Can assessors and therapists predict the outcome of long-term psychotherapy in borderline personality disorder?

Surprisingly few studies have investigated the accuracy of prognostic assessments of therapy outcome by clinicians. The objective of the present study was to investigate the relationship between clinicians' prognostic assessments and patient characteristics and treatment outcome. Seventy-one patients with a borderline personality disorder randomly allocated to schema-focused therapy (SFT) or transference-focused psychotherapy (TFP) were assessed every 3 months for 3 years. Prognostic assessments proved to be unrelated to patients' biographical (i.e., age, gender, education level, and employment level) and clinical characteristics (i.e., number of Axis I and Axis II diagnoses, and severity of psychiatric symptoms or borderline personality pathology). Clinical assessors as well as therapists rated the probability of success for SFT to be higher than for TFP. Prospective assessments of assessors and therapists accurately predicted different indices of outcome above and independent of patient characteristics. The prediction of outcome in the TFP condition in particular proved to be valid. Identifying prognostic markers of treatment outcome as used by clinicians in their prognostic assessments may improve current prediction models and patient-treatment matching.

[Reflections on cotherapy as a teaching instrument in an institution]. / Reflexiones sobre coterapia como instrumento docente en una institución.

In this paper I intend to present the different aspects of cotherapy as a teaching function beginning by the definition of the concept and its two meanings: the large one (the totality of means implemented in the treatment of a patient, (P.) and the narrow one (therapy session with two therapists who are present simultaneously). Then I carry on to the need of a basic agreement in therapeutic ideology and of permeability in the therapeutic team (T.T.) for mutual suggestions. I point to the advantages of the inclusion of the inexperienced therapist in the sessions, taping and observation through the Gesell chamber for the formation of therapists. Next there is a division of the treatment period in three stages; pre-session (the stage previous to the initiation of cotherapy for the first time and from then on previous to each one of the following sessions), the session (in which a therapeutic, a teaching and an intrapersonal period are differentiated and the post-session (in which the above mentioned periods are made explicit, are thought over and the therapeutic project is constantly adjusted. The advantages of the cotherapy for the P. are also mentioned. They are: a) betterment of the contention of the P. when his anxiety expresses itself in inadequate acting outs or is manifested in a very noisy manner; b) useful strengthening of the therapeutic action and of the making of limits: the fact that two therapists coincide in their view gives to their words more credibility and authority; c) the fact that there are two therapists instead of one makes the duplication superior to the sum of the same two therapists taken separately respect ot the offer of more information, models, views; d) a greater possibility of dramatizing roles due to the different personalities of therapists (roles that can be maintained by each therapist beyond the session period with the P.), facilitating in that way a better understanding by the P. of therapeutic interventions: e) unlike what happens with individual therapy, cotherapy allows the passage of a situation in which the third person is only included in fantasy to another in which the third one is included in the actual reality facilitating then a larger interplay between projections-introjections and its further comprehension by the P. Amongst its disadvantages there could be named: a) lack of intimacy as experienced by therapists and/or P.; b) risks of ill doing due to a T.T. wrongly combined; c) possibility of development of a "co-transference neurosis" that should require supervision by a third therapist; d) high cost to the institution. The advantages are, nevertheless, superior to the disadvantages so cotherapy is recommendable in any institution in which therapists are trained.