After the recent decade of the brain and in the present era of evidence-based practice, psychoanalytic treatment of personality disorder is being challenged. Not only are managed care companies questioning coverage for psychoanalytically oriented treatments, but other therapies are being promoted as having a better empirical foundation. Certainly, psychoanalytically oriented practitioners have been slow to research their treatment rigorously. This has begun to change, however, and a number of studies are underway or have been published (Kächele et al., 2000). The results suggest that psychoanalytic treatment of personality disorder can be modified to treat successfully even some of the most difficult patients.
Borderline personality disorder (BPD) is associated with serious morbidity. Nearly 10% of patients eventually commit suicide, and between 60% and 80% engage in seriously damaging self-injury at some point. Furthermore, patients make widespread use of mental health services and are frequently hospitalized. In this brief review, I will summarize some of the evidence for the effectiveness of psychoanalytic treatment for BPD and discuss its implications for the development of psychiatric services.
Limitations and Challenges to Current Research
A major problem for psychoanalytic treatments of BPD has been a reliance on cohort studies in which groups of patients are treated with a non-specific psychoanalytically oriented program, usually as inpatients, and followed over time. Of course, this can mean that any improvement that occurs could be a result of the passage of time rather than the treatment itself. Although the reported dropout rate is high at around 45%, the results are encouraging, indicating that personality change itself may take place, in addition to improvement in psychiatric symptoms (Bateman and Fonagy, 2000).
This limited research approach to personality disorder was challenged by the publication of a randomized controlled trial of a new behavioral treatment for BPD. Linehan et al. (1991) demonstrated that dialectical behavioral therapy (DBT) was effective in helping female patients with BPD. Therapy was conducted weekly and was offered both individually and in groups for one year. Interventions for patients receiving treatment-as-usual were not controlled. Twenty-two female patients were assigned to DBT and 22 to the control condition. Assessment was carried out during and at the end of therapy and again after one year follow-up. The dropout rate was low at 16%. Control patients were significantly more likely to attempt suicide, spent a longer time as inpatients over the year of treatment and were more likely to drop out of those therapies to which they were assigned. However, there were no between-group differences on measures of depression, hopelessness or reasons for living. Follow-up at one year found no between-group differences (Linehan et al., 1993). Comparing control patients who were in stable therapy with those who received DBT led to the disappearance of some of the differences. For example, although the DBT subjects had fewer suicidal acts, there was no difference in the medical risk of the behaviors.
Controlled studies of psychoanalytic therapy have only recently been instigated. Stevenson and Meares (1992) reported on 48 patients with BPD treated with twice-weekly psychoanalytic psychotherapy for one year. Patients acted as their own controls. Significant improvements in number of episodes of self-harm and violence, length of hospital admissions, and other measures were observed in the 30 patients who completed therapy. Of these patients, 30% no longer fulfilled criteria of BPD at the end of treatment. Improvement was maintained over one year. More recently, the same authors (Meares et al., 1999) compared the outcome of the same 30 patients with 30 further patients who were referred to the clinic but for whom no treatment was immediately available. Patients who received psychotherapy were significantly improved in personality disorder scores, while untreated patients were unchanged.
Despite the promising results from these studies, none of them matched the rigor of the study of DBT. An adequate design requires randomization of patients, is prospective, has a clearly described intervention, uses outcome measures specific to the condition being treated, and includes adequate follow-up since BPD is a chronic condition. In a perfect world, psychotherapeutic treatment would stimulate the development of the psychological capacities necessary to withstand the normal stresses and strains of everyday life. There is accumulating evidence that psychodynamic treatments are associated with gradual improvement after the cessation of treatment whereas behavioral treatments are not.
This is important for costs of future health care. Cost-effective treatments are those that stimulate permanent and enduring change. Palliative treatment, which brings rapid but temporary relief, may have short-term gains but long-term costs. In the terminology of psychotherapy: remoralization or instillation of hope is quick but temporary, remediation of symptoms takes longer but may be enduring, but the rehabilitative or long-term effects of a treatment are devoutly wished for and yet elusive.