Citation

López D, Cuevas P, Gomez A, Mendoza J. Salud Ment. (Mex) 2004; 27(4): 44-54.

Copyright

(Copyright © 2004, Instituto Mexicano de Psiquiatria)

DOI

unavailable

PMID

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Abstract

The objective of the study was to observe the changes in the psychopathology of women with Borderline Personality Disorder (BPD) after 48 sessions of Transference-Focused Psychotherapy (TFP) conducted by novel therapists, videotaped and supervised by experts. TFP is a specific treatment based on a manual, with two weekly individual sessions for BPD and also for the narcissistic and histrionic personality disorders. The treatment was developed in the last 20 years by Kernberg and colleagues at the Institute of Personality Disorders, Cornell Medical Center, according to the USA National Institute of Mental Health requirements. Transference-Focused Psychotherapy is important because it provides a systematic guide for the containment and analysis of the victim-victimizer and rescued-rescuer transference-countertransference paradigms that arise along the treatment sessions which, if not properly handled, are responsible for the failure of most treatments of BPD patients. Before starting TFP, a therapy contract is set with detailed prescriptions for the management of suicidal behavior (the patient must accept to self- contain suicidal urges in order to receive the treatment), other forms of impulsivity, affective instability and alterations of identity related to destructive decisions regarding leaving home, school or work, use of illegal and prescribed drugs and taking proper care of mental and physical comorbidities. Most BPD patients receive "treatment as usual" (TU) with supportive therapy, short and erratic courses of medication and brief hospitalisations. This is done despite the existence of specific therapies for them as psychodynamic therapy, supportive therapy, group therapy, family therapy and reliable and well- studied prolonged regimes of medications with fluvoxamine, olanzapine, valproate and omega fatty acid. Drop out rate of TU is almost 60% and the remaining patients exhibit little improvement even with several years of therapy conducted by experienced therapists. Specific therapies for BPD, besides TFP, are Linehan's Dialectical Behavioral Therapy (DBT) and Bateman and Fonagy's Partial Hospitalization (PH) treatment (these two treatments use a combination of individual and group therapies) and Stevenson and Meares's Self Psychotherapy (SP) (two individual sessions a week closely supervised in a weekly meeting with all therapists). These four therapies are effective for reducing the more destructive BPD manifestations within 12 to 18 months of treatment. Drop out rates are: PFT, 19.1%; DBT, 16.7%; PH, 12% and SP, 16%. In all these therapies, impulsivity and affective instability begin to remit after four to six months of treatment and the alterations of identity and the BPD diagnosis do not disappear at the end of the treatment. In a previous study carried out by some of us with experienced (mean experience, 12 years; S.D.=1.15) and novel therapists (mean experience, 4.67 years; S.D.=4.23), where the experience of each group was significatively different (U=7.5, p<.002), impulsivity remitted after 24 sessions and affective instability remitted almost completely after 48 sessions in 11 out of 19 patients of both sexes who were offered a two-year treatment with videorecorded supervised TFP. There were no differences in results between both groups of therapists. With that background, we planned the present study which, as far as we know, is the first TFP study with 48 sessions delivered only by novel therapists. The research project was approved by the Anahuac University research and ethical committees. Patients were recruited from respondents to an offer of treatment for BPD at the university psychotherapy clinic. Selection of patients was made with clinical and semi-structured interviews using the SCIDI and the SCID II. At least one of the supervisors interviewed all patients and their families and offered to be available in the case of emergencies for patients, families and therapists. Inclusion criteria were: being 18 to 40 years old; meeting the first three criteria and two other of the remaining six BPD criteria; having graduated at least from junior high school, and not suffering from schizophrenia, bipolar disorder, delusional disorder, severe substance abuse, severe mental organic disorder or antisocial disorder. Therapists were selected among recent graduates from the Anahuac University psychotherapy post-graduate program after attending two semesters on BPD psychopathology and therapy and a 20-hours course on the treatment manual given by the supervisors. Seven therapists, six female and one male, agreed to participate. Supervisors were two training analysts from the Mexican Psychoanalytic Association, trained in the treatment manual by Kernberg and colleagues at the Institute of Personality Disorders, Cornell Medical Center, in 1993. Training analysts hold at least a yearly meeting with Kernberg's group in order to guarantee adherence to the manual. The supervisors have taught extensively how to use the treatment manual in Mexico City and other Mexican cities. The supervisors explained to the patients and their families the nature and procedures of the treatment. They also explained to them that the use of the videorecordings would be only for research purposes and asked patients to sign an informed consent letter. Fourteen patients agreed to initiate therapy. Their mean age was 25 years, all of them were middle class and had a high education level. Nine had suicidal behavior and all suffered emotional outbursts and instability in vocational and value systems. All patients met criteria for BPD (1, 2, 3 and any two other of the remaining six), impulsivity (1 and 4 or 5), affective instability (2 and 6 or 8) and identity alterations (3 and 7 or 9). Four (29%) of them dropped out before reaching 24 sessions due to severe conflicts with parents and 10 completed 48 sessions. The manual used was Psychotherapy for Borderline Personality by Clarkin, Yeomans and Kernberg, a 370 pages text which contains a detailed theoretical and clinical presentation of the therapy aims, objectives, strategies, tactics, techniques, clinical assessment, therapy contract, phases of treatment and how to handle emergencies and comorbidities. Assessment evaluations were made at the time of entry, and after 24 and 48 sessions with the SCID II BPD section, the DSM IV Global Assessment of Functioning Scale (GAF) and the SCL 90. These instruments have a good reliability and validity in measuring changes during psychotherapy. Sessions were conducted in well adapted psychotherapy consulting rooms. Videorecordings were made having the vidoecamera inside the consulting room, handled by each therapist and always asking patients if they agreed with the procedure. All ten patients agreed in all sessions to do the videorecordings. Supervisions were carried out each week during three hours sessions attended by all therapists, the supervisors and the clinical coordinator of the psychotherapy program. All therapists showed a good adherence to the manual in the supervisory sessions and had no problems with being videorecorded. The following data analysis was made on the 10 patients who finished all 48 sessions.

Language: es

Keywords

adult; human; suicide; female; bipolar disorder; psychotherapy; Borderline personality disorder; hospitalization; treatment outcome; comorbidity; substance abuse; article; mental disease; antisocial behavior; clinical article; fluvoxamine; psychodynamics; family therapy; borderline state; olanzapine; valproic acid; group therapy; psychotherapist; Clinical trial; patient selection; omega 3 fatty acid; delusional disorder; Transference Focused Psychotherapy