics of patients with PD who are mostly borderline patients. These

attacks are not dealt with in a repressive way. This strict frame is used, rather, in a transitional

way like Winnicott’s (1941) use of the spatula in children, meaning that the frame stands the

same for everyone, therapists and patients alike, but the very divergent reactions which this

evokes in the individual patients are used as food for therapeutic reflection. One could say

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that safeguarding the therapeutic frame is fifty percent of the job of the staff. The transitional

attitude aims at keeping open the mental space and avoiding action-reaction sequences.

Giving the constant current of destructiveness, parasuicidality and suicidality in low-

level borderline patients, regular briefing of staff members is a prerequisite. Such briefings are

exercises in equilibrium, maintaining the balance between being protective on the one hand,

and guaranteeing an open, free and therapeutic atmosphere on the other. This is the primary

goal of the weekly patient-staff meeting. Topics under discussion at these meetings are the

dynamics and behaviour which undermine the frame, such as alcohol abuse, the formation of

small groups, sexual acting-out, splitting, malignant regression, gossiping, violating the group

therapy confidentiality, and absenteeism. The aim of these discussions is to interpret these

phenomena at the group level. The meetings focus on the therapeutic culture in an attempt to

safeguard a ‘good enough’ atmosphere at the ward. Working intensively with PD patients in

an inpatient treatment has the advantage that patients see their problems reflected in others but

the down side is that this causes a continuous need to prevent this milieu from becoming

toxic. This is the main reason why antisocial personality structures are contra-indicated for

admission. Their tendency to exploit the openness and vulnerability of other patients toxifies

the therapeutic atmosphere before the antisocial patient can even begin to regress, become

dependent, and gain from the treatment.

Another way to secure the feeling of safety consists in additional regular meetings

where non-personal and matter-of-fact scientific answers are supplied to problems or

questions submitted in writing and deposited in a box during a set of regular informative

meetings. The questions mostly relate to diagnoses, outcome, etiology, or genetics. These

open discussions are experienced as securing, as they make the therapeutic approach

predictable. The therapists do not partake in them, in order not to interfere with transference.

Moreover, the patient is informed individually about the extensive bimonthly evaluation of his

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or her process, not by the therapist, but by the psychiatrist of the ward. Depending on the

stage and the needs of the patients, such feedback may be either more confronting or

supportive. We always make sure, however, that the feedback is given in an open, unsaturated

way so as to ensure that it does not preclude the on-going spontaneous process of the patient.

Family members are seen and given information by staff members other than the therapists.

As the danger of such a strong frame is a malignant regression, we discourage that

patients continue to discuss group dynamics and inner feelings with each other outside the

therapy sessions. Besides the regular therapy programme with an analytic frame in all

therapies, we offer an elective programme of ateliers or workshops. These workshops, such as

running, poetry, assertiveness training, philosophy, gardening, and drama, are optional and

consist of a limited number of sessions. In contrast to the regular therapy programme, there is

in these workshops no focus on the inner process, and the activities are for the larger part in

the hands of the patients themselves. These occupations are seen as a way of stimulating non-

problematic and active parts of the patients. Furthermore, a high degree of freedom within the

setting and a free circulation with the outpatient milieu greatly contribute to the feeling of

safety. An important step in this respect was the decision to eliminate the ‘isolation room’.

The frequent use of it at the time may be seen as an enactment of internal cruel objects, a

short-circuiting of a mental processing, a collusion with an archaic need for being held in the

literal sense, and the evocation of intense counter-transference feelings of insecurity in the

staff. In doing this we noted a very strong decline of malignant regression, and the need for

this isolation room totally disappeared from the therapeutic culture at the ward.

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The Object-relational Dimension

The object-relational patterns are manifested in a transferential way in the group

psychoanalytic psychotherapy, group psychomotor psychotherapy, and group improvisation

during music therapy. The large and the small groups at the ward are the theatre of the

internal object-relations. At the differentiated or neurotic level, the intrapsychic conflicts

represented in the transferences may be linked with the past. A working through at this level,

however, takes place mostly at a later stage of the inpatient therapy or in the classic

psychoanalysis or individual psychoanalytic psychotherapy, in which 80% of the patients

engage after their inpatient therapy. During the inpatient therapy, however, most patients

function prominently at more undifferentiated levels, and dealing with the transference

consists in the first place of containing the multiple transferences, making patients aware of

them and giving form to them. In addition, many PD patients have to experience something in

reality first, before they can start to think about it. They have to put it on the stage so to speak.

What may be seen as an acting out of transference in patients functioning at a differentiated

level is at this undifferentiated level an ‘acting through‘ (Van Sina, 1993).

In the same vein the setting also offers new experiences in a relatively safe environment

which may give rise to new inner objects. Defences such as splitting groups and teams, denial,

and different relational patterns reflecting rivalry, envy, authority conflict, symbiosis, lack of

structure and boundaries, and repeating abuse, all become manifest during the stay. The

resulting counter-transference is again a major therapeutic tool in recognizing and handling

this. Intervision and supervision groups help to handle the transference-countertransference

matrix. Such groups exist at staff level but also at the level of the analysts and analytic

therapists and at the level of the nurses.

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The Mentalization Dimension

The mentalization dimension is a major concern in the treatment. Patients functioning at

an undifferentiated level are not in contact with their inner world and have no, or poor,

introspective capacities at the onset. From a psychoanalytic point of view, these patients

function for a great deal in a so-called operative (Marty, 1963) or two-dimensional modus

(Meltzer, 1967) or psychotic part (Bion, 1962), meaning that these experiences are evacuated

by creating sensorial excitations instead of being elaborated internally.

Such short-circuiting of psychic processing may consist in alcohol or drug abuse, eating

disorders, excitation by sexual behaviour, and self-mutilation with a view to instant-tension

reduction. Patients are often hard to reach when caught in this modus, as they find themselves

on another wavelength of communication. In psychoanalysis this is conceptualized as the so-

called Bionian beta-elements (Bion, 1962). As this condition is often marked by bodily

excitations, many of these behaviours can be seen in the context of Tustin’s autistic objects

(1986).

For many patients, finding a way out of this mode of psychic functioning is the primary

goal at the beginning of the treatment. We therefore instituted a pre-therapy group where

these types of short-circuiting in the psychic processing are addressed. In these meetings we

are concerned with what happens between the moment of an act and the emotions prior to the

act, in such a way as to attempt to open a psychic space. In this group, the anxiety level is kept

low by avoiding transference interpretations and maintaining a supportive stance. When

patients are in touch with their inner world and get used to talking and associating about their

feelings and thoughts without relying on acting-out behaviour to reduce psychic tension, they

are ready to commence the proper psychoanalytic group therapy.

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In our experience, the non-verbal therapies play a capital role in catalysing the process

of mentalization. It is more difficult to block inner feelings during the psychomotor, music

and art therapies than in the verbal therapies. Patients are confronted with, and often surprised

by, what they find themselves doing and feeling. The non-verbal therapists are very attentive

to these expressions of the patients’ inner world and try to sensitize the patients to this aspect

of their process by giving authentic feedback in the language of their therapeutic medium and

by avoiding at all costs rationalizing via pseudo-analytic interpretations. Instead, they search

and help to create psychic moulds which may shape and catalyse psychic processing. These

moulds can be tangible objects, words, or even a melody. Patients bring these inner

experiences of themselves or other group members to the group psychoanalysis, where the

inner dynamics are further elaborated. At a staff level the different aspects of the inner

process are brought together in regular patient evaluations, where there is room to discuss

staff counter-transferences as well as the patient’s socio-familial dimension.

In addition to fostering the psychic processing of affects and perceptions which is

predominantly based on Bion’s vision of mentalization, special attention is given to another

side of mentalization as well. This latter interpretation of mentalization is conceptualized by

Fonagy and colleagues (Fonagy & Target, 1996; Fonagy, Gergely, Jurist & Target, 2002) as

the way patients consciously and actively reflect on their behaviour and relationships. Such a

therapeutic approach can be done by nurses, trained in this Reflective Functioning approach.

It is a guideline in the brief and supportive talks with the patients, as well as during the small-

group meetings. The very concrete and shared experiences at the ward actually offer good

occasion to confront different ways of reflecting. This is an essential part of the

psychoanalytic group therapy as well, where patients are systematically put in touch with

what happens in the minds of others and with different ways of interpreting shared

experiences.

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Clinical vignette

Olga is 19 years old and was holding her father’s hands during the intake. She

hardly spoke at all and was trembling heavily. The father indicated that his daughter

was suffering from a neurological condition, recently aggravated by symptoms of

paralysis, for which she needed a wheel chair from time to time. Neurological exams

were, however, near to normal. The reasonable hypothesis of the father was that his

daughter was functioning far above her intellectual capacities and ultimately suffered a

mental breakdown. She herself expressed in a hardly audible way that she felt very

anxious and empty, and had suicidal ideation but never went as far as an attempt.

Although she was described by her father as a mild mentally retarded young woman and

she behaved in ways congruent with that description, there were reasons to see her as

an immature girl with histrionic personality traits.

In the setting she relied much on the support and took profit from numerous

individual sessions with the group nurse. This made her feel safe and less anxious.

During psychomotor therapy she experimented with her body image, which led to her

feeling more relaxed. The psychoanalytic group sessions centred on object relational

issues. Gradually she succeeded in differentiating herself from other group members

and in taking a more autonomous stance towards her parents. Her somatic complaints

about paresis disappeared after some months, probably by the fact that she could deal

now with her inner experiences at a mental level.

At another level, sexual themes surfaced in therapies such as the group therapy

and the art therapy, and she was able to talk about and reflect upon these issues. Finally

she engaged in a relationship with a man outside the setting. She left the setting at eight

months to take up her studies again, but continued to attend ambulant psychotherapy

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where oedipal issues and the complex relationship towards her father could be taken up.

The relationship with a man, years older than she is, can be seen as an acting out of

these conflicts but now at a more neurotic level.

Research on the Psychoanalytically-Informed Treatment of Personality Disordered Patients

Two Questions

In an RCT Bateman and Fonagy (1999, 2001) showed the effectiveness of

psychoanalytically informed hospitalization-based treatment in a selected group of borderline

patients. Two further questions are of particular clinical interest for the treatment under

discussion. For whom of a larger group of personality disorders with a borderline personality

organisation does this kind of treatment work and how does it work? The answer to the first

question is an outcome study with a naturalistic design, the answer to the second question is a

process-outcome study.

The Development of Model Specific Instruments to Measure the Process of Psychic Change in

Psychoanalytically Informed Hospitalization Based Treatment of P.D.

The process of psychic change in the psychoanalytically informed treatment of

persoality disorder being defined in this chapter by a three dimensional model of change, we

further developed and validated model specific measures to assess it. As the process is only

measurable in an indirect way, it is indicated to assess it from different perspectives.

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A first perspective is from a independent researcher's point of view and based on the

three-dimensional theoretical model. To measure the dimension of felt safety, we constructed

a Felt Safety Scale, for the dimension of the object relations we translated and the

Differentiation Relatedness Scale (Blatt et al., 1996), and for the dimension of mentalization

we translated the Reflective Functioning Scale (Fonagy et al., 1998) about the capacity to

perceive ones own and others' actions, thoughts and feelings in terms of mental states and we

constructed a Bion Grid Scale to measure the degree of creative exploration and mental

transformation of experiences. These scales were manualised to be assessed on the Object

Relation Inventory (Blatt, Stayner, Auerbach& Behrends, 1996). The scales are presented and

the reliability and the validity of the scales is studied and discussed in Chapter 3.

A second perspective is that from the patients. We found no instrument that was

appropriate to measure the inner changes during a psychoanalytically informed hospitalization

based treatment for personality disordered patients, therefore we decided to construct a scale

that was not theory driven, but derived from patient statements about their experience of inner

change during such a treatment. The Leuven Psychotherapy Scale is presented and its

reliabilty and validity is discussed in Chapter 4.

A third perspective is that from the therapists, we use of a newly developed scale by the

Dutch Institute of Psychoanalysis: the Psychoanalytic Process Rating Scale (Beenen &

Stoker, 2001; Stoker & Zevalkink, 2005 ). This scale and the examination of its realibility and

validity is discussed in Chapter 5.

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The Outcome and Process-Outcome Study

Participants.

We asked all patients admitted in the period between 23 June 2001 and 15 July 2002 to

the setting for psychoanalytically informed hospitalisation based treatment ( inpatient and day

hospital) at the University Centre, Kortenberg to take part at the study. We studied the

outcome trajectories of this large group. We further delineated a group that stayed at least

nine moths to have enough moments to study the process, this group could also be compared

with the treatment group of the Bateman and Fonagy 1999 RCT.

Instruments

Outcome measures.

To measure the outcome we used the following clinical symptom outcome measures: the

Symptom Checklist 90 (SCL-90) (Derogatis, 1977), translated by Arrindell & Ettema (1993),

the Spielberger State-Trait Anxiety Inventory (Spielberger et al., 1970) translated by Van der

Ploeg et al. (1980), the Spielberger State-Trait Anger Inventory (Spielberger et al., 1980)

translated by Van der Ploeg et al. (1982), the Beck Depression Inventory (1961) translated by

Bouman et al. (1985). As self-harm and suicidality and para-suicidality are important

symptoms of patients with a borderline personality organisation, we used the Sansone Self

Harm Inventory ( Sansone et al., 1998).

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As we expect the treatment to influence less volatile personality characteristics, we

assessed personality related measures as well. We used the questionnaire of the Structured

Clinical Interview for DSM-III-R Axis II disorders SCID-II (Spitzer & Williams,1985), which

has been translated in Dutch and adapted for DSM-IV, by Weertman, Arntz & Kerkhofs

(2000).

As this gives no indication of the severity of the personality disorder, we used the

Inventory of Personality Organization (Lenzenweger, Kernberg, Clarkin, Foelsch, 2001;

Normandin et al., 2002). The IPO is a self-report questionnaire used to assess a structural

diagnosis according to the model of Kernberg on borderline personality organization. The

reliability and validity of the IPO translated in Dutch was demonstrated by Vermote, Maes,

Vertommen et al. (2003) and Vermote, Smits, Claes & Vertommen (2005). We further used

the Inventory of Interpersonal Problems (IIP), circumflex version (Alden et al., 1990) which

measures interpersonal functioning. As traumatic experiences are common in personality

disorders, we employed the Traumatic Experience Checklist (TEC, Nijenhuis, Van der Hart &

Kruger, 2002) to measure this aspect of the patient characteristics. All these measures have a

well established reliability and validity.

Process measures.

See measures discussed in 'The development of model specific instruments to measure

the process of psychic change in psychoanalytically informed hospitalization based treatment

of P.D.'

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Procedure

We assessed the process measures and the clinical syptom outcome measures, every

three months. The personality related measures were measured on admission and discharge.

In follow-up, all measures were assessed three months and one year after discharge.

Answer of the questions

Whether it works : The change over time of the outcome measures is studied for the

therapy group with analysis of variance, repeated measures and compared with the therapy

group of the Bateman-Fonagy 1999 RCT study (Chapter 6).

For whom it works: We conducted a Trajectory analysis with Traj Proc on the large

group of all admitted patients and examined whether the trajectory groups are related with

patient varibales by an analysis of variance and subsequent post-hoc tests (Chapter 6). We

further studied the characteristics of the drop-out group of this large group by comparing

their patient variables with those of the therapy group with a t-test and by studying differences

in early process and in outcome change with a two-way analysis of variance (Chapter 7).

How it works:

1. We studied the process of psychic change measured from three perspectives: by an

independent resarcher (with the four ORI measures), by a patient self-report (the Leuven

Psychotherapy Scale) , by the therapists (the Psychoanalytic Process Rating Scale). Analysis

of variance, repeated measures (Chapter 8).

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2. We study the relation between outcome changes and the process as measured form

three perspectives (ORI-measures, LPS, PPRS). First the outcome scores were reduced in a

Global Symptom Score and a Global Personality Score by Principal Component Analysis and

then the change over time of these global scores were related to the change of the various

process easures by an analysis of variance (Chapter 8).

3. Patterns of the psychoanalytic process were exmined with a cluster analysis and the

relation of the the clusters with patient characteristics were examined with a t-test and

analysis of variance (Chapter 9).

Conclusion

The authors present an integration of the major psychodynamic theories on personality

disorders in a three-dimensional model. The clinical anchoring of this model is discussed and

it is shown how a setting for treatment of personality disorders on analytic lines was organised

on the basis of this model. The effectiveness of such a setting having been shown in RCT

studies, the authors wanted to study the intrapsychic changes happening during the

psychoanalytic-informed treatment of personality disorders and the relationships among those

changes and clinical and personality outcomes. The advantage of an inpatient treatment is that

it was possible to assess process and outcome without being disruptive to the treatment and to

collect data on a larger scale, making it possible to analyse these data with parametric

statistical methods. The authors discuss the operationalisation of the three-dimensional model

of psychic change in personality disorders and the research design of an outcome and process-

outcome study on a psychoanalytically informed hospitalization-based treatment of patients

with personality disorders.

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Chapter 2

Two Sides of Mentalization: Comparing the Bion and the Fonagy

Approach

Mentalization is a powerful concept. One may even see psychoanalysis as ‘mentalizing

in the presence of another’ (Green, 2001). It can be defined as the psychic processing of

experiences from the outer and the inner world, such as drives, perceptions, impressions,

sensations, feelings, emotions, fantasies, thoughts, acts. These transformations may occur at

an unconscious, a preconscious and a conscious level.

The term mentalization is of French origin and linked to the work of Marty and De

M’Uzan (1963) with psychosomatic patients, in whom they supposed a lack in the symbolic

elaboration of affects. These ideas were integrated with Bion’s concepts on thinking by Green

(1973) and further extended by Marty (1991) and Luquet (1981, 2002). The French approach

of mentalization is very well elaborated in the study of Lecours and Bouchard (1997).

In the present text, we focus on the two main Anglo-Saxon approaches of mentalization

First we concentrate on the evolution of Bion’s theory of thinking and how this is reflected in

his Grid, in which he categorizes the psychic elements according to their use (x-axis) and

genesis (y-axis). Then we will compare this approach with Fonagy’s and colleagues approach

of mentalization.

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The Various Stages in Bion’s Theory of Thinking

Bion’s Basic Model of Thinking

Freud (1911) based his psychoanalytic theory of thinking on the existence of a reality

principle which implies a latency period between impulse and action. In this latency period he

distinguishes notation, attention, inquiry and action. Bion replicated these categories in the x-

axis of his GRID. The y–axis of this Grid shows the genesis of thoughts according to Bion

(1957,1962a). Bion elaborated Klein’s (1932) concept of phantasy, an unconscious and

continuous ‘mental processing’, in a way which is close to English philosophical tradition.

Sensorial data (beta-elements) are transformed into impressions with a budding psychic nature

(alpha elements). These alpha-elements correspond to Locke’s (1698/1975) sensations.

Proust’s ‘le goût des madeleines’2 for instance, is such a sensation or alpha-element, and is

clearly more than a mere sensory perception (Anzieu, 1993). These alpha-elements are linked

in a spontaneous, associative process just as they are in Hume’s vision of thinking

(1739/1985, p.153): ‘thinking is a custom before reflection’. Alpha-elements are contained in

pre-existing patterns or pre-conceptions, similar to Berkeley’s pre-existing patterns

(1710/1993). The spontaneous, associative process results in more complex and abstract

elements.

However, this automatic, creative process is not yet thinking, and at this point this

theory shifts to the psychoanalytical field. Thinking emerges when these elements are used to

represent something, which is not present. A thought for a no-thing as Bion (1962a) puts it.

This thinking process needs an environment to help bearing the affects and to provide

thoughts to contain them (Bion (1962a). Thoughts are there before thinking. Bion’s

2 Madeleines are an old fashioned type of French cookies, often served with champaign.

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containment model of thinking is widespread and became one of the watersheds of

contemporary psychoanalysis.

Bion’s Second Model of Thinking: Thinking and Transformation in Knowledge

In 1963 Bion added a new dimension to his model of thinking by presenting it as a

process of transformation of elements. A spontaneous dialectical movement between a mental

state in which the inner and the outer reality are perceived as phenomena without cohesion

(Ps) shifts into a mental state in which some order and relatedness between phenomena

emerge (D). The shift from PS to D is occasioned by the emergence of a ‘selected fact’, which

creates order in the complexity (Bion, 1962b, p.72). There is a constant oscillation between

PS and D, generating new selected facts. Bion’s model of creativity and thinking is rooted in

this PS-D oscillation and not in the depressive position as in Klein’s and Segal’s models. To

Bion (1962b, 1963a) this Ps-D shift is not a cognitive but an emotional experience.

In this second model of thinking he relies more on Plato and on Kant than on the

empiricist philosophers as in his first model. He sees the elements of a session as related to an

unknowable psychoanalytic object, a Kantian ‘ Thing in itself’ (Kant, 1781/1929) or O, an

invariant which expresses itself in a flow of ever changing manifest psychic elements. Bion

(1965) suggests that the analyst ought to desaturate his thinking in the sessions as much as

possible trying to ‘see, feel, intuit’ this O. He thus propagates an attitude marked by a formal

regression of thought (De M’Uzan, 1989 and Botella e.a., 2001), a radical free-floating

attention to enhance transformations in K of O.

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Bion’s Third Model of Thinking: Thinking and Transformation in O

Bion became increasingly convinced of the impossibility of getting in touch with O even

when K is desaturated as much as possible This is due to the fact that thinking is originally

too utilitarian and sensorial to get through to O. Bion (1965, p.144) saw thinking as a curtain

of illusions, a protective coat of lies (Bion, 1965, p.129). In ‘ Transformations’ Bion (1965)

tried to transcend the limitations of the senses with a mathematical and formulaic approach,

but did not succeed. Therefore he decided to concentrate on O itself, instead of focusing on

the continuously changing phenomena which are expressions of the transformations of O.

This contact with the O of a session must be found in the void between two thoughts, when

imagination fails, when there is no thought to fit it. In Bion’s terms one has to become O

instead of trying to know it. He saw psychic growth as being achieved through

transformations in O while knowing about growth happens through transformations in K

(Bion, 1965, p.156).

An example: The patient suspects that she was sexually abused as a child, but does

not remember it. She has been in analysis for nearly two years, without much

regression. In line with Bion’s recommendations the analyst refrains to concentrate on

his free associations and logical thinking, what Bion calls an act of faith. A period

comes about when the patient is scared during the sessions and experiences her body as

if it were poisoned. She develops some kind of asthmatic reaction and needs to consult a

doctor. Then she introduces the image of a ramshackle, flaking wall with electric wires,

the insulation of which has been pulverized, lying beneath it. The image happens within

her, not in the analyst. The catastrophic feelings present in the sessions for patient and

analyst, were transformed in an image, but this transformation in O happens in her. It is

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an emotional experience, a becoming. This is different from the usual technique where

the analyst understands (a transformation in K) and communicates this as an

interpretation.

Applications of Bion’s Theory of Thinking, as Expressed in His GRID

Bion’s GRID as a Map

Bion conceived his Grid as a device for observation, to be open to psychic elements to

come or yet unknown. We present this Grid as a map to explore the landscape of

mentalization, this way we are able to make a link between zones of mentalizing and

psychopathology. Three zones of psychic functioning can be discerned: a zone of unmediated

elements, a closed zone and an open zone. As thinking is a multilayered phenomenon, it spans

several zones of the GRID simultaneously. For reasons of clarity, the three zones will be

discussed separately.

The first zone or the A-row consists of unmediated beta-elements. These elements are

unknowable and fit for evacuation or A6 (Bion, 1963a), which makes them manifest. Such an

evacuation can take place by some forms of projective identification or by generating surface

experiences such as self-cutting, excessive eating or dieting, vomiting, some kinds of physical

exercise and sexual activity, drugs, alcohol. These actions (A6) are a substitute for thought.

They have to be repeated over and over to evade intolerable mental states. Such A6 elements

are excessively present in borderline pathology.

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Figure 1. Three zones in the GRID: the zone of the unmentalized elements (black), the closed

zone (dark grey) and the open zone (light grey).

Definitory

hypotheses

1

ψ

2

notation

3

attention

4

inquiry

5

action

6

...n

A βelements

A1

A2

A6

B αelements

B1

B2

B3

B4

B5

B6

...Bn

C Dream

thoughts...

C1

C2

C3

C4

C5

C6

...Cn

D pre-concep

D1

D2

D3

D4

D5

D6

...Dn

E conception

E1

E2

E3

E4

E5

E6

...En

F concept

F1

F2

F3

F4

F5

F6

...Fn

G Scientific

deductive

G2

H algebraic

calculus

In contrast, A1-A2 unmediated elements remain in the darkness of the unthought reality,

for instance after trauma. These non-mediated elements can be seen as deposited in crypts

within the personality (Wilgowicz, 1991). It is often ‘après-coup’, catalysed by a sensorial

experience that a patient may bump up against them and have a flashback.

Some patients with a borderline organization, are characterised by unmentalized A1 and

A2 elements rather than by A6 elements. They have less symptoms and are more quiet. They

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function to a large extent in two-dimensional way (Meltzer, 1975), displaying autistiform

traits. These patients seem to suffer from a developmental lack in mentalization, which may

be compensated by intellectual skills.

In psychosis not only psychic experiences but also fragmented parts of the ego and ego-

functions such as seeing, hearing are evacuated by projective identification (A6), forming A-

row elements which Bion named ‘ bizarre objects’, resulting in hallucinations (Bion, 1962a,

p.25). Delusions are formed by an agglomeration of beta-elements and debris of fragmented

thoughts and precursors of thoughts. This may function as a beta-screen (A2), which

precludes a further processing of emotional experiences.

An example of the presence of such a beta-screen in psychosis is a patient giving the

same stereotypical delusional explanation of his world, session after session for years. This

explanation has turned into an artificial, sterile thing to ward off the psychic processing of

emotional experiences

A-row or beta-elements are not as excessively and disturbingly evacuated in neurotic

patients as in borderline patients, but unthought experiences in neurotic patients are a point of

attention in contemporary psychoanalysis (Bollas, 1987).

In all other rows than the A- row of the Grid, the elements have a psychic quality.

Column 1 & 2 is called the closed zone, because these elements are used to restrain the

thinking process and avoid psychic pain by fixating the experience in a definition (column 1)

or by denying it (column 2). This is characteristic for narcissistic patients, the price to pay

being an emotional poverty and a lack of creative functioning. In sociopathy there is often a

combination of these elements with A6 elements.

For instance, a sociopath hiding behind the fantasy of standing at the helm of a ship that

has to be kept in balance during a storm. Every emotional situation, which this patient has to

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deal with, is closed down and reduced to this static fantasy (C2-E2). However when he is

frustrated too much, he becomes violent (A6).

The third zone consists of columns 3, 4, 5, 6 except A6. These are the elements with a

psychic nature which emerge spontaneously and go with the experience of the opening up of a

mental space. This open psychic processing is a kind of creative preconscious process, with

an automatic, spontaneous generation of psychic elements. Psychopathology in the open zone

is characterised by a diminished presence of elements of columns 3, 4, 5 and a diminished

fluidity of the shifts between elements in this zone. This is similar to what Green (2000)

described as the ‘central phobic position'. Patients in whom the problem merely centres on the

fluidity, which is the case in high-level borderlines and neurotic patients, are good candidates

for psychoanalytic work (Van Lysebeth, 2001).

According to Bion (1957) patients with personality disorders and psychosis feel more

pain when entering the open zone and have a tendency to withdraw into the closed zone or to

attack emerging and existing links and to lapse into the A-row level. This is the therapeutic

dilemma in low-level borderline patients and psychotics (Vermote, 2002a).

Some Implications for Treatment

Layers of the psychoanalytic process.

The psychoanalytic process differs according to the zones in which the transformations

of the elements take place. In the unmentalised zone (the A-row level), the elements are

distorted by projective transformation and by transformation in hallucinosis (Bion, 1965) and

remain concrete, unmentalized experiences in the here and now. Mental space is lacking,

actions speak louder than words and boundaries fuse. Containment, basic safety and giving

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meaning are fundamental at this level – the so-called ‘basic psychoanalytic process’ (Balint,

1968, Godfrind, 1993) which is always part of the psychoanalytic process, but especially

important in personality disorders and psychotics.

In the open-zone the elements reflect the internal objects with hardly any deformation in

the transference, hence Bion’s term ‘Rigid motion transformations’ (Bion, 1965,p.19). The

resulting as-if character of the transference makes it suitable for interpretations. This is the

level of the ‘classic psychoanalytic process’.

Elements at the level of the closed zone (columns 1 and 2) are fixed in protective

organizations, leading to an impasse in the process as Steiner (1993) described.

Wavelengths of communication and action.

Communications can take place at different wavelengths (Lucas, 1993), according to the

zone of psychic functioning. The same flag may have different ‘charges’. At the A-row level

for instance, communication does not serve to transfer meaning, but to do something, to evoke

something in someone else, to get rid of something. This kind of communication is for the

greater part exempt of symbolic meaning. Patients at this level tend to listen less to what the

therapist is communicating than to his voice, to the music of the words, scanning the

environment for safety.

The actions may reflect these different wavelengths: actions in A6 are substitutes for

thought, actions in B6 are a prelude to thought (Bion, 1977, p.7) and acting-out is in relation

to a repressed unconscious conflict (C6 for instance). Bion’s Grid makes it possible to

differentiate the level at which an act takes place.

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Kinds of repetition-compulsion.

Repetition-compulsion has a different character according to the zone to which the

elements belong. Unconscious elements from the open zone may then be repeated till they

become conscious (for instance mental representations repeated in transference). This is in

contrast with elements from the unmentalized zone, which may be repeated until a form is

found to contain them, thus allowing them to be mentalized. This repetition may take place by

evacuating and controlling them in someone else through projective identification, a

characteristic of the relationships and transference of many borderline patients.

Fonagy’s Various Concepts of Mentalization

Reflective Functioning

Although both Fonagy’s Reflective Functioning and Bion’s Thinking go by the name of

mentalization, both concepts have different origins. The concept of ‘Reflective Functioning’

is grounded in attachment research, and (Fonagy, Steele et al.,1991, 1993; Fonagy, Steele,

Steele et al., 1994, 1995; Fonagy & Target, 2000; Fonagy, Gergely et al., 2002). Fonagy and

colleagues' (1991) RF is an elaboration of Main’s concept of ‘metacognitive monitoring’. It is

the capacity to perceive ones own and others’ actions in terms of mental states such as

feelings, beliefs, intentions, wishes (Fonagy & Target, 1996).

Fonagy and colleagues developed a scale, to assess the RF on the AAI and found that

the RF of future parents was predictive of the attachment of the children to their parents

(Fonagy, Steele et al., 1991,1993). Attachment patterns are not copied mechanically by

children, but a child assimilates its parents’ psychical dealing with relationships (Fonagy &

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Target, 1996b). The link between the attachment patterns and RF is merely indirect, both

being rooted in a common base, namely security (Fonagy et al., 2002).

Target and Fonagy (1996) elaborated this concept of RF from the point of view of

developmental psychology. A child initially functions in the equivalent mode: it makes no

difference between its experience of the world and how the world really is. In the pretend

mode the inner and outer world are gradually differentiated but the inner world is experienced

as having no connection with the outer world. At the age of 3-4 the child integrates the two

modes in the reflective mode. This process seems to be impeded when the environment fails

to see the child as an intentional being. This is seen in borderline patients who remain stuck in

their inner turmoil and remain functioning in the equivalent mode, as they do not have a RF to

develop an object and self-constancy.

Empirical research has further shown that borderlines and patients with antisocial

personality disorders have a significantly lower RF than normal people (Fonagy et al.,

1995,1996a), that RF was protective against post-traumatic pathology (Fonagy et al., 1996a),

and that there are good reasons to see it as a factor of resilience in people with constitutional

or environmental vulnerabilities (Fonagy et al., 1994).

Psychoanalysis and psychoanalytic therapy offer an opportunity for patients to develop

their capacity for reflective functioning, reflections on their mental states being worded by

patient and analyst and differences between their own reflections and the one’s of the analyst

becoming clear through interpretations (Fonagy & Target, 1996). This is a necessary

developmental help in severe psychopathology (Bateman & Fonagy, 2001) and in child

psychotherapy (Fonagy & Target, 1998b).

The major point of criticism on RF (Bram & Gabbard, 2001) is that, although it is not

conceptualised as a cognitive function, its operationalization in the RF scale is mainly

cognitive.

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Mentalization and Interpretive Interpersonal Function

Fonagy, Gergely et al.(2002) further expanded their theory of mentalization to the

concept of Interpretive Interpersonal Function (IIF). It is a function of an overarching neural

system in the related domains of affect-regulation, psychic processing and reflective

functioning. RF or the interpretation of relational experiences in terms of mental states is now

seen as part of this larger interpretive function. The other parts are the psychic processing by

the creation of second-order representations which are the base of affect-regulation. Parental

mirroring is crucial to this function. Although based on developmental and biological theories

it is close to Bion’s approach of mentalization: the psychic processing of affects and

experiences into psychic elements with the parental containment as a base.

Moreover, IIF is seen as a dual function: IIF-affective, which is closer to empathy, and

IIF-cognitive, which is closer to RF. This dichotomy overcomes the former critique that the

mentalization concept of Fonagy and colleagues is too cognitive in nature.

The psychopathological hypotheses stemming from this new model are somewhat different

from the ones linked with the original RF theory. Borderline pathology was explained

originally as not having a model of what happens in the mind of another, which leads to a lack

of object-constancy and having to rely on other mechanisms to release tension (Fonagy,

Steele et al., 1994), and on the persistence of the dual (equivalent-pretend) mode of

functioning (Fonagy & Target, 2000). In the recent model (Fonagy, Gergely et al, 2002)

borderline pathology is linked with a lack of parental affect regulation, causing a failure in the

creation of second-order representations, which is close to Bion’s point of view. Narcissistic

pathology is explained as a special failure of parental affect regulation. When the infant’s

emotion is misperceived by the caregiver, the mirrored state is incongruent with the infant’s

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feelings. This gives raise to an alien state, which is the accumulation of un-mirrored internal

(self) states that have acquired a representation in terms of the other rather than the self. Yet

they are experienced as part of and within the self.

The Bion and the Fonagy Approach of Mentalization Compared

Empirically

To study whether changes in the mentalization according to Bion are a significant

dimension of the therapeutic process, we constructed a scale to rate changes in the Bion

mentalization level (B-Grid scale). Bion made an open Grid of at least 34 categories to

categorize the level and the use of psychic elements in the automatic, preconscious

mentalization process. The 6 point scale is based on the presence of these categories in the

answers of the ORI 1. means no psychic elaboration in the responses, 2. some psychic

markers, 3. clichéd, existing forms of containing an affective experience or mentally warding

off affective experiences for instance by rationalisation, 4. spontaneous and creative use of

metaphors, dream images, thoughts, 5. the use of more than one category in mentally dealing

with an emotional experience evoked by a question in the ORI, 6. a flexible use of a wide

range of categories. The B-Grid scale is assessed on the Object Relation Inventory of Blatt

(1996). Preliminary results about inter-rater reliability and validity are good (Vermote,

Vertommen, Verhaest et al., 2004).

Fonagy and his colleagues’ Reflective Functioning, is operationalised in the Reflective

Functioning Scale (Fonagy et al., 1998a). This is a 7 point scale with intermediate levels

about the capacity to perceive ones own and others actions in terms of mental states (Fonagy

et al, 1998):1. means Lacking RF, 3. Questionnable or low RF, 5. Ordinary RF, 7. Marked

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RF. The RFS is assessed on the Adult Attachment Interview. The RFS has an established

reliability and validity (Fonagy et al., 1998a).

The main difference between the two scales is that RF as expressed in the RFS relates to

the way people reflect (cognitively and consciously) on self-other relationships, while Bion’s

thinking as reflected in the B-GRID scale concerns the way people process their perceptions

and affects at a preconscious level.

Both approaches do not necessarily coincide, there are patients who have a high capacity

for interpreting others’ behaviour without being in contact with their own affects. On the other

hand, there are also patients with highly creative, associative psychic functioning who are in

contact with their emotions, but who lack the capacity for interpreting their own behaviour

and that of others. This contrasts with the view of Lecours and Bouchard (1997), who

hypothesize the Reflective Functioning of Fonagy and colleagues being on top of the

mentalization as formulated by Bion, they suggest that the psychic processing as described by

Bion is the basis of Reflective Functioning.

In a pilot study we examined the relation between the Reflective Functioning of Fonagy

and colleagues and the mentalization according to Bion. We further examined whether the

DSM IV axis II borderline group showed a significant difference with the non-borderline

group in RF and in Bion Grid measures. A significant lower RF was expected in the

borderline group (Fonagy, 1996a).

The subjects of this pilot study were 14 personality disordered patients, 5 M, 9 F,

admitted to the setting for psychoanalytically informed hospitalization at the University

Centre St.-Joseph, Kortenberg, Belgium. Their DSM IV axis II diagnoses were: 8 borderline,

3 narcissistic, 1 schizoid-narcissistic, 1 dependent, 1 not otherwise specified.

An ORI and an AAI were assessed wihin the same week by two separate psychologists,

one trained in assessing the ORI and one trained in assessing the AAI. The anonymised ORI

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transcripts were rated with the Bion Grid Scale by a third psychologist, who was blind to any

information about the patients and who was using a manual to rate this scale. The anonymised

transcripts of the AAI were rated with the RFS (Fonagy et al., 1998) by a fourth psychologist,

trained in rating RF on the AAI.

The correlation between the Bion Grid scores and RF scores was calculated with the

Pearson Correlation Coëfficient. The difference of RF measures of the borderline versus the

non-borderlinegroup was calculated with a t-test. The same was done for the Bion GRID

measure. Given a lacking equality of variances in this small group, non parametric

alternatives such as the Wilcoxon Rank Sums, the Chi-square and Exact tests were calculated

as well.

As a result we found no significant correlation (r = .37, p = .19) between RF values (M

= 5.43, SD = 1.91) and Bion Grid values (M = 5.57, SD = 1.22). The mean RF of the

borderline group was 4.13 (SD = 1.36) and that of the non-borderline group was 7.17 (SD =

0.74). The mean Bion GRID scale of the borderline group was 5.00 (SD = 0.75) and that of

the non-borderline group 4.67 (SD = 0.82). As expected from Fonagy et al. (1996a), the RF

differs significantly as a function of the DSM IV axis II diagnosis of BPS (t (12) = – 4.92, p =

.0004), while this is not the case for the Bion Grid scale (t (12) = –0.70, p = .49). Non

parametric tests yielded similar results.

We may conclude that the poor correlation between RFS and Bion Grid scale suggests

that the RFS and B-Grid scale measure different aspects of mentalization, rather than RF

being on top of the Bionian mentalization, as Lecours and Bouchard (1997) hypothesized. The

difference of the mean RFS for the borderline versus the non- borderline group was expected

from Fonagy et al. (1996a). The fact that this is not the case for the Bion Grid Scale is another

argument that it are two different aspects of mentalization.

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Clinically

The difference and relationship between the two concepts of mentalization is illustrated

in the following sequence of sessions of a psychoanalysis.

Session 1. The patient associates about eagles with powerful claws, which reminds

her of her father.’ My family says that, as a child, I had a tendency of staring out in

front of me at the world.’ The staring eyes evoke in her the image of an owl. She

imagines a large owl behind her, who is covering her with his wings. She contrasts the

owl with the eagle. (The elements in this session have the characteristics of what we

called the GRID open zone, emotional experiences evoking dreams, images, thoughts.

The communication between analyst and analysand is on the same wavelength. It is

clear that this owl refers to me (one of the authors which was the analyst) as a good,

backing object).

Session 2. The analysand expresses her anxiety over some serious problems with

one of her adolescent children, which she interprets from her own feelings of guilt. She

is not in a mood for associative work and wants to act and take immediate decisions

about a hospitalization of her daughter. (It is striking that despite her usual rich

mentalizing in the Bionian sense, she shows a low RF capacity in the Fonagy and

Target sense. She has no idea at all of what is going on in the mind of her daughter. She

is in the equivalent mode, making hardly any distinction between her inner psychic

reality and the reality outside.) After giving it a thought, I decide to ask her how she

thinks her child is experiencing what is happening. Through reflection she develops a

number of points of view, which her daughter might be holding, and then decides to find

out what happens in the mind of her daughter instead of taking an immediate decision.

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Session 3. In the next session, the analysand says how much the previous session

has helped her. Her daughter took a good solution herself for her problem. The patient

has the feeling that she understands her daughter better. (Nevertheless, I felt very

ambivalent. On the one hand, I had the feeling of having helped her, but on the other

hand I might have broken the spontaneous mentalization process by asking her

questions, stimulating a cognitive stance). Then she mentions a dream she had the other

night, a dream about the splitting of a Siamese twin. (The image reflects how she

experiences her daughter more as an individual on her own. The dream also shows that

while she felt helped at a conscious level, at a preconscious level, she felt put at a

distance by my asking her questions and taking a cognitive stance, which is not my usual

attitude. It is switching from the open to the closed zone in the Bion Grid.

Preconsciously she perceives this switch, she feels put at a distance by the cognitive

stance and elaborates this creatively in the dream of the splitting of the Siamese twin.

She repairs at a preconscious level what could have been a rupture of the mentalization

process according to Bion. Her dream brings the mental functioning and the interaction

between analyst and analysand, again in the so-called open zone of Bion’s Grid.

Theoretically

We argued how the recent concept of Interpersonal Interpretive Function (IIF), is closer

to the Bion model of mentalization, than is the case with RF alone. However it is difficult to

compare the two models. The IIF concept integrates genetic, biological, affective, and

learning theory, developmental psychology, as well as several empirical and conceptual

approaches to psychoanalysis, while Bion’s model is rooted in his experiences as an analyst.

A clinical meeting ground for the two approaches may be found with the Mentalized

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Affectivity (M.A.) concept (Fonagy, Gergely et al., 2002, p.436) which is defined as a

sophisticated kind of affect regulation that denotes how affects are experienced by a person

which is self reflective, while he/she remains within or recaptures the affective state. This

concept may be particularly helpful in the treatment of borderline patients, whose capacity for

reflective functioning needs to be increased.

Fonagy discriminates three dimensions in dealing with affects in M.A, which he calls

elements. This is different from the meaning of the word element in the Bion where it denotes

a manifestation of psychic functioning which can be placed in a single Grid category (Bion,

1963a). The three M.A. elements are the identifying, the modulating and the expression of

affects. The ‘identifying of affects’ dimension is in its basic form the naming of affects and in

its complex form the discerning of their relation. The ‘modulating of affects’ dimension

consists basically of a modification of affects in intensity and duration, in the complex form it

is about the making of coherent links with one’s history. The ’expression of affects’

dimension is in its basic form the restraining or expressing of affects, outwardly or inwardly.

The inward mode is especially consistent with self-reflexivity. The complex form indicates a

communication with the expectation of how it will be received by the others.

Fonagy’s M.A. scheme and Bion’s Grid both offer a good reference in dealing with

personality disorders, to know at which level they are functioning at a given moment and to

know at which level one has to respond. A patient in an emotional storm for instance, with

undifferentiated feelings and an intense outward expression is not helped with sophisticated

interpretations but with a restoration of his feeling of safety. The M.A. offers a good frame of

reference to detect at which level the patient deals self-reflexive with his affects so that the

therapist can match his intervention.

This way, it is similar with Bion’s Grid, which is as well an instrument to increase the

awareness of the level at which the patient is functioning (Chapter 1). The Grid is finer in this

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respect in showing also the preconscious and unconscious associative-creative dealing with

affects, in having a larger scope of notation (preconcept, conception, dream-images, thoughts,

abstract ideas) and that the use of the notation is also taken into account (definition- denial-

exploration-action). In addition, the B-Grid offers in addition an elaboration of the dealing

with affects which are warded off by the psyche, the elements of the A row and the second

column.

The element of M.A, denoted as ‘ expression of affects’ is divided in an inward

expression which corresponds to the first five columns of the B-Grid, and an outward

expression which corresponds with the last column of the B-Grid. In comparing M.A. and the

B-Grid, the Bion Grid proves to be more complicated and serves to elaborate a session after

the session, while M.A. may be used as a compass during a session which is useful especially

in intense sessions with personality disordered patients. Furthermore, the Bion Grid lacks the

relational component of the M.A. approach, as it focuses only on intrapsychic processing.

Both approaches are overlapping in some aspects and complementary in others, but at

large the dichotomy between the two approaches of mentalization remains. The Fonagy

approach is more on the ego-psychological side (a thinking agent) while the approach of Bion

is more kleinian and stresses the unconscious and preconscious side of psychic functioning

where feeling and thinking are interwoven in alpha-elements, phantasies, preconcepts, to

more conscious thoughts and theories.

Conclusion

Mentalization is a many-sided concept. The RF concept was developed of research

findings and proved to be predictive of the transmission of psychopathology, and is lowered

in BPS and antisocial disorders. As it is rooted in research, it is a simple and well-defined

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concept, which offers a model for understanding psychopathology. The concept of RF is

concerned with the conscious dealing with inter-psychic issues, a register which received less

attention in adult psychoanalysis because of the limits of the psychoanalytic frame based on

free association. In contrast, the bionian concept of thinking deals with the way preconscious-

unconscious psychic processing occurs in the sessions. Bion elaborated his concept over a

period of twenty years into a kind of epistemology with consequent implications for practising

analysts. By using Bion’s Grid as a map, we could explore psychopathology with his model

on psychic functioning and explore the psychoanalytic process. Preliminary results of

operationalization in a GRID scale indicate that Fonagy’s RF and the bionian thinking are two

sides of mentalization.

Fonagy and his colleagues’ new IIF model of mentalization integrates RF but also pays

attention to the aspect of psychic processing and affect regulating. There is no empirical

operationalization of this global IIM model yet. The notion of Mentalized Affectivity is a

translation of this model in the practice of psychotherapy and psychoanalysis. This makes it

possible to hold the Fonagy and Bion models against the light of clinical experience. In so

doing, the difference between an ego-psychological and a kleinian watershed becomes clear,

as two different, largely complementary sides of a complex phenomenon.

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PART 2

INSTRUMENTS TO MEASURE PSYCHIC CHANGE IN A

PSYCHOANALYTICALLY INFORMED HOSPITALIZATION

BASED TREATMENT OF PERSONALITY DISORDERS

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Chapter 3

Measuring the Psychoanalytic Process in Personality Disorders on the

Object Relations Inventory: the Independent Researcher's Perspective.

Chiesa (2000) reported overall improvement with a psychoanalytically informed

hospitalization, followed by outreached therapy. The Bateman and Fonagy RCT study (1999,

2001) demonstrates significant clinical improvement in an 18-month psychoanalytically

oriented partial hospitalisation program and found that the improvement continued in the 18

months after the treatment. This study caused a reappraisal of a psychoanalytic approach for

personality disorders as expressed in the guidelines of the APA (Sanderson et al., 2002).

The therapy being effective, the underlying mechanism of change remains unclear.

Psychoanalysts traditionally link this outcome with the psychoanalytic process they focus on.

As we described in Chapter 1, the focus on inner change entails other techniques, evaluations

and length of stay than symptom oriented therapy. It is therefore important to examine these

inner changes with psychoanalytic model specific measures and to study their relation with

changes in symptoms and ways of coping and relating. The problem is however that there is

no clear definition of the psychoanalytic process (Vaughan, Spitzer, Davies & Roose, 1997).

There exist nevertheless several scales for rating it by independent researchers. Most of these

scales have a large number of items which may be related to a process of inner change. The

Psychotherapy process Q-set (Jones, 2000), is such a scale with 100 items describing patient's

and therapist's actions, attitudes and experiences and their interaction. The scale does not rely

on a definition of the analytic process but categorises what happens in a session, which is then

considered to be related to the analytic process. Clinical judges watch a videotape or read the

transcripts of a therapy session and then sort the 100-items on a continuum from least to most

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characteristic. Although this instrument has high levels of reliability and validity, it was

problematic for us to use this time consuming instrument, in a prospective process-outcome

study on a larger group of hospitalised patients. Furthermore it is difficult to use it in an

integrated therapy programme, based on group therapy.

Another instrument is the Columbia Analytic Process Scale (CAPS) (Vaughan et al.,

1997) which is based on a definition of the psychoanalytic process as existing of free

association, interpretation and working through. The CAPS measures these facets of an

analytic process. We have discussed in Chapter 1 why, in our opinion, this definition of the

PA process is not appropriate for PD. Moreover, the scale did not reach construct validity

(Vaughan & Roose, 1995).

Another overall scale which may be used to measure the psychoanalytic process is the

Scale of the Psychological Capacities (SPC, Wallerstein, 1994), describing 17 psychological

capacities which are measured on an audio-or videotaped clinical interview. This instrument

with an ego-psychological base has a good reliability and validity, but it is a measure which

seems more apt to measure outcome than the mechanism of inner change.

Most other psychoanalytic model specific process scales for independent researchers

measure components of the psychoanalytic process. The Core Conflictual Relationship Theme

(CCRT, Luborgsky & Crits-Christoph, 1999) is a reliable method to capture the 'central

relationship pattern' on transcripts of sessions. Three components are rated: a subject's wish,

need, or intention; a response from another person to the subject's wish; and the response of

the subject to the response of the other. Another scale about the specific interaction in

psychoanalytic sessions is the Transference Countertransference Analysis (TCA, Normandin

& Foelsch, 1999), which is applied to videotapes. It has good inter-rater reliability but there

are no data available about validity.

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Other tests study facets of the process in detail, like the Referential Activity Scale

(RA, Mergenthaler & Bucci, 1999) which is a measure about the linking of verbal and non-

verbal representations. This scale measures the concreteness, imagery, specificity and clarity

of speech. A detailed examination of the interaction between therapist and patient can be

studied by using Facial Action Coding System (FACS, Ekman & Rosenberg, 1997). The scale

makes it possible to register descriptively on videotapes, every facial movement on patient

and analyst that is anatomically feasible. It is evident that these mesaures are difficult to use in

a study of a large number of personality disordered patients in a psychoanalytically informed

hospitalisation with a integrated programme existing of several kinds of therapies.

It was J. Clarkin who suggested to try to operationalize the three dimensional model of

change discussed in Chapter 1, in trying to measure the psychoanalytic process of P.D.

patients. It was a major advantage that there existed already two well established measures

about inner change in patients, the Differentiation Relatedness Scale (Blatt et al., 1996) and

the Reflective Functioning Scale (Fonagy et al., 1998) which could be related to this model.

This project which was supported by the authors of these scales (P. Fonagy and S. Blatt).

The three dimensional model of inner changes in personality disorders (Chapter 1) is based on

the common assumption (Balint, 1968; Bion, 1962; Fonagy, 1999; Kernberg, 1980 and

Winnicott, 1965) that psychoanalytic change is not about the interpretation of unconscious

meaning or about searching for a historical truth. We see intrapsychic change in personality

disorders as being related to changes in three inter-related dimensions. The first dimension is

about the subjective experience of security or safety and is related to a range of concepts. The

second dimension is about mentalization of which we discussed two facets. The first facet

being the psychic processing of intrapsychic and interpersonal experiences, a preconscious,

automatic, spontaneous process which is studied in detail by Bion (1962, 1963, 1965) in his

theory on thinking. The second facet being the intentional stance toward interpersonal

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experiences in taking a step back and trying to understand one’s own and others' behavior in a

psychic way, which is called Reflective Functioning by Fonagy and colleagues (Fonagy,

Steele, Moran, Steele & Higgitt, 1991; Fonagy, Moran, Edgcumbe, Kennedy & Target, 1993;

Fonagy, Leigh, Steele, Steele, Kennedy, Mattoon et al., 1996; Fonagy &Target, 2000;

Fonagy, Gergely, Jurist & Target, 2002). The third dimension is the transformation of mental

representations of self and others, into more differentiated and stable ones with an increasing

tolerance of ambivalence. Mental representations are active schemata, which may be

conceived as linked to autobiographical as well as to procedural memory (Blatt & Auerbach,

2001; Blatt, Stayner, Auerbach, & Behrends, 1996). They structure and modulate how one

feels and thinks about others and oneself.

The aim of this study is to examine whether it is possible for external researchers to assess

and measure the psychoanalytic process in personality disorders according to these three

hypothesised dimensions of intrapsychic change.

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Measuring the Three Dimensions of Intrapsychic Change on the Object Relations Inventory

(ORI).

To measure the first dimension or the feeling of safety, we considered at first to rely

on existing scales such as the Barett-Lennard (1966) or existing attachment scales. However

they are more about the therapeutic relationship and take the therapist into account as well,

while we are interested in measuring psychic changes in the patient, more specific his psychic

experience of safety. Therefore we decided to construct our own scale. It is a 5-point scale

about felt safety (FS), which reflects the security a patient is experiencing in the setting at a

given moment (Figure 1).

Figure 1. Felt Safety Scale (Vermote & Vertommen, 2004).

Felt Safety Scale

1. No felt safety in therapy

2 Predominance of feelings of unsafety, minimal expression of safety

3. Fragile, changing feeling of safety

4. Predominant feeling of safety

5. Strong feeling of safety

To assess the second dimension or mentalization we used two scales. For the reflective

functioning aspect of mentalization, we used the Reflective Functioning Scale (RFS; Fonagy

et al., 1998, Figure 2). This is an 11-point scale designed to be assessed on the Adult

Attachment Interview (AAI; Main et al., 1991), ranging from anti-reflective responses to

responses with an exceptional sophistication. The RFS as measured on the AAI has

established reliability and validity (Fonagy et al., 1998).

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To assess the psychic processing aspect of mentalization, the generation and

transformation of mental representations, we rely on Bion’s theory (1963) of the elements of

thought and his theory of the transformations of these elements (Bion, 1965; Vermote, 1998).

Bion categorizes the levels and the use of these elements in a Grid (Chapter 2). A translation

of Bion’s Grid into a scale was achieved by discerning four zones in his Grid (Figure 3).

These zones could be placed in a ranked order. Taking the flexibility of switching within and

between zones into account as well led to 6 distinguished categories (Figure 4).

To assess the third dimension or the mental representations of self and others, we use

the Differentiation Relatedness Scale (DRS) (Diamond, Blatt, Stayner, & Kaslow, 1993; Blatt

& Auerbach, 2003). The DRS (Figure 5) integrates the conceptual level of the representations

with the level of self-other differentiation which they reflect, both seen from an interpersonal

perspective. The DRS is based on the assumption that development moves toward (a) a

consolidated, integrated, and individual sense of self-definition and (b) an empathically

attuned mutual relationship relatedness with significant others (Diamond, Blatt, Stayner, &

Kaslow, 1993). Differentiation and relatedness are seen as interactive dimensions that unfold

throughout development (Blatt & Auerbach, 2001). The DRS is an ordinal scale with ten

levels

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Figure 2. Reflective Functioning Scale (Fonagy et al., 1998).

Level/ Scale Point Description

-1 Negative reflective

functioning

Responses that are anti-reflective, hostile, bizarre, or inappropriate

in the context of the interview

1. Absent Reflective

functioning

Responses either totally or almost totally lacking in reflective

functioning, with little evidence that the person thinks about mental

states. Accounts are barren, lacking in detail pertaining to mental

states, or are egocentric and self-serving.

3. Questionable Reflective

Functioning

Responses contain some evidence of consideration of mental states,

but most references are not made explicit. The person’s

understanding of mental states is either banal and cliched or diffuse

and unintegrated.

5. Ordinary Reflective

Functioning

The subject displays an ordinary capacity to make sense of

experiences in terms of thoughts and feelings and has a consistent

model of mental states that requires little or no inference from the

rater. The subject’s model is limited and does not include

understanding of conflict and ambivalence

7. Marked Reflective

Functioning

Responses contain numerous instances of full reflective functioning

suggestive of a stable psychological model of the mind. Much detail

about thoughts and feelings is present and implications of mental

states are explicitly spelled out. The subject is usually able to

maintain a developmental interactional) perspective and to arrive at

original reintegrations of states of mind

9. Exceptional Reflective

Functioning

Responses show exceptional sophistication. They are commonly

surprising in their insights, are quite complex or elaborate, and

consistently manifest causal reasoning with regard to mental states.

The subject displays a consistent reflective stance across all

contexts.

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Figure 3. Zones in Bion's Grid

Definitory

hypothesis

psi notation attention inquiry action …n

A

Beta-elements

A1 A2 A6

B

Alfa-elements

B1 B2 B3 B4 B5 B6 ….Bn

C

dreams, myth

C1 C2 C3 C4 C5 C6 ….Cn

D

Pre-conception

D1 D2 D3 D4 D5 D6 ….Dn

E

Conception

E1 E2 E3 E4 E5 E6 ….En

F

Concept

F1 F2 F3 F4 F5 F6 ….Fn

G

Wet. syst

G2

H

Algebr.calculus

Bion distinguishes eight rows from A to H in the vertical axis of the GRID, which represent the genesis of thinking and levels of psychic functioning. -A: Beta-elements are sense data, which have not yet been processed. and are unfit for

linking-articulating. Therefore they can only be placed in columns 1, 2 and 6. -B: Alpha-elements, bear a trace of something psychic and are the building bricks of dream

thought. -C: C-elements are the products of dream thought: dreams, myths, phantasms; usually visual

in nature, but olfactory, tactile and auditive images exist as well.

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-D: Pre-conceptions are empty, existing moulds (congenital, or as part of culture and language). They are open to a limited range of experiences, have the capacity of containing sensory and affective perceptions.

-E: Conceptions emerge when a perception or feeling meets an appropriate form or mould, thus resulting in a realization.

-F: Concepts are conceptions which have freed themselves to certain extent from concrete experiences or perceptions, and are therefore more generally applicable.

-G: Scientific Deductive System: is a linking of various concepts resulting in a predictable theory. Bion (1963) believes that psychoanalysis does not reach this level, G can only be found in the second column.

-H: Algebraic calculus: a scientific system in algebraic terms, to make predictions, free from actual reality (e.g. physics). H does not yet exist for psychoanalysis.

The horizontal axis shows how these elements are put to use. 1. Definition: elements used as a statement which closes or anchors something (e.g. you are

depressed). 2. Ψ: elements used to dissipate something (denial: e.g. a handshake to dispel anger), or to lie.

According to Bléandonu (1994), the term “Ψ” is derived from “προτον ψευδοσ”, the first lie as described by Freud in is work on Hysteria.

3. Notation: taking note of (e.g. writing something down, transposing something into images, stories, etc.).

4. Attention: the rêverie, the free-floating attention which allows for the emergence of a “selected fact”. Bion held on to this state of non-fixation and labelled the category D4 as the locus of the love of the analyst for his patient (Bion, 1965).

5. Inquiry: a more goal-oriented scrutiny; marked by obstinacy and curiosity. Therefore labelled first the “Oedipus” column (Pontes de Miranda Ferreira, 1997).

6. Action: doing something with the elements (e.g. evacuation of a beta-element, giving an interpretation, or making a decision).

Figure 4. The Bion – Grid Scale. 1 No psychic quality, not articulated A1,A2, A6 2 Psychic impression, trace, marker, barely psychic B1,B2,B3,B4,B5,B6 3A Elements used for closing the psychic elaboration of an experience

C1,C2,D1,D2,E1,E2,F1,F2,G3 3B Searching for an existing form to contain an impression, an experience D3,D4,D5,D6 4 Emerging dreams, myths, images C3,C4,C5,C6 / Spontaneous finding of a psychic form

to contain a concrete experience E3,E4,E5,E6/ Open elaboration by concepts (less concrete) F3,F4,F5,F6 : All this by remaining at the same level, in the same row

5 When the patient uses elements from different rows in elaborating an experience, an emotion, a perception or a thought (see arrows)

6 When a large field of elements in the GRID is covered during the ORI (see arrows)

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Figure 5. The Differentiation-Relatedness Scale (Diamond et al., 1993).

Level/Scale Point Description

1 Self/Other boundary

compromised

Basic sense of physical cohesion or integrity of

representations are lacking or breached

2. Self/other boundary confused Self and other are represented as physically intact and

separate, but feelings and thoughts description may consist of

single global impressionistic quality or a flood of details with

a sense of confusion and vagueness

3. self/other mirroring Characteristics of self and other, such as physical appearance

or body qualities, shape or size, are virtually identical

4. self/other idealisation or

denigration

Attempt to consolidate representations based on unitary,

unmodulated idealisation or denigration. Extreme,

exaggerated one-sided description.

5. Semi-differentiated, tenuous

consolidation of representations

through splitting (polarisation)

and/or by an emphasis on concrete

part properties

Marked oscillation between dramatically opposite qualities or

an emphasis on manifest external features

6.Emergent, ambivalent constancy

(cohesion) of self and an emergent

sense of relatedness

Emerging consolidation of disparate aspects of self and other

in a somewhat hesitant, equivocal, or ambivalent integration.

A list of appropriate conventional characteristics but they

lack a sense of uniqueness. Tentative movement toward a

more individuated and cohesive sense of self and other

7. Consolidated constant (stable)

self and other in unilateral

relationships

Thoughts, feelings, needs and fantasies are differentiated and

modulated. Increasing tolerance for and integration of

disparate aspects. Distinguishing qualities and characteristics.

Sympathetic understanding of others.

8. Cohesive, individuated,

empathically reated self and

others

Cohesive, nuanced, and related sense of self and others. A

definite sense of identity and interest in interpersonal

relationships and a capacity to understand the perspective of

others

9. Reciprocally related integrated Cohesive sense of self and others in reciprocal relationships

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unfolding self and others that transform both the self and the other in complex,

continually unfolding ways

10. Creative integrated

constructions of self and other in

empathic, reciprocally attuned

relationships

Integrated reciprocal relations with an appreciation that one

contributes to the construction of meaning in complex

interpersonal relationships

To obtain data for the DRS (Diamond et al., 1991, 1993), Blatt and Auerbach (2003)

use the Object Relation Inventory (ORI), a simple semi-structured interview with open

questions about parents, self, therapist, and significant other.

Assessing the RFS is very time consuming. It takes intensive training to administer the

AAI and another intensive training to rate the RFS on it. The procedure of interviewing and

rating takes more than 10 hours for one interview. Therefore, rating the RFS on the ORI

instead of on the AAI is an idea favoured by Fonagy and colleagues and by Blatt (Target &

Blatt, 2001; Vermote, Vertommen, Corveleyn & Peuskens, 2002; Blatt & Auerbach, 2003).

As the ORI consists of questions about self-other relationships and RF is about the capacity to

deal mentally with self-other relationships, it is reasonable to do so.

The Bion Grid Scale can be scored as well on the ORI, as the ORI questions are open

and invite for association and creative elaboration. A problem in measuring the two facets of

mentalization on an ORI is that the Bion Grid scale is about the spontaneous, preconscious,

creative generation and use of thoughts in all levels of sophistication, while the RFS is about a

conscious, intentional stance evoked by ‘demand questions’ of the AAI. In other words,

assessing the first aspect of mentalization requires an open attitude which leaves the

possibility to associate freely, while the second needs thought-provoking, stringent questions.

We decided, therefore, to let patients freely associate on the four questions of the interview in

the first part and to ask for elaboration on specific examples in a second part of the interview

(Blatt & Auerbach, 2003; Vermote, Vertommen,Verhaest et al., 2004).

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We constructed the Felt Safety Scale to be rated on the ORI. The scale is about the

way patients experience the safety of the therapy and is rated on the parts of the ORI

concerning the therapist and on the elaboration of an example about the therapist.

The DRS and RFS were translated into Dutch. For the DRS manual, difficulties in

interpreting were submitted by way of ORI examples to S. Blatt (Yale University, New

Haven), author of the scale, to be sure that we interpreted the DRS categories correctly.

The original manual constructed for rating the Reflective Functioning on the AAI was

adapted for use with the ORI. This was done with permission of P. Fonagy and colleagues

(University College London) and with permission of S. Blatt. To be sure that valid

interpretations were made, one of us (M. Franssen) engaged in RF rating training with Fonagy

and Target. The FS and B-Grid scale are newly constructed scales to be rated on the ORI.

Each of the scales went through several phases of development: the construction or translation

of the scale, the making of a manual, pilot testing, revision of the manual, and subsequent

retesting. For all the scales, a global mean was determined, relying on an overall impression

after all the parts of the interview were rated separately.

Table 1

Parts of the ORI Which are Rated for Each Scale Measured on the ORI

Scale Mother Father Self Therapist Ex.Mother Ex.father Ex. Th. Global

DRS

RFS

BGS

FSS

X

X

X

X

X

X

X

X

X

X

X

X

X

(x)

X

X

(x)

X

X

(x)

X

X

X

X

X

X

X

(x): these fragments were rated in addition in study 1

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Reliability and Validity of Measuring the Three Dimensions of the Psychoanalytic Process on

the ORI

Study 1. Inter-Rater Reliability of the ORI Measures

Method

Participants.

Reflective Functioning and Bion Grid Scale: Fifteen patients (6 males, 9 females)

referred to a setting for hospital treatment on psychoanalytic lines for personality disorders at

the University Center Kortenberg, Belgium (see Chapter 1) were tested. The patients were

between the ages of 17 and 45 years (M = 24.4, SD = 7.36). Two patients were single, 10

lived with their parents, 2 were married or living together with a partner, 1 was divorced. One

patient completed primary education, 6 secondary education and 8 higher education or

university.

Based on the SCID-II we assigned all patients to one of the three clusters of personality

disorders according to the DSM-IV axis II (APA,1994): Cluster B, 11 (7 borderline, 3

narcissistic, 1 histrionic and borderline); Cluster C, 3 (1 avoidant and dependent, 2 NOS);

Clusters B+C, 1. DSM-IV Axis I diagnoses were 5 mood disorders, 1 anxiety disorder, 3

adjustment disorders and 2 substance related disorders.

Differentiation Relatedness Scale: Fifteen patients (4 males, 11 females) referred to a

setting for hospital treatment on psychoanalytic lines for personality disorders at the

University Center Kortenberg, Belgium (see Chapter 1) were tested. The patients were

between the ages of 19 and 58 years (M = 35.4, SD = 11.33). Ten patients were single, 3 were

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married or living together with a partner, 2 were divorced. Three patients completed

secondary education and 12 higher education or university.

Based on the SCID-II we assigned all patients to one of the three clusters of personality

disorders: B, 13 (10 borderline, 2 narcissistic, 1 narcissistic and borderline); C, 1 (1 NOS);

B+C, 1. DSM-IV Axis I disorders were 5 mood disorders, 4 adjustment disorders, 1 eating

disorder, and 1 substance-related disorder.

Felt Safety Scale: Fifteen patients (3 males, 12 females) referred to a setting for hospital

treatment on psychoanalytic lines for personality disorders at the University Center

Kortenberg, Belgium (see Chapter 1) were tested. The patients were between the ages of 18

and 37 years (M = 27.73, SD = 6.0). Seven patients were single, 4 lived with their parents, 4

were married or living together with a partner. Six patients completed secondary education

and 9 higher education or university. Based on the SCID-II we assigned all patients to one of

the three clusters of personality disorders according to DSM-IV: cluster B, 9 (5 borderline, 1

narcissistic, 2 narcissistic and borderline, 1 histrionic and borderline); cluster C, 3 (2

dependent, 1 NOS); clusters B+C, 3. DSM-IV Axis I disorders were 7 mood disorders, 2

adjustment disorders, and 1 substance-related disorder.

Instruments and procedure.

The ORI interviews were assessed by a psychologist who did not have any other contact

with the patients. The transcripts of the interviews were rated by three raters for each scale,

with a total of 12 raters. Each rater had a short training with the manual of the scale he or she

was rating. There was a difference in the background of the raters. For each scale there was an

experienced psychoanalytic psychotherapist or psychoanalyst and two students of psychology,

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except for the Bion Grid Scale, which was rated by two senior and one junior psychoanalytic

therapist-psychoanalyst. The transcripts were anonymized, distributed at random, and the

raters had no contact with the patients and were blind to any information about them.

Analysis of data.

The inter-rater reliability was measured with Kendall’s coefficient of concordance. As

the inter-rater reliability of the original DRS was measured with the intraclass correlation of

Shrout-Fleiss although it is an ordinal scale, we calculated this correlation as well for the

DRS.

Results

Inter-rater reliability, assessed with Kendall’s coefficient of concordance among three

raters for the global scores of each ORI scale is shown in Table 2. The Shrout-Fleiss intraclass

correlation coefficient for the DRS global score, fixed set mean scores, is.83.

Study 2. Validity of the ORI Measures

The validity of the four ORI scales is further studied by examining the correlations

among the different parts of the ORI and examining their independence from

sociodemographic variables. To study the hypothesized relationship of the scale scores with

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level of psychopathology, we examined the correlations among three kinds of scales

(structural, descriptive, symptomatic) measuring degree of psychopathology.

Table 2

Inter-Rater Reliability of the ORI Scales, Kendall’s coefficient of concordance

Scale W

p

RFS glob, raters 1,2,3 .74 < .0001

BGS glob, raters 4,5,6 .77 < .0001

DRS glob, raters 7,8,9 .70 0.0005

FSS glob, raters 10,11,12 .84 < .0001

(n=15)

Method

Participants.

Eighty-two patients (54 male, 28 female) referred to a setting for hospital treatment (day

hospital and in-patients) on psychoanalytic lines for personality disorders at the University

Center Kortenberg, Belgium (see Chapter 1) were tested. The patients were between the ages

of 17 and 58 years (M = 27.1, SD = 8.5). Sixty-one patients were single, 29 lived with their

parents, 17 were married or living together with a partner, 3 were divorced, and 1 lived in a

community center. Three patients completed primary education, 32 secondary education, and

47 higher education or university. On the basis of the SCID-II, we assigned all patients to one

of the three clusters of personality disorders according to DSM-IV: cluster A, 2 (1 schizoid, 1

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schizotypal); cluster B, 62 (1 histrionic, 44 borderline, 10 narcissistic, 4 narcissistic and

borderline, 3 histrionic and borderline); cluster C, 10 (1 avoidant, 2 dependent, 1 avoidant and

dependent, 6 NOS); clusters A+B, 1; clusters B+C, 10.

According to patients' medical files, there were diagnoses of 33 mood disorders, with 7

cases of major depressive disorder, single episode and 11 cases of major depressive disorder,

mild, recurrent; 5 anxiety disorders; and 14 cases of adjustment disorder, commonly with

mixed anxiety and depressed mood. Other Axis I diagnoses were anorexia nervosa, alcohol

abuse, and cannabis abuse.

Instruments.

The ORI interviews were assessed by a psychologist who did not have any other contact

with the patients. The transcripts of the interviews were rated by the raters from the reliability

study, utilizing the DRS, RFS, BGS and FSS. The transcripts were anonymized, random, and

the raters were blind to all other information.

The Inventory of Personality Organization (IPO) is a self-report questionnaire

(Kernberg, & Clarkin, 1995) which measures intrapsychic structure in three dimensions

according to Kernberg's model of borderline personality organisation: primitive defenses,

identity diffusion, and reality testing. Higher IPO sores correspond with more pathological

personality organizations. The scales show good to excellent reliability and validity

(Lenzenweger et al., 2001; Normandin, 2002). The reliability and validity of the IPO

translated in Dutch was demonstrated by Vermote, Vertommen et al. (2004), Vermote, Smits,

Claes & Vertommen (2005).

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The Symptom Checklist 90 (SCL-90; Derogatis, 1977), translated by Arrindell &

Ettema (1993), consists of 90 items that tap eight psychopathological domains. The

Spielberger State-Trait Anxiety Inventory (Spielberger,1970) was translated by van der Ploeg

et al. (1980), the Spielberger State-Trait Anger Inventory (Spielberger et al., 1980) was

translated Van der Ploeg et al. (1982), and the Beck Depression Inventory (Beck, 1961) was

translated by Bouman et al. (1985).

The Structured Clinical Interview for DSM-IV Axis II disorders (SCID-II) is a

structured clinical interview for DSM-III-R Personality Disorders by Spitzer & Williams

(1985). The SCID-II Personality Questionnaire has been translated in Dutch and adapted for

DSM-IV by Weertman, Arntz & Kerkhofs, 2000.

Analysis of data.

Correlations among the four measures of the ORI were examined with the Pearson

Product Moment Correlation Coëfficient. The relationship with sociodemographic variables

was examined by correlating age with the various measures with the Pearson Product Moment

Correlation Coëfficient, by studying the effect of three levels of education by an analysis of

variance with the General Linear Model procedure and by evaluating gender differences with

a classical t-test. Correlations between the DRS and the IPO, SCID, and SCL-90 were also

analyzed by using the Pearson Product Moment Correlation Coëfficient.

Results

The Pearson correlations of the global scores on DRS, BGS, RFS, and FS with the

components of the ORI are shown in Table 3.

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Table 3

Pearson Correlation Coefficients for ORI Global Scale Scores with Separate ORI Interview

Scale Scores

Scale Moth Fath self therap Ex. moth Ex. Fat Ex Ther

RFS glob .68* .70* .60* .53* .64* .74* .69*

BGS glo .79* .74* .78* .79* .79* .73* .77*

DRS glob .81* .77* .82* .76*

FSS glob .70* .81*

(n = 82). * p <.001

There is a significant correlation between the two measures of mentalization and

between RFS and FSS, as shown in Table 4.

Table 4

Pearson Coefficients for ORI Global Scale Score Intercorrelations

Scale RFS BGS DRS FSS

RFS — .42** .26 .30*

BGS — .15 .12

DRS — .10

FSS —

(n = 82). *p <.01, **p <.001

The DRS and RFS ratings were not influenced by sociodemographic variables. There

was a significant correlation between FS and age (r = .23, p = .03) and a significant

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correlation of the BGS with age (r = .36, p = .001) and with education (r = .48, p = .01).

There were no gender differences on any of the four scales. The correlations among the four

global scores and the subscales of the IPO are significant only for DRS, with IPO primitive

defense mechanisms (r = -.21, p < .05), with IPO identity diffusion (r = -.21, p < .05) and

with IPO reality testing (r = -.24,p < .05).

When correlating the DRS, RFS, BGS, and FSS scores of 82 patients with their SCID-II

measures, we found a significant correlation between the DRS and avoidant (r = -.30, p =

.005), dependent (r = -.24, p = .03), and borderline (r = -. 23, p = .037) categories, as well as

a marginally significant correlation with the paranoid category (r = -. 20, p = . 067). We found

a significant negative correlation of the RFS with avoidant (r = -27, p = .01) and depressive

(r = -.22, p = .05) categories and a positive correlation with the narcissistic category (r = .21,

p = .05). The BGS tended to correlate negatively with the antisocial category (r = -.20, p =

.06). The FSS correlated with the schizotypal category (r = .33, p = .002) and tended to

correlate with the dependent category (r = .21, p = .06).

The correlations of the four global scales with the symptom scales on 82 patients

showed a significant negative correlation of the DRS with the SCL-90 (r = -.24, p < .05), with

the BDI (r = -.26, p < .05), with the STAI (r = -.22, p < .05) and with the STAXI (r = -.24, p <

.05) and a significant negative correlation of the global RFS scores with the Spielberger Trait

Anxiety Scale (r = -.22, p < .05). The FS and the BGS showed no reliable correlations with

SCL-90, BDI, STAI and STAXI.

The DRS Self subscale correlated significantly with nearly all SCL subscales, ranging

between r = -.26 and -.39 (p's < .01), except for the subscales of insufficiency in thought and

problems with sleep.

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Table 5

Pearson Correlation Coefficient of the Global Scores of the ORI-Scales With Symptom Scales

Scale RF B-Grid DRS FS

SCL-90 -.08 .03 -.24* .19

BDI -.17 -.04 -.26* .05

STAI -.22* .01 -.22* -.03

STAXI -.18 -.01 -.24* -.11

(n = 82) *p < .05

Study 3. Convergent Validity of the ORI-RFS and AAI-RFS

To further study the convergent validity of the ORI-RFS with the original AAI-RFS, we

correlated both measures. In this analysis, however, there were three variables which we

correlated: two different interviews (AAI and ORI) on which the RFS was rated, two different

raters, and two manuals: the original and one adapted for rating the RFS on the ORI.

Method

Participants.

Fourteen personality-disordered patients were included in this study (5 M, 9 F). Their

DSM-IV Axis II diagnoses were as follows: 8 borderline, 3 narcissistic, 1 schizoid-

narcissistic, 1 dependent, and 1 NOS.

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Procedure.

An ORI interview and AAI interview were assessed within the same week by two

separate psychologists, one trained in assessing the ORI and one trained in assessing the AAI

by the Main method (George, Kaplan, Main, 1985), both blind to other patient data. The

anonymized ORI transcripts were rated with the Leuven manual (see ORI Leuven 1 in table

6). The anonymized transcripts of the AAI were rated with the original RFS manual (Fonagy

et al., 1998) by a psychologist, trained at the UCL by Fonagy and colleagues (AAI Ucl

manual in table 6).

Given the poor reliability between RFS rated with the Leuven manual on the ORI and

that rated with the original manual on the AAI, we decided to ask the psychologist trained by

Fonagy and colleagues to rate the RFS as closely as possible to the London method but on the

ORI instead of on the AAI (ORI,UCL training in table 6). We wanted to exclude the

possibility that the poor correlation was based on a misinterpretation of rating Reflective

Functioning. Vice versa, we asked the psychologist trained with the Leuven ORI manual to

rate the AAI as good as possible without having got a proper training in doing this (AAI

Leuven1 in table 6).

Because two separate psychologists rated the RFS on the ORI, we have an extra rating

of the ORI (ORI Leuven 2 in table 6).

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Results

The results of the Pearson correlation between mean global RFS scores for 14 patients

rated with the several methods are given in Table 6. The results of the correlation with

Kendall Tau B correlation coefficient are similar and therefore not presented.

Table 6

Pearson Correlation Coefficient of the Correlation Between Mean Global RFS Scores Rated

With Several Methods.

Method AAI Ucl man AAI Leuven1 ORI Ucl train ORI Leuven1 ORI Leuven2

AAI Ucl man

AAI Leuven1

ORI Ucl train

ORI Leuven1

ORI Leuven2

— .44

—

.32

.01

—

.09

-.14

.78 **

—

.12

-.15

.76 *

.95 **

—

(n = 14) *p <.01, **p <.001

The correlation between the scores of the RFS-AAI by the rater trained by Fonagy and

Target using their RFS-AAI manual (AAI Ucl man) and the RFS-ORI by a rater using the

Leuven-RFS-ORI manual (ORI Leuven 1), is only r = .09, n.s. When the AAI rater scored the

ORI adhering to the London training, the correlation between his ORI-RFS (ORI Ucl training)

and his AAI-RFS scores (AAI Ucl manual) was r = .32, n.s.

When the ORI-RFS scores, London method, (ORI ucl training) were correlated with the

ORI-RFS of the rater using the Leuven ORI-RFS manual (ORI Leuven 1), the correlation is

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significant, r = .78, p < .001. When this rater scores the RFS on the AAI (AAI Leuven 1), but

without a training for doing this and using the Leuven ORI manual, the correlation is non-

significant. The correlations of the ORI-RFS scores of this rater with the ORI-RFS scores of a

second ORI-rater using the same method (ORI Leuven 2) were high, r = .95, p < .001.

Discussion

Every psychoanalyst agrees that he does not concentrate on symptom or behaviour

changes, but on inner psychic changes, the development of a psychoanalytic process.

Psychoanalysts have the experience from their own analysis and from what they see happen in

patients that such a process exists. Yet this approach is based on concepts. One cannot hear,

see or smell such a process. Till now, there even exists no clear comprehensive definition of

it. Most of the literature links it with working through, resistance and undoing repression

(Weinshel, 1988, Vaughan-Roose, 1995). From clinical experience and literature we

argument (see chapter 1) that such a model may fit for patients with a neurotic personality

organisation but falls short for patients with personality disorders. As an alternative we

developed in Chapter 1, a tentative three-dimensional model, in which we integrated the

former one by distinguishing two layers, a classic and a basic psychoanalytic process. This

model is not just a intellectual exercise, but a tool for daily work and for the organisation and

evaluation of the treatment of personality disordered patients.

Such treatments are often painful and long term and demand a lot of motivation,

engagements of patients, their families and therapists and they cost to the community.

Therefore we cannot retreat comfortably to ideological convictions, but it is necessary to try

to examine in an objective way, the psychoanalytic process which is at the heart in such a

treatment. Although necessary, it is however a somewhat grandiose project. The

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psychoanalytic process is not only imperceptible by the senses, it varies considerably between

patients and it does not have a linear course but progresses and retreats. It is understandable

that many psychoanalysts think that only a heuristic approach of it is possible and that the

empirical approaches are doomed to fail, even worse that such an approach may damage this

process and our understanding of it.

We thought that our three-dimensional model (Chapter 1) offers a chance for a

comprehensive approach of the psychoanalytic process in personality disordered patients. In a

first phase we searched for scales measuring each of the three dimensions of the model. For

measuring the first dimensions of the subjective experience patients have of the safety of the

therapy, we had to create a scale. For the second dimension of mentalization, we made a scale

based on Bion's Grid. Seeing his GRID as a map with sveral zones of mental functioning

made this possible (see Chapter 2). Another facet of mentalization, reflective functioning

became more important in recent years - an advantage of it, being that it is already based on

empirical grounds with an existing scale, the RFS. For the third dimension, the object

relations, we found an empirical approach on the concepts of mental representations in the

work of Blatt and his DRS scale.

To gather material to rate these dimensions of the process, we choose an indirect and

psychoanalytical way in which patients could answer freely to questions. These questions

offer information about representations of self and others and are at the same time emotional

stimuli stimulating the mental functioning of the patients in the here and now. The ORI

offered these characteristics. The rating of the DRS on ORI-transcripts had already a proven

reliability and validity. The ORI questions such as ' tell my about your mother, tell me about

yourself ' provoke affects and their processing and make it possible to rate the Bion Grid

Scale on it. To measure the RF of Fonagy and colleagues we had to find a way to get

equivalents of the AAI demand questions which sollicit to think about relations. Therefore we

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let patients freely associate in the first part of the interview for being able to rate the Bion

GRID scale and asked for an elaboration of the examples in a second part of the interview, a

substitute of the AAI demand questions, to have material to rate the RFS on it.

The next step was to make manuals of each of the scales. For the DRS we only needed a

translation, for the other scales new manuals were made to rate the scales on the ORI. After a

phase of training with the scales and try outs, scales and manual were further refined.

We found a sufficient inter-rater reliability as well for the global scores of the four

scales as for the scores of each component of the ORI. This proved the feasibility to measure

the concepts on which the model is based. Given the fact that the raters were of a different

background (students and experienced therapists), we may conclude that the rating by means

of the four manuals is reliable. This is remarkable as the DRS and the B-Grid scale are theory

driven and based on difficult concepts. The inter-rater reliability of the DRS on the ORI was

examined by Stayner (mentioned in Blatt & Auerbach, 2003) with a Shrout-Fleiss correlation

coefficient of .83., which equals the Shrout-Fleiss correlation coefficient which we found for

the DRS global score.

As the patients are blind to what is rated on their answers to the four open questions and

examples, in which there is no mention made of the process. This way chances of test-retest

confounds are minimised. The ORI's are rated on transcripts of the interviews and the raters

had no information about the patients, nor about the moment in therapy that interviews took

place. There were three raters for each scale, 12 raters in total, so that there is no confound

between the scoring of several measures.

In the next phase different raters for each of the 4 measures, rated 82 ORI to test the

measures for reliability and convergent and divergent validity.

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The correlations between scores from each of the components of the ORI and mean

global scores proved to be high for each scale. Given this correlation and for reasons of space,

we will limit ourselves to the discussion of the global scores. This high correlation for each of

the four measures of the scores of the components of the ORI with the global scores, is an

argument that it may be possible to use global scores instead of the component scores when

studying the process with the three-dimensional model and to reduce the number of variables

this way.

When looking at the intercorrelation of the four measures, we found a correlation

between the global scores of the two measures of mentalization, which come from very

different backgrounds as discussed in Chapter 2. This intercorrelation is significant but not

strong enough to consider them as measuring the same aspects of mentalization. We find a

small correlation between RFS and FS, which is to be expected as they are, in fact, measuring

aspects of the psychoanalytic process that are theoretically supposed to influence each other

(Fonagy, Gergely et al., 2002). The remaining correlations between the four measures,

however, were not significant, which is an argument to use all four scales in measuring the

dimensions of the psychoanalytic process.

The global RFS and DRS scores as measured on the ORI were not associated by

sociodemographic factors such as age, gender, or educational level. This is not obvious for the

RFS which expresses the way of thinking about oneself and others, and for which an

influence of education and intelligence could haven been possible. This is the case, however,

for the BGS, which reflects the way that experiences are dealt with in a creative, associative

way. Education and age play a role here, which we shall take into account when refining the

scale and in the analysis of the data when using the Bion Grid Scale. There is a slight positive

association between age and the FS scale. A possible explanation may be that the mean age of

the patients in partial hospitalization was higher than that of patients in full hospitalization.

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Patients in partial hospitalisation tend to show a lower level of pathology than do the patients

in full hospitalisation, certainly when admitted at a higher age.

To test the convergent and divergent validity of the four scales measured on the ORI, we

correlated them with symptom sales and scales related to personality structure and personality

categories. For the symptom related scales, the DRS correlates significantly with the

Symptom Check List (SCL) positive symptom total, with the Beck Depression Inventory

(BDI), the Spielberger Trait Anxiety (STAI) and Anger Inventories (STAXI). The correlation

with symptoms is even higher for the DRS self-score because the questions about the self

reflect more a present state of mind than the questions about father, mother, therapist. This

significant correlation with symptom scores may be explained by the fact that less integrated

mental representations give rise to more psychopathology and more symptoms. Furthermore,

of the other three ORI scales, it is only the RFS which shows a correlation - it correlates

negatively with anxiety as measured on the STAI. The fact that there are few correlations of

the ORI measures with symptom scales is not unexpected, the ORI scales are supposed to

measure inner psychic change and not symptoms. There might however be a methodological

explanation for these low correlations: the data are obtained by two different methods, the

ORI-scales are assessed on the transcripts of an interview, while the other scales are self-

report scales.

For the personality related scales, we would expect a correlation with the Inventory of

Personality Organisation (IPO), a scale about the level of psychic organisation. We found that

the DRS correlates in a significant way with all three IPO subscales. This is in line with the

fact that both scales are theory driven, relying for a great deal on Object Relations theory and

concepts such as splitting. The fact that the BGS and the FSS do not correlate may be

explained by the fact that both scales are less correlated with severity of personality

organisation and must be judged in the context of other data. Associative processing of

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emotions, as we intend to measure with the BGS may be easier for a creative borderline

patient than for a rigid narcissistic patient, for instance, although the borderline patient may

present more severe psychopathology. In regard to the SCID-II results, we expect negative

correlations for the DRS, with the Axis II categories considered in terms of differentiation and

relatedness. This is the case for the avoidant and dependent categories in which the

relatedness dimension is prominent, and for the borderline and the paranoid categories, in

which the differentiation dimension is prominent. The positive significant correlation of Felt

Safety with the dependent category is as expected. The BGS scores correlate in a significant

negative way with the antisocial category, which can be accounted for by the fact that

antisocial personality disorders have the least mental processing of their emotional

experiences. The finding of the positive significant correlation of the RFS with the narcissistic

category and not with the borderline category is unexpected and raises questions about the

validity of measuring the RFS on the ORI. The RFS as measured on the AAI correlates

significantly negative with BPS (Fonagy et al., 1996) and the mentalization based treatment of

borderline personality disorders (Bateman and Fonagy, 2004) is based on enhancing the

reflective functioning in borderline patients. Furthermore, these findings were corroborated by

an own pilot study mentioned in Chapter 2, in which the RF as measured on the AAI

correlated as well significantly negative with BPS.

The project of rating the RFS on the ORI, was favoured by Fonagy , Target & Blatt

(preconference workshop, J.Sandler Research Conference 2001) as rating the RF on the AAI

is very time consuming and when our method proved to be valid, it would mean that the RFS

could be used on a larger scale in psychotherapy research. Therefore we examined the validity

in greater detail, correlating RF scores, rated on the AAI and rated on the ORI, ORI and AAI

being administered in the same week. The correlation between the RFS rated on the ORI and

the RFS rated on the AAI by a psychologist trained in the latter was not significant, which

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means that we failed in our attempt to find an alternative for the original time-consuming

AAI-RFS rating. We were interested to know whether this was because of the difference in

manual and method of rating, because of the difference in raters or because of the type of

interview. This is explored in the third study. The reason of the lack in correlation was not

that the meaning of Reflective Functioning is not well respected in the ORI-RFS Leuven

manual compared with the UCL AAI-RFS manual; indeed the correlation between RFS rated

on the ORI by the psychologist trained with Fonagy and colleagues using this way of scoring

as much as possible and the RFS rated on the ORI using the Leuven manual is significant at

the p = .002 level. The reason was not the difference in raters, because when the UCL-trained

rater scores both the ORI and the AAI, the correlation between mean global RFS values

remains non significant, just as when the Leuven rater rates both the AAI and the ORI.

Moreover, the correlation between the two Leuven raters RF on ORI is high.

The major reason must be, therefore, the difference in interview, in material on which the

raters rate. Indeed the AAI offers 'permit’ questions and ‘demand’ questions in which the

subject is pushed to the limit to see whether she or he can reflect or not on self-other

relationships, mostly situations of loss in the past. In contrast, the ORI is composed of four

open questions about father, mother, self, and therapist and often concern present

relationships. We tried to compensate for the lack of demand questions by asking patients to

elaborate on examples in a second part of the ORI interview, safeguarding the possibility for

associative exploration in the first part of the interview. This way of dealing with these

examples was clearly not demanding enough to be an alternative to the demand questions of

the AAI. According to these results, the RFS training with Fonagy and colleagues plays a role

as well, but to a lesser degree than the interview format itself.

It appears like that with the ORI-RFS, present or state Reflective Functioning is

measured during the interview, while the AAI-RFS measures the capacity for Reflective

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Functioning. This may explain as well the significant correlation of the ORI-RFS with the

SCID-II category of narcissism: it is peculiar for this category to use more rationalisation and

cognitive processing of their experiences, rather than being highly emotionally involved.

In conclusion, we may say that all scales may be reliably rated on the ORI, in their

present state. The validity of the DRS is further established with this study. Felt Safety is a

new scale, and all correlations are in the direction which we expected, which is a strong

indication of its validity. The BGS is promising; the scores may best be interpreted in relation

with other results. The ORI-RFS did not prove to be an alternative for the time consuming

AAI-RFS but is a reliable instrument in itself, which measures the state Reflective

Functioning rather than the capacity for Reflective Functioning, as the AAI-RFS does. The

ORI-RFS and the BGS correspond with the way we conceptualised the two sides of

mentalization (Chapter 2).

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Chapter 4

Het Meten van Psychische Verandering met de Leuvense

Psychotherapie Schaal: het Perspectief van de Patiënt.3

Wanneer men bij persoonlijkheidsstoornissen onderzoek doet naar de effectiviteit van

verschillende therapieën, wordt vaak een beroep gedaan op metingen van veranderingen van

klinische symptomen (Bateman & Fonagy, 1999, 2001 en Linehan et al., 1993). Specifieke

verdiensten van specifieke therapieën zijn door deze focus op symptoomreductie niet steeds

vaststelbaar (Luborsky et al., 1994), zeker niet wanneer de focus van de therapie breder is dan

enkel maar symptoomreductie. Daarom is een focus op de psychologische processen

onderliggend aan deze symptoomvermindering aangewezen. In het vorig hoofdstuk bespraken

we de meetinstrumenten die vanuit psychoanalytische hoek ontwikkeld zijn om de innerlijke

psychische processen te meten vanuit het oogpunt van een extern onderzoeker. We wilden

ook een meting van het therapeutisch veranderingsproces vanuit het oogpunt van de patiënt,

maar op een manier die niet symptoomgericht was. Vermits de schalen over het

veranderingsproces die door therapeuten of door externe onderzoekers gescoord worden

meestal vanuit de theorie gevormd zijn, leek een empirisch gevormde schaal het meest

geschikt voor ons doel. Empirisch gevormde schalen om het innerlijk veranderingsproces bij

de behandeling van persoonlijkheidsstoornissen te meten vanuit het standpunt van de patiënt

zelf bestaan nog niet.

Het maken van een zelfrapporteringsschaal die een innerlijke verandering poogt weer te

geven die kan optreden tijdens een intensieve klinische psychotherapie en die niet vanuit de

3 An English translation is available on request.

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theorie maar vanuit de ervaring van patiënten zelf uitgaat, was de doelstelling van het

onderzoek.

In het huidig onderzoek worden de constructie van de nieuwe psychotherapieschaal en

de waarde van deze schaal besproken in een vijftal studies.

Studie 1: Constructie van de Experimentele Versie van de Leuvense Psychotherapie Schaal

Om een schaal te construeren uitgaande vanuit de ervaring van de cliënten, steunden we

ons op de uitspraken van cliënten zelf, zoals weergegeven door alle teamleden van een

afdeling klinische psychotherapie.

Proefgroep

Aan het team van de afdeling voor Klinische Psychoanalytische Psychotherapie van

Persoonlijkheidsstoornissen (KLIPP) van het Universitair Centrum St. Jozef te Kortenberg

(Vermote, 1997, Vermote en Vansina, 1998, Pieters en Vermote, 2002), beschreven in

hoofstuk 1, werd gevraagd uitspraken van patiënten te verzamelen die iets zeggen over hoe ze

veranderingen tijdens klinische psychotherapie ervaren. De 11 teamleden die meewerkten

waren vijf verpleegkundigen, de creatieve therapeut, de muziektherapeut, de

bewegingstherapeut, twee psychotherapeuten en de psychiater.

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Procedure

Er werd aan deze teamleden gevraagd om uitspraken op te schrijven zoals ze die van

patiënten horen en die een verandering weerspiegelen die de patiënt ervaart tijdens de

therapie. Vijf verpleegkundigen verzamelden 100 uitspraken, de groepstherapeut 17, de

creatieve therapeut 21, de psychomotorisch therapeut 39 en de psychiater 38.

Opbouw van de Experimentele Versie

Alle uitspraken werden op afzonderlijke kaartjes genoteerd, waarna dubbels of gelijke

inhouden eruit gehaald werden. Vervolgens werd de structuur van de items aangepast, zodat

het uitspraken werden met volgende kenmerken: de items geven niet de verandering zelf aan,

maar een toestand die kan veranderen. De graad van aanwezigheid van deze toestand wordt

aangeduid op een Likert-schaal met vijf antwoordmogelijkheden gaande van helemaal oneens

(score 1) tot helemaal eens (score 5). De items werden omgezet tot enkelvoudige items (die

maar één ervaring weergeven), en geformuleerd zijn in de ik-vorm en in de tegenwoordige

tijd. Uitspraken die twee ervaringen weergaven werden gesplitst of weggelaten. Alle

frequentie–aanduidingen zoals ‘soms’, ‘dikwijls’, ‘altijd’, ‘nooit’, werden weggelaten. De

items kunnen positieve ofwel negatieve ervaringen weergeven, maar worden steeds in

positieve zin geformuleerd (dus: ik ben triestig of ik ben gelukkig, maar niet: ik ben niet

gelukkig of ik ben niet triestig). Op basis van deze criteria werden 26 items van de 215

verzamelde items niet opgenomen. Daardoor ontstond de experimentele versie van de

Leuvense Psychotherapie Schaal, bestaande uit 189 items opgesplitst in twee delen 1.

uitspraken over jezelf en 2. uitspraken over de afdeling.

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Studie 2: Constructie en kenmerken van de definitieve versie van de LPS

Voor de schaalconstructie werd op exploratieve wijze nagegaan welke psychologische

constructen gemeten worden door de experimentele versie van de LPS en hoe betrouwbaar

deze metingen zijn. Op grond van dit resultaat werden de definitieve schalen samengesteld.

De eigenschappen van de schaal en de invloed van demografische factoren en psychiatrische

diagnose werden nagegaan.

Methode

Proefgroep

De proefgroep werd samengesteld uit patiënten die een behandeling volgen op een

residentiële therapeutische afdeling in negen centra uit Vlaanderen. In verband met de

uitspraken over de afdeling diende de opnameduur minstens een week te bedragen en

patiënten die een acute psychotische episode doormaakten of mentaal geretardeerd waren,

werden uitgesloten. Vragenlijsten die onvoldoende volledig ingevuld waren, werden niet

meegenomen in het onderzoek.

Dit leverde een onderzoeksgroep op van 482 deelnemers, waarvan 180 mannelijke

(37.3%) en 292 vrouwelijke (60.6%) patiënten. Van 10 patiënten (2.1%) bleef het geslacht

onbekend. Er werden vijf verschillende leeftijdscategorieën onderscheiden: 17-20 jaar (12%),

21-30 jaar (36.7%), 31-40 jaar (24.4%), 41-50 jaar (17.8%) en 51-65 jaar (4.9%). Wat de

burgerlijke status betreft, was 58.3% van de patiënten ongehuwd, 20.1% was gehuwd, 13.9%

was gescheiden en 5.2% was samenwonend. Van 12 patiënten (2.5%) was de burgerlijke staat

onbekend. Wat het opleidingsniveau betreft, was 4.8% enkel in het bezit van een diploma

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lager onderwijs 47.7% van een diploma middelbaar onderwijs, 28.2% had het hoger onderwijs

succesvol doorlopen en 10% bezat een universitair diploma. Van 44 deelnemers (9.1%) bleef

het opleidingsniveau onbekend.

Het merendeel van de deelnemers was minder dan drie maanden in opname (70.8%). Bij

8.3% van de deelnemers was de opnameduur minder dan zes maanden, bij 4.4% was deze

minder dan negen maanden, en bij 3.5% minder dan één jaar. De opnameduur was langer dan

één jaar bij 3.6% van de deelnemers en onbekend bij 9.4% van de deelnemers.

Tijdens de opname volgden 80.1% van de deelnemers een psychoanalytisch of

psychodynamisch georiënteerde psychotherapie, 15.5% een gedragstherapeutische

behandeling en 4.4% een systeemtheoretische therapie. Verder kreeg 65.1% van de

deelnemers alleen groepstherapie, 31% zowel groeps- als individuele therapie en 4% enkel

individuele therapie.

Wat de aanwezigheid van As-I diagnoses binnen de onderzoeksgroep betreft, ziet de

vertegenwoordiging er als volgt uit: Stemmingsstoornis: 49.6% (239 patiënten),

Angststoornis: 7.9% (38 patiënten), Stoornis gebonden aan middelengebruik: 7.6% (37

patiënten), Schizofrenie en andere psychotische stoornissen: 7.2% (35 patiënten),

Aanpassingsstoornis: 7% (34 patiënten), Eetstoornis: 3% (14 patiënten), Stoornis in de

impulscontrole: 1.5% (7 patiënten), Dissociatieve stoornis: 1.2% (6 patiënten), Somatoforme

stoornis: 0.8% (4 patiënten), Andere stoornissen: 3.2% (15 patiënten). Bij 44 deelnemers werd

geen As-I stoornis vastgesteld en 9 deelnemers werden geclassificeerd in de categorie

Uitgestelde of onbekende As-I diagnose.

Wat de aanwezigheid en vertegenwoordiging van As-II diagnoses betreft, werden 286

patiënten (59.3%) van de onderzoeksgroep gediagnosticeerd aan de hand van een Cluster B

persoonlijkheidsstoornis, waarvan aan 188 patiënten (39%) een borderline

persoonlijkheidsstoornis, aan 50 (10.4%) een narcistische, aan 42 (8.7%) een theatrale en aan

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6 (1.2%) een antisociale persoonlijkheidsstoornis toegeschreven werd. Bij 51 patiënten

(10.6%) werd een Cluster C persoonlijkheidsstoornis vastgesteld, bestaande uit 28 patiënten

(5.8%) met een afhankelijke persoonlijkheidsstoornis, 12 patiënten (2.5%) met een obsessief-

compulsieve en 11 patiënten (2.3%) met een vermijdende persoonlijkheidsstoornis. Tot de

groep met een Cluster A persoonlijkheidsstoornis behoorden 26 patiënten (5.4%), waarvan 11

(2.3%) met een schizoïde, eveneens 11 met een schizotypische en 4 (0.8%) met een paranoïde

persoonlijkheidsstoornis. Bij 59 patiënten (12.2%) werd geen As-II stoornis vastgesteld en 60

deelnemers (12.5%) werden geclassificeerd in de categorie Uitgestelde of onbekende As-II

diagnose.

Instrument

De experimentele LPS uit studie 1 met 189 items.

Analyse

Schaalconstructie.

Op de resultaten van de afname van de experimentele LPS op de proefgroep werden de

dimensies van de LPS bepaald met een Principale Componenten Analyse gevolgd door

VARIMAX-rotatie. Er werd gezocht naar de meest eenvoudige en best interpreteerbare

oplossing, waarbij een voldoende aantal ladende items op de verschillende factoren werd

nagestreefd. Voor de interpretatie werden alle ladingen hoger dan.30 in rekening gebracht.

Het samenstellen van de voorlopige schalen gebeurde op basis van dit factorpatroon. Een item

dat op meer dan één factor.30 laadde, werd enkel opgenomen als het verschil in lading meer

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dan.15 bedroeg. In dat geval behoorde het item tot die schaal, waar het de hoogste lading op

had. De interne consistentie werd gemaximaliseerd door repetitief Chronbach’s alpha

coëfficiënt te berekenen, met een successief weglaten van items die een lage correlatie met de

schaal vertoonden, totdat de alpha coëfficiënt niet meer steeg.

Op die manier werden de definitieve schalen samengesteld. Hiervan werden de

gemiddelde scores, de standaarddeviaties en de intercorrelaties nagegaan. Het benoemen van

de schalen gebeurde in de positieve richting, zodat de hoogste score de meest gezonde positie

aanduidt.

Invloed van demografische variabelen en psychiatrische diagnose.

De invloed van demografische variabelen (geslacht, leeftijd, opleiding en burgerlijke

staat) en psychiatrische diagnose (zoals door de behandelende psychiater in het medisch

dossier vermeld) werden met variantie-analyse onderzocht volgens de GLM-procedure zonder

uitspraak te doen over de richting van het effect. Multivariate- (Wilks’ Lambda) en univariate

analyses, als ook post-hoc toetsen (volgens het principe van Tukey) werden uitgevoerd.

Resultaten

Factoranalyse van de Experimentele LPS

Een exploratieve factoranalyse met varimaxrotatie leidt op grond van scree-test en

interpretatiecriteria tot een acht factorenoplossing. Deze verklaart 38.62% van de initiële

totale variantie. De acht factoren met telkens het percentage van de verklaarde variantie en de

hoogstladende items zijn de volgende:

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1. positief welbevinden (14.76%): ‘Ik ben depressief’, ‘Ik voel me goed’, ‘Ik voel me leeg’ en

‘Ik heb zin in het leven’.

2. openheid tegenover anderen (5.02%): ‘Ik kan praten over mijn gevoelens’, ‘Ik durf iets van

mezelf te laten zien’ en ‘ Ik kan moeilijk mensen dicht bij mij verdragen’.

3. autonomie (4.98%): ‘Ik heb veel bescherming van anderen nodig’, ‘Ik kan tegen een duw’

en ‘Ik durf weinig’.

4. affectregulatie en afwezigheid van splitsing (3.34%): ‘Ik voel nu nog een oud verdriet’,

‘Het verleden achtervolgt mij’ en ‘ Ik ben voor iemand of tegen’.

5. zelfgerichtheid (3.19%): ‘Ik ben meer met de noden van anderen bezig dan stil te staan bij

wat ik zelf wil’, ‘De mening van anderen vind ik erg belangrijk’ en ‘Negatieve

opmerkingen van anderen raken mij niet’.

6. positieve ervaring van de afdeling (3.10%): ‘Ik wil hier weg’ en ‘De afdeling is een beetje

mijn thuis’.

7. ervaring van steun en erkenning (2.14%): ‘De mensen zijn tegen mij’ en ‘Ik ervaar echte

bekommernis’.

8. controle over het gebruik van genotsmiddelen (2.09%): ‘Ik heb genotsmiddelen nodig’ en

‘Ik kan gemakkelijk stoppen met het gebruik van genotsmiddelen’.

Schaalsamenstelling van de LPS

Met de beschreven procedure werden de voorlopige schalen uit dit factorpatroon

afgeleid. Van de oorspronkelijke 189 items bleven op die manier 132 items over. Door het

maximaliseren van de interne consistentie verdwenen nog eens 20 items, waardoor de

definitieve schaal uit 112 items bestaat. Op basis van de itemanalyse konden we zeven

schalen weerhouden, waarvan de alpha coëfficiënt groter is dan.50 (Tabel 1). De

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oorspronkelijke schaal zeven ‘Ervaring van steun en erkenning’ bleek slechts uit drie items te

bestaan en niet intern consistent te zijn (α = .07) en werd niet weerhouden.

Tabel 1

Itemverdeling Voorlopige en Definitieve Versie van de Leuvense Psychotherapie Schaal Met

Vermelding Chronbach α

Subschaal Voorlopig Definitief α

Schaal ‘Positief welbevinden’ 61 57 0.97

Schaal ‘Openheid tegenover anderen’ 18 18 0.85

Schaal ‘Autonomie’ 11 7 0.81

Schaal ‘Affectregulatie’ 10 9 0.64

Schaal ‘Gerichtheid op zichzelf’ 10 5 0.64

Schaal ‘Positieve ervaring afdeling’ 13 13 0.82

Schaal ‘Ervaring van steun’ 3 0

Schaal ‘Genotsmiddelen’ 6 3 0.85

Totaal 132 112

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Basiskenmerken van de LPS

In tabel 2 geven we de basiskenmerken van de zeven definitieve schalen, waaruit blijkt

dat er voldoende variabiliteit is op de schalen.

Tabel 2.

Gemiddelde, Standaarddeviatie, Minimum- en Maximumscore van de Zeven Definitieve

Schalen van de Leuvense Psychotherapie Schaal

In tabel 3 geven we de intercorrelaties tussen de schalen. Daaruit blijkt dat alle schalen

positief met elkaar correleren. De hoogste correlatie vinden we tussen S1 ‘Positief

welbevinden’ en S3 ‘Autonomie’ met r = .63. Verder is er ook een hoge correlatie tussen S1

‘Positief welbevinden’ en S2 ‘Openheid tegenover anderen’ met r = .57, en tussen S1 en S4

‘Affectregulatie’ met r = .54. De ‘Positieve ervaring met de afdeling’ heeft de laagste

positieve verbanden met de andere schalen, die alle persoonlijke ervaringen weergeven.

Subschaal N M SD Min Max

‘Positief welbevinden’ (PW) 482 2.76 0.76 1.21 4.89

‘Openheid tegenover anderen’(OA) 482 3.27 0.61 1.50 4.78

‘Autonomie’ (AUT) 482 2.78 0.83 1.00 5.00

‘Affectregulatie’ (AR) 482 2.61 0.58 1.00 4.20

‘Gerichtheid op zichzelf’ (GZ) 482 2.53 0.73 1.00 5.00

‘Positieve ervaring afdeling’(PEA) 482 3.40 0.65 1.23 4.92

‘Genotsmiddelen’ (GEN) 482 3.06 1.33 1.00 5.00

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Tabel 3

Intercorrelaties Tussen de Schalen van de Leuvense Psychotherapie Schaal

*p <0.05, **p <0.01, ***p <0.001

De LPS en Demografische Variabelen

De multivariate variantie analyse (MANOVA) toont dat er een significant effect is van

geslacht op het antwoordpatroon met Wilks’ Lambda F(7, 463) = 6.075 met p < .0001.

Mannen scoren gemiddeld genomen hoger dan vrouwen op S1 ‘Positief welbevinden’ (2.97

vs. 2.64), S2 ‘Openheid tegenover anderen’ (3.37 vs. 3.21), S3 ‘Autonomie’ (3 vs. 2.65), S4

‘Affectregulatie’ (2.80 vs. 2.55) en S5 ‘Gerichtheid op zichzelf’ (2.74 vs. 2.39).

Er is geen effect van leeftijd verdeeld over vijf leeftijdsgroepen, met Wilks’ Lambda

F(28, 1631) = 1.305 met p = .132. Ook een univariate analyse van de zeven schalen

afzonderlijk toont geen effect van leeftijd.

Subschaal 1 2 3 4 5 6 7

1. Positief welbevinden _ 0.57*** 0.63*** 0.54*** 0.38*** 0.27*** 0.34***

2. Openheid tegenover anderen _ 0.36*** 0.26*** 0.22*** 0.31*** 0.13**

3. Autonomie _ 0.43*** 0.26*** 0.08 0.22***

4. Affectregulatie _ 0.36*** 0.16*** 0.27***

5. Gerichtheid op zichzelf _ 0.04 0.08

6. Positieve ervaring afdeling _ 0.10*

7. Genotsmiddelen _

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De drie opleidingsgroepen (lager, middelbaar en hoger onderwijs) tonen geen effect aan

van opleiding, met Wilks’ Lambda F(14, 856) = 0.956 met p = .50, ook niet wanneer de

schalen afzonderlijk bekeken worden.

Er is een significant effect van burgerlijke staat (verdeeld in vier groepen (ongehuwd,

samenwonend, gehuwd en gescheiden) met Wilks’ Lambda F(21, 1318) = 3.052 met p <

.0001). Een univariate analyse van de zeven schalen afzonderlijk toont dat burgerlijke staat

een significant effect heeft op S2 ‘Openheid tegenover anderen’ met F(3, 465) = 2.815 met p

< .05, op S3 ‘Autonomie’ met F(3, 465) = 2.934 met p < .05, op S4 ‘Affectregulatie’ met

F(3, 465) = 5.840 met p < .01 en op S6 ‘Positieve ervaring van afdeling’ met F(3, 465) =

5.028 met p < .01.

De LPS en de DSM IV As-II Persoonlijkheidsdiagnoses

Alleen van de DSM IV-as II diagnoses die voldoende frequent aanwezig zijn in de

proefgroep (borderline, narcistische, theatrale en afhankelijke persoonlijkheidsstoornis) kan

het effect op de beantwoording van de LPS worden berekend. De andere as II diagnoses zijn

niet voldoende vertegenwoordigd in de proefgroep, evenmin als de DSM IV- as I diagnoses.

Uit de multivariate analyse van de vier bestudeerde groepen persoonlijkheidsstoornissen

blijkt dat er een significant effect is van de As-II stoornis, met Wilks’ Lambda F(21, 850) =

3.82, p < .0001. De univariate analyse van de zeven schalen toont aan dat er een significant

effect is op S1 ‘Positief welbevinden’ met F(3, 302) = 5.56, p < .01, op S2 ‘Openheid

tegenover anderen’ met F(3, 302) = 3.30, p < .05, op S3 ‘Autonomie’ met F(3, 302) = 8.97, p

< .0001, op S4 ‘Affectregulatie’ met F(3, 302) = 7.37, p < .0001 en op S7 ‘Controle over

genotsmiddelen’ met F(3, 302) = 3.05, p < .0001. De post-hoc toets van Tukey geeft aan dat

de narcisten significant gemiddeld hoger scoren op S1 ‘Positief welbevinden’(3.1) dan

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borderlines(2.57) en afhankelijken (2.55), die onderling niet significant verschillen. Op S2

‘Openheid tegenover anderen’ en op S 7 ‘Controle over genotsmiddelen’ is er een significant

verschil tussen narcisten (3.43 en 3.30) en borderlines (2.57 en 2.73). Op S 3 ‘Autonomie’

scoren de borderlines (2.76) significant hoger dan de theatralen (2.22). Verder blijkt dat de

narcisten (3.08) op deze schaal een significant hogere score behalen dan de theatralen (2.22)

en afhankelijken (2.57). Op S 4 ‘Affectregulatie’ is de gemiddelde score van de narcisten

(2.90) significant hoger dan die van borderlines (2.47) en theatralen (2.50). Hoewel de

univariate analyse aangaf dat er geen significant effect van diagnose was op schaal 5

‘Gerichtheid op zichzelf’, blijkt uit de post-hoc toets van Tukey dat er op deze schaal een

significant verschil is tussen narcisten (2.72) en borderlines (2.42).

Samenvattend kunnen we stellen dat narcisten gemiddeld een hogere score op de LPS

behalen dan de andere drie As-II diagnoses, die onderling niet veel verschil tonen. De

borderlines scoren enkel op schaal 3 ‘Autonomie’ significant hoger dan de theatralen.

Studie 3: Congruente Validiteit: de LPS en de Neo-Pi-R

Methode

Proefgroep

Bij zesenvijftig deelnemers uit de proefgroep van studie twee waarvan de leeftijd

varieerde tussen 17 en 65 jaar werd ook de NEO-PI-R afgenomen. Onder hen bevonden zich

39 vrouwen. 16 deelnemers waren gehuwd of samenwonend, 14 gescheiden, 26 ongehuwd. 3

volgden lager onderwijs, 31 middelbaar, 15 hoger en van 7 deelnemers was de opleiding

onbekend. Diagnostisch werd aan 47 deelnemers de borderline persoonlijkheidsstoornis

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toegeschreven. Vier deelnemers hadden een narcistische persoonlijkheidsstoornis, 3 hadden

een histrionische persoonlijkheidsstoornis, 1 een afhankelijke persoonlijkheidsstoornis en 1

onbekend.

Instrument

De Neo-PI-R werd afgenomen als algemene persoonlijkheidsvragenlijst met

aangetoonde begripsvaliditeit. We maakten gebruik van de Nederlandstalige NEO-PI-R

persoonlijkheidsvragenlijst (Hoekstra, 1996). Deze vragenlijst telt 240 items, die elk vijf

antwoordmogelijkheden hebben, gaande van helemaal oneens tot helemaal eens. De NEO-PI-

R meet de vijf belangrijkste dimensies van de persoonlijkheid volgens het vijf factoren model

van Costa en Widiger, 1994, en binnen elk van die vijf domeinen een zestal facetten, die de

dimensie in kwestie definiëren. De schalen van de NEO-PI-R zijn neuroticisme, extraversie,

openheid, altruïsme, consciëntieusheid.

Analyse

We berekenden een Pearson Correlatie Coëfficient van alle scores van de LPS schalen

met alle scores van de NEO-PI-R.

Resultaten

S1 ‘positief welbevinden’ van de LPS correleert negatief met de N ‘neuroticisme’ schaal

van de Neo-PI-R (-.27, p < .05), vooral met N 2 ‘ergernis’ (-.37, p < .01) en N3 ‘depressie’

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(.36, p < .01). De correlatie is positief met de E ‘extraversie’ schaal (.37, p < .01), vooral met

E1 ‘hartelijkheid’ (.25, p < .25), E4 ‘energie’ (.35, p < .01) en E6 ‘vrolijkheid’ (.26, p < .05).

Verder is er nog een significante correlatie met de C5 ‘zelfdiscipline’ (.24, p < .05) van de C

‘conscientieusheid’ schaal.

S2 ‘openheid tegenover anderen’ van de LPS correleert significant positief met de E

‘extraversie’ schaal van de Neo-Pi-R (.37, p < .01), vooral met E1 ‘hartelijkheid’ (.30, p <

.05) en E5 ‘avonturisme’(.23, p < .05). Er is verder een positieve correlatie met de O3

‘gevoelens’ (.28, p < .05) uit de O ‘openheid ‘ schaal. De A ‘altruïsme’ schaal correleert

eveneens significant positief (.27, p < .05), met vooral A2 ‘oprechtheid’(.29, p < .05) en A4

’inschikkelijkheid’ (.23, p < .05) en A6 ‘medeleven’ (.26, p < .05). Uit de C

‘consciëntieusheid’ schaal correleert C6 ‘bedachtzaamheid’ (.27, p < .05).

Met S3 ‘ autonomie’ van de LPS correleren de volgende schalen uit de Neo-Pi-R

significant: N3 ‘ergernis’ (.37, p < .01) en N6 ‘ kwetsbaarheid’ (.32, p <01) uit de N

‘neuroticisme’ schaal. E 4 ‘ energie’ (.37, p < .01) en E6 ‘vrolijkheid’ (.25, p < . 05) uit de E

‘extraversie’ schaal. Verder de O ‘openheidsschaal’ (.40, p < .05) met O1’ fantasie’(.26, p <

.05) en O2 ‘esthetiek’(.25, p < .05) en O3 ‘gevoelens’(.22, p < .05) en O4

‘veranderingen’(.31, p < .01). Uit de C ‘consciëntieusheid’ schaal, de C1 ‘doelmatigheid’

(.29, p < .05)en de C5 ‘zelfdiscipline’(.23, p < .05).

De S4 ‘ affectregulatie’ van de LPS correleert significant negatief met de N

‘neuroticisme’schaal van de Neo-Pi-R (-.38, p < .01), vooral met N1 ‘angst’ (-.23, p < .05),

N2’ergernis’(-55, p < .01), N5 ‘impulsiviteit’ (-.27, p < .01). Er is een positieve correlatie met

E1’hartelijkheid’ (.26, p < .05) uit de E ‘extraversie’schaal en C3 ‘betrouwbaarheid’(.23, p <

.05) uit de C ‘ consciëntieusheid’ schaal en een negatieve correlatie met de A2

‘oprechtheid’(.25, p < .05) uit de A ‘altruïsme’schaal.

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S5 ‘gerichtheid op zichzelf’ uit de LPS correleert sterk met de N ‘neuroticisme’ schaal

(.35, p < .01), vooral met N2 ‘ergernis’(.27, p < .05) en N5 ‘impulsiviteit’ (.32, p < .01).

Verder E6 ‘avonturisme’ (.41, p < .01) uit de E ‘extraversieschaal’ en C3

‘betrouwbaarheid’(.37, p < .01) uit de C ‘consciëntieusheid’ schaal.

S6 ‘ positieve ervaring van de afdeling’ uit de LPS correleert significant met E6

‘vrolijkheid’ uit de E ’extraversie’ schaal en met A1 ‘vertrouwen’ (.34, p < .01) uit de A

‘altruïsme’ schaal van de Neo-Pi-R.

S7 ‘ controle over het gebruik van genotsmiddelen’ van de LPS correleert negatief met

de N ‘neuroticisme’ schaal (-.30, p < .05) van de Neo-Pi-R, vooral met N1 ‘angst’(-.24, p <

.05), N3 ‘depressie’ (-.38, p < .01), N4 ‘schaamte’ (-.32, p < .01). Verder is er nog een

significante correlatie met C1 ‘doelmatigheid’ (.33, p < .01) van de C ‘ consciëntieusheid’

schaal.

Studie 4: Congruente Validiteit van de LPS.

Naast de correlatie van de LPS met een dimensionele persoonlijkheidsdiagnose (Neo-PI-

R) werd ook de correlatie met een beschrijvende categoriale diagnose (SCID) en met een

structurele diagnose (IPO) nagegaan.

Methode

Proefgroep

Deze steekproef bestond uit 82 deelnemers (54 vrouwen en 28 mannen) bij opname op

de klinische psychotherapie afdeling voor persoonlijkheidsstoornissen in het U.C. St.-Jozef te

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Kortenberg (Vermote & Vansina, 1998, Pieters & Vermote, 2002, Hoofdstuk 1), 58

residentieel en 24 in daghospitaal. De patiënten waren tussen 17 en 58 jaar met een

gemiddelde leeftijd van 27,1 jaar (SD = 8.5). Tweeëndertig deelnemers waren alleenwonend,

29 woonden bij hun ouders, 17 waren gehuwd of samenwonend, 3 deelnemers waren

gescheiden en 1 woonde in een gemeenschapshuis. Wat het studieniveau betreft volgden 3

deelnemers alleen het lager onderwijs, 32 volgden het secundair of technisch onderwijs en 47

hoger of universitair onderwijs. Op basis van de SCID II wezen we alle patiënten toe aan één

van de drie clusters van de DSM IV, as II: cluster A: 2 (1 schizoid, 1 schizotypisch); cluster

B: 62 (1 histrionisch, 44 borderline, 10 narcistisch, 4 narcistisch en borderline, 3 histrionisch

en borderline); cluster C: 10 (1 ontwijkend, 2 afhankelijk, 1 ontwijkend en afhankelijk, 6 niet

anders omlijnd); clusters A+B: 1;clusters B+C: 10.

Volgens het medisch dossier waren er 33 diverse stemmingsstoornissen, met 7 maal een

majeure depressieve stoornis, eenmalig voorkomen en 11 maal een majeure depressieve

stoornis, matig, heroptredend als meest voorkomende en 5 angststoornissen en 14 maal een

aanpassingsstoornis, met gemengde angst en depressieve gevoelens als meest voorkomende.

Instrumenten

Het Structured Clinical Interview for DSM-III Axis II Personality Disorders (SCID-II)

is een semi-gestructureerd interview ontworpen om een betrouwbare DSM-IV diagnose te

stellen. In het onderzoek werd de SCID-II Persoonlijkheidsvragenlijst gebruikt, een

Nederlandse vertaling en aanpassing voor de DSM IV door Weertman, Arntz & Kerkhofs,

2000.

De Inventory of Personality Organization (IPO) is een zelfrapportage vragenlijst

gebaseerd op psychodynamische constructen die afgeleid werden van Kernbergs theorie over

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persoonlijkheidsorganisatie en persoonlijkheidsstoornissen (Kernberg, O., Clarkin, J., 1995).

Tot op heden werd de IPO bij meer dan 1500 personen afgenomen. De schalen vertonen een

goede tot excellente interne consistentie en test-hertest betrouwbaarheid. Constructvaliditeit

werd aangetoond door factor analyse. Daarenboven kon de IPO patiënten met As II

pathologie differentiëren in neurotische, high en low borderline categoriëen van

persoonlijkheidsorganisatie, zoals door de theorie is verondersteld (Lenzenweger et al., 2000).

Het onderzoek naar de constructvaliditeit werd door Normandin et al. (2002) gerepliceerd. De

IPO werd in het Nederlands vertaald en gevalideerd met exploratieve factoranalyse (Vermote

et al., 2003) en met confirmatorische factoranalyse (Vermote, Smits, Claes en Vertommen,

2005).

Analyse

Een Pearson Correlatie Coëfficient werd berekend van alle gemiddelde scores van de

LPS schalen met alle gemiddelde scores van de SCID II en van de IPO.

Resultaten

Deze resultaten worden weergegeven in tabel 4 en 5.

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Tabel 4

Correlaties Tussen de Gemiddelde Scores van de LPS –schalen en de Gemiddelde Scores Op

de SCID II Categorieën

Subschaal LPS Subschaal

SCID 1 2 3 4 5 6 7 M

Ontwijkend -0.53*** -0.52*** -0.48*** -0.16 -0.29** -0.09 -0.27* -0.55***

Afhankelijk -0.41*** 0.05 -0.35** -0.28* -0.21 0.03 -0.39*** -0.43***

Obs.-Comp. -0.28* -0.15 -0.24* -0.23* -0.16 -0.11 0.02 -0.22*

Passief Agr. -0.26* 0.01 -0.15 -0.53*** -0.20 -0.07 -0.24* -0.35**

Depressief -0.58*** -0.21 -0.48*** -0.45*** -0.34** -0.18 -0.37*** -0.61***

Paranoid -0.38*** -0.24* -0.20 -0.58*** -0.36*** -0.03 -0.29** -0.51***

Schizotypisch -0.31** -0.35** -0.23* -0.15 -0.21 0.10 -0.12 -0.32**

Schizoid -0.38*** -0.44*** -0.30** -0.24* -0.09 -0.05 -0.09 -0.35**

Theatraal 0.11 0.37*** 0.16 -0.19 -0.04 0.05 -0.12 0.04

Narcistisch -0.01 0.04 0.03 -0.33** 0.12 0.02 -0.12 -0.07

Borderline -0.45*** -0.14 -0.38*** -0.52*** -0.38*** -0.10 -0.33** -0.56***

Antisociaal -0.06 -0.12 -0.10 -0.30** -0.03 -0.10 -0.22* -0.22*

Som -0.49*** -0.23* -0.38*** -0.57*** -0.31** -0.07 -0.36*** -0.59***

(n = 82) *p <0.05, **p <0.01, ***p <0.001

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Tabel 5

Correlaties Tussen de Gemiddelde Scores Op de Schalen van de LPS en de Gemiddelde

Scores Op de Schalen van de IPO

Subschaal LPS

Subschaal IPO 1 2 3 4 5 6 7 M

Primitieve defensies -0.41*** -0.20 -0.17 -0.58*** -0.49*** -0.05 -0.37*** -0.57***

Identiteitsdiffusie -0.50*** -0.16 -0.37*** -0.49*** -0.42*** -0.03 -0.35** -0.58***

Realiteitstoetsing -0.19 -0.13 -0.09 -0.30** -0.16 -0.07 -0.07 -0.22*

Som-score -0.46*** -0.23* -0.28* -0.57*** -0.40*** -0.11 -0.32** -0.57***

(n = 82) *p <0.05, **p <0.01, ***p <0.001

Schaal 1 van de LPS (positief welbevinden) correleert significant negatief met de

ontwijkende, afhankelijke, depressieve, paranoïde, schizoïde en borderline categorieën van de

SCID II, Schaal 2 (openheid naar anderen) correleert significant negatief met de ontwijkende,

schizoïde, schizotypische en positief met de theatrale categorieën van de SCID II. Schaal 3

(autonomie) correleert in hoge mate significant negatief met de ontwijkende, afhankelijke,

depressieve, schizoïde, borderline en in mindere mate met obssessief-compulsieve en

schizotypische categorieën van de LPS. Schaal 4 van de LPS (aanwezigheid en omgaan met

negatieve gevoelens) correleert significant negatief met de passief-agressieve, depressieve,

paranoïde, borderline, antisociale en narcistische categorieën van SCID II. Schaal 5 van de

LPS (gerichtheid op zichzelf) correleert significant negatief met de borderline, paranoïde en

de depressieve en ontwijkende categorieën van de SCID II. Schaal 6 van de LPS (positieve

gevoelens tegenover de afdeling) heeft geen significante correlatie met categorieën van de

SCID II. Schaal 7 van de LPS (gebruik van genotsmiddelen) correleert het meest significant

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negatief met de depressieve, ontwijkende, borderline, paranoïde en afhankelijke categorieën

van de SCID II.

De gemiddelde schaalscore van de LPS correleert significant negatief met de som score

en met de drie subschalen van de IPO, waarvan het meest met primitieve defensies en

identiteitsdiffusie en het minst met realiteitstoetsing. Schaal 1 en 7 van de LPS correleren

significant negatief met de primitieve defensies en identiteitsdiffusie subschalen van de IPO,

schaal 2 en 6 van de LPS hebben geen significante correlaties met de subschalen van de IPO,

schaal 3 van de LPS correleert negatief met de identiteitsdiffusie subschaal van de IPO, schaal

4 correleert significant negatief met de drie subschalen van de IPO.

Discussie

De LPS is een zelfbeoordelingsschaal om de innerlijke verandering bij psychotherapie te

meten zoals die wordt ervaren door de patiënten zelf. De schaal werd samengesteld op basis

van uitspraken van patiënten zelf. Op basis van factoranalyse en repetitieve Chronbach alfa,

kwamen we tot een schaal van 112 items en zeven subschalen. (tabel 1 & 2).

Op tabel 3 zien we dat de meeste schalen positief intercorreleren, maar niet van die aard

dat we kunnen besluiten dat ze hetzelfde meten. We kunnen ervan uitgaan dat elke schaal een

afzonderlijk concept meet, dat voor een deel overlap vertoont met de concepten gemeten door

de andere schalen. De positieve correlaties wijzen er ook op dat alle schalen steun geven aan

de veronderstelling van een onderliggend concept dat een dimensie van pathologie naar

gezondheid meet.

Wat de invloed van demografische variabelen betreft (tabel 4), zien we dat mannen

globaal beter scoren op de LPS dan vrouwen, dit lijkt voor alle schalen zo te zijn behalve voor

controlegevoel over middelengebruik en positieve ervaring van de afdeling. Dit fenomeen zou

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kunnen verklaard worden door het feit dat er in de proefgroep relatief meer mannen met een

narcistische problematiek zijn dan vrouwen en dat de groep met de narcistische problematiek

globaal beter scoort in hun zelfbeleving zoals die in verschillende dimensies gemeten wordt.

Er is geen effect van leeftijd of opleiding, wel van de burgerlijke staat: ongehuwden vinden

zichzelf ‘autonomer’ en beschrijven een betere affectregulatie bij zichzelf dan

samenwonenden en gescheiden personen. Gescheiden personen geven aan dat ze de afdeling

als positiever ervaren dan ongehuwden en samenwonenden. Dit zou kunnen verklaard worden

door het feit dat verschillende patiënten eerder recent gescheiden waren, zodat het alleen

leven een wat nieuwe situatie was – waarbij ze veel emotionele feedback van de afdeling

kregen. Leeftijd en opleiding hebben geen effect op de resultaten van de LPS. Deze resultaten

kunnen van dienst zijn bij de normering van de vragenlijst bij toekomstig onderzoek.

Het voorkomen van de afzonderlijke DSM as I stoornissen was niet talrijk genoeg om de

invloed op de antwoorden op de LPS na te gaan. Vier van de tien DSM IV as II

persoonlijkheidsdiagnoses, zoals door de psychiater klinisch waren gediagnosticeerd, waren

dat wel (tabel 5). Narcisten beschrijven meer positief welbevinden dan borderlines en

afhankelijken, ze vinden zich ook meer in staat tot het aangaan van authentieke relaties en zijn

meer gecontroleerd in middelengebruik dan borderlines. Ze rapporteren een betere

affectregulatie dan borderlines en histrionici en geven aan meer gericht te zijn op zichzelf.

Deze verschillen komen uiteraard overeen met de zelfbeleving die bij de narcistische

persoonlijkheidsstoornis hoort, zeker in vergelijking met de borderline en ook met de

afhankelijke persoonlijkheidsstoornis. Dit komt ook overeen met het klinisch beeld van deze

verschillende psychopathologieën: de borderline heeft veel moeite met het aangaan van

relaties, lijdt daaronder en heeft een groter middelengebruik (Zanarinini et al., 2003). De

affectregulatie is klinisch ook beter bij narcistische patiënten dan bij borderlines en theatrale.

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Daarenboven komt het gevonden onderscheid tussen narcistische pathologie enerzijds

en borderlines, afhankelijke en theatrale anderzijds—met weinig verschil binnen deze laatste

groep, overeen met het onderscheid dat Blatt (1992) vond bij zijn analyse van de resultaten

van de Menninger studie. Het betreft een onderscheid tussen introjectieve patiënten (zoals de

narcistische patiënten) en de anaclytische patiënten (zoals de borderlines en de histrionische

patiënten).

De eerste schaal, positief welbevinden, hangt sterk samen met alle andere schalen en

kan als een gemeenschappelijk ervaringselement gezien worden. De alfa-coëfficient van 0.97

toont dat deze schaal homogeen is. De correlaties met de subschalen van de Neo-Pi-R (tabel

6) laten toe de eerste schaal meer specifiek te omschrijven: ze correleert positief met energie,

hartelijkheid, vrolijkheid, extraversie en negatief met neuroticisme, ergernis en depressie. De

naam ‘positief welbevinden’ geeft dit goed weer. De correlatie met de SCID II – categorieën

ligt in dezelfde lijn. Deze correlatie is het meest negatief met de meest angstige en

depressieve categorieën (ontwijkend, afhankelijk, depressief, paranoid, schizoid, borderline en

dwangmatig), maar toont een groter positief zelfbevinden in de categorieën van de SCID die

minder met hun psychisch lijden in contact zijn zoals de narcistische, de antisociale en de

theatrale categorieën. Vermits het een algemene maat is, correleert ze negatief met de

subschalen van de IPO die primitieve defensies en identiteitsdiffusie weergeven, en aldus de

ernst van de structurele persoonlijkheidsstoornis weergeven.

De tweede schaal over ‘openheid naar anderen’ is met een alfa-coëfficient van 0.85 ook

vrij homogeen. Uit de correlatie met de Neo-Pi-R zien we dat ze correleert met extraversie en

hartelijkheid maar ook met gevoelens, oprechtheid, avonturisme, altruïsme, medeleven en

inschikkelijkheid. Meer specifiek gaat het dus eerder om de mogelijkheid om authentieke

relaties aan te gaan zoals beschreven vanuit een innerlijke beleving, dan om een sociale

vaardigheid. Dit is een van de hoofddoelen van de klinische psychotherapie.

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De schaal correleert zoals verwacht negatief met de meest introverte categorieën uit de

SCID II met name de ontwijkende, schizoïde en schizotypische categorie en positief met de

meest extraverte met name de theatrale.

De derde schaal ‘autonomie’ heeft met een Chronbach coëfficiënt van 0.81 ook een

goede interne consistentie. Uit de correlatie met de Neo-Pi-R blijkt dat de schaal negatief

correleert met ergernis en kwetsbaarheid en positief met energie, openheid, veranderingen

(openstaan voor nieuwe veranderingen), gevoelens(innerlijke gevoelswereld), fantasie

(innerlijk verbeeldingsleven), esthetiek (interesse voor kunst), doelmatigheid en

zelfdiscipline. De meeste verbanden zijn met de O-schalen en de laagscoorders op deze

schalen hebben een uitgesproken voorkeur voor het vertrouwde. De aanvankelijke term

autonomie is niet misplaatst, maar het accent ligt zoals bij de tweede schaal ook duidelijk op

een innerlijke attitude en niet op een sociale vaardigheid. Het gaat om de mogelijkheid om op

een autonome en creatieve manier met nieuwe gebeurtenissen om te gaan, wat een belangrijke

therapeutische verworvenheid is.

De correlatie met de IPO subschalen is niet zo hoog, waarschijnlijk omdat de

moeilijkheid in het omgaan met nieuwe gebeurtenissen niet alleen een borderline structuur

typeert maar ook bij hogere persoonlijkheidsorganisaties zoals de obsessief-compulsieve terug

te vinden is.

De vierde schaal ‘ affect regulatie’ correleert op de Neo-Pi-R vooral met de

aanwezigheid van negatieve gevoelens (neuroticisme, angst, ergernis, impulsiviteit) en hoe

ermee omgegaan wordt (oprechtheid, hartelijkheid en betrouwbaarheid). In die zin is de term

affectregulatie niet verkeerd gekozen maar is ‘de aanwezigheid en de omgang met negatieve

gevoelens’ een meer specifieke omlijning. Vermits we in deze schaal zowel de aanwezigheid

als de omgang met negatieve gevoelens vinden, is het niet verwonderlijk dat de interne

consistentie hier lager is (α = .64).

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Het is niet verwonderlijk dat deze schaal sterk correleert met de twee eerste IPO

schalen. Volgens Kernberg worden low level borderlines immers getypeerd door de sterke

aanwezigheid van splitsing en een infusie van agressie. De correlatie met de agressieve SCID

II categorieën zoals de paranoide, de passief-agressieve, de borderline en de antisociale ligt in

dezelfde lijn.

De vijfde schaal over de ‘zelfgerichtheid’ correleert op de Neo-Pi-R niet negatief met

extraversie, sociabiliteit en altruïsme zoals we zouden verwacht hebben maar wel negatief met

de aanwezigheid van negatieve gevoelens, vooral impulsivitiet, en sterk positief met

avonturisme en betrouwbaarheid. De schaal lijkt dus niet zozeer een negatieve zelfgerichtheid

weer te geven maar een mogelijkheid tot zelfreflectie en een vertrouwen om met nieuwe

zaken om te gaan en waarvan impulsiviteit het omgekeerde is. Het is inderdaad zo dat de

klinische psychotherapie bij persoonlijkheidsstoornissen zich de laatste jaren focust op de

omgang met impulsen en tegelijk op het openstaan voor en het opdoen van nieuwe

ervaringen. Dit wordt door Fonagy en collega’s (1996) als de mogelijkheid tot zelfreflectie

beschreven. In deze schaal wordt een duidelijke focus van de behandeling weerspiegeld,

zonder dat het om een eenduidig construct gaat (α = .64).

Het is niet onverwacht dat deze schaal positief correleert met de narcistische SCID II

categorie die inderdaad een grotere gerichtheid op zichzelf inhoudt terwijl ze negatief

correleert met het merendeel van de categorieën van persoonlijkheidsstoornissen. Het meest

negatief correleert ze met de borderline en de paranoide categorieën, die volgens Fonagy et al.

(2002) een expliciet tekort aan deze zelfreflectie vertonen.

De sterke correlatie van deze schaal met de eerste twee IPO schalen is ook verwacht,

vermits de mogelijkheid tot zelfreflectie omgekeerd evenredig is met de primitieve defensies

en de grensverwarring bij low level borderlines.

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De zesde schaal over een ‘positieve ervaring van de afdeling’ correleert weinig met

persoonlijkheidstrekken van de SCID en ook niet van de Neo-Pi-R. Wel met kenmerken die

een algemeen gevoel weergeven zoals vrolijkheid en vertrouwen. Zoals verwacht is er ook

een sterke correlatie met schaal 1 (positief welbevinden) en schaal 4 (negatieve gevoelens en

hoe ermee omgaan). Het is een homogene schaal (α = .82).

De zevende schaal over het ‘middelengebruik’ correleert zoals verwacht sterk met de

aanwezigheid van negatieve gevoelens uit de ‘neuroticisme’ schaal van de Neo-Pi-R, maar

ook met doelmatigheid (wat de aanwezigheid van een innerlijke beleving van inefficiëntie bij

middelengebruik weerspiegelt). Het is een homogene schaal (α = .85). De schaal komt

overeen met SCID II persoonlijkheidscategorieën waar middelengebruik klinisch meer lijkt

voorte komen zoals de ontwijkende, de afhankelijke, de depressieve en de borderline. De

correlatie met de IPO en dus met de mate van borderline structuur is ook verwacht gezien het

middelengebruik als manier om niet psychisch met spanning te moeten omgaan ook een

borderline kenmerk is.

Uit de omlijning van de schalen blijkt dat de patiënten in hun eigen woorden

hoofdzakelijk innerlijke belevingen weergeven. Dit komt tegemoet aan het doel van de schaal,

die het specifieke van de klinische psychotherapie voor persoonlijkheidsstoornissen wou

weergeven. De focus van de behandeling is een innerlijk psychisch proces.

Op basis van de het onderzoek naar de congruente validiteit van de LPS veranderden we

namen van de subschalen in de experimentele versie in namen die beter weergeven wat de

subschalen meten: S1: Positief Welbevinden; S2: Openheid voor authentieke relaties; S3:

Capaciteit om met onverwachte en stressrijke situaties om te gaan; S4: Capaciteit om met

negatieve emoties om te gaan; S5: Capaciteit voor verinnerlijking; S6 : Positieve ervaring van

de setting; S7: Controle over middelengebruik.

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Besluit

De LPS is een empirisch samengestelde zelf rapportage vragenlijst aan de hand van items die

gebaseerd zijn op uitspraken van patiënten zelf. De bedoeling is om het innerlijke

veranderingsproces te meten tijdens psychotherapie vanuit de beleving van de patiënt. De

congruentie van deze schaal blijkt uit de correlaties met verschillende

persoonlijkheidsschalen. Uit deze resultaten blijkt ook dat eerder innerlijke veranderingen

worden weergegeven dan puur klinisch symptomatische.

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Chapter 5

Measuring the Psychoanalytic Process with the Psychoanalytic

Process Rating Scale: The Perspective of the Therapist.

In the two previous chapters, we discussed the measuring of the process of inner change

in personality disordered patients in psychoanalytically informed hospitalization-based

treatment, with treatment specific measures from the perspective of independent researchers

and from the perspective of the patients themselves. We found few scales to rate the process

from the therapist's point of view. There are scales to measure the relationship between

patient and therapist such as the Helping Alliance Questionnaire (Luborgsky et al., 1996), the

Barett-Lennard Relationship Inventory (Barett-Lennard, 1962) and the Working Alliance

Inventory (Horvath & Greenberg, 1994). We found one scale measuring several facets of the

psychoanalytic process, the Psychoanalytic Process Rating Scale or PRS (Gerber, Fonagy,

Bateman & Higgitt, 2004). A Dutch scale is constructed based on a translation and

elaboration of this PRS: the Psychoanalytic Process Rating Scale (PPRS, Stoker & Beenen,

2001; Stoker & Zevalkink, 2005). This scale has an established reliability by now, but was in

a stage of development when we started using it. Therefore, before using it in the process-

outcome study we did some preliminary tests about the reliability and the validity of the scale

in using it with personality disordered patients. Our data confirmed the validity of the scale

(Stoker & Zevalkink, 2005).

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Construction and Reliability of the PPRS

Beenen and Stoker (1997) constructed the ' Periodische Beoordelingsschaal' (PBS) or

Periodic Rating Scale (PRS). Their scale consisted of 262 items and was a translation and

elaboration of the 'Anna Freud Centre Session Rating for Children and Adolescents' and the '

Anna Freud Centre Young Adult Weekly Rating Scale' (Gerber, Fonagy, Bateman & Higgitt,

2004). The PRS consists of three parts: 1. General aspects of the process, 2. Characteristic

Aspects, 3. Interaction. The PRS was assessed every two weeks on a random session from

1996 by analysts of the Dutch Psychoanalytic Institute.

To construct the PPRS (Psychoanalytic Process Rating Scale), 860 PRS of 60

psychoanalyses were analysed in 2000. The sensitivity of the items to change was examined

and the items were cluster analysed for each of the parts of the scale. Based on the results of

this processing, a scale on 'contact development' was made with items from part 1 and 3. This

scale consists of 44 items. 23 items describe the patient by the analyst during the session, 21

items describe how the therapist feels and interacts in regard to this session. A factor analysis

on 612 PRS revealed five factors, explaining 37.5 % of the total variance with an internal

consistency ranging between.70 and.82 (table 1).

These factors were:

1. Co-operation: this refers to a productive and positive process focused on the

therapeutic relationship, to a close co-operation, to the process of alliance, to the degree of

clicking between analyst and patient.

2. Tension: this refers to negative feelings in both participants and can be used as an

indication of the degree the two participants clash. It does not mean that the treatment has

reached a deadlock or does not progress well.

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3. Exploration: this refers to the therapist making thoughts and feelings of the patient

explicit, showing implicit patterns to the patient and linking with external reality.

4. Disillusion: this refers to the degree that the analysand experiences, expresses and

behaves as a rejected lover.

5. Contentment: this factor refers to a positive idealising counter-transference in which

the analyst may see the analysand as an ideal son, daughter or partner. Moreover it refers to

the healthy affective mood of the analysand and his enjoying the treatment.

Table 1

Subscales of the Psychoanalytic Process Rating Scale Version 1

Subscales Internal consistency

1997-1999

number of items

Cooperation (CP) .82 11

Tension (TE) .82 12

Exploration (EX) .70 6

Disillusion (DI) .81 13

Contentment (CT) .70 5

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The analyses of part 2 revealed too many clusters to be useful. The items can be used for

a qualitative examination of content. Together with the 44 item 'Contact Development Scale'

they formed the first version of the PPRS (Beenen & Stoker, 2001). In our study we used the

44 item Contact Development Scale of the PPRS.

Recently a new factor analysis was done based on the results of this 44 item Contact

Development Scale of 969 PPRS assessed between 2001 and 2003. This factor analysis

revealed the same five factors with an increased explanation of the total variance (48.3 %) and

with some items jumping to another scale. This 44 item scale forms the PPRS version 2

(Stoker & Zevalkink, 2005).

Table 2

Subscales of the Psychoanalytic Process Rating Scale Version 2

Subscales Internal consistency

2001-2003

% of variance

explained

number of items

Cooperation (CP) .82 16% 11

Tension (TE) .86 9.75% 12

Exploration (EX) .72 8.76% 6

Disillusion (DI) .71 7.29% 13

Contentment (CT) .78 6.50% 5

PPRS-total .84 48.3%

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Convergent and Divergent Validity of the PPRS

The aim of this study is to examine the intercorrelation of the subscales of the PPRS, the

correlation with related measures and the correlation with clinical scales. Related measures

were the 4 expert measures on the ORI, discussed in Chapter 3, and the LPS, discussed in

Chapter 4. These correlations were investigated on a group of patients on admission and a

group of patients with a variable length of stay, because the PPRS measures contact

development. Clinical scales were a symptom scale (SCL), a scale based on the categorical

approach to personality disorders (DSM-IV Axis II, evaluated with the SCID-II

questionnaire) and a scale based on the structural approach to personality disorders (IPO). The

intercorrelation of the PPRS scales and the correlation with the LPS was also investigated

with a comparable group of PD patients which were of varying length in therapy, this to see

whether the correlations changed with therapy, compared to a first assessment.

Method

Participants.

The first study group consists of 82 PD patients at the very beginning of their treatment.

These are first assessments with the PPRS. The study group is the same group as described in

Chapter 3. Eighty-two patients (54 male, 28 female) referred to a setting for hospital treatment

(day hospital and in-patients) on psychoanalytic lines for personality disorders at the

University Center Kortenberg, Belgium (see Chapter 1) were tested. The patients were

between the ages of 17 and 58 (M = 27.1, SD = 8.5). Sixty-one patients were single, 29 lived

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with their parents, 17 were married or living together with a partner, 3 were divorced and 1

lived in a community center. Three patients completed primary education, 32 secondary

education and 47 higher education or university. On the basis of the SCID-II, we assigned all

patients to one of the three clusters of personality disorders according to DSM-IV: cluster A,

2 (1 schizoid, 1 schizotypal); cluster B, 62 (1 histrionic, 44 borderline, 10 narcissistic, 4

narcissistic and borderline, 3 histrionic and borderline); cluster C, 10 (1 avoidant, 2

dependent, 1 avoidant and dependent, 6 NOS); clusters A+B, 1; clusters B+C, 10.

The second study group consists of 53 PD patients that were in therapy for a duration

of varying length. This group is part of the first group. Fifty-three patients (18 males, 35

females) followed a treatment on psychoanalytic lines for personality disorders (see

Chapter1), 39 in an open-ended residential setting and 14 in a day-treatment setting. The

patients were between the ages of 17 and 58 (M = 28.0, SD = 9.2). Twenty-one were single,

19 lived with their parents, 10 were married or living together with a partner and 4 were

divorced. Nineteen patients completed secondary education and 34 higher education or

university. On the basis of the SCID II we assigned all patients to one of the three clusters of

personality disorders according to DSM IV; cluster B: 40 (28 borderline, 9 narcissistic, 2

narcissistic and borderline, 1 histrionic and borderline); cluster C: 6 (1 dependent, 1 avoidant

and dependent, 4 not otherwise specified); clusters B+C: 7.

These patients had a variable length of stay at the moment of assessment of the PPRS: <3

months: 1; 3-6 months: 5; 6-9 months: 4; 9-12 Months: 30; >12 Months: 13.

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Instruments.

Besides the Psychoanalytic Process Rating Scale version 1 (PPRS, Beenen and Stoker, 2001),

we used the Felt Safety Scale, the Differentiation Relatedness Scale, the Reflective

Functioning Scale and the Bion Grid Scale as related measures; these measures are discussed

in Chapter 3. Another related measure is the Leuven Psychotherapy Scale (LPS), discussed in

Chapter 4.

As clinical measures we used the Symptom Checklist 90 (SCL-90) (Derogatis,1977),

translated by Arrindell & Ettema (1993), which consists of 90 items that tap eight

psychopathological domains. As personality related scales we used the SCID-II questionnaire

that has been translated in Dutch and adapted for DSM-IV by Weertman, Arntz & Kerkhofs

(2000). The SCID-II is a structured clinical interview of DSM-III-R Personality Disorders by

Spitzer & Williams, 1985) and the Inventory of Personality Organization (IPO). The IPO is a

self-report questionnaire (Kernberg & Clarkin, 1995) measuring the intrapsychic structure in

three dimensions according to the model of Kernberg on borderline personality organization.

The reliability and validity of the IPO translated in Dutch has been demonstrated by Vermote,

Vertommen et al., 2004 and by Vermote,Smits, Claes & Vertommen, 2005.

Procedure.

After written informed consent, the PPRS was assessed by the therapist, in this case two

senior psychoanalytic psychotherapists and one psychoanalyst. The patients were in group

analysis (three times, 1.5 hour sessions three times a week), and because it was difficult to

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rate all patients on one session, the PPRS was assessed every three months for each patient

about the last two weeks of treatment.

The other scales were assessed by an independent researcher in the same periods of the

assessment of the PPRS. The Object Relation Inventories were assessed at the same moments

of assessment of the Clinical Symptom Measures by a psychologist having no contact with

the therapeutic staff and the patients besides of these interviews. The transcripts of the

anonimised ORI’s were distributed in a random order to raters blind to any information about

the patients and having had no contact with them. The ORI – interviews were rated on the Felt

Safety Scale, the Differentiation Relatedness Scale, the Reflective Functioning Scale and the

Bion Grid Scale by a group of 12 raters, three raters for each scale, who had a previous

training with the manual of their scale and a satisfactory reliability test for this scale.

Analysis of data.

The correlations between the scales of the PPRS were examined using the Pearson

Product Moment Correlation Coëfficient. The correlations of the PPRS scales with the LPS,

FSS, DRS, RFS, BGS, IPO, SCID, SCL scales were also analysed by using the Pearson

Product Moment Correlation Coëfficient.

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Results

The Pearson correlation coëfficients of the intercorrelation between the five PPRS scales

for study group 1 after a first assessment are given in table 3.

Table 3

Correlations between PPRS Subscales at the First Assessment, Pearson Correlation

Coefficient (n=82)

Subscale PPRS CP PPRS TE PPRS EX PPRS DI PPRS CT

PPRS CP ― .32** .37*** .27* .39***

PPRS TE ― .53*** .41*** -.36***

PPRS EX ― .20 .15

PPRS DI ― -.18

PPRS CT ―

* p < .05, ** p < .01, *** p < .001

The correlations of the PPRS scales at a first assessment with the SCID-II categories are

given in table 4.

There were few significant correlations of the PPRS scales with the SCID-II

categories.These correaltions are show in table 5. Weak negative correlations were found

between the obsessive compulsive category and the PPRS ct (r = -.25, p = .03), the depressive

category and the PPRS cp (r = -.27, p = .01) and the PPRS ct (r = .22, p = .04) and between

the schizoid category and the PPRS ct (r = -.31, p < .01).

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Table 4

Correlations between PPRS Subscales of a Group of Patients for a Duration of Therapy of

Varying Length, Pearson Correlation Coefficient (n=53)


PPRS CP ― .14 .38** .57*** .54***

PPRS TE ― .53*** .26 -.49***

PPRS EX ― .33* -.08

PPRS DI ― -.02

PPRS CT ―

* p < .05, ** p < .01, *** p < .001

The only significant correlations between the scales of the SCL-90-R and the scales of

the PPRS were with the PPRS te scale: with SCL interpersonal sensitivity (r = .22, p = .05)

and with SCL anxiety (r = .23, p = .03).

When correlating the three IPO subscales (Pdm, Id, Rt) with the 5 PPRS subscales, there

were only significant correlations with the PPRS di scales: with IPO Pdm (r = .22, p = .05)

and with IPO Rt (r = .27, p = .01).

The correlation between the subscales of the LPS and the subscales of the PPRS of a

group of patients for a duration of therapy of varying length, is shown in table 6.

The correlation between the four ORI expert rating scales (FS, DRS, RFS, BGS) and the

PPRS scales is shown in table 7.

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Table 5

Correlation of the SCID II and PPRS at the First Assessment, Pearson Correlation

Coefficient ( n=53)


SCID AVOI -.02 .04 -.11 .08 -.22

SCID DEP -.03 -.02 -.11 .10 -.06

SCID OC -.10 .11 -.01 .06 -.25*

SCID PA -.09 .02 -.09 .17 .01

SCID DEPR -.27* .11 -.08 .10 -.22*

SCID PAR -.07 .10 -.06 .08 -.02

SCID SCT .06 .07 .00 .013 -.03

SCID SCI -.14 .12 .03 .17 -.32**

SCID HIS .10 -.02 -.07 .06 .14

SCID NAR -.06 .01 -.00 .14 .06

SCID BOR .01 .08 -.14 .21 -.06

SCID ANT -.03 .11 .06 .18 -.13

* p < .05, ** p < .01

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Table 6

Correlation between LPS and PPRS of a Group of Patients for a Duration of Therapy of

Varying Length, Pearson Correlation Coefficient (n=53)


LPS Pos. Well Being .03 -.33* -.33* -.09 .32*

LPS Cap. Authentic Relationships. -.13 -.19 -.25 -.05 .16

LPS Cap. Unexpected Events .01 -.10 -.18 -.11 .22

LPS Cap. Negative Emotios -.09 -.41** -.35** -.22 .17

LPS Cap. Interiorization -.03 -.17 -.07 -.03 .14

LPS Positive Exp. Setting .06 -.48*** -.17 .00 .53***

LPS Control Substance Use -.19 -.26 -.43** -.33* .24

* p < .05, ** p < .01, *** p < .001

Table 7

Correlation between LPS and Felt Safety Scale(FSS), Differentiation Relatedness Scale(DRS),

Refelctive Functioning Scale(RFS) and Bion Grid Scale (BGS) of a Group of Patients for a

Duration of Therapy of Varying Length, Pearson Correlation Coefficient (n=53)


FSS global .16 -.32* -.05 .08 .42**

DRS global .30* -.10 .15 .05 .48***

RFS global -.06 .02 -.06 -.17 .17

BGS global .18 -26 .09 -.15 .49***

* p < .05, ** p < .01, *** p < .001

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Discussion

The PPRS issued from factor analysing the 262-item PRS and was constructed with the

theory driven items from the general process and the interaction parts of it. The scale is

designed to reflect the therapist’s impression about the analytic relation in a way that makes it

possible to rate it and to subject those ratings to statistical analysis. The scale contains

therapist and patient related items.

Not all scales correlate; the correlations that we find are in line with clinical logic. The

Exploration scale correlates with the Cooperation scale and goes with increased Tension. We

find a positive correlation between Disillusion and Tension scales, a negative correlation

between Tension and Contentment and a positive correlation between Cooperation and

Contentment. These correlations are expected and remain during therapy as table 3 and 4

show. We see that in patients under therapy, a former correlation between Cooperation and

Tension stops, just as between Disillusion and Tension. It is indeed expected to be an effect of

the therapy that patients are less afraid to cooperate and that they support negative feelings

better. These intercorrelations fit with what we expect and support the validity of the scale.

Although most scales are interrelated, they measure separate qualities of the process, as the

highest value is.57.

We wondered whether the factors describing the process by the PPRS, the result of a factor

analysis of theory driven items in a sample of patients in psychoanalysis, were related to the

factors describing the process by the LPS, the result of a factor analysis of items based on

statements of the patients in a PD sample. There is indeed a correlation between the LPS scale

of 'Positive well-being' and the PPRS scale 'Contentment' and a negative one with 'Tension'.

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Both the PPRS and LPS seem to reveal this same basic dimension. There is indeed a

correlation between the LPS scale 'Capacity to deal with negative emotions' and the PPRS

scale ' Exploration', but to our surprise it is a negative one. We further see that this

'Exploration' scale correlates negatively with the LPS scale 'Positive Well-Being'. An

explanation may be that the items of the PPRS scale 'Exploration' are all therapist related

items in which the therapist confronts or interprets and such sessions may be accompanied

with a temporally lessening of the feeling of well-being. At least in this sample of PD patients

this seems to go with a diminished State Reflective Functioning. The fact that the LPS '

Capacity to deal with negative emotions' correlates negatively with the PPRS ' Tension' is as

expected. A correlation in the relation dimension, between the LPS scale 'Openness to

authentic relations' and the PPRS scale ' Cooperation' is not found.

When correlating the PPRS with the dimensions of the three dimensional model as

measured on the ORI (see Chapter 3), we found the Felt Safety Scale correlating positively

with the PPRS scale ' Contentment' and negatively with the ' Tension' scale, which is

expected. The DRS that is about the mental representation of self-other relationships,

correlates with the PPRS scale ' Cooperation ' scale, which is the PPRS scale which is most

relationship orientated and with the 'Contentment ' scale. The Reflective Functioning Scale as

measured on the ORI, does not correlate with any of the PPRS scales. The Bion Grid Scale,

which reflects the way of creatively linking experiences with several levels of thought

correlates with the PPRS scale ' Contentment', indeed it is only in a relaxed contact between

patient and therapist that this mental functioning goes well.

We found few relations of the PPRS with personality related measures. With the SCID

II, consisting of items describing the DSM IV Axis II categories, we see a negative correlation

between the PPRS 'Cooperation' scale with the Depressive category and a negative correlation

between the PPRS 'Contentment' scale with the Obsessive Compulsive, the Depressive and

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the Schizoid categories. These correlations fit clinical logic as well, because these categories

consist of anxious patients that are just admitted and adjusting to the setting. The PPRS does

not seem to measure personality traits, but the relations are coherent As far as the level of

Borderline Personality Organisation is concerned, we see only a correlation with the PPRS

'Disillusion' scale. This is in line with Kernberg's (1996) model on which the IPO is based,

lower degrees of personality organisation going with higher IPO scores are characterised by a

greater aggression infusion. There are no relationships with the SCL-90 except for the PPRS '

Tension ' scale with the SCL interpersonal sensitivity and anxiety subscales.

In conclusion we may say that for a sample of personality disordered patients, the

relations of the PPRS are coherent with the process measures assessed on the ORI and the

self-report LPS scales. There are few relations with clinical scales, but these are coherent.

This is a good argument for validity given the fact that the study group, personality disordered

patients in psychoanalytically informed hospitalization, differs greatly from the group on

which the scale has been constructed, clients in ambulant psychoanalysis or psychoanalytic

psychotherapy. We wonder however whether the PPRS reflects sufficiently the domains of

change which we judge important in personality disorders; felt safety seems to be present, and

a relation aspect as well but the mentalisation dimension is not really present. This may due to

the fact that in the client group on which data the PPRS is constructed, mentalization is not

the main issue. There are no others groups of patients to compare with at the moment. These

data are the first data on validity of the PPRS. The PPRS is part of an evaluation procedure of

the Dutch Psychoanalytical Institute which will provide soon data that will be used studying

the validity of the PPRS. In Italy the PPRS is used in the evaluation of Psychoanalytic

Psychotherapies by G. Amadei (Stoker and Zevalkink, 2005).

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PART 3

OUTCOME, OUTCOME TRAJECTORIES AND DROP-OUT

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Chapter 6

Outcome and Outcome Trajectories of Personality Disordered

Patients During and After Hospitalization on Analytic Lines

According to meta-analyses (Perry et al., 1999; Leichsenring & Leibing, 2003),

psychotherapy on analytic lines proves to be an effective treatment for personality disorders.

A specific form of this therapy, namely partial hospitalization premised on analytic lines, has

been examined for borderline patients utilizing an RCT design by Bateman and Fonagy

(1999, 2001). These researchers found significant clinical improvement during a treatment

period of 18 months; gains which continued in a follow-up period of 18 months.

RCT studies such as the Bateman and Fonagy study are bound to a selection of

homogeneous groups but in most settings for a hospital-based treatment of personality

disorders, the population includes a wider range of persons within the spectrum of borderline

personality organization (Kernberg, 1996).

Several authors (Bergin & Lambert, 1979; Frank, 1979; Clarkin & Levy, 2004) suggest

that the largest proportion of variance in therapy is due to personal characteristics and

qualities of the clients. Lambert (1992) attributes as much as 40 % of client improvement in

psychotherapy to client variables and extratherapeutic influences. When it is possible to

discern differences in outcome trajectories, it must be possible to study the impact of pre-

treatment client variables by post-hoc examinations, given a naturalistic composition of the

study group.

In the present two-year prospective study, the study group comprises 78 consecutively-

admitted patients in a psychoanalytically informed hospitalization based treatment of

personality disorders. Symptom change during therapy (which is open-ended with a

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maximum duration of 1 year) and during a 1 year follow-up period is measured. In this study,

we want to examine whether it is possible to reliably discriminate different trajectories and

whether these trajectories are linked to patient characteristics at the start. We may suppose

that the effect of patient variables on outcome trajectories is prominent as the patients all get

the same treatment and because extratherapeutic influences are relatively small in this

hospitalization-based treatment. In the future clinical settings might benefit from these

findings to adapt and specify treatment technique and treatment goals to the needs of the

patients.

For the process-outcome study (Chapter 8) we study a part of this group, namely the 47

consecutively admitted patients that stayed at least nine months, this to have enough moments

to study the process. We can compare the results of this group with the results of the treatment

group of the Bateman and Fonagy, 1999 RCT study, because in their treatment group of

nineteen patients, the drop-outs neither were included and the treatment duration was up to 18

months. This comparison may compensate partly for the fact that there is no control group in

the naturalistic design of our project. The Kortenberg group comprises consecutively admitted

DSM IV axis II personality disordered patients within the spectrum of borderline personality

organisation, while the group of the Bateman and Fonagy study is a selected group of DSM

IV axis II borderline patients.

First study: Outcome of Personality Disordered Patients During and After a Hospitalization

on Analytic Lines.

In this study we examined the change in clinical symptoms and in personality related

characteristics of personality disordered patients in psychoanalytically informed

hospitalization for 9 to 12 months and during one year follow-up.

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We compared anxiety and depression scores assessed with the same scales, at the same

time intervals in our study as in the therapy group of the RCT study of Bateman and Fonagy

(1999).

Treatment

The treatment of patients with personality disorders with psychoanalytically informed

hospitalization based treatment (KLIPP) at the University Centre Kortenberg is to a large

extend comparable to the treatment model, recently described by Bateman and Fonagy

(2004). The Kortenberg hospitalization treatment focuses on three dimensions of inner

change: felt safety, mentalization, and self-other object relations (Chapter 1). Two setting

characteristics distinguished the present setting and that described by Bateman and Fonagy

(1999, 2001, 2004): the present study was an open-ended in-patient and day-hospital

treatment with a maximum stay of approximately one year, rather than the 18 months of day

hospital treatment in the Bateman and Fonagy (1999) study.

Method

Participants

The study group comprised personality disordered patients who stayed long enough in

psychoanalytically informed open-ended hospitalization to have at least the measures at

outset, after 3, 6 and nine months of treatment and three months after discharge. This in order

to have enough moments to enable a process study and to have a length of time of treatment

comparable with the Bateman and Fonagy study (1999).

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47 consecutively admitted patients corresponded to these conditions. Of these 47

patients, three patients were not included in the statistical analysis because of missing data at

discharge or follow-up: one refused further assessments, the self-reports of another got lost by

mail delivery service, one patient was acutely discharged because of selling drugs.

Thus the patients in the study consisted of 44 admitted patients (13 males, 31 females).

31 were in-patients, 13 in a day-treatment setting. The patients were between the ages of 17

and 58 (M = 28.0, SD = 9.24). 17 were single, 17 lived with their parents, 7 were married or

living together with a partner, 3 were divorced. 16 patients completed secondary education

and 28 higher education or university. Using the SCID-II we assigned all patients to one of

the three clusters of personality disorders according to DSM-IV; cluster B: 32 (23 borderline,

7 narcissistic, 1 narcissistic and borderline, 1 histrionic and borderline); cluster C: 7 (1

dependent, 1 avoidant and dependent, 5 not otherwise specified); clusters B+C: 5. On DSM-

IV Axis I, we diagnosed 20 mood disorders, 2 anxiety disorders, 1 eating disorder, 5


Measures

Clinical symptom measures.

The Self Harm Inventory (SHI) (Sansone et al., 1998) applied to the last two weeks, the

Symptom Checklist 90 (SCL-90) (Derogatis, 1977) translated by Arrindell & Ettema(1993),

the Spielberger State-Trait Anxiety Inventory translated by van der Ploeg et al. (1980), the

Spielberger State-Trait Anger Inventory translated by Van der Ploeg et al. (1982) and the

Beck Depression Inventory translated by Bouman et al. (1985).

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Personality characteristics.

The questionnaire of the Structured Clinical Interview for DSM-IV Axis II disorders

SCID-II (Spitzer & Williams, 1985) has been translated in Dutch and adapted for DSM-IV,

by Weertman, Arntz & Kerkhofs (2000). The Inventory of Personality Organization

(Kernberg & Clarkin,1995), is a self-report questionnaire used to assess a structural diagnosis

according to the model of Kernberg on borderline personality organization. The reliability and

validity of the IPO translated in Dutch was demonstrated by Vermote,Vertommen et al.

(2004) and Vermote, Smits, Claes and Vertommen (2005). The Inventory of Interpersonal

Problems, circumflex version (Alden et al., 1990) measures interpersonal functioning in 8

scales: domineering (pa), vindictive (bc), cold (de), socially avoidant (fg), nonassertive (hi),

exploitable (jk), overly nurturant (lm), intrusive (no). All these measures have a well

established reliability and validity.

Procedure

The patients were assessed within the first two weeks of admission, every three months,

and upon discharge. In follow-up, the patients were assessed three months and one year after

discharge.

The personality related measures were assessed within the first two weeks of admission,

upon discharge and three months and one year after discharge.

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Data Analysis

Analysis of variance, repeated measures. We used the Cohen d in comparing the

Kortenberg outcome with the London outcome.

Table 1

Mean Scores of the Sansone Self Harm Inventory (SHI), Symptom Check List (SCL) and Beck

Depression Inventory (BDI)

SHI SCL psn BDI

Time M SD M SD M SD

admission 2.32 2.53 210 57.9 25.4 10.4

3m. 2.41 2.5 210 60.4 23 11.1

6m. 1.88 2.23 211 69.5 22.5 10.9

9m. 1.73 2.21 201 62.6 18.9 9.84

12m. 1 1.54 175 56.7 15.2 9.59

15m 1.25 2.8 169 65.5 14.3 11.5

24m 1.29 1.95 170 60.6 13.7 11.1

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Results

The results for each of the symptom outcome measures are shown in table 1 and 2.

There was a significant change over time. We noted an improvement during therapy and the

year after discharge for the following symptom measures: SHI last two weeks (F

(6,248)=4.88, p =< .0001), SCL pst (F (6,248)=9.99, p =< .0001) with a cubic component

(F(1,248)=5.77, p = .02) and BDI (F (6,248)=16.45, p =< .0001), STAI state (F

(6,248)=5.84, p =< .0001), STAI trait (F (6,248)=14.52, p =< .0001), STAXI trait (F

(6,248)=5.21, p =< .0001) with a quadratic component (F(1,248)=4.32, p = .04). These

changes over time are presented in figures 1-7. Only the STAXI state showed no significant

change (F (6,248)= .95, p = .45).

Table 2

Mean Scores of the Spielberger State and Trait Anxiety and Anger Inventory (STAI & STAXI)

Every Three Months During Treatment and Three Months and a Year After Discharge

STAI state STAI trait STAXI state STAXI trait

Time M SD M SD M SD M SD

admission 47.6 13.4 59 10.2 11.9 3.1 17.8 6.77

3m. 46.1 11.5 57.4 10.6 11.7 3.93 18.1 5.97

6m. 45.2 12.1 56.5 11.9 12.1 4.6 17.9 5.15

9m. 43.8 11.9 54.1 10.7 12.3 5.06 18.1 4.06

12m. 40.9 13.9 49.4 13 11.1 2.65 16.8 4.96

15m 39.3 14 48 14.6 11.6 4.66 15.5 4.76

24m 39.5 13 46.8 14.7 10.9 1.11 15.5 3.89

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Figure 1. Time related change of the mean scores on the Self Harm Inventory (SHI) of the

last two weeks (Moment 4 is at discharge).

Figure 2. Time related change of the mean scores of the Symptom Checklist (SCL-90-R)

Positive Symptom Total.

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Figure 3. Time related change of the mean scores of the Beck Depression Inventory (BDI).

Figure 4. Time related change of the mean scores of the Spielberger Anxiety Inventory, State

(STAI).

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Figure 5 . Time related change of the mean scores of the Spielberger Trait Anxiety Inventory

(STAI).

Figure 6. Time related change of the mean scores of the Spielberger State Anger Inventory

(STAXI).

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Figure 7. Time related change of the mean scores of the Spielberger Trait Anger Inventory

(STAXI).

The results for each of the personality related measures are shown in table 3. There

was a significant change over time. We noted an improvement during therapy and the year

after discharge for all personality related characteristics: IPO sum (F (3,128)=6.15, p =

.0006), SCID II sum (F (3,128)=11.17, p < .0001) with a quadratic trend (F(1,128)= 4.22, p =

.04) and the IIP mean (F (3,128)=6.84, p = .0003). These changes over time are presented in

figures 8-10.

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Table 3

Mean Scores of the Sum Scores of the Inventory Personality Organisation (IPO), of the Sum

Scores of the Structured Interview DSM III-R ( adapted questionnaire for DSM IV) and of the

Inventory Interpersonal Problems (IIP)

IPO SCID II IIP

Time M SD M SD M SD

admission 136.93 42.09 1.69

12m. 129.18 35.57 1.56

15m 126.54 31.86 1.41

24m 122.20 31.41 1.35

Figure 8. Time related change of the mean sum scores of the Inventory of Personality

Oganisation ( IPO), at 4 moments.

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Figure 9. Time related changes of the mean sum cores of the Structural Clinical Interview of

DSM III -R Personality Disorders ( SCID II), adapted questionnaire for DSM IV.

Figure 10. Time related changes of the mean scores of the Inventory of Interpersonal

Problems (IIP).

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The results of the STAI state, the STAI trait and the BDI of this study group

(Kortenberg group) can be compared with the results of the therapy group in the Bateman &

Fonagy (1999) RCT study (London group), at similar time moments.This is shown in table 4.

The therapy in the Kortenberg group stops at 12 months, in the London group at 18 months.

The baseline of the two groups is different, the Kortenberg group starts at a lower level of

pathology than the London. The effect sizes (Cohen d) of the STAI state are .6 for this study

group and 2.1 for the London group, of the STAI trait are 1.1 for this study group and 1.6 for

the London group and of the BDI they are 1.1 for this study group and 1.6 for the London

group.

Table 4

Comparison of the Mean Scores of the Spielberger State and Trait Anxiety Scores (STAI) and

of the Beck Depression Inventory Scores (BDI) Between the Study Group in Kortenberg and

the Therapy Group of the Bateman & Fonagy 1999 RCT in London, with Assessments Every

Three Months

STAI state STAI trait BDI

Kortenberg London Kortenberg London Kortenberg London

Time M SD M SD M SD M SD M SD M SD

admission 47.6 13.4 68.4 7 59 10.2 66.5 6.1 25.4 10.4 36 7.6

3 months 46.1 11.5 66.7 7.9 57.4 10.6 65.8 5.8 23 11 36.2 7.3

6 months 45.2 12.1 64.3 12.1 55.8 11.9 62.3 9.8 21.6 10.9 36.3 8.9

9 months 43.8 11.9 60.2 12.1 54.2 10.7 60.3 7.4 18.9 9.8 30.7 10.4

12 months 40.9 13.9 55.6 9.8 49.4 13 60.4 7.4 15.2 9.6 26.7 8.7

15 months 39.3 14 53.8 9.7 48 14.6 56.4 8.9 14.3 11.5 23.7 5.7

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Study 2. Outcome trajectories of personality disordered patients during and after a

hospitalization on analytic lines.

In this study, we want to examine whether it is possible to reliably discriminate different

trajectories and to study whether different trajectories are linked to patient characteristics. To

study the trajectories of treatment, we asked all consecutively admitted patients

between.23/5/01-15/7/02 to participate in this prospective study. The group of the first study

is part of this larger group.

Method

Treatment

The treatment is the same as in Study 1.

Participants

78 consecutively-admitted patients in a psychoanalytically informed hospitalization

based treatment of personality disorders (in-patient and partial hospitalization) were asked to

participate at the present prospective study. Two patients refused and six patients left within

the first days and could not be implied because of missing data. They are discussed in Chapter

7 on attrition. After obtaining written informed consent, the remaining 70 consecutively-

admitted patients (24 males, 46 females) were enrolled in the study. Of the 70 participants, 51

were treated in an open-ended hospital setting and 19 in a day-treatment setting. Patients were

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between the ages of 17 and 58 (M = 27.7, SD = 9.0). 26 were single, 26 lived with their

parents, 14 were married or living together with a partner, 3 were divorced and 1 lived in a

community centre. 2 patients completed primary education, 27 secondary education and 41

higher education or university. Using the SCID-II we assigned all patients to one of the three

clusters of personality disorders according to DSM-IV; cluster A: 2 (1 schizoid, 1

schizotypal); cluster B: 52 (1 histrionic, 36 borderline, 9 narcissistic, 3 narcissistic and

borderline, 3 histrionic and borderline); cluster C: 8 (2 dependent, 1 avoidant and dependent,

5 not otherwise specified); clusters A+B: 1; clusters B+C: 7. On DSM-IV Axis I, we

diagnosed 35 mood disorders, 4 anxiety disorders, 1 eating disorder, 20 adjustment disorders

and 8 substance related disorders. Five patients stayed 0 to 3 months; 16 patients, 3 to 6

months; 5 patients, 6 to 9 months; 30 patients, 9 to 12 months; and 14 patients, 12 to 13

months.

Procedure

The patients were assessed within the first two weeks of admission, every three months, and

upon discharge. In follow-up, the patients that stayed less than six months were again

assessed one year after admission. All other patients were assessed three months and one year

after discharge. Personality related measures were assessed at the first moment of assessment.

Measures

The same clinical outcome measures and measures of personality related characteristics

were used as in study 1.

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Data Analysis

Multiple clinical outcome measures were reduced to a single global outcome component

score, the Global Symptom Score (GSS) by means of a Principal Component Analysis (PCA)

on the seven outcome-scores of the patients at the first measurement. The PCA yielded a first

factor accounting for 50 % of the total variance. The loadings on this principal component

were the following:.53 for the Self Harm Inventory (SHI 2w),.86 for the Symptom Check

List-Positive symptom total (SCLpst) ,.85 for the Beck Depression Inventory (BDI), .73 for

the Spielberger State, .89 for the Trait Anxiety Inventory Scores (STAI) and .44 for the

Spielberger State and .49 for the Trait Anger Inventory Scores (STAXI). This PCA solution

was used to calculate GSS component scores at each of the seven time moments.

We modelled global outcome trajectories during treatment and during the year after

treatment using the SAS TRAJ procedure (Nagin, 1999; Jones, Nagin & Roeder, 2001). This

procedure allows for the identification of distinct groups of trajectories and allows to estimate

the proportion of each trajectory group. Trajectory modelling is based on a semi-parametric,

group-based modelling strategy, which is of use in the statistical analysis of trajectories.

Technically this trajectory model is a mixture of probability distributions that are suitably

specified to describe the data that are to be analysed. Differences in patient characteristics

between groups with a different trajectory were studied with univariate analysis of variance

followed by unadjusted t-tests.

Results

The model with one trajectory for the Global Symptom Scale (GSS) showed the global

outcome change of the total study population (see Fig. 1). We found a significant

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improvement during therapy, with a continuation of improvement during the post-treatment

phase, as reported in the Bateman and Fonagy study. The trend of the GSS decreases over the

period of treatment and follow-up was cubic (z = 2.19, p = < .05). This cubic trend shows that

there is a small improvement in the first three months of the therapy, a major improvement in

the following period which continues in the first three months after discharge, followed by a

stabilisation till the next assessment one year after discharge.

Figure 11. Global trajectory of seventy patients treated with hospitalization on analytic lines

for 1 year and 1 year follow-up.The dotted line presents the cubic trend.

Outcome Trajectories

The principal aim of this study was to differentiate outcome trajectories within the study

group. On the basis of information criteria (Akaike’s Information Criterion, Bayesian

Information Criterion) of models with 2, 3 and 4 trajectories, the four - trajectory model was

chosen. Analyses presented here are based on this four-trajectory model, with individuals

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being assigned to their most likely trajectory of outcome change over time, using posterior

probabilities. The trends of the four trajectories are presented in Table 5, the membership of

the four trajectories in Table 6; the trajectories in Figure 12.

Table 5

Model of Four Change Trajectories of 70 Patients

Group Parameter Estimate SE t p

1 Intercept 80.08 1.66 48.33 .0000

2 Intercept 101.70 1.39 73.02 .0000

Linear -0.39 0.06 -6.37 .0000

Quadratic 0.00 0.00 4.07 .0001

3 Intercept 100.40 0.91 110.75 .0000

4 Intercept 112.14 2.38 47.09 .0000

Linear -0.00 0.12 -0.02 .9843

Quadratic -0.00 0.00 -2.14 .0330

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Table 6

Group Membership of the Four Trajectories of Symptom Change

Group membership (%) SE t p

1 8.97 3.87 2.31 .0211

2 49.55 7.14 6.94 .0000

3 25.90 6.86 3.77 .0002

4 15.58 5.43 2.87 .0044

Figure 12. Four trajectory model of seventy patients treated with hospitalization on analytic

lines for 1 year and 1 year follow-up. The dotted lines presents the trends.

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The first trajectory group consists of patients with very few symptoms at the start and

for whom the Global Symptom Score does not change significantly during the treatment or in

follow-up. This group includes 9 % of the patients.

The second and the third groups show the same level of clinical symptoms at the start.

Together they account for 75% of the patients. The second group shows a significant change

in clinical symptoms over time, while the third group does not. The relation of the symptom

change of the second group with the length of treatment is quadratic. The change in clinical

symptoms starts after three months and continues after discharge. This group comprises 49.5

% of the patients. The third group, starting at the same level of symptoms but with no change

over time, includes 25.9% of the patients.

The fourth group includes the patients with the highest severity of symptoms at the start.

This group includes 16 % of the patients. The trajectory of this group shows a quadratic trend:

change beginning late in the treatment with a marked continuing improvement in the post-

treatment period. One year after discharge, the level of symptoms of the fourth group is the

same as that of the second group.

Differences in Pre-Treatment Variables Among Groups of Outcome Trajectories

The difference in the manifestation of symptoms at the start is reflected in the difference

of intercept values of the Global Symptom Score of the four trajectories. These intercept

values show that the first group presents very few symptoms and the fourth group shows

many symptoms at the start, while group two and three start at the same intermediate level of

the global symptom score. The groups had a comparable percentage of drop-outs within the

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first six months, except for the third which had a lower drop-out rate: traj. 1: 33%, traj. 2: 27

%, traj. 3: 12 %, traj. 4: 27 %.

The differences between the four groups in patient characteristics showed that the history of

self harm as measured with the SHI is discriminative (F(3,66) = 5.66, p = .002) for the four

groups. Self-reported traumatic experiences from the past, measured with the TEQ, were

significantly different among groups for the total number of experiences (F(3,66) = 3.63, p =

.02). Groups also differed regarding emotional traumatic experiences (F(3,66) = 5.40, p =

.002) and the difference between groups approached significance for physical traumatic

experiences (F(3,66) = 2.60, p = .06). There were no reliable differences with respect to

sexual traumatic experiences (F(3,66) = 2.14, p = 3,66, n.s.).

For the personality-related characteristics, the level of borderline personality

organization was significantly related to the trajectories. This was found for each of the three

dimensions of personality organization according to Kernberg (1996): primitive defences

(F(3,66) = 5.88, p = .001), identity diffusion (F(3,66) = 5.41, p = .002) and reality testing

(F(3,66) = 4.16, p = .009). The sum score of the IPO, a measure of the severity of borderline

personality organization, is significantly different for the four groups (F(3,66) = 6.57, p =

.0006).

Of the IIP scales, the BC 'vindictive' scale is the most different among the four groups

(F(3,66) = 4.76, p = .004). Additionally, PA 'domineering' (F(3,66) = 3.96, p = .01), DE 'cold'

(F(3,66) = 3.83, p = .01), JK 'exploitabe' (F(3,66) = 3.16, p = .03) and LM 'overly nurturant'

(F(3,66) = 3.25, p = .03) scales are significantly different. This is not the case for the FG

'socially avoidant', HI 'non assertive' and NO 'intrusive' scales. The total IIP score is highly

discriminative (F(3,66) = 6.68, p = .0005).

For the item scores on the DSM-IV axis II categories (SCID), we found a significant

distinction between the groups for the avoidant (F(3,66) = 6.11, p = .001), paranoid (F(3,66)

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= 6.11, p = 002), borderline (F(3,66) = 5.40, p = .002), schizotypal (F(3,66) = 5.09, p = 003),

schizoid (F(3,66) = 4.14, p = .009) and depressive (F(3,66) = 4.54, p = .006) categories.

We further investigated the particular differences between these groups by post-hoc

tests. The results of the post-hoc comparisons are shown in table 7 and 8.

Table 7

Mean scores and Standard Deviations of the 4 Trajectory Groups on the Inventory of

Personality Organisation(IPO), SCID Scales and Symptom Checklist (SCL-90-R), With

Indication of Significant Differences Between the Groups

Trajectory group 1 Trajectory group 2 Trajectory group 3 Trajectory group 4

Scale M SD M SD M SD M SD

IPO sum 105.83bcd 29.08 140.03ad 26.5 135.24ad 23.12 164.55abc 30.98

SC avoid 1.67bcd 1.21 3.94ad 2.22 3.65ad 1.54 5.73abc 1.62

SC dep 2 1.41 3.19 1.93 3.59 2.4 4.36 1.75

SC oc 4 2.28 4.61 1.83 4.41 2 5.36 1.86

SC pa 1.33bd 1.37 3.22a 1.96 2.59 1.37 3.55a 1.7

SC sct 1.5 1.52 3.14 1.94 3.71 1.9 5.09 2.12

SC schiz 0.67bd 0.52 2.22ac 1.53 1.35bd 0.7 2.36a 1.29

SC par 1.33 0.85 3.81ac 2.14ac 2.65b 0.51 5.00ac 0.63

SC his 0.83b 2.04 2.17a 1.78 1.59 1.28 1.64 1.69

SC nar 2.33 3.39 4.22c 3.03 2.77b 1.79 4 2.97

SC bor 4.00bcd 2.9 8.69a 2.98 8.41a 3.3 10.36a 3.59

SC ant 0.83 2.04 0.75 1.08 1.12 2.21 1.46 1.86

SCL hos 7.00bd 1.49 9.89a 0.61 8.53bd 0.88 11.45ac 1.1

SCL pst 114.17 17.96 199.72 55.75 207.71 46.86 296.36 41.28 abcd differs significantly from (a) traj 1 (b) traj 2 (c) traj 3 (d) traj 4

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Table 8

Mean scores and Standard Deviations of the 4 Trajectory Groups on theInventory of

Interpersonal Problems (IIP), Self Harm Inventory (SHI) ever, Traumatic Experiences

Checklist (TEQ) and Length of Stay, With Indication of Significant Differences Between the

Groups

Trajectory group 1 Trajectory group 2 Trajectory group 3 Trajectory group 4

Scale M SD M SD M SD M SD

IIP pa 1.5 1.64 8.97 5.88 8.71 3.98 9.82 5.53

IIP bc 3.33bd 2.34 10.56ac 5.99 7.12bd 4.36 12.27ac 6.94

IIP de 5.50bcd 5.79 12.53a 4.92 11.77a 7.47 15.46a 5.91

IIP fg 12 9.32 16.06 7.77 16.06 8.3 21.36 7.19

IIP hi 12 11.95 18.53 7.99 18.53 8.05 20.55 6.09

IIP jk 8.83 6.43 16.75 6.69 17 7.13 19.55 7.87

IIP lm 8 7.62 15.94 6.93 16.59 7.19 19.18 7.69

IIP no 3.67bcd 2.58 10.97a 6.66 11.24a 7.01 10.18a 6.31

SHI ever 3.50cd 3.33 6.56d 3.96 7.71 ad 4.09 11.82 a b c 6.51

TEQ emo 0.33 b c d 0.82 1.77 a d 1.57 1.88 a d 1.22 3.36 a b c 2.11

TEQ phy 0.00 c d 0 0.51 0.66 0.77 a 0.75 0.91 0.94

TEQ sex 0.67 b 0.82 0.86 c 1.26 1.71 b 1.49 1.46 1.21

TEQ tot 3.50 b c d 1.69 6.77 a d 0.7 7.23 a d 1 10.18 a b c 1.25

length stay 2.34 0.64 2.53 c 0.26 3.47 b 0.38 2.55 0.47 abcd differs significantly from (a) traj 1 (b) traj 2 (c) traj 3 (d) traj 4

We focused in the post-hoc comparison on the differences between group two and three,

which account for 75 % of the patients and were not discerned at a symptom level at the start

but showed a very different outcome trajectory. Distinguishing the patient characteristics of

these two groups is therefore clinically very meaningful. Comparing the Trajectory 2 group,

that shows change, with the Trajectory 3 group, who does not, we see that Trajectory 2 group

is not different in IPO sum (t = 0.61, p = .54) and SHI (t = -0.88, p = .38), but the Trajectory

2 group has higher scores on SC schiz (t = 2.31, p = .02), SC par (t = 1.89, p = .06), SC nar (t

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= 41.77, p = .08) and IIP bc (t = 2.09,p = .04). Trajectory 3 group shows the highest TEQ

scores and the longest stay of all trajectory groups and showed more sexual traumata in the

past TEQ sex (t = -2.23, p = .03) and a longer length of stay (t = -2.04, p = .05) in

comparison with the Trajectory 2 group.

Comparing the Trajectory 3 group (poor change), with the Trajectory 4 group (more

severe pathology, but changes), we see differences in IPO sum (t = -2.83, p = .006) and SHI

(t = -2.39, p = .02) which reflect the difference in level of borderline personality organisation,

and further in SC avoid (t = -2.80, p = .007), SC par (t = -2.92, p = .005), SCL host (t = -

2.07, p = .04) and IIP bc (t = -2.37, p = .02).

Comparing the Trajectory 1 group (less severe pathology) with the Trajectory 2 and 3

groups, we see lower scores than the Trajectory 2 on TEQ total (t = -1.78, p = .08), IPO (t = -

2.90, p = .005), SC avoid (t = -2.69, p = .009), SC bord (t = -3.38, p = .001) and lower scores

than Trajectory 3 group on the same scales: TEQ total (t = -1.78, p = .08), IPO (t = -2.32, p =

.02), SC avoid. (t = -2.17, p = .03), SC bord (t = -2.94, p = .004). However the Trajectory 1

group has significantly lower scores than the Trajectory 2 group on SC pa. (t = -2.45, p =

.02), SC schiz. (t = -2.76, p = .007), SC par. (t = -2.70, p = .009), SCL host. (t = -1.8,p =

.08), IIP bc (t = -2.92, p = .005), IIP de (t = -2.72, p = .008) and TEQ emo (t = -2.10, p =

.04) while the differences between the Trajectory 1 group and the Trajectory 3 group are not

significant for the same scales.

Discussion

Time related outcome changes corroborate the findings of the RCT study of Bateman

and Fonagy (1999, 2001) which shows the effectiveness of a hospitalization on analytic lines

for borderline personality disorders. For a group of patients within the spectrum of borderline

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personality organization that was treated by a similar hospitalization on psychoanalytic lines

for a period of at least nine months, we found a significant decrease in self-harm, anxiety,

anger, depression and global symptoms with a continuation of the improvement after

discharge. Compared with the Bateman and Fonagy (1999) treatment group, our study shows

a significant decrease in symptoms but starts and ends with lower mean scores on the

symptom scales. This may be due to the fact that our study group consists of a heterogeneous

group of personality disorders, while the Bateman and Fonagy (1999) treatment group

comprised selected DSM IV axis II borderline patients. Furthermore we waited for the first

assessment till the patients were acclimatized on the setting.

We found a significant decrease during the treatment and a further decrease in the three

months after discharge, not only in symptom scores, but also in all scores related to

personality characteristics. These scores reflect change in broad domains of human life such

as self-experience, coping strategies, affect-regulation, relationships, work. These

characteristics are more stable than volatile symptoms and may reflect so-called structural

changes. This structural change is particularly reflected in the change of the IPO, which

measures the borderline personality organisation. A further argument for structural change

may be found in the continuation of improvement of most measures after discharge from the

treatment program. This was found in the Bateman and Fonagy study as well. However in the

Bateman and Fonagy follow-up study (2001), 75% percent of the patients continued with a

twice weekly group psychotherapy in the post -treatment phase. In our study group no such

organised post- hospitalization treatment was offered at the time of the study, however 50 %

of the patients of the study group started an ambulant psychoanalytical psychotherapy - a

form of treatment that was not successful before the hospital treatment, hence the admission.

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These results suggest that psychic change happens during treatment resulting in an

outcome which is enduring and fruitful in the long term. A psychoanalytically informed

treatment aims at such psychic change rather than being symptom oriented.

Given a continuing improvement after discharge, it is a point for discussion whether in

the studied program with a maximum stay of one year, the patients are discharged too early

and at a moment they are still improving, or whether this time limit is an important

therapeutic factor as the study of Chiesa (2000) shows. Chiesa compared a two-stage model (a

shorter in-patient admission followed by outreached therapy) with a one-stage treatment

model without aftercare and found that the former yielded significantly better results for

borderline patients.

The main aim of the second study of the large group was to examine the trajectories of

change behind the global result of the whole group of heterogeneous personality disorders.

Given the heterogeneity of this group, it was possible to examine whether these outcome

trajectories were related to pre-treatment patient characteristics. With such data, it would be

possible in naturalistic settings to predict more accurate treatment outcome from the outset

and to adapt the treatment to the needs of the patients.

As expected, we saw different trajectories related with the symptom level at the start in

this study group: in relation with the symptom baseline of this studygroup we can speak of a

low symptom level, a medium symptom level and a high symptom level. The majority of the

patients starts at the medium level and then we see two different trajectories: one with a good

and one with a bad outcome.

A small group of patients presented few symptoms at the outset, and hence showing few

clinical outcome change. This group had a high level of borderline personality organisation.

These patients were in crisis when admitted to the hospital, but they recovered fast and were

admitted to the treatment setting on psychoanalytic lines because of the diagnosis of a

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personality disorder in order to obtain a psychic, structural change to prevent similar

breakdowns in the future and in order to increase their quality of life. We cannot judge

whether this is achieved from the clinical symptom outcome.

The trajectory of the group with a high frequency of symptoms at the start is interesting.

This group shows not only significantly more symptoms (SCL- 90-R) but also more suicidal

treat and self-harm, a higher SCID-sum score and higher IPO -scores compared to the other

groups. These patients have a low level borderline personality organisation. Post hoc tests

show that they are considerably more paranoid, hostile and vindictive than the other groups.

They are so-called difficult patients. The trajectory of this group is remarkable: they only start

to improve in the last phase of the treatment, an improvement that goes on in the post-

treatment phase. It is a group that puts a lot of stress on the staff and the other patients and the

poor change across several months often raises questions about their suitability for this kind

of treatment. The marked improvement which starts only after a long period might be an

argument that it is important to have patience with these patients and to tolerate their

disruptive behavior within a holding, secure environment with a coherent treatment program

(Bateman & Fonagy, 2004). The continuing improvement in the post-treatment phase may

indicate that this group found another way of dealing with their problems than before

treatment. It is possible that some structural change occurred and that these patients

internalized other ways of dealing with their inner chaos and suffering, and perhaps finding

ways to rely on others instead of evacuating their inner suffering and distress in self

destructive behavior.

The group with a moderate level of symptoms at the start was our main interest. Not

only because they are the majority of the patients in a naturalistic setting (seventy-five percent

of the patients in this sample), but also because in this group we have a group with a trajectory

of good outcome and a group with a trajectory of poor outcome with the therapy as it is. The

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severity in borderline personality organisation is not different between these two groups at the

start: the level of personality organization (IPO), the level of borderline symptoms (SCID)

and self harm (SHI). Therefore, it was important to study whether we could find other

characteristics which differentiate the two groups at the start. This would it make possible to

predict more accurate outcome according to patient characteristics and to adapt the treatment

program in the future to the needs of specific patients. We found that the group with good

outcome showed more avoidant, schizoid, paranoid and narcissistic features (SCID) and had

more difficulty in expressing emotions, as rated with the IIP than the group with poor

outcome. This also corroborates with the findings of attachment studies which show that

patients with a dismissive-avoidant attachment style respond best to psychodynamically

oriented interpretive, explorative therapy (Blatt and Shahar, 2004; Gabbard 1994; Fonagy,

1996). The similarity of this group with Blatt's categorisation of a introjective group (Blatt

and Blass, 1996, Blatt & Auerbach, 2003) is striking. He found the introjective group being

composed of individuals with paranoid, schizoid, avoidant and narcissistic personality

disorders, exactly the personality characteristics which specify this trajectory group with a

good outcome. In his analysis of the data of the Menninger Psychotherapy Research Project

(Wallerstein, 1986), he found that these patient characteristics discerned the group of patients

that clearly benefited from a psychoanalytic, explorative treatment. In fact Blatt and

colleagues integrated the diversity of personality disorders into two primary organisations

based on the differentiation of two polarised psychological dimensions of relatedness and

self-definition. The introjective group shows a greater preoccupation with issues of self-

definition, while the anaclitic group shows a greater preoccupation with issues of relatedness.

In this study, the group with a poor outcome shows all the borderline features but without a

concomitant controlling and introjective attitude. This group reported far more sexual abuse

and corresponds to the so-called anaclitic group, where Blatt found the mutative dimension

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being a supportive therapeutic relationship and not so much insight and self-understanding as

in the introjective group. They tend to improve by relying on the support and structure of the

therapy rather than by an explorative attitude, certainly in the beginning of the therapy. Their

dependency on relationships makes that this facet needs to be addressed first before there is

enough therapeutic alliance to work in an explorative way. The poor outcome of the third

group is probably related to the fact that the specific needs of this group were not met enough.

Our impression is that these patients were included too soon in a classic psychoanalytic

interpretive group approach and were easily overwhelmed by this approach. Our process-

outcome study of the inner change during treatment of borderline patients points in the same

direction (see Chapter 8). According to Blatt and Shahar (2004), this group develops an

unrealistic positive therapeutic alliance towards the end of the treatment and the ending of the

therapy is difficult. The fact that they stay longer and show fewer drop-out despite of a poor

outcome may reflect the insecure attachment (Holmes, 2001) described in such patients.

The late improvement of the group with the very difficult patients, borderlines with a

high level of psychopathology at the start, is thought-provoking. It may be that these patients,

which clinical picture is more severe, are more demanding and threatening and therefore for a

very long time approached in a supportive way with many individual contacts and a long

delay before they take part in the intensive group therapy sessions. They do not run the risk to

be included too soon in an explorative phase of the treatment, consisting of classic

psychoanalytic group approach. It may be that the psychic change within the treatment under

study happens mainly by a mechanism of introjection and that it takes a long time before this

change becomes manifest in a decrease of clinical symptoms, and the longest time for the

most severe group.

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Both groups with a good outcome show a more introjective style than the groups with a

poor outcome. This difference in personality style seems to have a strong impact on outcome

within a certain kind of treatment, maybe a stronger impact than the level of psychopathology.

In conclusion:

We found an improvement in the symptom and personality measures of personality

disordered patients during psychoanalytically informed treatment. The improvement

continued in the post- treatment period, as in the Bateman and Fonagy RCT study

(1999,2001). This is an argument for a structural change, which will be further examined in a

process-outcome study (Chapter 8).

The major finding of this study is that the outcome trajectories of personality disordered

patients in psychoanalytic informed hospitalisation relate to pre-treatment patient

characteristics. We discerned a high, medium and low level borderline symptomatology at the

start. Patients with a high level of borderline symptomatology, that are more hostile and

paranoid, take a very long time before they start to change. This change seems related with

introjective mechanisms. But it is worth to have patience and to contain for a long time their

threatening behaviour because post treatment changes are prominent. In the medium level of

borderline symptomatology, the different trajectories depend on the personality style. The

introjective, more avoidant and narcissistic borderline patients profit from the

psychoanalytically informed therapy as it is, while the more anaclitic borderline patients seem

to depend on relational support which has probably to be continued after the treatment. These

patients seem to gain less profit from this explorative treatment as it is. Clinicians tend to

predict outcome according to the severity of symptoms. This study shows that this distinction

is lacking and that differences in personality style, reflected in coping and interpersonal

relation, and already present at the outset of the therapy are important factors in predicting the

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response to the treatment and the outcome. Knowing this distinction, it becomes possible to

adapt the treatment to the needs of the patients and further ameliorate the effectiveness of the

psychoanalytically informed hospitalisation based treatment for personality disorders.

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Chapter 7

Patient Attrition in a Psychoanalytically Informed Hospitalization-

Based Treatment for Personality Disorders

As discussed by Clarkin and Levy (2004) and Chiesa (2000), clients with personality

disorders have been found to be at high risk for dropping out of treatment. The authors argue

that with the large numbers of patients who leave therapy prematurely, study in this area

should be given high priority. Indeed, the literature on personality disorders shows drop-out

rates varying between 32% and 66% in hospitalization-based treatments (Skodol et al., 1983;

Gunderson et al., 1989; Kelly et al., 1992; Chiesa, 2000). Reported differences between

attrition groups and therapy groups related to client characteristics are contradictory. Skodol

et al. (1983) found more severe symptoms in the attrition group at the start of the treatment

but Gunderson et al. (1989), Kelly et al. (1992), Chiesa (2000) and Thunissen (2004) did not

find such differences. In a study of ambulant psychodynamic psychotherapy, Smith,

Koenigsberg, Yeomans, Clarkin & Selzer (1995) found more hostility in the attrition group of

borderline patients.

The present study was designed to examine the attrition group in a psychoanalytically

informed hospitalisation based treatment for patients with personality disorders, comparable

to the setting in the study of Chiesa (2000) and to the treatment program described by

Bateman and Fonagy (2004).

We were interested in identifying factors that predicted early termination. Therefore, in

a first study we examined the differences on pre-treatment variables between the attrition

group and the longer- term therapy group and in a second study we looked at differences in

the psychotherapeutic process at three months for the drop-out group that stayed at least that

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long. In a third study we compared the outcome of the drop-out group and the therapy group

one year after admission regarding clinical symptoms, personality related measures and

psychoanalytic process measures.

Treatment

Hospitalization-based treatment (inpatient and dayhospital) on psychoanalytic lines for

personality disorders at the University Center Kortenberg, Belgium. The treatment focuses on

three dimensions of inner change: felt safety, mentalization, and self-other object relations

(Chapter 1).

Definition of Drop-out

For this study, we applied a definition of attrition in a small and in a broad sense.

In a small sense we rely on the definition of Chiesa (2000), who defined drop-out in a

similar setting as any premature termination of treatment not mutually negotiated and agreed

upon by staff and patient occurring within 14 weeks of admission. We call it the 'small DO

group'.

In a large sense we define the drop-out group as all patients who left the therapy

program earlier than was negotiated at the beginning of treatment. This is relative as the

treatment was open-ended with a focus on the psychic process and on the possibility to switch

to an ambulant psychotherapy when possible. However, prior to therapy, there was an

agreement with the patients that the hospitalization based treatment (in-patient or partial

hospitalization) takes at least 6 months till a maximum duration of 12 months. By this

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definition every patient who fell out of the program in the first six months was part of the

attrition group. We call it the 'large DO group'.

In the second study we examine the therapeutic process parameters at three months for

the drop-out patients which stayed at least three months. We call this group the ' late DO

group'.

Table 1 shows how these DO groups are related.

Table 1

Large Drop Out group, With Indication of the Small Drop Out Group

With advice of staff Against advice of staff

Charateristic Less than 3M 3M-6M Less than 3M 3M-6M

Male 1 1 2 1

Female 2 5 7 5

In-patiënts 2 5 8 5

Day-hospital 1 1 1 1

n 3 6 9 6

Late DO

group

Small DO

group

Late DO

group

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Study 1

In this study we compared the pre-treatment variables of the patients of the small DO group

and of the large DO group with those of the therapy group that stayed at least nine months.

Method

Participants.

For a process-outcome study (Chapter 1), we assessed 78 consecutively-admitted

patients in the period from 23 -5-01 to 17- 7-02. Of these 78 patients, one patient refused to

take part in the study and one patient with an experience in psychological tests was deemed to

have unreliable test results and was removed from the study. Of the 76 consecutively admitted

patients, 26 left treatment within the first six months. With two of these 26 patients, a short

stay was already decided at the start of the treatment (one because of professional reasons,

one because of a rehospitalization). With the broad definition of drop-out, this brings the

drop-out before six months of treatment to 24 (15 female, 9 male), this is the large drop-out

group (see table 1).

Of the large DO group, twenty patients followed a treatment in an open-ended hospital

setting and 4 in a day-treatment setting. 15 patients were between the ages of 17 and 46 (M =

25.8, SD = 7.8). Ten were single, 9 lived with their parents, 4 were married or living together

with a partner and 1 lived in a community center. Three patients completed primary

education, 10 secondary education and 11 higher education or university. Using the SCID-II

we assigned patients to one of the three clusters of personality disorders according to DSM-

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IV; cluster A: 2 (1 schizoid, 1 schizotypal); cluster B: 17 (1 histrionic, 13 borderline, 1

narcissistic, 1 narcissistic and borderline, 1 histrionic and borderline); cluster C: 2 (1

dependent, 1 not otherwise specified); clusters A+B: 1; clusters B+C: 1; unknown: 1. No

patients committed suicide. As shown in table 1, of this 'large DO group', 9 patients left with

advice of the staff: 3 patients were transferred to a setting for young psychotic patients, 2

patients were transferred to a secluded ward because of severe danger for suicide, 1 patient

was discharged because of breaking the rules and antisocial behavior, 2 because of

improvement and stepping over to ambulatory treatment and 1 patient was transferred to a

rehabilitation setting because he did not respond to the treatment approach.

In the ' small DO group' drop-outs were limited to the 9 patients who left against advice

during the first three months. Of the two males and seven females, eight followed a treatment

in an open-ended hospital setting and one in a day-treatment setting. The patients were

between the ages of 17 and 38 years (M = 23.2, SD = 6.0). Four were single and 5 lived with

their parents. Three patients completed primary education, 2 secondary education and 4

higher education or university. Using the SCID-II we assigned patients to one of the three

clusters of personality disorders according to DSM-IV; B: 7 (7 borderline); C: 1 (1 not

otherwise specified); unknown: 1.

The large DO group and the small DO group were compared with the therapy group

defined in the prospective process-outcome study (see Chapter 6 & 8) as the group that stayed

at least 9 months. The latter group consisted of 47 patients (14 males, 33 females); 34

followed a treatment in an open-ended residential setting and 13 in a day-treatment setting.

The patients were between the ages of 17 and 58 (M = 27.8, SD = 9.1). Eighteen were single,

19 lived with their parents, 7 were married or living together with a partner and 3 were

divorced. Seventeen patients completed secondary education and 30 higher education or

university. Using the SCID-II we assigned all patients to one of the three clusters of

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personality disorders according to DSM-IV; B: 34 (23 borderline, 7 narcissistic, 2 narcissistic

and borderline, 2 histrionic and borderline); C: 7 (1 dependent, 1 avoidant and dependent, 5

not otherwise specified); B+C: 6. On DSM-IV Axis I we daignosed 19 mood disorders, 4

anxiety disorders, 1 eating disorder, 6 adjustment disorders and 6 substance related disorders.

Procedure.

The patients were assessed within the first two weeks of admission.

Instruments.

In assessing the clinical symptoms we used the Self Harm Inventory about the last two

weeks (Sansone et al., 1998), the Symptom Checklist 90 (SCL-90) (Derogatis, 1977),

translated by Arrindell and Ettema (1993), the Spielberger State-Trait Anxiety Inventory (

Spielberger, 1970) translated by Van der Plaog et al. (1980), the Spielberger State-Trait Anger

Inventory (Spileberger et al., 1980) translated by Van der Ploeg et al. (1982) and the Beck

Depression Inventory (Bouman et al., 1995). As personality related measures we used the

Dutch translation of the SCID II ( DM III-R, Axis II; Spitzer and Williams,1985)

questionnaire and its adaptation for the DSM IV by Weertman, Arntz & Kerkhofs (2000), the

Inventory of Personality Organisation (Kernberg and Clarkin, 1995) translated ad validated in

Dutch by Vermote, Vertommen et al. (2004) and Vermote, Smits, Claes, Vertommen (2005)

and the Inventory of Interpersonal Problems, circumflex version (Alden et al., 1990) which

measures the interpersonal functioning. The Self Harm Inventory (Sansone et al., 1998)

measures the history of suicidality and self-harm. The Traumatic Experience Checklist

(Nijenhuis et al., 2002) measures the history of trauma.

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Data analysis.

A classical t-test was performed to compare the means of scores on admission between

the therapy group and the large DO group and the small DO group. Because we had the

clinical impression that the large DO group consisted of patients who had a personality

organisation (measured by the IPO) that was either too severe to be treated in the setting or,

conversely, too high functioning to be treated in the setting, comparing mean scores could

have given a false impression. Therefore, we calculated the difference between the score of

each individual patient and the mean for the patients of the large DO group for whom this

value could be assessed (n = 14) and for the 47 patients in the therapy group. Then we

compared these difference scores of the large DO group and the therapy group with a t-test.

Results

When comparing the small DO group with the therapy group (Table 2), we found that

the group that left within the first three months against advice of the staff was less depressed

(SCL, SCID, BDI), less anxious (Spielberger scales), but, again, significantly angrier (STAXI

state and trait). These characteristics were also reflected in the frequency of items from DSM-

IV Axis II categories: the therapy group had more items rated in the controlling, anxious and

depressive sphere, associated with the avoidant, obsessive-compulsive and depressive

diagnostic categories.

When comparing the large DO group and the therapy group we found no significant

differences on the following measures: TEQ, SHI, BDI, IIP, SCID, SCL, IPO, and patient

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Table 2

Significant Differences in Pre-Treatment Variables for the Small DO group and the Therapy

Group

Small DO group Therapy group Statistical Test

Subscale M SD M SD t p

SCID avoidant 2.44 1.42 4.11 2.056 -2.31 .02

SCID obsess-comp 3 2.29 4.53 1.92 -2.13 .04

SCID depressive 3.67 2.5 5.30 1.64 -2.50 .02

IIP fg avoidant 8.71 4.07 16.94 7.97 -2.66 .01

IIP Hi nonassertive 11.71 6.70 19.28 7.77 -2.44 .02

SCL depressive 34.14 12.81 47.17 14.80 -2.20 .03

SCL sensitive 30 7.19 38.60 10.81 -2.03 .05

BDI 15.17 8.38 25 10.57 -2.19 .03

STAI state 33.33 23.340 44.05 13.22 -2.32 .02

STAI trait 33 23.13 59.17 10.46 -4.91 < .0001

STAXI state 27.67 21.27 11.87 3.04 5.02 < .0001

STAXI trait 32.67 14.60 18.06 6.61 4.34 < .0001

age. Patients of the large DO group were significantly angrier as measured by the Spielberger

Trait Anger Inventory Score, t(64) = 2.89, p = .005) with a mean score of 24.35 (SD = 10.98)

versus the therapy group mean of 18.06 (SD = 6.61). A similar pattern was found with the

Spielberger State Anger Inventory Score, t(64) = 2.43, p = .02, with mean scores of 16.9 (SD

= 13.50) versus 11.87 (SD = 3.04), respectively. On the Spielberger Trait Anxiety Inventory,

the large DO group was characterized by less anxiety as a trait than the therapy group, t(64) =

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-2.12, p = .04, 51.2 (SD = 20.37) versus 59.17 (SD = 10.46). When comparing the IPO

difference scores, between the large DO group and the therapy group, we found the

differences to be significant, t(58) = 3.21, p = .002. The results indicated that it was the

patients with the most and the least severe personality organisation who terminated early.

Study 2

In this study, we compared the change in process measures of drop-out patients who

stayed long enough to have a second assessment at three months with comparable data for the

therapy group. The process is judged by the therapists and by the patients themselves.

Method

Participants.

Patients of the attrition group who stayed between three and six months, the so called '

late ' DO group, were included in these analyses and were compared to those in the therapy

group from the first study. (Table 1: 12 patients, but missing data of 2 of 10).

This late DO group consisted of 10 admitted patients (4 males, 6 females); 8 followed a

treatment in an open-ended residential setting and 2 in a day-treatment setting. The patients

were between the ages of 18 and 46 (M = 25.2, SD = 7.9). Three were single, 4 lived with

their parents and 3 were married or living together with a partner. Six patients completed

secondary education and 4 higher education or university. Using the SCID-II we assigned

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patients to one of the three clusters of personality disorders according to DSM-IV; cluster A:

2 (1 schizoid, 1 schizotypal); cluster B: 6 (1 histrionic, 4 borderline, 1 narcissistic and

borderline); cluster C: 1 (1 dependent); clusters B+C: 1.

Instruments.

We used the Leuven Psychotherapy Scale (LPS), to study the process from the

perspective of the patients. The construction of the Leuven Psychotherapy Scale (LPS), its

reliability and congruent and divergent validities are discussed in Chapter 4. The LPS self-

report scale is composed of 112 items that are ordered, following factor analysis, into 7

subscales: General positive well-being, Openness to authentic relationships, Capacity to deal

with unexpected events, Capacity to deal with negative emotions, Capacity for interiorisation,

Positive experience of the setting and Control over substance use

We used the Psychoanalytic Process Rating Scale (PPRS, Stoker & Zevalkink, 2001,

2005) to study the psychoanalytic process from the therapist's point of view. The scale

focuses on the features of contact development in a session and is based on theory driven

items. The scale counts 47 items divided over 5 subscales: Cooperation, Tension, Exploration,

Disillusion, Contentment..

The Nurse's rating scale of the process, is a 6- point categorical scale that the nurses

use in rating the treatment process from their point of view ( Table 3).

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Data analysis.

The results of the change between the first and second measurements were examined

with Analysis of Variance, with one repeated measures factor (time) and one between subjects

factor (group).

Table 3

Nurses Rating Scale of the Treatment Process

Nurses Rating Scale of the treatment process

-1

0

destructive, poor contacts, very poor participation, breaking the rules

discussion about breaking the rules is possible, poor participation

1

2

conscious about what is going wrong, more control, partcipation but not active

control, good participation at therapies, trust, contacts with fellow patients

3 good control, infrequent breaking of the rules, attached to at least one fellow

patient

4 active participation in therapies, absence of destructive acts, close relationship

with more than one fellow patient

5 rich contacts, active and independent partcipation, helps in creating psychic

space and therapeutic culture at the setting

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Results

The late DO group and the therapy group did not differ significantly on the difference in

process measures between the beginning of treatment and assessment at three months. These

findings held for the process as evaluated by the patients with the LPS and the process as

evaluated by psychotherapists with the PPRS. There was, however, a group by time

interaction effect for the nurses' rating of the process (F(1,54) = 6.50, p = .01), with the late

DO group starting at a mean score of.90 (SD = 1.10) at moment 1 and decreasing to a mean

score of.40 (SD = 1.58) three months later. This is in contrast with the therapy group, which

starts with a mean score of 1.00 (SD = 0.69) and increases to a mean score of 1.6 (SD = 0.90)

three months later.

Study 3

In this study we compared the outcome of the large DO group with the outcome of the

therapy group for symptom measures, personality related measures and measures related with

the therapeutic process.

Method

Participants.

We obtained assessments of 13 patients from the DO group one year after admission.

Two patients were left out of the study group, as they were treated during this year in a

different intensive hospitalization based behaviour treatment setting in our hospital (Pieters &

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Vermote, 2002). Thus the final DO follow-up group consisted of 11 patients (5 males, 6

females); 8 followed a treatment in an open-ended hospital setting and 3 in a day-treatment

setting. The patients were between the ages of 18 and 46 (M = 25.3, SD = 7.8). Four were

single, 5 lived with their parents and 2 were married or living together with a partner. Two

patients completed primary education, 4 secondary education and 5 higher education or

university. Using the SCID-II we assigned the patients to one of the three clusters of

personality disorders according to DSM-IV; cluster A: 1 (1 schizoid); cluster B: 8 (1

histrionic, 6 borderline, 1 narcissistic and borderline); cluster C: 1 (1 dependent); clusters

B+C: 1. Four patients continued a psychiatric follow-up, no one of the DO group received

further psychotherapy.

The therapy group is the same as in study 1 and 2.

Procedure.

DO patients who left the treatment were assessed again one year after admission and the

therapy group was assessed three months after discharge. The lapse of time between

admission and this follow-up assessment was comparable for the therapy group and the DO

group.

Measures.

In assessing the clinical symptoms we used the Self Harm Inventory about the last two

weeks (Sansone et al., 1998), the Symptom Checklist 90 (SCL-90) (Derogatis, 1977),

translated by Arrindell and Ettema (1993), the Spielberger State-Trait Anxiety Inventory (

Spielberger, 1970) translated by Van der Ploeg et al. (1980), the Spielberger State-Trait Anger

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Inventory (Spielberger et al., 1980) translated by Van der Ploeg et al. (1982) and the Beck

Depression Inventory (Bouman et al., 1995). As personality related measures we used the

Dutch translation of the SCID II ( DM III-R, Axis II; Spitzer and Williams,1985)

questionnaire and its adaptation for the DSM IV by Weertman, Arntz & Kerkhofs (2000), the

Inventory of Personality Organisation (Kernberg and Clarkin, 1995) translated ad validated in

Dutch by Vermote, Vertommen et al. (2004) and Vermote, Smits, Claes, Vertommen (2005)

and the Inventory of Interpersonal Problems, circumflex version (Alden et al., 1990) which

measures the interpersonal functioning. The Self Harm Inventory (Sansone et al., 1998)

measures the history of suicidality and self-harm. The Traumatic Experience Checklist

(Nijenhuis et al., 2002) measures the history of trauma.

In assessing the psychoanalytic process, we used the measures to be rated on the ORI by

independent researchers (discussed in Chapter 3): the Felt Safety Scale, the Differentiation

Relatedness Scale, the Reflective Functioning Scale and the Bion Grid Scale and the Leuven

Pyschotherapy Scale, a self-report scale where the process is measured from the perspective

of the patient (discussed in Chapter 4).

Analysis of data.

Analysis of Variance, with one repeated measures factor (time) and one between

subjects factor (group).

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Results

Interaction effects were not significant for the symptom and personality related outcome

measures except for the measure which had differed most at the beginning of the treatment

between the therapy group and DO group: the Spielberger Trait Anger Scale (F(1,53) = 3.23,

p = .08), changed from 22.45 (SD = 7.83) to 17.00 (SD = 5.00) for the drop-out group, while

the therapy group changed from 17.89 (SD = 6.70) to 15.53 (SD = 4.70).

However there is a significant interaction effect between the drop-out group and the

therapy group for measures of the psychoanalytic process such as the Differentiation Relation

Scale about Self: F(1,56) = 4.46, p = .04 with a change from 5.00 (SD = 1.35) to 4.92 (SD =

1.68) for the drop-out group and a change from 4.93 (SD = 1.04) to 6.02 (SD = 1.27) for the

therapy group and a significant difference change in Felt Safety F (1,56) = 3.15, p = .08) with

a change from 2.27 (SD = 0.47) to 3.09 (SD = 1.22) for the drop-out group and a change from

2.30 (SD = 0.66) to 3.72 (SD = 0.93) for the therapy group.

Discussion

We delineated a small DO group according to Chiesa (2000), that is, a group that left

against advice within the first three months. With this definition, the attrition rate of our

treatment setting is low, 11.8% (9 of 76), compared with attrition rates ranging between 32%

and 66 % in hospitalisation based treatments for personality disorders using the same

definition (Skodol et al., 1983; Gunderson et al., 1989; Kelly et al., 1992; Chiesa, 2000).

Reasons for the low drop-out rate are probably found in a strategy which we imply since

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several years and which corresponds for the most part to the recommendations of Blount,

King & Menzies (2002) and Chiesa, Drahorad & Longo, S. (2000) to mitigate drop-out rates.

There is a pre-hospitalization phase during which there are contacts between patient and

family and the psychiatrist and the head nurse; during this phase patients are provided with

coherent information about the treatment program. In this phase a verbal contract is made as

well. When admitted, patients participate in a special sociotherapy group for newcomers and

in an introductory psychotherapy group where the anxiety level is kept low and the goal is

trying to deal mentally with what happens in the here-and-now. During this initial phase, the

patients have individual sessions with the therapists as well. Only when the patients are

capable to do so, they switch to the proper thrice-weekly, 90-minute group analytic sessions.

At the wards, there is a structured and coherent program, 24 hour staffing and several avenues

of response when patients are in emotional crisis. The staff pays special attention to patients'

felt safety, which is seen as one of the primordial mediators of the treatment. This strategy is

discussed at length in chapter 1.

When the pre-treatment variables of the small DO group and the long term therapy

group were compared, the DO group was less anxious, less depressed than was the therapy

group at the start but reported considerably more anger.

We examined drop-out from a broader perspective as well. During the intake sessions,

an agreement was made with patients that a period of at least six months of psychodynamic-

informed inpatient or partial hospitalization would be necessary to promote more lasting

changes. In a broad sense we can consider all patients who stop the treatment earlier as drop-

outs. Even in this broad sense the attrition rate is 32%, which still puts the program at the low

end of the range. However, drop-out is relative in this large DO group as the treatment was

open-ended in this hospital setting, and patients stop the treatment for several reasons with or

without advice of staff often by transfer to ambulatory treatment or to another setting. A

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major reason of this drop-out is that patients who do not meet all indication guidelines are

often given a try-out phase. This may be the reason that there is a tendency for a mainstream

effect and explains why patients in this large DO group are of the highest and the lowest level

of personality organization when compared with the therapy group. When this large drop-out

group was compared with the therapy group, it showed significantly more aggressive features

just as the small DO group did. In our study, anger was clearly shown to be the most

predictive symptom for early termination of the treatment. This corroborates the findings of

Smith et al. (1995), who found more hostility in the attrition group of borderline patients in

ambulant psychodynamic psychotherapy.

We further examined whether the evaluation of the therapeutic process by the therapists

and by the patients themselves yielded a predictive factor. Therefore we compared the

patients of the large DO group, that stayed at least three months, to have an assessment of the

process, (the so called 'late DO group') with the therapy group. There was no interaction effect

for the rating of the process by the patients or the therapists, except for the evaluation of the

process by the nurses. The nurses judged the overall participation on the ward, and we

hypothesize that they possess a broader view of whether a patient was engaging in the

treatment as a whole or not. This suggests that their evaluation is of considerable importance

when trying to improve attrition rates.

As far as outcome differences between drop-out and therapy groups are concerned,

psychotherapy research shows that, in general, drop-outs from different kinds of

psychotherapy do not have a bad outcome, although it is seen as a missed chance (Clarkin &

Levy, 2004). The results of the present study tend to corroborate this: we found no significant

interaction effects between the large drop-out group and the therapy group in any of the

symptom scales or personality-related scales.

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This is in contrast with changes measured with the process parameters. As discussed in

chapter 1, the treatment focused on inner changes in three dimensions: felt safety, integration

of split mental representations of self-other relations, and mentalization. When these inner

changes of the large DO group were compared to the changes in the therapy group one year

after admission, there was a significant interaction effect on the integration of mental

representations or inner object relational patterns, as measured with the DRS (Differentiation

Relatedness Scale) especially on the Self subscale and on Felt Safety. This suggests that

staying longer in treatment has an effect on these dimensions of inner psychic functioning and

this is what is the primary goal of the treatment. The relation between these inner changes and

outcome is studied in detail in a process-outcome study (Chapter 8).

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PART 4

THE RELATION BETWEEN PROCESS AND OUTCOME

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Chapter 8

The Kortenberg - Leuven Process Outcome Study on Patients with

Personality Disorders in Psychoanalytically Oriented Hospitalisation4

The RCT study of Bateman and Fonagy (1999, 2001) showed the effectiveness of

psychoanalytically informed day hospitalization of patients with a borderline personality

disorder. The specificity of a psychoanalytic therapy is that it is not symptom oriented but

focuses on intrapsychic changes. These intrapsychic changes over time are denoted as the

psychoanalytic process in contrast to symptom outcome. It is only one of the many conflicting

ways of defining the psychoanalytic process (Boesky, 1990; Weinshel, 1990; Abrams, 1990).

Given the effectiveness of this treatment in symptom outcome, we wanted to know whether

these changes in symptoms are related with the intrapsychic changes targeted by the

treatment.

This is important as relations between the psychoanalytic process and outcome were

found to be weak or non-existing (Vaughan and Roose, 1995) while psychoanalytic therapy is

effective (Leichsenring & Leibing, 2003). Furthermore very different therapies for personality

disorders show similar results (Blatt, 2003), which is known as the dodo verdict referring to

Lewis Caroll's ' Alice in Wonderland': all have won, everybody shall have prices. There may

be different reasons for the dodo effect such as the use in RCT studies of uniform symptom

scales which may fail to grasp treatment or model specific changes, or the focus in

effectiveness studies on limited homogeneous groups or the fact that therapeutic agents may

4 Granted by the Research Advisory Board of the International Psychoanalytical

Association in 2001, 2002, 2003 and by Lotto

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be aspecific and shared by all kind of treatments. Given the intensity of a psychoanalytically

informed treatment, it is important to know whether targeted intrapsychic changes are reached

and whether there is a relation with outcome. To avoid aspecific results because of

methodological reasons, it is important to use model specific measures in a naturalistic design

(Clarkin & Levy, 2004).

The relation between the hypothesized intrapsychic changes and symptom changes, is

studied in a group of consecutively admitted patients in a psychoanalytically informed

hospitalization based treatment for personality disorders (day and residential) at the

University Centre St.-Joseph at Kortenberg. The treatment is described in chapter 1 and

comparable to the one described by Bateman and Fonagy (2004). Two setting characteristics

distinguished the present setting and that described by Bateman & Fonagy (1999, 2001): the

present study was an open-ended in-patient and day-hospital treatment with a maximum stay

of approximately one year and a follow- up of one year, rather than 18 months of day hospital

treatment only with a follow-up of 18 months.

We used the same clinical symptom outcome measures as used in the Bateman and

Fonagy (1999, 2001) RCT study and additional clinical measures related to personality

characteristics. These clinical outcome scores and additional personality related scores will be

related with psychoanalytic model specific measures about the process. Measuring the

psychoanalytic process is not evident because, although it is seen as the heart of every

psychoanalytic therapy, it is in itself imperceptible and a highly conceptual hypothesis.

Therefore it seems logical to study the psychoanalytic process from different perspectives and

with different measures to see whether coherent patterns of change are revealed pointing at

the existence of such a process.

In the following studies we examined the intrapsychic changes from three different

perspectives, from the perspective of independent researchers, from the perspective of the

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patients themselves and from the perspective of the therapists and this with very different

measures: theory driven, empirical, based on transcripts, on patient self-reports and on

therapist reports. Then we studied the relation of the process with changes in clinical

symptom and personality related measures.

Study 1 The Relation Between Process and Outcome, with the Process Seen from the

Perspective of Independent Researchers.

According to J. Clarkin (personal communication), the best way to approach the

psychoanalytical process is by a model. We described a three-dimensional model of the

process in personality disorders in Chapter 1. We operationalized the assessment of the

intrapsychic changes according to the three dimensions of this model (Chapter 3), that consist

of increasing felt safety (measured with the Felt Safety Scale, FSS); of developing more

mature and differentiated representations of self and others (measured with the Differentiation

Relatedness Scale, DRS); and of enhancing mentalization (measured with two scales: the

Reflective Functioning Scale, RFS and the Bion Grid Scale, BGS). In this study we examined

the changes over time of these four measures of intrapsychic changes, and we related these

intrapsychic changes with symptom and personality changes during the therapy. Therefore we

first reduced the outcome changes to two component scores: a Global Symptom Score (GSS)

and a Global Personality Score (GPS).

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Method

Participants

The study group comprised patients who were consecutively admitted at the

psychoanalytically informed hospitalization for personality disorders. Of this group we

selected the patients who stayed long enough in the psychoanalytically informed treatment to

have at least the measures at 0-3-6-9 months and three months after discharge. This to have

enough moments to enable a process study. Forty seven consecutively admitted patients

corresponded to these conditions. Of these 47 patients, three patients were not included in the

statistical analysis because of missing data at discharge or follow-up: one refused further

assessments, the self-reports of another got lost by mail delivery service, one patient was

acutely discharged because of selling drugs.


31 were in-patients, 13 in a day treatment setting. The patients were between the ages of 17


living together with a partner and 3 were divorced. Sixteen patients completed secondary

education and 28 higher education or university. Using the SCID-II we assigned all patients to

one of the three clusters of personality disorders according to DSM-IV; cluster B: 32 (23

borderline, 7 narcissistic, 1 narcissistic and borderline, 1 histrionic and borderline); cluster C:

7 (1 dependent, 1 avoidant and dependent, 5 not otherwise specified); clusters B+C: 5. On

DSM-IV Axis I, we diagnosed 20 mood disorders, 2 anxiety disorders, 1 eating disorder, 5


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Measures


The Self Harm Inventory (SHI) (Sansone et al., 1998) about the last two weeks, the

Symptom Checklist 90 (SCL-90) (Derogatis,1977), translated by Arrindell & Ettema (1993),

the Spielberger State-Trait Anxiety Inventory translated by van der Ploeg et al. (1980), the

Spielberger State-Trait Anger Inventory translated by Van der Ploeg et al. (1982), the Beck

Depression Inventory translated by Bouman et al. (1985).


The questionnaire of the Structured Clinical Interview for DSM-III-R Axis II disorders

SCID-II (Spitzer & Williams, 1985) has been translated in Dutch and adapted for DSM-IV,

by Weertman, Arntz & Kerkhofs (1999). The Inventory of Personality Organization

(Lenzenweger, Kernberg, Clarkin, Foelsch, 2001; Normandin et al., 2002) is a self-report

questionnaire used to assess a structural diagnosis according to the model of Kernberg on

borderline personality organization. The reliability and validity of the IPO translated in Dutch

was demonstrated by Vermote, Maes, Vertommen, Corveleyn, Verhaest & Peuskens (2004)

and Vermote, Smits, Claes & Vertommen (2005). The Inventory of Interpersonal Problems,

circumflex version (Alden et al., 1990) measures interpersonal functioning. All these

measures have a well established reliability and validity.

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Intrapsychic process measures.

Intrapsychic Process Measures were measured with the Object Relation Inventory (Blatt

et al., 1996), a semi- structured interview with open questions about parents, self, therapist

and significant other.

The Felt Safety Scale (FSS) is a five point scale to rate on the ORI ranging from 1.No

felt safety in therapy to 5. Strong feeling of safety (Vermote, Vertommen,Verhaest, Franssen,

Geenen, Corveleyn, Peuskens, 2004a; Vermote, Vertommen, Corveleyn, Verhaest,2004b;

Chapter 3).

The Differentiation Relatedness Scale (DRS, Blatt et al., 1996) is a ten point scale which is

rated on the ORI, measuring the degree of self-other differentiation and relation ranging from

1-2:. Lack of basic differentiation between self-other to 10:. Reflectively constructed

integrated representations of self and others in reciprocal and mutual relationships.

The Reflective Functioning Scale (RFS) is a 11 point scale about the capacity to

perceive ones own and others' actions and feelings in terms of mental states (Fonagy et al,

1998) ranging from 1: Lacking RF to 7:. Marked RF. The Reflective Functioning Scale is

used in the Adult Attachment Interview (Main et al., 1991) where it measures the capacity for

reflective functioning (Fonagy et al., 1998), while when used on the ORI, it measures more

the state reflective functioning (Vermote et al., 2004a, b; Chapter 3).

The Bion Grid Scale (BGS) is a 6 point scale in which answers on the ORI can be put in

6 categories according to their level of mentalization, openness to explore and degree of

switching between levels. The scale reflects the degree of creative exploration and mental

transformation of experiences (Vermote et al., 2004a, b; Chapter 3).

These FSS, DRS, RFS, BGS showed a sufficient inter judge reliability and validity

when rated on the ORI.

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Procedure

After written informed consent, clinical symptom measures were assessed on admission,

each three months, at discharge and three months and a year after discharge. Personality

characteristics were assessed on admission, at discharge and three months and a year after

discharge. The Object Relation Inventories were assessed at the same moments of assessment

of the Clinical Symptom Measures by a psychologist having no contact with the therapeutic

staff and the patients besides of these interviews. The transcripts of the anonimised ORI’s

were distributed in a random order to raters blind to any information about the patients and

having had no contact with them. The ORI – interviews were rated on the Felt Safety Scale,

the Differentiation Relatedness Scale, the Reflective Functioning Scale and the Bion Grid

Scale by a group of 12 raters, three raters for each scale, who had a previous training with the

manual of their scale and a satisfactory reliability test for this scale.

Analysis

To study the relation between the clinical symptom measures and the psychoanalytic

process measures, multiple clinical symptom measures were reduced to a single symptom

component score, the Global Symptom Score (GSS) by means of a Principal Component

Analysis (PCA) on the seven symptom-scores of the patients at the first measurement of a

group of seventy patients of which the study group is a part (see Chapter 6). The PCA yielded

a first component accounting for 50 % of the total variance. The loadings on this component

were the following:.53 for the Self Harm Inventory (SHI 2w), .86 for the Symptom Check

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List, positive symptom total, .85, for the Beck Depression Inventory (BDI), .73 for the

Spielberger State, .89 for the Trait Anxiety Inventory Scores (STAI), .44 for the Spielberger

State and .49 for the Trait Anger Inventory Scores (STAXI). These loadings were used to

calculate GSS component scores at each of the seven time moments.

A similar PCA was performed on the total scores of the different personality

characteristics (IPO, SCID, IIP) resulting in a component, the Global Personality Score (GPS)

explaining 74.6 % of the variance. The loadings on this component, were .88 for the IPO, .87

for the SCID and .81 for the IIP. Also in this case, the loadings of the scales at the first time

moment of a larger group of 70 patients were used to calculate component scores at each of

the three time moments.

Changes over time of the clinical symptom measures, the personality related measures

and the psychoanalytic process measures are studied with analysis of variance, repeated

measures analysis. Then separate random coefficient models with patient-specific intercepts

and time moments as a fixed predictor variable were estimated to test for different trends

(linear, quadratic, cubic trends) between time moments and the clinical symptom measures,

the personality related measures and the psychoanalytic process measures.

Next, a model with patient specific intercepts and fixed slopes

for the time moments for the Global Symptom Score was estimated to predict the intrapsychic

process variables (FS, DRS, RF, BGS assessed on ORI). Similar analyses were performed to

predict these intrapsychic process variables on the basis of the Global Personality Score.

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Results

Outcome

The Global Symptom Score (GSS) showed a significant change over time and

improvement (F (6, 246)=14.25, p < .0001). The mean scores at several time moments are

shown in table 1. The trends are shown in table 2. The changes over time are plotted in Figure

1.

There was a significant change over time and improvement during therapy and the year

after discharge for the Global Personality Score (F(3,128)=10.48, p.< .0001). The mean

scores are presented in Table 1. The trend is linear (Table 2). The changes over time are

plotted in Figure 2.

Process

The change over time of the process measures is shown in table 1. There is a significant

change over time and an improvement of the means of the global Felt Safety score

(F(6,242)=17.06,p = < .0001). The same holds true for the Differentiation Relatedness Scores

(F(6,244)=7.49, p = < .0001). The change over time and improvement of the Reflective

Functioning Scores (RF state on the ORI) shows a tendency to be significant

(F(6,255)=1.97,p = .07). The Bion Grid scores show a significant change and improvement

(F(6,245)= 2.82, p = .01). The trends of the change of the mean global scores of the four

ORI-measures is shown in table 2. The changes over time of the four ORI - measures are

plotted in figures 3 - 6.

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Table 1.

Means and SD of the Felt Safety Scale (FSS), the Differentiation Relatedness Scale (DRS), the

Reflective Function Scale State(RFS), the Bion Grid Scale (BGS) and the Global Symptom

Score (GSS) at Different Moments in Time. 12 M Corresponds with Discharge

FSS DRS RFS BGS GSS GPS

Time M SD M SD M SD M SD M SD M SD

admission 2.32 0.67 4.84 1.29 4.34 1.22 3.95 1.01 0.01 0.87 -0.08 0.87

3M 2.81 0.92 5.43 1.28 3.91 1.29 3.93 0.95 -0.10 0.91

6M 2.62 1.03 5.28 1.20 3.79 1.28 3.60 1.18 -0.27 0.93

9M 3.36 0.99 5.44 1.11 4.42 1.18 4.14 1.15 -0.35 0.98

12M 3.56 1.03 5.95 1.18 4.14 1.34 3.95 1.03 -0.78 0.97 -0.43 0.93

15M 3.70 0.95 5.91 1.31 4.20 1.34 4.16 1.20 -0.87 1.23 -0.66 1.64

24M 3.54 1.02 5.64 1.06 4.40 1.39 4.35 1.27 -0.99 1.04 -0.83 1.08

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Figure 1. Change over 7 moments of the Global Syptom Score. The cubic trend is presented

by the dotted line.

Figure 2. Change of the Global Personality Score over 4 moments. The linear trend is

presented by the dotted line.

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Table 2

Trends of Change Over Time for the ORI- measures and the Global Symptom Score

(df=1,249)and for the Global Personality Score (df=1,128)

Subscale Trend df F p

Felt Safety Scale Linear 1,245 70.86 < .0001

Quadratic 1,245 17.59 < .0001

Cubic 1,245 3.34 .07

Differentiation Relatedness Scale Linear 1,247 24.14 < .0001

Quadratic 1,247 11.54 < .001

Cubic 1,247 .65 .04

Reflective Functioning Scale Linear 1,248 1.64 .20

Quadratic 1,248 1.18 .28

Cubic 1,248 2.86 .09

Bion Grid Scale Linear 1,248 8.26 .004

Quadratic 1,248 1.39 .24

Cubic 1,248 2.00 .16

Global Symptom Score Linear 1,249 73.80 < .0001

Quadratic 1,249 4.47 .04

Cubic 1,249 5.47 .02

Global Personality Score (df= 1,128) Linear 1,128 29.57 < .0001

Quadratic 1,128 .63 .43

Cubic 1,128 1.26 .26

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Figure 3. Mean global scores of the Felt Safety Scale over 7 moments. The quadratic trend is

presented by a dotted line.

Figure 4. Mean global scores of the Differentiation Relatedness Scale over 7 moments. The

quadratic trend is presented by a dotted line.

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Figure 5. Mean global scores of the Reflective Functioning Scale over 7 moments. The cubic

trend is presented by a dotted line.

Figure 6. Mean global scores of the Bion Grid Scale over 7 moments. The linear trend is

presented by a dotted line.

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Process-outcome

To test the relation between the four ORI-measures and the GSS, the significance of the

fixed slope was tested. Changes of the global symptom score over 6 time moments are

strongly related with changes in Felt Safety: F(1, 206) = 27.24, p < .0001 and in

Differentiation Relatedness: F(1, 208) = 17.86, p < .0001. We found no significant

relationship with the Reflective Functioning Scale measured on the ORI : F(1, 205) = 2.30, p

= .13 nor with the Bion Grid Scale: F(1, 208) = .20, p = .65.

To test the relation between the four ORI-measures and the GPS, the significance of

the fixed slope was tested. Changes of the global personality outcome score over 3 time

moments are strongly related to changes in Felt Safety: F(1, 86) = 16.86, p < .0001 and

significantly related to changes in Differentiation Relatedness: F(1, 86) = 6.31, p = .01 and

changes in Reflective Functioning: F(1, 86) = 4.16, p = .04. They are not related with changes

in the Bion Grid Scale: F(1, 86) = .46, p = .49.

Discussion

The Global Symptom Score shows a significant improvement with a cubic trend. The

major improvement is during the last phase of the therapy, which suggests that one should be

careful in discharging patients too early. The Global Personality Score shows a linear

improvement during therapy, also with a continuation after discharge. These phenomena point

at a structural change. However, half of the patients recieved ambulatory psychotherapy after

discharge.

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The ORI-process measures improved significantly except for the RFS of which the

change over time tends to be significant. The major improvement of all measures takes place

in the second half of the treatment. In the first half of the treatment, the process measures

show an increase in FSS going with a decrease in RFS. This is peculiar and seems to point at

the phenomenon of regression, people letting their usual defensive attitudes go within a safe

psychoanalytic frame.

Our major goal was to examine whether and how these outcome changes are related to

the process variables of a psychoanalytically informed treatment: felt safety, mental

representations of self-object relations and mentalization. The relation of changes in the

Global Symptom Score and in the Global Personality Score with the change of Felt Safety is

strongly significant. It seems that increasing felt safety is an important condition to generate

changes in symptoms and in more stable personality patterns in personality disorders during a

psychoanalytic informed hospitalization. Felt safety is a basic dimension in most treatments of

personality disorders and can therefore be considered as a non specific factor. More

particularly in the psychodynamic model, felt safety is a central concept about the role of the

environment in the etiology and treatment of personality disorders. It is most related to the

attachment theory (Bowlby, 1969; Sroufe, 1996) but many concepts are related to it, such as

the background experience of safety (Sandler, 1960), holding (Winnicott, 1960), containment

(Bion, 1959). The experiencing of it and the possibility to regain it in moments of distress and

emotional storms is a primary goal of the treatment (see Chapter 1). A creation and

enhancement of felt safety provides the basis for a change in relational patterns such as less

splitting and a greater individuality (Stern, 1985). According to Bion (1962) it is the base of a

psychic processing of affects and according to Fonagy et al. (2002) it is the base of the

reflective functioning in self-other relationships.

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We found a significant relation as well between changes in the Global Symptom Score

and the Global Personality Score and changes on the Differentiation Relatedness Scale. The

DRS is a theory driven scale about the representations of self - object relations, which are

since Kernberg’s approach the central focus in the treatment of personality disordered

patients. The relation of the DRS with symptom change supports the assumption (Blatt &

Auerbach, 2001; Kernberg, 1984) that a decrease in splitting and a more stable and coherent

mental representation of self and others go with a decrease in anxiety and mood lability. The

psychodynamic conceptualisation of personality organisation is closely related to the

construct of self-other representations, hence the relation between the change on the DRS and

changes in the Global Personality Score is expected.

We found no significant relation between changes in the Global Symptom Score and

changes in RF as measured on the ORI, while the relation with the Global Personality Score

was significant. The ORI-RF reflects a state RF rather than the capacity for RF as with AAI-

RF which can be seen as a trait (see Chapter 4). The relation between change in the ORI-RF

and symptom change is probably complex. When anxious for instance, narcissistic patients

are expected to show an increase in their RF to get control, while borderline patients will

show a disintegration of their state RF. The significant relation between the changes in state

RF and the change in the Global Personality Score, while this relation is lacking for the

Global Symptom Score, may be explained by the fact that RF is more about the way a patient

copes with a symptom which is reflected in personality related measures, than with the

manifestation of the symptom itself.

Changes in the BGS show no significant relation with changes in the Global Symptom

Score, nor with changes in the Global Personality Score. A reason may be that the degree of

creatively and associatively transforming experiences is not linked with the level of

personality organisation and with symptoms, for instance severe borderline patients may do

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better for instance than obsessive-compulsive patients (see Chapter 3). It seems difficult to

judge this mentalization score on its own, we may hypothesize that changes in this form of

mentalization may resort in a therapeutic effect for a group of restricted patients while having

adverse effects in patients who need a stronger ego-control like patients with a low level

personality organisation (Fertuck et al., 2004; Blatt, 1992).

Study 2 The relation between process and outcome, with the process seen from the

perspective of the patients.

To study the therapeutic process of personality disordered patients and its relation with

changes in clinical symptom and in personality related measures from the perspective of the

patients, we used the Leuven Psychotherapy Scale (LPS, Chapter 4). This is a self-report

scale, with items based on patient statements and therefore a non theory driven scale. In other

words the scale reflects the experience of inner change in the words of the patients

themselves.

In this study we examined the changes over time of the LPS and we related these

changes with symptom and personality changes during the therapy. The outcome data were

first reduced to two component scores, a Global Symptom Score (GSS) and a Global

Personality Score (GPS).

Method

Participants

The study group is the same as in study 1.

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Measures

For the clinical symptom change and personality related outcome change, we used the

same measures and the reduction of these data in a Global Symptom Score (GSS) and a

Global Personality Score (GPS), as described in study 1.

The construction of the Leuven Psychotherapy Scale (LPS), its reliability and congruent

and divergent validities are discussed in chapter 4. The LPS self-report scale is composed of

112 items that are ordered, following factor analysis, into 7 subscales: S1, 'General positive

well-being' ; S2, 'Openness to authentic relationships'; S3, 'Capacity to deal with unexpected

events'; S4, 'Capacity to deal with negative emotions'; S5, 'Capacity for interiorisation'; S6,

'Positive experience of the setting'; S7, 'Control over substance use'.

Procedure

After obtaining written informed consent, the LPS and clinical symptom measures were

assessed on admission, every three months, at discharge, three months after discharge and one

year after discharge. Personality characteristics were assessed on admission, at discharge,

three months after discharge and one year after discharge.

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Data Analysis

Changes over time of the LPS and of the clinical symptom measures and the personality

related measures are studied with analysis of variance, repeated measures analysis.

Then separate random coefficient models with patient-specific intercepts and time

moments as a fixed predictor variable were estimated to test for different trends (linear,

quadratic, cubic trends) between time moments and the LPS scales.

To examine whether changes in clinical outcome were related to the intrapsychic

changes we used the results of the data reduction of Study 1, by Principal Component

Analysis of the clinical symptom measures (resulting in the Global Symptom Score -GSS)

and of the personality related measures (Global Personality Score - GPS).

Then, for each of the scales of the LPS, a model with patient-specific intercepts and

fixed slopes for 7 time moments of the Global Symptom Score were estimated to predict the

LPS Scales. Similar analyses were performed to predict LPS scales on the basis of the Global

Personality Score for 4 time moments.

Results

Process

We found significant improvement over time for six of the seven scales of the LPS. For S1 '

Positive well-being' this was F (6, 246)=21.25, p = < .0001, for S2 'Openness to authentic

relationships' F (6, 246)=10.19, p = < .0001, for S3 'Capacity to deal with unexpected and

stressful events' F (6, 246)=2.97, p = .008, for S4 'Capacity to deal with negative emotions'

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F (6, 246)=16.67, p = < .0001, for S5 'Capacity for interiorization' F (6, 246)=16.41, p = <

.0001, for S6 'Positive experience of the setting' F (6, 246)=5.99, p = < .0001, for S7

'Control over substance use' F (6, 246)=1.71, p = .11. The mean scores for each subscale,

scored every three months are plotted in figures 7-13. The trends of this change over time

are given in table 3 and indicated in Figures 7 through 13 by dotted lines.

Figure 7. Mean scores of the ' Positive Well Being' Scale of the LPS over 7 moments. The

cubic trend is presented by a dotted line

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Table 3

Trends of Change Over Time for the LPS Scales (df=1,246)

Subscale Trend F p

Positive Well Being Linear 121.66 < .0001

Quadratic .18 .67

Cubic 4.16 .04

Openness to Authentic Relationships Linear 52.81 < .0001

Quadratic 1.92 .17

Cubic 5.21 .02

Capacity to deal with unexpected and stressful events Linear 9.02 .003

Quadratic 3.07 .08

Cubic 4.52 .03

Capacity to deal with negative emotions Linear 88.22 < .0001

Quadratic 6.91 .009

Cubic 4.26 .04

Capacity for interiorization Linear 89.32 < .0001

Quadratic .02 .90

Cubic 5.80 .02

Positive experience of the setting Linear 25.62 < .0001

Quadratic .93 .33

Cubic 2.91 .09

Control of substance use Linear 6.48 .01

Quadratic .05 .82

Cubic 1.90 .17

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Figure 8. Mean scores of the ' Capacity to Authentic Relationships' Scale of the LPS over 7

moments. The cubic trend is presented by a dotted line.

Figure 9. Mean scores of the ' Capacity to deal with unexpected and stressful events' Scale of

the LPS over 7 moments. The cubic trend is presented by a dotted line.

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Figure 10. Mean scores of the ' Capacity to deal with negative emotions' Scale of the LPS

over 7 moments. The cubic trend is presented by a dotted line.

Figure 11. Mean scores of the ' Capacity for interiorization' Scale of the LPS over 7 moments.

The cubic trend is presented by a dotted line.

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Figure 12. Mean scores of the 'Positive experience of the setting' Scale of the LPS over 7

moments. The cubic trend is presented by a dotted line.

Figure 13. Mean scores of the ' Control of substance use' Scale of the LPS over 7 moments.

The linear trend is presented by a dotted line.

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Process Outcome

To test the relation between the LPS scales and the GSS, the significance of the fixed

slope was tested. Changes of the GSS (Global Symptom Score) were related to changes in

each of the LPS scales. This relation was very strong for the S 1 ‘Positive well being’: F(1,

250) = 736.03, p < .0001. The scales S2 ‘Openness to authentic relationships’: F(1,250) =

178.78, p < .0001) S3 ‘Capacity to deal with negative emotions’: F(1, 250) = 201.11, p <

.0001, S5 ‘Capacity for interiorization’: F(1, 250) = 130.73, p < .0001, S3 ‘Capacity to deal

with unexpected and stressful events’: F(1, 250) = 88.94, p < .0001, S7 'Substance control':

F(1, 250) = 43.06, p < .0001, and S6 'Positive experience of the setting': F(1, 250) = 43.06, p

< .0001 were significant as well.

To test the relation between the LPS scales and the GPS, the significance of the fixed

slope was tested. Changes of the GPS (Global Personality Score) were significantly related to

changes in each of the scales. This relation was again very strong for the S1 ' Positive well

being': F(1,129) = 135.30, p < .0001. The relation with S 4 ‘Capacity to deal with negative

emotions’: F(1,129) = 98.94, p < .0001, S5 ‘Capacity for interiorization’: F(1,129) = 63.35, p

< .0001), S2 ‘Openness to authentic relationships’: F(1,129) = 56.48, p < .0001, S3

‘Capacity to deal with unexpected and stressful events’: F(1,129) = 37.52, p < .0001, S7

'Substance control': F(1,129) = 1.91, p < .0001 and S6 'Positive experience of the setting':

F(1,129) = 8.08, p < .0001 were all significant as well.

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Discussion

All scales of the LPS show a significant positive improvement except for the 'Control of

substance use' scale. In the six scales showing an improvement, the major improvement is

after six months of therapy and goes on till three months after discharge, to remain at a high

level a year after discharge. We see also a major improvement after six months in our own

outcome results (see Chapter 5) and in the process changes as measured by independent

researchers (Study 1 of this Chapter). In the findings of Bateman and Fonagy’s (1999, 2001)

RCT study of borderline patients, most outcome differences in clinical symptoms became

manifest after six to nine months in a comparison to a treatment control group.

Looking at the process in more detail, three scales of the LPS start with a small

improvement in the first six months, with the major improvement starting afterwards: S1

'Positive well being', S2 'Capacity to engage in authentic relationships' and S5 ' Capacity for

interiorization'. The concepts which were revealed in these three scales seem to be related

with the three dimensions of our treatment model (see Chapter 1): felt safety, mental

representations of objectrelations and mentalization. In our study of the validity of the LPS

(see Chapter 4), we found in fact a significant correlation of LPS-S1 'Positive well being' and

the ORI-Felt Safety Scale. We suppose that this inner experience of 'Positive Well Being' is

enhanced by offering a secure, coherent environment and cohesive program to the patients.

The many moments of distress during the treatment going with the possibility to rely on

fellow-patients, therapists and nurses and the experience of finding new ways to deal with

these states of mind, undoubtedly create such a basic feeling to which one can fall back in

later moments of emotional difficulty. S2 about the 'Capacity to engage in authentic

relationships', with intimacy and emotional vulnerability, is connected to changing mental

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representations of self and others, the second dimension of our treatment model. The S3

‘Capacity for interiorization’ (‘Verinnerliching’) subscale is about a self-reflective attitude

accompanied by not being afraid to try new experiences, and is close to the concept of

mentalization which is the third dimension focused on during the treatment.

It is striking that the mean scores of three other scales show a marked decrease in the

first six months before the improvement starts. These scales are S3 'Capacity to deal with

unexpected and stressful events', S4 ' Capacity to deal with negative emotions' and S6 '

Positive experience of the setting'. S3 and S4 seem to show that people have to release their

usual maladaptive coping in response to stress and unexpected events, and this results at first

in a decrease in their capacity to cope. This lowering of defences is known in psychoanalytic

theory as regression. This regression is typical in a psychoanalytically informed treatment,

where it used to be called a regression in function of the ego (Meisnner, 1988). People have to

release their usual maladaptive coping in response to stress and unexpected events, and this

results at first in a decrease in their capacity to cope. It is in accordance with psychoanalytic

theory that this can happen at a moment when there is enough safety. S3, S4 are at their

deepest point, while S1 ' Positive well being' is increasing sharply. The same regression is

manifest in the change over time of the S6 scores ‘Positive experience of the setting'. Clinical

experience shows that only when patients feel safe enough they can start criticizing and de-

idealizing the setting and experience that nevertheless their inner safety can remain. Figures 7

and 12 show that after a ‘honeymoon‘ feeling of being contained within the setting, the '

Positive experience of the setting' (S6) score drops to its lowest point at 6 months, while the

'Positive feeling of well being' (S1) is increasing at that moment. After this decrease at six

months, the S6 'Positive experience of the setting' increases again sharply.

For the scale 'Control over substance use’, there is no significant improvement in this

two year study. There is an improvement in control during therapy and in the first months

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after treatment. This decrease after discharge, as there are at once more occasions to use than

during the hospitalization period.

Given this image of the process, with its marked positive change, we wondered about

the relation of this inner change with outcome. The change, manifest in the scores of the LPS,

relates for all scales significantly with outcome. This for outcome as measured with symptom

scales, as with scales related to personality characteristics. The relation is stronger than we

expected, and stronger than with the measures assessed by independent researchers (study 1)

and the measures assessed by the therapists themselves (study 3).

This is remarkable because the LPS is an atheoretical, purely empirically constructed

scale, drawn from patient statements while some of the personality related measures, such as

the IPO and the IIP, are highly theory driven. It may be that the factors on which the LPS is

constructed touch the mutative factors in the treatment, and in this respect we found it

stimulating that the three dimensions of the proposed model revealed themselves in the LPS.

For a part the strong correlation can be explained, at least for the clinical symptom scales by

the fact that these scales and the LPS are both self-report scales, while the method of

assessing the process in Study 1 and 3 differs from the method of assessing the outcome by

self-report scales. A major reason may be that the LPS is constructed for personality

disordered patients in hospital treatment, which is not the case for the process measures of

study 1 and 3.

Study 3 The relation between process and outcome, with the outcome seen from the

perspective of the therapists.

Having studied the therapeutic process of personality disordered patients in a

psychoanalytically informed hospitalization-based treatment, from the perspective of

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independent researchers with FSS, DRS, RFS and BGS (Study 1) and from the perspective of

the patients themselves with the LPS (Study 2), we wanted to examine whether the therapists

saw the same dimensions of change at similar moments as patients and external researchers.

Reliable measures to study the psychoanalytic process as a whole from a therapist's

point of view and which are fit to assess on a larger number of patients are rare, the

Psychoanalytic Process Rating Scale (PPRS) was the only scale which we came across. It is a

newly developed scale, which we discussed in Chapter 5. The scale focuses on the features of

contact development in a session and is based on theory driven items. For this reason it is of

particular interest to compare the results of the PPRS with those of the LPS, as the latter is

based on statements of the patients.

In this study we examined the changes over time of the PPRS and we related these

changes with symptom and personality changes during the therapy. The outcome data were

first reduced to two component scores, a Global Symptom Score (GSS) and a Global

Personality Score (GPS).

Method

Participants

The participants are the same as in the study 1 and 2.

Measures

The outcome measures are the same as in study 1 and 2. The PPRS is discussed in Chapter 5,

it is a 47 item scale with 5 subscales: Co-operation (close co-operation), Tension (negative

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feelngs), Exploration (explicatation of behaviour,thoughts and feelings), Disillusion (feelings

of being rejected), Contentment (enjoying the treatment). For the clinical symptom change

and personality related outcome change, we used the same measures and the reduction of

these data in a Global Symptom Score (GSS) and a Global Personality Score (GPS), as

described in study 1

Procedure

After obtaining written informed consent, clinical symptom measures were assessed

on admission, every three months and at discharge. As the treatment ended as this moment,

therapists could not score in the post treatment period. Personality characteristics were

assessed on admission and at discharge. The PPRS was assessed around the same moments

as the assessment of the clinical symptom measures. As the psychotherapy was a group

psychoanalysis (1.5 hours, three times a week), we decided to rate each patient on the

sessions of the last two weeks before the moment of assessment. The PPRS was assessed

by the therapist of each patient, there are three senior group therapists who are treating two

groups each.

Data Analysis

Changes over time of the PPRS and of the clinical symptom measures and the

personality related measures are studied with analysis of variance, repeated measures analysis.

Then separate random coefficient models with patient specific intercepts and time

moments as a fixed predictor variable were estimated to test for different trends (linear,

quadratic, cubic trends) between time moments and the PPRS scales.

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To examine whether changes in clinical outcome were related to the intrapsychic

changes we used the results of the data reduction of Study 1, by Principal Component

Analysis of the clinical symptom measures (resulting in the Global Symptom Score -GSS)

and the personality related measures (Global Personality Score - GPS).

Then, for each of the scales of the PPRS, a model with patient specific intercept and

fixed slopes for the 5 time moments of the Global Symptom Score were estimated to predict

the PPRS Scales. Similar analyses were performed to predict PPRS scales on the basis of the

Global Personality Score (3 time moments).

Results

Process

We found significant changes over time for the five subscales of the PPRS. For S1

'Cooperation' F (4, 162)=20.56, p < .0001, for S2 'Tension' F (4, 162)=2.97, p = .02, for S3

'Exploration' F (4, 162)= 18.9, p < .0001, for S4 'Disillusion' F (4, 162)= 5.08, p = .0007, for

S5 'Contentment' F (4, 162)= 14.17, p < .0001.

Significant trends of these changes are given in Table 4. The mean scores of the PPRS scales

and the trends of the change over time of each of the PPRS scales are plotted in Fig 14-18.

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Table 4

Trends in change over time of the five scales of the PPRS (df=1,162)

Trend F p

Cooperation Linear

Quadratic

Cubic

62.06

9.48

6.64

< .0001

.002

.01

Tension Linear

Quadratic

Cubic

.02

9.12

2.32

.88

.003

.13

Exploration Linear

Quadratic

Cubic

36.91

26.94

6.43

< .0001

< .0001

.01

Disillusion Linear 13.23 .0004

Quadratic

Cubic

3.9

1.57

.05

.21

Contentment Linear

Quadratic

Cubic

53.67

.06

1.84

< .0001

.81

.18

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Figure 14. Mean scores of the 'Cooperation' Scale of the PPRS over 5 moments. The cubic


Figure 15. Mean scores of the 'Tension' Scale of the PPRS over 5 moments. The cubic trend

is presented by a dotted line. The quadratic trend is presented by a dotted line.

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Figure 16. Mean scores of the 'Exploration' Scale of the PPRS over 5 moments. The cubic


Figure 17. Mean scores of the 'Disillusion' Scale of the PPRS over 5 moments. The quadratic


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Figure 18. Mean scores of the 'Contentment' Scale of the PPRS over 5 moments. The linear


Process-outcome

To test the relation between the PPRS scales and the GSS, the significance of the fixed

slope was tested. Changes over time of the Global Symptom Score were related with changes

in the S5 'Contentment' scale: F(1,161)=15.86, p = .0001, in the S1 'Cooperation' scale:

F(1,161)=10.95, p = .0012 and in the S2 'Tension' scale: F(1,161)= 4.48, p = .04. We found

no significant relationship to the S3 'Exploration' scale: F(1,161)= .06, p = .45 nor to the S4

'Disillusionment' scale: F(1,161)=2.35, p = .13.

To test the relation between the PPRS scales and the GPS, the significance of the fixed

slope was tested. Changes in the Global Personality Score were not significantly related to

change in any of the scales of the PPRS.

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Discussion

When studying the process with the PPRS, we saw that all the scales showed a

significant improvement over time, with quadratic and cubic trends, as illustrated in Figures

1-6, except for the S5 'Contentment', which shows a linear improvement.

In our study group of patients with personality disorders in psychoanalytically informed

hospitalization, the therapists rated a marked increase during the first three months for the S1

‘Cooperation’ and S3 ‘Exploration’ scale going with an increase in S2 ‘Tension’. As we

discussed in the previous studies, this complex phenomenon of an increased cooperation and

exploration going with an increased tension, which occurs within the holding environment of

the setting, is known as regression. We find it back from another angle in this study.

It is remarkable that in study 3, where the patients rated their process with the Leuven

Psychotherapy Scale at the same moments in time, they reported positive changes to occur

later than the therapists do. This discrepancy may be explained by the fact that therapists rate

this regression as positive at a moment that the patient only feels that he or she gets worse and

can not see that this phase might be an essential part of the treatment. What therapists evaluate

as positive change in the way patients deal with their feelings and thoughts is not experienced

in the same way by the patients. For instance, when a patient relies less on his usual coping

like denial or splitting, he will feel more distressed at first and he will evaluate this in a

negative way while the therapist will judge this as a progress.

After this initial period of marked increase of cooperation, exploration and tension as

well, we see that cooperation and exploration remain at the same level while tension decreases

and contentment improves. This would be an ideal evolution, with a continuing exploration

during therapy, but which is better supported by the patients. We may wonder whether there is

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not a bit wishful thinking in the rating of the therapists in this regard. Our outcome study

(Chapter 6) suggests that a number of patients are treated in an explorative way, at a moment

that they are probably not at that level yet. We may wonder perhaps, whether the therapists

are not overestimating some of the patients, at least in the first period. As the PPRS in

particular is a mixture of statements about the patient and about the therapist in the session,

the attitude of the therapist is well reflected in this scale. This is for instance the case in the

'Exploration' scale where five of the six items are therapist related. On the contrary in the

'Disillusion' scale five of the seven items are patient related. In this regard, it is striking that

the 'Disillusion' scale scores are high at six months, the same moment as the Leuven

Psychotherapy Scale, S6 'Positive experience of the setting' is at its deepest point, as shown in

Study 3. This is probably because the 'Disillusion ' scale is closer to the experience of the

patients themselves, while the other scales reflect the mixture of the attitude and experience of

therapist and patient.

The results of this process-outcome study show the strongest relation between the

Global Symptom Score and the S5 'Contentment' Scale and the S1 'Cooperation' Scale of the

PPRS, in which half of the items express a feeling of feeling fine in the session such as item

P-07, ‘I feel careful- friendly- full of love’; P-12, ‘I feel calm - satisfied- relaxed’; P-17, ‘I

feel strong- fine- powerful’.

It was remarkable that there was no relationship between Global Symptom Score

change and the PPRS S3 ‘Exploration’ Scale, with exploration being a specific aspect of a

treatment on analytic lines. This finding gives support to our conclusion of the Outcome study

(Chapter 5),that an explorative approach is probably not suited for a number of the patients,

especially not in the beginning of the treatment.

It is unexpected that none of the PPRS scales was related to the change in the Global

Personality Score, in contrast with the relations of most other scales such as the FSS, DRS,

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LPS with the GPS. This is unexpected as the PPRS is an instrument to measure the

psychoanalytic process, which is theoretically more related to personality characteristics than

to volatile symptoms. Too, the PPRS is derived from a theory-driven scale developed for this

psychoanalytic process and personality related scales are for a large part theory driven as well

(such as the IPO). It may also be that the items about the feelings and interactions during

psychotherapy as expressed in the PPRS, are more expressing a current state, while the LPS

for instance contains more items about change in relationship with other people and in dealing

with emotional difficulties, which are more related to personality characteristics. In this

regard, when examining the convergent validity of the PPRS (Chapter 5), we found a poor

correlation of the PPRS with the SCID II and with the IPO and this may be a reason.

In general we may conclude that the PPRS offered another perspective on the same

process as described in Study 1 and 2, in which we see the phenomenon of regression,

revealed from another angle and interpreted differently than by the patients. Furthermore, the

results obtained with the PPRS revealed that non-specific factors of the psychoanalytic

relation as rated by the therapist, the contentment scale and the cooperation scale, are

significantly related to symptom change.

General Discussion

We discussed that the outcome results of this study in Chapter 6. These outcome results

are reflected in the change over time of the component scores, the global symptom score and

the global personality score.These outcome results of this study corroborate the findings of

the Bateman and Fonagy RCT study; with a comparable treatment we also found an

improvement with a continuation after discharge of clinical symptom measures. Furthermore

we found the same improvement for more stable personality related measures.

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It proved to be possible to measure the psychoanalytic process from three perspectives.

The change over time showed a coherent pattern. In nearly all scales we see a marked

improvement in the second half of the treatment, just like in the symptom scores.

During the first months, we see a coherent pattern of regression which is revealed from

the three perspectives, followed by an improvement of most parameters after 6 months. The

ORI- measures show a decrease of mentalization with an increase of felt safety in the

beginning of the treatment. The same phenomenon is shown in the patients' self-report

approach: there is a decrease in defence mechanisms while the feeling of positive well-being

is slowly increasing. Therapists rate this period as positive, in contrast with the patients who

only feel the distress at this moment.This phenomenon of regression was much debated

(Meissner, 1988) and was often seen as a contra-indication for the hospital treatment of

personality disorders. Within a specialised and structured therapeutic setting it seems possible

to control this regression; without such a setting a regression in psychoanalytic therapy of

patients with a borderline personality organisation may be malignant (Meissner, 1988) as

shown in the DPV outcome study (Leuzinger- Bohleber, 2002).

We hypothesize that this regression is a 'new beginning' (Balint, 1968) for most of the

patients but it may as well be a handicap for others, this will be further examined taking

trajectories of change and client variables into account (Chapter 9). This phenomenon of

regression is shown in other studies of the psychanalytic proces as well (Dahl,1988).Weiss,

1995 found the same parabolic curve when measuring the evolution of insight during

tretatment as we found with the RF state measured on the ORI, which he also interprets as a

regression being an essential part of the treatment process. Verheul (2004) points at a

destabilisation as a necessary condition for change. Anyhow, the evolution of the various

process and outcome scores show that such a regression can be controlled within the setting.

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This specific dose response relation with a stagnation and regression in the beginning,

suggests that a treatment which is too short (3-6 months) might cause an adverse effect, while

the major gain of the treatment is clearly after 6 months.

The most important finding of this study is that symptom and personality related

changes are related with the changes targeted at with the treatment: the enhancement of an

inner experience of safety by offering a structured environment and a reflective attitude of the

staff members (Fonagy et al., 2002) and the increase of the integration of self-other mental

representations by working with transferences in the here and now and by offering new

experiences both show a strong relation with symptom and personality changes. The relation

between change in outcome measures and mentalization is probably more complex and not

similar for all kinds of patients.

The strong relation of outcome measures with 'Felt Safety' from the researcher's point of

view, with the ' Positive Well-Being' from the patient's point of view and with 'Contentment'

from the therapist's perspective, indicate that this is an important dimension in the treatment.

This is in vein with Sandell's (2005) recent finding that when comparing patients who had a

successful psychoanalytic treatment with a control group, differences were not found in an

increased self-reflection, or a greater insight, but in the presence of 'inner soothing objects'

wich are helpful in moments of distress.

Finally the relation of psychic change with changes in personality related outcome

measures and the continuation of improvement after treatment of the process-variables are

arguments for a structural change.

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PART 5

PATTERNS OF PSYCHIC CHANGE

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Chapter 9

Patterns of Inner Change and Their Relation with Patient

Characteristics and Outcome in a Psychoanalytically Informed

Treatment of Patients with Personality Disorders

A hospitalization premised on analytic lines for personality disordered patients was

shown to be effective in an RCT study conducted by Bateman and Fonagy (1999, 2001). With

a comparable treatment for patients in the borderline spectrum we also found a significant

decrease in clinical symptom measures and in personality-related measures during treatment

and in follow-up. Furthermore these outcome changes were shown to be related to the inner

changes at which the treatment aims. We conceptualised these inner changes to happen along

three dimensions: felt safety, mental representations of self-object relations and mentalization.

These inner changes were measured with four psychoanalytic model-specific measures scored

on Object Relational Interviews (ORI). This way a psychoanalytic process could be revealed

in a group of personality disordered patients in a psychoanalytically informed hospitalization-

based treatment (Chapter 8).

Inner changes during psychotherapy, however, are not homogeneous. In the present

study, we want to examine whether we can delineate patterns of psychic change and whether

these patterns are related to patient variables and clinical outcome. Therefore we cluster the

patients according to their scores on the four ORI- measures of psychic change at six

moments of assessment. A better understanding of the differences in intrapsychic process and

their relation with patient's pre-treatment characteristics and with outcome may help

modulating the treatment to the needs of patients.

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Treatment

The psychoanalytically informed hospitalization based treatment of patients with

personality disorders at the University Center St.-Joseph at Kortenberg, Belgium treats four

groups of 8 patients on a hospitalization-base and two groups of 8 patients in day hospital

(Vermote & Van Sina 1998, Pieters & Vermote, 2002). This treatment is similar to the

treatment provided in the randomised controlled trial of Bateman & Fonagy (1999, 2001)

described in Bateman & Fonagy (2004).

Method

Participants

We defined the study group to forty seven consecutively admitted patients, which

stayed long enough to have at least the measures at 0-3-6-9 and three months after discharge,

this to have enough moments to enable a process study and to have a length of time of

treatment comparable with the Bateman and Fonagy study (99, 01) where patients were

treated for 18 months. Of these 47 patients, three patients were not included in the statistical

analysis because of missing data at discharge or follow-up: one refused further assessments,

the self-reports of another got lost by mail delivery service, one patient was acutely

discharged because of selling drugs.


31 were in-patients, 13 in a day-treatment setting. The patients were between the ages of 17


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living together with a partner, 3 were divorced. Sixteen patients completed secondary

education and 28 higher education or university. Using the SCID-II we assigned all patients to

one of the three clusters of personality disorders according to DSM-IV; cluster B: 32 (23

borderline, 7 narcissistic, 1 narcissistic and borderline, 1 histrionic and borderline); cluster C:

7 (1 dependent, 1 avoidant and dependent, 5 not otherwise specified); clusters B+C: 5. On

DSM-IV Axis I, we diagnosed 20 mood disorders, 2 anxiety disorders, 1 eating disorder, 5

adjustment disorders, 5 substance related disorders.

Measures


The Self Harm Inventory (SHI) (Sansone et al., 1998) about the last two weeks, the

Symptom Checklist 90 (SCL-90) (Derogatis,1977), translated by Arrindell & Ettema

(1993), the Spielberger State-Trait Anxiety Inventory translated by van der Ploeg et al.

(1980), the Spielberger State-Trait Anger Inventory translated by van der Ploeg et al.

(1982), the Beck Depression Inventory translated by Bouman et al. (1985).


The questionnaire of the Structured Clinical Interview for DSM-III-R Axis II disorders

SCID-II (Spitzer & Williams,1985) has been translated in Dutch and adapted for DSM-IV, by

Weertman, Arntz & Kerkhofs (2000). The Inventory of Personality Organization

(Lenzenweger, Kernberg, Clarkin, Foelsch, 2001; Normandin et al., 2002) is a self-report

questionnaire used to assess a structural diagnosis according to the model of Kernberg on

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borderline personality organization. The reliability and validity of the IPO translated in Dutch

was demonstrated by Vermote, Maes, Vertommen, Corveleyn, Verhaest & Peuskens (2003)

and Vermote, Smits, Claes & Vertommen (2005). The Inventory of Interpersonal Problems,

circumflex version (Alden et al., 1990) measures interpersonal functioning. All these

measures have a well established reliability and validity.

Intrapsychic process measures

Intrapsychic Process Measures were measured with the Object Relation Inventory (Blatt

et al., 1996), a semi- structured interview with open questions about parents, self, therapist

and significant other.

The Felt Safety Scale (FSS) is a five point scale to rate on the ORI ranging from 1.No

felt safety in therapy to 5. Strong feeling of safety. (Vermote, Vertommen,Verhaest, Franssen,

Geenen, Corveleyn & Peuskens, 2004; Vermote, Vertommen, Corveleyn & Verhaest, 2004;

Chapter 3).

The Differentiation Relatedness Scale (DRS (Blatt et al., 1996) is a ten point scale which is

rated on the ORI, measuring the degree of self-other differentiation and relation ranging from

1-2:. Lack of basic differentiation between self-other to 10:. Reflectively constructed

integrated representations of self and others in reciprocal and mutual relationships.

The Reflective Functioning Scale (RFS) is a 11 point scale about the capacity to

perceive ones own and others' actions in terms of mental states (Fonagy et al, 1998) ranging

from 1: Lacking RF to 7:. Marked RF. The Reflective Functioning Scale is used in the Adult

Attachment Interview (Main et al., 1991) where it measures the capacity for reflective

functioning (Fonagy et al., 1998), while when used on the ORI, it measures more the state

reflective functioning (Vermote, Vertommen, Verhaest & Peuskens, 2004; Chapter 3).

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The Bion Grid Scale (BGS) is a 6 point scale in which answers on the ORI can be put in 6

categories according to their level of mentalization, openness to explore and degree of

switching between levels. The scale reflects the degree of creative exploration and mental

transformation of experiences (Vermote, Vertommen , Verhaest et al., 2004; Vermote,

Vertommen, Corveleyn et al., 2004; Chapter 3).

Procedure

The Object Relation Inventories were conducted by a psychologist blind to all other

patient information and who had no contact with the therapeutic staff. The interviews were

conducted upon admission, every three months during treatment, at discharge and finally

three months after discharge. Anonymized interview transcripts were distributed in random

order to raters blind to all patient information and having had no contact with them. The ORI

interviews were evaluated by a group of 12 trained raters, three raters per scale, for whom

satisfactory reliability was established with each of the following scales: the Felt Safety Scale,

the Bion Grid Scale, the Reflective Functioning Scale, and the Differentiation Relatedness

Scale.

Clinical symptom measures were assessed at the same moments as the ORI. Personality

characteristics were assessed on admission, at discharge, and three months after discharge,

with the exception of the lifetime history of trauma and self-harm which were assessed only at

admission.

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Data Analysis

To examine whether there were different patterns of therapeutic process, a k-means

clustering was used to cluster the 4 measures of therapeutic change measured at six moments.

We preferred a cluster analysis over a trajectory analysis, because we were interested in the

differences in relation between the measures at given moments of the process. A trajectory

analysis shows individual trajects for the four measures. The characteristics (SHI, SCL, STAI,

STAXI, BDI, SCID, IPO) of two clusters of patients were compared with the t-test.

To examine whether changes in clinical outcome were related to the clusters of

intrapsychic process, multiple clinical symptom measures were reduced to a single symptom

component score, the Global Symptom Score (GSS) by means of a Principal Component

Analysis (PCA) on the seven symptom-scores of the patients at the first measurement of a

group of seventy patients of which the study group is a part (see Chapter 6). The PCA yielded

a first component accounting for 50 % of the total variance. The loadings on this component

were the following: .53 for the Self Harm Inventory (SHI 2w), .86 for the Symptom Check

List-psychoneuroticism scale, .85 for the Beck Depression Inventory (BDI), .73 for the

Spielberger State, .89 for the Trait Anxiety Inventory Scores (STAI), .44 for the Spielberger

State and .49 for the Trait Anger Inventory Scores (STAXI). These loadings were used to

calculate GSS component scores at each of the seven time moments.

A similar PCA was performed on the total scores of the different personality

characteristics (IPO, SCID, IIP) resulting in a component, the Global Personality Score (GPS)

explaining 74.6 % of the variance. The loadings on this component, were .88 for the IPO, .87

for the SCID and .81 for the IIP. Also in this case, the loadings of the scales at the first time

moment of a larger group of 70 patients were used to calculate component scores at each of

the three time moments.

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The clinical change over the six moments of assessment (SHI, SCL, BDI, STAI,

STAXI) was compared for the two clusters with Analysis of variance, repeated measures with

one between groups effect.

Results

Patterns of Intrapsychic Change

A two cluster solution was the most parsimonous and meaningful solution, Table 1

shows the non-standardized means of the four ORI scales at the six moments of assessment

for the two clusters Figures 1 and 2 show the plots of the 4-ORI measures of the two clusters

with measures standardized at Assessment 1. In one cluster the pattern over time of the

process scores shows a stable increase (therefore we call it the stable cluster), in the other

cluster the process measures fluctuate (therefore we call it the fluctuating cluster).

The scores of the four scales were each higher at similar times of assessment for the

stable cluster compared to the fluctuating cluster. In both clusters, FS showed an increase over

time with continuation after discharge, but in the fluctuating cluster FS decreased between 2

and 4 months, which is not the case for the stable cluster. The increase in DRS was higher in

the stable cluster compared to the fluctuating cluster. In the stable cluster, the measures of

mentalization, RFS and APP increased steadily (with only a minor decrease in RFS at three

months), while in the fluctuating cluster both measures initially decrease, begin to increase

after 6 months, but fall again at the moment of discharge and regain after discharge.

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Table 1

Non standardized measures of intrapychic change (Cluster cl.1,n=27, cl.2,n=17)

FSS global DRS global RFS global BGS global

Time M SD M SD M SD M SD

Admission

fluctuating Cl 2.2 0.7 4.5 1.2 4 1.3 3.8 1

stable Cl. 2.5 0.6 5.4 1.3 4.8 1 4.2 1

3 months

fluctuating Cl 2.7 1 4.9 1 3.5 1 3.7 0.9

stable Cl 3 0.7 6.2 1.2 4.6 1.4 4.2 0.9

6 months

fluctuating cl 2.3 1 4.8 1.2 3.4 1 3 0.9

stabe cl 3.1 0.9 6 0.8 4.4 1.4 4.5 0.9

9 months

fluctuating cl 3.1 0.9 4.9 0.9 4.1 1.2 3.7 1.2

stable cl 3.7 1 6.2 0.9 4.8 1 4.8 0.9

12 months

fluctuating cl 3.3 1.1 5.4 0.9 3.5 0.9 3.4 0.9

stable cl 3.9 0.7 6.9 1 5.1 1.3 4.8 0.7

Discharge + 3months

fluctuating cl 3.5 1 5.3 0.9 3.6 0.9 3.6 0.9

stable cl 4 0.7 6.9 1.1 5.2 1.3 5.1 1

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Figure 1. Traject of the mean global Felt Safety measure and of the mean global

Differentiation Relation measure for the fluctuating-anaclitic (1) and the stable-introjective

(2) cluster of patients

Figure 2. Traject of the mean global Reflective Functioning Scale and of the mean global

Bion Grid Scale for the fluctuating-anaclitic (1) and the stable-introjective (2) cluster of

patients

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Patient Characteristics Associated with the two Clusters of Intrapsychic Change

The difference between the stable and the fluctuating cluster in severity of borderline

personality organization, as measured on the IPO, was not significant M = 137.4 (SD = 24.82)

versus M= 130.6 (SD = 27.28) with t(42) = .80, p = .43. There was no significant difference in

the degree of past traumatic experience, M = 7.33 (SD= 3.01) versus M = 5.14 (SD = 4.15)

(t(42) = 1.29, p = .20) and no difference in self harm, the SHI being M=7.37 (SD= 4.77) for

the fluctuating cluster and M=7.36 (SD = 3.86) for the stable cluster (t(42) = .01, p = .99).

We found significant differences in clinical symptoms as measured on the SCL-90-R,

with the fluctuating cluster having more hostile symptoms compared to the stable cluster

group M= 9.67 (SD =2.79) versus M=7.07 (SD =1.92) (t(42) = 2.08, p = .04) and the

depressed range M= 50.07 (SD = 12.89) versus M= 42.41 (SD = 15.78) (t(42) = 1.90, p = .06).

We also found a significant difference in the descriptive pattern on the SCID-II, the

fluctuating cluster having more avoidant: M= 4.81 (SD = 1.73) versus M=1.87 (SD = 1.88)

(t(42) = 3.21, p = .002), more borderline: 8.81 (SD = 3.10) versus 7 (SD = 2.97) (t(42) =1.92,

p = .061), more dependent 3.74 (SD = 2.09) versus 2.52 (SD = 2.10) (t(42) =1.87, p = .068)

and more depressive features 5.78 (SD = 1.40) versus 4.53 (SD = 1.84) (t(42) =2.55,, p =

.014) on the SCID-II. The stable cluster shows significantly more narcissistic features than the

fluctuating cluster M= 4.24 (SD = 2.95) versus M= 2.48 (SD = 1.89) (t(42) = .02, p = .02).

Outcome Comparisons for Intrapsychic Change Clusters

The Global Symptom Score shows a significant decrease for the whole group across

the moments of assessment (F (5,198) = 14.90, p < .0001), with a difference in clinical

symptom change between the two clusters (F (1,42)=5.77, p = .02). The fluctuating cluster

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was associated with more symptoms at the start that decreased more quickly during therapy,

reaching the level of the stable group at discharge. The stable group had fewer symptoms at

the start, and those symptoms decreased more slowly, but after discharge this global symptom

score tended to decrease further.

When we looked at the separate clinical symptom scales, each measured at six

moments, we saw a significant difference in outcome for the SCL anger subscale (F(5, 201) =

2.17, p = .058). Fluctuating cluster patients being more angry at the start (SCL ang 27.78 SD

9.43) than the stable cluster (SCL ang 23.59 SD 10.25), but this anger diminished in a way

that the fluctuating cluster reached the same level of anger at moment six as the stable cluster

(st.cl.: 19.93 SD 9.86; fl.cl. 2 19.58 SD 7.35). We found a similar difference for the BDI (F(5,

200) = 2.31, p = .046): fluctuating cluster patients being more depressed at moment 1 (BDI M

= 28.59, SD = 8.70) than stable cluster patients (M = 20.29, SD = 11.17) and showing a faster

decrease in BDI scores but remaining more depressed at moment 6 (BDI M = 15.90, SD =

12.00) than stable cluster patients (BDI M = 11.8, SD = 10.48).

Analysis of changes in personality characteristics, measured with the Global

Personality Score at three moments, showed a significant decrease for the two groups with no

difference between the clusters.

When looking at the separate scales we see that all SCID-II categories score higher for

the cluster 1 group than for the cluster 2 group, except for the narcissistic SCID-II features

which are higher for the cluster 2 group and show a continuous pronounced decrease with a

tendency for a significant difference in change between the two clusters (F(2, 84) = 2.81, p =

.065).

For every other score the greatest change is seen during the therapy phase for the first

group and after discharge for the second group. For the SCID-II Paranoid features (F(2, 84) =

3.47, p = .035), we found the cluster 1 starting at a higher score and showing a continuing

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decrease, while cluster 2 patients start at a lower level, show an increase during therapy but a

large decrease after dismissal. There is a difference in the change of the borderline SCID-II

features (F(2, 84) = 2.77, p = .068): cluster 1 starts at a higher level, there is a decrease during

treatment and an increase after discharge in comparison with the scores at discharge while

cluster 2 shows a large and continuing decrease. This is similar for the SCID-II schizotypal

features (F(2, 84) = 2.82, p = .065), the major decrease also happens after treatment for

cluster 2.

Discussion

The clinical impression that there are different patterns of inner change during a

psychoanalytically-informed hospital treatment for personality disorders is supported by our

findings. A cluster analysis of the scores of the four measures of intrapsychic change at the six

moments of assessment revealed two clusters of patients.

In a first cluster, the pattern of inner change shows a fast increase in felt safety once the

patients are in the setting. After this so-called ‘honeymoon’ phase, their felt safety decreases

sharply, to increase again gradually during further treatment. The scores of the two

mentalization measures show a disintegration associated with this period of decrease in felt

safety. After this period, the mentalization process recuperated slowly. There was, however, a

new decrease in the mentalization parameters at the intensive emotional moment of separation

from the setting, with mentalization increasing again after discharge. The changes in mental

representations of self-other relationships were minimal in this fluctuating cluster.

A second cluster of patients showed a more stable pattern of inner change. In

comparison with the fluctuating cluster of patients, at six months there is only an asymptote of

the growth of Felt Safety and no disintegration of mentalization. After this moment at six

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months, the Felt Safety and the two measures of mentalization (RFS and BGS) steadily

increased. There was also a major increase in the quality of mental representations of self and

other, as measured with the DRS. The positive changes of all measures continued after

discharge.

The critical moment at six months is present in both clusters and seems to correspond

with the regression described in Chapter 8. In general the stable cluster of patients seemed to

profit by the treatment as it was offered, with a post treatement increase of their explorative

and associative capacities, a development of their reflective attitude toward the inner world,

and a substantial change in the inner representations of self and other, while this is not the

case for the fluctuating cluster.

We further found that the two discussed patterns of inner change were related to some of the

patient characteristics. As far as the severity and nature of their personality disorders and

degree of psychic suffering were concerned, we found very few differences between the

clusters: we found that they were as severely disordered regarding borderline organization,

had similar histories of suicidal threat and self harm, had no significant differences in past

traumatic experiences and could not be reliably distinguished on the sum score of the SCID-II

personality scales. However, the two clusters showed a different clinical picture at the outset,

which is of great value in the prediction of the kind of therapeutic process. The fluctuating

group, manifesting substantially greater symptomatology, reported more anger and depressive

symptoms than did the stable group, which showed less symptoms and a better impulse

control. Furthermore, from a descriptive DSM point of view as measured on the SCID-II, we

see that the fluctuating cluster of patients tends to show significantly more avoidant and

borderline features, while the second shows significantly more narcissistic features.

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The distinction of these two groups seems to correspond to the differentiation between

the borderlines as described from a psychodynamic point of view by Kernberg (1975), and the

group of the narcissistic borderlines as described by Kohut (1971).

Our results, based on an analysis of the therapeutic process with theory-specific

measures for the psychoanalytic model of inner change, fit very well with the findings of

Blatt. When reanalyzing the results of the Menninger study (Blatt, 1992), Blatt found that the

results of the treatment were meaningfully related to patient characteristics. He distinguished

a group of so-called anaclitic patients, who were more relation-oriented and benefited from

supportive therapy, from a group of introjective patients, who were more concerned with self

definition and benefited from explorative or insight-focused therapies. In the present study,

we found the fluctuating cluster of patients showing more borderline and avoidant

characteristics, which corresponds to the anaclitic group of Blatt. The stable cluster was

associated with more narcissistic characteristics which is typical for Blatt’s introjective group.

The pattern of the psychoanalytic process which we found in the fluctuating - anaclitic

group corresponds well with the mechanism of change that Blatt hypothesises for this group.

He states that the process of this group is dependent on the therapeutic relationship. In the

process pattern of this group we see that changes in mentalization and diffrentiation

relatedness correspond with changes in felt safety, and drop when this is low as in th

ebeginning of the treatment and at the moment of separation at discharge. Furthermore

changes are not consolidated in the post treatment phase, when the environmental support is

no longer present.

For the introjective patients, Blatt supposes an introjective mechanism of change

through interpretation and insight. In our stable-introjective cluster, we see that changes are

less vulnerable to felt safety and occur late in the treatment and continue after discharge. This

is compatible with the hypothesized change by relection and interiorization..

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Fertuck et al. (2004) found that anaclitic patients benefited more from a structuring

attitude toward their mental processes, while the narcissistic group clearly profited from an

increase in their associative functioning. This corresponds with our results: the anaclitic

cluster showed less improvement on the mentalization dimensions, their Reflective

Functioning being vulnerable to emotional moments such as the separation on discharge. The

introjective cluster clearly showed an improvement on the mentalization parameters.

The outcome for both groups was good, but there were differences. The fluctuating -

anaclitic group with strong borderline features and a more irregular process decreased more

quickly in depressive and anger symptoms but patients from this cluster showed a difficulty in

maintaining these improvements after dismissal. Their major inner psychic changes were in

the domain of Felt Safety and were therefore more relational and support-based. As they had a

poorer change in their representations of self and other and less change in their mentalization,

one might recommend that a continuous follow-up and prolonged ambulatory treatment are

needed. In contrast, the stable- introjective cluster, exhibiting a more controlled process,

showed therapeutic gains continuing to increase after dismissal. We argue that the reason for

this is a structural inner change caused by the explorative side of the treatment to which these

patients seemed to respond much more than the anaclitic group.

In summary, we may conclude that specific patterns of change could be related to types

of patients. We found a difference between an anaclitic group that probably profits more by a

supportive and structuring approach and an introjective group that probably profits more by

an explorative approach. These groups proved not to differ in the severity of the personality

disorder, but in personality style. This may indicate that it is possible from the outset of the

treatment to discern the group that would benefit from more support and structure in the initial

phases of the treatment and on dismissal, from the group that profits from the explorative

treatment as it is provided now.

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Blatt suggests that the anaclitic group needs enough safety and relational support before

they can start to explore in a second stage of the treatment, while the needs of the introjective

group must first be addressed by offering insight and understanding before they can gain form

the relational aspect of the treatment.

These findings based on the analysis of the process, need to be confirmed by studying

the process, starting from two distinctive groups in anaclitic and introjective characteristics. In

this sense it is important to remark that contrary to their expectations Blatt & Shahar, 2005

found that a group with mixed anaclitic and introjective features evidenced significantly

greater gain over the course of long-term intensive, inpatient treatment. They hypothesize that

this group has less consolidated modes of adaptation and is therefore more accessible to

treatment.

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Conclusion

Pointers in Hospitalization-Based Psychoanalytic Therapy of


1. Hospitalization-based psychotherapy for Personality Disorders works.

The prevalence of patients with personality disorders (PD) is high. In a large U.S. NIH

epidemiological survey (Grant et al., 2004), 14.8 % of the population meets the standard

DSM-IV criteria for a personality disorder. Borderline personality disorder occurs in 1 to 2%

of the population and 14-20 % of the psychiatric population (Zannarini et al., 2003). This is a

serious condition: borderline personality disordered patients have a 10% chance of suicide,

and a combination of BPD, mood disorder, and alcoholism is associated with a life

expectancy of only 50% (Stone, 1990). Two recent meta-analyses showed the effectiveness of

psychodynamic therapy and cognitive behavior therapy in the treatment of personality

disorders, with large overall effect sizes (Perry et al., 1999 ; Leichsenring & Leibing, 2003).

Both treatments ware of a comparable intensity (Migone, 2003). Psychoanalytically informed

hospitalization-based treatment is an intensive form of psychotherapy for PD, being offered in

specialised centres. The outcome data in Chapter 6 corroborate the findings of the Bateman

and Fonagy study.

2. There is a continuation of the effect and an improvement in the post-treatment phase.

One of the most intriguing findings in the Bateman-Fonagy (1999, 2001) study is that

the improvement continues in the post-treatment phase. We found the same phenomenon on

most measures for the whole group. As seen in the outcome trajectories, the worst group,

defined by clinical presentation, even changes dramatically in this post treatment period

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(Chapter 6). The late and the post-treatment symptom outcome improvement may be due to

an indirect effect of psychic changes that occur during treatment. Studies about symptom-

oriented treatments were inconclusive about post-treatment effects (Linehan, Heard &

Armestrong, 1993;Verheul et al., 2003, Bohus et al., 2004), certainly with regard to

hopelessness and depression.

However, the post-treatment effect can be attributed to the fact that in our sample 50%

continued with ambulatory treatment outside the setting and 75% in the Bateman & Fonagy

(1999) sample. Before the hospitalisation treatment, in contrast, these treatments failed, which

led to the hospitalisation treatment in a majority of cases. The hospitalisation that offered a

sound base for a continuing ambulant psychotherapy seems to be a good result. Based on

these findings, we decided to focus on the process of inner change, while also organising less

intensive post-treatment formulas by which the process can continue. In this regard Chiesa

(2000) and Chiesa & Fonagy (2003) showed better results in a step down programme where

inpatient therapy was followed by day-hospital and ambulatory treatment versus a prolonged

inpatient treatment.

3. Patient drop-out can be low, paying attention to a first phase in the treatment; some

predictors for drop-out were established.

Drop-out rates in the therapy programs for personality disorders are high, ranging

from 32-66 % ( Chiesa, 2000). Our study showed that the drop-out group differed

significantly in vindictiveness and hostility. This corroborates the findings of Smith et al.

(1994). The judgement of the nurses predicted drop-out; this was not the case, however, for

the judgement of the psychotherapists or for the quality of the therapeutic process in the

beginning. These findings help us to better delineate the group that is vulnerable for drop-out

(Chapter 7).

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4. It is possible to measure the treatment process.

The psychonalytically informed treatment focuses on inner psychic change, which is

one of the definitions of the psychoanalytic process. This process is typically imperceptible

and hard to define. There exists however a wealth of theoretical concepts and clinical

knowledge about this process, but it is in the soft clinical tissue of individual therapists

without much empirical bones. One of the reasons is that there are few instruments to measure

the process as a whole in personality disorders. Although highly inferential, the different

process measures that we examined and/or developed showed a sufficient reliability and

validity (Chapters 3, 4, 5).

5. The psychoanalytic process was revealed when measured from different perspectives.

Measuring the psychotherapeutic process from different perspectives in a larger group

of patients revealed a coherent pattern. The elephant becomes obvious for the blind man

(Bucci, 1996). The pattern is peculiar: nearly all scales show a stagnation or decrease in the

first half of the treatment and an increase in the second half, with a continuing improvement

after discharge.

When looking in detail at this phenomenon in the first half of the treatment, we see

that while the patients cooperate with the treatment, they feel worse and show less adaptive

coping. From the independent researcher's point of view as measured with the ORI measures,

we see an increase in 'felt safety' and a decrease in 'state reflective functioning'. The patients'

self-reports show a decrease in the 'capacity to deal with unexpected and stressful events' and

in the 'capacity to deal with negative emotions'. The therapists rate an increased 'tension' with

an increased 'cooperation' and 'exploration' in this first period.

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In psychoanalysis this phenomenon is known as regression (Meissner, 1988 ). It was

often considered to be a contra-indication to hospitalise personality disorders because of the

danger of malignant regression, but we see that in a psychoanalytically informed

hospitalisation-based treatment, this regression may be well managed and is part of the

process. One way of interpreting it is that patients let their old and ineffective ways of coping

go and thus suffer more distress in the beginning. This is described from several theoretical

points of view ( Balint ,1968; Dahl,1988; Weiss, 1995; Verheul, 2005).

6. The three dimensional model of psychic change in PD was not falsified.

As a complement to the classic model of the psychoanalytic process (resistance,

interpretation, working through), we suggested a three dimensional model: felt safety,

mentalization, and object relations. In patients with a neurotic personality there is no failing in

felt safety and mentalization, and the classic process of interpreting object relations in the

transference can take place. In personality disorders, significant development in the three

dimensions must take place (this being what we called the basic psychoanalytic process,

Chapter 1).

When measuring the process in the three interrelated dimensions, we indeed saw

different and meaningful changes taking place during the treatment (Chapter 8). Fonagy &

Target (2005) recently proposed a model of psychic change that shows some resemblance

with the three dimensional model that we studied. They outlined three modes of psychic

change: first, a mode of intersubjective shifts that allows the patient to externalise alien parts

within an atmosphere of human generosity (this corresponds for a part to the background

dimension of felt safety); second, a mode about the revitalisation of mental processes, going

with a regression in the beginning (this corresponds with our dimension of mentalization); and

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third, a mode of representational change (this is similar to the dimension regarding mental

representations of object relations).

7. Measured from three different perspectives (independent researchers, patient self-

report, and therapists), treatment outcome is meaningfully related to the psychoanalytic

process.

Relations between treatment process and outcome were low or non-existent in prior

investigations (e.g., Fonagy et al., 2002; Vaughan & Roose, 1995). We found significant

relations between outcome change and psychic change from each of the three perspectives we

took as part of the process: the independent researcher's point of view (ORI-measures), the

patient's point of view (LPS) and the therapist's point of view ( PPRS).

8. Of all the process variables, the variables related to a background experience of safety

showed the strongest relation with outcome change in PD.

The same factor reveals itself as having the strongest relation with symptom change

from the three perspectives: 'Felt Safety' in ORI, 'Positive well being' in LPS and

'Contentment' in PPRS. This relation is not only for symptom change but for personality

change as well.

This background experience of safety is a subjective feeling about the human

environment. It is not just a vague notion of being loved. In psychoanalytically informed

hospitalisation, it corresponds to a culture on the ward where discipline, care, authenticity,

respect, and non-judgmental attitudes are of high value (Chapter 1). Although mentalization is

perhaps not the primary agent of change, a mentalizing attitude on the part of the caregivers

seems important to guarantee this background of safety. Patients with a low level borderline

organisation attack this frame and the attitude of the staff. We hypothesize that keeping this

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frame and attitude while being confronted with patients being in emotional storms and

enacting violent traumas of the past and aggressive internal objects makes it possible for

patients to introject this experience and permit new internal objects develop. This finding adds

further empirical value to the psychoanalytical ideas of treating so called 'primitive mental

disorders' by the Hungarian School of Ferenczi and Balint, the attachment theory of Bowlby,

the theories of Fonagy and Bion, and the approach of the Sandlers (see Chapter 1).

Recent findings from Sandell (2005) are in the same vein: comparing patients with a control

group after a successful analysis revealed that differences were not in insight or self

reflection, but in having soothing inner objects to turn to in difficult moments.

9. Changes in mental representations of self and others are related to changes in

symptom and personality related outcome.

Blatt & Auerbach (2001) and Fonagy (1999) defined the mental representations of

object relations as implicit, procedural patterns (see Chapter 1). We suppose that felt safety

and the mental processing of interpersonal experiences may lead to alterations in these mental

representations. In psychoanalytically informed hospitalisation treatment, this is enhanced by

experiencing new types of interactions and the interpreting in the here and now of the multiple

transferences which are happening in the group psychotherapies. The Differentiation

Relatedness Scale (DRS) measures the mental representations of object relations. Blatt found

a relation between changes in the DRS and outcome measured with the Global Adjustment

Scale in severe psychopathology (Blatt et al., 1996). Likewise, we find a significant relation

between changes in the DRS and changes in symptoms and in personality related measures.

In line with Blatt & Auerbach (2001) and Fonagy (1999), we may hypothesize that it

might be the changes in these deeply ingrained patterns that provoke long lasting changes. It

is probably not a coincidence that the group in which we see changes in the DRS during

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therapy is also the group which shows a continuing improvement of symptom and personality

related measures in the post-treatment phase. This is not the case in the group without

substantial changes in the DRS.

10. The role of mentalization seems to depend on the phase of the treatment and the

personality type of the patient.

The relation of mentalization with outcome change is not as unequivocal as for the

other two dimensions of the model. We studied two types of mentalization, the reflective

functioning according to Fonagy and the psychic processing according to Bion (see Chapter

2). Changes in reflective functioning are related with changes in personality related measures,

but changes in the Bion type of mentalization are not. The regression in the first half of the

treatment is strongly reflected in the decrease of the 'state' reflective functioning, as measured

on the ORI (Chapter 8). There is a difference in the change over time of the mentalization

parameters according to the personality type of the patient (Chapter 9).

These findings support the hypothesis of Blatt & Shahar (2004) that the importance of

focusing on mentalization in the patient seems to depend on the phase of the therapy and of

the personality type of the patient. In introjective patients, this dimension is very important

from the start and a necessary condition before they can start to experience and change object

relational patterns. In anaclitic patients, a preceding phase of attention to the felt safety with

environmental support and structure seems necessary before they can adapt a mentalizing

attitude.

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11. We found different patterns of the psychoanalytical process, probably pointing to

different mechanisms of change for different types of patients.

We found a rather unstable pattern of change in the three dimensions with an anaclitic

type of patient. This may be explained by the findings of Blatt, that the mechanisms of change

in this kind of patient depends on the support and the structure from the environment. We

found a stable pattern of change in the three dimensions, which continues in the post-

treatment phase to be related with an introjective type of patients. This supports the findings

of Blatt & Shahar (2004) that the mechanism of change in this kind of patients is probably

due to introjective mechanisms of change.

12. The treatment programme can be adapted to the needs of the patients.

At the moment, the psychoanalytically informed hospitalisation-based treatment offers

a uniform treatment for the different types of personality disorders. Differences in what is

offered to the patients depend on the severity of the personality disorder. We found, however,

that the groups with an improving trajectory of outcome and the group with a trajectory of

poor outcome differ not in severity of the personality disorder but in personality style. The

findings of Chapters 6, 8, and 9 show that the group of anaclitic patients have other needs than

does the group of introjective patients. The introjective patients seemingly benefit from the

treatment as it is. This corresponds to Karterud et al. (1992) finding that patients from the

anxious cluster C improved more in a day hospital therapeutic community treatment for

personality disorders than patients with borderline personality disorder.The anaclitic type of

patients probably needs more environmental support in the beginning of the treatment and at

discharge and follow-up. The distinction between the two kind of patients can be made from

the outset. These findings were unexpected and based on comparing the patient variables of

trajectories of outcome and of patterns of psychoanalytic process. The hypothesis needs to be

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confirmed by starting with a pure anaclitic group and an introjective group and studying the

process.

13 The criteria of health economy tend to be based on short term studies with symptom

outcome measures in selected groups of patients. This threatens the most effective

therapeutic agents of change in an effective treatment setting.

It is obvious that the therapeutic effects which we found to be related with outcome

changes, such as the increase of felt safety and the changing of deeply ingrained patterns of

self-other relationships, cannot be changed in three or four weeks. Based on meta reviews,

Perry et al.(1999) and Leichsenring & Leibing (2003) point at the fact that the effects of

psychotherapy in PD are clearly related to the length of treatment. They warn against

interpreting short term RCT based on symptom self-report measures which may reflect short

term honeymoon effects but not long term effects.

In this study we found that there is a probably necessary regression in the first months

of the treatment while there is continuing improvement in the post-treatment phase. This

corroborates the findings of the Bateman & Fonagy (1999, 2001) RCT effectiveness study.

Therefore, it seems illogical to discharge patients early in the treatment or to compare this

form of effective treatment in its early phases with other forms of treatment. For a long time,

one saw PD as a fairly untreatable condition, and it is true that these patients are very difficult

to handle in private practices. The mentioned meta reviews show that there is no longer

reason to hold this defeatist opinion when one treats these patients long enough. Given the

high prevalence of this psychopathology and its psychological and sociofamilial burden, it is

important to avoid creating revolving door patients by keeping unrealistically hopeful or,

contrarily, defeatist expectancies about their treatment. Both are at the base of short term

treatments. Perry et al. (1999) showed that an effective treatment of personality disorders may

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be associated with a sevenfold faster rate of recovery in comparison with the natural history

and that treatments of less than a year may better be characterised as treating crises and

concurrent axis I disorders but not the personality disorder. Gabbard , Lazar & Hornberger

(1997) and Bateman & Fonagy (2003) show the cost-effectiveness of long-term treatments.

14. Doing psychotherapy research is not harmful for therapeutic skills and intuition. A

personal experience.

Psychotherapists and psychoanalysts show an ambivalent attitude towards research. It is a

widespread idea that the generalisations and simplifications, necessary to answer research

questions in a statistically valid way, do not respect the wealth and inifinite varieties of what

happens in a psychotherapy and may even be harmful to the discipline. The caricature being

that of a researcher who does not pay attention to the very indivual feelings of his patient.

Others like Gabbard (2003,p. 837) state 'that it makes no sense to write about therapeutic

action as if somehow the question of what is therapeutic and how best to help our patients is

one that can be settled by logical argument and debate. It is in fact an empirical question ,

which can no more be answered by logic and debate than the question of whether one and

another treatment for heart disease is more effective'. I would not be so radical as Gabbard.

Many of our findings confirm existing clinical experience and theoretical knowledge. But

because of research the psychoanalytically oriented treatment under study is no longer based

on a belief, but grounded and that makes a world of difference. Such a base offers even more

room for open questions and for the creativity of the individual therapists confronted with the

very individual problems of the patients. Furthermore, I experienced that the modes of

functioning as a researcher and as an analyst are not contradictory. I learned that research is a

highly creative and emotional process with moments of despair when nothing seems to fit and

moments of esthetic beauty when after complex analyses something simple and true or new

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reveals itself. This way, the basic attitude of research is not so different from a genuine

psychoanalytic attitude in the sessions. I experienced research as a refreshing antidote against

an authoritative form of knowledge in psychotherapy, which is inherent in learning

psychotherapy as a skill from masters and in the necessary combination of personal therapy

and teaching. Furthermore I enjoyed the solidarity within the research community. Although I

am convinced that research is of vital importance for our profession, I do not think that it is

necessary that psychotherapists need to do the research themselves. But I have the impression

that being a therapist helps to ask the right research questions about psychotherapy and that in

this sense, a close connection between the two disciplines will always be necessary.

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