Development of a scale for measuring techniques in the psychotherapy of borderline patients

The Development of Transference-Focused Psychotherapy and Its Model of Supervision

Transference-focused psychotherapy (TFP) is an empirically based, manualized psychodynamic psychotherapy that emerged as an adaptation of psychoanalytic techniques to meet the needs of patients with personality pathology. As it became more clearly defined through a series of treatment manuals and empirical research, TFP has also come to be considered a conceptual and technical model of therapy that can be used to introduce therapists in training to the principles of psychodynamic psychotherapy in a systematic way. Advanced levels of TFP training and practice involve an emphasis on supervision that is applied in a more structured way than traditional psychodynamic supervision, while respecting the depth and subtlety of psychoanalytic exploration. This article reviews the development of the treatment model and the supervisory process that guides the therapist to carry out TFP in accordance with its proposed mechanism of change.

Measuring Verbal Psychotherapeutic Techniques-A Systematic Review of Intervention Characteristics and Measures

Language is one of the most important “tools” of psychotherapists. The working mechanisms of verbal therapeutic techniques, however, are still marginally understood. In part, this is due to the lack of a generally acknowledged typology as well as a gold standard for the assessment of verbal techniques, which limits the possibility of conducting studies focusing this topic. The present study reviews measures used in clinical research which assess directly observable dimensions of verbal interventions in a reliable manner. All measures were evaluated with respect to their theoretical foundation, research goals, assessment modes, and various psychometric properties. A systematic search in databases (PubMed, PsycInfo, PsycArticles, PSYNDEX, Web of Science, Embase) followed by an additional “snowballing” search covering the years 1940–2013 yielded n = 179 publications eligible for review. Within these publications, 34 measures were identified showing great heterogeneity regarding the aspects under study. Only two measures reached the highest psychometric standards and can be recommended for clinical use without any reservation. Central problems include deficiencies in the systematization of techniques as well as their partly ambiguous and inconsistent definitions. To promote this field of research, it will be important to achieve a consensus concerning the terminology, conceptions and measures of verbal interventions.

Are advanced psychiatry residents more skillful than beginning residents in the conduct of psychodynamic psychotherapy?

The psychotherapy skills of psychiatry residents were assessed by using a structured-response supervisor inventory, the Supervisor Report (SR). Longitudinal data on the same resident across time showed a small but positive trend toward the acquisition of skill in doing psychodynamic psychotherapy. Mixed cross-sectional and longitudinal comparisons between ratings of the beginning residents and advanced residents demonstrated a significant, but small, increase in skill over the course of outpatient training. SR score changes also corroborated observational data on individual residents. While these findings suggest the utility of the SR in measuring changes in psychotherapy skill, the results must be considered in light of the relatively poor interrater reliability and only somewhat better test-retest reliability.

Studying the treatment contract in intensive psychotherapy with borderline patients

A pilot study on the process of psychodynamic psychotherapy of borderline personality disorder at the Cornell University Medical College is designed to investigate the teaching and application of a specific model of treatment for borderline patients (Clarkin et al. 1992; Kernberg and Clarkin 1992). The project has involved teaching a group of self-selected trainees and faculty the manualized therapy (Kernberg et al. 1989); taping each of the twice-weekly therapy sessions over a period of 2 years; and rating (1) each therapist's adherence to the manual (Koenigsberg et al. 1985), (2) each therapist's skill, and (3) patient change. The patients are women with borderline personality disorder, between 20 and 40 years of age, diagnosed by DSM-III-R criteria (American Psychiatric Association 1987), SCID-II (Spitzer et al. 1987), and a self-report questionnaire for level of personality organization. At regular intervals, the patients are evaluated for symptom status, change in BPD criteria, and functioning. The therapists are evaluated for adherence to the manual and level of therapeutic skill. In teaching and carrying out the manualized therapy, it became clear that a critical moment in the treatment was the setting up of the treatment contract. A study was organized to look systematically at the adherence of the therapists to the model of treatment with regard to this initial phase of the therapy.

Deterministic chaos and the sciences of complexity: psychoanalysis in the midst of a general scientific revolution

A combination of new concepts and the enormous powers of computation now available have created the beginnings of a major new scientific revolution. It does not have to do with psychoanalysis per se, but with some basic assumptions among the sciences generally. The result is already showing in new visions of nature variously called "deterministic chaos," "nonlinear dynamics," or "sciences of complexity." For the first time it is possible to study complex systems in process, over time. This paper, especially attending to issues of separation and integration, focuses on two components of the new understandings, fractal geometry (part of the mathematics of topology) and deterministic chaos (the tendency of nonlinear systems to oscillate toward and away from absolute chaotic disorganization). In a diverse group of intellectual disciplines, it is now possible to describe systems in operation in detail, in terms of nonlinear differential equations. From these, computer models of multiple variables in interaction can be produced. In turn, this allows experimentation on the models by altering variables. At this time, psychoanalysis can only use deterministic chaos and fractals metaphorically, but in the future, especially if psychoanalysis is seen in terms of process or organismic theory, it is likely that such models can be produced.

Crisis intervention response and long-term outcome: a pilot study

We investigated whether process variables (therapeutic alliance and insight) measured at the termination of crisis intervention predict long-term treatment compliance and 2-year outcome. Thirty-seven consecutive depressed psychiatric patients assigned to outpatient crisis intervention (CCI) were assessed with both questionnaires and standardized instruments at intake, 1 week, and CCI termination (mean, 6 weeks). Thirty-one subjects (84%) were also evaluated at 1-year and 2-year follow-up. We found that working alliance and development of insight predicted positive global change and symptom improvement at 1 and 2 years' follow-up. Furthermore, the observed correlation between process measures and 2-year outcome was found to be independent of age, sex, symptoms severity at intake, improvement of symptoms at CCI termination, premorbid adjustment, DSM-III-R axis I/axis II diagnosis, and therapeutic alliance at intake.

Psychotherapy research between process and effect: the need of new methodological approaches

The methodological problems and scanty results of psychotherapy research are noted and placed in a metascientific context. Efforts to attain ever greater specificity and standardization, guided by the idea of uniform methodology, are leading researchers steadily further away from the unique case. The underlying assumptions in current psychotherapy research are defined and the necessity of returning to case studies is indicated. Research methods need to be relevant and to make use of essential aspects of what is being researched (care of the research object). Psychotherapy research cannot avoid interpretations of meaning, and clinical methods should have a steering role. Case-study methods lead to specific problems of control and generalization. The scientific research strategy used in case studies is described and compared with the hermeneutic circle.

Borderline defenses and countertransference: research findings and implications

Among Main's (1957) several cogent insights about the nature of defensive and countertransferential reactions to those so-called "special" patients who ungraciously refuse to improve - patients who in today's parlance would most assuredly be diagnosed as borderline - is his hypothesis that some of us may flee some of the time into research activities to avoid the frustrations and disappointments of clinical work. Writing from the dual perspectives of researchers and psychotherapists, and with the interest of furthering the integration of these often split-off enterprises, we offer some observations on the amassing body of empirical data about the borderline patient, observations which bear upon and lend support for Main's speculation regarding the detachment of researchers from the emotionally charged dilemmas facing the therapist in working with the borderline patient. We also present some findings from our ongoing investigations of borderline dynamics in groups and organizations, which underscore the role of defensive and countertransferential processes in the psychotherapeutic treatment of borderlines. Finally, based upon our observations of the extant data as well as our own findings, we offer a suggestion about the direction of future research on borderline pathology, proposing a shift away from the largely descriptive-level diagnostic studies and toward the investigation of the therapeutic relationship, with a particular focus on countertransferential dynamics.