Abstract
Promising reports from studies of coherent and structured treatments for patients with personality disorders (PDs) have turned treatment pessimism to optimism for this group of patients, especially for patients with borderline PD. However, several important questions remain insufficiently addressed. Although various treatments are provided in different settings (e.g., outpatient, dayhospital, and inpatient treatments), there is still no consensus on the optimal treatment format or levels of care for patients with PDs. Also, there is great variety in the severity and types of personality pathology, both between the PDs and within specific PDs; perhaps different subgroups of patients with PD benefit from different treatment formats. Moreover, most studies of the treatment of patients with PDs only include short-term follow-up. Given the entrenched and chronic nature of PDs, long-term follow-up is central for establishing the significance of treatment programs.
In recent decades, particularly in Europe, traditional inpatient units have often been replaced by various day-hospital treatments that also serve as step-down programs. Compared to inpatient treatment and outpatient individual psychotherapy, it has been suggested that day-hospital treatment offers an optimal level of care with suitable levels of intensiveness and containment. This dissertation utilizes data from the Ullevål Personality Project (UPP), a randomized clinical trial to compare a day-hospital step-down treatment program with outpatient individual psychotherapy for 113 patients with various PDs. The patients in step-down treatment in the UPP were initially offered short-term intensive day-hospital treatment (consisting of several types of group therapy for 18 weeks) followed by long-term outpatient psychotherapy (group and individual therapy), with a corresponding reduction in treatment intensity. In contrast, the outpatient psychotherapy condition consisted of a variety of individual psychotherapies; the therapists in this treatment condition were instructed to treat the patients according to their own preferred method and practice. Patients were assessed at several time points during the 6-year follow-up period.
The findings from this dissertation support both treatment formats as viable options for patients with PDs. There were no statistically significant differences in outcome at the 6-year follow-up in the total sample of mixed PDs. However, as a group, patients in the outpatient condition experienced a marked decline in psychosocial functioning during the period between the 3- and 6-year follow-ups; in contrast, psychosocial functioning continued to improve in the step-down condition during the same period, indicating that longer-term changes were stimulated during treatment. For the subsample of patients with borderline PD, findings indicate that a more-intensive treatment format combining group and individual psychotherapy is particularly helpful for patients struggling with emotional dysregulation, stormy relationships, and destructive acting-out behaviors, at least more than outpatient individual therapy alone. Moreover, this thesis indicates that patients’ capacity for understanding their own and others’ mental states (patients’ capacity for mentalization) may impact the outcome of treatment. Patients with a low capacity for mentalization had better outcomes in outpatient individual therapy than in the step-down program. In contrast, patients with a greater capacity for mentalization achieved better results in the step-down program. Also, findings in this dissertation indicate that mentalization capacity is associated with core aspects of personality pathology and captures clinically relevant phenomena in adult patients with PDs. Last, consistent with previous prospective naturalistic studies and treatment trials, in the UPP, patients with PD frequently continued to function at suboptimal levels of psychosocial functioning, long after achieving diagnostic remission. This impact was also evident in the UPP at the 6-year follow-up. Using statistical models for causal inference, we found strong and reciprocal positive associations between personality functioning and global psychosocial functioning. These results indicate that a successful intervention on one of the two constructs positively affects the results of the other construct.
Various explanations and implications for the above findings are considered in this dissertation, as are possible explanations for differences in long-term clinical course between treatment conditions. This dissertation also discusses how different treatment formats and different levels of care may be suitable for some patients but not for others. A limitation of this study is that it did not control for other types of treatment that patients may have received outside of the UPP.
The UPP primarily compared treatment provided in different formats and at different levels of care. However, one of the main challenges in the field of psychotherapy for PDs is to better understand how and why change occurs. To meet this challenge, theoretically promising concepts must be identified. The results from this dissertation suggest that both mentalization and personality functioning have future roles in the treatment and assessment of personality pathology. Both concepts are also interesting as potential processes that lead to change during psychotherapy. While this dissertation establishes a causal inference with regard to change in personality functioning and psychosocial functioning, such analysis is lacking for the concept of mentalization. Future research should investigate the causal inference linking improvement in mentalization capacity and psychotherapeutic outcome.