fJaylorStFrancis B healthsciences

Experienced therapists' opinions on central issues in psychodynamic psychotherapy of patients with personality disorders
KJERSTI NARUD, ARNSTEIN MYKLETUN, ALVA. DAHL

Narud K, Mykletun A, Dahl AA. Experienced therapists' opinions on central issues in psychodynamic psychotherapy of patients with personality disorders. Nord J Psychiatry 2003;57:461-467. Oslo. ISSN 0803-9488. Individual psychodynamic psychotherapy is a recommended, but controversial, treatment for patients with personality disorders (PDs). The aim of this study was to examine the relationship between demographic and professional characteristics of experienced psychotherapists and their attitudes and opinions towards aspects of this kind of psychotherapy. A questionnaire covering these issues of psychodynamic psychotherapy with patients belonging to all three DSM-IV clusters of PD was developed. A sample of 324 Norwegian psychiatrists and clinical psychologist with considerable experience in individual dynamic psychotherapy of patients with PDs filled in valid questionnaires. The therapists' age, gender, profession, postgraduate courses and degree of experience were examined as to their opinions on the following issues: alliances, aims, contraindications, needs to terminate, suicides, use of drugs, length of treatment, need for supervision and complaints to colleagues about patients' behaviour in such therapy with PD patients. Independent sample ?-tests of the mean z-transformed group scores were the main statistical method applied. Therapist experience made the most significant differences as to treatment issues, while some differences also were found for age, gender and profession. The influence of postgraduate courses was negligible. Our study might have a selection bias towards therapist with strong psychodynamic orientation and particular interest in the psychotherapy of patients with PDs. Personality disorder, Psychodynamic psychotherapy, Therapist characteristics. Kjersti Narud, M.D., Department of Psychiatry, Aker University Hospital, Sognsvannsveien 21, NO-0320 Oslo, Norway, E-mail: kjersti.narud@psykiatri.uio.no; Accepted 9 December 2002.

sychotherapy is an effective treatment for personality disorders (PDs), although, in all studies, patients P with PDs do not improve to the same degree as those

considered central to change in psychodynamic psychotherapy, we presume that therapists' characteristics will be of particular importance in therapy with PD without PDs (1). Despite the variety of dynamically patients. As no research studies on therapists' characteroriented treatments available, few studies of their effec- istics specific to such therapy in this patient group could tiveness with PD patients have been reported (2). The be identified by our searches of the literature, some largest body of research on psychotherapy of PDs has relevant findings on therapists' characteristics from addressed the issue of treatment alliance (3) and treat- psychotherapy research in general will be given (9). ment outcome (4-6). Bateman & Fonagy (7) recently The age of therapists is at least partially confounded stated that new research strategies are needed in order to with both level of experience and theoretical orientation, show that personality changes are measurable in a as reflected in the theories that are dominant at the time clinically meaningful way, and that efficacy studies using of the therapists training. Most studies have failed to randomized controlled designs are required. The clinical find therapist's age, by itself, to be significantly related literature suggests that effective psychotherapy of pa- either to the efficacy of psychotherapy or to early tients with PDs shall be long-term, integrated, theoreti- treatment drop-out. Most studies of the relationship of cally coherent and focused on compliance (8). therapist gender to the outcome of psychotherapy have The influence of therapists' characteristics has long not indicated any significant relationship, been a major focus of psychotherapy research. Since the Therapist values, skills and behaviours change during personal interaction between patient and therapist is the course of their formal training and with widening
2003 Taylor & Francis DOI: 10.1080/08039480310003489

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clinical experience. Studies showed that therapists' level of training, profession and experience exerted the most powerful effects on psychotherapeutic outcome. Studies of therapists from different professions also present mixed results. The overall effect size for psychologists has been shown to be somewhat higher than that of psychiatrists. Patients and non-patients rated the attitudes of psychologists as more positive than those of psychiatrists. Psychiatrists and psychologists were judged to have different areas of competence, but PD was not among the areas rated. Generally more-experienced therapists obtain better outcomes compared to less-experienced ones. The relative efficacy of pharmacotherapy and psychotherapy, and their eventual combination, often evokes strong feelings and beliefs related to professional ideology in psychiatrists and clinical psychologists (10). Psychiatrists have a tendency to overvalue psychopharmacological treatment while psychologists may be too sceptical about its value. To sum up the empirical evidence so far, it has not been consistently demonstrated that therapists' characteristics such as age, personality, profession, personal psychotherapy or the amount of supervision have any significant relationship to the therapists' skill or the outcome of psychotherapy. However, psychiatrists and clinical psychologists with many years of training, personal therapy and supervision tend to have lower attrition rates. The aim of this study was to investigate how demographic and professional characteristics of therapist were related to opinions on the following treatment issues: alliances, aims, contraindications, needs to terminate, suicides, use of drugs, length of treatment, need for supervision and complaints to colleagues about patients' behaviour in such therapy with PD patients. In accordance with the general findings of psychotherapy research, we hypothesized that there would be significant differences in these issues related to therapists' experience and probably to gender, but less so for age, profession and training.

developed concerning dynamic psychotherapy with PD patients. On the 736 returned forms (64.2%) we applied the following exclusion criteria in order to identify experienced therapists: 1) less than 5 years of clinical practice; 2) did not report about experience with PD; 3) had treated less than five patients with PDs in the last 5 years, and 4) had missing values on more than 10% of the questionnaire. These four exclusion criteria eliminated 412 forms, and finally left us with a sample of 324 (44.0%) valid forms from therapists with considerable experience in the psychotherapy of PD patients. Questionnaire For this study, we developed a four-page questionnaire concerning various aspects of psychodynamic individual psychotherapy with PD patients. The questionnaire requested the following background information: therapist demographics, work situation and training in various modalities of psychotherapy. Other sections concerned: the number of PD patients treated during the last 5 years; frames and contract; treatment aims and duration; difficulties and complications; the relevance of co-morbidity, and priority of treatment modalities. All questions had to be answered for each of the three PD clusters of DSM-IV The questionnaire consisted of 380 items. The dependent variables examined in this report were taken from the "therapists' background" section: age, gender, profession, postgraduate courses and experience in treating patients with PD. The independent variables studied were: alliance, experienced suicides, complaints from colleagues, number of sessions needed for solid learning in therapy, aims of treatment, use of drugs, attitudes towards patients who used drugs and alcohol, contraindication, and the need for supervision. The rating alternatives were given as absolute numbers and three- or four-point ordinal scales. Examples of variables, questions and rating alternatives are shown in Table 1.

Statistical methods
The therapists' characteristics that were not obviously dichotomized, such as gender and profession, were dichotomized based on median values and frequency distributions on skewed response distributions. All questions were addressed to each PD cluster (A, B and C) separately, but as responses differed minimally between clusters, they were collapsed for analyses. Student's ?-tests for independent samples were used to analyse for significant differences between the independent variables. A correlation analysis (Pearson's r) was performed in order to test the relationship between the therapist variables. Because of the variability of rating scale alternatives, the ratings were transformed to zscores, and group differences in experiences from
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Subjects and Method Subjects

To obtain a relevant sample of therapists, we accessed the membership lists of the Norwegian Psychiatric Association and the Norwegian Psychologist Association. Since we had no method for pre-selection of therapists with experience in psychotherapy of patients with PD, we addressed all 738 psychiatrists who were below the retirement age of 70 years. Among non-retired psychologists, we addressed the 409 that were qualified in the sub-speciality of "clinical psychology", so the total number of professionals addressed were 1147. These professionals were sent the questionnaire we had

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Table 1. Treattnent variables examined.

Variables Alliance Questions in the questionnaire Operationalization

"How good do you assess the usual alliance in treatment of PD patients?" Four-point scale from "very good" to "bad" "Have you experienced suicide among PD patients in treatment; number?" Number of suicides Suicide "What have you heard colleges complain about the in psychotherapy with Number of complaints Complaints by colleagues PD patients?" Items: Contact difficulties, aggression, acting out, affectivity, missing sessions, payment, non-acceptance of limits Three-point scale from "easy" to Perceived degree of difTiculty "General degree of difficulty in treatment of PD?" "difficult" Three-point scale from "often" to "How often do the patient terminate therapy?" Termination by patient "rarely" Three-point scale from "good" to "How regularly do the PD patients attend the sessions?" Regularity of attendance "bad" Four categories: < 20, 2 0 - 4 0 , 4 0 Number of sessions needed for "How many sessions do patients with PD need to benefit from the 80, > 80 sessions treatment?" solid change Number of aims marked "What aims of treatment do you usually go for?" Items: Symptom relief, Treatment aims improved interpersonal functioning, reduced impulsivity, improved objectrelations, reduced vulnerability and improved affect regulation "Which contraindications do you assess as important in psychotherapy with Number of contraindications Contraindications PD patients?" Items: Mendacity, demands of intimacy, irregular attendance, marked aggression, and substance or alcohol abuse Three-point scale from "often" to "Do you need supervision in psychotherapy with PD patients?" Need for supervision "rarely"

therapy in relation to therapists' characteristics were reported as differences in mean z-scores. The level of significance was set at 0.05 (two-sided tests). The statistic analyses were performed to with SPSS-PC version 11.0. Ethics The Norwegian Psychiatric Association and the Norwegian Psychologist Association approved the study. All questionnaires were completed anonymously.

Table 2. Characteristics of the therapists.*

Therapist variables Demographics Gender: females/males Age: < 50/ > 50 years Main work situation Private practice Outpatient department Inpatient department Other Basic/postgraduate education Psychiatrists/clinical psychologists Courses in individual psychotherapy Courses in group-analytical psychotherapy Experience with > 30 PD patients n (%) 97 (30)/227 (70) 187(58)/134(41) 68 (21) 110(34) 78 (24) 68 (21) 210(65)/114(35) 210 (65) 81 (25) 140 (43)

Results
Therapist demographics Seventy per cent of the therapists were males, 41.4% were older than 50 years, 65% were psychiatrists and a majority of them worked in outpatient (34%) and inpatient departments (24%) (Table 2). Most of the therapists had postgraduate courses in individual psychotherapy (65%) or group-analytical psychotherapy (25%). Eorty-three per cent of the therapists had experience with 30 or more PD patients during the last 5 years. The female therapists were somewhat younger than the males, and the psychiatrists had more postgraduate education than the psychologists.

According to the inclusion criteria, all therapists had experience with five or more PD patients the last 5 years.

correlate with any of the other therapist variables. The confounding of the therapist characteristics thereby was found to be negligible.

Therapist gender Correlation of therapist characteristics Female therapists have experienced significantly more We found small and non-significant correlations besuicides among PD patients than males (Table 4). Males tween most ofthe therapist characteristics (Table 3). The only exceptions were that being a psychiatrist was also stated that a significantly lower mean number of significantly correlated to having taken postgraduate sessions were needed for solid learning in PD patients. courses in psychotherapy. In particular, being experi- Eemale therapists also found significantly more contraenced with dynamic psychotherapy of PDs did not indications to psychotherapy.
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Table 3. Correlation tnatrix of therapist variables.

Individual Courses Group courses

Gender Age Profession Individual courses Group courses Experienced -0.117* 0.055 -0.002 -0.024 -0.035

Age 0.037 0.095 - 0.064 -0.015

Profession

-0.263* -0.221* - 0.040

0.075 0.077

- 0.027

*P < 0.05. Numbers are differences in z-scores of number of responses on items.

Therapist age Younger therapists have heard significantly more complaints about patient behaviour from colleagues than older therapists. Younger therapists experienced more violations of treatment contracts. Older therapists significantly more often found contraindications for psychotherapy. Younger therapists have significantly more need for supervision than older ones. Therapist profession Psychiatrists heard significantly more complaints from colleagues than clinical psychologists concerning patient behaviour. Psychologists generally thought that more sessions were necessary in order to get solid learning from treatment. Psychiatrists significantly more often used drugs, and they found significantly more contraindications for therapy than the clinical psychologists.

Issues unrelated to therapist characteristics No differences between the therapist variables were found as to give permissions to patients to call between sessions, information given to relatives, or the feeling that the patients wear down the therapists. All these variables showed low mean z-scores, indicating that these issues were infrequent. The therapists' characteristics did not either show any differences concerning experienced difficulties of psychotherapy, or termination and irregular attendance by patients. The use of treatment contracts did not differ in relation to the therapists' characteristics examined. The same was true as for the treatment aims of symptom relief, improved object relations and reduced impulsivity. These data are not shown.

Discussion

Therapist experience made the most significant differences as to treatment issues examined in this study, while Postgraduate courses Therapists with courses in individual and group psy- some differences also were found for age, gender and chotherapy were significantly more often of the opinion profession. The influence of postgraduate courses was that more sessions were needed in order to obtain solid negligible. In the literature, the therapists' age did not show learning in the PD patients. No other significant differences were related to the experience of attending important differences as to the effects of therapy, but in most studies age is confounded with experience. In our courses. study, we found some significant differences between younger and older therapists when we used 50 years as Therapist experience with PD patients cut-off age. As expected, younger therapists were more Therapists that were more experienced with PD patients in need of supervision, and they also meant that the (defined by having treated > 30 PD patients during the patients needed more sessions for solid learning from last 5 years) felt that they established more stable therapy. Younger therapists also heard more complaints alliances with the patients than the less-experienced from colleagues concerning various stresses in this kind therapists. The more-experienced therapists had heard of psychotherapy. An interesting hypothesis might be more complaints from colleagues concerning various that there is a "cultural generation change" as to the aspects of patients' behaviours. The less-experienced allowance of therapists to get frustrations in therapy "off therapists thought that the patients needed significantly their chest" instead of keeping them inside. Older more sessions in order to obtain solid learning from therapists significantly less often stated contraindicatherapy. The experienced therapists had significantly tions to therapy, and this might reflect that they have a more ambitious therapeutic aims compared to the wider perspective as to what PD patients they can work inexperienced therapists. Experienced therapists were with in a productive way. also significantly more willing to take on patients with We found that more female therapists had experienced complicating substance abuse. They also significantly suicides in PD patients. Many explanations can be made more rarely found contraindications for treatment. for this finding, but we can only state that the number of

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patients treated is not the most plausible one, since we did not find gender to be a confounder of experience. Female therapists also reported that they had heard more complaints from colleagues coticerning patients' acting out and failitig acceptance of limit setting. Our study does not, however, report the gender of patients and therapists in this regard, sitice our finding simply might endorse the fact that females have a lower threshold for expressitig their emotions. We found that clinical psychologists significantly less often used psychotropic drugs in their therapies. This could be due to ideological attitudes, but also to the lack of knowledge of what drugs can do in the treatment of PD patients, and the lack of authorization to prescribe. Psychiatrists heard more complaints from colleagues, and this finding might refiect professional attitudes. Psychologists also saw fewer cotitraindicatiotis to treatment, and that might meati that they were willing to take on patients that represent more bad prospects than were psychiatrists. This could also explain why they thought that more sessions were needed for solid learning in therapy. In line with psychotherapy research in general, we found that therapists' experience was the factor that made most significatit differences as to treatment variables. The experienced therapists stated better alliances, more-ambitious treatment aims and less contraindication than the less-experieticed ones. We might hypothesize that experienced therapists in the psychodynamic therapies of patients with PD, are those who have stood the test of time with such difficult and demanding patietits without leaving the field. However, we do not know if there was any difference as to the kind of PD patients treated by therapists of the two levels of experietice. We could entertain the hypothesis that the most seasotied among experienced therapists select lessdifficult patients. Somewhat surprisitigly, we found that attetiding courses in individual and group psychotherapy influenced the therapists' opinions very little on the issues we studied. We can hold the hypothesis that the opinions we examined were more infiuenced by the clinical and psychotherapeutic supervision at their local departments. Our finding should not be interpreted in the way that such courses are without influetice on the opinions of the therapists. The therapist variables we have examined did not show any significant differences withiti several treatment issues of importance such as permission to call between sessions, contact with relatives and difficulties experienced in treatment. We might conclude that issues other than therapist variables might itifiuence variations within these treatment variables. To our knowledge, this is the first study of the attitudes and opinions of experienced therapists con-

cerning various issues of treatment in dytiamic psychotherapy with PD patients. Our study had some advantages. The correlatioti between the therapist variables was very low, and in particular, therapists' age utider or above 50 years did not confound the experience variable. Since the focus of our questiontiaire was on psychodynamic psychotherapy, we presume that therapists with other theoretical orientations hardly bothered to participate and fill iti the comprehensive questionnaire. We reasoned iti the same way concerning therapists who did not take an interest in the treatmetit of patients with PD. On the 436 valid forms, we applied three criteria to select therapists that were experienced in dynamic psychotherapy with PD patients. Thus, we think that our 324 respondents might be represetitative of experienced therapists with psychodynamic attitudes and traitiing, atid with considerable interest in the psychotherapy of patients with PD. Our study also has several weaknesses. We have already mentioned the low response rate, atid in particular, the high rate of incomplete forms returned. Our main explanation is twofold: the form took considerable time to fill in, and thereby we got a selection bias favouring professiotials particularly interested in psychodynamic therapy of patients with PD. In this study, we also made multiple comparisons betweeti groups, and the risk of obtaining significatit differences just by chance, is otie in 20. However, we found that most sigtiificant differences made itituitive and clinical sense, and thereby supported the study. We coticlude that our findings on the infiuence of therapists' characteristics iti psychodynamic psychotherapy of patients with PD are in accordance with the research findings on the infiuence of such characteristics of psychotherapy in general.
AcknowiedgementsThis study was supported by research grants from the Department of Psychiatry, Aker University Hospital, University of Oslo, Solveig og Johan P. Sommers' Legacy, Upjohn Pharmaceutics Norway and Lundbeck Pharmaceutics Norway.

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psychiatry series, vol. 19, no. 3; Oldham JO and Riba MB, series editors). Washington DC: American Psychiatric Press; 2000. p. 65-94. Kjersti Narud, M.D., Research Fellow, Department of Psychiatry, Aker University Hospital, Oslo, Norway. Amstein Mykletun, Ph.D., Research Fellow, Faculty of Psychology, University of Bergen, Bergen, Norway. Alv A. Dahl, M.D., Dr.Med.Sci., Professor, Department of Psychiatry, Aker University Hospital, Oslo, Norway.

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