Successful BPD Therapies Focus on Clinician-Patient Relationship

An expanding body of evidence indicates that a variety of psychotherapies for patients with borderline personality disorder (BPD) are effective. But convincing insurance companies and other payers of the effectiveness of psychotherapy is challenging because all of the psychotherapies are lengthy, said John Oldham, M.D.

He served as discussant at the symposium “Comparison of Three Therapies for BPD” at APA's 2008 annual meeting in May in Washington, D.C.

Moreover, since BPD represents a constellation of symptoms, with individual patients meeting different criteria for the disorder, the challenge for clinicians is to fit the individual patient to a specific psychotherapy that meets his or her unique challenges.

Oldham made his comments following presentations on mentalization-based therapy (MBT), dynamic deconstructive psychotherapy (DDP), and transference-focused therapy (TFP). He is senior vice president and chief of staff at the Menninger Clinic and professor and executive vice chair of the Menninger Department of Psychiatry and Behavioral Sciences at Baylor College of Medicine.

The three therapies focus on the relationship between the therapist and patient and on sustaining that alliance over a period of time in the face of the problems that BPD patients typically have with interpersonal relationships.

“One of the most important things that needs to happen [in therapy] regardless of the nature of the treatment is to pay attention to the treatment alliance and to sustain that alliance,” Oldham said. “That can be hard to do in part because frequently [health care payers] disallow treatment plans that support that kind of need. So the more evidence we have, the better.

“I think our biggest challenge is to figure out how to get that word out there to the people who pay for treatment so that they understand that it is cost-effective in the end to pay for treatment that lasts long enough for therapy [to work], because we know that it does.”

Oldham cited one insurance company in his region that indicated it was willing to pay for six weeks of inpatient therapy for a patient with BPD. The company “called and said, 'We have figured out we are breaking the bank on this patient, paying over and over again for all the things that aren't working.'

“That was an enlightened insurance company,” Oldham said.“ There aren't many of them.”

Therapies Focus on Treatment Alliance

At the symposium, Anthony Bateman, M.A., presented information about the use of MBT. It is a manualized psychotherapy based on attachment theory and on observations that BPD patients have a failure of“ mentalization”—the ability to observe their own emotions and those of other people and to appreciate how their behavior may affect others.

A report appearing in the May American Journal of Psychiatry showed that eight years after the beginning of treatment and five years after discharge, patients with BPD treated with mentalization-based therapy during partial hospitalization followed by maintenance mentalizing group therapy showed clinical and statistical improvement on a range of measures compared with patients receiving treatment as usual (Psychiatric News, April 18).

Robert Gregory, M.D., an associate professor of psychiatry and behavioral sciences at the State University of New York Upstate Medical University, described DDP. It is based on the hypothesis that borderline pathology and related behaviors reflect impairment in specific neurocognitive functions that form the basis for a coherent sense of self.

Gregory said that because of these neurocognitive deficits, BPD patients typically reduce interpersonal relationships to polarizing binary states such as helpless victim versus guilty perpetrator or angry victim versus demigod perpetrator. The therapy seeks strategies to “deconstruct” each state and facilitate the development of new ways to think about relationships.

The therapy is described in “A Manual-Based Psychodynamic Therapy for Treatment-Resistant Borderline Personality Disorder” in the March 1 Psychotherapy: Theory, Research, Practice, Training.

John Clarkin, Ph.D., discussed TFP. He is codirector of the Personality Disorder Institute at New York Presbyterian Hospital and a clinical professor of psychology in psychiatry at Weill Medical College and Graduate School of Medical Sciences of Cornell University.

Clarkin said that the therapy focuses on the current behavior and experience of the patient both during and outside of therapy, interpreted in the context of the patient's transferential relationship with the therapist.

A report in the June 2007 American Journal of Psychiatry found that patients receiving TFP, dialectical-based therapy, and supportive therapy all showed significant positive change in depression, anxiety, global functioning, and social adjustment across one year of treatment, but that only TFP was effective in resolving specific symptoms (Psychiatric News, June 1, 2007).

No Such Thing as the 'Answer' to BPD

In discussing the three approaches, Oldham noted that despite differences in nuance, all three therapies share common elements—especially a focus on the present and on current challenges and experience, as opposed to exploring past and childhood origins of problems. And all of them emphasize the maintenance of an alliance between patient and therapist and the exploration and resolution of problems in that relationship.

He cautioned against crowning any one therapeutic approach as the“ answer” to managing BPD.

“Sometimes inadvertently there develops a cult or religious flavor” around a particular favored therapy, he said. “We get bands of followers, and that translates into a belief that the treatment is the one therapy for BPD. And that is never going to be the case.”

He noted that the DSM criteria for BPD describe patients who meet five of nine possible criteria, in any combination. “If you do the math, that means there are 256 different types of BPD,” he said. “Often we talk about BPD as if it is one thing, and it just isn't. It's a family or a constellation of disorders.

“So we really have a range of types of patients,” Oldham said.“ We have a need for many different types of approaches.”

“Eight-Year Follow-Up of Patients Treated for Borderline Personality Disorder: Mentalization-Based Treatment Versus Treatment as Usual” is posted at<http://ajp.psychiatryonline.org/cgi/content/full/165/5/631>.“ A Manual-Based Psychodynamic Therapy for Treatment-Resistant Borderline Personality Disorder” is posted at<http://psycnet.apa.org/index.cfm?fa=search.displayRecord&uid=2008-02963-002>.“ Evaluating Three Treatments for Borderline Personality Disorder: A Multiwave Study” is posted at<http://ajp.psychiatryonline.org/cgi/content/full/164/6/922>.▪