Effective Therapies for BPD
By Garry Cooper, LCSW
Borderline personality disorder (BPD) was once thought virtually impervious to psychotherapy. That view is quickly disappearing. Psychiatrist Kenneth Silk, Director of the Personality Disorders Program at the University of Michigan, in an editorial in the April, 2008 American Journal of Psychiatry, writes about the increasing number of well-designed controlled studies demonstrating success with BPD. These treatments include “cognitive behavior, such as dialectical behavioral therapy and other more straightforward cognitive behavioral therapies, psychodynamic and psychoanalytically based therapies, which include mentalization-based therapy and transference-focused psychotherapy, and blends of cognitive and dynamic therapies in schema-focused therapy.” While evidence for the effectiveness of pharmacologic treatment of BPD remains murky, says Silk, it’s now clear that many psychotherapies are effective.
The increasing evidence for effective psychotherapy treatments, Silk writes, has led to a profound change in how therapists approach BPD with their clients. Those days are disappearing when therapists shied away from even telling clients that they were BPD, fearing that such a diagnosis of an intractable disorder was “equivalent to a type of death sentence,” and that diagnosing a person with BPD would unleash their rage. There is no longer any need for therapists to fear uncontrollable mood swings, boundary violations and frequent phone calls, or to refuse to take on clients with BPD. Therapists with a clear understanding of how to treat BPD can for the most part manage these cases.
The reconceptualizing of BPD from a disorder that’s an intractable part of personality structure to a condition highly amenable to therapy gained steam largely thanks to Marsha Linehan’s empirically supported dialectical behavior therapy (DBT). DBT’s behavior component and its manualized technique fit in well with the research and practice currents that swept therapy away from its traditional moorings in the last few decades. (For a more complete description of BPD, see article #8 in this course). But even before DBT, some classic psychoanalysts like Otto Kernberg insisted that therapy with BPD worked. Like much psychoanalytically-oriented therapy, however, the news and research about it was seldom accepted or heard outside psychoanalytic circles, cementing the view that unless you were trained in DBT or didn’t mind clients calling you at home or shrieking in your office, you should avoid working with BPD. But a study, in the June American Journal of Psychiatry, presents the increasingly common and accepted view that BPD cases are quite manageable. The study compares DBT with Kernberg’s transference-focused therapy, and also with an emotionally supported therapy and finds that all three therapies, after a year of treatment, are significantly successful.
The study’s especially useful for clinicians. Unlike many studies that use narrow inclusion and exclusion criteria in an effort to work with “pure” conditions rarely seen in the real clinical world, the borderline patients in this study resemble the kinds of patients seen in typical community clinics. And while other studies often manualize therapies so tightly that they seem more like a concentrated distillation of the treatment than real-world therapy, therapists in this study were encouraged to conduct therapy for one year in their customary manner. Thus, DBT consisted of weekly individual and group sessions with available telephone consultations. Transference-focused psychotherapy (TFP) consisted of two weekly individual sessions focusing on the emotional themes that emerged between patient and client. Emotionally supportive psychotherapy (ESP) was one weekly session with additional sessions if desired that provided emotional support for facing daily life problems.
The results revealed that although the three therapies were each effective, some worked better than others on different aspects of BPD. Although all therapies produced significant positive change in depression, anxiety, global functioning and social adjustment, DBT and TFP were more effective at decreasing suicidality. Both TFP and ESP were better at reducing impulsivity and anger. Only TFP—which fared better in more domains than the other two therapies—showed significant success in reducing irritability and verbal and direct assaults.
In an accompanying editorial, psychiatrist Glen Gabbard cautions against viewing the study as a “horse race” between the three therapies. It may be, he says, that all roads lead to Rome, or at least to a suburb in its vicinity. Or, he says, there may well be differential effects and that the future of therapy with BPD may lie in tailoring the best therapy with the most troubling clinical considerations. But for now, the overall news is encouraging: several therapies work.
More evidence for the effectiveness of psychotherapy in treating BPD comes from the Psychodynamic Diagnostic Manual (PDM). Reporting on its meta-analysis of eight studies of psychotherapy with BPD patients, the manual presents an encouraging view of psychotherapy. The average effect size (anything higher than .5 is considered significant) for psychodynamic psychotherapy was 1.31—1.0 for self-rated measures and 1.45 for observer-rated measures. Cognitive behavioral therapy was also effective, with an average effect size of 0.95. (The PDM article includes Linehan’s dialectical behavioral therapy in the CBT part of the meta-analysis). “There is evidence that both psychodynamic therapy and cognitive behavioral therapy are effective treatments for personality disorders,” concludes the PDM.
There has also been success claimed for Interpersonal Psychotherapy (IPT), a technique developed by psychiatrist Gerald Klerman and psychologist Myrna Weissman which straddles psychodynamic and cognitive therapy. Although originally developed for treating depression, IPT is based upon several core concepts which tap into the particular psychology of BPD. Because it draws partly upon the attachment theories of John Bowlby, the therapy is sensitive to people with attachment difficulties. It also focuses on interpersonal relationship difficulties. And IPT pays close attention to the relationship between the therapist and client, stressing the importance of a supportive, albeit structured bond. Finally, because IPT has such strong empirical support for alleviating depression, and because research finds that when the comorbid depression of a BPD client is alleviated, the BPD itself may go into remission, IPT seems strongly indicated for depressed BPD clients. As both a structured and supportive treatment, IPT offers both the therapist and the client an opportunity to work on their relationship, with the structured elements helping both of them to avoid both over-intimacy and the anger triggered by perceived abandonment.
IPT usually entails 12-16 weekly sessions. In the psychoeducation component, clients receive information about BPD, and they come to understand that their mood and life events influence each other. This helps remove the stigma from the diagnosis of BPD, which is often a major stumbling block in working with BPD clients. It follows from the understanding of the reciprocal influence of mood and life events that because one can seldom control life events, working on one’s moods and on their reactions to life events is an important focus of treatment.
The IPT therapist quickly determines which of four areas of clients’ lives are linked to their depression: they may be mired in delayed grieving; stuck at an impasse in a relationship; slogging through a role transition, such as retirement or divorce; or laboring under some habitual interpersonal deficit, such as not being able to state feelings or desires. Grieving-delayed clients are encouraged to mourn; later they are directed toward new activities and relationships that will compensate for the loss. Clients at a relationship impasse are encouraged to quickly decide whether to end the relationship or to find a way to move it off dead center. Those in a role transition receive support in looking at the positive and negative aspects of both the new role and the old role. Clients with interpersonal deficits get help working on the missing skills, often in role play. More information on IPT is available at their website: www.interpersonalpsychotherapy.com.
Theoretically, mentalization-focused interventions would seem highly effective for treating borderline personality disorder (BPD), and in fact a 1999 study provided preliminary evidence of its effectiveness (Bateman & Fonagy, 1999). After all, the fundamental aim of mentalization- focused treatment zeroes in on a primary characteristic of people with BPD: in their frequent and intense onrushes of emotion, they lose all perspective about their own and others’ emotional and cognitive processes. Mentalization-focused therapy develops the capacity to think about oneself in relation to others and to understand others’ state of mind. Now an eight year followup of Bateman and Fonagy’s original study finds that the positive effects of mentalization have endured (Bateman & Fonagy, 2008).
In their 1999 study, Bateman and Fonagy compared 19 patients in partial hospitalization for severe BPD, including suicide attempts, with 19 severely BPD patients treated in outpatient. Partial hospitalization included 18 months of psychoanalytic therapy with a mentalization-focused component. The outpatient treatment consisted of twice monthly psychiatric reviews by psychiatric nurses, with additional review by psychiatrists when necessary, other community supportive services, and inpatient readmission when necessary but did not include formal psychotherapy. Compared to the outpatient group, the partially hospitalized group showed significant improvement in depressive symptoms, a decrease in suicidal and self-mutilatory acts, reduced inpatient days, and better social and interpersonal functioning.
The post-partial hospitalization, five year follow-up showed ever more improvement. Only 23 percent of the partially hospitalized group had made at least one suicide attempt, compared to 74 percent of the outpatient group. Only 13 percent of the mentalization-based treatment patients still met the diagnostic criteria for BPD, compared to 87 percent of the outpatient group. Forty-six percent of the partially hospitalized group scored above 60 on their global assessment of functioning, compared to 11 percent of the outpatients, and they used significantly fewer medications. The formerly partially hospitalized group also received fewer years of subsequent outpatient treatment and community support.
The dramatically better outcomes of the formerly partially hospitalized group, of course, could be due to several treatment components and not just to the mentalization-focused aspects of psychotherapy. The structure of partial hospitalization, the closer monitoring, or other aspects of treatment could have accounted for the differences. But it seems likely that most clients with BPD could benefit from a therapy that teaches clients to pay thoughtful, specific attention to mentalizing. Although Fonagy insists that mentalization-focused therapy requires training and a manualization-based protocol, the fact remains that mentalizing is a core common factor in many psychotherapies. As they point out, it “cuts across treatment modalities and theoretical approaches ranging from psychodynamic to interpersonal and cognitive therapies.” (Allen, Fonagy and Bateman, 2008) Thus, most therapists already use it, and perhaps if they use it more thoughtfully, deliberately and transparently with their BPD clients, it could be an effective tool—and one that would help avoid the kinds of rage and despair that can sabotage the therapeutic relationship.
References
For additional information on mentalization-focused treatment, see http://www.menningerclinic.com/resources/Mentalizing06.htm
For additional information on Interpersonal Psychotherapy, see www.interpersonalpsychotherapy.com
For additional information on Dialectical Behavior Therapy, see www.behavioraltech.org
Allen, JG, Fonagy, P, and Bateman, AW (2008). Mentalizing in Clinical Practice American Psychiatric Publishing
Allen, JG & Fonagy, P (Eds.) (2006). Handbook of Mentalization-Based Treatment. Chichester, UK: John Wiley & Sons
Bateman, AW and Fonagy, P (2008). 8-year follow-up of patients treated for borderline personality disorder: mentalization-based treatment versus treatment as usual. American Journal of Psychiatry 165: 631 – 638
Bateman, AW and Fonagy, P (1999). Effectiveness of partial hospitalization in the treatment of borderline personality disorder: a randomized controlled trial, American Journal of Psychiatry 156:1563-1569
Clarkin, JF, Levy, KN, Lenzenweger, MF, and Kernberg, OF (2007). Evaluating three treatments for borderline personality disorder: A multiwave study, American Journal of Psychiatry 164: 922-928
Gabbard, GO, (2007) Do all roads lead to rome? New findings on borderline personality disorder, American Journal of Psychiatry 164: 853-855
Silk, KR (2008). Augmenting psychotherapy for borderline personality disorder: the STEPPS program, American Journal of Psychiatry: 165, 413-415