1
2	Psychotherapy for Borderline Personality American Psychiatric Association Annual Meeting Toronto, Canada May 21, 2006 Today’s Faculty: Frank Yeomans, M.D. Eve Caligor, M.D. John Clarkin, Ph.D. info@borderlinedisorders.com
3	Educational Objectives Describe BPD and BPO Understand concepts of object relations theory and techniques of TFP Apply a treatment contract Identify strategies, tactics and techniques of TFP Identify and manage crises Understand use of pharmacotherapy Identify patterns of change in treatment Understand current research data
4	Today’s Outline I. Borderline Personality – Phenomenology II. The Object Relations Model III. Treatment Strategies IV. Treatment Techniques – 1 Clarification, Confrontation, Interpretation and Transference Analysis V. Treatment Techniques – 2 Technical Neutrality and Countertransference VI. Treatment Tactics – 1 The Treatment Contract VII. Treatment Tactics – 2 VIII. Medication and Complications of Treatment IX. Research Questions, and Some Answers X. Discussion
5	Two Dominant Approaches to PERSONALITY Dispositional or trait theory approach: goal is to characterize people in terms of a comprehensive but small set of stable behavioral dispositions Processing approach: personality as a system of mediating units (expectancies, goals, motives) and psychological processes (cognitive-affective units) that interact with the situation Mischel & Shoda, 1999
6	Four Aspects of Psychological Processing Organized pattern and sequence of activation of cognitive-affective mental representations Behavioral expressions of individual’s processing Perceptions of self across situations Particular environments the individual seeks out and constructs Mischel & Shoda, 1999
7	Personality Personality is the integration of all the psychological functions of the individual. It is the dynamic organization of character traits Personality involves: The subjective experience of one’s internal needs Assessment of and adaptation to the environment Ref: Kernberg & Caligor (2005). A psychoanalytic theory of personality disorders. In: Major Theories of Personality Disorders, 2^nd Ed. Eds: Clarkin & Lenzenweger. NY, Guilford, 115-156.
8	Component Structures of Personality - 1 Temperament / Reactivity – thresholds and rythym of perceptual, behavioral, cognitive and affective intensity. The combination of temperament and interactions with caregivers leads to the internalization of perceived interactions. These determine habitual behaviors, or character traits
9	Component Structures of Personality -2 Character is the integration of character traits and the behavioral manifestation of Identity Intelligence – the potential for cognitive assessment Ethical Value systems (“superego”)
10	Descriptive Features of Personality Disorder Rigidity of Personality – poor adaptation Inhibition of normal behaviors Exaggeration of certain behaviors Secondary defenses against inhibitions/fears (reaction formations) Oscillation, contradictory behaviors Given the above, vicious circles develop: abnormal behaviors elicit abnormal responses
11	Axis II Personality Disorders 10 distinct disorders with their own polythetic criteria Grouped into 3 clusters based on descriptive similarities, with no consistent validation
12	Limitations of Axis II (skip) Atheoretical Mixture of symptoms, attitudes, behaviors, traits Polythetic (heterogeneous) classification Ignores the meaning of behaviors Leaves out many important areas of life, e.g., sexuality, intimacy, quality of object relations, self-esteem Rampant co-morbidity Ignores organization; just lists symptoms Not used systematically by clinicians Not sufficient for treatment planning
13	Categoricalists vs. Dimensionalists (skip) DSM-IV ICD-10 ----------------------- Advantage: the medical model likes categories Disadvantage: the problem of co-morbidity 5 Factor Theory: Conscientiousness Amiability Openness Extraversion Neuroticism Advantage: more reliable Disadvantage: the problem of the clinical usefulness of the factors
14	Axis II from a Personality Organization Point of View – A mixed Categorical and Dimensional System Neurotic level of personality organization Borderline level of personality organization: High level borderline Low level borderline Psychotic level of personality organization
15
16	Borderline Personality Organization Basic Characteristics Identity Diffusion vs. integrated view of self and others (internal sense of continuity) Primitive Defenses Decreased Reality Testing Differentiation of self from non-self Internal from external reality Empathy with social criteria of reality
17	Identity Diffusion No integrated concept of self No integrated concept of significant others
18	Examples of Defenses against Psychological Conflict Primitive Defenses – these distort the immediate interaction Splitting Idealization/devaluation Projective identification Omnipotent control Denial Non-primitive Defenses Repression Rationalization Reaction formation Healthy Defenses Anticipation, humor, suppression, sublimation
19	Reality Testing Differentiation of self from non-self Internal from external reality Empathy with social criteria of reality Affect Thought content Way of talking When evaluating, look at what’s inappropriate in affect, thought, behavior
20	BPO: Clincal Implications Nonspecific ego weakness Lack of impulse control, anxiety tolerance Disturbed object relations Difficulties with work and love Sexual pathology (Two levels: inhibition of all sexual functioning; chaotic sexuality) Pathology of moral functioning
21	FIGURE 1 Relationship between familiar, prototypic, personality types and structural diagnosis. Severity ranges from mildest, at the top of the page, to extremely severe at the bottom. Arrows indicate range of severity. Kernberg & Caligor (2005). A psychoanalytic theory of personality disorders. In: Major Theories of Personality Disorders, 2^nd Ed. Eds: Clarkin & Lenzenweger. NY, Guilford, 115-156.
22	FIGURE 2 Continuities and clinically relevant relationships among the personality disorders. Gray lines indicate clinically relevant relationships among disorders. Ref: Kernberg & Caligor (2005). A psychoanalytic theory of personality disorders. In: Major Theories of Personality Disorders, 2^nd Ed. Eds: Clarkin & Lenzenweger. NY, Guilford, 115-156.
23	Clinical Assessment Identity Object Relations Defenses-Coping and Rigidity Ethical Functioning Aggression Reality Testing
24	Etiology of BPD Complex etiology: no single pathway Genetic Disposition Neurotransmitter Systems Abnormal Affectivity: Negative affects, aggression, and abnormal control of affects Temperament Object Relations Insecure Attachment/Early family disruptions/ Neglect Trauma/Abuse
25
26	Treatments Psychopharmacology SSRI’s, Low-dose Neuroleptics, Mood Stabilizers Psychotherapy Cognitive Behavioral Dialectical Behavior Therapy (Linehan) Others Psychodynamic Supportive Psychotherapy (Rockland) Mentalization-Based Psychotherapy (Batemen &Fonagy) Transference-Focused Psychotherapy (Us)
27	Prognostic Factors Pervasive aggression Antisocial features Secondary gain (chronic support system) Severely restricted object relations No love life; low attractiveness Low intelligence No work or shifting lifestyle Negative therapeutic reaction
28	Introducing the theory behind the treatment The concept of the split internal psychological structure as the basis for the clinical picture of borderline pathology described thusfar.
29	Theoretical Underpinnings of TFP: Object Relations Theory
30
31	Split Organization: Consciousness of all-good or all-bad
32	Normal Organization: Consciousness of Integration/complexity
33	The Evolution of Treatment From Splitting to Integration (from the Paranoid-schizoid position to the Depressive position) From the projection of motivations to the capacity to hold responsibility for one’s thoughts, feelings, actions. ----------------------------------------- Why the focus on the transference (the patient’s immediate experience of self and other with the therapist)?
34	Patient’s Internal World S = Self-Representation O = Object - Representation a = Affect Examples S1 = Meek, abused figure O1 = Harsh authority figure a 1 = Fear S2 = Childish-dependent figure O2 = Ideal, giving figure a2 = Love S3 = Powerful, controlling figure O3 = Weak, Slave-like figure a3 = Wrath
35	Why focus on TRANSFERENCE? (the immediate experience of self and other) Experience of Self …and of therapist
36
37
38	Dyad Defending Against Dyad: Example
39	Moving from Theory to Therapy A treatment that has been developed in a clinical research context over the past 25 years
40
41
42
43
44	Illustrative role pairs…. Cont’d Naughty, sexually excited child Seductive parent Dependent, gratified child Perfect provider Child longing to be loved Withholding parent Controlling, omnipotent self Impotent parent Friendly, submissive self Doting, admiring parent Aggressive, competitive self Punitive, sadistic parent
45
46	Techniques Clarifying, confronting, and interpreting Conducting transference analysis (systematic analysis of distortions in the relationship) Managing technical neutrality (attitude of concerned objectivity; not drawn into patient’s problems) Utilizing countertransference awareness
47	Clarification This technique is requesting clarification, not offering clarification The therapist must resist the counter-transference pull to be the omniscient other In addition to eliciting data, this technique serves to elaborate the patient’s distortions (especially in the transference) more fully
48	The 3 Channels of Communication The therapist observes: 1 – the patient’s verbal communication 2 – the patient’s non-verbal communication 3 – his/her countertransference
49	Confrontation This technique is not a hostile challenge, but rather an honest inquiry into an apparent contradiction in the patient’s communication It is an invitation for the patient to reflect It is assumed that the different elements of the contradiction represent aspects of the self that are split off from one another
50	Confrontation The contradiction can be within one channel of communication: “You said earlier that I was a terrific therapist, now you’re saying I’m worthless….” Or the contradiction can be between different channels of communication: “You’re saying you’re furious, but you’re looking at me with a smile….”
51	Interpretation - I A hypothesis about unconscious determinants of present experience An attempt to increase awareness of the impact of unconscious material on the patient’s thoughts, affects, and behaviors Interpretations address and attempt to resolve psychological conflicts
52	Interpretation - II In borderline patients, conflicts are based on the lack of identity integration and are manifested in the diverse dyads that emerge in the transference Interpretations attempt to explain the motivations for maintaining splitting defenses as the basis of the patient’s psychological structure
53	Characteristics of Interpretations Depth of interpretation Surface to depth = defense before impulse, except in crises Timing and tempo of interpretations Early interpretations focus on the “here and now” Later interpretations link the “here and now” to the past Accuracy of interpretation
54	Steps of Interpretation Understand/Identify self state in the moment Elaborate understanding of the therapist Consider therapist’s experience of the moment, and that it may be different from the patient’s Contrast the immediate experience of self and of therapist with that at other times (address splits) Consider reasons for splits Put the above in the context of other relations
55	Consistent Transference Analysis On-going analysis of distortions of a “normal” relationship in the treatment setting (“How would a ‘normal’ person react in this situation?”) Link these distortions to similar distortions in the patient’s relations outside of the therapy The difficulty with narcissistic patients (the non-relation is the relation)
56	Maintaining Technical Neutrality In TFP What is technical neutrality? What are the functions of technical neutrality? When do I deviate from technical neutrality? (Introducing a parameter) How can I reestablish technical neutrality after I have introduced a parameter?
57	Technical Neutrality A therapist who intervenes from a position of technical neutrality avoids siding with any of the forces involved in the patient’s conflicts Neutrality means maintaining the position of a neutral observer in relation to the patient and his difficulties as they unfold in the transference (implies the third position) When working from a position of technical neutrality the therapist is aligned with the patient’s “observing ego”, and encourages its growth
58	Technical Neutrality Do not side with the forces involved in patient’s conflicts The part of the patient pushing for instinctual expression The part of the patient wanting to inhibit instinctual expression The reality demands placed on the patient
59	Why Neutrality? Encourages redirection of patient’s conflicts into the therapy Allows therapist to diagnose internal object relations dominant at any given moment Strengthens patient’s observing ego Interpretations presented from a position of neutrality facilitate integration of split off internal object representations
60	Technical Neutrality: Clinical Example In a neutral intervention, the therapist: Supports the observing ego Points out the division within the patient Describes the two sides of the division without siding with one or the other
61	Deviations From Technical Neutrality Deviations from neutrality are part of the treatment strategy of TFP They attempt to control dangerous acting out that cannot be contained by confrontation and interpretation
62	Deviations From Technical Neutrality: Indications Threat to safety of patient Threat to safety of others Threat to continuation of the treatment Confrontation and interpretation fail to contain acting out
63	Deviating from Neutrality Attempt to control acting out from a position of technical neutrality using clarification, confrontation and interpretation Introduce parameter, explaining why Return to transference, making link between deviation from neutrality and self and object representations externalized in transference
64	Reinstating Neutrality Acknowledge the deviation and explain why it was necessary Explore the meanings patient attributes to therapist’s actions (Therapist-protector to child/patient) Confront and interpret conflict that has been externalized (Responsible mother vs. negligent mother) Link to underlying transferences (Negligent therapist-mother)
65	Summarizing Technical Neutrality Technical neutrality is essential to therapist’s stance in TFP since it facilitates analysis of transference Deviate only when patient’s acting out poses threat to patient, to others or to the treatment Reinstate neutrality when parameter no longer needed Unnecessary deviations from neutrality result from countertransference, and often result in sliding into a more supportive therapy
66	Countertransference in TFP When evaluating countertransference, consider the therapist’s total emotional reaction to the patient
67	Defining Countertransference Therapist’s total emotional reaction to patient “Countertransference in the broad sense” Therapist’s transference to patient Classical view is “therapist-focused” Therapist’s reactions to patient’s transference Kleinian view is “patient-focused”
68	Countertransference In TFP Countertransference to borderline patients says more about patient than it says about therapist. Borderline patients defensively project aspects of their inner worlds into therapist. Primitive defenses involve affecting therapist
69	Two Types of Countertransference Concordant Identification Therapist identifies with patient’s self experience Complementary Identification Therapist identifies with patient’s internal and external objects
70	Typical Characteristics of Countertransference To Borderline Patients Rapidly developing Intense Unstable Confusing Pressure to “Do something”
71	Countertransference Countertransference, used correctly, is the“Third channel of communication” serving as essential source of information about patient’s inner world and object relations activated in the transference When not used correctly, Countertransference can disrupt therapist’s ability to understand patient’s inner world and to effectively communicate with patient
72	Third Channel of Communication Borderline patients express in action what they cannot express in words Dominant affective themes and object relations are expressed through inducing thoughts and feelings in therapist To clarify how patient is experiencing therapist in the transference, ask “How am I being made to feel?”
73	Containment of Countertransference The therapist “metabolizes” the patient’s projections in the countertransference Allows that patient to affect him internally Tolerates his emotional experience without turning to action Reflects upon what the patient has stimulated in him and what this might say about the object relation enacted in the transference
74	Containing Countertransference Careful assessment Clear treatment contract and frame Explicit theory of technique Consultation or peer supervision
75	Countertransference Acute countertransference reactions Affect the therapist moment-to-moment Rapidly shifting with borderline patients Mirrors shifting developments in the transference Affective intensity Can be difficult to contain Chronic countertransference reactions Affect the therapist over periods of time Stable attitude on the part of the therapist May be subtle / typically not highly affectively charged Can be difficult to notice / often with the aid of a consultant Reflects therapist’s characteristic response to transference
76	Countertransference And Technical Neutrality Countertransference is most common cause of unnecessary deviations from neutrality It is only from a position of neutrality that the therapist can reflect upon and metabolize countertransferences to deepen his understanding of the patient
77
78
79
80	Functions of the Contract Defining patient and therapist responsibilities Protecting therapist’s ability to think clearly 3. Providing a safe place for the patient’s dynamics to unfold Setting the stage for interpreting the meaning of deviations from the contract Providing an organizing therapeutic frame that permits therapy to become an anchor in the patient’s life
81	Treatment Contract: Standard Content Patient Responsibilities Attendance and participation Paying fee Reporting thoughts and feelings without censoring Therapist Responsibilities Attending to the schedule Making every effort to understand and, when useful, comment Clarifying the limits of his/her involvement Predicting Threats to the Treatment
82	Treatment Contracting Process Therapist presents a part of the contract Patient responds to those conditions of treatment Therapist pursues elaboration of patient’s response Consensus -- or not
83	Examples of Threats to the Treatment Suicidal and self-destructive behaviors Homicidal impulses or actions, including threatening the therapist Lying or withholding of information Substance abuse Eating disorder - uncontrolled Poor attendance Excessive phone calls or other intrusions into the therapist’s life Not paying the fee or arranging not to be able to pay Problems created external to the sessions that interfere with therapy A chronically passive lifestyle, favoring secondary gain of illness
84	Contract around Suicidality in a Chronically Suicidal Borderline Pt. Pt. feels urge to kill self between sessions Scenario I The patient experiences suicidal ideation and feels he can control his behavior The patient does not call the therapist and discusses it in the next session
85	Scenario II Pt. feels cannot control impulse Patient calls therapist, who reminds him of contract. Patient goes to ER OR II. Pt. refuses. Tpist does what is necessary in the moment, then, when the treatment frame is back in place, discusses with the patient if therapy can continue Patient takes self to ER. Pt. is discharged from ER and attends next session OR II. Hospitalization recommended Pt. agrees and resumes therapy upon discharge OR Pt. refuses, ending the therapy
86	Scenario III – Pt. has taken suicidal action Pt. calls family, friend, 911, etc. to get to hospital for eval. Decision to admit or not admit Pt. calls therapist, who does all he can to help save the pt’s life. Then, when calm and neutrality re-instituted, therapist addresses possibility of continuing treatment or not
87	Offering a Second Chance Some patients do not believe that others mean what they say Therapist response: Point out the risk and consequences of this Breaking the contract may be an attempt to get out of the therapy and “blame” the therapist for it Therapist response: interpret the patient’s ambivalence about therapy and reasons for resistance
88
89	THREE CHANNELS OF COMMUNICATION 1 -Verbal 2 -Non-verbal 3 -Countertransference Any of the channels may seem blocked (1-patient silent; 2-patient robotic; 3- therapist somnolent or indifferent)
90	CHOOSING WHAT MATERIAL TO ADDRESS Economic principle: intervene where there is the most affect Dynamic principle: 1) conflict: defensively activated object relation and impulsive object relation; 2) go from defense (surface) to impulse (depth) Structural principle: structural aspects of defense and impulse. One object relation that defends against another – which is the healthier side? The hierarchy of thematic priorities
91	HIERARCHY OF THEMATIC PRIORITY - I Obstacles to Transference Exploration – alarm signals suicide or homicide threats Threats to treatment continuity (inc. financial probs, plans to move, requests to meet less often) dishonesty or deliberate withholding in sessions (e.g., lying to the therapist, refusing to discuss certain subjects, silences occupying most of the sessions) contract breaches (e.g., failure to act on other parts of treatment such as AA, failure to take prescribed meds) in-session acting out (e.g., abusing office furnishings, refusing to leave at the end of the session, shouting) narcissistic resistances non-lethal between-session acting out non-affective or trivial themes
92	HIERARCHY OF THEMATIC PRIORITY – II What, when, and how to interpret Overt Transference Manifestations verbal references to therapist nonverbal references to the therapist (e.g., positioning body in overtly seductive manner) as inferred by therapist (e.g., references to other doctors, to figures of authority, etc.) the patient’s way of being with the therapist Nontransferential Affect-Laden Material
93	Typical evolution of therapy The patient tests/challenges the contract Early emphasis on nonverbal and counter-transference channels of communication Decrease in acting out Increasing awareness of the importance of the therapist for the patient, and defenses against this (attachment themes); increase in affect intensity Interpretation of defenses against integration A cycle where the problematic dynamics reappear, but in a more contained and limited way Practical problems stemming from earlier life choices that no longer “fit” well
94	Typical Dynamics of the Midphase The patient oscillates between projecting the bad object, seeing the other as persecutor, and experiencing it internally as a vague sense of badness or depression There is an alternation of negative and positive transferences The patient become more aware of denied/rejected parts of the self (the “other half” of the dyad) Integration proceeds, but in a “two steps ahead and then one step back” fashion (i.e., progress toward integration is often followed by partial regression to the split state)
95	The Midphase of Therapy: alternating levels of themes As therapy progresses, discussion evolves from an early focus on the “here and now” to include: The “here and now” in the transference The patient’s current life outside of treatment Screen memories The genetic past Dreams and fantasy material
96	Termination Every separation (end of session, vacation, etc.) can bring up the dynamics of termination Successful termination involves successful internalization and integration Termination involves the dynamics of healthy vs. pathological mourning
97	Psychopharmacology Overall approach Reduce unnecessary medication use Medicate target symptoms Understand the dynamics of medicating Algorithms: Three Paranoid/suspiciousness, mild thought disorder, hallucinations, dissociation Depressed/angry/anxious/labile mood Impulsive aggression, self-injurious behavior, binges
98
99
100
101	TREATMENT COMPLICATIONS Acting out – first interpret, then set limits The threat of drop-out Suicide and parasuicide Eating disorders, substance abuse, antisocial behavior – all need containment, “extra” frame Erotization Affect storms – overt and silent Paranoid regression/micro-psychotic episodes Dissociative reactions – a form of splitting Severe hatred in the transference: syndrome of arrogance Psychopathic transferences Hospitalizations
102	INDICATIONS OF INTEGRATION AND STRUCTURAL CHANGE The patient’s comments indicate reflection on and exploration of therapist’s interventions The patient is able to accept the interpretation of primitive defense mechanisms The patient can contain and tolerate the awareness of his hatred The patient can tolerate fantasies and the development of a transitional space The working through of the pathological grandiose self The evolution of predominant transferences The patient can experience guilt and enter into the depressive position
103	Empirical Research: Data On Impact of TFP Containment In the context of growing attachment between patient and therapist With deepening in the exploration of the nature of attachment between the two
104	Therapist Patient Sets frame via contract Experiences safe haven to express self ↓ Expression of affect includes actions and interactions based on implicit OR dyads Observes the action without judging or reacting Tries to understand/explicate the OR underlying the actions, using 1 – Clarification 2 - Confrontation 3 – Interpretation Increases reflection (these appeal for reflection & address obstacles to it) Further reflection, with Progress toward increased contextualization integration Increased modulation of affects
105	TFP FOSTERS CONTAINMENT BY: Setting of the treatment contract Priority given to a focus on destruction of self and the treatment Articulating and tolerating feelings that previously would have lead to action
106	TFP CONTAINMENT RESULTS Continuation in treatment Reduction in suicidal behavior Improvement in general functioning
107	LENGTH OF TREATMENT AND CONTRACT SETTING Significant r (.64) between therapist contribution to contract and length of treatment (LOT) Significant r (.48) between therapist understanding and involvement (CALPAS) and LOT Significant r (-.51) between patient impulsivity and LOT (from Yeomans et al., 1994)
108
109
110	GAF SCORE AS A FUNCTION OF GROUP AND TIME
111	TFP FOSTERS ATTACHMENT BY: Frequency (2 times a week) of sessions fosters attachment Alliance with part of patient that wants to improve Focus on the transference, both positive and negative
112	TFP: ATTACHMENT RESULTS Regular attendance at TFP sessions: only 19% dropped-out of treatment Reduction in hospitalization and emergency room visits for routine care
113
114	Days Hospitalized as a Function of Time
115
116
117
118	TFP FOSTERS EXPLORATION OF ATTACHMENT BY: Interpretation in the here-and-now interaction between therapist and patient Experience, observation, and interpretation of separation at the end of sessions, vacations, termination
119	TFP: RESULTS, EXPLORATION OF ATTACHMENT Changes in current conceptualization of early attachment figures (AAI) Changes in mentalization (AAI) Development in conceptualization of therapist (PTAAI)
120	Attachment Theory Constructs as Central Mechanisms of Change Coherence Resolution of trauma and loss Reflective Function
121	Adult Attachment Interview On the AAI: Individuals are asked to describe parents generally and to give 5 adjectives with specific examples to (episodic memories) to back up general descriptions Individuals are asked what parents did when they were upset, ill, or in distress Individuals are asked to reflect on the impact of early experience on current adult personality functioning
122	Adult Attachment Interview The AAI: “surprise the unconscious” provides numerous opportunities for the speaker to elaborate upon, contradict or fail to support previous statements
123	Assessment of Coherence Coherence Quality—truthful, i.e., evidence for what was presented Quantity—succinct, and yet complete Relation—relevant to the topic at hand Manner—clear and orderly Rated on 9 point scale, from 1 to 9, with 1= low coherence and 9 =high coherence Score of 5 = cut-off for secure attachment
124	Mentalization/ Reflective Function The social cognitive and affective process of interpreting or making sense of behavior in oneself and others in terms of intentional mental states, such as desires, feelings, and beliefs. The capacity to reflect upon one’s own experience, whatever his or her attachment status.
125	Mentalization/Reflective Function Thoughts, feelings, and events are not seen concretely or experienced literally as a rigid reality, but are experienced implicitly and sometimes explicitly as symbolic representations of experience, which one has some control over (i.e., One can shift one’s attention or think differently about an event). Events remain in perspective and lose their re-traumatizing capacity.
126	Reflective Function Scale (Fonagy, Target, Steele, Steele, 1998) -1 Negative Rejection, totally barren, grossly distorted, overly concrete, unintegrated, or inappropriate RF 1 Disavowal, distorted/self-serving 3 Naive simplistic or over-analytic/hyperactive 5 Ordinary or inconsistent model of mind is fairly coherent, but somewhat one dimensional or simplistic 7 Marked 9 Exceptional unusually complex, elaborate or original reasoning about mental states
127	Change in Coherence as a Function of Time and Treatment
128	Change in RF as a Function of Time and Treatment
129	Questions and Future Directions What are the mechanisms of action in psychotherapy that result in behavioral, phenomenological, and structural change? How do these changes in psychological structure relate to symptom changes? What are the long-term implications of structural change for maintaining treatment gains? Ken Howard distinguished between Remoralization, remediation, and rehabilitation