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.


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.

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).


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.


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.


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.


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.


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.

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


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