Resumen de Psicoterápia focalizada en la transferencia para el transtorno límite de la personalidad. Un estudio con pacientes femeninas
Pablo Cuevas, Josefina Mendoza Norelis, Araceli Gómez, D. López
- español
El objetivo del estudio fue observar los cambios en la psicopatología de mujeres con trastorno límite de la personalidad (TLP) tratadas con 48 sesiones de psicoterapia focalizada en la transferencia (PFT), que fue aplicada por terapeutas noveles, y videograbada y supervisada por expertos. La PFT es una psicoterapia específica para el TLP, sistematizada en un manual por Kernberg y colaboradores de acuerdo con los requisitos del Instituto Nacional de Salud Mental de Estados Unidos, que se aplica en dos sesiones individuales por semana, dirigida a la contención y análisis de los paradigmas transferenciales-contratransferenciales de víctima-victimario y rescatador-rescatado que se escenifican en las sesiones a lo largo del tratamiento. La mayoría de los pacientes con TLP recibe el ¿tratamiento usual¿ (TU) con psicoterapia de apoyo, medicación y hospitalizaciones breves, aun cuando existen terapias específicas para ellos. Con el TU, la tasa de deserción es de 60% y los pacientes que persisten en tratamiento por varios años tienen muy poca mejoría, aun con terapeutas experimentados.
Las terapias específicas para el TLP, además de la PFT, son la Terapia Dialéctico-Conductual (TDC), la Hospitalización Parcial (HP) y la Psicoterapia del Self (PS). Con todas ellas se obtienen mejorías significativas entre los 12 y 18 meses. Sus tasas de deserción son de 19.1, 16.7, 12 y 16%, respectivamente. Con estas terapias, la impulsividad y la inestabilidad afectiva empiezan a remitir entre los primeros cuatro y seis meses de terapia. En otro estudio nuestro con terapeutas experimentados y noveles, la impulsividad remitió a las 24 sesiones y la inestabilidad afectiva a las 48, en 11 de los 19 pacientes de uno y otro sexo a los que se ofrecieron dos años de PFT. Hasta donde sabemos, el que ahora presentamos es el primer estudio sobre la PFT aplicada en 48 sesiones por terapeutas noveles. La selección de pacientes se hizo mediante el SCID I y el SCID II. Uno de los dos supervisores entrevistó a todos los pacientes y familiares y ofreció estar disponible, en caso de urgencia, para pacientes, familiares y terapeutas.
Los criterios de inclusión fueron: tener entre 18 y 40 años; cumplir con los primeros tres criterios y con dos de los seis restantes del TLP; contar con una escolaridad mínima de secundaria; no sufrir esquizofrenia, t. bipolar, t. delirante, t. agudo por abuso de sustancias, t. mental orgánico grave o t. antisocial. Catorce pacientes dieron su consentimiento y empezaron el tratamiento. Cuatro (29%) desertaron antes de las 24 sesiones y 10 completaron las 48 sesiones. La media de edad fue de 25 años, pertenecían a la clase media y poseían una buena escolaridad. Nueve presentaban conducta suicida y todas sufrían crisis emocionales e inestabilidad vocacional y de valores, y reunían los criterios del trastornolímite, de impulsividad, inestabilidad afectiva y alteraciones de identidad. Los siete terapeutas participantes se seleccionaron entre estudiantes que recién habían terminado un posgrado en psicoterapia en la Universidad Anáhuac, donde tomaron dos semestres de psicopatología y psicoterapia del TLP, y luego un curso de 20 horas sobre el manual de PFT. Los supervisores fueron dos psicoanalistas didácticos de la Asociación Psicoanalítica Mexicana, adiestrados por Kernberg y colaboradores.
El manual usado fue Psychotherapy for Borderline Personality, de Clarkin, Yeomans y Kernberg. Se hicieron mediciones al ingresar y a las 24 y 48 sesiones con el módulo del TLP del SCID II, la Escala de Evaluación de la Actividad Global (EEAG) del DSM-IV y el SCL 90. Las sesiones se realizaron en consultorios para psicoterapia, con la videocámara dentro del consultorio manejada por el terapeuta. Las supervisiones se realizaron en sesiones semanales de tres horas con asistencia de los supervisores, los terapeutas y la coordinadora del posgrado en psicoterapia. Los terapeutas mostraron buena adhesión al manual durante las supervisiones. El análisis se efectuó sobre las 10 pacientes que completaron las 48 sesiones.
Las tres pacientes que habían tenido intentos suicidas, no los repitieron; las que habían tenido varias hospitalizaciones psiquiátricas, no volvieron a internarse; y al completar 24 sesiones desaparecieron las amenazas suicidas. De las siete pacientes que no estudiaban y no trabajaban, seis reanudaron sus actividades al terminar la terapia. El único caso que necesitó apoyo telefónico de los supervisores fue la familia de una paciente que ingirió cáusticos, por lo que se le practicó una gastrectomía.
A las 24 sesiones dejaron de cumplirse los siguientes criterios: los de impulsividad en nueve pacientes; los de inestabilidad afectiva en dos y los de alteraciones de identidad en tres. A las 48 sesiones, el décimo paciente dejó de tener impulsividad, y otros seis sujetos dejaron de tener inestabilidad afectiva. No hubo otras que dejaran de cumplir los criterios de alteración de identidad y sólo una paciente dejó de tener presentes los cinco criterios necesarios para el diagnóstico del TLP. En el análisis estadístico se observó que las medias, tanto del SCL 90 como de la EEAG, mostraron cambios positivos y significativos al comparar las puntuaciones iniciales con las obtenidas a las 24 y 48 sesiones, e igual sucedió al comparar las mediciones de la EEAG obtenidas a las 24 y 48 sesiones; asimismo, casi resultaron significativas las diferencias de las puntuaciones del SCL 90 entre las 24 y 48 sesiones. Entre las limitaciones del estudio está la falta de un grupo control, el escaso número de pacientes y que no participaran pacientes varones.
Las conclusiones fueron que 48 sesiones de PFT, aplicadas por terapeutas noveles y supervisados por expertos con videograbaciones de las sesiones, son efectivas para corregir la conducta suicida y la impulsividad y recuperar la funcionalidad escolar y laboral en mujeres con TLP. Es necesario repetir el estudio con poblaciones mayores, de uno y otro sexo y en forma comparativa con el TU.
- English
The objective of the study was to observe the changes in the psychopathology of women with Borderline Personality Disorder (BPD) after 48 sessions of Transference-Focused Psychotherapy (TFP) conducted by novel therapists, videotaped and supervised by experts. TFP is a specific treatment based on a manual, with two weekly individual sessions for BPD and also for the narcissistic and histrionic personality disorders. The treatment was developed in the last 20 years by Kernberg and colleagues at the Institute of Personality Disorders, Cornell Medical Center, according to the USA National Institute of Mental Health requirements.
Transference-Focused Psychotherapy is important because it provides a systematic guide for the containment and analysis of the victim-victimizer and rescued-rescuer transferencecountertransference paradigms that arise along the treatment sessions which, if not properly handled, are responsible for the failure of most treatments of BPD patients. Before starting TFP, a therapy contract is set with detailed prescriptions for the management of suicidal behavior (the patient must accept to self- contain suicidal urges in order to receive the treatment), other forms of impulsivity, affective instability and alterations of identity related to destructive decisions regarding leaving home, school or work, use of illegal and prescribed drugs and taking proper care of mental and physical comorbidities.
Most BPD patients receive “treatment as usual” (TU) with supportive therapy, short and erratic courses of medication and brief hospitalizations. This is done despite the existence of specific therapies for them as psychodynamic therapy, supportive therapy, group therapy, family therapy and reliable and well- studied prolonged regimes of medications with fluvoxamine, olanzapine, valproate and omega fatty acid. Drop out rate of TU is almost 60% and the remaining patients exhibit little improvement even with several years of therapy conducted by experienced therapists.
Specific therapies for BPD, besides TFP, are Linehan’s Dialectical Behavioral Therapy (DBT) and Bateman and Fonagy’s Partial Hospitalization (PH) treatment (these two treatments use a combination of individual and group therapies) and Stevenson and Meares’s Self Psychotherapy (SP) (two individual sessions a week closely supervised in a weekly meeting with all therapists).
These four therapies are effective for reducing the more destructive BPD manifestations within 12 to 18 months of treatment. Drop out rates are: PFT, 19.1%; DBT, 16.7%; PH, 12% and SP, 16%.
In all these therapies, impulsivity and affective instability begin to remit after four to six months of treatment and the alterations of identity and the BPD diagnosis do not disappear at the end of the treatment.
In a previous study carried out by some of us with experienced (mean experience, 12 years; S.D.=1.15) and novel therapists (mean experience, 4.67 years; S.D.=4.23), where the experience of each group was significatively different (U=7.5, p< .002), impulsivity remitted after 24 sessions and affective instability remitted almost completely after 48 sessions in 11 out of 19 patients of both sexes who were offered a two-year treatment with videorecorded supervised TFP. There were no differences in results between both groups of therapists.
With that background, we planned the present study which, as far as we know, is the first TFP study with 48 sessions delivered only by novel therapists. The research project was approved by the Anahuac University research and ethical committees. Patients were recruited from respondents to an offer of treatment for BPD at the university psychotherapy clinic. Selection of patients was made with clinical and semi-structured interviews using the SCID I and the SCID II. At least one of the supervisors interviewed all patients and their families and offered to be available in the case of emergencies for patients, families and therapists. Inclusion criteria were: being 18 to 40 years old; meeting the first three criteria and two other of the remaining six BPD criteria; having graduated at least from junior high school, and not suffering from schizophrenia, bipolar disorder, delusional disorder, severe substance abuse, severe mental organic disorder or antisocial disorder.
Therapists were selected among recent graduates from the Anahuac University psychotherapy post-graduate program after attending two semesters on BPD psychopathology and therapy and a 20-hours course on the treatment manual given by the supervisors. Seven therapists, six female and one male, agreed to participate. Supervisors were two training analysts from the Mexican Psychoanalytic Association, trained in the treatment manual by Kernberg and colleagues at the Institute of Personality Disorders, Cornell Medical Center, in 1993. Training analysts hold at least a yearly meeting with Kernberg’s group in order to guarantee adherence to the manual. The supervisors have taught extensively how to use the treatment manual in Mexico City and other Mexican cities.
The supervisors explained to the patients and their families the nature and procedures of the treatment. They also explained to them that the use of the videorecordings would be only for research purposes and asked patients to sign an informed consent letter.
Fourteen patients agreed to initiate therapy. Their mean age was 25 years, all of them were middle class and had a high education level. Nine had suicidal behavior and all suffered emotional outbursts and instability in vocational and value systems. All patients met criteria for BPD (1, 2, 3 and any two other of the remaining six), impulsivity (1 and 4 or 5), affective instability (2 and 6 or 8) and identity alterations (3 and 7 or 9). Four (29%) of them dropped out before reaching 24 sessions due to severe conflicts with parents and 10 completed 48 sessions.
The manual used was Psychotherapy for Borderline Personality by Clarkin, Yeomans and Kernberg, a 370 pages text which contains a detailed theoretical and clinical presentation of the therapy aims, objectives, strategies, tactics, techniques, clinical assessment, therapy contract, phases of treatment and how to handle emergencies and comorbidities.
Assessment evaluations were made at the time of entry, and after 24 and 48 sessions with the SCID II BPD section, the DSM IV Global Assessment of Functioning Scale (GAF) and the SCL 90. These instruments have a good reliability and validity in measuring changes during psychotherapy. Sessions were conducted in well adapted psychotherapy consulting rooms. Videorecordings were made having the vidoecamera inside the consulting room, handled by each therapist and always asking patients if they agreed with the procedure. All ten patients agreed in all sessions to do the videorecordings. Supervisions were carried out each week during three hours sessions attended by all therapists, the supervisors and the clinical coordinator of the psychotherapy program. All therapists showed a good adherence to the manual in the supervisory sessions and had no problems with being videorecorded.
The following data analysis was made on the 10 patients who finished all 48 sessions. The three patients who attempted to commit suicide did not repeated attempts; the two patients with psychiatric hospitalizations no longer returned to hospital. At the end of 24 sessions, suicidal threats remitted in the nine patients who had them at the time of entry. Beside this, the seven patients who interrupted the attendance to school or work because of the BPD, reassumed their duties before ending the treatment.
In the 24 sessions measurements, the following criteria were no longer met: impulsivity in nine patients, alterations of identity in three patients and affective instability in two patients. In the 48 sessions measurements the following criteria were no longer met: impulsivity in one more patient; no other patients had changes in alterations of identity; six more patients in affective instability;
and only one patient no longer met the required five criteria to make the BPD diagnosis.
There were positive and significative differences in the SCL 90 and GAF measurements between the basal and the 24 and 48 sessions and in the GAF measurements between the 24 and 48 sessions, and almost significative differences in the SCL 90 measurements between the 24 and 48 sessions, as shown in the next values. Regarding the SCL 90, means were: initial: 2.14, S.D.=1.00; 24 sessions: 1.09, S.D.=0.84; 48 sessions: 0.67, S.D.=0.47. These decreasing values were significatives when comparing initial values with those obtained after 24 sessions (t=3.36, p=.01) and after 48 sessions (t=4.32, p=.002), and almost significative in the comparisons made between the 24 and the 48 sessions measurements (t=2.22, p=.054). When analyzing the GAF measurements, means were: initial: 37.10, S.D.=18.90;
24 sessions: 68.10, S.D.=11.28; 48 sessions: 86.00, S.D.=3.95).
These increasing values were significative when comparing initial values with those from the 24 sessions (t=6.85, p=.00) and the 48 sessions (t=9.03, p=.00) measurements, and also when comparing the values from the 24 and the 48 sessions (t=6.02, p=.00).
These results from the GAF and the SCL 90 show that the clinical and clinimetric improvement is corroborated with the measurements made by these two reliable instruments of change with psychotherapy.
Because the main improvement was significative after the first 24 sessions, we think a 24-session treatment may be useful even for the most severe BPD manifestations.
Our results were due to several factors: a) patients were young and educated; b) suicidal behavior was not severe; c) they had not suffered sexual abuse in infancy nor sexual violations in childhood or adolescence; d) they were treated by therapists trained with a treatment manual that emphasizes control of suicidal behavior, impulsivity and affective storms and the need to return soon to school and to work; e) all patients had psychological mindedness, genuine wishes to change and absence of huge secondary gains; f) supervisors interviewed all patients and families and were available to advice them and therapists. The only parent that asked for medical guidance and support was the mother of a patient who ingested caustics and had a gastrectomy immediately before starting treatment and, g) therapy was closely supervised using videotapes from the sessions.
In comparing our results with those of the other specific treatments for BPD, we can see that our drop out rate was almost ten points higher than theirs, but still much more better that the 60% rate of the treatment as usual. The fact that the specific treatments studied, namely PFT, PS, DBT, PH and also the medications mentioned, had good results, speak of the need of designing a combined treatment that could be compared with the treatment as usual.
The limitations of the study were that there was no control group, the short number of subjects and that they were only females. Conclusions are that TFP is effective to treat female subjects with suicidal and school and work dysfunction using novel therapists supervised by experts. There is a need to replicate this study with larger populations of both sexes in comparative studies with the treatment as usual.
