Alliance Ruptures and Resolutions in Personality Disorders

Abstract Purpose of Review This review provides an overview of the state of research on alliance ruptures and resolutions in the treatment of personality disorders (PDs). We discuss frequently used instruments to measure alliance ruptures and resolutions. We discuss the effectiveness of rupture resolution processes and highlight possible avenues for research to explore. Innovative assessments with the potential to reveal the link of ruptures and resolutions and mechanisms of psychotherapeutic change are discussed. Recent Findings The assessment of alliance rupture and resolutions is heterogeneous. Instruments vary largely with respect to a direct or indirect assessment, the time resolution of assessment (integral therapy, phase, session, event), session sampling strategy and perspectives (patient, therapist, observer). The heterogeneity in the instruments and study designs impedes comparability and interpretation of the findings. Results support the hypothesis that ruptures are more frequent in PD. Results also point towards beneficial effects of rupture resolution patterns, early alliance quality, and resolution complexity. Few studies control findings for pretreatment factors. Summary Evidence points to the direction that rupture resolution processes can be considered a general principle of change in the treatment of PD. The concept of alliance ruptures and resolutions provides a useful tool for the management of the therapeutic alliance and its moments of deteriorations throughout the treatment course. Dimensional pretreatment personality functioning is considered a key variable in future studies to highlight what works for whom.

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Repairing Alliance Ruptures

Psychotherapy Relationships that Work ◽

10.1093/med-psych/9780190843953.003.0016 ◽

2019 ◽

pp. 549-579 ◽

Cited By ~ 3

Author(s):

Catherine F. Eubanks ◽

J. Christopher Muran ◽

Jeremy D. Safran

Keyword(s):

Patient Outcome ◽

Confidence Interval ◽

Personality Disorders ◽

Behavioral Therapy ◽

Meta Analysis ◽

Psychodynamic Therapy ◽

Treatment Goals ◽

Rupture Resolution ◽

Alliance Ruptures ◽

The Impact

A rupture is a deterioration in the therapeutic alliance, manifested by a disagreement between the patient and therapist on treatment goals, a lack of collaboration on therapeutic tasks, or a strain in their emotional bond. This chapter presents the most frequently used measures of alliance ruptures and clinical examples to illustrate their repair. To examine the relation of rupture repairs to outcome, the authors conducted a meta-analysis on 11 studies (1,314 patients) that compared the treatment outcomes of patients with rupture-repair episodes to those of patients with unrepaired ruptures. Results yielded an effect size of r = .29, d =.62, 95% confidence interval [.10, .47], p =.003, indicating a moderate relation between rupture resolution and positive patient outcome. To examine the impact of rupture resolution training or supervision on patient outcome, the authors examined 6 studies (276 trainees/supervisees) that compared the outcomes of trainees who received rupture resolution training with a comparison group. Results did not find a significant relation, r = .11, d = .22, 95% confidence interval [-.09, .30], p = .28. Moderator analyses indicated that the relation between training and outcome was stronger when the sample included fewer patients with personality disorders, when the training was more closely aligned with cognitive behavioral therapy than psychodynamic therapy, and when the treatment was brief. The chapter concludes with limitations of the research, diversity considerations, and research-informed therapeutic practices for repairing ruptures in ways that contribute to good outcome in therapy.

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The Relationship between Affect Integration and Psychopathology in Patients with Personality Disorder: A Cross-Sectional Study

Medicina ◽

10.3390/medicina57060627 ◽

2021 ◽

Vol 57 (6) ◽

pp. 627

Author(s):

Christina Frederiksen ◽

Ole André Solbakken ◽

Rasmus Wentzer Licht ◽

Carsten René Jørgensen ◽

Maria Rodrigo-Domingo ◽

...

Keyword(s):

Personality Disorder ◽

Personality Disorders ◽

Interpersonal Problems ◽

Symptom Distress ◽

Central Component ◽

Psychotherapeutic Treatment ◽

Cross Sectional ◽

Personality Functioning ◽

Emotional Dysfunction ◽

The Relationship

Background and Objectives: Emotional dysfunction is considered a key component in personality disorders; however, only few studies have examined the relationship between the two. In this study, emotional dysfunction was operationalized through the Affect Integration Inventory, and the aim was to examine the relationships between the level of affect integration and the levels of symptom distress, interpersonal problems, and personality functioning in patients diagnosed with personality disorder according to the Diagnostic and Statistical Manual of Mental Disorders, fifth edition. Materials and Methods: Within a hospital-based psychiatric outpatient setting, 87 patients with personality disorder referred for treatment were identified for assessment with the Affect Integration Inventory and other measures (e.g., the Symptom Checklist-90, Revised, the Inventory of Interpersonal Problems 64 circumplex version, and the Severity Indices of Personality Problems). Results: The analyses revealed that problems with affect integration were strongly and statistically significantly correlated with high levels of symptom distress, interpersonal problems, and maladaptive personality functioning. Additionally, low scores on the Affect Integration Inventory regarding discrete affects were associated with distinct and differentiated patterns of interpersonal problems. Conclusion: Taken together, emotional dysfunction, as measured by the Affect Integration Inventory, appeared to be a central component of the pathological self-organization associated with personality disorder. These findings have several implications for the understanding and psychotherapeutic treatment of personality pathology. Furthermore, they highlight the importance of considering the integration of discrete affects and their specific contributions in the conceptualization and treatment of emotional dysfunction in patients with personality disorders.

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Three Dimensional Approaches to Personality Disorders: a Review on Personality Functioning, Personality Structure, and Personality Organization

Current Psychiatry Reports ◽

10.1007/s11920-021-01250-y ◽

2021 ◽

Vol 23 (7) ◽

Author(s):

Susanne Hörz-Sagstetter ◽

Ludwig Ohse ◽

Leonie Kampe

Keyword(s):

Personality Disorders ◽

Empirical Studies ◽

Three Dimensional ◽

Personality Pathology ◽

Personality Structure ◽

Assessment Instruments ◽

Personality Organization ◽

Personality Functioning ◽

Clinical Observations ◽

Categorical Classification

Abstract Purpose of Review The concept of personality functioning (Alternative DSM-5 Model of Personality Disorders) has led to increased interest in dimensional personality disorder diagnosis. While differing markedly from the current categorical classification, it is closely related to the psychodynamic concepts of personality structure and personality organization. In this review, the three dimensional approaches, their underlying models, and common instruments are introduced, and empirical studies on similarities and differences between the concepts and the categorical classification are summarized. Additionally, a case example illustrates the clinical application. Recent Findings Numerous studies demonstrate the broad empirical basis, validated assessment instruments and clinical usefulness of the dimensional concepts. Their advantages compared to the categorical approach, but also the respective differences, have been demonstrated empirically, in line with clinical observations. Summary Evidence supports the three dimensional concepts, which share conceptual overlap, but also entail unique aspects of personality pathology, respectively.

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Early intervention in personality disorders

Early Intervention in Psychiatric Disorders Across Cultures ◽

10.1093/med/9780198820833.003.0014 ◽

2019 ◽

pp. 167-174

Author(s):

John M. Oldham

Keyword(s):

Risk Factors ◽

Early Intervention ◽

Personality Disorders ◽

Early Development ◽

Early Identification ◽

Early Onset ◽

Early Adulthood ◽

Critical Component ◽

Personality Functioning ◽

Attachment Process

Personality disorders have their onset in adolescence or early adulthood. It is now well-established that these conditions emerge in individuals who have heritable risk factors and who experience disruptions in the attachment process, a critical component of early development that, when successful, sets the stage for healthy, stable personality functioning in adulthood. The importance of early identification of, and intervention for, emerging personality disorders is increasingly recognized. A new dimensional model for personality disorders relies on assessing self and interpersonal functioning, impairment of which during adolescence may signal the early onset of potentially disabling personality disorders.

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Repairing Ruptures in the Therapeutic Alliance

Psychodynamic Therapy Techniques ◽

10.1093/med-psych/9780190676278.003.0016 ◽

2019 ◽

pp. 208-218

Author(s):

Brian A. Sharpless

Keyword(s):

Therapeutic Alliance ◽

Premature Termination ◽

Therapy Outcome ◽

Rupture Resolution ◽

Alliance Ruptures ◽

Stage Process

:Ruptures (i.e., deteriorations or strains in the therapeutic alliance) are an inevitable part of any psychotherapy. They are not only common but are also clinically meaningful. If not adequately attended to, ruptures are associated with poor therapy outcome and premature termination. Fortunately, a strong research base is available that provides clinically useful guidance for identifying and resolving alliance ruptures. After a brief review of the theoretical and empirical literatures, a list of “markers” used to identify the two subtypes of ruptures (i.e., withdrawal and confrontation) is provided. Proper assessment of the subtype is critical, as they each require slightly different rupture resolution techniques across a four-stage process. Finally, a list of specific rupture resolution techniques is provided.

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The DSM-5 Levels of Personality Functioning and Severity of Iranian Patients With Antisocial and Borderline Personality Disorders

Iranian Red Crescent Medical Journal ◽

10.5812/ircmj.17(5)2015.19885 ◽

2015 ◽

Vol 17 (8) ◽

Cited By ~ 4

Author(s):

Mehdi Amini ◽

Abbas Pourshahbaz ◽

Parvaneh Mohammadkhani ◽

Mohammad Reza Khodaie Ardakani ◽

Mozhgan Lotfi

Keyword(s):

Personality Disorders ◽

Borderline Personality ◽

Borderline Personality Disorders ◽

Personality Functioning ◽

Dsm 5 ◽

Iranian Patients

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Relating DSM-5 section III personality traits to section II personality disorder diagnoses

Psychological Medicine ◽

10.1017/s0033291715002226 ◽

2015 ◽

Vol 46 (3) ◽

pp. 647-655 ◽

Cited By ~ 42

Author(s):

L. C. Morey ◽

K. T. Benson ◽

A. E. Skodol

Keyword(s):

Personality Disorder ◽

Personality Traits ◽

Personality Disorders ◽

Alternative Model ◽

Work Group ◽

Taxonomic Structure ◽

Personality Functioning ◽

Dsm 5 ◽

Criterion A ◽

Dsm Iv

BackgroundThe DSM-5 Personality and Personality Disorders Work Group formulated a hybrid dimensional/categorical model that represented personality disorders as combinations of core impairments in personality functioning with specific configurations of problematic personality traits. Specific clusters of traits were selected to serve as indicators for six DSM categorical diagnoses to be retained in this system – antisocial, avoidant, borderline, narcissistic, obsessive–compulsive and schizotypal personality disorders. The goal of the current study was to describe the empirical relationships between the DSM-5 section III pathological traits and DSM-IV/DSM-5 section II personality disorder diagnoses.MethodData were obtained from a sample of 337 clinicians, each of whom rated one of his or her patients on all aspects of the DSM-IV and DSM-5 proposed alternative model. Regression models were constructed to examine trait–disorder relationships, and the incremental validity of core personality dysfunctions (i.e. criterion A features for each disorder) was examined in combination with the specified trait clusters.ResultsFindings suggested that the trait assignments specified by the Work Group tended to be substantially associated with corresponding DSM-IV concepts, and the criterion A features provided additional diagnostic information in all but one instance.ConclusionsAlthough the DSM-5 section III alternative model provided a substantially different taxonomic structure for personality disorders, the associations between this new approach and the traditional personality disorder concepts in DSM-5 section II make it possible to render traditional personality disorder concepts using alternative model traits in combination with core impairments in personality functioning.

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