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The Development of a Psychodynamic Treatment for Patients with Borderline Personality Disorder: A Preliminary Study of Behavioral Change

  • Instituto Medico Schilkrut, Santiago Chile

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This study examines the effectiveness of a modified psychodynamic treatment called Transference Focused Psychotherapy (TFP) designed specifically for patients, with borderline personality disorder (BPD). Twenty-three female patients diagnosed with DSM-IV BPD began twice-weekly TFP. Patients were assessed at baseline and at the end of 12 months of treatment with diagnostic instruments, measures of suicidality, self-injurious behavior, and measures of medical and psychiatric service utilization. Compared to the year prior to treatment, the number of patients who made suicide attempts significantly decreased, as did the medical risk and severity of medical condition following self-injurious behavior. Compared to the year prior, study patients during the treatment year had significantly fewer hospitalizations as well as number and days of psychiatric hospitalization. The dropout rate was 19.1%. This uncontrolled study is highly suggestive that this structured and manualized psychodynamic treatment modified for borderline patients shows promise for the ambulatory treatment of these patients and warrants further study.
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John F. Clarkin, PhD, Pamela A. Foelsch, PhD, Kenneth N.
Levy, PhD, James W. Hull, PhD, Jill C. Delaney, MSW, and
Otto F. Kernberg, MD
This study examines the effectiveness of a modified psychodynamic
treatment called Transference Focused Psychotherapy (TFP) designed
specifically for patients with borderline personality disorder (BPD).
Twenty-three female patients diagnosed with DSM-IV BPD began
twice-weekly TFP. Patients were assessed at baseline and at the end of 12
months of treatment with diagnostic instruments, measures of
suicidality, self-injurious behavior, and measures of medical and psychi-
atric service utilization. Compared to the year prior to treatment, the
number of patients who made suicide attempts significantly decreased,
as did the medical risk and severity of medical condition following self-in-
jurious behavior. Compared to the year prior, study patients during the
treatment year had significantly fewer hospitalizations as well as number
and days of psychiatric hospitalization. The dropout rate was 19.1%.
This uncontrolled study is highly suggestive that this structured and
manualized psychodynamic treatment modified for borderline patients
shows promise for the ambulatory treatment of these patients and war-
rants further study.
Borderline personality disorder (BPD) is a highly prevalent and chronic psy-
chiatric problem and constitutes one of the most important sources of
long-term impairment in both treated and untreated populations
(Weissman, 1993; Oldham, et al., 2000). Approximately 11% of psychiatric
outpatients and 19% of inpatients meet the DSM-IV (American Psychiatric
Journal of Personality Disorders, 15(6), 487-495, 2001
© 2001 The Guilford Press
From the Personality Disorders Institute and Department of Psychiatry, Weill Medical College
of Cornell University.
This research was supported in part by grant MH-53705-02from the National Institute of Men-
tal Health, Washington, DC. (PI: Dr. Clarkin), and the DeWitt Wallace Reader’s Digest Fund.
The authors wish to thank Jack Barchas, MD, for institutional support. We acknowledge the
consultation of Marsha Linehan, PhD, to this study, the assistance of Heidi Heard, PhD, in
training with the PHI and THI, and the suggestions of Gerhard Dammann, MD. The authors
wish to thank our colleagues who served as therapists in the study. We would also like to thank
Ann Appelbaum, MD, Michael Stone, MD, and Frank Yeomans, MD, for providing therapy su-
pervision. Finally, we would like to thank members of the Personality Disorders Institute.
Address correspondence to John F. Clarkin, PhD, Personality Disorders Institute, Macy Villa,
The New York Presbyterian Hospital-Weill Medical College of Cornell University, Westchester
Division, 21 Bloomingdale Road, White Plains, NY 10605; E-mail:
Association, 1994) criteria for BPD (Skodol, et al., 2001). Suicidal
(McGlashan, 1986; Stone, 1993) and self-injurious behavior is particularly
prevalent among BPD patients, with rates ranging from 69% to 75%
(Cowdry, Pickar, & Davies, 1985; Clarkin, Widiger, Frances, Hurt, &
Gilmore, 1983).
Psychotherapy is the most widely practiced technique for treating border-
line patients. Among other common treatment approaches to BPD is the ob-
ject relations approach based on Kernberg’s clinical theorizing (1984,
1996). Kernberg and his colleagues have published a treatment manual de-
scribing a modified psychodynamic treatment of patients with borderline
personality organization called Transference-Focused Psychotherapy (TFP;
Clarkin, Yeomans, & Kernberg, 1999).
TFP relies principally on the techniques of clarification, confrontation,
and interpretation within the evolving transference relationship between
the patient and the therapist. The primary focus of TFP is on the dominant
affect-laden themes that emerge in the relationship between borderline pa-
tients and their therapists in the here-and-now of the transference. During
the first year of treatment, TFP focuses on a hierarchy of issues: the contain-
ment of suicidal and self-destructive behaviors, the various ways of destroy-
ing the treatment, and the identification and recapitulation of dominant
object relational patterns, as they are experienced and expressed in the
here-and-now of the transference relationship. Although psychoanalytic
psychotherapy based on Kernberg’s theory is a widely practiced technique
for treating BPD, research concerning the effectiveness and efficacy is lim-
ited and is greatly needed.
We report findings from an NIMH-funded treatment development study ex-
amining pre-post changes observed in the 1-year outpatient treatment of
borderline patients with TFP. Our primary hypotheses were that subjects
would show a significant reduction in the number and severity of suicidal
and self-injurious behavior; a decrease in physical harm resulting from sui-
cidal and self-injurious behavior; a significant reduction in hospitaliza-
tions, emergency room visits, and number of days hospitalized; and
improved psychosocial functioning.
Subjects were recruited from all treatment settings (i.e., inpatient, day hos-
pital, and outpatient clinics) within the New York-Presbyterian Hospi-
tal—Weill Cornell Medical Center system. Written informed consent was
obtained after all study procedures had been explained. Potential subjects
were screened with both clinical and semi-structured interviews. Women
who met the following selection criteria were eligible for the study: (1) five or
more DSM-IV criteria for BPD as assessed on the SCID-II; (2) at least two in-
cidents of suicidal or self-injurious behavior in the last 5 years; (3) absence
of DSM-IV criteria for schizophrenia, bipolar disorder, organic pathology,
and/or mental retardation as assessed using the SCID-I; (4) between the
ages of 18 and 50; and (5) agreement to the study conditions, including ter-
mination from other individual psychotherapy. Upon admission to the
study, patients were given a number of additional assessment instruments
described in detail below. Subjects were reevaluated after 12 months of
Twenty-three patients met criteria for BPD, agreed to the study conditions,
and entered the treatment. Two patients dropped out around the 4-month
mark and two patients dropped out after 8 months of treatment. An addi-
tional two patients were administratively discharged from TFP early in the
process because of protocol violations (i.e., consistent failure to adhere to
the treatment contract despite verbal assurances to the contrary).
The treatment group (N = 17) had a mean age of 32.7 years (SD = 7.52;
range of 19 to 48). Thirteen (76.5%) subjects were Caucasian, and four
(23.5%) were Hispanic. Ten were single and never married, four were mar-
ried, and three divorced. At the beginning of the treatment period, eight
were unemployed, seven worked at the technical or clerical level, one was a
minor professional, and one was a student/homemaker. Most subjects met
criteria for more that one Axis I disorder and at least one Axis II personality
disorder. The most common clinical Axis I diagnoses in this sample were:
major depression (n = 8; 47.1%); dysthymia (n = 4; 23.5%) and eating disor-
der (n = 3; 17.6%). The most common Axis II conditions comorbid with BPD
were narcissistic (82%), paranoid (76%), obsessive compulsive (71%), and
avoidant personality disorder (65%).
The therapists ranged from six experienced, senior individuals with at least
10 years of experience, to six faculty/staff psychologists and postdoctoral
trainees in psychology, all of whom had 2 or more years of experience treat-
ing BPD patients with psychodynamic treatment and training in TFP. All
therapists selected for this phase of the study were judged by independent
supervisory ratings to be both competent and adherent to the TFP manual.
Throughout the study, all therapists regularly videotaped sessions and
were supervised on a weekly basis. Consensual adherence and competence
ratings were made during the weekly supervision sessions.
The Parasuicidal History Interview. (PHI; Linehan, Wagner, & Cox, 1989)
was used to assess the number of suicidal and parasuicidal behaviors as
well as the medical severity and physical outcomes of these behaviors for
the year prior to treatment and during the treatment year. The methodology
for assessing medical risk and physical condition was derived using the
scales described by Linehan (Linehan, Wagner, & Cox, 1989).
The Treatment History Interview. (THI; Linehan, 1987) was used to as-
sess the types and amount of treatment received during the target period,
including emergency room visits, and number and length of psychiatric
The Global Assessment of Functioning Scale. (GAF; APA, 1994) provides
a single global rating of functioning and symptomatology. We used a modi-
fied version of the GAF included in DSM-III-R. In this version, scores range
from a low of 1 (e.g., needs constant supervision, serious suicide act with
clear intent and expectation of death) to a high of 90 (e.g., superior function-
ing in a wide range of activities, no symptoms).
Two sets of analyses were conducted. The first set compared pre- and
post-treatment scores in the intent-to-treat group, that is, all patients who
agreed to enter treatment. The intent-to-treat group included the 17 pa-
tients who completed TFP, the 4 therapy dropouts, and the 2 subjects who
were administratively discharged (N= 23). In order to be statistically conser-
vative, pretreatment scores were carried forward in those cases where
post-test scores were not available. The two subjects who were administra-
tively discharged were only available at pre-treatment. The second set com-
pared patients who completed TFP (N=17) pre- and post-treatment. For both
analyses, three repeated multivariate analyses of variance measures
(MANOVAs) were performed, one on the set of suicide variables (number of
suicide attempts, average medical risk of all attempts, average resulting
physical condition after the attempts), one on the set or parasuicide vari-
ables (number of parasuicide attempts, average medical risk of all attempts,
average resulting physical condition after the attempts), and finally, one for
the set of treatment utilization variables (number of hospitalizations and
length of hospitalizations). In each MANOVA, time was the repeated factor
and there was no between-subjects grouping variable. Individual treatment
effects were considered significant only when the overall multivariate model
was significant and the
level for the individual effect was less than 0.05. All
comparisons employed two-tailed tests. For each outcome variable, we also
investigated the effect size that treatment had on outcome using a formula
provided by Cohen (1992). In that formula, effect size equals the difference
in mean score pre- and post-treatment divided by the pre-therapy standard
Before analyzing pre-post changes for the intent-to-treat group and treat-
ment completers, demographic and study variables were compared for pa-
tients who completed treatment and those who declined to enter treatment,
dropped out, or were administratively discharged using chi-square analysis
and t-test for independent samples. There were no significant differences
between the groups in terms of age, education, employment, marital status,
ethnicity, or religion. Similarly, no significant differences were found be-
tween the groups in distribution of Axis I and II diagnoses except for the di-
agnosis of schizoid personality disorder based on the SCID-II-Q. Those in
the treatment group were more likely to meet criteria for schizoid personal-
ity disorder (treatment completers = 6 [35%]; treatment decliners, dropouts,
and discharged = 0;
= 6.52, p
.01). We also compared the two groups on
the amount of psychotropic medications prescribed and used. Results of
chi-square analyses indicated that at pre-treatment there were no be-
tween-group differences in the number of subjects using psychotropic med-
For both the intent-to-treat and the completer analyses, the overall
multivariate model was not significant for the set of suicide variables. Al-
though the multivariate results were not significant, we did observe a sugges-
tive decrease in the number of suicide attempts from the year prior to the
treatment year (see Table 1). In addition, a decrease is also reflected in the
number of patients who made suicide attempts. In the prior year, 9 of the 17
(53%) patients made a suicide attempt, and during the 1-year treatment, only
3 of 17 (18%) made such an attempt (McNemar’s test (1) = 4.64, p =
For the completer analyses, the overall multivariate model was significant
for the parasuicide variables (Pillai’s trace = 0.42, F(3,14) = 3.38, p
.05). In
the intent-to-treat group, this model approached significance (Pillai’s trace
= 0.31, F(3,20) = 3.01, p
.06). Means, standard deviations, F tests, and ef-
fect sizes from subsequent univariate tests are shown in Table 1. There was
not a significant decrease in the number of self-injurious behaviors, but
there was a significant decrease in average medical risk and average physi-
cal condition following such incidents. The intent-to-treat results parallel
these results for completers.
With regard to service utilization, the overall MANOVA was significant for
the completer group (Pillai’s trace = 0.35, F(2,15) = 3.97, p
.05) as well as
the intent-to-treat group (Pillais trace = 0.26, F(2,21) = 3.61, p
Means, standard deviations, F tests, and effect sizes from subsequent
univariate tests for these models are shown in Table 1. There was a signifi-
cant reduction in the number of hospitalizations (72%) for the completer
group, with the reduction in days hospitalized approaching significance
(88%, p
.06). Parallel results were obtained for the intent-to-treat group.
The magnitude of effect was investigated by calculating the effect size (d) for
each of the variables. Almost all of the effect sizes indicated favorable
change. The average effect sizes were 0.38 and 0.56 for the intent-to-treat
analyses and completer analyses, respectively.
We examined the treatment outcome for patients diagnosed with BPD who
were treated in a 1-year modified psychodynamic outpatient psychother-
apy. The major finding in this study is that TFP appears to be a promising
psychotherapeutic technique that warrants additional research. In both the
intent-to-treat and treatment completion groups, borderline patients re-
ceiving TFP showed considerable improvement in a number of important ar-
The 1-year dropout rate was low (19.1%; 4 of 21 of patients dropped out of
treatment) and no patient committed suicide. This dropout rate compares
well with previous studies (Bateman & Fonagy, 1999; Linehan, Armstrong,
Suarez, Allmon, & Heard, 1991; Linehan, Schmidt, Dimeff, & Craft et al.,
1999; Stevenson & Meares, 1992), which reported a range between 16.7% to
21.0%. Additionally, none of the treatment completers deteriorated or were
adversely affected by the treatment. Therefore, it appears that TFP is toler-
ated quite well.
There was a significant reduction in the number of patients who had made
a suicide attempt during the treatment year compared with the year prior to
treatment (18% vs. 53%). However, the number of suicide attempts, the
medical risk of these acts, and the patients’ physical condition afterward
were not significantly improved. Although non-suicidal self-injurious be-
TABLE 1. Univariate Tests on the Intent-to-Treat Group and the Computer Group
Intent-To-Treat Analysis (N = 23)
Baseline Follow-up
M SD M SD F df p d prime
Number of Incidents
4.39 6.34 3.44 4.57 0.60 1,22 0.45 0.15
Medical Risk
2.06 1.17 1.62 1.24 6.88 1,22 0.02 0.37
Physical Condition 2.10 1.24 1.54 1.17 8.46 1,22 0.01 0.46
Pillai’s trace = 0.31,
(3,20) = 3.01,
< .06.
Hospitalizations 1.48 1.59 0.83 1.4 6.89 1,22 0.02 0.41
Days Hospitalized 55.33 84.32 29.7 70.83 4.21 1,22 0.06 0.31
Pillai’s trace = 0.26, F(2,21) = 3.61,
< .05.
Completer Analysis (N = 17)
Baseline Follow-up
M SD M SD F df p d prime
Number of Incidents 5.18 7.25 4.24 5.08 0.6 1,16 0.45 0.13
Medical Risk
1.72 1.13 1.14 0.99 7.61 1,16 0.02 0.51
Physical Condition
1.89 1.31 1.12 0.99 9.64 1,16 0.01 0.58
Pillai’s trace = 0.42,
(3,14) = 3.38,
< .05.
1.24 1.35 0.35 0.61 7.63 1,16 0.02 0.61
Days Hospitalized 39.21 67.03 4.53 9.61 4.45 1,16 0.06 0.52
Pillai’s trace = 0.35,
(2,15) = 3.97,
< .05.
havior did not decrease in frequency, the medical risk was significantly re-
duced, and the physical condition of the patients was significantly
Compared to the year prior, study patients during the treatment year had
significantly fewer psychiatric hospitalizations (67% reduction) and days of
inpatient hospitalization (89% reduction). While 64.7 % of patients were
hospitalized the year prior, only 29.4 % were hospitalized during the treat-
ment year.
Two other points are worth noting. First, TFP relies principally on trans-
ference interpretations, which are controversial (Piper, Azim, Joyce, &
McCallum, 1991; Gabbard, 1991). Future research should examine the role
of transference interpretation more directly as one of the specific mecha-
nisms of change in TFP. Second, Linehan et al. (1991), Stevenson and
Meares (1992), Bateman and Fonagy (1999), and this study all employed
close supervision, a team approach, and provided structured treatments.
Future research should examine these as common factors in the successful
treatment of BPD.
As a preliminary study, there are a number of design issues that limit the
interpretation and the generalizability of our results. First, the absence of a
comparison group limits the interpretation of positive change, as the
changes we observed in our patients may have occurred over time without
TFP or even without treatment. However, previous research with borderline
patients has found fair stability over 2- to 5-year periods in terms of the di-
agnosis and severity of emotional difficulties (Hoke, Lavori, & Perry, 1992;
Vaglum, Friis, Karterud, Mehlum, & Vaglum, 1993). Nevertheless, a ran-
domized controlled trial of TFP would constitute a more stringent test of the
efficacy of this treatment, and with the positive results presented here we
are proceeding to such a study.
The sample in the present study was a relatively homogeneous group of
severely disturbed, chronically self-destructive borderline women. It is un-
clear if our results would generalize to less severely disturbed borderline in-
dividuals or whether the treatment would be as effective for men.
Another important issue with regard to generalizability concerns the fact
that none of our treated patients was currently abusing substances at the
time of entry into the study. A number of studies have found a high preva-
lence of alcohol and substance use in individuals with BPD. Although none
of our patients met criteria for alcohol or substance dependence at the be-
ginning of treatment, more than half of our treatment completers (N = 9) had
significant drug use/abuse histories. Therefore, while our findings may not
generalize to patients with current alcohol or substance dependence, cer-
tainly our findings are generalizable to borderline patients with significant
drug and/or alcohol histories.
This study, which used the patients as their own controls, is highly sugges-
tive that extended TFP is well-tolerated and may result in considerable im-
provement in functioning in a broad range of areas. Based on the present
findings, future research with TFP is warranted. Future studies should in-
clude a randomized controlled trial of TFP, as well as an exploration of the
treatment process and underlying mechanisms of action that result in
change for these patients (Shea, Benjamin, Clarkin, & Magnativa, 1999).
Additionally, given the severity and chronicity of BPD, follow-up data is im-
perative to establish the long-term significance of these findings.
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... As with other treatment modalities, including short term psychodynamic psychotherapy, Dialectical Behavioral Therapy, mentalization-based therapy and schema-focused therapy, there are no randomized controlled trials (RCTs) of TFP for NPD only (Diamond et al., 2022). However, in two RCTs Doering et al., 2010) and one uncontrolled trial (Clarkin et al, 2001), TFP was shown to be effective treatment for patients with combined BPD and NPD. TFP has been found to improve mood symptoms such as depression and anxiety as well as psychosocial functioning, and impulsive aggression and suicidality and self-injurious behaviors (Clarkin et al 2001;Doering et al., 2010) in patients with severe personality disorders. ...
... However, in two RCTs Doering et al., 2010) and one uncontrolled trial (Clarkin et al, 2001), TFP was shown to be effective treatment for patients with combined BPD and NPD. TFP has been found to improve mood symptoms such as depression and anxiety as well as psychosocial functioning, and impulsive aggression and suicidality and self-injurious behaviors (Clarkin et al 2001;Doering et al., 2010) in patients with severe personality disorders. These improvements benefit patients with NPD who often have co-morbid anxiety and mood disorders as well as substance use disorders (Hörz-Sagstetter et al., 2018). ...
Transference-focused psychotherapy (TFP) is an evidence-based, psychodynamic psychotherapy empirically validated for patients with borderline personality disorder (BPD) and successfully adapted for the treatment of narcissistic personality disorder (NPD). Personality disorders are characterized by the behavioral and affective dysregulation associated with pathological identity formation. Based on contemporary object relations theory (ORT), the goal of TFP is symptom relief through improvement in self and interpersonal functioning. The TFP treatment frame, established through an initial contracting phase and combined with the therapist’s technical neutrality, facilitates activation, identification and containment of affectively charged perceptions of self and other. These perceptions, or object relations dyads, are repeatedly identified, labeled and explored through the interpretative process. Over the course of treatment, the patient’s capacity for affect containment and reflection improves and a better integrated, realistic sense of self develops consistent with healthier personality functioning. Utilizing a compilation of several patients, the treatment of NPD with TPF is described and the evidence for the efficacy of TFP for NPD is summarized.
... Researchers examining risk-related issues in youth and adults have reported complex methodological constraints on longitudinal studies for the past decades [41,42]. At the same time, in acknowledging such constraints, authors like Pierrat et al. [16] have recommended the use of qualitative methods as complementary methodologies in neonatology research to address some of the methodological challenges in longitudinal research with neonates, for example, maintaining the same sample for different age cohorts, using the same measurement tool over time [43,44]; being constrained to smaller samples, and experiencing large attrition rates [45]. ...
Background: A methodological review of 78 empirical articles focusing on the neurodevelopmental outcomes of at-risk infants was conducted. Aims: To examine ways language and terminology are used to describe methods, present results, and/or state conclusions in studies published during 1994-2005, a decade reflecting major advances in neurodevelopmental research and in medical intervention. More specifically, to investigate to what extent the design of the study and the language in the results section aligned in regard to causality. Methods: A process of search and selection of studies published in pediatric journals was conducted through Google Scholar. Criteria of inclusion and exclusion, following PRISMA, were used. Selected studies reported neurodevelopmental outcomes of infants and young children considered at-risk, and were further categorized accordingly to their study designs. Language use in regard to whether the presentation and interpretation of results may convey causal relationships between birth risk factors and neurodevelopmental outcomes was examined following two analytical steps. Results: Forty out of 78 studies, (51.28 %) used causality-implying language (e.g., effect, predict, influence) notwithstanding that the study design was non-causal. Conclusions: Anticipating the next generation of neurodevelopmental-outcomes research, a framework that aims to raise awareness of the importance of language use and the impact of causality-related terms often used in longitudinal studies is proposed. The objective is to avoid ambiguities and misunderstandings around causal or non-causal connections between birth risk factors and developmental outcomes across diverse audiences, including early intervention practitioners working directly with infants and their families.
... Finally, should adolescents be challenged with persistent identity formation problems and be at risk of developing psychopathology, they should be able to receive psychotherapy that includes identityspecific modules prioritizing the treatment of problems related to self and identity. Effective evidence-based interventions for treating both symptom and personality disorders, consisting of (among others) Mentalization-Based Treatment (MBT; 97), Dialectical Behavior Therapy (DBT; 98), and Transference-Focused Psychotherapy (TFP; 99), have been adapted for use in adolescents. All of these interventions assume that psychopathology results in part from a poorly developed, unstable, or negative sense of self and others, and may thus be effective in bolstering identity development in adolescence. ...
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To advance our understanding of adolescents’ identity formation and how it may play into their psychological functioning, this study investigated developmental trajectory classes of adaptive and disturbed dimensions of identity formation, and whether adolescents belonging to different trajectory classes develop differently on self-esteem, resilience, symptoms of depression, and borderline personality disorder (BPD) features. Three-wave longitudinal data from 2,123 Flemish adolescents was used (54.2% girls; Mage = 14.64, range = 12–18 at T1). Results pointed to four trajectory classes of identity formation: adaptive identity, identity progression, identity regression, and diffused identity. The adaptive identity class presented with stable high levels of self-esteem and resilience, and stable low levels of symptoms of depression and BPD, whereas opposite results were obtained for the diffused identity class. The identity progression class reported an increase in self-esteem and resilience as well as a decrease in symptoms of depression and BPD, whereas opposite results were obtained for the identity regression class. These results emphasize that adaptive and disturbed dimensions of identity formation are closely related to markers of well-being and psychopathology among adolescents, and could help identify adolescents with an increased risk for negative psychological functioning or increased opportunity for positive psychological functioning.
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The chapter deals with psychodynamic therapeutic approaches to treating patients with problems in violence and aggression. Within psychodynamic therapies, two approaches can be differentiated: One is the more classic insight‐oriented approach and the other aims more to enhance personality functioning. After a description of the common principles of psychodynamic treatment, recommendations for adaptation when treating violent patients are discussed. A systematic review shows promising results for psychodynamic individual and group therapies as well as integrated therapeutic approaches.
Counseling performers in distress is a highly gratifying yet complex professional endeavor that requires the practitioner to be flexible, self-aware, and committed to engaging in evidence-based practice regularly guided by the ever-evolving scientific literature. Performers come to the attention of sport/performance psychologists with an array of personal needs and levels of psychological distress. To effectively meet their needs, practitioners must have a conceptual understanding of the construct of distress, be able to assess distress along the continuum of severity, determine appropriate targets of intervention, and choose an efficacious intervention that remediates subclinical or clinical concerns while promoting psychological health and well-being. This chapter therefore provides a conceptual and practical understanding of the nonclinical, subclinical, and clinical needs of performers; describes an evidence-based approach to assessment and treatment; and highlights how setting, counselor, client, and cultural variables can affect the counseling process.
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Based on interview data from 76 18–45 yr old outpatients, the implications of a prototypic rather than a classical model of personality-disorder classification were demonstrated for DSM-III Axis II Borderline Personality Disorder (BPD). Heterogeneity of membership is described, and conditional probabilities are used to demonstrate the relative efficiency of single diagnostic criteria and combinations of criteria and the degree of overlap among BPD and other personality disorders. The conditional probability approach can be used to determine empirically the covariation of symptoms and to link the study of prototypicality to the individual patient rather than to the group. (17 ref) (PsycINFO Database Record (c) 2012 APA, all rights reserved)
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This study evaluated the effectiveness of well-defined outpatient psychotherapy for patients with borderline personality disorder. Thirty patients with borderline personality disorder diagnosed according to the DSM-III criteria were given twice weekly outpatient psychotherapy for 12 months by trainee therapists who were closely supervised. The treatment approach was based on a psychology of self (this term being used in its broad sense), and strong efforts were made to ensure that all therapists adhered to the treatment model. Outcome measures included frequency of use of drugs (both prescribed and illegal), number of visits to medical professionals, number of episodes of violence and self-harm, time away from work, number of hospital admissions, time spent as an inpatient, score on a self-report index of symptoms, and number of DSM-III criteria (weighted for frequency, severity, and duration) fulfilled. The subjects showed statistically significant improvement from the initial assessment to the end of the year of follow-up on every measure. Moreover, 30% of the subjects no longer fulfilled the DSM-III criteria for borderline personality disorder. This improvement had persisted 1 year after the cessation of therapy. The results suggest that a specific form of psychotherapy is of benefit for patients with borderline personality disorder.
To study the diagnostic stability of severe personality disorder (PD) diagnoses (Cluster A and/or B) over time and using a European sample, 73 day patients were followed over a period of mean 2.8 years and rediagnosed by means of the Structured Clinical Interview for DSM-III-R. Among the severe PD patients (n = 37), only 4 (11%) were clearly without severe personality problems at follow-up, although 11 (30%) had their severe PD diagnosis removed as a result of the follow-up interview. Only 5% of the patients initially with no PD or a Cluster C disorder were given a severe PD diagnosis at follow-up. The findings validate the concept of severe PD diagnoses being related to long-standing dysfunctional traits and behavior. The question should also be raised whether the diagnostic stability in previous studies has been underestimated due to reliability problems.
• Relationships between the proportion of transference interpretations provided by therapists and both therapeutic alliance and therapy outcome were investigated for a sample of 64 patients who had received approximately 20 sessions of short-term individual psychotherapy within a controlled, clinical trial investigation. Inverse relationships were found between the proportion of transference interpretations and both therapeutic alliance and favorable therapy outcome for patients with a history of high quality of object relations. An examination of individual sessions revealed evidence that was consistent with two different, but not mutually exclusive, causal explanations. The first concerned the negative effects of high proportions of transference interpretations; the second concerned the reaction of the therapist to the presence of a weak therapeutic alliance. While the evidence from our study was correlational, it was sufficiently strong to warrant alerting clinicians to the possibility of negative treatment effects when high levels of transference interpretations are used with certain types of patients receiving short-term individual psychotherapy.
Reviews the problems in epidemiologic studies of personality disorders (PDs) and the available epidemiologic data on rates and associated risk factors. Although this 1990 update shows the availability of more data, only about 1,300 Ss with PDs have been studied, and only 6 methods of assessment have been used. The overall lifetime rate of an Axis II disorder is in the range of about 10/100–23/100. Paranoid, schizoid, and narcissistic PDs are uncommon, with a lifetime rate of less than 1/100. The data are best for antisocial personality, which suggests a lifetime rate of 2/100–3/100 in the US, Canada, and New Zealand, and a considerably lower rate in Taiwan. The possibility of developing an epidemiology of PD based on community studies is addressed. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
A randomized clinical trial was conducted to evaluate whether Dialectical Behavior Therapy (DBT), an effective cognitive-behavioral treatment for suicidal individuals with borderline personality disorder (BPD), would also be effective for drug-dependent women with BPD when compared with treatment-as-usual (TAU) in the community. Subjects were randomly assigned to either DBT or TAU for a year of treatment. Subjects were assessed at 4, 8, and 12 months, and at a 16-month follow-up. Subjects assigned to DBT had significantly greater reductions in drug abuse measured both by structured interviews and urinalyses throughout the treatment year and at follow-up than did subjects assigned to TAU. DBT also maintained subjects in treatment better than did TAU, and subjects assigned to DBT had significantly greater gains in global and social adjustment at follow-up than did those assigned to TAU. DBT has been shown to be more effective than treatment-as-usual in treating drug abuse in this study, providing more support for DBT as an effective treatment for severely dysfunctional BPD patients across a range of presenting problems.
One possible reason for the continued neglect of statistical power analysis in research in the behavioral sciences is the inaccessibility of or difficulty with the standard material. A convenient, although not comprehensive, presentation of required sample sizes is provided here. Effect-size indexes and conventional values for these are given for operationally defined small, medium, and large effects. The sample sizes necessary for .80 power to detect effects at these levels are tabled for eight standard statistical tests: (a) the difference between independent means, (b) the significance of a product-moment correlation, (c) the difference between independent rs, (d) the sign test, (e) the difference between independent proportions, (f) chi-square tests for goodness of fit and contingency tables, (g) one-way analysis of variance, and (h) the significance of a multiple or multiple partial correlation.
This report addresses the need for prospective studies of personality disorders, as well as some of the difficulties encountered in longitudinal studies when missing data occur due to subject attrition and variable follow-up intervals. Various statistical methods for handling repeated measurements data are reviewed. Many of these methods are quite complex and require expert statistical skills. A simpler way to handle multivariate data using single-number summary scores is proposed as an alternative which is efficient and more readily understood by professionals in many disciplines. Findings are presented from a prospective study of borderline personality disorder which utilized repeated observations over time. Individual regression models were applied to each subject's repeated measurements to obtain a summary of his or her trend on measures of mood and global functioning. The individual regressions produced separate statistics, slopes summarizing rates of change and intercepts which estimated initial levels of functioning. These summaries were then used in group analyses. Findings indicated that subjects showed mild to moderate impairment in mood and moderate impairment in overall functioning. The individual slopes indicated that little overall change was observed during the 5-year period after initial assessment. Neither presence of borderline diagnosis (definite vs. trait vs. no borderline diagnosis) nor gender predicted initial levels of functioning or rates of change. Further examination of other predictors which may influence longterm outcome, such as history of childhood trauma or presence of schizotypal personality features, is suggested. It is concluded that prospective studies are essential in establishing the validity of personality disorders and in understanding individual variation in outcomes.