The Dynamic Assessment Interview: testing the psychodynamic assessment variables.

The Dynamic Assessment Interview (DAI) is a semi-structured interview with anchored scales to rate patients; suitability for psychodynamic psychotherapy. The DAI was inspired by the Personality Assessment Interview developed by Selzer et al. in 1987 and it introduces from the beginning of the assessment interview an explicit focus on the patient's immediate interactions with the interviewer. Seven theoretical derived variables are assessed, namely psychological mindedness, capacity for self-observation, capacity for empathy, tolerance of frustration, motivation, response to confrontation, and ability to contain and work with affect. In addition, the patient's attractiveness as a psychotherapy patient and his or her assumed confidence in the forthcoming treatment are assessed. The patient's personality organization ad modum Kernberg is measured from a global assessment of the interview. The present paper describes the DAI and presents its psychometric properties. An acceptable level of inter-rater agreement was found for the theoretically derived variables and for the personality organization diagnosis, with intra-class correlations or kappa coefficients ranging from 0.68 to 0.80.

Delusions in the transference. Psychotherapy with the paranoid patient.

This article has attempted to combine a theoretical and practical approach to the challenge presented in psychotherapy of paranoid and delusional patients. The essential ingredients of psychotherapy of non-psychotic patients--such as the frame, the therapeutic alliance, transference, countertransference, and interpretation--all play roles in the psychotherapy of paranoid, psychotic, delusional patients as well. Differences in defense mechanisms and dynamics and their working through, however, can make unfamiliar the factors that are basic to any psychotherapy. A familiarity with the unique problems of psychotic individuals in psychotherapy may help to make the work less bewildering and frightening, although no less challenging.

Predictors of dropout in psychodynamic psychotherapy of borderline personality disorder.

This study aimed to identify patient factors that predict early dropout from psychodynamic psychotherapy for borderline personality disorder (BPD). Thirty-six BPD patients began an open-ended course of twice per week psychodynamic psychotherapy that was defined in a treatment manual and supervised. Dropout rates were 31% and 36% at 3 and 6 months of therapy, respectively. Survival analysis techniques demonstrated that age and hostility ratings predicted early dropout, with continuers more likely to be older and expressing lower levels of hostility than dropouts. Many variables hypothesized to predict dropout failed to do so. Both the positive and negative findings are discussed relative to the literature.

Factors Related to Drop-outs by Borderline Patients : Treatment Contract and Therapeutic Alliance.

High patient drop-out rates have traditionally interfered with both treatment and study of patients with borderline personality disorder (BPD). The authors tested hypotheses that an adequate treatment contract, a positive therapeutic alliance, and the severity of illness would all correlate with continuation of treatment versus drop-out in a BPD cohort receiving psychodynamic psychotherapy. Therapists' contributions to the contract and to the alliance correlated with the length of treatment. Patients' impulsivity was negatively related to length of treatment. This study supports the view that the therapist's technique plays a role in engaging the borderline patient to remain in treatment.

The continuity of personality in schizophrenia.

Some schizophrenic patients claim that their personalities have been damaged or destroyed so that they bear little or no resemblance to their former selves. This assertion has several unfortunate consequences: patients believe that they no longer have access to skills they had acquired previously, and they believe that understanding their past has no relevance in trying to make sense of the present or in appreciating the source of their expectations for the future. This article provides clinical examples of the continuity of personality and considers why patients and some clinicians might hold opposite points of view on this issue.

The PEH. A questionnaire to assess acknowledgment of psychiatric illness.

The aim of this research project was to develop an instrument to measure acknowledgment and denial of illness in hospitalized psychiatric patients. The investigators developed a 23-item, 4-point self report scale, the Patient's Experience of Hospitalization (PEH), and collected validity data from a sample of inpatients. A total of 29 subjects completed the PEH, the Marlowe-Crowne Social Desirability Inventory (MCSD), the MMPI, and a Global Assessment Scale (GAS) report. The patients' psychotherapists also provided GAS scores. Kuder Richardson split-half reliability and point biserial correlations of 18 items were adequate. The PEH total score correlated significantly and positively with the difference between the GAS scores assigned to the patient by the patient and by the therapist, with the patient's self-report GAS score, with MCSD scores and with the MMPI L and K scales, considered to assess crude and subtle defensive denial. Correlations with MMPI clinical scales (symptom reports) were negative, further supporting the idea of the PEH as a measure of denial.

Treatment alliance and the chronic schizophrenic.

When something in common can be found to establish relatedness; when therapists can trust that the patients will eventually be able to contain their destructiveness and that on some level they struggle with their pathology, then patients begin to identify with their therapists and with those aspects within themselves. This activity requires that first a climate of safety, based on a frame, be established. Once it is established, the search for the common "thing"--the organizing object--and the ability to work with it can go on with far less distraction. Along the way, therapists insist that words can be used to convey meaning, creating the climate for eventual interpretation. In the case described, the therapist made it clear that he disagreed with the patient's delusional viewpoint, but at the same time was interested in hearing the material as a source of ideas about how the patient experienced her world, and how to discover what remained of her capacity for self observation and nonpsychotic thought. The therapist's acceptance of the need for such a preliminary phase may make it possible for severely resistant patients to become engaged with those treating them.

The initial contract in the treatment of borderline patients.

The initial treatment contract with a borderline patient recognizes the patient's potential for destructiveness and builds in safeguards. The therapist's effort to protect the treatment mobilizes the patient's primitive defenses. The therapist must be prepared to respond to resistance to the contract by clarification, confrontation, and occasionally interpretation. Although countertransference reactions evoked by the patient's use of primitive defenses complicate the therapist's task of defining the necessary treatment frame, the therapist's recognition of countertransference responses can enable him to establish and enforce an appropriate contract.

The Personality Assessment Interview: preliminary report.

This is the first report of the Personality Assessment Interview (PAI), a new clinical and research instrument designed to address the need for a theoretically sound, clinically relevant, comprehensive yet easily administered method for assessing personality organization. By personality organization we mean those structures that stabilize the mental apparatus and become the underlying matrix from which behavioral traits and symptoms develop. Following Otto Kernberg, we define three basic structural constellations: neurotic, borderline and psychotic (Kernberg 1976). The paper describes the interview technique, the hypotheses on which it rests and its aims and structure.

The shared field: a precursor stage in the development of a psychotherapeutic alliance with the hospitalized chronic schizophrenic patient.

Psychotherapeutic work with chronic schizophrenic patients is difficult for both patient and therapist. Such patients lack many of the capacities necessary to participate in psychotherapy: motivation, observing ego, the ability to communicate verbally about thoughts and feelings, the capacity to sustain a relationship. Treatment of such patients may require phases in which such capacities are nurtured until the patient is able to form a therapeutic alliance of the ordinary kind. This paper discusses the ways in which hospitalization can be helpful during pre-alliance phases of psychotherapeutic work, through the provision of a protected setting and a team approach, in conjunction with individual psychotherapy. A perspective is offered for conceptualizing the early relationship between patient and hospital staff as a stage in the development of an alliance.

The role of the consultant in the case conference: some neglected aspects.

THE case conference is a staple of academic life in psychiatry. Ostensibly, it provides the teaching hospital with a forum for considering issues of diagnosis, treatment, and interview technique. On an inpatient service, the case conference also holds the potential for uncovering the covert dynamics at work in the treatment setting; it is the task of the consultant who leads the conference to see that this potential is met. A major part of the consultant's work is bringing to life the hidden agendas of the conference. These hidden agendas are usually unconscious needs or wishes of the staff which are played out in relation to the consultant. Staff members attempt to influence the consultant to fulfill one of three basic wishes: the wish that the consultant ally himself with a certain faction; the wish that he sanction a position that has already been adopted; the wish that he expose or punish those whom the staff members are afraid to confront directly. These agendas provide the key to identifying central conflicts which obstruct therapeutic work. Although most often these conflicts appear between staff and patient, they also arise among staff members as well as between the unit staff and the hospital administration. This paper will examine examples of the dynamics of these hidden agendas and show how they reflect the influence which the patient has on the staff.