The wish to do psychotherapy with borderline adolescents—and other common errors.

Contends that psychotherapy with borderline adolescents is a difficult undertaking requiring specialized understanding and technique and that becoming an expert in this area of treatment is predicated on specialized development. The expert therapist may begin to lose sight of his/her limitations, and certain characteristic errors may ensue. Three types of common errors in adolescent psychotherapy are examined: a conceptual error, a countertransference error, and a technical error. Rigorous self-examination of the therapist's work (underlying theory, interventions, experience) is recommended to recognize errors. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Depression in borderline adolescents

Etiologically, adolescents considered borderline by the criteria in common use are on a continuum between primarily biological and primary psychological disorders. Depression is common, and may be masked (in many cases of ulcer, anorexia, substance abuse, school avoidance) or overt (viz., early onset endogenous depression, hysteroid dysphoria, cases with severe deprivation). Illustrative cases are provided, along with recommendations for treatment.     

Generic psychotherapy case formulation training improves formulation quality.

Psychotherapy case formulations written by 20 clinicians who received a 2-hr training session in case formulation were compared with those of 23 clinicians not receiving training. Formulations based on intake interviews conducted at a university-based psychiatric outpatient clinic, two to three per clinician, were reliably coded for quality and content. Clinicians in the training group produced formulations rated as higher in overall quality and as more elaborated, comprehensive, complex, and precise. These formulations were also more likely to address precipitants, predisposing factors, and an inferred mechanism to explain symptoms and problems. Effect sizes indicated that the average clinician in the training group produced a better formulation than 86% of those in the control group. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The future of psychotherapy with children: Developmental psychotherapy.

Discusses the concept of developmental psychotherapy for children as a way of integrating information about human development, basic biological processes, and psychopathology with knowledge gained from studies of therapeutic change. In developmental psychotherapy, rather than trying to provide a permanent cure, the therapist tries using a variety of methods to help the child regain a footing on a developmental pathway more likely to lead to adequate adaptation in subsequent periods of life. Research in this field should concentrate on continuing refinement of models for developmental pathways leading to specific outcomes in a number of domains, particularly those involving externalizing disorders and substance abuse. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The psychotherapy relationship with borderline personality disorders.

Discusses different points of view concerning the psychotherapy relationship with borderline personality disorders from the standpoint of their possible effects on the process and outcome of psychotherapy. The following major positions are reviewed: (a) traditional psychoanalytic position of technical neutrality, (b) reality relationship in which the therapist shares thoughts and feelings with patients, and (c) establishment of a relationship to facilitate gratification of primitive developmental phases. It is proposed that the major position that theorists take in the psychotherapy relationship with borderline personality disorders, especially their handling of the developmental arrest and transference–countertransference issues, differentially affects the patients' personality structure within the context of separation–individuation. A case vignette of a 15-yr-old male is used to demonstrate this point. (26 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Research perspectives on psychotherapy with borderline patients.

Outlines psychotherapeutic implications of previous research findings on the borderline diagnosis and subgroups of borderline patients. Developmental patterns of object relations in neurotic, borderline, and schizophrenic patients are examined. It is suggested that when Rorschach records for these psychiatric groups were scored for differentiation, articulation, integration, content, and accuracy, an ideal database for assessing an individual's representational world was developed. Findings of significant differences in the developmental level of the concept of the object, the quality of reality testing, and regressive potential that successfully distinguished hospitalized from nonhospitalized borderline patients suggest that the borderline diagnosis may be conceptualized along a continuum of severity. Case illustrations are included, involving a 17-yr-old female presenting with depression and suicidal ideation and a 36-yr-old female who felt she had been fated by her father's death. (49 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Cultural intersections in the psychotherapy of borderline personality disorder

Psychotherapy can be essentially considered a journey in which two individuals embark, each carrying a formidable cultural legacy. The psychotherapeutic enterprise then becomes a succession of stops and intersections as the two protagonists struggle to identify their culturally determined behaviors, using culturally determined procedures to take care of them. In this sense, cultural procedures are not a technical term but the appropriate combination of learned concepts, experiential modifiers, and common sense indicators of contemporary realities both at the individual and collective levels. The fascinating and challenging nature of BPD does have a significant cultural component encompassing explanatory, interpretive, pathogenic, pathoplastic, diagnostic/nosological, and service management aspects. It is in the psychotherapeutic arena, however, where both patient and therapist must face a multitude of culturally determined situations that may have a significant impact on the outcome of treatment. Culture can help the therapist to dispose of misleading clinical labels, with obvious advantages for the patient's well-being. Psychotherapy can correct the pathogenic elements of the patient's culture, recognize the pathoplastic clothing of the patient's symptoms, and provide culturally sanctioned and valued success experiences that may increase self-esteem, strengthen stability and, particularly, contribute to the patient's achievement of an identity with which he or she can feel comfortable. Finally, it must be remembered that it is not up to the therapist to offer infallible explanatory models of the patient's plight, but only culturally acceptable premises on which to build such explanations. On the other hand, it is up to the therapist to recognize the "idioms of distress," both physical and psychological, that the patient conveys in the psychotherapeutic context which is, as had been said many times here, totally immersed in the environment of culture. Two vignettes illustrate several of the issues under discussion.     

Object relations development and psychotherapy dropout in borderline outpatients.

Used Rorschach object relations measures to identify patterns of object representations in borderline outpatients that would distinguish those at risk for premature termination from those likely to continue in expressive psychodynamic psychotherapy. Existing data from the Borderline Psychotherapy Research Project (O. Kernberg et al, 1989) were used. Ss were 12 women, aged 21–39 yrs, with borderline personality disorder. Ss who dropped out showed a predominance of narcissistic themes in their Rorschach responses at the outset of treatment, as scored by the Rorschach Separation-Individuation Scale (S-I Scale), and produced almost 4 times as many narcissism as rapprochement themes on the S-I Scale as Ss who continued treatment. Overall findings lend support to the salience of developmental themes related to separation-individuation within the population of borderline patients. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Narcissism and borderline states: Kernberg, Kohut, and psychotherapy.

The post-Freudian era of consciousness is examined, wherein the individual is reconsidered from two viewpoints--narcissism and borderline states--via two seminal thinkers, Kohut and Kernberg. This is elaborated on through discussion of a "conflict" in Freud's work (i.e., the paradoxical conflicts in Freud between personal insight and natural science metaphors) and the utilization of paradigm shift and crisis in science. This continues in the dialectic concerning the theoretical and treatment styles of Kohut and Kernberg. The advantages, liabilities, and linguistic structures of both writers are studied in relation to their explorations of disturbances of the self. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Review of Dynamic psychotherapy of the borderline patient.

Reviews the book, Dynamic psychotherapy of the borderline patient by William Goldstein (1996). The reviewer notes that The Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV; American Psychiatric Association, 1994) defines the essential feature of borderline personality disorder as a pervasive pattern of instability of interpersonal relationships, self-image, and affects, along with marked impulsivity that begins by early adulthood and is present in a variety of contexts. This pattern is observable in many kinds of DSM-IV personality disorders, and as a result: the borderline personality diagnosis overlaps with many other types of DSM-IV disorders. This has led to a plethora of theories, techniques, and suggestions regarding the borderline patient. Goldstein has made an effort in this book to present a primer outlining some of the basic approaches along with his own approach to treatment: of borderline patients. His orientation is said to be pragmatic, much like the reviewer's, except that he has a Kernberg-influenced penchant for distinctions and categories which perhaps will help some beginners to organize the variety of their patients who tend to get labeled as borderline. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Preliminary socialization for psychotherapy of behavior-disordered adolescents.

A common problem in treating adolescent delinquents is their failure to participate in traditional psychotherapeutic procedures. Small cash bonuses given contingent on participation in tape-recorded nondirective interviews were shown to be effective in shaping dependable and prompt attendance. Using a variable schedule of reinforcement, extrinsic rewards could be gradually reduced without corresponding decrement in attendance behavior. The rationale for using such a procedure is emphasized. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Metaphor in psychodynamic psychotherapy with borderline and non-borderline clients: A qualitative analysis.

Conducted an intensive, qualitative analysis of borderline and non-borderline client's and therapist's experiences of metaphoric expression in a single psychotherapy session. Open-ended interviews were conducted with 2 therapists and 4 clients (aged 24–38 yrs; 2 borderline and 2 non-borderline) who were actively engaged in psychoanalytically-oriented, long-term psychotherapy. The intensive analyses of inquiry interview transcipts revealed 3 important categories of metaphor functions that were shared by all 4 psychotherapy dyads: (1) metaphors illuminate clinical issues, (2) metaphor functions to depict clients' self and object relationships, and (3) therapist metaphor stimulates an intensification of client experiential engagement in therapy. Patterns differentiating the borderline and non-borderline dyads in relation to metaphor use were discussed in the context of 2 core categories: the Representation Mode of Interaction and the Literal Mode of Interaction. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The structure of psychotherapy: Control-mastery theory's diagnostic plan formulation.

The view that psychotherapy patients unconsciously organize their therapy process in the service of their treatment goals has been advanced and empirically supported by Control-Mastery theory proponents. This article discusses the patient's plan according to Control-Mastery theory and shows how it is made explicit in the Diagnostic Plan Formulation. It describes how the plan formulation can be used to guide the therapist's interventions, and shows how it creates a structure which organizes the whole therapeutic enterprise. A case example is given to illustrate the therapeutic clarity and power which can result from the use of this approach. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Assessing the effects of clinic-based psychotherapy with children and adolescents.

Recent meta-analyses suggest that psychotherapy is quite effective with children and adolescents. However, most research in those analyses involved controlled laboratory interventions that may not represent typical therapy in clinics. We studied more representative treatment as it routinely occurs, in 9 clinics. We compared 93 youngsters who completed a course of therapy with 60 who dropped out after intake. At intake, the groups did not differ on demographic, family, or clinical measures, including Child Behavior Checklist (CBCL) scores. Six months later (when therapy had ended for 98% of the treated children) and again 1 year later, the 2 groups were compared on CBCL scores, parent ratings of each child's major referral problem, and (for a subsample) teacher reports. No comparison showed significant main effects of therapy. The findings (a) raise questions about the generalizability of findings from research-oriented therapy and (b) suggest that the control and precision of research therapy may be needed in clinical practice. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The therapeutic alliance in schema-focused therapy and transference-focused psychotherapy for borderline personality disorder.

This study investigated the quality and development of the therapeutic alliance as a mediator of change in schema-focused therapy (SFT) and transference-focused psychotherapy (TFP) for borderline personality disorder. Seventy-eight patients were randomly allocated to 3 years of biweekly SFT or TFP. Scores of both therapists and patients for the therapeutic alliance were higher in SFT than in TFP. Negative ratings of therapists and patients at early treatment were predictive of dropout, whereas increasingly positive ratings of patients in the 1st half of treatment predicted subsequent clinical improvement. Dissimilarity between therapist and patients in pathological personality characteristics had a direct effect on growth of the therapeutic alliance but showed no relationship with clinical improvement. The authors conclude that the therapeutic alliance and specific techniques interact with and influence one another and may serve to facilitate change processes underlying clinical improvement in patients with borderline personality disorder. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Techniques for psychotherapy with defiant, aggressive adolescents.

Defiant, aggressive adolescents are among the most difficult and challenging of all psychotherapy clients. This article presents a number of techniques and strategies for working with this population, along with several case examples illustrating their proper use. The techniques are intended to supplement existing approaches and focus on motivating apathetic clients and directly addressing anger and violent impulses. A few of the techniques mentioned are therapeutic "button-pushing," disengaging the motor controls, addressing the hurt, externalizing, and resurrecting empathy. Strategies are aimed toward managing countertransference and strengthening the therapeutic relationship. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A controlled trial of psychodynamic psychotherapy for co-occurring borderline personality disorder and alcohol use disorder.

A randomized controlled trial was conducted to determine whether a manual-based psychodynamic treatment, labeled dynamic deconstructive psychotherapy (DDP), would be feasible and effective for individuals with co-occurring borderline personality disorder (BPD) and alcohol use disorder. Thirty participants were assessed every 3 months during a year of treatment with either DDP or treatment as usual (TAU) in the community. DDP participants showed statistically significant improvement in parasuicide behavior, alcohol misuse, institutional care, depression, dissociation, and core symptoms of BPD, and treatment retention was 67% to 73%. Although TAU participants received higher average treatment intensity, they showed only limited change during the same period. The results support the feasibility, tolerability, and efficacy of DDP for the co-occurring subgroup and highlight the need for further research. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Developmental factors in the treatment on adolescents.

Most empirically supported interventions for adolescent mental health problems are either downward adaptations of adult treatments or upward adaptations of child treatments. Although these treatments show respectable effects with teens, a review of the outcome research reveals significant gaps, both in coverage of adolescent conditions and problems (e.g., eating disorders, suicidality) and in attention to the biological, psychological, and social dimensions of adolescent development. The authors critique the field, propose a biopsychosocial framework for the development of dysfunction and intervention, and discuss ways the developmental literature can and cannot inform intervention and research. A long-term goal is an array of developmentally tailored treatments that are effective with clinically referred teens and an enriched understanding of when, how, and why the treatments work. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Progression of borderline increases in albuminuria in adolescents with insulin-dependent diabetes mellitus

We aimed to determine the natural history of borderline increases in albuminuria in adolescents with insulin-dependent (Type 1) diabetes mellitus (IDDM) and factors which are associated with progression to persistent microalbuminura. Fifty-five normotensive adolescents with IDDM and intermittent microalbuminura (overnight albumin excretion ratte of 20-200 micrograms min-1 on one of three consecutive timed collections, n = 29) or borderline albuminura (mean overnight albumin excretion rate of 7.2-20 micrograms min-1 on one of three consecutive timed collections, n = 30) were followed prospectively at 3 monthly intervals. The endpoint was persistent microalbuminuria defined as a minimum of three of four consecutive overnight albumin excretion rates of greater than 20 micrograms min-1. One hundred and forty-two adolescents with IDDM and normoalbuminura were also followed prospectively. Fifteen of the 59 patients (25.4%) with intermittent (9/29) or borderline (6/30) albuminura progressed to persistent microalbuminura (progressors) over 28 (15-50) months [median (range)] in comparison with two of the 142 patients with normoalbuminuria at entry (relative risk = 12.6; p = 0.001). Progressors to persistent microalbuminura were pubertal and had higher systolic (p = 0.02) and diastolic (p = 0.02) blood pressure, and HbA1c (p = 0.004) than non-progressors. All patients remained normotensive. Glomerular filtration rate, apolipoproteins, dietary phosphorus, protein and sodium intakes, and prevalence of smoking did not differ between progressors and non-progressors. Total renin was higher in the diabetic patients without a difference between progressors and non-progressors. In conclusion there is a relatively high rate of progression to persistent microalbuminuria in pubertal adolescents with borderline increases in albuminura and duration greater than 3 years. These patients require attention to minimize associated factors of poor metabolic control and higher blood pressure in the development of incipient nephropathy.