Merete Johansen - Academia.edu (original) (raw)

Papers by Merete Johansen

Research paper thumbnail of En litteraturviters personlige erfaring med psykoanalyse

Tidsskrift for Den Norske Laegeforening, 2008

Research paper thumbnail of Combined group and individual therapy for patients with avoidant personality disorder—A pilot study

Frontiers in Psychiatry, May 4, 2023

Objective: Avoidant personality disorder (AvPD) is a common disorder within mental health service... more Objective: Avoidant personality disorder (AvPD) is a common disorder within mental health services, associated with significant psychosocial impairment. The disorder has been neglected in research. There are currently no evidence-based treatments for AvPD, and there is a need for treatment studies focusing particularly on this form of personality pathology. The present study was a pilot study of combined group and individual therapy for patients with AvPD, based on mentalization-based and metacognitive interpersonal therapy. The aim was to investigate the feasibility of the treatment program and the course of symptoms and personality functioning during treatment and-year follow-up. Methods: The study included patients. Clinical evaluation at baseline comprised structured diagnostic interviews and patients' self-report of symptoms, psychosocial function, interpersonal problems, personality functioning, alexithymia, self-esteem, attachment style, therapeutic alliance, and client satisfaction. Patients' self-report were repeated at the end of treatment and-year follow-up. Results: The drop-out rate was %. Average treatment length among the treatment completers was months. Mean levels of therapeutic alliance and client satisfaction were satisfactory. E ect sizes were large for global symptom distress, depression, anxiety, and psychosocial adjustment, and in the moderate range for aspects of personality functioning. Yet, the results showed a wide range of outcomes among the patients. Conclusions: This pilot study shows promising results for combined group-and individual therapy for AvPD patients with moderate to severe impairment. Larger scale studies should be conducted to increase empirically based knowledge to guide development of di erentiated treatments adapted to patients' various levels of AvPD severity and profiles of personality dysfunction.

Research paper thumbnail of An investigation of the prototype validity of the borderline DSM-IV construct

Acta Psychiatrica Scandinavica, Apr 1, 2004

Objective: To investigate the prototype validity of the borderline personality disorder (BPD) DS... more Objective: To investigate the prototype validity of the borderline personality disorder (BPD) DSM‐IV construct.Method: Patients (n = 930) from the Norwegian Network of Psychotherapeutic Day Hospitals. Exploratory/confirmatory factor analyses, correlation and reliability statistics, chi‐square, and frequency distributions.Results: Number of BPD criteria showed no distinct threshold between No‐BPD and BPD patients among whom 136 different combinations of criteria occurred. Both factor analyses supported that one component/latent variable accounted for the variance of the BPD criteria, showing a high convergent and discriminant validity. The criterion of unstable relationships displayed the highest diagnostic efficiency, and that of chronic feelings of emptiness the lowest.Conclusion: The prototype theoretical model for BPD fitted the data well and appeared to be satisfactory described by the current criteria. The emptiness criterion needs a more appropriate definition and the hierarchy of the criteria in DSM‐IV should be revised.

Research paper thumbnail of A borderline focused Reflective Functioning measure – Interrater reliability of the Mentalization Breakdown Interview

Nordic Journal of Psychiatry

Research paper thumbnail of Avoidant and borderline personality disorder patients during the first Covid-19 wave in Norway – a survey-based comparison of therapy changes and patients’ accommodations

Nordic Journal of Psychiatry

Research paper thumbnail of Vulnerability of personality disorder during COVID-19 crises: a multicenter survey of mental and social distress among patients referred to treatment

Nordic Journal of Psychiatry, 2021

På de neste sidene finner du spørsmål om hvordan du har det på ulike områder, og hvordan koronasi... more På de neste sidene finner du spørsmål om hvordan du har det på ulike områder, og hvordan koronasituasjonen har påvirket deg. Vi regner her starten på koronakrisen i Norge til 12. mars, siden dette er datoen da det ble innført en rekke begrensninger. Spørsmålene under besvares på tre ulike måter. Det ene er der du setter kryss i de firkanter som passer, det andre er der du setter en ring rundt tallet til venstre for svaralternativet, og det tredje er fritekst der du beskriver med egne ord. Områdene med fritekst er lagt til for å gi deg mulighet til å utdype svarene hvis du vil. Spørreundersøkelsen vil gi verdifull informasjon selv om du ikke skriver i disse feltene. Denne spørreundersøkelsen er anonym, og det er derfor viktig at du ikke skriver noe i de åpne tekstfeltene som kan identifisere deg, eller som gir opplysninger om hvor du går i behandling.

Research paper thumbnail of Development of therapeutic alliance in mentalization-based treatment—Goals, Bonds, and Tasks in a specialized treatment for borderline personality disorder

Psychotherapy Research, 2020

Objective: Mentalization-based treatment (MBT) is an evidence-based long-term treatment for borde... more Objective: Mentalization-based treatment (MBT) is an evidence-based long-term treatment for borderline personality disorder (BPD). Alliance is central for effective psychotherapies. Few studies have addressed aspects of working alliance in BPD evidencebased treatments. This study aimed to investigate alliance development in MBT therapies with different clinical outcomes. Method: The sample included 155 patients in an MBT programme. Clinical outcomes were based on Global Assessment of Functioning (GAF). The sample was divided in two subgroups according to GAF levels at the end of treatment (cut-off = 60). Working alliance was assessed by patient report (Working Alliance Inventory, subscales, Goals, Bonds and Tasks) and assessed repeatedly over 36 months. The method for statistical analyses was linear mixed models. Results: Initial levels of Goals, Bonds, and Tasks did not differ by subgroup, but change over time differed significantly by subgroup. In the good outcome subgroup, ratings of Goals, Bonds, and especially Tasks increased significantly over time. In the poor outcome subgroup, paranoid PD was associated with poorer alliance development over time. Conclusions: Good outcome therapies were characterized by a process where the working alliance grew over time. Results encourage an explicit focus on tasks in therapy particularly for patients with high levels of mistrust.

Research paper thumbnail of Patients with Borderline and Avoidant Personality Disorders in the Pandemic Their Mental Distress During the Covid-19 Crisis in Norway

Background Even if people with mental disorders are vulnerable, few authors have studied patients... more Background Even if people with mental disorders are vulnerable, few authors have studied patients with personality disorders (PDs) in the pandemic. We wanted to examine and compare mental and social distress among patients with borderline PD (BPD) and avoidant PD (AvPD) during the first wave of Covid-19. Methods In Summer 2020 a survey was distributed to 1120 patients referred to PD treatment units in Norway, with questions on social situation, mental distress, and changes in mental health after the lockdown. Among 133 responders we studied 40 patients with BPD and 30 with AvPD as their only PD. Results 70% of the patients in both groups were more alone than before the pandemic, more than 40% felt lonelier, and 50% more aggressive. Both PD groups reported high levels of depression and anxiety, many with suicidal thoughts, and worries about health issues. Several BPD patients reported an improvement in some issues compared to the AvPD patients, with more initiative and energy. Conclu...

Research paper thumbnail of Mentalization as a moderator of treatment effects: Findings from a randomized clinical trial for personality disorders

Psychotherapy Research, 2013

Mentalization is the capacity to understand behavior as expressions of various mental states. It ... more Mentalization is the capacity to understand behavior as expressions of various mental states. It is assumed to be important for understanding the underlying psychopathology, the therapeutic process, and the outcome of therapy associated with patients with personality disorders (PDs). However, to date, empirical findings are scarce and inconsistent. This study aimed to examine whether the pre-treatment level of mentalization, operationalized as Reflective Functioning (RF), was associated with differential responses to two different treatment modalities and might predict clinical improvement. We analyzed data from a randomized clinical trial (Ullevål Personality Project). Seventy-eight patients with borderline and/or avoidant PD had been randomly assigned to either a step-down treatment program or outpatient individual psychotherapy. The step-down treatment comprised short-term day hospital treatment, followed by long-term, combined group and individual psychotherapy. RF was rated before treatment and after 36 months. Outcome measures were administered at baseline and after 8, 18, and 36 months. The moderator analyses indicated that patients with low RF levels at baseline responded better to outpatient individual psychotherapy than to the step-down treatment in terms of improvements in psychosocial functioning. Patients with medium-high RF levels responded equally well to both therapy formats. Determining which therapy format is appropriate for specific groups of patients can improve treatment efficiency. Therefore, our findings may have important clinical implications. Future research should address RF as a mediator of change.

Research paper thumbnail of Is treatment in a day hospital step-down program superior to outpatient individual psychotherapy for patients with personality disorders? 36 months follow-up of a randomized clinical trial comparing different treatment modalities

Psychotherapy Research, 2012

Despite increasing interest in the development of effective treatments for patients with PDs, the... more Despite increasing interest in the development of effective treatments for patients with PDs, there is still no consensus about the optimal treatment setting for this group of patients. This study reports the 36 months follow-up of the Ullevål Personality Project (UPP) (n=113), a randomized clinical trial comparing two treatment modalities for patients with PDs: an intensive long-term step-down treatment program, consisting of short-term day hospital treatment followed by combined group and individual psychotherapy organized in a hospital setting, with "ordinary" outpatient individual psychotherapy in private practice for patients with moderate to severe PDs. Patients in both treatment groups showed improvements in several clinical measures after 36 months. However, contrary to our expectations, patients in the outpatient treatment setting improved significantly more. Possible explanations for this surprising finding are discussed. The study cannot exclude the possibility that treatment aspects other than differences in modalities could explain some of the differential effectiveness (e.g. differences between therapists).

Research paper thumbnail of Psychotherapy for Personality Disorders: 18 Months' Follow-Up of the Ullevål Personality Project

Journal of Personality Disorders, 2010

The Ullevål Personality Project is a randomized controlled trial (N = 114) initiated as a respons... more The Ullevål Personality Project is a randomized controlled trial (N = 114) initiated as a response to the limited evidence justifying provision of day hospital treatment for patients with personality disorders (PDs). A step-down model (CP) consisting of initial short-term day hospital treatment followed by conjoint group and individual outpatient treatment was compared with outpatient individual psychotherapy (OIP). The patients were evaluated at baseline, 8 months, and 18 months on a wide range of clinical measures assessing symptoms, interpersonal problems, psychosocial functioning, and personality pathology. This study indicates that eclectic psychotherapy provided by private practitioners has at least as good an effect upon personality-disordered patients as a more comprehensive day hospital and outpatient follow-up treatment. However, this study has to be supplemented with a cost-benefit analysis before any consideration of implications for health care planning.

Research paper thumbnail of Psychotherapy for personality disorders: Short-term day hospital psychotherapy versus outpatient individual therapy – a randomized controlled study

European Psychiatry, 2009

This article describes the results of an eight-month follow-up investigation from a randomized co... more This article describes the results of an eight-month follow-up investigation from a randomized controlled trial of day hospital psychotherapy (DHP) compared with outpatient individual psychotherapy (OIP) for patients with personality disorders (N = 114). The patients were randomly assigned to either 18 weeks of day hospital treatment followed by long-term conjoint group and individual therapy (DHP), or outpatient individual psychotherapy (OIP). The main outcome measures were attrition rate, suicide attempts, suicidal thoughts, self-injury, psychosocial functioning, symptom distress, and interpersonal and personality problems. The study showed a low dropout rate and a moderate improvement on a broad range of clinical measures for both treatments. However, there was no indication of the superiority of one treatment over the other. Neither was there any indication that day hospital treatment was better for the most poorly functioning patients. Further studies will follow this group of ...

Research paper thumbnail of Is low affect consciousness related to the severity of psychopathology? A cross-sectional study of patients with avoidant and borderline personality disorder

Comprehensive Psychiatry, 2013

This study examined the relationships between affect consciousness (AC) and symptom distress, int... more This study examined the relationships between affect consciousness (AC) and symptom distress, interpersonal problems, low self-esteem, and the number of PD traits in patients with avoidant personality disorder (APD) and borderline personality disorder (BPD). Within the setting of a treatment trial, 52 patients with APD or BPD were examined with structured interviews and self-report questionnaires before treatment and at 3-year follow-up. The evaluations included the Affect Consciousness Interview, the SCID-II interview, the Symptom Checklist 90-R, the Circumplex of Interpersonal Problems, and the Index of Self-esteem. A low global level of AC was expected to be associated with the severity of psychopathology; a low AC for interest, joy, and tenderness was expected to be associated with social detachment; and a low AC for anger, contempt, and disgust was expected to be associated with nonassertiveness. A low AC was associated with interpersonal problems and low self-esteem, but not symptom distress or the number of fulfilled SCID-II criteria. Despite a significant reduction in the psychopathology based on most clinical variables, the associations measured at baseline were maintained after 3years. Examination of specific affect categories showed a pattern of convergent and discriminative relationships with different types of interpersonal problems. A low AC for pleasant affects was specifically related to communion problems, like cold, detached behavior, both at baseline and follow-up. In contrast, a low AC for self-boundary affects was specifically related to agency problems, like non-assertiveness, at follow-up. Our results showed that a low AC was associated with central domains of psychopathology in patients with PDs. This suggested that AC would be an important focus for treatment and further research in PDs. Future studies are needed to examine how AC is related to various forms of personality pathology.

Research paper thumbnail of Step-down versus outpatient psychotherapeutic treatment for personality disorders: 6-year follow-up of the Ulleval personality project

Research paper thumbnail of The MBT Adherence and Competence Scale (MBT-ACS): Development, structure and reliability

Psychotherapy Research, 2013

This article may be used for research, teaching, and private study purposes. Any substantial or s... more This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. The publisher does not give any warranty express or implied or make any representation that the contents will be complete or accurate or up to date. The accuracy of any instructions, formulae, and drug doses should be independently verified with primary sources. The publisher shall not be liable for any loss, actions, claims, proceedings, demand, or costs or damages whatsoever or howsoever caused arising directly or indirectly in connection with or arising out of the use of this material.

Research paper thumbnail of The Relationship Between Reflective Functioning and Affect Consciousness in Patients With Avoidant and Borderline Personality Disorders

Psychoanalytic Psychology, 2018

Avoidant personality disorder (APD) and borderline personality disorder (BPD) are the most freque... more Avoidant personality disorder (APD) and borderline personality disorder (BPD) are the most frequent personality disorders (PDs) in clinical practice. Although BPD research dominates the field, both PDs are clearly associated with severe functional impairments and substantial treatment challenges. Few have investigated the relationship between core personality vulnerabilities across PDs. However, such research has high clinical relevance, could expand our understanding of the distinct nature of the disorders, and thus have important therapeutic implications. Central PD vulnerabilities have been conceptualized in two, possibly overlapping, constructs: mentalization and affect consciousness (AC). The interrelationship between mentalizing and AC and PD specific differences are, as yet, not well established. The present study investigated the relationship between mentalizing capacity and AC among 73 treatment-seeking patients with APD and/or BPD, 81% females. Mentalization was measured b...

Research paper thumbnail of “Yes, there is actually hope!”—A qualitative investigation of how patients experience mentalization-based psychoeducation tailored for borderline personality disorder

Journal of Psychotherapy Integration

Research paper thumbnail of Mentalization-based treatment or psychodynamic treatment programmes for patients with borderline personality disorder - the impact of clinical severity

Psychology and Psychotherapy: Theory, Research and Practice

Objectives. Mentalization-based treatment (MBT), originally designed for patients with borderline... more Objectives. Mentalization-based treatment (MBT), originally designed for patients with borderline personality disorder (BPD), may be particularly indicated for severe conditions. However, there is limited documentation of how increasing severity of personality disorder (PD) effect outcomes of highly specialized treatments. This study aimed to investigate associations between clinical severity and outcomes for patients in MBT as compared to a psychodynamic group-based treatment programme (PDT). Design. A naturalistic, longitudinal, comparison study. Methods. The sample included 345 patients with BPD (PDT n = 281, MBT n = 64). The number of diagnosed PDs, PD criteria, and symptom disorders were chosen as baseline indicators of clinical severity. Clinical outcomes (global functioning, symptom distress, interpersonal problems) were repeatedly assessed over three years. Therapists' fidelity to MBT was satisfactory. Linear mixed models were the applied statistics. Results. In PDT, greater clinical severity was associated with poorer improvement rates. Clinical severity was not associated with significant differences in outcomes for patients in MBT. Differences in outcomes for patients in MBT and PDT increased significantly with higher severity of disorder. Conclusions. Supporting previous research, this study indicates that clinical benefits associated with MBT also apply for BPD patients with severe conditions. The results also suggest that increasing severity was a challenge in PDT. Practitioner points MBT may be particularly beneficial for severely disordered BPD patients Differences between MBT and PDT were less pronounced in moderately disordered BPD patients. This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.

Research paper thumbnail of Primary emotional traits in patients with personality disorders

Personality and Mental Health, 2016

There is a longstanding tradition that connects temperament pathology and personality disorders. ... more There is a longstanding tradition that connects temperament pathology and personality disorders. Emotions are the major constituents of temperament. In mammals, seven primary emotions have been identified: SEEKING, FEAR, CARE, RAGE, SADNESS/PANIC, LUST and PLAY. The study aimed at exploring the relationship between primary emotions and personality disorders (PDs). Five hundred forty-six patients with different degrees and qualities of personality pathology, admitted to treatment in specialized PD services, were diagnosed according to Structured Clinical Interview for DSM-IV Axis II Personality Disorders, and their primary emotional profiles were assessed by the Affective Neuroscience Personality Scales. The Affective Neuroscience Personality Scales explained 19% of the variance in borderline and avoidant criteria. The DSM-IV PD categories displayed different patterns of association to the primary emotions, e.g. the borderline PD profile suggested low thresholds for RAGE and SADNESS, but on the positive side a propensity for SEEKING. In contrast, the dependent PD profile suggested a low threshold for SADNESS but a high threshold for RAGE and SEEKING. The results are promising for a more coherent and evolution-based overall theory of PDs, and the correlations found in this study indicate testable causal pathways to PDs. Copyright © 2016 John Wiley & Sons, Ltd.

Research paper thumbnail of Personality Disorder and Changes in Affect Consciousness: A 3-Year Follow-Up Study of Patients with Avoidant and Borderline Personality Disorder

PLOS ONE, 2015

Personality disorders (PDs) are highly prevalent in patients receiving psychiatric services, and ... more Personality disorders (PDs) are highly prevalent in patients receiving psychiatric services, and are associated with significant personal and social costs. Over the past two decades, an increasing number of treatment studies have documented the effectiveness of treatment for patients with PDs, especially when it comes to reduction of symptom distress, risk taking behavior, self-harm, or suicide attempts. However, less is known about the more complex aims of improving the personality structure itself, such as identity-and interpersonal disturbances. Emotional dysfunction is closely associated with PD pathology. The present study investigated changes in affect consciousness (AC) in patients with avoidant or borderline PD, and how these changes were associated with clinical status after 3 years of follow-up. The study included 52 individuals; 79 percent were females, and mean age was 30 years. The evaluations included the Affect Consciousness Interview, Symptom Checklist-90-R, Circumplex of Interpersonal Problems, the Index of Self-Esteem, and three domains (Identity Integration, Relational Capacities, and Self-Control) of the Severity Indices of Personality Problems (SIPP-118). There was a significant increase in the Global AC and AC scores for most of the specific affects from baseline to follow-up. As the present study did not include a control group, it cannot be concluded that changes in AC are effects of psychotherapy, and the possibility of age-related maturation processes cannot be excluded. The change in Global AC contributed significantly to explained variance in the follow-up levels of Circumplex of Interpersonal Problems, and the two SIPP-118 domains Relational Capacities and Identity Integration. Improved AC was not associated with change in the Self-Control domain or the Global Severity Index of Symptom Checklist-90-R. The results suggest that AC may be altered for patients with borderline and avoidant PDs, and this is the first

Research paper thumbnail of En litteraturviters personlige erfaring med psykoanalyse

Tidsskrift for Den Norske Laegeforening, 2008

Research paper thumbnail of Combined group and individual therapy for patients with avoidant personality disorder—A pilot study

Frontiers in Psychiatry, May 4, 2023

Objective: Avoidant personality disorder (AvPD) is a common disorder within mental health service... more Objective: Avoidant personality disorder (AvPD) is a common disorder within mental health services, associated with significant psychosocial impairment. The disorder has been neglected in research. There are currently no evidence-based treatments for AvPD, and there is a need for treatment studies focusing particularly on this form of personality pathology. The present study was a pilot study of combined group and individual therapy for patients with AvPD, based on mentalization-based and metacognitive interpersonal therapy. The aim was to investigate the feasibility of the treatment program and the course of symptoms and personality functioning during treatment and-year follow-up. Methods: The study included patients. Clinical evaluation at baseline comprised structured diagnostic interviews and patients' self-report of symptoms, psychosocial function, interpersonal problems, personality functioning, alexithymia, self-esteem, attachment style, therapeutic alliance, and client satisfaction. Patients' self-report were repeated at the end of treatment and-year follow-up. Results: The drop-out rate was %. Average treatment length among the treatment completers was months. Mean levels of therapeutic alliance and client satisfaction were satisfactory. E ect sizes were large for global symptom distress, depression, anxiety, and psychosocial adjustment, and in the moderate range for aspects of personality functioning. Yet, the results showed a wide range of outcomes among the patients. Conclusions: This pilot study shows promising results for combined group-and individual therapy for AvPD patients with moderate to severe impairment. Larger scale studies should be conducted to increase empirically based knowledge to guide development of di erentiated treatments adapted to patients' various levels of AvPD severity and profiles of personality dysfunction.

Research paper thumbnail of An investigation of the prototype validity of the borderline DSM-IV construct

Acta Psychiatrica Scandinavica, Apr 1, 2004

Objective: To investigate the prototype validity of the borderline personality disorder (BPD) DS... more Objective: To investigate the prototype validity of the borderline personality disorder (BPD) DSM‐IV construct.Method: Patients (n = 930) from the Norwegian Network of Psychotherapeutic Day Hospitals. Exploratory/confirmatory factor analyses, correlation and reliability statistics, chi‐square, and frequency distributions.Results: Number of BPD criteria showed no distinct threshold between No‐BPD and BPD patients among whom 136 different combinations of criteria occurred. Both factor analyses supported that one component/latent variable accounted for the variance of the BPD criteria, showing a high convergent and discriminant validity. The criterion of unstable relationships displayed the highest diagnostic efficiency, and that of chronic feelings of emptiness the lowest.Conclusion: The prototype theoretical model for BPD fitted the data well and appeared to be satisfactory described by the current criteria. The emptiness criterion needs a more appropriate definition and the hierarchy of the criteria in DSM‐IV should be revised.

Research paper thumbnail of A borderline focused Reflective Functioning measure – Interrater reliability of the Mentalization Breakdown Interview

Nordic Journal of Psychiatry

Research paper thumbnail of Avoidant and borderline personality disorder patients during the first Covid-19 wave in Norway – a survey-based comparison of therapy changes and patients’ accommodations

Nordic Journal of Psychiatry

Research paper thumbnail of Vulnerability of personality disorder during COVID-19 crises: a multicenter survey of mental and social distress among patients referred to treatment

Nordic Journal of Psychiatry, 2021

På de neste sidene finner du spørsmål om hvordan du har det på ulike områder, og hvordan koronasi... more På de neste sidene finner du spørsmål om hvordan du har det på ulike områder, og hvordan koronasituasjonen har påvirket deg. Vi regner her starten på koronakrisen i Norge til 12. mars, siden dette er datoen da det ble innført en rekke begrensninger. Spørsmålene under besvares på tre ulike måter. Det ene er der du setter kryss i de firkanter som passer, det andre er der du setter en ring rundt tallet til venstre for svaralternativet, og det tredje er fritekst der du beskriver med egne ord. Områdene med fritekst er lagt til for å gi deg mulighet til å utdype svarene hvis du vil. Spørreundersøkelsen vil gi verdifull informasjon selv om du ikke skriver i disse feltene. Denne spørreundersøkelsen er anonym, og det er derfor viktig at du ikke skriver noe i de åpne tekstfeltene som kan identifisere deg, eller som gir opplysninger om hvor du går i behandling.

Research paper thumbnail of Development of therapeutic alliance in mentalization-based treatment—Goals, Bonds, and Tasks in a specialized treatment for borderline personality disorder

Psychotherapy Research, 2020

Objective: Mentalization-based treatment (MBT) is an evidence-based long-term treatment for borde... more Objective: Mentalization-based treatment (MBT) is an evidence-based long-term treatment for borderline personality disorder (BPD). Alliance is central for effective psychotherapies. Few studies have addressed aspects of working alliance in BPD evidencebased treatments. This study aimed to investigate alliance development in MBT therapies with different clinical outcomes. Method: The sample included 155 patients in an MBT programme. Clinical outcomes were based on Global Assessment of Functioning (GAF). The sample was divided in two subgroups according to GAF levels at the end of treatment (cut-off = 60). Working alliance was assessed by patient report (Working Alliance Inventory, subscales, Goals, Bonds and Tasks) and assessed repeatedly over 36 months. The method for statistical analyses was linear mixed models. Results: Initial levels of Goals, Bonds, and Tasks did not differ by subgroup, but change over time differed significantly by subgroup. In the good outcome subgroup, ratings of Goals, Bonds, and especially Tasks increased significantly over time. In the poor outcome subgroup, paranoid PD was associated with poorer alliance development over time. Conclusions: Good outcome therapies were characterized by a process where the working alliance grew over time. Results encourage an explicit focus on tasks in therapy particularly for patients with high levels of mistrust.

Research paper thumbnail of Patients with Borderline and Avoidant Personality Disorders in the Pandemic Their Mental Distress During the Covid-19 Crisis in Norway

Background Even if people with mental disorders are vulnerable, few authors have studied patients... more Background Even if people with mental disorders are vulnerable, few authors have studied patients with personality disorders (PDs) in the pandemic. We wanted to examine and compare mental and social distress among patients with borderline PD (BPD) and avoidant PD (AvPD) during the first wave of Covid-19. Methods In Summer 2020 a survey was distributed to 1120 patients referred to PD treatment units in Norway, with questions on social situation, mental distress, and changes in mental health after the lockdown. Among 133 responders we studied 40 patients with BPD and 30 with AvPD as their only PD. Results 70% of the patients in both groups were more alone than before the pandemic, more than 40% felt lonelier, and 50% more aggressive. Both PD groups reported high levels of depression and anxiety, many with suicidal thoughts, and worries about health issues. Several BPD patients reported an improvement in some issues compared to the AvPD patients, with more initiative and energy. Conclu...

Research paper thumbnail of Mentalization as a moderator of treatment effects: Findings from a randomized clinical trial for personality disorders

Psychotherapy Research, 2013

Mentalization is the capacity to understand behavior as expressions of various mental states. It ... more Mentalization is the capacity to understand behavior as expressions of various mental states. It is assumed to be important for understanding the underlying psychopathology, the therapeutic process, and the outcome of therapy associated with patients with personality disorders (PDs). However, to date, empirical findings are scarce and inconsistent. This study aimed to examine whether the pre-treatment level of mentalization, operationalized as Reflective Functioning (RF), was associated with differential responses to two different treatment modalities and might predict clinical improvement. We analyzed data from a randomized clinical trial (Ullevål Personality Project). Seventy-eight patients with borderline and/or avoidant PD had been randomly assigned to either a step-down treatment program or outpatient individual psychotherapy. The step-down treatment comprised short-term day hospital treatment, followed by long-term, combined group and individual psychotherapy. RF was rated before treatment and after 36 months. Outcome measures were administered at baseline and after 8, 18, and 36 months. The moderator analyses indicated that patients with low RF levels at baseline responded better to outpatient individual psychotherapy than to the step-down treatment in terms of improvements in psychosocial functioning. Patients with medium-high RF levels responded equally well to both therapy formats. Determining which therapy format is appropriate for specific groups of patients can improve treatment efficiency. Therefore, our findings may have important clinical implications. Future research should address RF as a mediator of change.

Research paper thumbnail of Is treatment in a day hospital step-down program superior to outpatient individual psychotherapy for patients with personality disorders? 36 months follow-up of a randomized clinical trial comparing different treatment modalities

Psychotherapy Research, 2012

Despite increasing interest in the development of effective treatments for patients with PDs, the... more Despite increasing interest in the development of effective treatments for patients with PDs, there is still no consensus about the optimal treatment setting for this group of patients. This study reports the 36 months follow-up of the Ullevål Personality Project (UPP) (n=113), a randomized clinical trial comparing two treatment modalities for patients with PDs: an intensive long-term step-down treatment program, consisting of short-term day hospital treatment followed by combined group and individual psychotherapy organized in a hospital setting, with "ordinary" outpatient individual psychotherapy in private practice for patients with moderate to severe PDs. Patients in both treatment groups showed improvements in several clinical measures after 36 months. However, contrary to our expectations, patients in the outpatient treatment setting improved significantly more. Possible explanations for this surprising finding are discussed. The study cannot exclude the possibility that treatment aspects other than differences in modalities could explain some of the differential effectiveness (e.g. differences between therapists).

Research paper thumbnail of Psychotherapy for Personality Disorders: 18 Months' Follow-Up of the Ullevål Personality Project

Journal of Personality Disorders, 2010

The Ullevål Personality Project is a randomized controlled trial (N = 114) initiated as a respons... more The Ullevål Personality Project is a randomized controlled trial (N = 114) initiated as a response to the limited evidence justifying provision of day hospital treatment for patients with personality disorders (PDs). A step-down model (CP) consisting of initial short-term day hospital treatment followed by conjoint group and individual outpatient treatment was compared with outpatient individual psychotherapy (OIP). The patients were evaluated at baseline, 8 months, and 18 months on a wide range of clinical measures assessing symptoms, interpersonal problems, psychosocial functioning, and personality pathology. This study indicates that eclectic psychotherapy provided by private practitioners has at least as good an effect upon personality-disordered patients as a more comprehensive day hospital and outpatient follow-up treatment. However, this study has to be supplemented with a cost-benefit analysis before any consideration of implications for health care planning.

Research paper thumbnail of Psychotherapy for personality disorders: Short-term day hospital psychotherapy versus outpatient individual therapy – a randomized controlled study

European Psychiatry, 2009

This article describes the results of an eight-month follow-up investigation from a randomized co... more This article describes the results of an eight-month follow-up investigation from a randomized controlled trial of day hospital psychotherapy (DHP) compared with outpatient individual psychotherapy (OIP) for patients with personality disorders (N = 114). The patients were randomly assigned to either 18 weeks of day hospital treatment followed by long-term conjoint group and individual therapy (DHP), or outpatient individual psychotherapy (OIP). The main outcome measures were attrition rate, suicide attempts, suicidal thoughts, self-injury, psychosocial functioning, symptom distress, and interpersonal and personality problems. The study showed a low dropout rate and a moderate improvement on a broad range of clinical measures for both treatments. However, there was no indication of the superiority of one treatment over the other. Neither was there any indication that day hospital treatment was better for the most poorly functioning patients. Further studies will follow this group of ...

Research paper thumbnail of Is low affect consciousness related to the severity of psychopathology? A cross-sectional study of patients with avoidant and borderline personality disorder

Comprehensive Psychiatry, 2013

This study examined the relationships between affect consciousness (AC) and symptom distress, int... more This study examined the relationships between affect consciousness (AC) and symptom distress, interpersonal problems, low self-esteem, and the number of PD traits in patients with avoidant personality disorder (APD) and borderline personality disorder (BPD). Within the setting of a treatment trial, 52 patients with APD or BPD were examined with structured interviews and self-report questionnaires before treatment and at 3-year follow-up. The evaluations included the Affect Consciousness Interview, the SCID-II interview, the Symptom Checklist 90-R, the Circumplex of Interpersonal Problems, and the Index of Self-esteem. A low global level of AC was expected to be associated with the severity of psychopathology; a low AC for interest, joy, and tenderness was expected to be associated with social detachment; and a low AC for anger, contempt, and disgust was expected to be associated with nonassertiveness. A low AC was associated with interpersonal problems and low self-esteem, but not symptom distress or the number of fulfilled SCID-II criteria. Despite a significant reduction in the psychopathology based on most clinical variables, the associations measured at baseline were maintained after 3years. Examination of specific affect categories showed a pattern of convergent and discriminative relationships with different types of interpersonal problems. A low AC for pleasant affects was specifically related to communion problems, like cold, detached behavior, both at baseline and follow-up. In contrast, a low AC for self-boundary affects was specifically related to agency problems, like non-assertiveness, at follow-up. Our results showed that a low AC was associated with central domains of psychopathology in patients with PDs. This suggested that AC would be an important focus for treatment and further research in PDs. Future studies are needed to examine how AC is related to various forms of personality pathology.

Research paper thumbnail of Step-down versus outpatient psychotherapeutic treatment for personality disorders: 6-year follow-up of the Ulleval personality project

Research paper thumbnail of The MBT Adherence and Competence Scale (MBT-ACS): Development, structure and reliability

Psychotherapy Research, 2013

This article may be used for research, teaching, and private study purposes. Any substantial or s... more This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. The publisher does not give any warranty express or implied or make any representation that the contents will be complete or accurate or up to date. The accuracy of any instructions, formulae, and drug doses should be independently verified with primary sources. The publisher shall not be liable for any loss, actions, claims, proceedings, demand, or costs or damages whatsoever or howsoever caused arising directly or indirectly in connection with or arising out of the use of this material.

Research paper thumbnail of The Relationship Between Reflective Functioning and Affect Consciousness in Patients With Avoidant and Borderline Personality Disorders

Psychoanalytic Psychology, 2018

Avoidant personality disorder (APD) and borderline personality disorder (BPD) are the most freque... more Avoidant personality disorder (APD) and borderline personality disorder (BPD) are the most frequent personality disorders (PDs) in clinical practice. Although BPD research dominates the field, both PDs are clearly associated with severe functional impairments and substantial treatment challenges. Few have investigated the relationship between core personality vulnerabilities across PDs. However, such research has high clinical relevance, could expand our understanding of the distinct nature of the disorders, and thus have important therapeutic implications. Central PD vulnerabilities have been conceptualized in two, possibly overlapping, constructs: mentalization and affect consciousness (AC). The interrelationship between mentalizing and AC and PD specific differences are, as yet, not well established. The present study investigated the relationship between mentalizing capacity and AC among 73 treatment-seeking patients with APD and/or BPD, 81% females. Mentalization was measured b...

Research paper thumbnail of “Yes, there is actually hope!”—A qualitative investigation of how patients experience mentalization-based psychoeducation tailored for borderline personality disorder

Journal of Psychotherapy Integration

Research paper thumbnail of Mentalization-based treatment or psychodynamic treatment programmes for patients with borderline personality disorder - the impact of clinical severity

Psychology and Psychotherapy: Theory, Research and Practice

Objectives. Mentalization-based treatment (MBT), originally designed for patients with borderline... more Objectives. Mentalization-based treatment (MBT), originally designed for patients with borderline personality disorder (BPD), may be particularly indicated for severe conditions. However, there is limited documentation of how increasing severity of personality disorder (PD) effect outcomes of highly specialized treatments. This study aimed to investigate associations between clinical severity and outcomes for patients in MBT as compared to a psychodynamic group-based treatment programme (PDT). Design. A naturalistic, longitudinal, comparison study. Methods. The sample included 345 patients with BPD (PDT n = 281, MBT n = 64). The number of diagnosed PDs, PD criteria, and symptom disorders were chosen as baseline indicators of clinical severity. Clinical outcomes (global functioning, symptom distress, interpersonal problems) were repeatedly assessed over three years. Therapists' fidelity to MBT was satisfactory. Linear mixed models were the applied statistics. Results. In PDT, greater clinical severity was associated with poorer improvement rates. Clinical severity was not associated with significant differences in outcomes for patients in MBT. Differences in outcomes for patients in MBT and PDT increased significantly with higher severity of disorder. Conclusions. Supporting previous research, this study indicates that clinical benefits associated with MBT also apply for BPD patients with severe conditions. The results also suggest that increasing severity was a challenge in PDT. Practitioner points MBT may be particularly beneficial for severely disordered BPD patients Differences between MBT and PDT were less pronounced in moderately disordered BPD patients. This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.

Research paper thumbnail of Primary emotional traits in patients with personality disorders

Personality and Mental Health, 2016

There is a longstanding tradition that connects temperament pathology and personality disorders. ... more There is a longstanding tradition that connects temperament pathology and personality disorders. Emotions are the major constituents of temperament. In mammals, seven primary emotions have been identified: SEEKING, FEAR, CARE, RAGE, SADNESS/PANIC, LUST and PLAY. The study aimed at exploring the relationship between primary emotions and personality disorders (PDs). Five hundred forty-six patients with different degrees and qualities of personality pathology, admitted to treatment in specialized PD services, were diagnosed according to Structured Clinical Interview for DSM-IV Axis II Personality Disorders, and their primary emotional profiles were assessed by the Affective Neuroscience Personality Scales. The Affective Neuroscience Personality Scales explained 19% of the variance in borderline and avoidant criteria. The DSM-IV PD categories displayed different patterns of association to the primary emotions, e.g. the borderline PD profile suggested low thresholds for RAGE and SADNESS, but on the positive side a propensity for SEEKING. In contrast, the dependent PD profile suggested a low threshold for SADNESS but a high threshold for RAGE and SEEKING. The results are promising for a more coherent and evolution-based overall theory of PDs, and the correlations found in this study indicate testable causal pathways to PDs. Copyright © 2016 John Wiley & Sons, Ltd.

Research paper thumbnail of Personality Disorder and Changes in Affect Consciousness: A 3-Year Follow-Up Study of Patients with Avoidant and Borderline Personality Disorder

PLOS ONE, 2015

Personality disorders (PDs) are highly prevalent in patients receiving psychiatric services, and ... more Personality disorders (PDs) are highly prevalent in patients receiving psychiatric services, and are associated with significant personal and social costs. Over the past two decades, an increasing number of treatment studies have documented the effectiveness of treatment for patients with PDs, especially when it comes to reduction of symptom distress, risk taking behavior, self-harm, or suicide attempts. However, less is known about the more complex aims of improving the personality structure itself, such as identity-and interpersonal disturbances. Emotional dysfunction is closely associated with PD pathology. The present study investigated changes in affect consciousness (AC) in patients with avoidant or borderline PD, and how these changes were associated with clinical status after 3 years of follow-up. The study included 52 individuals; 79 percent were females, and mean age was 30 years. The evaluations included the Affect Consciousness Interview, Symptom Checklist-90-R, Circumplex of Interpersonal Problems, the Index of Self-Esteem, and three domains (Identity Integration, Relational Capacities, and Self-Control) of the Severity Indices of Personality Problems (SIPP-118). There was a significant increase in the Global AC and AC scores for most of the specific affects from baseline to follow-up. As the present study did not include a control group, it cannot be concluded that changes in AC are effects of psychotherapy, and the possibility of age-related maturation processes cannot be excluded. The change in Global AC contributed significantly to explained variance in the follow-up levels of Circumplex of Interpersonal Problems, and the two SIPP-118 domains Relational Capacities and Identity Integration. Improved AC was not associated with change in the Self-Control domain or the Global Severity Index of Symptom Checklist-90-R. The results suggest that AC may be altered for patients with borderline and avoidant PDs, and this is the first