The Dynamic Therapist
No one is in any doubt that all therapies have to be modified if treatment of personality disorder is to be successful, and psychodynamic therapy is no exception. There is no place for the analyst as a blank screen onto which patients project their internal fantasies. Treatment has to be collaborative, structured and carefully organized, taking into account the behavioral and emotional crises that are inevitable during treatment of cluster B personality disorder.
One of the earliest outlines of the work of the dynamic therapist with patients with BPD is described in the controlled study of outcome of BPD conducted by Stevenson and Meares (1992). Therapy was organized over 12 months and offered in a modified form with careful attention given to the therapeutic alliance.
The overall aim of therapy is maturational and, more specifically, to enable the patient to represent a personal reality in terms of an emotionally meaningful inner life. In order to achieve this, the first task is to establish an enabling atmosphere in which generative mental activity can develop. A key technique is empathy with the patient's plight, but it is accepted that this will fail or be experienced as failing. The failures are used as a key to understanding the underlying mental processes that inhibit development. Indications of failure include negative affect, linear thinking, focus on the outer world and a change in the self-state (e.g., grandiosity, contempt). Transference phenomena are used to explore the detail of the empathic failures. It is important that therapy is sequenced carefully but that the therapist works flexibly. Initial sessions establish the interpersonal links of the patient's symptoms and identify the main problem areas by carefully exploring the relationships of the patient, agreeing on a focus and establishing a symptom history. Intermediate sessions may explicitly use transference to explore hidden feelings, stay with feelings and link change in symptoms with interpersonal events. This is followed by final sessions in which ending may be linked to earlier losses, negative feelings are scrutinized, gains are explicated and ways in which patients can continue working on themselves are discussed.
Despite this description, psychodynamic therapy has been criticized for the opacity of its treatment method. In the case of personality disorder, this has been remedied with the careful manualization of both TFP and MBT (Bateman and Fonagy, 2004; Clarkin et al., 1998). Transference-focused psychotherapy is a creative integration of drive theory and object relations theory, whereas MBT is specifically an integration of cognitive and psychoanalytic developmental theory and attachment theory. Interpersonal group psychotherapy is also manualized (Marziali and Munroe-Blum, 1994) but, to some extent, borrows only tangentially from dynamic therapy.
The hallmark of dynamic therapies is their emphasis on understanding unconscious process and meaning. Within a highly structured framework, both TFP and MBT focus on affect and affect-related cognitions, emphasize countertransference awareness, ask the therapist to consider relationship representations, and draw parallels between relationship patterns. Importantly, both approaches turn away from classical psychoanalytic therapy by de-emphasizing deep unconscious concerns in favor of conscious or near-conscious content, and both recognize that patients in these treatments perceive and exploit inconsistency, and therefore the treatment protocol has to minimize inter- and intraprofessional disputes. They share the therapeutic aim of achieving representational coherence and integration, and conceptualize their mode of action as working with endogenously activated representational systems.
However, there are some important differences, only two of which will be mentioned here. First, at the core of TFP is the understanding that externalizations in the transference are externalizations of mental representations of self-other relations internalized at moments of peak affect. Thus, the TFP therapist talks to the patient about the relational aspects of the transference and does so at the very beginning of treatment. Within MBT many such externalizations would not be seen as primarily relational but rather as externalizations of parts of the self, particularly the core self or a foreign aspect of the self. An important technical implication of this is that the MBT therapist would not expect the patient to understand much of the discourse that the therapist might verbalize in relational terms. The self and the therapist are experienced with a rigidity that is often strikingly without relationship implications. Interpretation in relational terms too early then leads to destabilization. Thus, the MBT therapist uses a gradual approach to interpretation of transference and does not necessarily challenge straightaway rigid relational patterns as exemplified in the relationship to the therapist.
Second, affect dysregulation is attributed to constitutional anomalies, temperamental differences and the absence of effortful control in TFP, but is seen in MBT as a consequence of symbolic failure, particularly associated with incongruent mirroring. In MBT the emphasis is therefore placed on identifying feelings; understanding the immediate precipitant of emotional states within present circumstances; expressing feelings appropriately, adequately and constructively within the context of a relationship; and recognizing the likely response of the other involved in an interaction.
Understanding psychodynamic processes can beneficially inform treatment planning. Many patients find themselves being treated within a divided-functions or two-person approach (Gabbard, 2000) in which, for example, a psychotherapist or psychologist conducts therapy while a general adult psychiatrist prescribes and looks after other aspects of care. But the two may be thrown together in a "clinical shotgun wedding" with little respect for or knowledge of each other working separately and possibly become engaged in professional rivalry. From a dynamic perspective, there is a conceptual price to pay for a division of roles since it implicitly separates treatment of an individual, who is already psychologically fragmented, into discrete components at a time when the task is to improve integration. Medication becomes split off from psychotherapy, the therapeutic alliance may be weakened by being attached to a number of different mental health care professionals, and treatment provision can develop into uncoordinated pockets of care. This lack of coordination is not inevitable (although far too common) and the model can work well if the practitioner roles are well integrated, good collaboration takes place between all individuals, and a coherent message is given to the patient. This provides a container for the splits and projections and may keep the patient with BPD in treatment, as well as diluting the negative transference reactions (Gunderson, 2001).
The American Psychiatric Association guidelines (2001) consider drug treatment as a useful adjunct to psychotherapy; patients with BPD are more likely to have used antianxiety, antidepressant and mood-stabilizer medication than patients with other personality disorders and equivalent amounts of antipsychotic medications to patients with schizotypal personality disorder (Bender et al., 2001). However, in trials of medication in personality disorders, dropout rates are high and noncompliance with dosage and frequency is common. Psychodynamic understanding of the prescription of medication may help reduce this lack of adherence if only because prescribing needs to be done carefully within the context of a trusting therapeutic relationship. The use and effects of medication must be discussed with patients prior to prescribing, the target symptoms clearly identified, an agreement made about how long a drug is to be used and a method to monitor its effect on symptoms established.
Clinician judgment is influenced by transference and countertransference phenomena. The psychiatrist is not immune from countertransference responses even if the task is solely to look after medication. It may become difficult for the psychiatrist to process feelings and so prescribe either in a desire to "rescue" the patient or in a vain attempt to "do something." To make matters worse, the patient who wishes to stop medication may be persuaded to continue it unnecessarily because the psychiatrist fears the patient will relapse, fails to recognize change and continues to present an image to the patient that is dangerously out-moded. These reactions may account for the high number of medications patients with BPD take over time. In a six-year prospective study, intensive polypharmacy remained relatively stable with 40% of patients taking three or more concurrent standing medications, 20% taking four or more and about 10% taking five or more during each follow-up period (Zanarini et al., 2004).
Treatment of personality disorder has never looked so promising. The task now is to determine which patient is best treated with which therapy and by which therapist. No one treatment is best for every patient and not everyone can treat patients with personality disorder. The skill, experience, attitudes and interpersonal ability of the psychiatrist or other mental health care professional may be as important as the type of therapy, particularly because treatment of personality disorder relies on an interpersonal process. It has been suggested that practitioners who are effete, genteel or controlling are positively contraindicated in treating patients with BPD (Gunderson, 2001). At the very least, the practitioner has to retain the capacity to be steady, skillful and competent despite provocation, anxiety and pressure to transgress boundaries. Psychiatrists and others trained in dynamic therapy are well positioned to meet this challenge and to advance our knowledge of the treatment of personality disorder.