[ Pobierz całość w formacie PDF ]
.Identity issues are central froma psychoanalytic viewpoint and therapists are constantly on the alert for split-off aspectsof patients and how these are played out in the patient therapist relationship.In DBTthere is less emphasis on identity issues, but nevertheless a black-and-white cognitivestyle is targeted using dialectical techniques to help the patient overcome the 20 | ANTHONY W.BATEMANall-or-none thinking and polarized approach to life.Both treatments prescribe the levelof contact allowable between patient and therapist.In DBT, emergency sessions areallowed to enable the therapist and patient to develop alternative ways of crisis resolu-tion other than hospital admission or self-destructive behaviour.In psychoanalytictherapy contact between sessions is not permitted, although discussion of alternativeroutes to support between sessions may be a focus of a consultation.Implementation ofthe two treatments is consistent with theoretical views.Linehan provides informationabout cognitive behavioural conceptualization of self-destructive behaviour, whilstKernberg uses exploratory interpretations using idiographic hypotheses; that is, formu-lations specific to that individual, relating self-destructive behaviours to feelings abouttreatment.Both discuss alternative pathways to resolution of conflict and distress.In contrast to these overlaps, RMP takes a more neutral stance.No formal contract ismade, no attempt is made to interpret or to explain the patient s anger or self-destructivebehaviour, and no emphasis is given to education or understanding about actions orthreats that may disrupt therapy.Instead the primary therapeutic task is to identify coremessages that reflect the polarities of conflict with which the patient is struggling.Ther-apists generate hypotheses about these as they are played out in the group setting whilstavoiding enacting any of the externalized, polarized selves.On theoretical grounds itmay be supposed that this is the least supportive therapy for borderline patients andlikely to lead to early dropout or failure to take up the offer of treatment, whilst DBT isthe most supportive, given its methods and the availability of the therapist.Whilst thereis no data on the dropout rate for RMP, Linehan has shown that the dropout rate is 16%in DBT, whilst that for psychoanalytic therapy is 42% (Clarkin and Kendall 1992).Butthe dropout rate for psychoanalytically orientated treatment may be altered.Batemanand Fonagy (1999) had an attrition rate of only 12% by focusing on engagement of thepatient in treatment and assertive follow-up of non-attendance.The marked overlap between therapies for long-term treatment of personality disor-der has significant implications for research since randomized controlled trials areincreasingly seen as the gold standard in evaluating treatments.Not only may this con-trol for many processes independent of the treatment and common to all psychologicaltreatments, it also may include tests between specific competing mechanisms.But horse-race comparative studies in long-term treatment are unlikely to be helpful inidentifying better methods of treatment since there is so much variance within eachtreatment and overlap between them that differential treatment effects are likely to bemasked.In effect they are all integrated treatments with a different balance of ingredi-ents.For research purposes it is more important to isolate the effective aspects of eachtreatment (Waldinger and Gunderson 1984).For example the low dropout rate for DBTis of interest to all clinicians, whatever their approach, because engaging personality-disordered patients is one of the many initial challenges to overcome if constructivetreatment is to follow. INTEGRATIVE THERAPY FROM AN ANALYTIC PERSPECTIVE | 21The day hospital and outpatient programme described by Bateman (1997) for bor-derline personality disorder has been developed with dismantling in mind.The effec-tiveness of the day hospital programme has been shown (Bateman and Fonagy 1999),but its effective ingredients remain unknown.So, using theoretical understanding andclinical experience, core aspects of the day hospital programme have been identified andpackaged as an outpatient programme.In effect the complex day hospital programmehad been dismantled into three specific components.Firstly, there is a psychoanalyti-cally based exploration within the transference and counter-transference relationship ofthe patient s internal object relational system within a weekly individual psychoanalyticsession.Secondly, a group-analytic session takes place once a week to explore relation-ships with others in the here and now.Thirdly, there is a weekly supportive group inwhich the therapists target current problems faced by the borderline patient.In thisgroup some cognitive techniques are used but there remains a focus on learningthrough the group.For example, a focus on reflective capacity helps the individual tothink about others within the group and to understand the mental states of others.Thisis based on the psychoanalytic view that borderline patients fail to fully develop amentalizing capacity (Fonagy 1991).Thus the programme is inherently integrative inthat it is based on identified problems specific to a group of patients and then combinestherapeutic techniques to help with those problems.In a recent review of psychotherapeutic treatment of personality disorder, Batemanand Fonagy (2000) conclude that treatments shown to be moderately effective have cer-tain common features [ Pobierz całość w formacie PDF ]
zanotowane.pl doc.pisz.pl pdf.pisz.pl centka.pev.pl
.Identity issues are central froma psychoanalytic viewpoint and therapists are constantly on the alert for split-off aspectsof patients and how these are played out in the patient therapist relationship.In DBTthere is less emphasis on identity issues, but nevertheless a black-and-white cognitivestyle is targeted using dialectical techniques to help the patient overcome the 20 | ANTHONY W.BATEMANall-or-none thinking and polarized approach to life.Both treatments prescribe the levelof contact allowable between patient and therapist.In DBT, emergency sessions areallowed to enable the therapist and patient to develop alternative ways of crisis resolu-tion other than hospital admission or self-destructive behaviour.In psychoanalytictherapy contact between sessions is not permitted, although discussion of alternativeroutes to support between sessions may be a focus of a consultation.Implementation ofthe two treatments is consistent with theoretical views.Linehan provides informationabout cognitive behavioural conceptualization of self-destructive behaviour, whilstKernberg uses exploratory interpretations using idiographic hypotheses; that is, formu-lations specific to that individual, relating self-destructive behaviours to feelings abouttreatment.Both discuss alternative pathways to resolution of conflict and distress.In contrast to these overlaps, RMP takes a more neutral stance.No formal contract ismade, no attempt is made to interpret or to explain the patient s anger or self-destructivebehaviour, and no emphasis is given to education or understanding about actions orthreats that may disrupt therapy.Instead the primary therapeutic task is to identify coremessages that reflect the polarities of conflict with which the patient is struggling.Ther-apists generate hypotheses about these as they are played out in the group setting whilstavoiding enacting any of the externalized, polarized selves.On theoretical grounds itmay be supposed that this is the least supportive therapy for borderline patients andlikely to lead to early dropout or failure to take up the offer of treatment, whilst DBT isthe most supportive, given its methods and the availability of the therapist.Whilst thereis no data on the dropout rate for RMP, Linehan has shown that the dropout rate is 16%in DBT, whilst that for psychoanalytic therapy is 42% (Clarkin and Kendall 1992).Butthe dropout rate for psychoanalytically orientated treatment may be altered.Batemanand Fonagy (1999) had an attrition rate of only 12% by focusing on engagement of thepatient in treatment and assertive follow-up of non-attendance.The marked overlap between therapies for long-term treatment of personality disor-der has significant implications for research since randomized controlled trials areincreasingly seen as the gold standard in evaluating treatments.Not only may this con-trol for many processes independent of the treatment and common to all psychologicaltreatments, it also may include tests between specific competing mechanisms.But horse-race comparative studies in long-term treatment are unlikely to be helpful inidentifying better methods of treatment since there is so much variance within eachtreatment and overlap between them that differential treatment effects are likely to bemasked.In effect they are all integrated treatments with a different balance of ingredi-ents.For research purposes it is more important to isolate the effective aspects of eachtreatment (Waldinger and Gunderson 1984).For example the low dropout rate for DBTis of interest to all clinicians, whatever their approach, because engaging personality-disordered patients is one of the many initial challenges to overcome if constructivetreatment is to follow. INTEGRATIVE THERAPY FROM AN ANALYTIC PERSPECTIVE | 21The day hospital and outpatient programme described by Bateman (1997) for bor-derline personality disorder has been developed with dismantling in mind.The effec-tiveness of the day hospital programme has been shown (Bateman and Fonagy 1999),but its effective ingredients remain unknown.So, using theoretical understanding andclinical experience, core aspects of the day hospital programme have been identified andpackaged as an outpatient programme.In effect the complex day hospital programmehad been dismantled into three specific components.Firstly, there is a psychoanalyti-cally based exploration within the transference and counter-transference relationship ofthe patient s internal object relational system within a weekly individual psychoanalyticsession.Secondly, a group-analytic session takes place once a week to explore relation-ships with others in the here and now.Thirdly, there is a weekly supportive group inwhich the therapists target current problems faced by the borderline patient.In thisgroup some cognitive techniques are used but there remains a focus on learningthrough the group.For example, a focus on reflective capacity helps the individual tothink about others within the group and to understand the mental states of others.Thisis based on the psychoanalytic view that borderline patients fail to fully develop amentalizing capacity (Fonagy 1991).Thus the programme is inherently integrative inthat it is based on identified problems specific to a group of patients and then combinestherapeutic techniques to help with those problems.In a recent review of psychotherapeutic treatment of personality disorder, Batemanand Fonagy (2000) conclude that treatments shown to be moderately effective have cer-tain common features [ Pobierz całość w formacie PDF ]