Studying the Treatment Contract in Intensive Psychotherapy with Borderline Patients

Abstract

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.

Effects of Motive-Oriented Therapeutic Relationship in Early-Phase Treatment of Borderline Personality Disorder

“…This diagnostic category of patients is known for being associated with particular difficulties in interpersonal and intimate relationships (APA, 1994;Barnow et al, 2009;Benjamin, 2003;Bohus, 2002;Perry, 2004, 2009;Ruiz et al, 1999;Stern et al, 1997), including in the interaction with the therapist, along with counter-transference issues (Gunderson et al, 1989;Spinhoven et al, 2007;Yeomans et al, 1993). These interpersonal difficulties may partially explain the high level of drop-outs, observed even in modern manual-based treatments.…”

“…Specific relational techniques were prescribed by the manuals, such as validation and acceptance in the context of DBT, to enhance the quality of the patient's way of entering the relationship with the therapist (Linehan, 1993;Lieb et al, 2004;Bohus, 2002). Yeomans et al (1993Yeomans et al ( , 2002 proposed, in the context of transference-focused psychotherapy, to focus on the negative contents projected onto the therapist and on the elaboration of a treatment contract starting right at the beginning of treatment. The limitations of these manual-based procedures focusing on relationship stakes have already been cited (Stiles et al, 1998).…”

Termination In Psychotheraphy: A Case Report Which Consists Of The Difficulties In Termination Phase

“…Kernberg'in [16] ve Kohut'un [7] geliştirdiği kuramlar psikoanalitik görüşün ilkelerini bu hastalarda kullanmayı olanaklı kılmış, danışan ve terapist arasındaki ilişki-nin öne çıktığı, daha aktif ve kısmen doyuran teknikler geliştirilmiştir. [17][18][19][20][21][22] Bu danışanların psikoterapisinde esas olan, egonun güçlendirilmesi, psikopatolojik nesne ilişkilerinin düzeltilmesi, ilkel savunmalardan daha gelişmiş savunmalara ilerlemenin sağlanmasıdır.…”

“…Birçok yazar, ağır kişilik bozukluğu olan kişilerde, ayrılma aşamasında çok çeşitli güçlüklerin ortaya çıktığı konusunda ortak görüşler belirtmektedir. [15,[20][21][22]26] Adler (1981), sınır kişilik bozukluğu gösteren hastaların iyileşme aşama-sında narsisistik bir yapı sergilediklerini, Waldinger (1984), genel eğilimlerinin, tedaviyi aşağılayarak ve olumsuz bir yaşantı ile bitirmeleri yönünde olduğunu belirtmektedir. [26,27] Bu durum, ağır kişilik bozukluğu gösteren kişilerin ayrılığa ve kayba ancak olumsuz bir yaşantı ile -değersizleştirerek-tahammül edebildiklerini göstermektedir.…”

Individualized behavior therapy programs applied to borderline personality disorder: A primer for clinicians

“…Yeomans, Seizer and Clarkin (1993) studied the application of treatment contracting with borderline patients as a component of intensive outpatient psychodynamic therapy. They found that the quality of the contract, therapist implementation skills, and patient collaboration (regarding goal-setting and patient acceptance of the contract) had a positive effect in reducing patient dropout rate.…”