Understanding the Usefulness of Psychosocial Interventions for Personality Disorders

July 2006, Vol. XXIII, No. 8

Recent research has supported the use of psychosocial interventions for persons with various personality disorders. However, few empirically supported therapies (ie, treatments that outperform control conditions in at least 2 randomized controlled trials by independent research groups¹) currently exist.

This article examines recent research on psychosocial treatments for persons with personality disorders, particularly focusing on randomized controlled trials and empirically supported therapies. The article then takes a closer look at dialectical behavior therapy (DBT),^2,3 an empirically supported treatment for borderline personality disorder (BPD), as an example of a psychosocial intervention for patients with personality disorders.

RESEARCH ON PSYCHOSOCIAL TREATMENTS

Many of the randomized controlled trials of psychosocial treatments for personality disorder have focused on treatments for BPD, although other studies have also examined treatments for cluster C personality disorders, comorbid affective disorders and personality disorders, and personality disorders in general.

A recent review of treatment for BPD4 covered 8 randomized controlled trials of psychosocial treatments for BPD.^5-12 Seven of these trials studied DBT and 1 studied psychoanalytic partial hospitalization.

BPD

Research on DBT has consistently indicated that it is an effective treatment for BPD. Indeed, studies of DBT indicate that it meets the criteria for an empirically supported therapy for BPD. The first randomized controlled trial for the treatment of BPD, by Linehan and colleagues,⁵ indicated that DBT was superior to a treatment-as-usual condition on the following outcomes:

• Percentage of patients with selfinflicted injuries (including suicide attempts)
• Number of self-inflicted injuries

• Medical risk of injuries

• Social and global adjustment

• Psychiatric inpatient days

• Treatment retention

• Anger

Both patients receiving DBT and those receiving treatment as usual had decreases in depression, hopelessness, and suicidal ideation. A 1-year followup¹³ indicated that patients in DBT had:

• Higher global adjustment scores throughout follow-up

• Less self-injurious behavior, less anger, and better social adjustment scores throughout the first 6 months of follow-up

• Better interviewer-rated social adjustment and fewer psychiatric inpatient days during the final 6 months of treatment

Another randomized controlled trial compared DBT to treatment conducted by expert community psychotherapists (as opposed to treatment as usual).¹¹ The researchers found that patients treated with DBT had half as many suicide attempts, lower medical risk of self-injuries, lower rates of treatment dropout and fewer psychiatric hospitalizations and psychiatric emergency department visits for suicidal behaviors. Patients in both conditions showed increases in reasons for living and decreases in depression and suicidal ideation.

Another study examined DBT as a treatment for BPD and comorbid substance use disorder.⁶ Patients were randomly assigned to DBT or a community treatment-as-usual condition. Patients treated with DBT had less drug use and less treatment dropout as well as better global adjustment and social adjustment than community treatment as usual.

Psychoanalytic partial hospitalization

Several other treatments have shown promise for the treatment of BPD; psychoanalytic partial hospitalization is one example. However, this approach has not reached the definition of an empirically supported therapy, since its findings have not been replicated by an independent research team.

In an 18-month randomized controlled trial, psychoanalytic partial hospitalization was compared with treatment as usual.¹² Patients in the partial hospitalization program showed reductions in self-harm behaviors and number of inpatient days.

Other therapies

A number of treatments have shown equivalent outcomes in the treatment of BPD. In 1 study, patients were randomized to either a group therapy specifically tailored for BPD or individual psychodynamic therapy.¹⁴ There were no significant differences between the outcomes of the 2 groups, although patients in both groups showed significant improvements.

Other studies of psychosocial treatments for BPD, including an open, uncontrolled clinical trial of cognitive therapy¹⁵ and transference-focused therapy,¹⁶ indicated that these treatments may be promising, but further study through randomized clinical trials is required.

Cluster C personality disorders

In a study examining a psychosocial treatment targeting cluster C personality disorders, 50 patients with 1 or more cluster C personality disorders were randomized to either 40 sessions of dynamic psychotherapy or cognitive therapy.¹⁷ Patients in both groups showed significant improvement in symptom distress, interpersonal problems, and cluster C personality pathology scores during treatment and at 2-year followup. There were no significant differences on any measure of outcome between the 2 groups at any time. Treatments for cluster C personality disorders require further study.

Comorbid affective and personality disorders

Two treatments have shown promise for comorbid affective disorders and personality disorder. Researchers looked at DBT modified for the treatment of major depressive disorder with at least 1 comorbid personality disorder (although not necessarily BPD) in patients 55 years or older.¹⁸ Results showed that compared to antidepressant medication alone, patients receiving DBT plus medication had significantly better outcomes for interpersonal aggression and interpersonal sensitivity as well as a trend toward better depression remission rates.

Another controlled trial randomized patients with a comorbid affective disorder and personality disorder to either 18 weeks of psychodynamic day hospital treatment or a wait-list control group.¹⁹ Those in the day hospital treatment group had significantly greater improvements in severity, social functioning, family functioning, interpersonal functioning, mood, self-esteem, and life satisfaction than those in the control group. Thus, both DBT and psychodynamic day hospital treatment show promise for being effective in the treatment of mood and personality disorders.

Personality disorders in general

Several studies have examined psychosocial treatments of personality disorders in general. In one such study, 81 patients with any personality disorder were randomly assigned to 40 weeks of either brief adaptive psychotherapy or short-term dynamic therapy, or a wait-list control group.²⁰ Patients in both treatment groups improved significantly more than patients in the control group on self-reported symptoms, social adjustment, and target complaint severity. There were no significant differences between outcomes of patients in the 2 active treatment groups.

In another randomized controlled trial, 156 patients with any personality disorder were randomized to either a community-based psychodynamic intervention or 40 sessions of supportive-expressive psychotherapy.²¹ No differences were found between treatments at the end of therapy, although patients in both conditions showed improved global functioning and had decreased personality disorder severity, rates of personality disorder diagnosis, and symptoms.

Prevention of personality disorders

Finally, one randomized clinical trial examined an experimental enrichment program for 3- to 5-year-old children designed to help prevent personality disorders in later life.²² The enrichment program included educational, nutritional, and physical exercise components. When measured at age 17, participants in the enrichment program had lower scores for schizotypal personality and antisocial behavior than participants in usual community conditions. This study suggests that early efforts at prevention may help decrease the likelihood of certain personality disorders later in life.

Overall, several psychosocial therapies show promise for the treatment of various personality disorders, and DBT has been proved to be an empirically supported treatment for BPD. Several of the treatments, including DBT and Bateman and Fonagy's partial hospitalization programs,¹² are multimodal and structured. These treatments use each modality to target specific aspects of patients' problems. One key aspect of psychosocial treatments may be the comprehensiveness and structure of the treatment.

DBT is a highly structured and comprehensive treatment. Other elements unique to DBT, such as mindfulness, validation, targeting, and dialectics, may contribute to its effectiveness.²³ The following section provides an overview of DBT, particularly focusing on how DBT uses its multiple modalities to target problem behaviors often seen in BPD.

Each patient has an individual therapist who is responsible for integrating all modes of DBT, planning treatment, managing all life-threatening behaviors and crises, ensuring progress toward targeted areas, and consulting with the patient on how to interact with other treatment providers in an effective manner. The individual therapist also aims to strike a balance between working to change the patient/s ineffective behavior and validating the patient. Patients typically attend 1 hour of individual therapy per week.

Individual therapists organize session time according to an explicit ranking of behavioral targets. The highest priority target is life-threatening behaviors, including suicide attempts, intentional self-injury, and urges for these behaviors. When these behaviors occur, the therapist and patient conduct a detailed behavioral analysis of the precipitating events and results of these behaviors. The goal of the analysis is to precisely identify moments when the patient can engage in more effective and skillful behavior and to teach patients skills to enable them to behave more effectively when similar situations occur in the future.

The second highest priority in individual therapy is to eliminate therapy interfering behaviors. Therapists focus on eliminating any behaviors that may impede therapy from proceeding, such as failure to attend or to complete homework. The third highest target is quality of- life interfering behaviors, such as criminal behaviors, interpersonal dysfunction, high-risk sexual behavior, or homelessness.

Group skills training

DBT explicitly addresses skill deficits by systematically teaching 4 sets of skills: mindfulness, distress tolerance, emotional regulation, and interpersonal effectiveness (Table).

The first target in group skills training is to eliminate any group-destroying behaviors; the second is to increase skill acquisition; and the third is to decrease group-interfering behavior. These targets help maximize the chances that group members will learn skills. A typical format for a skills group is to meet for 21.2 hours weekly, with the first half of the meeting focusing on homework review and the second half focusing on teaching new skills.

Mindfulness
Includes observing, describing, and fully participating in a nonjudgmental manner and focusing on 1 thing at a time and on being effective.

Distress tolerance
Helps patients survive crises without making things worse and helps them accept circumstances that cannot immediately be changed.

Emotional regulation
Helps patients decrease ineffective emotional responses and increase positive emotions.

Interpersonal effectiveness
Helps patients obtain their objectives, improve or maintain relationships, and maintain self-respect in interpersonal interactions.

Telephone consultation

Individual dialectical behavior therapists use phone consultations with patients outside of therapy sessions. The purpose of the consultation is to briefly intervene to help the patient avoid dysfunctional behavior and, instead, engage in effective behavior. Patients are encouraged to contact their therapist before engaging in self-harm behaviors and therefore do not have to engage in suicidal or self-harm behaviors to gain access to the clinician.

Therapist consultation team

All individual and group therapists participate in a consultation team designed to help therapists acquire, integrate, and generalize effective therapeutic behaviors. One of the main functions of the team is to help therapists avoid burnout when working with patients with BPD. The team helps its members adhere to DBT principles and progress toward competence, plan effective interventions, reduce personal characteristics that interfere with therapy, effectively operate within the mental health network, and provide support to one another.

CONCLUSIONS

A variety of psychosocial interventions for personality disorders show promise; DBT for BPD has specifically been proved to be effective. Further randomized controls are necessary, particularly of treatments for personality disorders other than BPD.

Dr Salsman is a research associate in the department of psychology at the University of Washington in Seattle. He works with Marsha Linehan, PhD, researching dialectical behavior therapy and borderline personality disorder. Dr Salsman/s work is supported by grants to Marsha Linehan from the National Institute of Mental Health and the National Institute of Drug Abuse.

References

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2. Linehan MM. Cognitive-Behavioral Treatment of Borderline Personality Disorder. New York: Guilford Press;1993.
3. Linehan MM. Skills Training Manual for Treating Borderline Personality Disorder. New York: Guilford Press;1993.
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5. Linehan MM, Armstrong HE, Suarez A, et al. Cognitive-behavioral treatment of chronically parasuicidal borderline patients. Arch Gen Psychiatry. 1991;48:1060-1064.
6. Linehan MM, Schmidt H 3rd, Dimeff LA, et al. Dialectical behavior therapy for patients with borderline personality disorder and drug-dependence. Am J Addict. 1999;8:279-292.
7. Linehan MM, Dimeff LA, Reynolds SK, et al. Dialectical behavior therapy versus comprehensive validation plus 12-step for the treatment of opioid dependent women meeting criteria for borderline personality disorder. Drug Alcohol Depend. 2002; 67:13-26.
8. Turner RM. Naturalistic evaluation of dialectical behavioral therapy-oriented treatment for borderline personality disorder. Cognitive Behav Practice. 2000; 7:413-419.
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11. Linehan MM, Comtois KA, Murray AM, et al. Two year randomized trial + follow up of Dialectical Behavior Therapy vs. therapy by experts for suicidal behaviors and borderline personality disorder. Arch Gen Psychiatry. In press.
12. 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.
13. Linehan MM, Heard HL, Armstrong HE. Naturalistic follow-up of a behavioral treatment for chronically parasuicidal borderline patients. Arch Gen Psychiatry. 1993;50:971-974.
14. Munroe-Blum H, Marziali E. A controlled trial of short-term group treatment for borderline personality disorder. J Personal Disord. 1995;9:190-198.
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16. 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.
17. Svartberg M, Stiles TC, Seltzer MH. Randomized, controlled trial of the effectiveness of short-term dynamic psychotherapy and cognitive therapy for cluster C personality disorders. Am J Psychiatry. 2004;161:810-817.
18. Lynch TR, Cheavens JS, Cukrowicz KC, et al. Treatment of older adults with comorbid personality disorder and depression: a Dialectical Behavior Therapy approach. Int J Geriatr Psychiatry. In press.
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Evidence-based references

• Linehan MM, Armstrong HE, Suarez A, et al. Cognitivebehavioral treatment of chronically parasuicidal borderline patients. Arch Gen Psychiatry. 1991;48: 1060-1064.

• Turner RM. Naturalistic evaluation of dialectical behavioral therapy-oriented treatment for borderline personality disorder. Cognitive Behav Practice. 2000; 7:413-419.