Psychotherapy of Borderline Patients: of similarities & differences in various approaches

Psychotherapy of Borderline Patients: ofsimilarities & differences in various approaches Michael H Stone, MD Professor of Clinical Psychiatry: Columbia

Major Psychotherapeutic Approaches • Psychodynamic//psychoanalytically informed • Cognitive-Behavioral (including approaches that are primarily cognitive; others, primarily behavioral; others – blending the two • Supportive

Some Branches of the Various Trees: (1) Psychodynamic Kernberg Akhtar Gunderson M Balint Searles Kohut Fonagy

Some Branches, cont’d:Cognitive-Behavioral Linehan LS Benjamin A Ryle Jeff Young Klerman/Weissman A Beck & A Freeman

Some Branches, cont’d:Supportive Arnold Winston Larry Rockland R Wallerstein Henry Pinsker

A Hierarchy Amalgam of all the elements below leading to a Healing/Therapeutic Self PSA CT Supp DBT ITP & other theories & modes of training Empathy, warmth, tolerance, intelligence, genuine conern, felexibility, calmness in the storm Unique personality of the therapist shaped by family, innate qualities, & culture

A comment on Interpersonal Theory Lorna Benjamin advocates a grid with 3 dimensions: 1.Focusing on the Other: attack v love or emancipate vs control the other 2. Focus on the self: recoil vs active love or separate vs submit 3. Introjective: self-attack vs self-love; or self-emancipation vs self control Intimacy//Affiliation Dominance Passivity Avoidance// withdrawal an earlier “Interpersonal Circle”

Benjamin’s schema for pathogensis of BPD • Chaos prevailed in the family; soap-opera lifestyle • Traumatic abandonment experiences. Abuse-laden aloneness becomes linked with the idea that the BPD Pt is a ‘bad person’. Unintegratable messages (daddy loves me; daddy says I’m a whore) predispose to numbing out (dissociation) • Autonomy is resented and depreciated; parent(s) may attack verbally//physically if Pt asserts separation & autonomy; Pt “protects” place within family via self-sabotage [= self-harm] viz., self-mutilation; this protects against the internalized abusers • BPD Pt learns that misery, debilitation, & sickness draw love & concern From L S Benjamin Interpersonal Diagnosis & Treatment of Personality Disorders. 2nd Edit. NY Guilford Press, 2003

Categories of Correct Therapist-response in Interpersonal Therapy • Facilitating Collaboration (rather than ‘enabling’ dependency-anger cycle by promising more than we can deliver); aim at strength-building; as in AA: give support if the first drink is resisted but not after it has been consumed (akin to, in DBT, talk on phone if Pt hasn’t yet cut herself; decline to talk if she has) • Facilitating Pattern Recognition • Blocking Maladaptive Patterns; validating Pt’s growing capacity for reality-testing [akin to DBT’s emphasis on validation] • Strengthening the Will to Give up Maladaptive Patterns: Pt can give up self-sabotage/suicidality if she can ‘divorce’ the internalized abusive attachment figures • Facilitating New Patterns

Some further comments on Interpersonal Psychotherapy Lorna Smith Benjamin drew attention to the earlier literature suggesting that the only approaches specific to the treatment of personality disorders that had proven to be effective – were the behavioral, the cognitive-behavioral, and the psychopharmacological. She regards that the efficacy claimed by proponents of these various techniques was probably overstated. Furthermore, because many of these techniques have been built around the idea of brief therapy (a number of weeks, a few months…), and because they focus on symptoms – rather than on relevant dynamic concepts like unconscious wishes & fears that organize one’s personality – the protocols used in these methods are inappropriate to the study of effective treatment of personality disorder Models that would be appropriate – require testable causal theory that is rationally linked to treatment interventions, therapy process, and outcome measures [preferably long-term outcome]. J Personality Dis 1997, 11: 307-324 Her criticisms and recommendations would seem all the more relevant to the study of BPD because of its severity, heterogeneity, and complexity.

Re: “Therapy-interfering Behaviors” in BPD Patients Allen makes the point [J Psychother Practical Research 1997, 6: 25-35] that successful management of patient behaviors that interfere with the process of psychotherapy is essential to treating BPD patients. Provocative patient-behaviors that induce a strong negative reaction in the therapist need to be attenuated. Kernberg in his Transference-Focused Psychotherapy advocates paying attention right from the beginning to the negative transference, and to setting appropriate limits vis-à-vis phone calls, requests for extra time or extra sessions etc. Patients with suicidal feelings are urged to present themselves to emergency units for necessary care, rather than to assume the therapist will always be there to rush to help… Linehan uses interventions that reward self-control (calling before one hurts oneself, so as to give the therapist a chance to help the patient not go forward with the action) and that discourage secondary gain – by not taking calls if the patient has already made a self-damaging act

Interpersonal Therapy: lines of influence Harry Stack Sullivan emphasized man as a social animal; he shifted the role of the psychiatrist to that of participant observer in the interpersonal field, noting also the impact of current life events on the patient’s psychopathoogy John Bowlby explored how children develop interpersonal attachments at first to mother, then to other care-givers; children develop either secure or insecure attachments. Frightening, inconstant, or unavailable care-givers will tend to produce insecure attachment, dependent or avoidant or dismissive patterns of interpersonal relationships, and certain personality disorders related to these abnormalities Klerman and Weissman (Basic Books, 1984), building on Sullivan & Bowlby, developed a therapy based on a medical model & a focus on interpersonal crises – treatable in the course of a time-limited, life-event related therapy

Usual length of Rx for BPD via ITP is 16 wks plus an additional 16 wks + 1 phone-call/wk Interpersonal Psychotherapy for BPD: John Markowitz’ recommendations ITP for BPD: takes into consideration that many BPD patients are chaotic, call frequently, threaten suicide, and are comorbid for mood- and anxiety disorders as well as substance abuse & eating disorders. They have impaired social & occupational function, and a suicide-tendency much higher than in the general population. Initial Phase: (about 3 sessions): therapist takes a careful, interpersonallly-focused history with dual-diagnostic aims (what Axis-I conditions are there?). One also works on developing a therapeutic alliance & a list of practical goals. Middle Phase: patient is helped to link a recent mood to an event or vice versa. If the event went well, the therapist offers praise; if not, sympathy - & asks “what else could you have done in that situation?” The focus is on social situations. There is no homework. Final Phase: Therapist bolsters patient’s sense of self-confidence and independence & excuses patient from unnecessary self-blame; a less intensive but longer-term therapy may be suggested, as needed.

Spectra related to Psychodynamic, Cognitive-Behavioral & Supportive Therapies for Borderlines PD Modified psychoanalytic Expressive-supportive Cognitive-analytic (A Ryle ’97) Self-psychological Supportive-expressive Cognitive/Behavioral With emphasis on skills- training Interpersonal (viz., Klerman/Weissman) Sup C-B

Some comments on Salman Akhtar’s psychoanalytic approach to BPD • Akhtar emphasizes that psychic reality of the BPD patient evolves in a 3-step process: • Experiencing & presenting disparate psychic states – without awareness of inherent contradictions • Observing , acknowledging & mending the splits involved in these contradictions • Developing a capacity for feeling & accepting paradox. The therapist’s holding [cf. Winnicott], unmasking, bridging, & depth-rendering interventions are what make the patient’s advance (to higher levels of psychic awareness & function) possible. (Int J Psa 1998 79: 241-252) Six tasks are outlined relevant to the analyst’s work: 1. Providing a holding environment, 2. Using affirmative interventions, 3. Helping to unmask fantasies & interpreting their defensive aspects, 4. Downplaying excessive hopes, 5. Reconstructing early patterns underlying these excessive needs/ hopes, & 6. Paying careful attention to countertransference feelings. J A Psa A 1996 44: 732-753

Akhtar’s distinction between Need & Wish A distinction that relates to people in general, as well as to our patients (borderline and other) concerns Need versus Wish. Needs (akin to older concepts of instinct and drive) are universal & not subject to either repression nor replacement via some other need. Wishes are “experience-bound” and can theoretically be replaced by different wishes. Whereas the frustration of a wish may lead to a dynamic shift, the frustration of a need can lead to structural disintegration. (parenthetically, we saw a horrific demonstration of the latter – in the New Orleans victims of Hurricane Katrina: suddenly deprived of food, water, shelter, basic protections, means of rescue or escape, family ties, etc – many experienced disintegration of personality & a push into a survival mode where “civility” became irrelevant). J A Psa A 1999. 47: 113-151

Akhtar’s Six Basic Psychological Needs • That one’s physical needs be deemed legitimate • For identity recognition & affirmation • For interpersonal & intrapsychic boundaries • To understand the causes of events that impinge on one • For optimal emotional availability of a love object • For the resilient responsiveness by one’s love object under special circumstances

Commonalities among the Psychodynamic Therapies • Focus on the “Here-and-Now” • Emphasis on well-defined structure • Encouragement of strong attachment-relationship between therapist & borderline patient • Therapists tend to be active rather than passive • Efforts are made to enhance compliance • Tendency toward long-term (> 1 or 2 yr) treatment • Exploration of thoughts & feelings related to events • Integration with meds & other services, as needed

Some Differences among the Psychodynamic Therapies Whereas most agree that formal psychoanalysis is contraindicated for BPD, because borderline patients tend to regress in very unstructured therapies, the more structured “modified” dynamic therapies are not all alike. Kernberg (whose “expressive therapy” is now called Transference-Focused Psychotherapy) advocates early confrontation of the negative transference in here-&-now situations – with the therapist referring to himself in speaking about the patient’s reactions. Gunderson agrees about the need to identify the aggressive motives that exist in the here-&-now “so as to make their inappropriateness visible and dystonic” [p 970 in Gabbard’s Synopsis of Treatment, 1996]. In hospitalized or otherwise quite ill BPD patients, Gunderson suggests that the early phase of therapy will have a more supportive cast, then moving on to a more exploratory mode later on. Kernberg strives to preserve a transference-focused mode from the beginning. Wallerstein (in the Menninger Study) noted that exploratory therapies tend to shift toward the supportive as time goes on – but good personality changes occur in that setting also.

Some Similarities in Results – with different methods Bateman & Fonagy (AJP 1999, p 1563) showed that in a randomized controlled study, BPD patients treated with psychoanalytically oriented therapy in partial hospitalized setting made fewer self-harm acts during the 18 month course (compared with the standard Rx group), noticeable already at 6 months, and more so at 12 & 18 month intervals Stevenson & Meares (AJP 1992) showed that 2x week dynamic therapy for BPD led within a year to reductions in impulsivity, affect instability, anger & suicidal behavior (with fewer self harm episodes). 9 of their 30 patients were no longer diagnosed ‘BPD’ Theirs was a ‘medium-term’ psychotherapy Clarkin et al (JPD 2001, p 487) showed that BPD patients began to show significantly fewer episodes of self-harm after about 8 months of 2x-weekly TFP Linehan et al (1993 AGP 50: 971) showed in their randomized trial that Dialectic Behav-ior therapy [DBT] proved superior to Treat-ment-as-Usual – in regard, e.g., to reduction in parasuicidal behavors during the 1 year of post-treatment follow-up; the DBT patients also showed higher GAS scores.

Further Comments on Suicidal thoughts & behaviors – in relation to treatment In the Personality Disorder Institute study, where 90 BPD patients were randomized into 3 groups: TFP, DBT, & Supportive – the scores for combined suicidal ideation & acts showed improvement (diminution) in both TFP & DBT, but not in the Supportive patients In a Finnish 3-yr follow-up study (Antikainen et al APScand 92: 327, 1995) depression & anxiety in 42 BPD patients (out of an orig. 62) declined at the end of hospitalization (of 1 to 10 months), but suicidal behavior did not show much change. In Ryle’s study of time-limited cognitive-analytic psychotherapy – of BPD patients from an inner-city population, 27 who completed the program could be divided 6 mos. later into 2 groups: those who were ‘improved’ – no longer met criteria for BPD; those with poorer out-comes had more severe features at the outset: self-cutting, alcohol abuse, & unemployment. Sabo & Gunderson (JNMD 183: 370, 1995) assessed 37 female BPD in-patients prospectively over 5 yrs.: suicidal behavior declined significantly; self-harm showed a trend toward decline; suicidal ideation did not decline notably. Zanarini (AJP 160: 274, 2003) found in 2-4-&-6 yr follow-up of 290 BPD patients that impulsive symptoms resolved most quickly; affective symptoms the most slowly.

BPD: Cognitive Therapyas recommended by Beck & Freeman The approach of Beck & Freeman focuses on the pathological “schemata” of patients with BPD (as well as with other PDs): mental structures with a highly personalized idiosyncratic content that are activated during disorders such as depression & anxiety – and at such times dominate and direct the person’s thoughts & activities. The schemata of personality disorders are opera-tive on a more continuous basis than those in the symptom-disorders. In their cognitive psychotherapy, the attempt is made via appeal to reason/ conscious thought/cognition – to undo the maladaptive schemata that have hitherto “ruled” the borderline patient. There is little focus on transference, dream analysis, early memories, etc – that figure so prominently in classical psychoanalysis and in the dynamic therapies. They agree with Linehan that in the early lives of BPD patients their parents & other significant figures – have often discounted their emotional experiences, in such a way as to foster self-doubt, self-disparagement, and an inability to tolerate strong emotion long enough to grieve significant losses. Inadequate skills for regulating emotion, impulsivity, & self-depreciation then lead to repeated crises along with a “need-fear” dilemma: a longing for attachment, yet a profound distrust of the reliability of love from others. Here are some typical BPD schemata>>>

Maladaptive Schemata in BPDBeck & Freeman: Cognitive Therapy of Personality Disorders 1990 Abandonment: “I’ll be alone forever: no one will be there for me” Unlovability: “no one would love me if they really got to know me” Dependence: “I can’t cope on my own: I need someone to rely on” Lack of individuation: “I must subjugate my desires to the desires of others” Mistrust: “People will take advantage of me; I must protect myself” Inadequate self-discipline: “I can’t seem to control myself” Fear of loss of emotional control: “something bad will happen if I don’t control myself” Guilt: “I’m a bad person. I deserve to be punished” Emotional deprivation: “No one is ever there to meet my needs, to care for me…”

Some differences & similarities in dynamic vs cognitive therapy Therapists of all schools draw attention to a pattern of thought in BPD patients characterized by adopting extreme positions – referred to by Beck & Freeman as “dichotomous thinking” and by Kernberg as “all-or-none” thinking, where self & others are (often alternatingly) pictured as “all good” of “all bad.” The phenomenon of transference is not much discussed as such – in behavioral or cognitive/ behavioral circles, yet the BPD patient’s reactions to the therapist will play an important role in cognitive therapy – and “may be problematical for therapists who are not used to dealing with strong, unprovoked emotional responses” from their patients [Beck&Freeman p193]. Thus, transference (& countertransference) are recognized in Cognitive Therapy, but do not form the primary basis for therapist-patient interaction. Linehan gives a beautiful illustration of a transference//countertransference response set in her 1993 book: a patient tried to convey that Dr L couldn’t appreciate how stressful her life was, and how she felt impelled to suicide, since Dr L was a successful professional – to which Dr L replied: “Oh, but I do understand: Imagine how stressful it is for me to have a patient constantly threatening to kill herself!” The terminology is different (unorthodox reframing), not the concept

Where similarities & differences blur – in the “different” approaches Though TFP therapists don’t assign ‘homework’ and engage in skills-training, and though CT/DBT therapists don’t work much with dreams or direct transference interpretations, and neither rely on pure intuition – in actual practice with BPD patients, it would not always be easy for someone secretly listening in to a session – to tell what the orientation of the therapist was. Linehan’s ‘paradoxical’ interventions aim at helping borderline patients see a middle ground where only extremes seemed to exist. Psychoanalysts try to accomplish this also. And Linehan works in a way reminiscent of Harold Searles, who relied mostly on an intuitive Gefuhl for his borderline patients. Kernberg will often use an appeal to reason (with its cognitive Gefuhl) in confronting a borderline patient about some glaring paradox to which the patient had hitherto been blind. Intuition Free associa- tion; Tx Cogni- tion

Some examples. 1. Searles once interviewed a young borderline woman of 20 at Psychiatric Institute. She sat very rigidly and “correctly” in her chair with her hands folded as if in church. She was quite pretty and spoke barely above a whisper. After some minutes of silence, Searles said – “sitting here next to you, I feel like a dirty old man !” He assumed that her posture of saintliness was a reaction to something important, and terrible – though he had no idea what. She then began for the first time to open up about the incest she experienced from her father & grandfather – about which she had never spoken to anyone, not even her therapist. She had been given up as a hopeless schizophren-ic at another hospital, where she received 89 shock treatments to no avail. She now began an upward course, that has led to her becoming a practicing psychologist, with a long & successful marriage, & two grown children (she is now 61). Searles’ intuition allowed him to dive underneath the surface and come up with a comment, delivered with whimsy and compassion, that freed this woman to open up. Fortunately, she also “clicked” with her new therapist, with whom she contin-ued to work for many years after he graduated & she left the hospital. When she graduated summa cum laude from the university, he shared a split of champagne with her – a supportive intervention in an otherwise transference-oriented therapy – that earned him a lot of criticism from his super-visor at the psychoanalytic institute. She has remained eternally grateful to these two unorthodox therapists, & recently wrote a letter of gratitude to Searles (now 85).

Some examples. 2. Some 30 years ago, Kernberg once interviewed a borderline woman in her mid 20s who regaled him with encomiums about the extraordinary goodness of her mother, whom she described as “tinky perfect” (tinky being perhaps a family-word to emphasize a point). Her mother, she went on to say, was of such saintliness as to retire after supper, locking herself in her bedroom so as to be undisturbed while reading the New Testament. Some minutes later, she said she would often cry herself to sleep during her childhood days, since no one ever read her a bedtime story. This led Kernberg to make a confrontation along the lines of: “You were telling me ten minutes ago about your mother’s earthly perfection & religious devotion – but just now, you spoke of how sad you were that she never took time out to read you a bedtime story. I wonder if this still seems to you like the actions of a perfect mother?” This was a very reasoned, cognitive appeal to the patient’s reason – and she did catch Kernberg’s meaning. She began to cry, and acknowledged that, viewed in this light, she could no longer give her mother a score of “100” This marked then beginning of her developing a more integrated & realistic view of her mother – as a kind of beatific bitch – a holy woman who neglected her daughter outrageously. And the patient became increasingly able to see her self as a basically good person, rather than as an ungrateful crybaby who made “unreasonable” demands on the “saint” in the locked bedroom.

Manual Labor All this brings up the issue of standardization of therapy for BPD patients. There are now published Manuals for TFP, DBT, Fonagy’s Mentalization-Based Psychotherapy for BPD, as well as lengthy structured guidelines for supportive therapy (by Winston), and the general-purpose APA Guideline for the Treatment of BPD, by Drs Oldham, Phillips, Soloff, Gabbard, Gunderson, Spiegel and myself. We are Manual Laborers these days, yet more than manual laborers… For optimal therapy devoted to any one approach, and especially for research purposes, the strict adherence to the manual one is using – represents an ideal approach. But the best and lengthiest manual is still a guideline – akin to Czerny’s piano exercises or a book about scales and octaves for piano students. There will be moments when the book does not cover some critical situation, and one finds oneself slithering over into a technique that belongs apparently to a different or “competing” approach. A bit of our humanity will always leak out around the edges of whatever technique we were schooled in, granted that it is absolutely necessary to BE grounded in one or another system for understanding the mind of another person, and for conducting oneself in a compassionate, empathic manner always within the bounds of profes-sional, ethical bounds. But, as I have said elsewhere, when a borderline patient starts to run toward the window, we grab him; when the seductive patient tries to plop herself in our lap, we gently push her off and ask what thoughts she was trying to express in that manner…

Beyond the Manual Dealing with BPD patients who are (a) also antisocial,and (b) whose antisociality takes the form primarily of lying – are scarcely covered adequately by any existing manual. This may be because one needs interventions that cut across any specific therapeutic modality – with the exception, perhaps, of Benjamin’s Interpersonal approach, that allows for anything that works. Patients who lie and are unscrupulous, if they are amenable to treatment of any sort at all – might respond to a combination of strong confrontation (such as might come more easily to a police officer than to a psychotherapist), behavioral techniques, and extensive recourse to collaterals: family members, friends, bosses – who know the things the patient is prone to do – that the patient would never tell spontaneously to the therapist. The therapist needs maximal flexibility, inventiveness, and an eclecticism that deviates pretty far from the interventions belonging to just one modality. A pertinent example: a borderline woman of 26 who was stalking her ex-boyfriend with hundred of phone-calls & emails – some written as if from some other person scolding him for treating his girlfriend so shabbily. I had access to her entire family and her ex-boyfriend so she could no longer fool me. What finally worked was “tough love” (on my part) & a few nights in jail (under the auspices of New York City).

Some differences between Beck & Freeman’s CT and Linehan’s DBT The treatment program embodied in Linehan’s DBT involves both individual and group therapy sessions (once/wk), along with a special way of handling requests for phone calls (which is not spelled out in CT, nor does CT emphasize concomitant group therapy for teaching behavioral coping skills. Supervision of the therapist(s) is not a regular feature in CT The individual sessions in DBT focus on a hierarchy of goals, dealing first with: suicidal behaviors … then behaviors that interfere with therapy… behaviors that interfere with the quality of life the acquisition of behavioral skills post-traumatic stress behaviors, and finally.. self-respect behaviors. A program for peer supervision/consultation for the therapists is built into the DBT program

Re: Efficacy of the Cognitive/Behavioral Therapies Long-term follow-up of BPD patients treated with Beck & Freeman’s CT is not available. The Ryle & Golynkina study mentioned before was based on a small N (27). The outcome measure of no longer meeting criteria for BPD was felt by Bateman & Fonagy to be less than optimal, since it could reflect to some extent the instability of diagnosis rather than a positive effect of the cognitive-analytic therapy. There is general agreement about the utility of DBT in diminishing the frequency of parasuicidal acts in BPD patients (Gunderson; Bateman & Fonagy) and also the retention rate (patients remaining in therapy) has been better with DBT than with TAU. But there are fewer data supporting the efficacy of DBT vis-à-vis reduction in depression, feelings of hopelessness, or in life-dissatisfaction – such that there is less evidence regarding the efficacy in relation to the underlying personality disorder, as distinct from the overlay of symptoms that almost invariably accompany BPD (a question raised by Bateman & Fonagy p 49 – that could presumably be answered by long-term [10 yr or more] follow-up of DBT-treated BPD patients)

Supportive Psychotherapy for BPD It is a safe assumption that fewer psychotherapists (world-wife) have training in psychoanalysis, in DBT or CT or in Ryle’s Cogn.-Analytic therapy, or in Self-psychology, etc etc – than in one form or another of Supportive Therapy. In addition, various supportive interventions form a part of the overall psychotherapy of many borderline patients, especially in the beginning phases, when severe symptoms dominate the clinical picture. If Limit-Setting is considered a supportive inter-vention (as Rocklans does) then at least that supportive intervention will play a role in all but the most well-functioning of borderline patients; i.e., those who barely make the cut in DSM. Winston et al [2004] make the point that when transference interpretation does not occur, the character-transforming (a la Valenstein’s “mutative”) factor is the patient’s capacity to form an identification with the more benign, accepting attitude of the therapist (Appelbaum & Levy 2002, Am J Psychoanal). This identification may permit gradual change from the harsh, punitive conscience [Super-Ego] the patient started out with – to one where the patient is more tolerant of the hateful//shameful attitudes toward self & other. Similarly, creating a sense of safety can help the BPD patient develop a more integrated sense of self & other in a context of reduced anxiety. Here are some typical interventions >>>

Supportive Interventions • Praise (if genuine & merited) • Reassurance (which must be honest, based on an understanding of the patient’s real situation • Encouragement; Exhortation • Rationalizing and Reframing (looking at something in a different, less harsh light, for ex.) • Advice and Teaching • Anticipatory Guidance//Rehearsal • Reducing & Preventing Anxiety; Strengthening Appropriate Defenses • Naming the Problem • Expanding the Patient’s Awareness (via clarification, confrontation, & some interpretation – as in dynamic therapy) • For BPD patients in particular: Limit Setting

The Red Thread Self-Psychology Therapy Dynamic Therapies Supportive Th Cognitive-Analytic Th. Cognitive-Behavioral Th. DBT Interpersonal Psychotherapy

The Skeins of the Red Thread Running through all the accepted psychotherapies for borderline patients is a “red thread” made up of such skeins as Setting Appropriate Limits//Preservation of the Therapy//Containment of Strong Affect// Helping the patient integrate disconnected (split) views of Self & Other Persons// Dealing with Symptoms// Fostering better coping skills, better ways of understanding and reacting to others// Maintaining proper professional boundaries// Recognizing one’s reactions (counter-transference) to the patient, and using these as indices of what the patient is not aware of or can’t acknowledge//Having the emotional strength not to be controlled by and fearful of the patient’s manipulative suicide gestures//Patience for a lengthy endeavor// Mastery of one “Manual” side by side with Flexibility//A forceful, honest, direct manner

Effectiveness of the therapies in different patient-populations There are several factors confounding the assessment of the various therapies for BPD as to their effectiveness. “BPD” with its polythetic definition in DSM describes an extremely heterogeneous patient-population. But any one study focuses on a particular sample, usually from one clinic or hospital – that gathers patients from a source (as to educational and economic and cultural backgrounds) that may be quite dissimilar to the source from which another sample was derived. The concomitant symptom-pictures also vary from sample to sample (the percent with substance abuse, eating disorder, depres-sion, self-harm, dissociative features,etc.). Levels of incest or physical abuse in childhood will not be comparable across samples. Only a few studies have been published or are about to be – using manualized ther-apies that measured compliance, and aimed at high adherence to the method used. Most follow-up studies, in contrast, have been naturalistic – dealing with BPD patients who, over the years, have been exposed to a variety of therapy-approaches.

Effectiveness…cont’d There are more short-term than long-term studies in the literature – and the former are of only limited value, because BPD patients take many years to improve substantially as to the personality (as opposed to the symptom-) aspects of their condition. If a BPD patient quits cutting herself after a year, but is still friendless and out of work 8 years later – what kind of “improvement” is that? A fair number of short-term (1 to 5 year) studies have shown that the clinical picture improves to the point where BPD is no longer diagnosible by DSM criteria – and that is encouraging. Yet one still wants to know how close to normal life the patients have approached ten or 15 years after the time they were first in treatment. And if they do show excellent recoveries – how much of that can be ascribed to DBT or TFP or CT or Supportive therapy per se, since very few will have been exposed over the years to just one, tightly-adherent methodology in all that time. Besides these complexities, there are the positive patient factors to which we hardly pay attention, since clinicians tend to focus on “pathology” in a largely “medical” model. We seldom measure positive qualities like perseverance, serenity, politeness, forgiveness, cooperativeness – all of which contribute to outcomes that my be more favorable than one would anticipate, if only the negative traits and symptoms were recorded.

More on Effectiveness Presumably, the long-range outcome in BPD is dependent upon the balance between the negative and the positive factors, both of which are numerous – and we seldom pay sufficient attention to the positive. Besides the positive personality traits – that may counteract the effects of the impulsivity, self-harm, storminess,etc. – there are also such matters as age and socioeconomic class. The task of the therapist is more difficult, if one begins with a 40-year old, than with a 20 year old patient, especially if many of those 40 years have been spent unproductively and with only meager social interaction. The lives of BPD patients who are very poor are often extremely chaotic and difficult to set straight: they lack resources for meeting the needs of everyday life; their intimate relationships may be tumultuous and marred by partner violence; their work skills may be very modest; they will usually be dependent upon a low-cost or free clinic for whatever care they can get – dispensed by overworked personnel whose training is not of the highest level. Their lives are often upset by weekly crises that make even getting to the clinic difficult. The therapeutic approach used in their treatment will usually be supportive; sometimes, DBT – but the unfavor-able life circumstances make hope of substantial improvement more a mirage than a reality.

Comparison of Effectiveness across different treatment modalities The Long-Term Follow-up studies of the 1980s were based on BPD in-patients & were of retrospective design, involving a naturalistic view; randomized assignment to different treatment modalities was not done, nor were there control groups. Still, there were some hints about comparative effectiveness. For instance: the Menninger Study written up by Wallerstein (Guilford Press 1986), based on 42 patients, showed that some showed as impressive improvements with what turned out to be a more supportive type of therapy –as did others with a more psychoanalytically oriented therapy (which was the therapy used at the outset in all the patients). Similar results emerged from the Chestnut Lodge study run by McGlashan and the Psychiatric Institute (“PI-500”) study that I carried out: major improvements in many BPD patients occurred not just with one modality, but with several: dynamic, supportive, & mixtures of the two. Since these were 10-25 or even 30 year follow-ups, few of the patients received just one consistent type of treatment over that long period. In the current randomized study of TFP, DBT & Supportive Rx at the PDI, however, more accurate comparison of certain variables can be made. We have been able to show that “reflective function” improves better with TFP & DBT>>

Change in RF as a Function of Time and Treatment

Effectiveness & Cognitive Style Patient: Intuitive, high moderately not very intro- rational/logical reflective function introspective spective limited access to feelings Primarily analytically DBT-trained trained in CT works best in oriented or interpersonal Th supportive mode Therapist Optimal therapist-patient fit might involve participants with similar “colors”; pairs with cognitive styles at opposite ends of the spectra might experience a less smooth-flowing therapy, with perhaps less good results.

Indications for one or another therapy Cognitive style is important as a factor influencing therapist-patient “fit” – but it is only one of many factors. Furthermore, a therapist with good flexibility, as emphasized by Judd & McGlashan (2003), can work well with a greater variety of patient-cognitive-styles than one who is uncomfortable with any modality other than the one that was learned when in training. There is reason to suppose that an experienced, empathic, dedicated therapist, whether trained in TFP, CT,DBT, IPT, MBT (mentalization-based), Supportive Th etc – can do good work with a majority of BPD patients, irrespective of their specific variations in cognitive style. One of the goals of the studies being carried out at the Personality Disorder Institute is to determine whether there are, nonetheless, certain BPD patients who would flourish with DBT but do poorly with the others, certain other patients who would flourish with TFP but not “click” with the other approaches, etc. It will take some time before convincing data are available to shed light on this question. That said, we do confront in our clinical work BPD patients whom we “feel” (rightly or wrongly) that they would be “ideal” for one specific approach, be it DBT, TFP, or whatever.

The Drop-out Rate among BPD patients Some years ago Gunderson and his colleagues at McLean Hosp surveyed a number of therapists who had wide experience in treating BPD patients, questioning them as to the rate of drop-out (premature quitting). The percentages converged around a figure of 40% [Waldinger & Gunder-son Am J Psychother 1984]. This figure highlights the tenuousness of the attachment in many BPD patients, as they embark on an odyssey from one therapist to another in quest of the “perfect” one. BPD patients tend to search for the therapist who will BE the person (ideal mother, ideal father…) that was missing in their life. They are less eager to find a therapist who wants (more realistically) to help them understand WHY they felt, so ardently, that they needed to actualize such a wish. The 40% figure (which accords with my experience also) obscures the fact that many BPD patients eventually find the “ideal” therapist (with whom they remain in treatment as long as needed) – and begin to improve dramatically with the 3rd, or the 5th, or the 8th therapist (such as Stanley Heller’s patient at Psychiatric Inst mentioned earlier: the one who is now a psychologist) The 40% figure reflects experience with analytically oriented therapists; less is known in this regard for the other modalities. But the overall improvement-rate in BPD (which in many studies is nearer 60% or more) means that the 40% drop-out does not mean 40% failure.

Attachment Style & Drop-out Rate Hi mod Lo Secure Entangled Dismissive Depr/masoch histrionic paranoid narcissistic antisocial dependent obsessive schizotypal explosive/irritable psychopathic

About mechanisms of change Interventions inInterpersonal therapy that help produce positive changes include: exploring parallels in other relationships, exploring relationship patterns, providing support, signaling what is significant, exploring affect, problem-solving, drawing analogies, challenging (unrealistic or paradoxical assumptions) [Crowe & Luty: Psychiatry 68: 43, 2005]. Benjamin also mentions the therapist’s affirmation of adaptive statement by the patient [Karpiak & Benjamin J Clin Psychol 60: 659, 2004]. Anything that leads to collaboration, learning about patterns, mobilizing will, blocking maladaptive patterns & teaching new patterns is legitimate In the dynamic therapies the focus is on resolving conflicts often centering on a pair of opposite wishes – one conscious and accepted, the other unconscious and repudiated. A common pair in female BPD patients is the outward wish to be close to an intimate partner and the unconscious wish to punish and avenge – for wrongs inflicted by one or another parent. Exploring and understanding the here-and-now conflicts is more important in BPD than focusing on early life. Working with transference & countertransference to bring to the surface the distorted object relations is a key mechanism, that is then followed by attempts to integrate the ‘splits’ so as to achieve unity, acceptance, more mature object relations, and more effective coping strategies

Mechanisms of change, cont’d In cognitive-behavioral approaches change occurs to the extent that the patient can be helped to realize more fully the underlying core beliefs that get activated by stressful life events, since it is a cornerstone of CBT that how one experiences and reacts to the environment is shaped by cognitive processes. Therapy is directed at the “automatic” thoughts based on core beliefs and negative schemata. Patients are encour-aged to formulate problem lists detailing their difficulties and complaints, including the dysfunctional thoughts responsible for the maladaptive behavior & disturbed mood. Therapy aims at correcting unreal-istic negative assumptions. Self-depreciation, e.g., leads to hypersensitivity to criticism and rage at the “critics.” By aiming at correcting the negative assumption, these maladaptive reactions can diminish DBT, in particular, employs as mechanisms of change – skills training, problem solving and homework (which address the conscious-cognitive aspects of the patient’s mind, in contrast to working on the “exhumation” of unconscious conflicts & their resolution. But DBT also utilizes the technique of validation, which is of particular importance & relevance to BPD, since so many borderline patients have been humiliated, lied to, abused, and have had their perceptions denied or turned upside down – and therefore need an objective observer agree that what really happened to them – really happened!

similarity & contrast between Fonagy’s Mentalization & Linehan’s Mindfulness as media of clinical change • Mentalization & Mindfulness • The skills of Mindfulness are intrapsychic, psychological and behavioral versions of meditation (as in Zen) • A balance is sought between the Reasonable Mind, the Emotional Mind – via the growth of the Wise Mind. • The Wise Mind, representing an integration of the other two faculties, leads to greater synthesis and stability. • DBT emphasizes “mindfulness” as a special skill – whereas Bateman & Fonagy see its counterpart -- “mentalization” as a high-level mental function taking place largely outside consciousness, first in the therapist, who is presumably better integrated than the patient; later on, in the patient. Valenstein used to speak of the necessary gradient in maturity between therapist and patient, without which there would be no way for the patient to grow toward the level of the therapist . [ Note the semantic similarity between the language of DBT here and that of the psychoana-lytic language – speaking of “Id” (emotional mind) and “Ego” (reasonable mind – and, if therapy succeeds – Wise Mind]

Mechanisms of change: supportive therapy Citing Appelbaum [AmJ Psa 62: 201, ’02], Winston states that Supportive Th strives to establish in the BPD patient an arousal level optimal for learning via factors akin to successful parenting – using reassurance, encouragement, teaching, exhortation, support, validation, and strengthening of adaptive defenses. By creating a sense of safety, via the therapist’s openness, compassion, acceptance – the patient begins to develop a more integrated sense of self & of other persons, within the context of reduced anxiety [[goals similar to those of TFP, but achieved via a different road]]. The effort is also made to avoid regression –which might otherwise aggravate the very problems the therapist was at pains to correct. Winston points to the presence of certain supportive elements as mechanisms of change – employed by DBT (use of mindfulness exercises, teaching how to gain distance from overwhelming distress, etc

Psychotherapy of Borderline Patients: of similarities & differences in various approaches