Download Stages of Change in Dynamic Psychotherapy With Borderline Patients

CLINICAL
AND
RESEARCH
REPORT
Stages
of Change
in
Dynamic
Psychotherapy
With Borderline
Patients
Clinical
and
JOlIN
Implications
M.D.
GENDERSON,
ROBERT
N.
authors
the first
therapy
stages
for
of long-tenn
the basis
dynamic
outline
methods
The
treatment
personality
current
personality
historical
therapy
parallels
for
for
vidual
bor-
disorder
with
for
(BPD)
the interest
schizophrenia
has
in psycho-
25 years
ago.
In
both areas,
clinicians’
interest
has been
ulated
by the publications
of influential
choanalytic
therapists.
psychotherapy
by
the
Optimism
of schizophrenia
writings
Fromm-Reichmann,
in
the
stimpsy-
about
the
was inspired
1940s
Arieti,
and
50s
Searles,
of
Will,
Semrad,
Lidz, and others.
Beginning
in the
late
1960s
the reports
by another
distinguished
group
that
included
Kernberg,
Masterson,
Adler,
Chessick,
and Giovacchini
evoked
a similar
atmosphere
of optimism
in
psychotherapy
for the treatment
of patients
with
this disorder.
In both
instances
these
therapists
suggested
that long-term
psychoanalytic
psychotherapy,
ifwell
conducted,
VOLUME
can
2
#{149}
NUMBER!
in the
psy-
who were
considtreatment
resistant
benefits
in ther-
psychotherapy
changes
documented
of phenothi-
therapy
introduced
a
for treating
schizophreas alternatives
to indi-
psychotherapy.
psychiatric
sort out
in
fundamental
azines
and behavioral
variety
of modalities
nia that were viewed
disorder.
interest
borderline
The
cases,
measuring
points
about
chopathology
of patients
ered to be among
the most
psycho-
treated
for
at different
bring
on
disorder.
successfully
of psychotherapeutic
derline
research
personality
offive
the effectiveness,
apy,
guidelines
borderline
the authors
Pn.D.
NAJAVITS,
offer
for
M.D.
SABO,
M.
LISA
The
M.D.
WALDINCER,
At.Ex
On
Research
In
community
the options.
response,
turned
However,
the
to research
to
many
of the
schizophrenia
research
projects
began
with
rather
naive
premises
about
the magnitude
of the changes
that might
be expected
and
the speed
with which
they
spite all the endorsements
pists
of the
value
might
written
of dynamic
occur.
Deby thera-
therapies
schizophrenic
patients,
it became
dramatic
or curative
results
were
for
clear
truly
that
rare,
took a long time, and might
depend
on either
gifted
therapists”2
or exceptional
patients.3
It
took decades
of studies
to develop
appropriate outcome
ing attained
Received
measures;
the benefits
October
16,
199!;
cepted
May 29,1992.
From
cial
Research
Program,
Massachusetts
Gunderson
02178.
at the
Copyright
WINTER
#{149}
1993
to recognize
that
of medications
revised
May
!4,
the Personality
and
McLean
Hospital,
Address
above
address.
© 1993
American
reprint
!992;
ac-
PsychosoBelmont,
requests
Psychiatric
havwas
to
Press,
Dr.
Inc.
CLINICAL
AND
RESEARCH
65
REPORT
often
prerequisite
(not detrimental)
to successful
outcome;
to identify
the unexpected
characteristics
of those patients
who might
be
crete
bility
amenable
offer
the
sequencing
test
to dynamic
therapy
for
therapies;
a sufficient
its effects.
The
subsequent
treatment
shown
that
psychosocial
and
then
to
duration
problems
to shorter
ond,
that
there
of such
of schizophrenic
medications
interventions,
literature
patients
has
and more
discrete
such as social skill
The
history
therapies
set the
oped
or established
stage
for
therapies
about
namic
effectively
the
still-to-be-develthat can then
residual
neg-
ative-and
perhaps
“core”-symptoms
schizophrenia.
It turns
out that it is only
these
negative
symptoms
that individual
ploratory
insight-oriented
psychotherapy
beneficial.5
patients
of
of
for
ex-
years,
has
research
documented
medication
and
with
shown
that
symptoms,6’7
value
therapy.
studies
have
positive
borderline
potential
behavioral
chopharmacologic
patients
minish
with
the
Psy-
studying
of these
claimed
to do this.
ment
of borderline
our
The
literature
patients
bears
authors
have
however,
we
of our own
of five suc-
involve
seem
so-called
unlikely
borderline
patients
meet
official
DSM
to
The
stages
has
on treatwitness
to
five
of
were
destructive.
of these
cases
change
from
which
were
borderline
prototypic,
impulse-laden,
and
self-destructive,
role performance,
were
dysfunctional
and comfortably
Interview
and
DSM-III
sessed).
Most
in therapy.
for
Borderhines
criteria
(as
had extensive
Moreover,
because
duct of research
evaluating
of this treatment.
Before
delineating
the
phases
we
that
observed
dynamic
dis-
we will highlight
with
ment
should
various
other
of borderline
develop
recognize,
first,
the
role
of individual
and its interactions
interventions
patients.
therapeutic
the
in the
Specifically,
strategies
multiplicity
JOURNAL
of
OF
the
treat-
PSUHOTHERAPY
of
likely
any
one
therapy
PRACTICE
with
AND
long-term
these
five
therathe
re-
to
of
the
be
free
therapist.
borderline
These
their
and
the
two observations
RESEARCH
five
as-
therapists,
are offered
because
of
for both
clinical
practice
during
(DIB)’8
the
required
dynamic
idiosyncrasies
cases
tions
different
more
their
both
retrospectively
prior experience
seemed
to sort out
psychotherapy
five
in
met
sults
claim
self-
At the beginning
of treatment,
all
young
adult
patients
were
openly
fectiveness
in diminishing
discrete
aspects
of
borderline
patients’
psychopathology.9
As
with
the development
of therapeutic
treatments
for schizophrenia,
research
is now
that
our
patients
involved
of modalities
who
cri-
we derive
pies
proliferation
written
in successful
dypatients
based
ef-
the
work
of the
timetable
1O13117
knowledge,
psychotherapy
magnitude
and the
cessfully
treated
and carefully
diagnosed
borderline
patients.’4
Identifying
such
cases
seemed
especially
important
because
the existing
case reports
of successful
treatments
Diagnostic
To
Such
on their clinical
experience;’#{176}’3
rely heavily
on a reconsideration
previously
reported
case material
borderline
drugs
can help
diand using a cog-
dynamic
aided
examples
patients.
Four
for
greatly
well-documented
treated
changes.
established
therapies.
been
the phases
of change
therapy
with borderline
who
individual
have
could
have
indicated
the
changes
that are possible
ni tive-behavioral
treatment
can
markedly
reduce
suicidality.8
Such
interventions
may
make borderline
patients
amenable
to having
their ongoing
and perhaps
still “core” psychological
traits
addressed
by other
still-to-beonly
on psychotherapy
could
successfully
be
an
CHANCE
of research
first
In recent
optimal
be
OF
schizophrenia
of
ongoing
may
on
by
address
amenaand, sec-
treatments.
STAGES
research
their
potential
interventions,
to
training
and psychoeducation,
can dramatically diminish
positive
symptoms
and recidivism.4
This research
has also shown
that such
may
and
term
implicathe con-
effectiveness
of change
psychopatients,
that
have
a
66
CLINICAL
direct
the
bearing
current
The
on
first
observation
cult it was to find
fully
completed
considerable
ing such
research
into
derline
searchers,
relates
good
examples
therapies.
to how
diffi-
lay claim,
the
literature
it proves
a “true”
seen
through
noted
high
elsewhere,
frequency
drop
difficult
BPD
to identify
case
that
to a successful
out
of
As
reflective
borderline
therapies-rarely
more
been
conclusion.
this is partly
with
which
Borderline
patients’
change
on
second
of long-term
to them.
is a very
about
and
how
remain
observation
dynamic
is that
therapy
borcriteria
at baseline
and
after
4 years
of therapy
4 Years
3.
4.
5.
6.
Impulsivity
or unpredictability
in at least two areas
that are potentially
self-damaging,
e.g., spending,
sex, gambling,
substance
use, shoplifting,
overeating,
physically
self-damaging
acts.
____________________
A pattern
relationships,
idealization,
(consistently
_______________________
Inappropriate,
anger,
e.g.,
anger.
intense
anger
frequent
displays
or lack of control
of temper,
constant
X
X
x
x
x
x
?
of
x
X
x
of being
alone,
alone,
depressed
feelings
e.g., frantic
efforts
when
alone.
of emptiness
x
X
X
x
x
x
X
X
X
_______________________
X
X
x
or
x
x
x
____________________
x
or boredom.
VOLUME
2
X
?
x
_______________________
to
acts, e.g., suicidal
recurrent
accidents,
X
____________________
Affective
instability:
marked
shifts from
normal
mood
to depression,
irritability,
or anxiety,
usually
hasting
a few hours
and only rarely
more
than a few days, with a return
to normal
mood.
Chronic
x
5
_________________________
7. Physically self-damaging
gestures,
self-mutilation,
physical
fights.
8.
x
Identity
disturbance
manifested
by uncertainty
about
several
issues relating
to identity,
such as
self-image,
gender,
identity,
long-term
goals
or
career
choice,
friendship
patterns,
values
and
loyalties;
e.g., “Who am I?”, “I feel like I am my
sister when
I am good.”
Intolerance
avoid
being
X
Cl)
53
53
-
intense
interpersonal
shifts of attitude,
manipulation
for one’s
own ends).
the effects
1 shows
how
changed
relaBy the end
of
Cl)
of unstable
and
e.g., marked
devaluation,
using
others
in such
for borderline
After
S
2.
psycho-
treatment,
all five patients
were
involved
in
socially
productive
roles and virtually
all impulsive
behaviors
had disappeared.
Relation-
is
Baseline
1.
For resobering
that
before
a
random-assigna great
deal
patients
are profound.
Table
dramatically
the five patients
tive to the DSM-III
criteria.
who
DSM-ffl
to be learned
to be engaged
The
giving
therapists,
including
experts,
the satisfaction
of bringing
the treatment
to a mutually
satisfactory
conclusion.’2’
This
observation
TABLE!.
needs
are likely
a therapy.
of the
pa-
should
be of comfort
to the clinicians
might
otherwise
feel that being
“dropped”
reflective
of the inadequacies
that their
patients
attribute
however,
this
REPORT
dynamic
therapists
can successfully
engage
such
patients
in therapy
or alternatively
about
how to select
borderline
patients
who
in
has
RESEARCH
observation
that
indicates
highly
expensive,
controlled,
ment
study
can be undertaken,
of successDespite
the
experience
in successfully
treatpatients
to which
many
therapists
can
tients
conducting
subject.
AND
NUMBER!
#{149}
x
WINTER
#{149}
x
1993
x
?
X
CLINICAL
ships,
AND
both
RESEARCH
within
and
were infused
with
and good
will that
67
REPORT
outside
of
an ambience
had replaced
In the third
year, acting
out greatly
diminished,
but acting
in (in the form of testing
therapy,
of affection
the distrust
and hostility
of earlier
periods.
inferred
from these cases that
In short,
we
dramatic
char-
acter
within
changes
period
previous
had
occurred
of 4-5#{189}years-changes
therapy
had helped
still seem
about
the
Figure
change
behaviors
around
and within
the therapy)
intensified.
The patients’
emerging
trust
in
the fact that the therapists
cared
about
them
a time
was accompanied
by increased
expression
of
hostility
in reaction
to limitations
or disap-
that, even if
pave the way,
pointments
ship.
The
incompatible
with what
is known
normal
course
of this disorder.
1 presents
a condensed
view of the
processes
that
were
observed
sence
in the
demanding-based
powerful
protector,
the patients
had
sponses
to the
these
roles. The
functional.
The
second
therapists’
patients
the
year
characteristics
diminished
tions
and
employment
routine
self-destructive
contacts.
of the craving
a more
explicit
edgment
of dependency
Four
patients
found
Proceas
upon
part-time
involving
with
change
Thus,
acThere
e observed
in five
Impulsive
Suicidal
Affects
Desperate
Rageful
Relationship
Unemployed
Year
and
more
Only
OF PS’HOTHERAPY
responsithen
did
RESEARCH
available
N S
case
studies
that
over
have
implications.
by which
or
on
preced-
time period.
clinical
and
In particular,
by which
lack of
researchers
ate measures
vals to assess
a longer
powerful
it
can
they
Three
areas
in which
give
therapists
can
within
therapy
find
appropri-
that require
shorter
time
whether
the psychotherapy
the
inter-
effective-
patients
2
Year
3
Ye ar 4
PRACTICE
Anxious
Sad
Vo cationa
Employed
Dependent
YearS
Testing
“Owned”
Anger
‘
within
of therapy,
their
social
schizophrenia
Self-destructive
Distrustful
JOURNAL
for
rise to hypotheses
gauge
progress
borderline
1
to the
is possible
these
cases
effective.
of chang
both
research
on the subject,
these
cases
that
specific
changes
are possible
discrete
periods
and
that
profound
research
for actual
acknowl-
nondemanding,
Action
Therapeutic
contrast
ed the
suggest
within
the therapist.
and/or
low-
Year
Function
AND
ab-
increased
of affects
M P L I C A T 1 0
psychotherapy
tasks.
FIGURE!.
Social
In
of
but
relative
with
to include
ambitions.
friendships.
CLINICAl,
director,
angry
re-
year
relation-
years’
associated
of a range
I
a continuation
first
severity
of the
extratherapeutic
was some diminution
signs of caring
and
level
saw
fifth
was
role performance
bility
and career
patients
develop
failures
to fulfill
were all socially
dys-
of the
and
therapeutic
and outside
of therapy.
Outside
patients
significantly
enhanced
on idealization
as a potentially
or nurturer-and
the
fourth
of action
expression
five patients.
A brief summary
of these
stages
follows.
The first year of treatment
was primarily
marked
by a broad
range
of acting-out
behaviors,
including
self-destructive
acts
and
threats
and
multiple
intersession
contacts.
The
relationship
to the therapist
was intermittently
within
‘
Collaborative
AND RESEARCH
Goals
Friendships
Warm
is
68
CLINICAL
ness
of a therapy
might
be assessed
apeutic
alliance,
impulse/action
pecially
self-destructiveness),
adaptation.
are
ther-
patterns
(esand
social
reach
which
these
they
Therapeutic
Alliance
Borderline
patients
in intensive
psychotherapy
are
dynamic
to
show
a
their
warmth,
thera-
gradual
growth
in the
trust,
and collaborativeness
attachment,
with
pist. Previous
if not most,
has shown
that many,
patients
who are be-
ginning
psychotherapy
attachment
ous research
dicates
that
months
independently
evaluation
means
should
that
and
do
a good
develop
out within
the
that at 6 months,
show
alliance
that a large
not develop
evidence
part
features
therapist,
this
an
of psychotherapy
as-
such
as positive
positive
attitudes
research
first
half
rative,
pected
of attachment
and
the
of
year than
this offers
therapeutic
therapy
should
tive
feelings
going
and
treatment
posiand
latter,
alliance
half.
significantly
than in the
area
in which
it is possifor change
Specificacts will be
likely in the first 6 months
6 months
and in the first
in the second
year. For researchers,
a relatively
short-term
way to assess
effectiveness.
For clinicians,
onserious
should
suicide
risk after
raise the question
acknowledge
dependency
upon
him or her.
Although
such
feelings
may appear
to be
present
very early in therapy,
when
they are
apeutic
more
failure
directly
or at best an impasse.
related
to the concept
pulse
control
is the
based
ments
other
types of self-destructive
as self-mutilation,
substance
on idealization
will often
not
or fantasy,
the
be secure
enough
sentito be
acknowledged
until there
is more
of a reality
base and a sense
of security
in the relationship.
The
generally
positive
tone
assigned
the relationship
will be recurrently
until
late in the therapy-perhaps
to a stable,
less
rative
relationship
The therapist
to meet
these
the
whose
criteria
designated
consultation.
There
degree
idealized,
in the
time
is considerable
to
which
borderline
to
disturbed
changing
patient
fails
at each
of
should
consider
variation
in
patients
VOLUME
the
may
2
recklessness.
tions
change
period
that
and more
collabofourth
or fifth year.
borderline
for change
periods
and
NUMBER!
#{149}
first
Our
Perhaps
of im-
diminution
in
behaviors,
such
abuse,
buhimia,
unpublished
observa-
is because
these
behaviors
are
more
connected
to the borderline
person’s
of him or herself
as bad. Indeed,
in the
year
tually
insofar
gradual
2 years in
of a ther-
have
suggested
that
these
behaviors
more
gradually
and
over
a longer
of time than suicidal
acts. We believe
this
closely
image
ex-
Patterns
major
more
second
in
collabo-
is to be
ble to develop
specific
hypotheses
involves
impulse/action
patterns.
ally, we hypothesize
that suicidal
alignment
with basic
treatment
goals
(e.g.,
understanding
his or her behaviors,
developing trust).
At best, patients
may even accept
the idea
that
the therapist
is trying
to be
helpful.
Between
12 and 24 months,
psychohelp the patient
to have
toward
the
therapist
of treatment,
A second
analytic
defirelationship
common
purposes.
can be expected
Impulse/Action
next 3 months.22
We
borderline
patients
toward
the
the value of
traditional
working
aspect
of a good
only in the second
is unlikely
majority
(72%)
of
such
an alliance
of the therameasures
of
feeling
about
with separate
roles
but
Whereas
positive
feelings
the
to
if
evaluated.
Yet independent
these
changes
would
be
for
the therapy,
and the
nition
of a collaborative
or trust in their therapist.2’
Previwith schizophrenic
patients
ina poor
therapeutic
alliance
at 6
to develop
those
who
will drop
propose
never
REPORT
sessment.
Certainly
assessments
peutic
alliance
must encompass
hypothesized
research
borderline
RESEARCH
landmarks
and
the degree
may be able
to profess
them
important
The
AND
of treatment,
see some
as many
expansion
borderline
the
therapist
of these
patients
may
ac-
activities
use such
actions
to evoke protective
responses
and test
the resilience
and reactivity
of their
therapists. Gradual
diminution
in the severity
and
WINTER
#{149}
1993
CLINICAL
AND
RESEARCH
69
REPORT
frequency
of such actions
should
be observed
from
the second
through
the fourth
years as
the patient
begins
to unconsciously
internalize
some
self-worth
of feeling
through
cared
about.
the
experience
Because
of both
the
public
health
significance
(in terms
of health
service
utilization
and burden
to others)
and
the relative
ease of documenting
overt
selfdestructive
and suicidal
acts, change
in this
domain
is particularly
important
to clinicians
and particularly
promising
for researchers.
The initial years of therapy
are all marked
by problems
in managing
the boundaries
the psychotherapy;
namely,
the payment
bills,
between-session
contacts,
self-destructiveness,
of
of
scheduling,
substance
abuse,
(without
diagnosis).
implications.
which
This
one
might
observation
First,
therapists’
doubt
but probably
should
be expected
to persome
productive
vocational
role in the
second
year. Achieving
work
identifying
career
goals and
the
fourth
table
can
and
lies gear
their
more
realistically-in
other
second
sorts
year
has two research
management
unstable,
and
for friendship
now
sought
research.
deed,
such
Kernberg
an effort.
third
year.
cannot
guided
overlook
dynamic
our deep
therapists
fears
will
that
lose
performance
the
In-
the
type
same
year
exploitative
until
emerges-potentially
but
more
usually
the
in
C
0
N
C
L
U
5 1 0
N
led
us
to
develop
a measure
by which
such actions
can
be weighed,
quantified,
and placed
within
a
common
conceptual
sure of change
(see
Social
A third
major
is the
domain
observable
patient’s
scheme
Appendix
as a major
A).
mea-
a sequence
of
changes
can be delineated
level of social adaptation.
One
area
involves
vocational
rehabilitation.
The
borderline
patient
in a useful
psychotherapy
might
not function
at work
during
the first
JOURNAL
the
fourth
effectiveness
patients.
of their
treatment
of
These
stages
of change
are relevant
to research
namic
psychotherapy
tients.
It should
on
with
be understood
the stages
of change
usually
well-informed
phases
of
treatment
in evalu-
described
clinical
long-term
borderline
that
dypa-
although
here
are unhypotheses,
that is all they are. If, but only if, prospective
research
confirms
them,
unsupported
clinical judgments
of the effectiveness
of therapy
Adaptation
in which
capacity
in the
S
ating
the
borderline
has
in-
we
manualmuch
of
own impulses
and actions
can be a
reliable
measure
for change
in the
observation
the
and
about
personal
issues
much
later. Heterosexual
will remain
intermittent,
his or her
reasonably
This
psy-
psychotherapy.
friendships
This report
has identified
specific
change
within
psychotherapeutic
that clinicians
can use as guidelines
years.
fami-
expectations
way that
the spontaneity
and creativity
required
for
effective
psychotherapy
for
this
patient
group.24
Second,
a patient’s
ability
to manage
early
of time-
in helping
individual
of stable
volving
self-disclosure
will not occur
until
involvements,
too,
to a clinically
of the kind
psychotherapy
This
benefit
is likely
to emerge
during
but will remain
intermittent
quirement
for
The
development
the
et al.23 recently
publishedjust
Although
we applaud
this,
years.
and
await
choeducation
has been
shown
to help families of schizophrenic
individuals.
In the area
of social
support,
involvement
with organizations
or social
groups
of
of such actions
could
lend itself
meaningful,
prescriptive
manual
in
fifth
be of great
satisfaction
ambitions
conflicted.
Sometimes
this process
can be
facilitated
if involvement
with a group
therapy or self-help
organization
is made
a re-
promis-
cuity,
etc. As distressing
as these
problems
are, they are the familiar
and even
routine
problems
that are associated
with this patient
group
year
form
OF PS’sCHOTHERAPY
will be rendered
less necessary.
We are especially
sensitive
amined
possibility
that prior
to the
therapies
unexmay
have laid an unusually
good base (e.g., diminished
testing
behaviors)
from
which
the
course
of change
seen
in these
successful
PRACTICE
AND
RESEARCH
70
CLINICAL
cases
began.
by prior
This
possibility
prospective
is underscored
research
showing
that
both
tients
borderline2’
and
schizophrenic22
who had more
prior therapy
were
pamore
likely
to engage
in a new
It seems
clear that
sons with BPD, as for
therapy.
psychotherapy
those
with
for perschizophre-
nia, involves
a variety
of sectors
behavioral,
interpersonal,
familial,
al, cognitive),
each of which
may
sive to different
modalities.
Even
area of individual
of interventions
fessional,
ments
psychotherapy,
seems
likely.
(affective,
vocationbe responwithin
the
a sequence
The more
pro-
authoritarian,
and
supportive
of psychotherapy
may
be
ele-
particularly
AND
RESEARCH
ogy are more
assessable.
a sequence
could
explain
REPORT
Recognition
why those
of such
who ad-
vocate
a psychoanalytic
model
for treatment
of BPD often
write
about
patients
who lack
the
prototypic
situational
and
behavioral
problems
that
are
usually
presenting
prob-
hems
for borderline
patients.
In view of the multiple
modalities
of treatment
that are deemed
useful
for treating
borderline
patients
and in view of the complex
sequence
significant
of changes
modification
accomplished,
any large-scale,
trolled
therapy
that is involved
in personality
before
can be
it seems
premature
to initiate
randomized,
assignment-con-
study
with
on the effects
of dynamic
psychoborderline
patients.
We feel that
effective
early in treatment,
when
the sectors
of impulsive
behaviors,
familial
conflict,
and
it is more
unemployment
are most disabling.
The more
unstructured
exploratory
characteristics
of
traditional
transference-based
psychodynamic
therapy
that require
more
collabora-
search
efforts
in methodological
developments,
in shorter
term strategies,
or in the first
stages of long-term
therapies.
In this article we
have suggested
strategies
for making
such in-
tion
vestments
in research
namic
psychotherapy.
may
exert
benefits
later,
affective
sectors
R
E
F
1. May
E
R
PRA:
their
particular
when
the
of borderline
F
N
C
E
Treatment
tive Study
of
Science
House,
and
sonal
Gen
accounts
Psychiatry
4. GundersonJG:
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1983,
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7. Cowdry
in per-
“schizophrenia.”Arch
HM,
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in psychotherapeudisorders,
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Individual
the
re-
effects
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in personality
treatment
disorder.
Arch
of bor-
Gen
of
VOLUME
Etiology
Psychiatry
borderline
2
Washington,
G: Borderline
Northvale,
NUMBER!
of borderline
in Borderline
Treatment,
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of the
DC,
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Adult.
and
Its Treat-
1976
Psychopathology
NJ,Jason
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ment.
PH: What’s
new
on pharmacologic
wiser
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Personality
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New Approaches
by Zales
MR. Brunner/Mazel,
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MM:
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ioral Perspectives.
by
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HW,
Borderline
Psychother0,
Selzer
Review
M,
of
72
CLINICAL
APPENDIX
A.
Action
AND
RESEARCH
REPORT
scale
RATER
DATE
NAME
OR
Actions
I-A
Weighting
Suicidal
Acts (past 6 months)
1. Not life-threatening
(e.g., scratch,
2. Life-threatening(e.g.,
overdose)
3. Deliberately
lethal
I-B
small
Self-mutilation
(past 6 months)
1. Not life-threatening
(e.g., scratching,
2. Disfiguring
(e.g., deep
burns,
slashes)
3. Disabling
(e.g., cut tendons)
Il-A
Substance
Abuse
(past 3 months)
1. Without
health
risk
2. With health
risk (e.g., potentially
somatic
symptoms)
3. Life-threatening
drug/alcohol
Il-B
number
biting
of pills)
Sexual
Misconduct
(past
1. Promiscuity,
adultery
II-E
2. Incest
(perpetrating)
3. Sexual
contact
Eating
Disturbances
1. Without
health
2. Health-endangering
3. Life-endangering
Ill-A
Ill-B
self-destructive
__________
__________
=
_________
=
_________
=
_________
__________ _________
_________
________
__________
=
=
=
_________
(e.g.,
=
_________
=
_________
excessive
(2)
career,
or family
out on spouse)
threats
does not
here)
(5)
(20)
go
(2)
(5)
(20)
__________
__________
__________
=
_________
3 months)
safety
(3)
(10)
(20)
at risk
(past 3 months)
risks
(anemia,
chronic
____________
Check
one Only
_______
_____
_______
_______
_______
hypokahemia)
_______
(3)
(10)
NA
NA
(20)
NA
(1)
threats,
etc.)
to limits)
actions;
__________
TOTAL
(5)
(20)
abuse
(2)
(3)
In-session
Resistance
(past
1 month)
1. Purposeful
obfuscations
(avoids
meaningful
subjects,
refuses
to respond
to therapist
intervention,
extended
silences)
2. Bodily
behaviors
(e.g., refusing
eye contact,
sexual
exhibitionism,
facing
away, or leaving
chair)
3. Lying
to therapist
=
Frequency
of episodes
causing
Testing
of Therapeutic
Boundaries
(past
1 month)
1. Unscheduled
contacts,
or attempts
at contact
(e.g., phone
calls, tape recordings,
letters,
attempts
at social
interaction)
2. “Testing
behaviors”
(e.g., tardiness,
leaves
early, late bills,
3. Behaviors
that threaten
the viability
of the therapeutic
relationship
(repeated
absences,
serious
payment
conflicts,
nonresponse
I.
placing
(5)
(10)
(20)
X
(2)
addictive
Aggressivity
(past 3 months)
1. Hot-tempered,
belligerent,
or threatening
(angry
of self-destruction
or taunting,
intimidation
which
on to actual
assaultive
behavior
should
be recorded
2. Destructive
acts to property,
minor
assaultiveness
3. Severe
assaultiveness
II-D
(5)
(20)
(50)
self)
Impulsive
Recklessness
(past 3 months)
1. Reckless
acts not seriously
endangering
self/others
money
spending,
accident
proneness)
2. Reckless
acts potentially
endangering
reputation,
life (e.g., suddenly
quitting
needed
job or walking
3. Reckless
acts that seriously
endanger
self/others
Il-C
ID.
II
=
impulsivity;
VOLUME
III
=
2
actions
NUMBER!
#{149}
(1)
(2)
(3)
in therapy.
WINTER
#{149}
1993
=_______
=
=