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Unread November 22nd, 2006, 06:21 PM
Gandalwaven Gandalwaven is offline
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Default Re: CBT with Borderline Personality Disorder

Hi

Just some comments on the comments.

However, I am very sceptical about the conclusion that all therapies work equally well and that it doesn't matter what treatment approach we use for a given client as long as we have a good therapeutic alliance.

This needs to be broken down into two parts. Firstly does it matter what treatment approach we take. Secondly is it just the therapeutic alliance that makes the difference. To begin with, this moves to the effectiveness vs efficacy debate and maybe this should have a separate posting. I would like to drop the abstract of Lambert 2003 paper in here called waiting for super-shrink.
Improving the effects of psychotherapy has been accomplished through a variety of methods. One infrequently used method involves profiling patient outcomes within therapist in order to find the empirically supported psychotherapist. This study examined data collected on 1841 clients seen by 91 therapists over a 2.5-year period in a University Counseling Center. Clients were given the Outcome Questionnaire-45 (OQ-45) on a weekly basis. After analysing data to see if general therapist traits (i.e. theoretical orientation, type of training) accounted for differences in clients' rate of improvement, data were then analysed again using Hierarchical Linear Modeling (HLM), to compare individual therapists to see if there were significant differences in the overall outcome and speed of client improvement. There was a significant amount of variation among therapists' clients' rates of improvement. The therapists whose clients showed the fastest rate of improvement had an average rate of change 10 times greater than the mean for the sample. The therapists whose clients showed the slowest rate of improvement actually showed an average increase in symptoms among their clients.
While it is not totally clear in the abstract the paper shows that orientation (therapeutic mode including CBT), age, gender or experience made no (and I underline) no difference to outcome. As a clinician involved in training psychologists in both CBT and psychodynamic therapy I find this research extremely disturbing. Not so much that treatment orientation was irrelevant but that experience was also irrelevant and raises for me the question of whether what I do as a trainer and supervisor makes any difference. This research also raises a specific problem for CBT. If CBT is better when measured under some circumstance why does it not show a difference in these real world studies? There are other studies but Lambert’s is the most powerful. If CBT is to lay claim to be being biggest and best it must provide rational explanations for this.

The degree to which the therapeutic alliance impacts on therapy is an ongoing debate. To frame it in is all or nothing is spurious as clearly most of the research indicates that it has some impact. It is the amount of impact we are arguing about. It seems to me that the debate you might be raising is that the therapeutic orientation is more important than the therapeutic alliance. Certainly people such as Linehan would put the alliance/relationship over the orientation. At a very basic level you can do therapy with any model but it is very difficult to do therapy without a relationship. To quote Linehan: “Indeed the strength of the relationship is what keeps the patients (and often the therapist as well) in therapy.”

Does anyone really believe that all the different therapies that have been developed are equally valid?

You use a straw man argument in picking an extreme example such as orgone therapy. To reframe the question slightly: Do you believe that most commonly used therapies are equally valid? Then Lambert cited above would say yes (in the real world) as would many others.

For years, many therapists thought that BPD was untreatable.

I think it was clear for many years it was treatable but that it was long and difficult. The recent Dutch study underlines this. Psychodynamic approaches such as Clarkin and Kernberg were developed well before CBT approaches however it is only recently that both comparison and open trials have shown its effectiveness. It is also important to recognise that a considerable percentage of borderlines up to thirty percent naturally remit over time.

It would be great if all that was needed was a good therapeutic alliance but it isn't that simple. We have a good example right here. This thread is about CBT with BPD. Does Wampold seriously believe that all you need to treat BPD effectively is a good therapeutic alliance?

I don’t believe that what is being said is all you need is a good therapeutic alliance. All therapies appear to work to some degree (all must have prizes) and they bring more to the room than just a therapeutic alliance. One of the key dysfunctions in borderline clients is one of relationship. This comes up in multiple diagnostic criteria for borderlines including DSM IV. It makes sense that a long and good therapeutic relationship is likely to be curative in itself.

While no one is claiming to have found a cure....

But both Young (Schema) and Clarkin (Transference focussed) are claiming to have found a cure at least in a significant percentage.

If we don't test therapies to find out what they accomplish, how are we to distinguish the valid therapeutic approaches from the absurd? It isn't that empirically-supported treatments are the only effective therapies or that they are necessarily the most effective therapies. It is that with some therapies we have reason to believe that they accomplish what their proponents claim they accomplish. With therapies that haven't been tested we have to decide whether to simply accept them on faith or not.

I agree that we need to test therapies but therein lies the rub. How do we test the therapies and is it the commonalities or the differences that are critical in showing these therapies to be effective.

I think what I want to emphasise in debating some of these points is that there are a number of ways to look at this and currently in the world of psychotherapy research much of this is unresolved.

Regards
Chris
In the Room
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