Academic journal article Journal of Cognitive Psychotherapy

Treatment Attitude and Therapy Outcome in Patients with Borderline Personality Disorder

Academic journal article Journal of Cognitive Psychotherapy

Treatment Attitude and Therapy Outcome in Patients with Borderline Personality Disorder

Article excerpt

This study investigated the degree to which two ways of defining attitude toward treatment (i.e., attitude toward talking with a therapist about problems, expectation for improvement) predicted therapy outcome. The sample consisted of 28 patients who participated in an open clinical trial evaluating the efficacy of cognitive therapy for borderline personality disorder and who completed assessments at baseline and 12-month follow-up (Brown, Newman, Charlesworth, Crits-Cristoph, & Beck, 2004). When attitude toward treatment was defined as attitude toward talking with a therapist, this variable predicted suicide ideation and scores on two measures of depression at the 12-month assessment. When attitude toward treatment was defined as expectation for improvement, this variable predicted scores on one measure of depression and number of borderline personality disorder criteria met at the 12-month assessment. These results provide preliminary evidence that positive attitudes toward treatment are associated with more clinical improvement, although future research should replicate this finding with a better developed measure of treatment attitudes.

Keywords: borderline personality disorder; treatment attitude; treatment expectations; treatment outcome

Borderline personality disorder (BPD) is the most common personality disorder observed in psychiatric settings, with approximately 20% of patients in inpatient units and 11% of patients in community mental health clinics carrying the diagnosis (Swartz, Blazer, & George, 1990). Because of the complexity and chronicity of this disorder, BPD has come to be viewed by clinicians as one of the most difficult mental illnesses to treat (Markham, 2003). One major area of investigation in the treatment of patients with BPD is the manner in which the patient-therapist relationship affects outcome (e.g., Livesley, 2000, Robins, Ivanoff, & Linehan, 2001). Although this literature clearly demonstrates a strong association between therapeutic alliance and outcome, less research has examined BPD patients' attitudes toward treatment and whether these attitudes are associated with therapy outcome.

Despite this limited research, there is a larger literature that examines attitudes toward treatment and their effects on therapy outcome in psychiatric patients in general. According to Arnkoff, Glass, and Shapiro (2002), client expectancy is defined as a client expectation pertaining to the length and procedure of treatment, the role of the therapist, and whether treatment will lead to change. Expectations of whether treatment will lead to change have been considered most often in the literature. Several empirical investigations have demonstrated that higher expectations for improvement in treatment are associated with an increased likelihood of recovery and a reduction in psychiatric symptoms (e.g., Devilly & Borkovec, 2000; Joyce & Piper, 1998 ; Safren, Heimberg, & Juster, 1997; Sotsky et al., 1991; see Shapiro & Shapiro, 1997, for a review). Recently, Meyer et al. (2002) reanalyzed data from the Treatment of Depression Collaborative Research Program (Elkin et al., 1989) and found that the association between expectations and outcome was mediated by the strength of the therapeutic alliance. That is, the more improvement patients expected from treatment, the more they engaged positively with their therapist, which in turn led to a greater reduction in symptoms (see Gibbons et al., 2003 , for similar findings).

Together, results from these studies indicate that higher expectations for improvement are associated with better treatment outcomes. However, expectations for improvement are only one type of attitude toward treatment. The Attitudes and Expectations (AAE) Questionnaire, developed by Elkin et al. (1989) for the Treatment of Depression Collaborative Research Program, contains a number of items about treatment expectations, such as the degree of improvement anticipated, the degree to which different modalities of treatment are anticipated to be helpful, and the degree to which patients have a positive attitude toward various treatment modalities. …

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