Psychodynamic Treatments

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 help—often when in crisis—looking 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 week—one 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.

The quality of the therapeutic alliance has been linked to outcome in a variety of forms of psychotherapy.¹³ However, patients with BPD are typically ill-equipped to establish a stable therapeutic alliance.¹⁴ As a result, it is necessary to employ specific strategies to promote an alliance.

Both the MBT and TFP treatment manuals recommend that the therapist share the diagnostic impression with the patient and discuss the core features of BPD in clear language that the patient can understand. The therapist should also describe the recommended treatment and explain how the treatment is expected to help the patient with the difficulties that caused the patient to seek treatment. This type of discussion, during the consultative process, lays the groundwork for a reality-based treatment alliance by conveying that the therapist understands the patient's illness and has a specific plan for treatment. Furthermore, this approach, in conjunction with establishing specific goals and discussing the responsibilities of the patient and therapist in the treatment, enlists the patient's active participation and collaboration.

MBT makes use of explicitly supportive interventions to help establish an alliance, such as offering advice and encouragement or intervening in the patient's life. In contrast, TFP avoids supportive interventions but pays great attention to the emergence of negative feelings and attitudes towards the therapist. The therapist openly accepts the patient's anxieties while helping the patient put his or her concerns about the therapist, which are representative of concerns about others in general, into words.

Reducing dropout

Patients with BPD are at high risk for dropping out of treatment. A number of studies across a variety of treatments report dropout rates between 40% and 60% at 6 months.¹⁵ MBT and TFP use strategies to improve patient retention, including the techniques described above—explicit discussion of treatment goals and treatment frame and fostering a therapeutic alliance. In both treatments, the therapist is alert to the possibility of dropout and actively tries to keep patients in treatment.

Regular attendance at therapy sessions is expected. If a patient fails to keep a scheduled appointment, the therapist responds actively by contacting the patient about the missed appointment and raising the issue of the missed session at their next meeting. Similarly, if a patient's behavior in a session raises the therapist's concern about the possibility of the patient's dropping out of treatment, addressing this issue becomes a priority in the session.

Managing suicidality and self-destructive behaviors

Both MBT and TFP provide an explicit plan and sequence of behaviors that a patient should use to respond to emergencies. The intention is to help him/her use the treatment to control destructive and self-destructive behaviors. These procedures are determined in a systematic fashion before treatment begins rather than haphazardly in the setting of an emergency.

MBT encourages patients to call the treatment team and make contact with the therapist before engaging in destructive behaviors. This protocol communicates the availability and reliability of the therapist when the patient is in need. TFP provides strategies for patients to call on social supports and seek emergency attention when needed independent of the therapist, with the aim of reducing secondary gain associated with destructive behaviors. Although these 2 approaches are fundamentally different, both treatments anticipate problems ahead of time and provide a coherent, clearly analyzed, and explicitly discussed strategy for dealing with emergencies, enabling the treatment to weather crises without becoming derailed.

Managing the therapist's emotional reactions

Patients with BPD often generate powerful emotional reactions in caregivers, including anxiety, guilt, demoralization, anger, fear, and paranoia. These reactions reflect the often dangerous, manipulative, or overtly aggressive behaviors frequently associated with BPD. The patient with BPD may use defenses that tend to control others and to project responsibility and intense affects onto them. MBT and TFP view powerful emotional reactions on the part of the therapist treating patients with BPD as inevitable, and both treatments recommend specific strategies to help therapists manage their emotions. They emphasize the role of the treatment frame and of a coherent treatment model in helping therapists contain their anxiety. When intense affects are stimulated, therapists can turn to clearly defined clinical principles to guide their behavior, organize their thinking, and understand what their reaction tells them about the patient's internal experience. Equally important, in both randomized clinical trials, therapists met regularly for peer supervision. The findings of the analyses of these 2 research groups suggest that optimal psychotherapeutic treatment of BPD may require ongoing consultation with colleagues, regardless of the treatment setting.

Coping with the chaotic nature of sessions

Confusion is a near-universal experience for therapists treating patients with BPD. MBT and TFP both provide strategies to guide therapists when deciding which aspects of a patient's chaotic and often overwhelming verbal and nonverbal communication to pursue. Sessions can be approached from the perspective of a hierarchy of priorities that organize the therapist's interventions. In any treatment setting, the highest priority is always imminent risk of danger to the patient, therapist, or others. The next priority for the therapist to address is any patient behavior that threatens to disrupt or undermine treatment. Next is self-destructive and destructive behavior (eg, self-cutting, binge drinking, sexual acting out) that does not immediately threaten the safety of the patient or the integrity of the treatment. Finally, when none of these priorities is active, the therapist can use sessions to explore the patient's chronic difficulties and the problems defined in the long-term treatment goals.

Comorbidity and maintaining a flexible approach

Patients with BPD are a complex, challenging, and highly varied group. There is a broad array of people who meet criteria for BPD, and it is quite clear that different kinds of patients are likely to benefit from different treatment approaches.¹⁶ Comorbidity with other personality disorders can present a complicated picture, and depression, anxiety disorders, substance misuse, and eating disorders are common.¹⁷

Both MBT and TFP recognize the importance of tailoring the treatment plan to meet the clinical needs of the individual patient. For example, both treatments recommend the use of adjunctive psychoactive medication, when indicated, for treatment of depression and anxiety. Similarly, patients with BPD who also abuse alcohol or drug, require a treatment plan that includes aggressive management of substance abuse.

In essence, while structure and consistency are essential for successful psychotherapeutic treatment of BPD, flexible implementation of treatment strategies is also needed. Combined experience with MBT and TFP suggests that an approach to treatment that is structured, coherent, and consistent, but also flexible and responsive to the clinical needs of each patient, can pave the way to successful treatment of BPD.

CONCLUSION

Clinicians can benefit from employing the treatment principles described in this article to help stabilize patients with BPD and to reduce symptoms and destructive behaviors. Clinicians who wish to help patients effect deeper levels of personality change with the goals of improving their subjective experience and adaptation to life are advised to become familiar with the more advanced stages of MBT or TFP.

Dr Caligor is clinical professor of psychiatry at Columbia University College of Physicians and Surgeons and director of the Psychodynamic Psychotherapy Program at the Columbia University Center for Psychoanalytic Training and Research, where she is also a training and supervising analyst. In addition, she is a consultant to the Personality Disorder Institute at New York Presbyterian Hospital, Westchester Division. Dr Caligor reports that she has no conflicts of interest concerning the subject matter of this article.

References

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Evidence-based References

• Bateman A, Fonagy P. Effectiveness of partial hospitalization in the treatment of borderline personality disorder: a randomized controlled trial. Am J Psychiatry. 1999;156:1563-1569.

• Clarkin JF, Foelsch PA, Levy KN, et al. The development of a psychodynamic treatment for patients with borderline personality disorder: a preliminary study of behavioral change. J Personal Disord. 2001;15:487-495.