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  #1  
Unread November 2nd, 2006, 11:00 AM
John Simon John Simon is offline
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Default Re: CBT with Borderline Personality Disorder

It is clear that this changing perspective happens all of the time because all of the most through research shows that all types of therapy are equal in terms of client outcomes (Read Bruce Wampold's "The Great Psychotherapy Debate" and Scott Miller's "The Heroic Client"). The cycle typically happens as follows: a new therapy comes out and some initial research is done (or not) and the proponents state that it is better than anything else. Then more research comes out proving that it is about the same as all of the other interventions/theories. Then people move on to the latest wonderful theory. If you think about it, this cycle has occurred with family therapy, Gestalt, Psychodynamic etc, and it will happen with cognitive/behavioral. The real factors that affect treatment are alliances with your client (40%) and working within the clients model of change (around 30%). Interventions, based on theory, are only worth about 15% of the client change on average.

John
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  #2  
Unread November 3rd, 2006, 10:19 AM
alexandra_k alexandra_k is offline
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Default Re: CBT with Borderline Personality Disorder

To the best of my knowledge... What therapy comes out as the most 'empirically validated' is highly dependent on what diagnosis you are trying to treat...

I do agree, however, that therapists have a tendancy to get all excited and to thus have higher degrees of faith in their patients ability to get better in virtue of the latests studies.

Linehan mentiones this point. In her handbook for the treatment of BPD she explicitly states that it is unclear what parts of the treatment program are the parts that is responsible for its success. She also allows that what might be responsible for the success of DBT is that it is a new therapy that has envigorated therapists. She allows that its success in the empirical studies could be more a function of therapists belief in the clients rather than in anything magical about the therapy...

I would agree with her. Therapists need something to invogorate them every now and then. DBT has done exactly that. Now there is success with mentalisation (based on attachment) approaches to treating BPD.

Don't get me wrong, CBT attempted to empirically validate the efficacy of treatment. That set something of a gold bar for other varieties of therapy. Other varieties of therapy have been coming to the party, however. That drives future reserach... So it is all good...

But more helpful still to appreciate somethign of the pattern...
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  #3  
Unread November 5th, 2006, 01:48 AM
John Simon John Simon is offline
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Default Re: CBT with Borderline Personality Disorder

What an interesting discussion!

Actually, from my understanding after reading Wampold's book where they did meta analysis of the research, diagnosis has little to do with favorable outcomes. There is normally a huge variance in diagnoses given a set of symptoms and yet people get better. In other words, therapists normally can not agree on a diagnosis and yet the clients are still able to get better so something else must be going on.

The research does show that allegiance to a model does help outcomes as long a the client is not in disagreement with the model. It seems that if a therapist believes that they will be helpful because of their theory then they are often helpful, which is hopeful. However, if the client disagrees with the premises of the model then outcomes will normally be very bad unless the therapist changes their interventions.

I look at the gold bar differently. 50 years of research has shown that therapy models are all about the same in terms of effectiveness. The fact that DBT or some cog/beh model has been "validated" only states the obvious. All therapy works in general so it is not surprising that co/beh therapy works also. It is like one team showing up at a game while the other team has already forfeited and then the first team says that they are empirically the best team. Notice that many therapy styles have not tried to validate themselves in the same way. The ones that have have been proven to be about equal to all of the other models. In the cases where one model is shown to be superior, they never are able to eliminate the allegiance factor that you detailed in your response. In other words, you will never see Salvador Minuchen vs. Albert Ellis. You will only see some researcher who believes in cog/beh vs. some local agency etc. This is not a fair comparison.

John
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  #4  
Unread November 13th, 2006, 08:11 PM
Gandalwaven Gandalwaven is offline
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Default Re: CBT with Borderline Personality Disorder

Hi

I think one of things we need to recognise with treating personality disorder is thatthere is a difference between reducing symptoms and producing character change. Pure CBT models are able to offer some symptom reduction but not a cure. This is similar to CBT and Chronic Fatigue Syndrome. Treatment leads to symptoms reduction not a cure.

Neither Linehan’s or Young’s model are strictly cognitive behavioural and both would acknowledge a considerable intake from psychodynamic approaches in developing their theories.

Wise mind, rational mind and emotional mind is hardly a cognitive behavioural concept and equates reasonably well with id, ego and super ego. Similarly Young’s ideas of modes is cast directly in this frame i.e. child and parental modes (id and superego) and a single adult mode i.e. ego.

Linehan introduces the idea of conflict with the dialectic; change or no change, safety or relationship. These are more psychodynamic concepts than pure CBT. I think it is the fact the pure CBT didn’t work with personality disorder that has actually led to the development of more in-depth approaches integrating stuff from other models.

What is interesting is the new Dutch study (Archives of General Psychiatry) showing apparent character change and a significant cure rate for borderlines using either Young’s Schema Focused Therapy or Kernberg and Clarkin’s Transference Focused Therapy. This is long term therapy twice a week for three years with outstanding results.

Looking at the April 2006, Journal of Clinical Psychology articles I think the paper on pure CBT with Borderlines is the weakest by far. One of the things that appears a commonality amongst the other papers is the need to help the borderline client build some type of reflective space. Until there is space to think then pure CBT is difficult to apply.

Linehan’s approach appears to be effective in reducing dysfunctional borderline behaviours particularly suicidal and parasuicidal behaviours. It does not appear to produce underlying character change as indicated in the Dutch study above.

I think we need to acknowledge that the therapies that are working with borderline clients are hybrids and we are seeing a maturing of CBT where it integrates many of the psychodynamic concepts such as drives or motivations (see Grosse Holtforth and Castonguay), resistance and defence see (Leahy), object relations (Young).

Regards
Chris
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http://gandalwaven.typepad.com/intheroom/
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  #5  
Unread November 20th, 2006, 10:31 PM
James Pretzer James Pretzer is offline
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Default A few comments

Just a few comments on the last several posts in this thread...

I can't really comment on Bruce Wampold's "The Great Psychotherapy Debate" and Scott Miller's "The Heroic Client" because I haven't read them. 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.

Does anyone really believe that all the different therapies that have been developed are equally valid? Should we revive Reich's Orgone Boxes? Manipulate undetectable "energy fields" to treat serious problems? Use past life regression as a treatment method? While these examples may seem extreme, remember the wide range of therapies that have their advocates. I've heard of at least one therapist in town who was using crystals and channeling and billing it to insurance companies as psychotherapy.

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.

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? If so, I wonder how many clients with BPD he has treated. For years, many therapists thought that BPD was untreatable. Now it is gradually becoming clear that some treatment approaches are ineffective, some actually make client's problems worse, and some at least are effective in decreasing symptomatology and improving functioning. While no one is claiming to have found a cure, there actually are a number of studies that suggest that CBT (and some other treatment approaches as well) can help people change to the point where they no longer qualify for a personality disorder diagnosis.
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  #6  
Unread November 22nd, 2006, 06:12 AM
alexandra_k alexandra_k is offline
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Default Re: CBT with Borderline Personality Disorder

It might be that some treatment approaches are better able to facilitate good therapeutic alliance than others.

I agree that there are limits. From memory... People with borderline personalitly disorder also have a disposition to join cult groups and churches and movements and the like, things that promise a relatively 'quick fix' by a charismatic leader. I'm sure that a charasmatic faith healer or channeler or spirit reader or whatever would offer a relatively 'quick fix' of acceptance in the first place but that... It would wear thin over time and there would be high drop out rates (which is of course a significant problem with people with BPD under any mode of therapy).

I think that internal consistency and consistency with scientific practice is nice. That being said I'll admit that I have difficulty with seeing a unified theory behind the practice of CBT and I think of CBT as an eclectic tool kit of strategies that have been individually empirically supported but I'm not at all sure there is a coherant or consistent theory lurking behind the scenes... The 'cognitive' in 'cognitive behaviour therapy' also doesn't seem to be (in most cases) inspired by (or informed by) the most recent research in cognitive psychology and I think it is unfortunate (and misleading) that they share the same name.

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

With respect to the ones that have been empirically supported... E.g., brief psychodynamic, schema therapy, DBT, humanistic etc... It might well be that they are ALL affective because they effect change on the SAME mechanisms. There is a certain amount of translation between theories that is possible and while different theorists might call the constructs by different names they can be the same thing really.

E.g., what is the difference between learning how to mindfully 'observe and describe' ones mental states and...

learning how to 'mentalize'?

Sounds like the same thing to me (but the first is in the language of CBT and the second is in psychodynamic terminology)

(Mentalization also has links to the notion of 'theory of mind' (TOM) as discussed in cognitive psychology, or the ability to 'adopt the intentional stance' as discussed in philosophy).

CBT has been shown to be effective for the treatment of BPD?

Reference please...

I know about schema therapy (cognitive therapy)
I know about DBT (dialectical behaviour therapy)

Are you using CBT to refer to the above two or is there something I'm missing?
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  #7  
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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  #8  
Unread December 7th, 2006, 05:15 PM
James Pretzer James Pretzer is offline
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Default Re: Are all therapies equally valid?

> 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.

Actually, I don't think it's a straw man argument. I don't know of anyone who still uses orgone boxes but I do know of instances where therapists were manipulating undetectable "energy fields", were using crystals and channeling, were using past-life regression, or were using questionable techniques to "recover" repressed memories. Unfortunately, some of our colleagues have very interesting ideas about what therapists should do.

Some hear that "all of the most through research shows that all types of therapy are equal in terms of client outcomes" and conclude that it doesn't matter what therapists do as long as there's a good therapeutic relationship. I think this is a risky conclusion.

Even if it were true that every therapy that was empirically tested turned out to be equally effective (which I doubt), this doesn't mean that all commonly used therapies are equally effective for every problem. I'd argue that we have reason to believe that the therapies that have been tested are effective, at least for the problems and populations they've been tested on. However, I'd also argue that the commonly used therapies which have not been tested are an unknown quantity. They may or may not turn out to be effective.

Thus, when I see a commonly used therapy (psychoanalysis) being used for a common problem (a driving phobia) and turning out to be ineffective, I'm inclined to think that a treatment approach that has been found to be effective with driving phobias would have been a better choice. (Note: this is a real example from a few years ago)
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  #9  
Unread December 13th, 2006, 12:48 AM
Gandalwaven Gandalwaven is offline
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Default Re: Do Empirically-Supported Treatments make a difference

Comments on the comments on the comments
Actually, I don't think it's a straw man argument. I don't know of anyone who still uses orgone boxes but I do know of instances where therapists were manipulating undetectable "energy fields", were using crystals and channelling, were using past-life regression, or were using questionable techniques to "recover" repressed memories. Unfortunately, some of our colleagues have very interesting ideas about what therapists should do.
There is a simple test for the straw man argument. Substitute some more middle of the road therapies (for example family therapy for orgone boxes and narrative therapy for crystals) and see if the argument carries as much weight. In my view it doesn’t. It is on this basis I conclude a straw man argument. I share your concern for bad therapists but think they exist no matter what the modality.
Some hear that "all of the most through research shows that all types of therapy are equal in terms of client outcomes" and conclude that it doesn't matter what therapists do as long as there's a good therapeutic relationship. I think this is a risky conclusion.
Which "some" are you talking about. Therapists of all varieties including CBT will abuse therapy. Again I think this is a fallacious argument. “All types of therapy” would only include those therapies that were reviewed in the research. You are extending this to both reviewed and unreviewed therapies. There is always a danger that some will misinterpret the conclusions or use this as an excuse to abuse, this does not invalidate the “rightness” of the conclusion. The conclusion and what people do with it are separate issues.
Even if it were true that every therapy that was empirically tested turned out to be equally effective (which I doubt).
There is a reasonable amount of evidence for this. See for example the Super-shrink article I cited in my earlier posting. I would also point you to the extensive work by Luborsky and Fonagy.
However, I'd also argue that the commonly used therapies which have not been tested are an unknown quantity. They may or may not turn out to be effective.
Most of the common therapies have been researched and have been found to be effective. How they have been tested is the issue of a whole debate. For an excellent example of this current debate have a look at Castelnuovo et al’s paper. She lucidly outlines the pros and cons of both sides of this debate.
Thus, when I see a commonly used therapy (psychoanalysis) being used for a common problem (a driving phobia) and turning out to be ineffective, I'm inclined to think that a treatment approach that has been found to be effective with driving phobias would have been a better choice. (Note: this is a real example from a few years ago)
Here you are arguing by example. Because it was ineffective in the case you cite does not make it in general ineffective. There may be research showing this and if there were then this would be a better argument. In general, psychoanalysis, is in my understanding about gaining a deeper understanding and insight of oneself and in general is not focussed on the curing of a single symptom.

If you are holding out CBT to be superior (more effective) and as having a scientific basis supporting this (this is my interpretation of your stance) then in my view some things must be addressed to maintain that position.

All science must be able to explain the exceptions to its theory or hypotheses. CBT seems good at explaining or providing why it does work (RCTs etc) but has difficulty explaining when it doesn’t work. Remember at best CBT only works for about 66% of clients suffering depression and this is under controlled conditions. It must also explain why large real world studies (therapy takes place here) show that CBT is neither better or worse than other therapies (Lambert and co cited above).

It also needs to be kept in context. CBT is great for reducing symptoms, is a readily learnable therapy and appears very cost effective but it still has little to say about dealing with the big things in life, love, sex, death, god and poetry. Other therapies appear to not be as effective at reducing symptoms but have a lot more to say about these others things in life.

Interestingly enough (although the research is limited) who do behavioural therapists go to see when they are having problems? Psychoanalysts (Lazarus 1971). Lazarus was a behaviourist btw.

Regards
Chris
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  #10  
Unread December 14th, 2006, 08:25 AM
Fionnula MacLiam Fionnula MacLiam is offline
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Default Re: Do Empirically-Supported Treatments make a difference

To answer your last side point: I think you'll find that in 1971 behaviour therapy was concerned with phobias, OCD, and other such behavioural problems which could be defined as 'current, repetitive, and measurable' - the mantra of my early days of training. If a behaviour therapist had problems which fell outside of this arena, then of course they would seek a different kind of therapy.

Here's a quote from Lazarus: “In the late 1960s I started adding
‘cognitive’ methods to the more objective
behavioral techniques and found a
synergistic outgrowth. Thus, Behavior
Therapy and Beyond was one of the first
books on (what has since been termed)
‘cognitive behavior therapy.’ The main
intent of the book was to expand the
legitimate base of behavioral operations.
Thus, in addition to the more usual
behavioral methods such as systematic
desensitization, graded sexual assignments,
and assertiveness training, a variety of
cognitive methods and other innovative
techniques were carefully described."
(Note use of the word 'objective')
(http://www.garfield.library.upenn.ed...HH36300001.pdf)
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