PSYCHOTHERAPY IN THE THREE PHASE MODEL OF TREATMENT
Psychological and behavioral symptoms are the major manifestations of borderline disorder. They cause serious emotional pain and significantly disrupt the normal development of effective behavior and important relationships. Therefore, it is critical that you have a safe, supportive, and effective relationship with a therapist who is able to help you learn about your illness, how it affects you, and how to make those changes that will enable you to gain the best control possible over your emotions, impulsive behaviors, thought patterns, and relationships. An experienced therapist skilled in the treatment of borderline disorder fulfills these needs as well as other roles.
Types of Psychotherapy for Borderline Disorder
There are six types of psychotherapy for borderline disorder that have replicated, research evidence of effectiveness.
- Dialectical Behavior Therapy (DBT)
- Mentalization-Based Therapy (MBT)
- Transference Focused Psychotherapy (TFP)
- Schema-Focused Therapy (SFT)
- General Psychiatric Management (GPM)
- Systems Training for Emotional Predictability and Problem Solving (STEPPS; Group)
Naturally, you may think that your main task is to determine which is the best form of therapy for you. This is rarely the case. It is to find a therapist in your vicinity who is skilled in any of these treatments. This is so because there is a significant gap between the increasing demand for psychiatrists and therapists skilled in the treatment of borderline disorder and their availability.
Fortunately, the field is now gradually moving in a direction that will simplify this problem to some degree. For example, there is growing evidence that most forms of psychotherapy for borderline disorder share common characteristics that are responsible for their therapeutic effects.28,31-33 Livesley also suggests that specific interventions then be used that are best tailored to the needs of the individual patient as therapy progresses,28 a position not supported by Bateman.33 At this time, it seems best to obtain therapy from a therapist who is available, skilled in any form of borderline disorder-specific therapy, and appears to meet as many of the other criteria as possible that are described elsewhere on this web site.
It may be helpful for you to understand clearly the changes in emphasis that occur in therapy as your treatment progresses. The Three Phase Model of Treatment may help you do so. The objectives of therapy in each of the Phases are:
In Phase 1, psychotherapy complements the main objective of achieving optimal medication management of your most distressing symptoms and is directed at the general features of borderline disorder. Therefore, the primary objectives of therapy in this Phase are:
- develop a clearly defined understanding with your therapist about: a) your mutual responsibilities in therapy; and b) enhancing the quality of collaboration
- improve your safety and that of others;
- minimize any threat to medication compliance and regular participation in therapy;
- decrease impulsive and harmful behaviors that are self-injurious;
- diagnose and treat promptly all co-occurring disorders, especially substance use disorders and major depressive eisodes;
- improve basic self-care e.g., eating, sleep, grooming and routine activities of daily living;
- focus on enhancing and the validation of feelings; and
- increase motivation
Psychotherapy becomes the main focus of your treatment in Phase 2. Medications are continued. Therapy shifts gradually to objectives and methods of therapy from those that are common to all BPD-specific therapies to those that address your specific symptoms and level of functioning.28 For example, the objectives may include many of the following:
- continue to validate feelings; enhance your recognition of them and their management by engaging in appropriate changes in attitude and behavior;
- continue to enhance your safety and that of others by developing effective alternative behavioral methods for dealing with problems;
- continue to decrease impulsive and harmful behaviors, especially those that are self-injurious and suicidal;
- identify, then modify inaccurate perceptions and thought patterns, such as split-thinking;
- enhance interpersonal skills and the quality of your relationships;
- enhance self-esteem and improve your general level of functioning;
- learn new skills sufficiently well to utilize them routinely
As described below, specific short-term and long-term objectives and methods of borderline disorder-specific psychotherapies vary from one type of therapy to another. Ideally, your therapist will be able to move easily from the strategies of one method to another in accordance with your needs as you understand yourself better and develop new strengths during the course of therapy.
The critical objective of Phase 3 is that you learn your new skills so well that you are able to do so most of the time without your therapist and with a minimal amount of medications. When this objective is achieved, you probably will require only occasional visits with your therapist and psychiatrist in order to deal with particularly difficult situations that may arise.
Summaries of Commonly Used Forms of Psychotherapy for Borderline Disorder
If you locate a therapist who is in your locality and experienced in one of the forms of BPD-specific psychotherapy, it will be helpful for you to know something about that specifcic approach. The following are brief descriptions of some of the most frequently used types of psychotherapy developed for the treatment of patients with borderline disorder. First, however, it worth mentioning individual supportive psychotherapy.
Individual supportive psychotherapy, not specifically adapted for borderline disorder, may be the most common form of psychotherapy used for patients with borderline disorder. This is so because this type of therapy is more familiar to therapists than those types of therapy developed specifically for borderline disorder. Note that supportive psychotherapy does not necessarily mean the same thing to and is not performed in the same way by every therapist.
1. Dialectical Behavior Therapy (DBT)
Dialectical behavior therapy is a modification of Cognitive Behavioral Therapy. It was developed by Marsha Linehan initially for patients with borderline disorder, especially those who engage in frequent self-destructive and self-injurious behaviors.34 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.
The primary behavioral targets of DBT are:
- decreasing suicidal behaviors,
- decreasing those behaviors that interfere with therapy and the quality of life,
- increasing behavioral skills,
- and decreasing behaviors related to post traumatic stress
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 attention 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. Although very popular, there is no consistent scientific evidence that DBT is more effective in the treatment of the 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. As with other BPD-specific therapies, in most communities, the scarcity of properly trained DBT therapists limits the broad use of this effective treatment approach for those people with borderline disorder.
2. Mentalization-Based Therapy (MBT)
MBT was developed by Bateman and Fonagy as a specific treatment for borderline disorder.35
The clinical use of MBT is characterized as having four key features:
- The therapist focuses exclusively on the patient’s current thoughts, feelings, wishes and desires;
- 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);
- The creation in therapy of a climate in which thoughts and feelings can be considered and “played with;” and
- 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 Bateman and Fonagy’s book.33
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.
3. Transference Focused Psychotherapy (TFP)
TFP is a specific form of psychodynamic psychotherapy that has been developed Otto Kernberg and his colleagues John Clarkin and Frank Yeomans specifically for patients with borderline disorder.36 A distinguishing feature of TFP, in contrast to many other treatments for borderline disorder, is the belief that psychological disturbances in the basic form or 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 your establishing with the therapist a behavioral agreement that deals with the likely threats that may occur in the course of the treatment, both to the treatment and to your well-being. Therapy then moves on to modify primary psychological disturbances and reduce symptoms, mainly by examining, understanding and improving your interactions with your therapist.
Psychodynamic psychotherapy of this type is not appropriate for all patients with borderline disorder. For example, some patients may not be able to tolerate the interpersonal 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 therapist before TFP is undertaken.
4. Schema-Focused Therapy (SFT)
Schema-focused psychotherapy was specifically developed Kellogg and Young for treating borderline disorder.37 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.
5. General Psychiatric Management (GPM)
General Psychiatric Management is a comprehensive, integrated and highly structured approach to the treatment of borderline disorder that is based on the APA Practice Guideline for the Treatment of Patients With Borderline Personality Disorder. 30 It is a coherent, high standard out patient treatment model that includes case management, symptom-targeted medication management prioritized to the treatment of mood lability, impulsivity, and aggressiveness according to the APA Guideline, and psychodynamic psychotherapy. 38 It appears to be effective as DBT when used by psychiatrists and other therapists with some experience and interest in the treatment of borderline disorder.
6. Systems Training for Emotional Predictability and Problem Solving (STEPPS)
STEPPS is a group outpatient treatment program developed in 1995 by Nancee Blum to supplement, but not replace, other treatment(s) such as individual psychotherapy and medications for patients with borderline disorder.39 The stated goals of STEPPS are to:
- “be fully manualized
- be easily taught and implemented in a variety of settings
- provide specific content/method for each session
- utilize a support system already in place
- be ‘value-added’”
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, are labor intensive, time consuming and require substantial therapist training. STEPPS has been utilized in the US and in the Netherlands.
6. Group Therapy
There is a consensus among experts, and recent evidence,40 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 led 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.