The median number of therapy sessions was 43, and a third of the patients were still in therapy at the time of the three-year follow-up. A significant share of the patients were thus receiving treatment on a level it is difficult to achieve at regional psychiatric clinics. The amount of therapy varied considerably nonetheless, and some had only had a few sessions.
There was a positive correlation between the number of therapy sessions and the patients’ satisfaction with the treatment. The results also showed that the treatment had a certain degree of flexibility in terms of appointment frequency. Some therapies started off as a weekly appointment and then changed to a less intensive phase. The continuity of the therapeutic relationship was thereby preserved.
For many patients with a personality disorder, their relations with caregivers as they grew up were characterised by insecurity or traumatic conditions. Such experiences influence the relational problems the patient has as an adult. Being able to relate to a therapist who is stable and predictable over time may therefore be especially important for these patients, and may enable them to work on core problems within a secure therapeutic relationship.
Patients with personality disorders have a tendency to become involved in negative interactions with others in a manner that reinforces their negative self-image, emotional imbalance and experience of rejection. In this study, several treatments were complicated by irregular attendance, disinhibited behaviour, substance abuse or concern associated with the patient's suicidality, circumstances that therapists may find demanding. Efforts to establish a good therapeutic alliance failed with some patients, and analyses of the patients’ satisfaction indicate that it is precisely those with substance abuse problems, extensive acting-out behaviour or serious suicidality who represent a challenge to therapy that may be difficult to handle in private practice.
Discontented patients displayed weaker functional improvement in the course of the three years. This study does not enable us to draw any conclusions as to whether this reflects inappropriate therapeutic processes in this or subsequent treatments or about other prognostic characteristics of the patients. On the whole, the therapists nonetheless found the treatments interesting and professionally stimulating.
The percentage of patients who dropped out of therapy was not particularly high compared with international studies, where dropout rates of well over 30 % are usual (7, 8). None of those still in therapy after three years will be classified as dropouts, so the final dropout rate will be less than 20 %.
The results must be interpreted with caution. The specialists who took part were self-selected for the study, and it is not certain how representative they were of private practitioners generally. They were probably highly motivated and many of them had extensive experience, although they did not necessarily have any special experience with this patient group. Some therapists treated several patients, so that there is some dependency in the data. The study design precluded the possibility of studying therapist effects.
The patient sample was representative of patients referred for third line service for treatment of personality disorders, but the results cannot necessarily be extended to patients with personality disorders more generally. Some patients were also hospitalised for different types of inpatient treatment or began a different therapy after ending treatment with the project therapist. We do not know whether their experience of other therapy influenced the patients’ reporting of satisfaction with the project treatment.
One main point, however, was that in the event of crises or when the treatment they themselves offered was regarded as insufficient, the specialists in private practice called on other available treatment. This should be possible in many places in Norway with a well developed and reasonably differentiated range of treatments services.