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There has been a significant shift from the view that personality disorder is untreatable; we do have treatments that have at least some efficacy and one of these is psychoanalytic psychotherapy. Evidence from randomized trials has shown that it is effective in treating borderline personality disorder, and follow-up studies confirm that the gains are robust.
Personality disorder is common, rarely treated in its own right and often only considered as an irritating impediment to effective treatment of medical and psychiatric problems. However, there has been a significant shift from the view that personality disorder is untreatable.
We do have treatments that have at least some efficacy, and one of these is psychoanalytic psychotherapy. Psychoanalytically based therapies, subsumed in this article as psychodynamic therapy, are a treatment in their own right, and psychodynamic ideas can usefully inform treatment planning and may guide appropriate prescription of medication.
Psychodynamic psychotherapy has been modified to suit the particular problems associated with personality disorder and has an increasing evidence base for its effectiveness, with most interest surrounding its use in the treatment of borderline personality disorder (BPD). An analysis of results from 15 studies of all psychotherapies that reported pretreatment-to-posttreatment effects suggested mean pre-post effect sizes within treatments were large: 1.11 for self-report measures and 1.29 for observational measures (Perry et al., 1999). The authors suggested a future study should examine specific therapies for specific personality disorders This has now been done in an objective meta-analysis of the effectiveness of psychodynamic therapy and cognitive-behavioral therapy (CBT) in the treatment of personality disorders (Leichsenring and Leibing, 2003). The study found that psychodynamic therapy yielded a large overall effect size of 1.46, with effect sizes of 1.08 for self-report measures and 1.79 for observer-rated measures. This contrasted with CBT in which the corresponding values were 1.00, 1.20, and 0.87, respectively. In addition, the psychodynamic studies had a mean follow-up period of 1.5 years, compared to only 13 weeks for CBT. However, the research literature was not extensive enough to draw firm conclusions from meta-analysis, and the authors were able to include only 14 psychodynamic studies and 11 CBT studies. The effect sizes cannot be compared directly because the studies differ, even within the same therapy group, in terms of therapy content, patient populations, length of treatments, outcome assessments and other variables. In an important early study of dynamic therapy, 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. At the end of treatment, 30% of patients no longer fulfilled criteria of BPD. Improvement was maintained over one year and continued over five years with substantial saving in health care costs. The same authors 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 (Meares et al., 1999). Patients who received psychotherapy were significantly improved in personality disorder scores, while untreated patients showed no change. The therapy concentrated early on the development of a therapeutic alliance and a relative or close friend was seen at the start of treatment. Both these factors may have accounted for the low dropout rate of 16%.
The most recent experimental support for a psychodynamic approach, now operationalized as mentalization-based treatment (MBT), has come from a randomized study examining the effectiveness of a group and individual partial-hospitalization program with standard psychiatric care for patients with BPD (Bateman and Fonagy, 2001, 1999). This has confirmed the indicative evidence from noncontrolled studies of the utility of partial-hospital group treatment. There was significantly greater improvement on all outcome measures in those patients allocated to psychotherapy. The dropout rate for the study was low. Gains were maintained after a further 18 months, indicating that rehabilitative effects were stimulated during the treatment phase (Bateman and Fonagy, 2001). The treatment has also been found to be cost-effective (Bateman and Fonagy, 2003). In a further randomized controlled trial, an outpatient version of MBT is currently being evaluated for use in patients with BPD and antisocial personality disorder.
A dynamic therapy known as transference-focused psychotherapy (TFP) has exhibited promising results, although the outcome of a randomized controlled trial comparing TFP, dialectical behavior therapy (DBT) and supportive psychotherapy is not yet known. In a cohort study, 23 female patients with BPD were assessed at baseline and at the end of 12 months of treatment with diagnostic instruments, measures of suicidality, self-injurious behavior, and measures of medical and psychiatric service utilization (Clarkin et al., 2001). Compared with the year prior to treatment, the number of patients who made suicide attempts significantly decreased, as did the medical risk and severity of medical condition following self-injurious behavior. The treatment year also saw significantly fewer hospitalizations, as well as number and days of psychiatric hospitalization compared with the previous year. The dropout rate was 19.1%. Conference reports of a comparison study between patients treated with TFP and a matched untreated control group confirm the benefits of treatment (Clarkin, 2002). Costs have not yet been examined.
The relative effectiveness of three psychodynamically oriented treatment models for a mixed group of personality disorders--long-term residential treatment using a therapeutic community approach, briefer inpatient treatment followed by community-based dynamic therapy (step-down program) and general community psychiatric treatment--has been studied.
Results suggest that brief inpatient therapeutic community treatment followed by outpatient dynamic therapy is more effective than both comparator treatments (Chiesa et al., 2002). Follow-up at 36 months has confirmed this finding (Chiesa and Fonagy, 2003).
In a dynamically related therapy using interpersonal group psychotherapy (IPG) to dilute some of the strong transference reactions found in patients with BPD, Monroe-Blum and Marziali (1995) found equivalent results between group and individual therapy, concluding that on cost-effectiveness grounds group therapy is the treatment of choice.
Further studies are needed to confirm all these experimental findings.
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.
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