Personality Disorder Treatment: Patient-focused approaches with Dr. Ueli Kramer

In this conversation, Dan and Dr. Ueli Kramer explore the intricacies of therapy, focusing on the change process, the concept of responsiveness, and the importance of case formulation in treating personality disorders. Dr. Kramer emphasizes the emotional aspects of therapy, the need for therapists to be responsive to clients' needs, and the significance of understanding the underlying motives behind clients' behaviours. They discuss how therapists can adapt their approaches based on the context and the individual client, ultimately aiming to enhance therapeutic outcomes.

Guest: Dr. Ueli Kramer

Additional Resources

Case Formulation for Personality Disorders: Tailoring Psychotherapy to the Individual Client

Understanding Mechanisms of Change in Psychotherapies for Personality Disorders

Psychotherapy Skills and Methods that Work

🎞️ Video version of the show@PsychotherapyAppliedPsychology on YouTube
🛜 Check out the website: Listen to every episode on your podcast player of choice

Connect with Dan
☏ Leave a voice message on Speakpipe
🔗 LinkedIn
🐥 @TheAPPod on twitter
📬 TheAppliedPsychologyPodcast@gmail.com
📸 Instagram

Chapters

• 0:00 Introduction
• 2:00 Exploring Therapist Responsiveness
• 7:30 Emotional Change as a Core Driver in Therapy
• 10:45 Understanding the Context of Therapeutic Techniques
• 16:30 Dialectical Behavior Therapy: Responsiveness in Action
• 20:00 Addressing Client Motives in Therapy
• 26:00 Effective Interventions for Challenging Clients
• 32:00 Case Formulation and Conceptualizing Personality Disorders
• 36:00 Mechanisms of Change and Resources for Further Learning
• 40:00 Closing Remarks

Transcript

0:00

[Music] Welcome to episode number 30 of Psychotherapy and Applied Psychology, where we dive deep with the world's leading applied psychology researchers to uncover practical insights, pull back the curtain, and hopefully have some fun along the way. If you find the show interesting, be much appreciated if you shared it with someone else who you think might enjoy it as well. Today I couldn't be more excited to welcome back one of the world's authorities on personality disorder treatment. My guest is a professor in the Department of Psychiatry at the University of Luzanne, where he directs the University Institute of Psychotherapy. He's also the president for the European Society of the Study of Personality Disorders, editor of the Journal of Psychotherapy Integration, and has received multiple prestigious awards for his psychotherapy research. In the show description, I have links to a couple of his recent books, Case Formulation for Personality Disorders, and Understanding Mechanisms of Change in Psychotherapies for Personality Disorders. In this conversation, we discuss several aspects of personality disorder treatment, including therapist responsiveness, case formulation, the therapeutic relationship, attending to clients underlying motives, and much more. This episode starts with my guest responding to my question about how he thinks about the interface between the change process that clients go through and how therapists can facilitate that change process. So without further ado, it's my pleasure to welcome back Dr. Ueli Kramer.[MUSIC] So, you know, process research has kind of gone back and forth between the two, or also kind of this is a huge book edited by Clara Hill and John Norcross last year, came out last year on 40 or so meta-analysis on different interventions and therapist skills. And actually quite, you know, this heartening conclusion is that there's something like nine interventions, therapist interventions or skills that are relating with outcomes, client outcomes, right? Which is, as I said, this heartening, or kind of, you know, a little bit frustrating after all this work, like 500 pages, that you can make a dressed as list of nine interventions, which, you know, we all knew there kind of work, but, you know, and of course, it's only an invitation for more research. But also really think about what type of research would be helpful. So let me pause here. That's one way to look at it, right? I mean, it's kind of a way, you know, that the therapist would actually do the job and, you know, kind of like a mechanic, go to the car and kind of change here a little bit, change here or something. And then we hope that the car runs again with all the expertise he brings into the understanding of how far the car works. But it creates a lot of problems. It is usually done within therapy schools that one technique is only actually studied within one particular therapy approach. And we don't know if you, if you explored it, whether it will still work, you know, let's say giving homework is helpful for CT or DVT, electrical behavior therapy for particular personalities or as one of the most heavily studied treatments for personal disorders, the heavily studied very good effects, where you have really precise predictions of outcomes and prop odds. But we don't know if it would work as a dynamics therapy because it's a whole different context of interaction, all different style relating and working together. So it doesn't transit easily if you just have a technique and you kind of put it somewhere else, like the contextual factor obviously. So a different way to look at it is to start with a client and just to ask yourself what are actually client processes that may be central. And of course, I've been doing quite some research there and it's really based on my own observation, like the intuition comes again from my observation of how clients change. Like what I see in my practice and then I see, I think about it with colleagues and ask myself what is it, right? And one of the, you know, change processes that you can observe in the therapy hour is an emotional change, right? And it's probably one of the core features of any human being, if you accept evolution theory, but we are human beings or any animals, but human beings in particular because we have the capacity to put words on our symbolizations. That actually you can say what we feel, like what we, what's the stare, is that we in response to interpersonal situations that are important for us, it's such as any situation, right? That, you know, that if I see the face of my mother as a child, I have a reaction. If I see some kind of beautiful landscape that's actually reminding me of vacation when I was a child, I have an emotional reaction. And if I see you, if we talk together, we have also mutual reactions because we affect each other. So there's a whole, like our life is emotions, right? We are driven by emotions really. So that's also, and I know you have invited Antonio Pasuelo and my dear colleague and friend, and I think a lot of what he mentioned is something that I, of course, want to study in treatment personalities, or something beyond. So this just to say that this is one of the core pieces of when we observe clients that drives change. It's my assumption, and I think has been, to some extent, confirmed by different research programs. But it's a very broad assumption finally, so it's maybe not very, or very specific yet. But of course, this is a different way to look at things. And then the final way to look at your question, you know, should we start with the client, but the therapist, but then it's actually the responsiveness, the idea of, you know, that you, that the therapist may have an idea of what to do, may have a program or a plan. And then the client comes in and presents something completely different, which is the usual, the usual business when you have treat clients with personal is, or that's why I think it's a concept that is has good potential to understand, explain the effects of treatments for personal is always responsiveness. And so then the therapist needs to revise and come up with a new explanation and kind of revise his case formulation and maybe revert, go to a different aspect, depending on what's happening in the treatment. I sort of think after sort of listening to you and thinking of and reading some of your more recent work, I think maybe the way to dig into this is just maybe go down the responsiveness road. So I wonder if you could give us just a very brief sort of like what is responsiveness. And then I really want to dig into how you think about this with when working with folks with personality disorders. Yeah, yeah, of course, this is what is responsiveness. I mean, this has been discussed on the different names, I should say also when Gordon Paul at the 1950s from a research perspective asked a question, what treatment is the most appropriate for this particular person under which circumstances and so forth, there's more to it. But really the notion what he wanted to get at is that we can't just study, say dynamic interpretations and look at them in a like under a glass, right? It's all in a context. And if you really want to understand how sector be works, we need to take into account the complexity of the interact the interaction in the interaction perspective. So this is what what's been up there of true sector researchers as a challenge since 1950s, but we have not really come up with good models, I think. We have always studied linear models or kind of trying to explain it differently in the in a simple model. And I think just starting to wrap, but I think that this relates to what you were talking about earlier with the Hill and Norcross sort of there, this idea of if we just think about homework, for example, or thought challenging or interpretations that those are just those are just behaviors of therapists does. But if they're when we look at them a contextually, when we look at them without considering, okay, who's the client, what is the client need in this moment, what's our goals, like if we, if we just say like, oh, how helpful is how, what's the correlation between interpretations and some sort of outcome without considering that context, well, that sort of misses the whole thing. That it needs to be contextualized at the bigger picture for this particular client, but also in this moment, it needs to be contextualized. If you talk about correlations, there has been studies and also Bill Stiles talked about it already in the 90s showing that there's actually there can be a negative correlation between economic correlations and the outcome. So the more the more a therapist proposes interpretations, the less good is the outcome. So the question is then does that mean that this particular intervention should be avoided and is harmful, right? I mean, this could be concluded, which of course would be nonsense because we know it's very helpful in certain situations, but maybe more tricky in others. And in particular, for this particular case can be the case, imagine the client that is just very difficult in terms of understanding what the therapist is meaning, right? The therapist may have to repeat more times than once his or her interpretation, which brings this score very high up, but it doesn't mean it's bad therapies, actually very good therapy for this particular client. So this is just to put everything a little bit more into context. So really it is using the information from context and being aware that it is the dimension of the therapist is affected by this context. So this is how Bill Stiles defines it. This is many other colleagues have to find it in a similar way, therapist responsiveness. So what has been the second part of your question, how we actually could conceptualize responsiveness for personalisers, right? Yeah, you know, and I think it's, you know, it's interesting, particularly with person I just orders, because I think at least in North America, you know, DBT is sort of the thing. I think there is this tendency for us in our training, our practice to really be like, oh, this client needs DBT. And that is, and I'm not trying to, because I think DBT is great. But I think in some ways we do think about it more mechanistically, rather than, okay, what, rather than responsively. Actually, I would argue just with a fundamental definition, responsiveness acts on all timescales. And what you say mechanistically may actually also be responsive in some sense, in a way in a sense that we do have a diagnosis. We have a client in front of us that presents certain features. It is totally, totally, at least as a first approach, defendable to propose, dialectical behavior, therapy for a client with severe personalisers that could be qualified as well as auto-lamb personalisers. So, you know, this is totally state of gr. So I would not question that. For me, it's not, you know, in any way, you know, not consistent with what I said before, but it's just a broader picture of responsiveness. What I meant earlier, and what's actually, what's really interesting, I think, for these clients, these folks is to think about responsiveness from a moment by moment perspective, which can be observed in DBT or in other treatments in any treatment, of course. This is interesting because we know that there's a lot going on in these treatments, right? You just have a look and I've looked at a lot of tapes of the years rating sessions from my own group or from other colleagues doing all kinds of different treatments for patients with Portland personalisers or any personal you. That these treatments and that that's also a way to say again, this is really fascinating, right? It's extremely rich material from a clinical perspective. His clients do everything in one session, like you name it. You say anything and they do it, right? And the therapist, a good therapist is acting in a very varied way. And just to take it up again, your example of dialectical behaviour therapy, dialectical behaviour therapy is a very responsive treatment. It has a lot of very varied components in it, particularly individual therapy, where the therapist is sometimes very empathic, but at other moments actually very irreferential and actually uses humoral metaphors or has specific techniques that he or she uses to have a shift in attention in the client that's quite remarkable. So, you know, it's not just one way of relating. There's a different, there's different types of relating, for example, and DBT or just the tasks or interventions that can be proposed can be very, very varied. Can you talk more about those different ways of relating and what that looks like in terms of when a therapist is being particularly responsive? So, again, the, the, the, a sicker patient who comes in, sorry, with, you know, with a difficulty in making a case for his employee, employer. Like, client comes in, he or she wants to change something in his contract, get a pay rise or something that, you know, would be helpful for him, but he or she does not dare to do it, right, for some kind of reason. So, this could be a problem. This is an interpersonal problem, but the, the therapist at the first level would probably just express some kind of validation that this is difficult. But then also see what kind of skills, you know, we don't know what this client is, but, you know, kind of, you know, support and reinforce certain skills that are already there. Right? So, this is something you have used and kind of that's that may be two aspects of responsiveness. Like, both validating this different, different types of validation can be used in DBT or in other treatments and also propose some, you know, reinforcement of what's already there. And then of course in DBT because it's a change or into the proponent focused treatment, teach new skills that can help the client will form and actually get to expose their goals. So, this is one thing. And there's another way of, you know, let's find the client who says, I actually, I don't really know what to do. I don't know if I really want to stop any behavior, let's say self harming or if I want to continue. So there's kind of a bit of lens. So in some of these situations, what in particular, the therapist feels stuck, it can be helpful to use humor or irregular statements, which is a different way. It's also in some ways responsive, right? It's responsive to the clinical presentation of the patient. Right? So it's a different way of working together. So I'm just giving you a whole lot of techniques, which are actually studied in the book, healing or cross. So these, you can just look them up and see, oh yeah, this relates to outcome. This doesn't, but, but what I mean by this is what these examples is that in the same session, you can find everything that just said it because clients, they shift from one moment to the next. So it requires some kind of skill in the therapist that can be broadly named responsiveness. But of course, if you study it, it is also responsiveness, right? This is a little bit of mix between two words, but you can study the phenomenon, but you can also train the therapist in perception skills and intervention skills. So I think this is the type of, this also consistent with research, which we have done. Maybe I can talk about that, but you know, responsiveness is, it's a no. It's an overarching concept on the which really the idea of if there is an event the client presents is present, what is the therapist action that should follow given what given the context. Yeah, and I was thinking about, I think it was in your 2020 paper where you talked about the process of change for clients in personality disorder treatment. And I think it was in that one, red, they blend together that the, you talked about how the interpersonal like the focus on the therapist varying their interpersonal process. And I think it was in specifically in relation to dependent person disorder. But really, so I guess, do you have any general framework or way of thinking about how, like how a therapist, a framework of therapist could have so that they could be personally responsive, so just in a personally responsive, not responsive in other ways. Two patients with personality disorders in ways that are effective. Does that make sense? So like, you know, I often think about sort of literature on when people act in certain ways, it pulls for us to act in certain ways, right? And so there's this general argument that one of the values for that one of the things the therapist can do that can be helpful is disrupt that right and they might have to fight their own tendencies to act in typical ways when a client is really angry and yelling at me to respond in whatever way would be typical but to act in different ways to create these unique learning moments and that sort of thing. So I guess that larger framework, have you sort of come to any ways of thinking that you find is helpful for therapists when working with clients that they can be personally effective with them based on, does that make sense? So I would come back to how to conceptualize clients first using case formulation and how this can affect the therapist intervention. I'm not sure this will address your question, but you know, I've done obviously lots of research on plan analysis that's been developed in Europe by carbon cusp which is a way to conceptualize patients problems, case formulation method. So the piece that's interesting, they're not going to go give like a whole class and this but really the piece that's interesting is that it differentiates between what you observe in the client from hypothesis that explain the purposes of these behaviors that you observe, behaviors and experiences. So for example, a client may present in session as interpersonal challenging or maybe not decide not to talk. Then the question would be what's the purpose of this client behaving in this particular way? Of course, now I can't answer this question generally but for a particular client you can imagine he may have a plan that's not conscious but just kind of a construction for you as a therapist. It's helpful that sense that says avoid trusting the therapist or even you know, present as somebody who is particularly difficult in this particular situation or just different aspects can explain this particular behavior. If you ask your questions in a specific way and then conceptualize this case, you will arrive at one moment to accept all plans that are the motives that drive the behavior and the problematic plans. As soon as you arrive to these acceptable motives, you will have a level where you can be using an effective therapeutic intervention. That is the motive or therapeutic relationship that's not a new therapy but that's just when you do a case formulation that you have a way to interact with the patient. Basically what you the example you gave that you actually open up a new space between you and the client but there's some way that you as a therapist you take away the motivational basis of some of by your action. That is within of course the framework of the therapy take away the motivational basis of the problematic behavior and the patient criticizes you that this is not needed anymore that he feels sufficiently safe with you. It's not a technique that's extremely complicated, it's just a principle that actually a lot of therapists use. We have done studies on therapists who have not involved, we have not learned this but who have a very good level of expertise in any therapy approach. A lot of therapists they do that, they use this principle to some extent but of course it can be trained in trainees which is really interesting. They think about first year trainees in psychotherapy and they get exposed to very difficult clients with the motive or the therapeutic relationship they get the handle right away to actually keep these patients in therapy and they feel more comfortable working with difficult clients. So this is a way to use responsiveness in a very concrete and effective way that the therapist also gets a handle of how to work with patients that are into personally challenging. Can you help me understand what you mean when you say take away the underlying motive? This has been very quick so I will have to give a little bit more explanations I realize. So the idea really is let's imagine again a client comes with just a different examples comes to therapy, a couple of sessions in and says I'm done. I think I don't need therapy anymore. So the question is what is the purpose of him or her saying this? It may be that there's some anxious anxiety so he wants to avoid further deepening of a topic. It may be that actually he or she is already satisfied with the results but it may also be to really keep the therapist at some distance. These are all explanations that I could formulate as possible explanations of one particular behavior, patient behavior. If it's something that's late with avoidance that's serving the purpose in this particular client to protect integrity or self-esteem or something like that to avoid being confronted with some negative effect for example. Then the therapist if this is acceptable and I'm going very fast, this is usually quite a detailed process of formulation. Then the therapist can ask oneself what is this is this a motive that I can work with and accept in this particular therapy for this particular client or is it interfering with further progress? So I can decide this avoid negative effect. I cannot guarantee but I can at least make a proposal to the patient as a therapist and tell him you know I can actually understand a negative effect. You cannot completely avoid it but please let me know if it's unbearable or if it's something too difficult for you. If this is you know kind of practically actually giving this control to the patient and giving offering kind of serving this particular motive of controlling the self-esteem and so forth. This can be done proactively by an intervention by the therapist. So this is the therapist intervention that is addressing what we understand as being the motive or the motive if you want of the problematic behavior if it is problematic. So this is the patient saying I am done with therapy, I don't need anything more. And this particular intervention may first look as quite off topic. It's typically the case because we haven't talked about that in this particular sentence. But the patient if it's the right intervention the patient will feel understood and it really goes at the core of what the patient experiences. My experience with this type of interventions is that if they're really done in a good way and that the patient feels very welcome and they really open up much more. After these interventions. So when you explain this I hear two broad things that are happening. One is to work with that motive to then facilitate the work that we're doing. The other is that attending therapeutically attending to that motive is the work. Yeah, of course it can be both. But attending to the motive I would say we just as a therapist first of all served the motive. That means I'm really thinking of what do I as a therapist have to do explicitly, specifying or by doing. Also give this implicitly give more space to the patient in the therapy or to make him experience that what he's developing is actually consistent with his self as deep, for example, that's the issue. I can make it explicit if I feel this is needed. So there's different ways I can do that. But the date actually shows is that the implicit aspects are much more predictive of the therapeutic alliance and outcome compared to the explicit ones. What do I mean the implicit ones are the parable and nonverbal aspect. So if the therapist is able to convey in a convincing fashion that this motive of the client is the one he focuses on in respects. This is the case where not questioning it while the problematic behavior may be problematic. But the behavior the motive is something we're serving directly as a therapist. This is kind of the truth in what the client is presenting. It's just a little piece of truth maybe in it. That this is something that is the therapist is resonating with and the client experienced is something validating. Then this theory as proposed suggests that this will reduce some of the interpersonal problems in the therapy hour and open up new spaces, new topics and new trust in the therapeutic relationship. So studies have shown that for severe personalis adult disorders is actually what happens that the alliance is getting better for patients who receive this type of intervention and also depression anxiety symptoms go down more. Not the borderline symptoms but depression anxiety general symptoms go down more in patients who receive the motive or the therapeutic relationship compared to those who denies it. So yeah this is I think a basic specific way of offering attention empathy. Of course you can offer attention empathy to anything as a therapist. This is a hoministic therapy but for clients who are extremely disturbed it may not be enough. It may even provoke difficulty. For some clients this is too difficult to receive this very strong empathy. For everything they do they know something is not right. It's more complex than that. So the motive or the therapeutic relationship just gives specifically an unlimited empathy to one particular piece that's the underlying motive of behavior and everything else it's not brief or more given attention to in this moment. You've written about mentalizing and metacognition in terms of what changes in clients in with personality disorders. Do you think about what you're talking about here in relation to those constructs at all? So this is really a idealized conception of the therapeutic relationship what I just said because of course what I would do with a case like Caroline is different than I would do with another case. It depends on how I conceptualize the case which I think is really the huge potential for the next 10 years that we can do our assessments for patients with personalities of disorders not only on specific variables such as mentalizing or emotional awareness or emotional you know the capacity to put oneself in other shoes which can be you know variables that we can measure. But that we use all these variables and that we get a good sense as a therapist and also as a researcher. What is the profile of this patient if we do this we have done published one paper that's you know methodologically quite sophisticated using cross-pollot prediction analysis. But when we look at the case formulation as a predictor for this it's quite complex it's published in personalities for us APA journal 2022. We can also use case formulation the bottom lines we can also use case formulation as a predictor for for these quite complex models. So case formulation is not only the individualized conception of personal disorders is not only usable as for clinicians but may also be helpful for researchers to really get that the core of each of the patients they have their sample. It seems like in the last few minutes it seems like it would be worth maybe helping the practitioner who's listening think what when you think about case formulation with folks with personality disorders you've talked about it a bunch but more explicit you know what does that mean how do you think about doing that in a useful way. So you know you could do it in different ways and just the bottom line is observed right and infer and then of course use it this information both what you've served and what you infer. So you know you can do it in different ways and then you can do it in different ways and then you can do it in different ways. And to be aware that each step has their own problems or limitations but also just potential. So I would probably just you know observe it by writing down what I observe in the patient what do I see what is that's there and then develop hypothesis what is this why does he do that what's the purpose in the plan of us approach or how can this relate with my conversation. So I think that's my constructs mentalizing or emotional regulation or what does it mean for my theory right and then what how can I intervene with the interventions I have. And how have you found to test those hypotheses with patients. So theory is an ongoing falsification of hypothesis so it's a beautiful right we as therapists create ideas and sometimes can be quite frustrating frankly to propose a new ideas to a patient who tells me no you actually not. Even if you have written about it it's not what I feel right and that's exactly where I think it's it's so important to then stop and actually listen to the client and say so can you can you do it yourself or what what could we do together what how can you correct this or how can we understand it better. So one of the things I would like to ask folks is if they've experienced any pushback for their for their work. Not so much when I submit a paper I always get reviewers I mean I like exactly what I write but this is part of the game. And I wouldn't say there's no pushback of course if I say these kind of things about integration of course this is you know can be understood in a way that you know is this criticizing some of the therapy schools that you have established that we're cherishing so much this could be a pushback. I haven't received that explicitly but I understand that you know and I also respect actually my colleagues who really are in one particular school of therapy approach of therapy which really cherishes also that diversity of therapy approaches. Otherwise I'm maybe ignoring it so which is also a good place to be in some sense but I think it's just yeah yeah just naively moving forward so are there are there one or two resources that you think would be helpful for listeners who wanted to dig more into what we what you're up to and what you've been doing and what could be helpful. So maybe just you know we didn't talk much about mechanisms of change but this is all kind of coming together in the book that I wrote with shelly and can leave you from a variety of perspectives actually the book that came out this year. The very psychological association understanding mechanisms of change in psychotherapies for personnel so a lot of the stuff we talked about today. Case formulation is very present from a variety of perspectives theory what's the clinical theory doing in all this all the the new dimensional constructs how we can understand and solve it there using six cases really dig down into six cases wanted to really exemplify the clinical work actually exemplify what we think about psychotherapy and how it works using six cases. Ladies and gentlemen doctor Oolie Kramer. That's a wrap on our conversation about personality disorder treatment and as I noted at the top be much appreciated if you could spread the word to anyone else who you think might enjoy the show. Until next time.[Music]