How Personality Disorders Change in Psychotherapy: a Concise Review of Process

Abstract

Purpose of Review

The present review summarizes the current state of the art in psychotherapy processes during treatments for clients with personality disorders. We outline some methodological challenges in the discipline of process research, give a brief historical account on process research, and then focus on specific processes studied from an empirical perspective.

Recent Findings

The current review acknowledges the centrality of the therapeutic relationship, in particular the therapeutic alliance, therapist empathy, and responsiveness in explaining outcome across treatment modalities for personality disorders. The review describes evidence from three overall and overlapping lines of inquiry that have garnered scientific interest in the past years.

Summary

For emotional change (regulation, awareness, and transformation), socio-cognitive change (mentalizing, meta-cognition, and interpersonal patterns), and increase in insight and change in defense mechanisms, evidence is moderate to strong for these processes to contribute to healthy change in treatments for personality disorders, in particular borderline personality disorder. Avenues of future studies are outlined.

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References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.

    Budge SL, Moore JT, Del Re A, Wampold BE, Baardseth TP, Nienhuis JB. The effectiveness of evidence-based treatments for personality disorders when comparing treatment-as-usual and bona fide treatments. Clin Psychol Rev. 2013;33(8):1057–66.

    PubMed  Article  Google Scholar 

  2. 2.

    • Cristea IA, Gentili C, Cotet CD, Palomba D, Barbui C, Cuijpers P. Efficacy of psychotherapies for borderline personality disorder: a systematic review and meta-analysis. JAMA Psychiatry. 2017;74(4):319–28. This meta-analysis demonstrates the efficacy of several bona-fide psychotherapies for borderline personality disorder.

  3. 3.

    Karyotaki E, Smit Y, Henningsen KH, Huibers M, Robays J, De Beurs D, et al. Combining pharmacotherapy and psychotherapy or monotherapy for major depression? A meta-analysis on the long-term effects. J Affect Disord. 2016;194:144–52.

    CAS  PubMed  Article  Google Scholar 

  4. 4.

    Clarkin J. Raising the bar in the empirical investigation of psychotherapy. Philadelphia: American Psychiatric Association; 2014.

    Google Scholar 

  5. 5.

    Kazdin A. Understanding how and why psychotherapy leads to change. Psychother Res. 2009;19(4–5):418–28.

    PubMed  Article  Google Scholar 

  6. 6.

    Kramer U. Mechanisms of change in treatments of personality disorders: introduction to the special section. J Personal Disord. 2018;32(Supplement):1–11.

    Article  Google Scholar 

  7. 7.

    •• Kramer U. Personality, personality disorders, and the process of change. Psychother Res. 2019;29(3):324–36. This review of the literature incorporates an integrated qualitative-quantitative re-analysis of eight clinical cases illustrating different pathways of change in borderline personality disorder.

  8. 8.

    Zilcha-Mano S. Major developments in methods addressing for whom psychotherapy may work and why. Psychother Res. 2019;29(6):693–708.

    PubMed  Article  Google Scholar 

  9. 9.

    Doss BD. Changing the way we study change in psychotherapy. Clin Psychol Sci Pract. 2004;11(4):368–86.

    Article  Google Scholar 

  10. 10.

    Dittes J. Previous studies bearing on content analysis of psychotherapy. In: Dollard J, Auld Jr F, editors. Scoring human motives: A manual; 1959. p. 325–51.

    Google Scholar 

  11. 11.

    Rogers CR. The use of electrically recorded interviews in improving psychotherapeutic techniques. Am J Orthop. 1942;12(3):429–34.

    Article  Google Scholar 

  12. 12.

    Crits-Christoph P, Gibbons MBC, Mukherjee D. Psychotherapy process-outcome research. In: Bergin and Garfield's handbook of psychotherapy and behavior change. Hoboken: Wiley; 2013. p. 298–340.

    Google Scholar 

  13. 13.

    Kiesler DJ. The process of psychotherapy: empirical foundations and systems of analysis. Piscataway: Transaction Publishers; 1973.

    Google Scholar 

  14. 14.

    Rice LN, Greenberg LS. Patterns of change: intensive analysis of psychotherapy process. New York: Guilford Press; 1984.

    Google Scholar 

  15. 15.

    Castonguay LG, Constantino MJ, Beutler LE. Principles of change: how psychotherapists implement research in practice. Oxford: Oxford University Press; 2019.

    Google Scholar 

  16. 16.

    • Goldfried MR. Obtaining consensus in psychotherapy: What holds us back? Am Psychol. 2019;74(4):484. This commentary outlines how science may develop in order to achieve a mature status, with regard to psychotherapy integration.

  17. 17.

    Greenberg LS. Ideal psychotherapy research: a study of significant change processes. J Clin Psychol. 1999;55(12):1467–80.

    CAS  PubMed  Article  Google Scholar 

  18. 18.

    Hayes SC, Hofmann SG. Process-based CBT: the science and core clinical competencies of cognitive behavioral therapy. Oakland: New Harbinger Publications; 2018.

    Google Scholar 

  19. 19.

    Cuijpers P, Reijnders M, Huibers MJ. The role of common factors in psychotherapy outcomes. Annu Rev Clin Psychol. 2019;15:207–31.

    PubMed  Article  Google Scholar 

  20. 20.

    Mulder R, Murray G, Rucklidge J. Common versus specific factors in psychotherapy: opening the black box. Lancet Psychiatry. 2017;4(12):953–62.

    PubMed  Article  Google Scholar 

  21. 21.

    Stiles WB. The variables problem and progress in psychotherapy research. 2013.

  22. 22.

    Smith TL, Barrett MS, Benjamin LS, Barber JP. Relationship factors in treating personality disorders. In: Principles of therapeutic change that work; 2006. p. 219–38.

    Google Scholar 

  23. 23.

    Norcross JC, Lambert MJ. Psychotherapy relationships that work: volume 1: evidence-based therapist contributions. Oxford: Oxford University Press; 2019.

    Google Scholar 

  24. 24.

    • Kramer U. Therapist responsiveness in treatments for personality disorders. In: Watson HWJC, editor. Responsiveness in psychotherapy. Washington, D.C: American Psychological Association; 2020. This chapter compares three levels of granularity of therapist responsiveness in treatments for personality disorder.

  25. 25.

    Kramer U, Stiles WB. The responsiveness problem in psychotherapy: a review of proposed solutions. Clin Psychol Sci Pract. 2015;22(3):277–95.

    Article  Google Scholar 

  26. 26.

    Kramer U, Kolly S, Berthoud L, Keller S, Preisig M, Caspar F, et al. Effects of motive-oriented therapeutic relationship in a ten-session general psychiatric treatment of borderline personality disorder: a randomized controlled trial. Psychother Psychosom. 2014;83(3):176–86.

    PubMed  Article  Google Scholar 

  27. 27.

    • Maillard P, Berthoud L, Kolly S, Sachse R, Kramer U. Processes of change in psychotherapy for narcissistic personality disorder. J Personal Disord. 2020;34(Supplement):63–79. This empirical process-outcome analysis is one of the first to rigourously assess psychotherapy process in a rather large sample of clients with narcissistic personality disorder.

  28. 28.

    Babl A, Gomez Penedo JM, Berger T, Schneider N, Sachse R, Kramer U. Change processes in psychotherapy for patients presenting with histrionic personality disorder. (submitted). 2020.

  29. 29.

    Flückiger C, Del Re A, Wampold BE, Horvath AO. The alliance in adult psychotherapy: a meta-analytic synthesis. Psychotherapy. 2018;55(4):316–40.

    PubMed  Article  Google Scholar 

  30. 30.

    Scala JW, Ellison WD, Levy KN, editors. The working alliance in the treatment of borderline personality disorder: a meta-analysis. 45th International Annual Meeting of the Society for Psychotherapy Research (SPR), Copenhagen, Denmark; 2014.

  31. 31.

    Kivity Y, Levy KN, Kolly S, Kramer U. The therapeutic alliance over 10 sessions of therapy for borderline personality disorder: agreement and congruence analysis and relation to outcome. J Personal Disord. 2020;34(1):1–21.

    Article  Google Scholar 

  32. 32.

    Kramer U, Flückiger C, Kolly S, Caspar F, Marquet P, Despland J-N, et al. Unpacking the effects of therapist responsiveness in borderline personality disorder: motive-oriented therapeutic relationship, patient in-session experience, and the therapeutic alliance. Psychother Psychosom. 2014;83(6):386–7.

    PubMed  Article  Google Scholar 

  33. 33.

    Hirsh JB, Quilty LC, Bagby RM, McMain SF. The relationship between agreeableness and the development of the working alliance in patients with borderline personality disorder. J Personal Disord. 2012;26(4):616–27.

    Article  Google Scholar 

  34. 34.

    • Zufferey P, Caspar F, Kramer U. The role of interactional agreeableness in responsive treatments for patients with borderline personality disorder. J Personal Disord. 2019;33(5):691–706. In this study, the authors develop and validate a new scale of interpersonal agreeableness based on data from psychotherapy process and case formulation for borderline personality disorder.

  35. 35.

    Levy KN, Beeney JE, Wasserman RH, Clarkin JF. Conflict begets conflict: executive control, mental state vacillations, and the therapeutic alliance in treatment of borderline personality disorder. Psychother Res. 2010;20(4):413–22.

    PubMed  Article  Google Scholar 

  36. 36.

    Boritz T, Barnhart R, Eubanks CF, McMain S. Alliance rupture and resolution in dialectical behavior therapy for borderline personality disorder. J Personal Disord. 2018;32(Supplement):115–28.

    Article  Google Scholar 

  37. 37.

    Cash SK, Hardy GE, Kellett S, Parry G. Alliance ruptures and resolution during cognitive behaviour therapy with patients with borderline personality disorder. Psychother Res. 2014;24(2):132–45.

    PubMed  Article  Google Scholar 

  38. 38.

    Greenberg LS, Pascual-Leone A. Emotion in psychotherapy: a practice-friendly research review. J Clin Psychol In Session. 2006;62(5):611–30.

    PubMed  Article  Google Scholar 

  39. 39.

    Linehan MM, Bohus M, Lynch TR. Dialectical behavior therapy for pervasive emotion dysregulation. In: Handbook of Emotion Regulation, vol. 1; 2007. p. 581–605.

    Google Scholar 

  40. 40.

    •• Rudge S, Feigenbaum JD, Fonagy P. Mechanisms of change in dialectical behaviour therapy and cognitive behaviour therapy for borderline personality disorder: a critical review of the literature. J Ment Health. 2020 29(1):91-152. This meta-analysis documents the process-outcome studies of the field of cognitive behavioral and dialectical-behavior therapy for borderline personality disorder.

  41. 41.

    McMain S, Links PS, Guimond T, Wnuk S, Eynan R, Bergmans Y, et al. An exploratory study of the relationship between changes in emotion and cognitive processes and treatment outcome in borderline personality disorder. Psychother Res. 2013;23(6):658–73.

    PubMed  Article  Google Scholar 

  42. 42.

    Neacsiu AD, Rizvi SL, Linehan MMJB. Dialectical behavior therapy skills use as a mediator and outcome of treatment for borderline personality disorder. Behav Res Ther. 2010;48(9):832–9.

    PubMed  PubMed Central  Article  Google Scholar 

  43. 43.

    Kramer U, Pascual-Leone A, Berthoud L, De Roten Y, Marquet P, Kolly S, et al. Assertive anger mediates effects of dialectical behaviour-informed skills training for borderline personality disorder: a randomized controlled trial. Clin Psychol Psychother. 2016;23(3):189–202.

    PubMed  Article  Google Scholar 

  44. 44.

    Kramer U. The role of coping change in borderline personality disorder: a process-outcome analysis on dialectical-behaviour skills training. Clin Psychol Psychother. 2017;24(2):302–11.

    PubMed  Article  Google Scholar 

  45. 45.

    •• Kramer U, Keller S, Caspar F, de Roten Y, Despland J-N, Kolly S. Early change in coping strategies in responsive treatments for borderline personality disorder: A mediation analysis. J Consult Clin Psychol. 2017;85(5):530. This mediation analysis demonstrates in a rare time-dependent randomized controlled design that improvement in in-session coping between sessions 1 and 5 explained symptom change one month later in treatments for borderline personality disorder.

  46. 46.

    Pascual-Leone A. Dynamic emotional processing in experiential therapy: two steps forward, one step back. J Consult Clin Psychol. 2009;77(1):113–26.

    PubMed  Article  Google Scholar 

  47. 47.

    Pascual-Leone A. How clients “change emotion with emotion”: a programme of research on emotional processing. Psychother Res. 2018;28(2):165–82.

    PubMed  Article  Google Scholar 

  48. 48.

    Kramer U, Pascual-Leone A, Rohde KB, Sachse R. Emotional processing, interaction process, and outcome in clarification-oriented psychotherapy for personality disorders: a process-outcome analysis. J Personal Disord. 2016;30(3):373–94.

    Article  Google Scholar 

  49. 49.

    Kramer U, Pascual-Leone A, Rohde KB, Sachse R. The role of shame and self-compassion in psychotherapy for narcissistic personality disorder: an exploratory study. Clin Psychol Psychother. 2018;25(2):272–82.

    PubMed  Article  Google Scholar 

  50. 50.

    Berthoud L, Pascual-Leone A, Caspar F, Tissot H, Keller S, Rohde KB, et al. Leaving distress behind: a randomized controlled study on change in emotional processing in borderline personality disorder. Psychiatry. 2017;80(2):139–54.

    PubMed  Article  Google Scholar 

  51. 51.

    Choi-Kain LW, Gunderson JG. Mentalization: ontogeny, assessment, and application in the treatment of borderline personality disorder. Am J Psychiatr. 2008;165(9):1127–35.

    PubMed  Article  Google Scholar 

  52. 52.

    Lis S, Bohus M. Social interaction in borderline personality disorder. Curr Psychiatry Rep. 2013;15(2):338.

    PubMed  Article  Google Scholar 

  53. 53.

    Fischer-Kern M, Doering S, Taubner S, Hörz S, Zimmermann J, Rentrop M, et al. Transference-focused psychotherapy for borderline personality disorder: change in reflective function. Br J Psychiatry. 2015;207(2):173–4.

    PubMed  Article  Google Scholar 

  54. 54.

    Levy KN, Meehan KB, Kelly KM, Reynoso JS, Weber M, Clarkin JF, et al. Change in attachment patterns and reflective function in a randomized control trial of transference-focused psychotherapy for borderline personality disorder. J Consult Clin Psychol. 2006;74(6):1027–40.

    PubMed  Article  Google Scholar 

  55. 55.

    •• De Meulemeester C, Vansteelandt K, Luyten P, Lowyck B. Mentalizing as a mechanism of change in the treatment of patients with borderline personality disorder: a parallel process growth modeling approach. Personal Disord. 2018;9(1):22. This questionnaire study shows the relevance of change in mentalizing for outcome in a rather large sample for clients with borderline personality disorder undergoing psychodynamic psychotherapy.

  56. 56.

    Glass CR, Arnkoff DB. Questionnaire methods of cognitive self-statement assessment. J Consult Clin Psychol. 1997;65(6):911–27.

    CAS  PubMed  Article  Google Scholar 

  57. 57.

    • Möller C, Karlgren L, Sandell A, Falkenström F, Philips B. Mentalization-based therapy adherence and competence stimulates in-session mentalization in psychotherapy for borderline personality disorder with co-morbid substance dependence. Psychother Res. 2017;27(6):749–65. This small study suggests that therapist use of mentalizing fostering interventions actually contribute to increase in client in-session mentalizing.

  58. 58.

    Antonsen BT, Johansen MS, Rø FG, Kvarstein EH, Wilberg T. Is reflective functioning associated with clinical symptoms and long-term course in patients with personality disorders? Compr Psychiatry. 2016;64:46–58.

    PubMed  Article  Google Scholar 

  59. 59.

    Gullestad FS, Johansen MS, Høglend P, Karterud S, Wilberg T. Mentalization as a moderator of treatment effects: findings from a randomized clinical trial for personality disorders. Psychother Res. 2013;23(6):674–89.

    PubMed  Article  Google Scholar 

  60. 60.

    Maillard P, Dimaggio G, Berthoud L, de Roten Y, Despland JN, Kramer U. Metacognitive improvement and symptom change in a 3-month treatment for borderline personality disorder. Psychol Psychother. https://doi.org/10.1111/papt.12219. 2019.

  61. 61.

    Arntz A, Hawke LD, Bamelis L, Spinhoven P, Molendijk ML. Changes in natural language use as an indicator of psychotherapeutic change in personality disorders. Behav Res Ther. 2012;50(3):191–202.

    PubMed  Article  Google Scholar 

  62. 62.

    • Keller S, Stelmaszczyk K, Kolly S, de Roten Y, Despland J-N, Caspar F, et al. Change in biased thinking in a treatment based on the motive-oriented therapeutic relationship for borderline personality disorder. J Personal Disord. 2018;32(Supplement):75–92. This study shows that change in in-session cognitive errors is important for treatments for borderline personality disorder, but is unrelated with symptom change.

  63. 63.

    Kramer U, Golam M. Cognitive heuristics in borderline personality disorder across treatment: a longitudinal non-parametric analysis. J Clin Psychol. 2019;75(7):1320–31.

    PubMed  Article  Google Scholar 

  64. 64.

    • Signer S, Estermann Jansen R, Sachse R, Caspar F, Kramer U. Social interaction patterns, therapist responsiveness, and outcome in treatments for borderline personality disorder. Psychol Psychother. 2019:e12254. This study develps and validates a observer-rated scale on the socio-cognitive functions related to social interaction in treatments for borderline personality disorder.

  65. 65.

    • Maccaferri GE, Dunker-Scheuner D, De Roten Y, Despland J-N, Sachse R, Kramer U. Psychotherapy of dependent personality disorder: the relationship of patient–therapist interactions to outcome. Psychiatry. 2019:1–16. https://doi.org/10.1080/00332747.2019.1675376. This study is one of the rare ones which observe in-session interaction behaviors of clients with a dependent personality disorder, and relate them with outcome in a controlled context.

  66. 66.

    Bond M, Perry JC. Long-term changes in defense styles with psychodynamic psychotherapy for depressive, anxiety, and personality disorders. Am J Psychiatr. 2004;161(9):1665–71.

    PubMed  Article  Google Scholar 

  67. 67.

    Johansson P, Høglend P, Ulberg R, Amlo S, Marble A, Bøgwald K-P, et al. The mediating role of insight for long-term improvements in psychodynamic therapy. J Consult Clin Psychol. 2010;78(3):438–48.

    PubMed  Article  Google Scholar 

  68. 68.

    Euler S, Stalujanis E, Allenbach G, Kolly S, De Roten Y, Despland J-N, et al. Dialectical behavior therapy skills training affects defense mechanisms in borderline personality disorder: an integrative approach of mechanisms in psychotherapy. Psychother Res. 2019;29(8):1074–85.

    PubMed  Article  Google Scholar 

  69. 69.

    •• Schnell K, Herpertz SC. Emotion regulation and social cognition as functional targets of mechanism-based psychotherapy in major depression with comorbid personality pathology. J Personal Disord. 2018;32(Supplement):12–35. This review establishes the importance of emotional processing and socio-cognitive processing in a mechanism-based conception of psychotherapy for personality pathology.

  70. 70.

    Lane RD, Ryan L, Nadel L, Greenberg L. Memory reconsolidation, emotional arousal, and the process of change in psychotherapy: new insights from brain science. Behav Brain Sci. 2015;38:e1.

    PubMed  Article  Google Scholar 

  71. 71.

    •• Lane RD, Nadel L. Neuroscience of enduring change: implications for psychotherapy. Oxford: Oxford University Press; 2020. This book synthesizes the current knowledge on memory reconsolidation in psychotherapy and outlines future research and clinical perspectives.

  72. 72.

    • Grandjean L, Beuchat H, Gyger L, de Roten Y, Despland JN, Draganski B, et al. Integrating core conflictual relationship themes in neurobiological assessment of interpersonal processes in psychotherapy. Couns Psychother Res. 2020. https://doi.org/10.1002/capr.12294. This methodological study proposes an integration between fMRI assessment and process-based assessment using core conflictual relationship themes.

  73. 73.

    • Kramer U, Kolly S, Maillard P, Pascual-Leone A, Samson AC, Schmitt R, et al. Change in emotional and theory of mind processing in borderline personality disorder: a pilot study. J Nerv Ment Dis. 2018;206(12):935–43. This pilot study shows feasibility of integrating neurobiological and process assessment using individualized stimuli in the context of psychotherapy for borderline personality disorder.

  74. 74.

    Pascual-Leone A, Herpertz SC, Kramer U. Experimental designs and the ‘emotion stimulus critique’: hidden problems and potential solutions in the study of emotion. Psychopathology. 2016;49(1):60–8.

    PubMed  Article  Google Scholar 

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Acknowledgments

This study was supported by Swiss National Science Foundation grant 100014_179457/1 (to Dr. Kramer). This article is based on a keynote address the first author delivered on November 8th, 2019 at the 13th Annual Meeting of Project Air Strategy, University of Wollongong, NSW (Australia).

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Correspondence to Ueli Kramer.

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Hélène Beuchat and Loris Grandjean each declare no potential conflicts of interest.

Ueli Kramer has received a grant from the Swiss National Science Foundation (100014_179457/1).

Antonio Pascual-Leone is a salaried professor at the University of Windsor. Part of his work is the publication of original research. However, his employer has no specific investment in what he publishes, and his salary is unrelated to this particular publication or this particular topic of research.

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Kramer, U., Beuchat, H., Grandjean, L. et al. How Personality Disorders Change in Psychotherapy: a Concise Review of Process. Curr Psychiatry Rep 22, 41 (2020). https://doi.org/10.1007/s11920-020-01162-3

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Keywords

  • Process research
  • Personality disorders
  • Borderline personality disorder
  • Psychotherapy integration
  • Methodology