borderline personality disorder - psychotherapy for patients

Based on research and experience, experts in the treatment of borderline disorder believe that psychotherapy is essential in most cases if you are to gain optimal control over your symptoms and your life. I agree strongly with this conclusion.

Many patients initially view psychotherapy as a mysterious and somewhat frightening experience. They fear that most of what they learn about themselves in therapy will be negative. Psychotherapy is often difficult work because it involves some changes in attitudes and behaviors, and change is always difficult. However, you will be pleasantly surprised to discover a number of your positive personal strengths during your therapy sessions and how best to enhance and utilize these strengths.

The Main Objectives of Psychotherapy for Borderline Disorder

In general, all types of psychotherapy for borderline disorder focus on a list of objectives that ranks the most pressing, fundamental issues at the top and those with less immediate importance lower on the list. Though this list may vary somewhat from one type of therapy to another, it is typically designed to achieve the following:

● assure the safety of the patient and that of others by developing effective alternative behavioral methods for dealing with problems

● decrease impulsive and harmful behaviors in addition to those that are self-injurious and suicidal

● improve basic self-care e.g., eating, sleep and exercise habits, medication compliance

● identify and modify inaccurate perceptions and thought patterns related to symptoms

Supportive Psychotherapy

1. Supportive Psychoanalytic Psychotherapy (SPP)

2. Interpersonal Therapy (IPT)

5. Systems Training for Emotional Predictability and Problem Solving

Psychodynamic Psychotherapy

6. Transference Focused Psychotherapy (TFP)

7. Schema-Focused Therapy (SFT)

8. Mentalization-Based Therapy (MBT)

^*Note: Classic psychoanalysis is now rarely utilized in the treatment of patients with borderline disorder, except in limited instances, and only after patients have responded well to other forms of therapy. Otherwise, experience suggests that traditional psychoanalysis is usually not advisable for most patients with borderline disorder.

SPP is a specific form of supportive psychotherapy for borderline disorder that has been developed recently by Appelbaum, in collaboration with Carsky, and can be clearly distinguished from Transference Focused Psychotherapy and DBT (discussed below). Conceptually, like TFP, it is grounded in basic psychoanalytic concepts. It differs from TFP in practice mainly by the avoidance of interpretations by the therapist, especially of the relationship of the therapist and the patient. It is thought that such interpretations disrupt the calm "learning state" that promotes in the patient the opportunity to reflect usefully on their emotional reactions. Further, in SPP the patient-therapist relationship is viewed as the main mechanism of change, and therapy must be seen by the patient to be a safe and calm place in order to optimize learning and undertake change in behaviors. In addition, SPP avoids the systematic teaching, written homework and concomitant group therapy methods employed in DBT. In order to enhance the learning and consistent application of SPP, a training manual is in the process of being developed.

Interpersonal Psychotherapy (IPT)

IPT has been adapted recently for the treatment of borderline disorder. IPT was originally developed by Klerman and his colleagues as short term psychotherapy for depression, and was based on the fundamental concept that interpersonal relationships are importantly related to the disturbances experienced in specific mental disorders. For example, there is evidence that the death of a significant person, substantial difficulties in an important relationship, major changes in life course (e.g., new job, divorce, geographic move, etc.), and social isolation are either precipitants or results of episodes of depression. Four treatment principles were described: 1) depression was defined as a treatable medical illness, not the fault or failure of the patient: 2) disturbances in interpersonal relationships were not considered to cause depression, but serve as precipitants that then determine the focus of therapy; 3) each treatment session focuses on the patient’s interpersonal successes or failures; and 4) IPT should establish a supportive, optimistic alliance between the patient and therapist. The effectiveness of IPT for depression was demonstrated in a number of well-controlled research clinical trials, and then was adapted for use in other disorders such as anxiety and substance abuse.

The rationale for the use of IPT in the treatment of borderline disorder includes the facts that significant emotional shifts, especially anger, anxiety and depression, and disturbed interpersonal relationships are central characteristics of borderline disorder, that depression of one type or another occurs in virtually all patients with the disorder, and that IPT has been found to be effective for the treatment of depression. Thus, the therapeutic focus of IPT is to use ones emotional reactions to identify troublesome interpersonal situations, then to define alternative and more successful responses to these emotionally charged situations. In ITP, borderline disorder is considered an illness with chronic emotional symptoms and sporadic outbursts of anger and impulsivity. Rather than the symptoms dominating interpersonal behaviors, IPT “raises the exciting expectation that the patient may be able to shed this disorder, even though he or she has had it throughout adulthood, in a relatively brief course of treatment.”

The use of IPT in borderline disorder requires a number of specific adaptations. One of these is the length of treatment which is extended due to the chronic nature of the disorder compared to the acute disorder of depression for which it was originally developed. The first, acute phase of treatment consists of 18 50-minute sessions over 16 weeks. If the patient tolerates this phase, a second 16-week phase of one session per week follows. Patients who present with suicidal risk are accepted into IPT if they are on stable doses of medication, agreeable to frequent assessments, telephone checks and participation each week in treatment. The results of an initial therapeutic trial of IPT in patients with borderline disorder are very preliminary but promising, even though they come from a small number of people so treated.

Cognitive behavioral therapy for borderline disorder (CT for BPD) was developed on the premise that people with the disorder have learned distorted beliefs and thought patterns. These, in turn, result in the distressing emotional responses and behaviors that characterize borderline disorder.

It is the initial objective of CT for BPD to identify the distorted, automatic thoughts and beliefs held by the patient with borderline disorder. Such beliefs typically include those related to dependency ("I am needy and weak"), distrust ("People will get me if I don't get them first"), rigid, all-or-nothing (dichotomous) perceptions, and other thought patterns that characterize the main cognitive-perceptual symptoms of the disorder. These distorted thoughts are then modified by self-monitoring, logical analysis and by questioning and testing them. In addition, CT for BPD attempts to produce positive change by improving the attitude of the patient toward treatment, the enhancement of specific skills, and the reduction of hopelessness. The CT therapist and the patient typically construct a list of specific problem areas. They then develop a set of tasks or exercises (homework) that generate and reinforce new attitudes, behaviors, and interpersonal strategies that replace the ones that have proven to be ineffective.

Dialectical behavior therapy (DBT) is a modification of CBT . It was developed initially for patients with borderline disorder , especially those who engage in frequent self-destructive and self-injurious behaviors. DBT is based on the concept that the symptoms of borderline disorder are the result of inherent biological impairments in those brain mechanisms that regulate emotional responses. The early behavioral results of these disturbances are magnified as the child interacts with parents and others who do not understand and validate (acknowledge and accept) the extent of the child’s emotional pain, and who do not help the child to learn effective skills to cope with her or his suffering.

A major therapeutic goal of DBT is to assist the patient with borderline disorder to achieve more appropriate balances of, and responses to, conflicting “dialectical” tensions such as:

DBT therapy requires a significant time commitment. It consists of the combination of once a week individual psychotherapy by a DBT-certified therapist, a two and one-half hour DBT skills training session conducted in a group setting, and substantial home work assignments. It also requires weekly team meetings of the therapists involved in your care. In DBT, you are usually discouraged from using the hospital as a means of controlling emotional tension, as the goal of treatment is to learn to manage the current emotional crisis in more effective ways.

DBT has gained considerable favor in the treatment of borderline disorder because of the results it has achieved in a number of controlled research studies, especially in reducing suicidal and self- injurious behaviors, and the frequency of acute hospitalizations. However, I know of no consistent scientific evidence that DBT is more effective in the treatment of other symptoms of borderline disorder than are other forms of psychotherapy .

In order to become a fully trained DBT therapist, participation is required in two five-day courses of training in DBT. Each year, an increasing number of therapists are receiving this “gold standard” of DBT training, but DBT therapists trained in this manner are not yet available in many communities. Attendance at a one or two day work shop on DBT does not qualify a person to be a DBT therapist. For the time being, the scarcity of properly trained DBT therapists limits the broad use of this effective treatment approach for those people with borderline disorder for whom it seems indicated.

Conceptually, in STEPPS borderline disorder is viewed as being a disorder of emotional and behavioral regulation, including perceptual disturbances such as all-or-nothing thinking (splitting). It was developed to address the major symptoms of the disorder, and to avoid the limitations of DBT and MBT (see below). DBT requires a greater time commitment (2 ½ hours per week of skills training for one year plus one hour with a DBT therapist trained by its developers compared to a 2 hour per week STEPPS classroom sessions over 20 weeks plus treatment with the current therapist. The therapist requirement of DBT results in separation of patients from their current therapists, if they are able to locate therapists trained in DBT. MBT has been utilized mainly as an 18 month, treatment intensive, partial hospitalization program. The developers of STEPPS point out that DBT and MBT are not readily accessible, labor intensive, time consuming and require substantial therapist training. STEPPS has been utilized in the US and in the Netherlands.

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be able to recognize your problems,
be committed to change these problems,
be able to control self-destructive behaviors under most circumstances,
be able to make an honest effort to abide by the terms of therapy initially set out with the therapist, and be willing to address and understand slips that do occur

Transference Focused Psychotherapy (TFP) is a specific form of psychodynamic psychotherapy that has been developed specifically for patients with borderline disorder. A distinguishing feature of TFP, in contrast to many other treatments for borderline disorder, is the belief that psychological disturbances in the structure of personality underlie the specific symptoms of the disorder. These disturbances divide individual’s perceptions into extremes of bad and good, a split that determines their way of experiencing themselves and others. In brief, it determines their experience of reality. Treatment in TFP initially focuses on setting up with the patient a behavioral agreement that deals with the likely threats that may occur in the course of the treatment, both to the treatment and to their well-being. Therapy then moves on to modifying primary psychological disturbances and reducing symptoms, mainly by examining, understanding and improving the patient’s interactions with the therapist.

Psychodynamic psychotherapy is not appropriate for all patients with borderline disorder. For example, some patients may not be able to tolerate the emotions raised in the process of therapy, be in sufficient control of their impulsive behaviors, or have the time or finances to devote to the process. Also, not all psychotherapists have the training, experience and skill to provide this type of therapy for patients with borderline disorder. These issues should be raised with the patient before such therapy is undertaken.

SFT was specifically developed for treating borderline disorder. Unlike the other types of therapy for this disorder, it offers a structured integration of the techniques of psychodynamic, supportive and cognitive behavioral therapies. SFT is based on the premise that people with borderline disorder have a more rigid personality structure, chronic psychological problems and deeply held but inaccurate belief systems than those without the disorder. Among the most difficult symptoms are the very rapid changes in mood from love to hate, and the total breadth and severity of all of the symptoms reported.

In an attempt to deal with these seemingly overwhelming challenges to therapy, SFT groups the behaviors into five modes, or schemas that the borderline patient "flips" through to attempt to cope with their difficulties. These five borderline modes are: 1) the abandoned and confused child; 2) the angry and impulsive child; 3) the detached protector; 4) the punitive parent; and 5) the healthy adult.

The four mechanisms of healing and change underlying treatment of borderline disorder with SFT are 1) "limited re-parenting" by the therapist; 2) emotion-focused work--especially imagery and dialogues; 3) cognitive restructuring and education; and 4) behavioral pattern breaking.

As is the case with all forms of psychotherapy for borderline disorder, the number of therapists specifically trained in SFT is very limited.

Mentalization-Based Therapy (MBT)

MBT was developed by Bateman and Fonagy as a specific treatment for borderline disorder. It is proposed that people with borderline disorder are limited in their ability to conceptualize (mentalize) and utilize their own and others' states of mind in important relationships, a condition that seriously interferes with their ability to develop healthy attachments. Briefly, this deficit is attributed to inherent dysfunctions in the brain’s attachment reward system. These dysfunctions may then be magnified by life experiences that are unsatisfying at their best, and physically and emotionally abusive at worst. Modern medicine is based on the premise that an improved understanding of basic human biology results in increased diagnostic precision and more specific and effective treatments. More than any other type of psychotherapy for borderline disorder, MBT is grounded in our current understanding of the neurobiological bases of the brain systems underlying the symptoms and behaviors that are characteristic of the disorder.

The clinical use of MBT is characterized as having four key features:

1) The therapist focuses exclusively on the patient’s current thoughts, feelings, wishes and desires;

2) The therapist avoids discussions that are not linked to subjectively felt reality, thus emphasizing more conscious information (the aim of therapy is not insight but increased mentalization);

3) The creation in therapy of a climate in which thoughts and feelings can be considered and “played with;” and

4) The enhanced understanding of the feelings and thoughts of situations prior to their enactments, not their unconscious meanings. The practice of MBT by therapists is enhanced by the availability of specific guidelines and other training materials in their book.

It is proposed that MBT may be closest to TFP in its orientation to mental states in the context of attachments. In support of this is the research finding that attachment-related mentalization (reflective capacity) improves in TFP, but not in DBT or SPP.

There is a consensus among experts, and recent evidence, that group therapy conducted by skilled therapists is effective in the treatment of patients with borderline disorder. The most commonly used types of group therapy in the treatment of borderline disorder are Interpersonal Group therapy, STEPPS and DBT skills training groups.

Typically, group therapy is utilized in addition to individual therapy. Group therapy is not intended to replace individual therapy for patients with borderline disorder. However, group therapy can serve to complement and to speed up the learning process of individual therapy. It is particularly reassuring for patients to meet other people with the disorder, to listen to their accounts of how the disorder has affected them, to share problems, and to attempt to help one another deal more effectively with these problems by recounting new strategies that have been attempted, and the results of these attempts.

Group therapy is especially suitable for those patients with borderline disorder who do not engage in serious destructive behaviors, who are able to tolerate the emotional content of the sessions, and who have difficulties with interpersonal relationships. In addition, it is essential that the group be lead by a therapist who is highly skilled in the use of this form of therapy in patients with borderline disorder. Otherwise, harm can be done to members of the group by a participant who is highly over emotional and impulsive.