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B. Review of Psychotherapy and Other Psychosocial Treatments

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1. Psychodynamic psychotherapy

Psychodynamic psychotherapy has been defined as a therapy that involves careful attention to the therapist-patient interaction with, when indicated, thoughtfully timed interpretation of transference and resistance embedded in a sophisticated appreciation of the therapist's contribution to the two-person field. Psychodynamic psychotherapy draws from three major theoretical perspectives: ego psychology, object relations, and self psychology. Most therapeutic approaches to patients with borderline personality disorder do not adhere strictly to only one of these theoretical frameworks. The approach of Stevenson and Meares (20, 138), for example, encompasses the self-psychological ideas of Kohut and the object relations ideas of Winnicott, whereas the technique of Kernberg et al. (4, 13, 28) is based on an amalgamation of ego psychology and object relations theory.

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a) Definition and goals

Psychodynamic psychotherapy is usually conceptualized as operating on an exploratory-supportive (also called expressive-supportive) continuum of interventions (Figure 2). At the more exploratory end of the continuum, the goals of psychodynamic psychotherapy with patients with borderline personality disorder are to make unconscious patterns more consciously available, to increase affect tolerance, to build a capacity to delay impulsive action, to provide insight into relationship problems, and to develop reflective functioning so that there is greater appreciation of internal motivation in self and others. From the standpoint of object relations theory, one major goal is to integrate split-off aspects of self and object representations so that the patient's perspective is more balanced (e.g., seeing others as simultaneously having both positive and negative qualities). From a self-psychological perspective, a major goal is to strengthen the self so that there is less fragmentation and a greater sense of cohesion or wholeness in the patient's self-experience. On the supportive end of the continuum, the goals involve strengthening of defenses, the shoring up of self-esteem, the validation of feelings, the internalization of the therapeutic relationship, and creation of a greater capacity to cope with disturbing feelings.

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Figure 2. The Exploratory-Supportive Intervention Continuum of Psychodynamic Psychotherapy.
Source. Adapted from Gabbard (139).

Of these interventions, only interpretation is unique to the psychodynamic approach. The more exploratory interventions (interpretation, confrontation, and clarification) may be focused on either transference or extratransference issues.

+ (i) Interpretation

Among the most exploratory forms of treatment, interpretation is regarded as the therapist's ultimate therapeutic tool. In its simplest form, interpretation involves making something conscious that was previously unconscious. An interpretation is an explanatory statement that links a feeling, thought, behavior, or symptom to its unconscious meaning or origin. For example, a therapist might make the following observation to a patient with borderline personality disorder: "I wonder if your tendency to undermine yourself when things are going better is a way to ensure that your treatment with me will continue."

+ (ii) Confrontation

This exploratory intervention addresses something the patient does not want to accept or identifies the patient's avoidance or minimization. A confrontation may be geared to clarifying how the patient's behavior affects others or reflects a denied or suppressed feeling. An example might be, "I think talking exclusively about your medication problems may be a way of avoiding any discussion with me about your painful feelings that make you feel suicidal."

+ (iii) Clarification

This intervention involves a reformulation or pulling together of the patient's verbalizations to convey a more coherent view of what is being communicated. A therapist might say, "It sounds like what you're saying is that in every relationship you have, no one seems to be adequately attuned to your needs."

+ (iv) Encouragement to elaborate

Closer to the center of the continuum are interventions that are characteristic of both supportive and exploratory therapies. Encouragement to elaborate may be broadly defined as a request for information about a topic brought up by the patient. Simple comments like "Tell me more about that" and "What do you mean when you say you feel 'empty'?" are examples of this intervention.

+ (v) Empathic validation

This intervention is a demonstration of the therapist's empathic attunement with the patient's internal state. This approach draws from self psychology, which emphasizes the value of empathy in strengthening the self. A typically validating comment is, "I can understand why you feel depressed about that," or, "It hurts when you're treated that way."

+ (vi) Advice and praise

This category includes two interventions that are linked by the fact that they both prescribe and reinforce certain activities. Advice involves direct suggestions to the patient regarding how to behave, while praise reinforces certain patient behaviors by expressing overt approval of them. An example of advice would be, "I don't think you should see that man again because you get beaten up every time you're with him." An example of praise would be, "I think you used excellent judgment in breaking off your relationship with that man."

+ (vii) Affirmation

This simple intervention involves succinct comments in support of the patient's comments or behaviors such as "Yes, I see what you mean" or "What a good idea."

Some patients with borderline personality disorder receive a highly exploratory or interpretive therapy that is focused on the transference relationship. This approach is sometimes called transference-focused psychotherapy (4, 140). Patients who lack good abstraction capacity and psychological mindedness may require a therapy that is primarily supportive, even though it is psychodynamically informed by a careful analysis of the patient's ego capacities, defenses, and weaknesses. Most psychotherapies involve both exploratory and supportive elements and include some, although not exclusive, focus on the transference. Hence, psychodynamic psychotherapy is often conceptualized as exploratory-supportive or expressive-supportive psychotherapy (16, 139, 141).

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b) Efficacy

While there is a great deal of clinical literature on psychodynamic psychotherapy with patients who have borderline personality disorder, there are relatively few methodologically rigorous efficacy studies. One randomized controlled trial assessed the efficacy of psychoanalytically informed partial hospitalization treatment, of which dynamic therapy was the primary modality (9). In this study, 44 patients were randomly assigned to either the partial hospitalization program or general psychiatric care. Treatment in the partial hospitalization program consisted of weekly individual psychoanalytic psychotherapy, three-times-a-week group psychoanalytic psychotherapy, weekly expressive therapy informed by psychodrama, weekly community meetings, monthly meetings with a case administrator, and monthly medication review by a resident. The control group received general psychiatric care consisting of regular psychiatric review with a senior psychiatrist twice a month, inpatient admission as appropriate, outpatient and community follow-up, and no formal psychotherapy. The average length of stay in the partial hospitalization program was 1.5 years. Relative to the control group, the completers of the partial hospitalization program showed significant improvement: self-mutilation decreased, the proportion of patients who attempted suicide decreased from 95% before treatment to 5% after treatment, and patients improved in terms of state and trait anxiety, depression, global symptoms, social adjustment, and interpersonal problems. In the last 6 months of the study, the number of inpatient episodes and duration of inpatient length of stay dramatically increased for the control subjects, whereas these utilization variables remained stable for subjects in the partial hospitalization group.

One can conclude from this study that patients with borderline personality disorder treated with this program for 18 months showed significant improvement in terms of both symptoms and functioning. Reduction of symptoms and suicidal acts occurred after the first 6 months of treatment, but the differences in frequency and duration of inpatient treatment emerged only during the last 6 months of treatment. In addition, depressive symptoms were significantly reduced. Although the principal treatment received by subjects in the partial hospitalization group was psychoanalytic individual and group therapy, one cannot definitively attribute this group's better outcome to the type of therapy received, since the overall community support and social network within which these therapies took place may have exerted significant effects. Pharmacotherapy received was similar in the two treatment groups, but subjects in the partial hospitalization program had a greater amount of psychotherapy than did the control subjects. In a subsequent report (10), patients who had received partial hospitalization treatment not only maintained their substantial gains at an 18-month follow-up evaluation but also showed statistically significant continued improvement on most measures, whereas the control group showed only limited change during the same period.

A study from Australia of twice-weekly psychodynamic therapy (20) prospectively compared the year before 12 months of psychodynamic therapy was given with the year after the therapy was received for a group of poorly functioning outpatients with borderline personality disorder. Among the 30 completers, there were significant reductions in violent behavior, use of illegal drugs, number of medical visits, self-harm, time away from work, severity of global symptoms, number of DSM-III symptoms of borderline personality disorder, number of hospital admissions, and time spent as an inpatient. Although this study did not include a control group, there were dramatic improvements in patients that support the value of the yearlong treatment intervention.

In another study (21), this same group of 30 patients who received psychodynamic therapy was compared with 30 control subjects drawn from an outpatient waiting list who then received treatment as usual, consisting of supportive therapy, cognitive therapy, and crisis intervention. The control subjects were assessed at baseline and at varying intervals, with an average follow-up duration of 17.1 months. In this nonrandomized controlled study, the group receiving psychodynamic therapy had a significantly better outcome than the control subjects (i.e., fewer subjects in the treatment versus the control group still met DSM-III criteria for borderline personality disorder), even though the group that received psychodynamic therapy was more severely ill at baseline. This study suggests that psychodynamic therapy is efficacious, but the investigation has a number of limitations, including the lack of randomization, different follow-up durations for different subjects, nonblind assessment of outcome, and lack of detail about the amount of treatment received by the control subjects. Without more data on the amount of treatment received, it is unclear whether the better outcome of the subjects who received dynamic therapy was due to the type of therapy or the greater amount of treatment received.

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c) Cost-effectiveness

The investigators of the Australian study also did a preliminary cost-benefit analysis (138) in which they compared the direct cost of treatment for the 12 months preceding psychodynamic therapy with the direct cost of treatment for the 12 months following this therapy. In Australian dollars, the cost of the treatment for all patients decreased from $684,346 to $41,424. Including psychotherapy in the cost of treatment, there was a total savings per patient of $8,431 per year. This cost-effectiveness was accounted for almost entirely by a decrease in the number of hospital days. Without a control group, however, one cannot definitively conclude that the cost savings were the result of the psychotherapy.

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d) Length and frequency of treatment

Most clinical reports of psychodynamic psychotherapy involving patients with borderline personality disorder refer to the treatment duration as "extended" or "long term." However, there are only limited data about how much therapy is adequate or optimal. In the aforementioned randomized controlled trial of psychoanalytically focused partial hospitalization treatment (9), the effect of psychotherapy on reducing hospitalization was not significant until after the patients had been in therapy for more than 12 months. There are no studies demonstrating that brief therapy or psychotherapy less than twice a week is helpful for patients with borderline personality disorder. Howard and colleagues (142), to study the psychotherapeutic dose-effect relationship, conducted a meta-analysis comprising 2,431 subjects from 15 patient groups spanning 30 years. One study they examined in detail involved a group of 151 patients evaluated by self-report and by chart review; 28 of these patients had a borderline personality disorder diagnosis. Whereas 50% of patients with anxiety or depression improved in 8–13 sessions, the same degree of improvement occurred after 13–26 sessions for "borderline psychotic" patients according to self-ratings (the same degree of improvement occurred after 26–52 sessions according to chart ratings by researchers [143]). Seventy-five percent of patients with borderline personality disorder had improved by 1 year (52 sessions) and 87%–95% by 2 years (104 sessions). While this study confirms the conventional wisdom that more therapy is needed for patients with borderline personality disorder than for patients with an axis I disorder, it is unclear whether raters were blind to diagnosis. It appears that a standardized diagnostic assessment and standard threshold for improvement were not used, there are no data on treatment dropouts, and little information is provided about the type of therapy or the therapists except that they were predominantly psychodynamically oriented. What can be concluded is that in a naturalistic setting outpatients who are clinically diagnosed as "borderline psychotic" will likely need more extended therapy than will depressed or anxious patients.

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e) Adverse effects

While no adverse effects were reported in the aforementioned studies, psychodynamic psychotherapy has the potential to disorganize some patients if the focus is too exploratory or if there is too much emphasis on transference without an adequately strong alliance. Intensive dynamic psychotherapy may also activate strong dependency wishes in the patient as transference wishes and feelings develop in the context of the treatment. It is the exploration of such dependency that is often essential to help the patient to achieve independence. This dependence may elicit countertransference problems in the therapist, which can lead to inappropriate or ineffective treatment. The most serious examples of this include unnecessary increases in the frequency or duration of treatment or transgression of professional boundaries.

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f) Implementation issues
+ (i) Difficulties with adherence

Most studies report a high dropout rate from dynamic psychotherapy among patients with borderline personality disorder. However, this is true for almost all approaches to the treatment of these patients, and it has not been demonstrated to be any higher for dynamic therapy. It does, however, emphasize the paramount importance of adequate attention to the therapeutic alliance as well as to transference and countertransference issues.

+ (ii) Need for therapist flexibility

Early in the treatment, and periodically in the later stages, a therapist who is also functioning as primary clinician may need to take a major role in management issues, including limit-setting, attending to suicidality, addressing pharmacotherapy, and helping to arrange hospitalization. A stance in which the therapist only explores the patient's internal experience and does not become involved in management of life issues may lead to adverse outcomes for some patients.

+ (iii) Importance of judicious transference interpretation

Excessive transference interpretation or confrontation early in treatment may increase the risk that the patient will drop out of therapy. One process study of psychoanalytic therapy with patients with borderline personality disorder (11) found that for some patients, transference interpretation is a "high-risk, high-gain" phenomenon in that it may improve the therapeutic alliance but also may cause substantial deterioration in that alliance. Therapists must use transference interpretation judiciously on the basis of their sense of the state of the alliance and the patient's capacity to hear and reflect on observations about the therapeutic relationship. A series of empathic and supportive comments often paves the way for an effective transference interpretation. Other patients may be able to use transference interpretation effectively without this much preparatory work.

+ (iv) Role of therapist training and competency

Psychodynamic therapy for patients with borderline personality disorder is uncommonly demanding. Consultation from an experienced colleague is highly recommended for all therapists during the course of the therapy. In some situations, personal psychotherapy can help the clinician develop skills to manage the intense transference/countertransference interactions that are characteristic of these treatments.

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2. Cognitive behavior therapy

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a) Definition and goals

Although cognitive behavior therapy has been widely used and described in the clinical literature, it has more often been used to treat axis I conditions (e.g., anxiety or depressive disorders) than personality disorders. Cognitive behavior therapy assumes that maladaptive and distorted beliefs and cognitive processes underlie symptoms and dysfunctional affect or behavior and that these beliefs are behaviorally reinforced. It generally involves attention to a set of dysfunctional automatic thoughts or deeply ingrained belief systems (often referred to as schemas), along with learning and practicing new, nonmaladaptive behaviors. Utilization of cognitive behavior methods in the treatment of the personality disorders has been described (19), but because persistent dysfunctional belief systems in patients with personality disorders are usually "structuralized" (i.e., built into the patient's usual cognitive organization), substantial time and effort are required to produce lasting change. Modifications of standard approaches (e.g., schema-focused cognitive therapy, complex cognitive therapy, or dialectical behavior therapy) are often recommended in treating certain features typical of the personality disorders. However, other than dialectical behavior therapy (17, 144–147), these modifications have not been studied.

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b) Efficacy

Most published reports of cognitive behavior treatment for patients with borderline personality disorder are uncontrolled clinical or single case studies. Recently, however, several controlled studies have been done, particularly of a form of cognitive behavior therapy called dialectical behavior therapy. Dialectical behavior therapy consists of approximately 1 year of manual-guided therapy (involving 1 hour of weekly individual therapy for 1 year and 2.5 hours of group skills training per week for either 6 or 12 months) along with a requirement for all therapists in a study or program to meet weekly as a group. Linehan and colleagues (8) reported a randomized controlled trial of dialectical behavior therapy involving patients with borderline personality disorder whose symptoms included "parasuicidal" behavior (defined as any intentional acute self-injurious behavior with or without suicide intent). Control subjects in this study received "treatment as usual" (defined as "alternative therapy referrals, usually by the original referral source, from which they could choose"). Of the 44 study completers, 22 received dialectical behavior therapy, and 22 received treatment as usual; patients were assessed at 4, 8, and 12 months. At pretreatment, 13 of the control subjects had been receiving individual psychotherapy, and 9 had not. Patients who received dialectical behavior therapy had less parasuicidal behavior, reduced medical risk due to parasuicidal acts, fewer hospital admissions, fewer psychiatric hospital days, and a greater capacity to stay with the same therapist than did the control subjects. Both groups improved with respect to depression, suicidal ideation, hopelessness, or reasons for living; there were no group differences on these variables. Because there were substantial dropout rates overall (30%) and the number of study completers in each group was small, it is unclear how generalizable these results are. Nonetheless, this study is a promising first report of a manualized regimen of cognitive behavior treatment for a specific type of patient with borderline personality disorder.

A second cohort of patients was subsequently studied; the same study design was used (148). In this report, there were 26 intent-to-treat patients (13 received dialectical behavior therapy, and 13 received treatment as usual). One patient who received dialectical behavior therapy committed suicide late in the study, and 3 patients receiving dialectical behavior therapy and 1 patient receiving treatment as usual dropped out. Nine of the 13 control patients were already receiving individual psychotherapy at the beginning of the study or entered such treatment during the study. Patients who received dialectical behavior therapy had greater reduction in trait anger and greater improvement in Global Assessment Scale scores.

One year after termination of their previously described study (8), the Linehan group reevaluated their patient group (5). After 1 year, the greater reduction in parasuicide rates and in severity of suicide attempts seen in the dialectical behavior therapy group relative to the control subjects did not persist, although there were significantly fewer psychiatric hospital days for the dialectical behavior therapy group during the follow-up year. These findings suggest that although dialectical behavior therapy produces a greater reduction in parasuicidal behavior than treatment as usual, the durability of this advantage is unclear.

In a subsequent report, Linehan and colleagues (149) compared dialectical behavior therapy with treatment as usual in patients with borderline personality disorder with drug dependence. Only 18 of the 28 intent-to-treat patients completed the study (7 who received dialectical behavior therapy and 11 given treatment as usual). Patients receiving dialectical behavior therapy had more drug- and alcohol-abstinent days after 4, 8, and 16 months. All patients had reduced parasuicidal behavior as well as state and trait anger; there was no difference between the groups. This study, too, involved small numbers of patients and had substantial dropout rates, but it represents an important attempt to evaluate the impact of dialectical behavior therapy with severely ill patients with borderline personality disorder and comorbid substance abuse.

In all of these studies, it is difficult to ascertain whether the improvement reported for patients receiving dialectical behavior therapy derived from specific ingredients of dialectical behavior therapy or whether nonspecific factors such as either the greater time spent with the patients or therapist bias contributed to the results. In a small study in which skills training alone was compared with a no-skills training control condition, no difference was found between the groups (unpublished 1993 study of M. M. Linehan and H. L. Heard). The researchers concluded that the specific features of individual dialectical behavior therapy are necessary for patients to show greater improvement than control groups. Linehan and Heard (150) reported that more time with therapists does not account for improved outcome. Nonetheless, other special features of dialectical behavior therapy, such as the requirement for all therapists to meet weekly as a group, could contribute to the results.

Springer et al. (151) used an inpatient group therapy version of dialectical behavior therapy for patients with personality disorders, 13 of whom had borderline personality disorder. The patients with borderline personality disorder exhibited improvement in depression, hopelessness, and suicidal ideation, but the improvement was not greater than it was for a control group. In this study, compared with control subjects, patients receiving the dialectical behavior therapy treatment showed a paradoxical increase in parasuicidal acting out during the brief hospitalization (average length of stay was 12.6 days).

Barley and colleagues (152) compared dialectical behavior therapy received by patients with borderline personality disorder on a specialized personality disorder inpatient unit with treatment as usual on a similar-sized inpatient unit. They found that the use of dialectical behavior therapy was associated with reduced parasuicidal behavior. It is unclear whether improvement was due to dialectical behavior therapy per se or to other elements of the specialized unit.

Perris (153) reported preliminary findings from a small uncontrolled, naturalistic follow-up study of 13 patients with borderline personality disorder who received cognitive behavior therapy similar to dialectical behavior therapy. Twelve patients were evaluated at a 2-year follow-up point, and all patients maintained the normalization of functioning that had been evident at the end of the study treatment.

Other controlled studies reported in the literature of cognitive behavior approaches are difficult to interpret because of small patient group sizes or because the studies focused on mixed types of personality disorders without specifying borderline cohorts (154–156).

In summary, there are a number of studies in the literature suggesting that cognitive behavior therapy approaches may be effective for patients with borderline personality disorder. Most of these studies involved dialectical behavior therapy and were carried out by Linehan and her group. Replication studies by other groups in other centers are needed to confirm the validity and generalizability of these findings.

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c) Cost-effectiveness

Published data are not available on the cost-effectiveness of cognitive behavior approaches for treatment of borderline personality disorder, although Linehan and colleagues (8) reported that patients receiving dialectical behavior therapy had fewer psychiatric inpatient days and psychiatric hospital admissions than did control subjects.

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d) Length and frequency of treatment

Short-term cognitive therapy involving 16–20 sessions has been described as a generic treatment approach; however, the patient characteristics thought to be necessary for a successful treatment outcome are not typical of patients with personality disorders (147). Instead, longer forms of treatment, such as "schema-focused cognitive therapy" (147), "complex cognitive therapy" (144), or dialectical behavior therapy (17), are usually recommended.

The standard length of dialectical behavior therapy is approximately 1 year for the most commonly administered phase of the treatment. It involves 1 hour of individual therapy per week, more than 2 hours of group skills training per week (for either 6 or 12 months), and 1 hour of group process for the therapists per week. Other versions of dialectical behavior therapy, such as that administered in a brief inpatient setting (151), may be useful but are not necessarily more effective than other forms of inpatient treatment.

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e) Adverse effects

Although there are no reports of adverse effects of cognitive behavior therapy, including dialectical behavior therapy, as administered on an outpatient basis, one inpatient study (151) reported a paradoxical increase in parasuicidal acting out in the dialectical behavior therapy group compared with the control group—a finding thought perhaps to be due to the contagion effect within a closed, intensive milieu.

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f) Implementation issues

Many components of cognitive behavior therapy are similar to elements of psychodynamic psychotherapy, although they may have different labels. For example, as Linehan (17) pointed out, focusing on "therapy-interfering behavior" is similar to the psychodynamic emphasis on transference behaviors. Similarly, the notion of validation resembles that of empathy. Beck and Freeman (19) noted that cognitive therapists and psychoanalysts have the common goal of identifying and modifying "core" personality disorder problems. However, psychodynamic therapists view these core problems as having important unconscious roots that are not available to the patient, whereas cognitive therapists view them as largely in the realm of awareness. It is not clear how successfully psychiatrists who have not been trained in cognitive behavior therapy can implement manual-based cognitive behavior approaches.

Although dialectical behavior therapy has been well described in the literature for many years, it is not clear how difficult it is to teach to new therapists in settings other than that where it was developed. Variable results in other settings could be due to a number of factors, such as less enthusiasm for the method among therapists, differences in therapist training in dialectical behavior therapy, and different patient populations. Although the Linehan group has developed training programs for therapists, certain characteristics recommended in dialectical behavior therapy (e.g., "a matter-of-fact, somewhat irreverent, and at times outrageous attitude about current and previous parasuicidal and other dysfunctional behaviors"[17]) may be more effective when carried out by therapists who are comfortable with this particular style.

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3. Group therapy

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a) Goals

The goals of group therapy are consistent with those of individual psychotherapy and include stabilization of the patient, management of impulsiveness and other symptoms, and examination and management of transference and countertransference reactions. Groups provide special opportunities for provision of additional social support, interpersonal learning, and diffusion of the intensity of transference issues through interaction with other group members and the therapists. In addition, the presence of other patients provides opportunities for patient-based limit-setting and for altruistic interactions in which patients can consolidate their gains in the process of helping others.

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b) Efficacy

Some uncontrolled studies suggest that group treatment (157), including process-focused groups in a therapeutic community setting (158), may be helpful for patients with borderline personality disorder. However, these studies had no true control condition, and the efficacy of the group treatment is unclear, given the complexity of the treatment received. Another small chart review study of an "incest group" for patients with borderline personality disorder (159) suggested shorter subsequent inpatient stays and fewer outpatient visits for treated patients than for control subjects. A randomized trial (160) involving patients with borderline personality disorder showed equivalent results with group versus individual dynamically oriented psychotherapy, but the small sample size and high dropout rate make the results inconclusive. Wilberg et al. (161) did a naturalistic follow-up study of two cohorts of patients with borderline personality disorder. This quasi-experimental, nonrandomized study showed that patients with borderline personality disorder discharged from a day program with continuing outpatient group therapy (N=12) did better than those who did not have group therapy (N=31). They had better global health and lower global severity index symptoms, lower Health-Sickness Rating Scale scores, lower SCL-90 scores, lower rehospitalization rates, fewer suicide attempts, and less substance abuse. There were, however, important differences between the two comparison groups that could account for outcome differences.

Perhaps the most interesting aspect of group therapy is the use of groups to consolidate and maintain improvement from the inpatient stay. Linehan and colleagues (8) combined individual and group therapy, making the specific effect of the group component unclear. They reported that, contrary to expectations, the addition of group skills training to individual dialectical behavior therapy did not improve clinical outcome. For those patients with borderline personality disorder who have experienced shame or have become isolated as a result of trauma, including those with comorbid PTSD, group therapy with others who have experienced trauma can be helpful. Such groups provide a milieu in which their current emotional reactions and self-defeating behaviors can be seen and understood. Groups may also provide a context in which patients may initiate healthy risk-taking in relationships. Group treatment has also been included in studies of psychodynamic psychotherapy; although the overall treatment program was effective, the effectiveness of the group therapy component is unknown (9, 162). Clinical wisdom indicates for many patients combined group and individual psychotherapy is more effective than either treatment alone.

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c) Cost-effectiveness

Group psychotherapy is substantially less expensive than individual therapy because of the favorable therapist-patient ratio. Marziali and Monroe-Blum (163) calculated that group psychotherapy for borderline personality disorder costs about one-sixth as much as individual psychotherapy, assuming that the fee for individual therapy is only slightly higher than that for group therapy. However, this potential saving is tempered by the fact that most treatment regimens for borderline personality disorder combine group interventions with individual therapy.

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d) Length and frequency of treatment

Groups generally meet once a week, although in inpatient settings sessions may occur daily. In some studies, groups are time-limited—for example, 12 weekly sessions—whereas in other studies they continue for a year or more.

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e) Adverse effects

Acute distress from exposure to emotionally arousing group issues has been reported. Other potential risks of treating patients with borderline personality disorder in group settings include shared resistance to therapeutic work, hostile or other destructive interactions among patients, intensification of transference problems, and symptom "contagion."

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f) Implementation issues

Groups take considerable effort to set up and require a group of patients with similar problems and willingness to participate in group treatment. Patients in group therapy must agree to confidentiality regarding the information shared by other patients and to clear guidelines regarding contact with other members outside the group setting. It is critical that there be no "secrets" and that all interactions among group members be discussed in the group, especially information regarding threats of harm to self or others.

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4. Couples therapy

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a) Goals

The usual goal of couples therapy is to stabilize and strengthen the relationship between the partners or to clarify the nonviability of the relationship. An alternative or additional goal for some is to educate and clarify for the spouse or partner of the patient with borderline personality disorder the process that is taking place within the relationship. Partners of patients with borderline personality disorder may struggle to accommodate the patient's alternating patterns of idealization and depreciation as well as other interpersonal behaviors. As a result, spouses may become dysphoric and self-doubting; they may also become overly attentive and exhibit reaction formation. The goal of treatment is to explore and change these maladaptive reactions and problematic interactions between partners.

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b) Efficacy

The literature on the effectiveness of couples therapy for patients with borderline personality disorder is limited to clinical experience and case reports. In some cases, the psychopathology and potential mutual interdependence of each partner may serve a homeostatic function (164–166). Improvement can occur in the relationship when there is recognition of the psychological deficits of both parties. The therapeutic task is to provide an environment in which each spouse can develop self-awareness within the context of the relationship.

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c) Adverse effects

One report (41) described an escalation of symptoms when traditional marital therapy was used with a couple who both were diagnosed with borderline personality disorder. Clinical experience would indicate the need for careful psychiatric evaluation of the spouse. When severe character pathology is present in both, the clinician will need to use a multidimensional approach, providing a holding environment for both partners while working toward individuation and intrapsychic growth. Because the spouse's own interpersonal needs or behavioral patterns may, however pathological, serve a homeostatic function within the marriage, couples therapy has the potential to further destabilize the relationship.

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d) Implementation issues

At times, it might be helpful for the primary clinician to meet with the spouse or partner and evaluate his or her strengths and weaknesses. It is important to recognize the contingencies of the extent of the partner's loyalty and his or her understanding of what can be expected from the patient with borderline personality disorder before recommending couples therapy. Couples therapy with patients with borderline personality disorder requires considerable understanding of borderline personality disorder and the attendant problems and compensations that such individuals bring to relationships.

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5. Family therapy

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a) Goals

Relationships in the families of patients with borderline personality disorder are often turbulent and chaotic. The goal of family therapy is to increase family members' understanding of borderline personality disorder, improve relationships between the patient and family members, and enhance the overall functioning of the family.

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b) Efficacy

The published literature on family therapy with patients with borderline personality disorder consists of case reports (167–170) and one published study (12) that found a psychoeducational approach could improve communication, diminish alienation and burden, and diminish conflicts over separation and independence. The clinical literature suggests that family therapy may be useful for some patients—in particular, those who are still dependent on or significantly involved with their families. Some clinicians report the efficacy of dynamically based therapy, whereas others support the efficacy of a psychoeducational approach in which the focus is on educating the family about the diagnosis, improving communication, diminishing hostility and guilt, and diminishing the burden of the illness.

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c) Adverse effects

Some clinicians report that traditional dynamically based family therapy has the potential to end prematurely and have a poor outcome, since patients may alienate their family members or leave the treatment themselves because they feel misunderstood (171) when family involvement is indicated. A psychoeducational approach appears to be less likely to have such adverse effects; however, even psychoeducational approaches can upset family members who wish to avoid knowledge about the illness or involvement in the family member's treatment.

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d) Implementation issues

Traditional dynamically based family therapy requires considerable training and sufficient experience with patients with borderline personality disorder to appreciate their problems and conflicts and to be judicious in the selection of appropriate families.

Figure 2. The Exploratory-Supportive Intervention Continuum of Psychodynamic Psychotherapy. Source. Adapted from Gabbard (139).

References

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