This chapter is short but important. The importance of consistency is stressed by most therapies and that failure to maintain consistency is a common cause of treatment failure. Research shows that consistency is necessary for effective outcomes and interestingly patients who benefit from treatment frequently mention therapist consistency as a major factor in their improvement. However, the maintenance of consistency is challenging when treating patients with boundary problems, unstable emotions, ever-changing self-states, and difficulties with cooperation and collaboration. As a result, substantial frame violations are relatively common, occurring in about nearly 50 per cent of patients with borderline personality disorder (BPD) in the first six months of treatment.

What Is Consistency?

Therapy needs to be as predictable as possible, which means that it needs to be delivered in adherence to the therapeutic frame and treatment contract discussed in Chapter 7. Consistency has a practical component to do with the routine arrangements for therapy and an interpersonal component that concerns the way the therapy is conducted. The practical component requires adherence to the therapeutic contract in terms of frequency and duration of appointments and that changes in the agreed arrangement are discussed with the patient well in advance. This is a necessary part of therapy for patients who are often in a disorganized state with strong feelings of distrust and attachment insecurity. Failure to maintain these practical requirements confirms patient expectations and undermines treatment. Although this principle is widely understood, it is violated surprisingly frequently. Individual therapists often announce absences such as vacations without warning and in institutional settings treatment sessions are all-too-often cancelled at the last minute or therapists changed without prior warning. Punctuality is also important. It is an indication of the therapist's commitment to the process, and it is unreasonable to expect patients to be committed to their treatment if the therapist does not show an equal commitment. The interpersonal component requires that the therapist uses the same basic approach throughout therapy and interacts with the patient in a consistent way.

Consistency Is Not Rigidity

Being consistent is not the same as being rigid in maintaining the treatment frame. Discussion of structure (Chapter 7) noted the importance of therapist flexibility in dealing with the complexity of borderline pathology and especially when managing crises and when the patient feels stuck.