July 2006, Vol. XXIII, No. 8
Personality disorders are characterized by pervasive and stable patterns of cognition, affect regulation, impulse control, and interpersonal functioning that are maladaptive and inflexible. The majority of patients who present for treatment of personality disorders fall in the "cluster B" group. In particular, patients with borderline personality disorder (BPD), as well as patients with borderline personality features in conjunction with other pathologic character traits, tend to be above-average users of mental health services.1 These patients seek helpoften when in crisislooking for relief from symptoms such as depression and anxiety, self-destructive behaviors, and psychosocial dysfunction associated with borderline pathology. Despite this, patients with BPD are notoriously difficult to engage in treatment and, until recently, the degree to which BPD could be successfully treated has remained an open question.
CAN PERSONALITY DISORDERS BE TREATED?
Psychotherapy is the primary form of treatment for personality disorders in general, and for BPD in particular.2 Although available medications can help with the management of anxiety, impulsivity, affective disturbance, and paranoid thinking that can accompany personality disorders, they do not target the patient's capacity to establish stable interpersonal relationships, function professionally at a level commensurate with his/her abilities and education, or enjoy leisure time.3
Two meta-analyses offer encouragement regarding the effectiveness of psychotherapeutic treatment of personality disorders. In 1999, Perry and associates4 reviewed all studies of psychotherapies that reported pretreatment to posttreatment effect sizes. A total of 15 studies met these criteria, and mean effect sizes within treatments were 1.11 for self-report measures and 1.29 for observational measures.
More recently, Leichsenring and colleagues5 conducted a meta-analysis to address the effectiveness of psychodynamic and cognitive behavior therapy in treating those with personality disorders. They found 14 studies of psychodynamic therapy and 11 of cognitive behavioral therapy that met their criteria of using standardized diagnostic measures, employing reliable and valid outcome measures, and reporting data that allowed for calculation of within-group effect sizes.
The authors found that psychodynamic therapy yielded an overall effect size of 1.46, with an effect size of 1.08 for self-report measures and 1.79 for observerrated measures. Cognitive-behavioral therapy yielded an overall effect size of 1.00, with 1.20 for self-report measures and 0.87 for observer-rated measures. The effect sizes of the 2 forms of treatment cannot be meaningfully compared because of differences in sample size, patient population, treatment duration, and research methodology among the various studies included in the meta-analysis. Leichsenring and associates concluded that there is evidence that both forms of psychotherapy are effective treatments for personality disorders. However, only 2 of the psychodynamic therapies and 3 of the cognitive-behavioral treatments included in the analysis were conducted within randomized controlled clinical trials. The authors emphasize the need for additional studies that provide empiric data on the effectiveness of specific forms of psychotherapy for treatment of specific personality disorders.
PSYCHODYNAMIC TREATMENTS FOR BPD
Although empiric support for treatment of personality disorders remains in its early stages, a number of promising specialized psychotherapeutic approaches using both cognitive-behavioral and psychodynamic therapies have been developed to treat specific aspects of borderline psychopathology.6-9 Psychodynamic treatments in particular are oriented towards modifying psychological capacities and functions thought to underlie observable symptoms of personality disorder.
Two psychodynamic treatments for BPD, mentalization-based treatment (MBT)10,11 and transference-focused psychotherapy (TFP),12 have been manualized and studied in randomized controlled clinical trials. Both are longterm treatments, as are other treatments that are likely to have a meaningful impact on BPD.2 Each treatment is organized around a particular psychological capacity or area of functioning that appears to be deficient in patients with BPD and is thought to be central to the disorder.
MBT is oriented toward enhancing the capacity of patients with BPD to accurately perceive and understand the nature of internal thoughts and feelings, both their own and those of others. It is hypothesized that this capacity, referred to as "mentalization," is impaired in borderline pathology, and this deficit is thought to play a central role in establishing and maintaining the maladaptive character traits associated with BPD.8
TFP shares the goal of enhancing the capacity of patients to more accurately perceive and better understand internal states. TFP approaches this goal by focusing on the partial and fragmented internal representations of self and others that color the experience of the patient with BPD. These representations leave the borderline patient with an unclear and changing sense of self and significant others, a condition referred to as "identity diffusion." TFP is oriented toward promoting identity consolidation as patients develop an enhanced capacity to establish and maintain stable, accurate, and complex experiences of themselves and others. Identity consolidation seems to be associated with both reduction in symptoms and enhancement of the overall quality of the patient's life experience.9
MBT is carried out in 2 sessions per weekone 50-minute individual therapy session and one 90-minute group therapy session. A randomized controlled study of MBT was conducted in the setting of a partial hospitalization program in the British National Health Service. In this study, 38 patients were assigned to the treatment program or to standard psychiatric care; treatment lasted 18 months. Outcome measures included suicidal behavior and self-harm, hospital admissions, psychoactive medication, and selfreport measures of symptoms of depression, anxiety, general distress, interpersonal functioning, and social adjustment. In contrast to the control group, in which there was little change, patients in the treatment group showed significant improvement across all measures at 18 months.10 Gains were maintained and patients in the treatment group continued to show improvement over 18 months of follow-up.11
TFP is carried out in 45- to 50-minute individual therapy sessions twice a week. In a randomly controlled clinical trial, 90 patients were assigned to 1 year of TFP; dialectic behavior therapy (DBT), a cognitive-behavioral treatment for BPD and the treatment that has garnered the most empirical support to date; or a manualized supportive psychotherapy. Patients in all treatment cohorts made significant gains across a variety of outcome measures of depression, social adjustment, and global functioning. TFP and DBT significantly reduced suicidality but supportive psychotherapy did not (J. F. Clarkin et al, unpublished data, 2006). Reflective functioning, a measure closely tied to the capacity for mentalization, significantly improved in the TFP group but not in the DBT or supportive treatment groups (K. N.Levy et al, unpublished data, 2006). Since this finding reflects a change in the patients' thought processes as well as symptoms, it can be hypothesized that the improvement in mentalization will help patients maintain that improvement over time. The complete data analysis from this study will be published shortly, and long-term follow-up of patients is ongoing.
TREATMENT OUTSIDE SPECIALIZED SETTING
MBT and TFP are both relatively complex and specialized treatments. It is possible, however, to use the MBT and TFP treatment manuals to derive general principles for psychodynamically informed management of BPD. Despite differences between the 2 treatments, careful reading of the manuals, which were the first to be developed for the long-term psychodynamic therapy of patients with BPD, demonstrates shared principles, strategies, and technical approaches. These shared features can be viewed as something of an "expert consensus" among 2 leading groups of psychodynamic clinicians and researchers for treatment approaches for this patient population. We present some of these principles below, focusing on aspects of treatment that are readily learned and can be adapted to a variety of treatment settings.
Establishing the treatment frame
The internal and external lives of individuals with BPD are frequently chaotic, and efforts to treat BPD often become chaotic as well. Patients typically resist and often refuse to comply with necessary conditions for treatment, either insisting on treatment on their own terms or agreeing to a particular treatment and then failing to comply with the required conditions. As a result, the conditions for treatment are not met, and treatments tend to unravel, typically ending either in crisis or patient dropout.
Both MBT and TFP emphasize the need to clearly define, explicitly describe, and consistently maintain the treatment frame, ensuring that patients understand what participation in treatment entails and that failure to maintain the frame can undermine the treatment. Treatment does not begin until the treatment frame has been agreed upon, including the frequency of sessions, the expected duration of treatment, respective roles of patient and therapist, and procedures for scheduling appointments, cancellations, billing, phone calls, and contact after hours.
As part of this discussion, the therapist and patient determine how emergencies will be handled and the extent to which the therapist is available for phone contact between sessions. A clearly defined and clearly described frame provides a safe, consistent, and reliable structure for treatment, and the limits established by the frame help to contain the patient's acting out and the therapist's emotional reactions to the patient.
Agreeing upon treatment goals
In both MBT and TFP, the patient and therapist agree upon treatment goals before treatment begins. It is helpful to establish both short-term goals (eg, to control self-destructive behaviors or to avoid the need for hospitalization) as well as long-term goals (eg, to establish and maintain a stable relationship with a partner). Treatment goals organize the treatment and help ensure that treatment time is used productively. When sessions become confused or content seems trivial or superficial, referring back to the goals and the question of whether the patient is using the treatment to pursue the goals can help keep the treatment on track.
Treatment goals also enable the patient and therapist to monitor progress. While it may take many months to see therapeutic benefits in the psychotherapy of patients with BPD, over time there should be clear indications of clinical improvement.