Borderline personality disorder (BPD) is difficult to treat. Patients with BPD have complex symptoms that can make them uncooperative, extremely sensitive, and exhibit alternating positive and negative emotions that often inflict intense negative emotional reactions on therapists, such as frustration, anger, or feeling incompetent (1). Prevalence studies suggest that the prevalence of BPD in the general population is approximately 1.6% to 1.8%. The prevalence of this disorder is higher in psychiatric outpatient populations (approximately 11%) and reaches 20% in psychiatric inpatient population (2–4). In Indonesia, although no nationwide data are available on the prevalence of BPD, there appears to be an increase in the number of patients with BPD, according to data from the psychiatric clinic and ward of Indonesia’s national referral center, Dr. Cipto Mangunkusumo National Central General Hospital (RSUPN-CM), Jakarta, Indonesia. In 2020, 242 clinic visits were recorded from 71 patients, including four new patients. Additionally, 25 cases of hospitalization of patients with BPD were recorded. In 2021, the number of polyclinic visits and hospitalizations increased to 775 clinic visits and 190 patients, including 26 new patients in polyclinics and 68 inpatient hospitalization cases (5).

Psychotherapy and psychopharmacology are both used to assist individuals with BPD (6). Psychodynamic psychotherapy can be applied as a psychotherapeutic approach, whose main goals in individuals with BPD include improving self-cohesion, self-other representations, affect regulation, and mentalization capacity by helping them attain a better understanding of their own and others’ experiences (7). Moreover, it is effective in reducing suicidal behavior, anger, and impulsivity, as well as in enhancing psychosocial functioning (8). However, several challenges may also be encountered during psychodynamic psychotherapy, such as intense transference and countertransference, which can hinder the therapist-patient relationship. Therefore, understanding and managing the transference-countertransference dynamics in therapy present central strategies in conducting psychodynamic psychotherapy for BPD to prevent such reactions from disrupting the therapeutic relationship and subsequently improve therapeutic benefits. Therefore, to be psychodynamic psychotherapists for individuals with BPD, therapists require self-awareness, perseverance, and neutrality to survive intense transference-countertransference reactions and strike a sound balance between empathy and detachedness (9, 10).

The Indonesian College of Psychiatry has defined the competency of performing psychodynamic psychotherapy as a general competency that must be achieved by psychiatry residents who become full-fledged therapists once they graduate and can perform psychodynamic psychotherapy for BPD (11). Therapist competence has been conceptualized as the level of the therapist’s knowledge and skill to implement a treatment to an acceptable standard (12, 13). The need to evaluate therapists’ competence in psychotherapy has been widely recognized (14). Psychodynamic psychotherapists’ competencies are essential as higher levels of competence lead to better patient outcomes, such as clinical symptoms and social functioning (15, 16). However, deficiencies or misapplication of these techniques are related to negative therapy outcomes (17). Assessment of psychotherapeutic competence could be achieved through knowledge tests, evaluation of patient outcomes, patient feedback, or evaluation of treatment sessions using evaluation scales (12, 15, 18). Structured evaluation scales facilitate a systematic assessment of competence (19). Using a competency assessment scale also enables the provision of performance-based feedback for trainee psychiatrists (20). Most of these scales are constructed as a rating scale to be used by supervisors based on their observation of the psychotherapists’ performance and are developed based on expert consensus or the authors’ expertise (13, 21). Although several standardized psychotherapy competency assessment scales have been developed for psychotherapists, these are primarily used in general practice, such as the Cognitive Therapy Scale-Revised or the Supervisor’s Evaluation Scale (15, 22–24). Several competency assessment scales have been developed to assess psychotherapeutic competency based on distinct mental disorders. Currently, standardized competency assessment scales for evaluating psychotherapists’ competency in conducting psychodynamic psychotherapy for BPD are limited.

Moreover, limited psychotherapy competence scales exist that implement the assessment of the three domains of learning, namely the cognitive, affective, and psychomotor domains, as defined by Bloom in the Taxonomy of Educational Objectives. Each learning domain comprises hierarchical categories of learning objectives ranging from the simplest to the most complex, which can be applied to assessment scales (25). The application of Bloom’s domains of learning in medical education has helped establish a model of clinical competence as a combination of intellectual knowledge, attitudes or awareness of values, and psychomotor abilities (26). Assessments should involve all domains of learning and specify the learning objectives that must be achieved so that the competence being assessed can be comprehensively measured (27). Additionally, a method of assessment should possess good psychometric properties, such as validity and reliability, to ensure its ability to correctly measure the intended performance, and the results should be consistent across different instances and raters (15, 28). Therefore, it is essential to develop comprehensive scales to assess cognitive, affective, and psychomotor competency (CS-CAPC) in psychodynamic psychotherapy for BPD to determine the competency of psychodynamic psychotherapists who conduct psychodynamic psychotherapy in individuals with BPD. The CS-CAPC comprises two scales. The first scale, the psychodynamic formulation competency assessment scale (PF-CAS), was developed to assess the skill of creating a psychodynamic formulation by evaluating the therapist’s written psychodynamic formulation. The second scale, the practical competency assessment scale (PC-CAS) in psychodynamic psychotherapy for BPD, was developed to assess therapists’ skills in performing psychodynamic psychotherapy for patients with BPD in real-life clinical settings by assessing a video recording of a psychotherapy session or by direct observation of a session. The PF-CAS was designed for cognitive and affective domain evaluations, whereas the PC-CAS in psychodynamic psychotherapy for BPD was designed to assess the cognitive, affective, and psychomotor domains.

This study described the psychometric properties of comprehensive assessment scales for the competency of psychodynamic psychotherapy for BPD among individuals who were trained as psychodynamic psychotherapists for BPD patients. The decision to design the scales in scoring rubrics was considered for the utility of rubrics in performance-based assessment. A scoring rubric objectively evaluates complex skills or behaviors by breaking them down into observable criteria (33, 34).

The CS-CAPC in psychodynamic psychotherapy for BPD was developed through the sequential activities of a Delphi survey, panel discussion, and validity testing. The scales in CS-CAPC in psychodynamic psychotherapy for BPD indicated satisfactory content validity, with S-CVI/Ave = 0.981 for the PF-CAS and S-CVI/Ave = 1.00 for the PC-CAS. The data collected during content validation indicated that all scale items were relevant for assessing the skills of psychodynamic formulation writing and conducting psychodynamic psychotherapy for BPD in real-life clinical settings. Most qualitative feedback was centered on creating a clear distinction between all the scores on the scale, allowing us to ensure an accurate grading of the assessed competency. Every revision of the scale was made based on participant feedback. One of the strengths of this study was the recruitment of a diverse sample of psychotherapy experts, psychiatrists experienced in psychotherapy, and teaching staff psychiatrists from nine psychiatry residency program institutions in Indonesia, allowing them to provide written feedback for the scale items during all activities. This helped us accumulate opinions and perspectives on the scales from the major stakeholders directly involved in learning situations across various institutions in Indonesia.

The CS-CAPC was designed to evaluate the competency of psychodynamic psychotherapy for BPD, as measured in the cognitive, affective, and psychomotor domains. This characteristic is among the novelties of our scale, as no previous scales for the competency of psychodynamic psychotherapy, let alone psychotherapy, defined the cognitive, affective, and psychomotor domains present in the task. The PF-CAS was used to evaluate the level of therapists’ competency in the cognitive and affective domains. The psychodynamic formulation is a tentative hypothesis that contains a succinct conceptualization of a patient’s clinical picture and guides the treatment plan (35). Our assignment of the cognitive and affective domains to the competency of writing a psychodynamic formulation was positively aligned with how creating a psychodynamic formulation requires the therapist’s willingness to delve into the patient’s internal world to discern central conflicts and themes in their lives (36). Mace and Binyon (37) stated that, in addition to gathering information from questioning, therapists might need to reflect on the feelings they experienced when interacting with a patient to infer the patient’s characteristic style of interpersonal relationships. These requirements correspond to the affective domain of learning and cognitive domain of understanding the theoretical framework of the psychoanalytic theories (20).

For the PC-CAS in psychodynamic psychotherapy for BPD, which assesses the cognitive, affective, and psychomotor domains, Ackerman and Hilsenroth (38) previously discussed how performing psychotherapy required a combination of cognitive, affective, and interpersonal skills. Several non-verbal elements are ubiquitous in psychotherapy, including eye contact, aligning body gestures per the patient’s emotional state, and voice and interruption behaviors (39, 40). This supports our assignment of the psychomotor domain to all items of the PC-CAS in psychodynamic psychotherapy for BPD.

The final version of the PF-CAS contained six items. The items on our scale reflect the structured components of a psychodynamic formulation as delineated in the literature. Sperry (41) defined three components of psychodynamic formulation: (1) a description of the patient’s clinical picture and stressors; (2) an etiological rationale for the factors contributing to the patient’s clinical picture; and (3) a formulation of treatment and prognosis based on the first two components. Similarly, a format proposed by Perry (42) and later updated by Summers (43) outlined the four essential components of a psychodynamic formulation: (1) summary of the patient’s problems; (2) description of the non-dynamic factors; (3) psychodynamic explanation of the patient’s central conflicts; and (4) prediction of the course of the therapy. The first item on our scale, “describing the patient’s condition and stressors,” summarizes the patient’s clinical picture and related stressors. The second item, “formulating the biological, intrapsychic, and sociocultural factors that influence the patient’s condition,” corresponds with describing the factors that contributed to the patient’s condition. The third item, “determining the suitable psychoanalytic theory to explain the patient’s condition,” embodies the formulation of the patient’s central conflicts using one or more psychodynamic theories. The fourth, fifth, and sixth items, “describing the potential resistance, transference, and countertransference that might occur in the therapy sessions,” “explaining the goals of the psychotherapy and the management plan for the potential resistance, transference, and countertransference that might occur in the therapy sessions,” and “explaining the patient’s prognosis in the course of the psychotherapy,” reflect the formulation of treatment and prognosis.

Our findings on the PF-CAS are consistent with those in previous studies that attempted to develop a method to assess written psychodynamic formulations. The case formulation content coding method (CFCCM) designed by Eells et al. (44) was used to evaluate the completeness and quality of the case formulation based on four content areas: (1) symptoms and problems; (2) the patient’s precipitating stressors; (3) predisposing life events; and (4) an explanation of the patient’s current difficulties by linking the three previous categories. The CFCCM rates the quality of the formulation as a whole and in the three dimensions of complexity, degree of analytic inference, and precision of language on a 5-point scale (44). Our rating scale contains a combination of the dimensions in the CFCCM’s rating scale, with the highest level of 3 representing the most comprehensive, analytical, and easily understood explanation of each component. Other models have focused on assessing the completeness of a patient’s psychodynamic conceptualization, such as Perry et al.’s (45) idiographic conflict formulation method and Curtis et al.’s (46) plan diagnosis method. The PF-CAS assesses the components of the patient’s psychodynamic conceptualization, similar to these existing methods, and it adds items that evaluate the hypothetical course of the therapy and treatment plan.

The PC-CAS in psychodynamic psychotherapy for BPD comprises 12 items: (1) beginning the session; (2) paying attention to the patient without judgment and prejudice; (3) conducting conversations that aim to build rapport with the patient; (4) maintaining good eye contact throughout the therapy session for most of the time; (5) aligning the gestures and posture per the patient’s state during the therapy session; (6) paraphrasing the patient’s statements to show that the therapist is empathetic and understanding toward the patient’s feelings; (7) using appropriate PP interventions per the patient’s state; (8) managing the patient’s resistance in the session; (9) responding adequately to the changes in the patient’s emotional states; (10) managing the patient’s transference; (11) managing countertransference reactions; and (12) summarizing and closing the session. Our findings agree with previous evaluation scales for competency in psychodynamic psychotherapy (20, 22). The rating scale developed by Winer and Mostert (20) evaluates the following items: establishing a therapeutic situation; facilitating the formation of a therapeutic alliance; recognizing the therapist’s own emotional reactions; experiencing the patient’s feelings while maintaining objectivity; communicating an empathic understanding in a way that enables the patient to feel understood; detecting multiple meanings in the patient’s communication; making interpretations; and formulating a psychodynamic explanation for the patient. The 29-item supervisor’s evaluation scale contains items that assess residents’ capacity to establish a working alliance of empathy, recognize and interpret transference, deal with resistance and countertransference, and close the session (22). The new item proposed in the PC-CAS in psychodynamic psychotherapy for BPD assesses a therapist’s ability to respond to a patient’s emotional changes. Maroda (47) and Kernberg (48) have stated that a therapist’s capacity to respond to a patient’s emotions plays a vital role in the psychodynamic psychotherapy of borderline patients, as emotional dysregulation causes these patients to exhibit frequent bouts of “affect storms.”

The PC-CAS in psychodynamic psychotherapy for BPD also emphasized the management of transference and countertransference in the psychodynamic psychotherapy of BPD. Transference interpretations may be viewed as “high-risk, high-gain” interventions in the psychotherapy of borderline patients, as these patients appear to be more vulnerable and easily overwhelmed by transference interpretations (9, 49). Transference interpretations in the psychodynamic psychotherapy of borderline patients must be performed in a timely and appropriate yet still evocative manner, to propel the process of psychotherapy (9, 20, 49). These features are consistent with the emphasis on timing and directed elaboration when managing transference in the PC-CAS in psychodynamic psychotherapy for BPD. Working with borderline patients is known to elicit a wide array of strong countertransference reactions within the therapists, including rage and hatred, guilt, inadequacy, anxiety, and parental feelings (9, 49). A meta-analysis by Hayes et al. (50) found that the management of countertransference was related to better therapeutic outcomes. However, the scope of this meta-analysis was not restricted to psychodynamic psychotherapy and borderline patients. The countertransference factors inventory (CFI) measures therapists’ countertransference management behavior by assessing five attributes related to countertransference management: self-insight, self-integration, anxiety management, empathy, and conceptualizing ability (51). The characteristics of self-insight, self-integration, anxiety management, and conceptualizing ability are reflected within the highest score of Item 11 on the PC-CAS in psychodynamic psychotherapy for BPD. Meanwhile, the empathy attribute is reflected in Item 6 on the PC-CAS in psychodynamic psychotherapy for BPD.

Our study had several strengths and limitations. The first strength is the robust data collection from a diverse sample of psychotherapy experts, psychiatrists experienced in psychotherapy, and teaching staff psychiatrists in Indonesia. The number of samples in the Delphi method, panel discussion, and content validity testing fulfilled the minimum number of participants for the respective activities (31, 52–54). Another strength of this study lies in the comprehensive steps taken in developing and validating the scales, including collecting qualitative feedback. The limitation of the study is the small number of experts in the panel discussion due to the limited number of psychotherapy consultants in Indonesia. The scales demonstrated potential utility in assessing the specific competency of psychodynamic psychotherapy for BPD and could be used in both learning and clinical situations. Future studies should investigate the application of these scales in education and clinical environments. The scales could be used for psychotherapy training or monitoring purposes and the results could be analyzed in comparison with other measures of psychotherapeutic competence, such as patient outcome.

The CS-CAPC in psychodynamic psychotherapy for BPD was designed to evaluate the cognitive, affective, and psychomotor domains of competency in psychodynamic psychotherapy for BPD, and it was found to have satisfactory content validity. The first scale in the CS-CAPC in psychodynamic psychotherapy for BPD, PF-CAS, could be used to assess the quality of written psychodynamic formulation. Meanwhile, the second scale, PC-CAS, assesses the practice of psychodynamic psychotherapy for BPD through direct or indirect observation via video recordings of the therapists’ psychotherapy sessions. The scale serves as a tool for a more objective and systematic assessment of the competency of psychodynamic psychotherapy for BPD, which could aid the didactic practice for psychodynamic psychotherapy for BPD among trainee therapists, such as psychiatry residents.