Influence of therapist competence and quantity of cognitive behavioural therapy on suicidal behaviour and inpatient hospitalisation in a randomised controlled trial in borderline personality disorder: Further analyses of treatment effects in the BOSCOT study

<br>Objectives. We investigated the treatment effects reported from a high-quality randomized controlled trial of cognitive behavioural therapy (CBT) for 106 people with borderline personality disorder attending community-based clinics in the UK National Health Service – the BOSCOT trial. Specifically, we examined whether the amount of therapy and therapist competence had an impact on our primary outcome, the number of suicidal acts, using instrumental variables regression modelling. Design. Randomized controlled trial. Participants from across three sites (London, Glasgow, and Ayrshire/Arran) were randomized equally to CBT for personality disorders (CBTpd) plus Treatment as Usual or to Treatment as Usual. Treatment as Usual varied between sites and individuals, but was consistent with routine treatment in the UK National Health Service at the time. CBTpd comprised an average 16 sessions (range 0–35) over 12 months.</br> <br>Method. We used instrumental variable regression modelling to estimate the impact of quantity and quality of therapy received (recording activities and behaviours that took place after randomization) on number of suicidal acts and inpatient psychiatric hospitalization.</br> <br>Results. A total of 101 participants provided full outcome data at 2 years post randomization. The previously reported intention-to-treat (ITT) results showed on average a reduction of 0.91 (95% confidence interval 0.15–1.67) suicidal acts over 2 years for those randomized to CBT. By incorporating the influence of quantity of therapy and therapist competence, we show that this estimate of the effect of CBTpd could be approximately two to three times greater for those receiving the right amount of therapy from a competent therapist.</br> <br>Conclusions. Trials should routinely control for and collect data on both quantity of therapy and therapist competence, which can be used, via instrumental variable regression modelling, to estimate treatment effects for optimal delivery of therapy. Such estimates complement rather than replace the ITT results, which are properly the principal analysis results from such trials.</br&gt

Trying to make sense of the chaos: Clinical psychologists' experiences and perceptions of clients with borderline personality disorder'

Background Evidence of negative perceptions of clients with borderline personality disorder (BPD) in mental health professionals has been well documented. However, few researchers have focused upon perspectives of clinical psychologists on this client group. The aim of the present research was to explore clinical psychologists' experiences and perceptions of clients with BPD. Method Sixteen female clinical psychologists (including trainees and qualified staff) participated in focus groups, 12 of whom had direct clinical experience with this client group. All four groups' audio recordings were transcribed verbatim and analysed using interpretative phenomenological analysis (Smith, 1996). Results The following eight superordinate themes emerged from the analysis: negative perceptions of the client, undesirable feelings in the psychologist, positive perceptions of the client, desirable feelings in the psychologist, awareness of negativity, trying to make sense of the chaos, working in contrast to the system and improving our role. Discussion Implications include concerns regarding negativity, yet also the suggestion of hope and optimism in working with this client group. Copyright (C) 2012 John Wiley &amp; Sons, Ltd.</p

A Focused Sequent Calculus Framework for Proof Search in Pure Type Systems

Basic proof-search tactics in logic and type theory can be seen as the root-first applications of rules in an appropriate sequent calculus, preferably without the redundancies generated by permutation of rules. This paper addresses the issues of defining such sequent calculi for Pure Type Systems (PTS, which were originally presented in natural deduction style) and then organizing their rules for effective proof-search. We introduce the idea of Pure Type Sequent Calculus with meta-variables (PTSCalpha), by enriching the syntax of a permutation-free sequent calculus for propositional logic due to Herbelin, which is strongly related to natural deduction and already well adapted to proof-search. The operational semantics is adapted from Herbelin's and is defined by a system of local rewrite rules as in cut-elimination, using explicit substitutions. We prove confluence for this system. Restricting our attention to PTSC, a type system for the ground terms of this system, we obtain the Subject Reduction property and show that each PTSC is logically equivalent to its corresponding PTS, and the former is strongly normalising iff the latter is. We show how to make the logical rules of PTSC into a syntax-directed system PS for proof-search, by incorporating the conversion rules as in syntax-directed presentations of the PTS rules for type-checking. Finally, we consider how to use the explicitly scoped meta-variables of PTSCalpha to represent partial proof-terms, and use them to analyse interactive proof construction. This sets up a framework PE in which we are able to study proof-search strategies, type inhabitant enumeration and (higher-order) unification

Towards a canonical classical natural deduction system

Preprint submitted to Elsevier, 6 July 2012This paper studies a new classical natural deduction system, presented as a typed calculus named lambda-mu- let. It is designed to be isomorphic to Curien and Herbelin's lambda-mu-mu~-calculus, both at the level of proofs and reduction, and the isomorphism is based on the correct correspondence between cut (resp. left-introduction) in sequent calculus, and substitution (resp. elimination) in natural deduction. It is a combination of Parigot's lambda-mu -calculus with the idea of "coercion calculus" due to Cervesato and Pfenning, accommodating let-expressions in a surprising way: they expand Parigot's syntactic class of named terms. This calculus and the mentioned isomorphism Theta offer three missing components of the proof theory of classical logic: a canonical natural deduction system; a robust process of "read-back" of calculi in the sequent calculus format into natural deduction syntax; a formalization of the usual semantics of the lambda-mu-mu~-calculus, that explains co-terms and cuts as, respectively, contexts and hole- filling instructions. lambda-mu-let is not yet another classical calculus, but rather a canonical reflection in natural deduction of the impeccable treatment of classical logic by sequent calculus; and provides the "read-back" map and the formalized semantics, based on the precise notions of context and "hole-expression" provided by lambda-mu-let. We use "read-back" to achieve a precise connection with Parigot's lambda-mu , and to derive lambda-calculi for call-by-value combining control and let-expressions in a logically founded way. Finally, the semantics , when fully developed, can be inverted at each syntactic category. This development gives us license to see sequent calculus as the semantics of natural deduction; and uncovers a new syntactic concept in lambda-mu-mu~ ("co-context"), with which one can give a new de nition of eta-reduction

Schema therapy for emotional dysregulation: Theoretical implication and clinical applications

The term emotional dysregulation refers to an impaired ability to regulate unwanted emotional states. Scientific evidence supports the idea that emotional dysregulation underlies several psychological disorders as, for example: personality disorders, bipolar disorder type II, interpersonal trauma, anxiety disorders, mood disorders and posttraumatic stress disorder. Emotional dysregulation may derive from early interpersonal traumas in childhood. These early traumatic events create a persistent sensitization of the central nervous system in relation to early life stressing events. For this reason, some authors suggest a common endophenotypical origin across psychopathologies. In the last 20 years, cognitive behavioral therapy has increasingly adopted an interactiveontogenetic view to explain the development of disorders associated to emotional dysregulation. Unfortunately, standard Cognitive Behavior Therapy (CBT) methods are not useful in treating emotional dysregulation. A CBT-derived new approach called Schema Therapy (ST), that integrates theory and techniques from psychodynamic and emotion focused therapy, holds the promise to fill this gap in cognitive literature. In this model, psychopathology is viewed as the interaction between the innate temperament of the child and the early experiences of deprivation or frustration of the subject\u2019s basic needs. This deprivation may lead to develop early maladaptive schemas (EMS), and maladaptive Modes. In the present paper we point out that EMSs and Modes are associated with either dysregulated emotions or with dysregulatory strategies that produce and maintain problematic emotional responses. Thanks to a special focus on the therapeutic relationship and emotion focused-experiential techniques, this approach successfully treats severe emotional dysregulation. In this paper, we make several comparisons between the main ideas of ST and the science of emotion regulation, and we present how to conceptualize pathological phenomena in terms of failed regulation and some of the ST strategies and techniques to foster successful regulation in patients