Shared Elements Across Therapies for Suicidal Patients With BPD

The goal of this new column—Psychiatry and Psychotherapy, written by the Group for the Advancement of Psychiatry Committee on Psychotherapy—is to respond to the decreasing support for the teaching and provision of psychotherapy by psychiatrists. Psychiatric physicians are the sole members of medical and mental health care teams educated to make medical differential diagnoses, assume full responsibility for biopsychosocial patient care, and provide and supervise all aspects of psychiatric care, which must include psychotherapy as an integral element. On the most basic level, every patient encounter has an element of psychotherapy. On the most sophisticated level, specialized therapies are known to be effective, and psychiatrists trained in these can provide advanced therapeutic care.

In this first column on psychotherapy, we focus on our recent work as a “consensus panel” exploring “shared elements” or “common factors” for the treatment of suicidal patients with borderline personality disorder (BPD).

BPD is characterized by affect dysregulation, behavioral dyscontrol, interpersonal hypersensitivity, and identity diffusion, with self-destructive or suicidal behavior common. We have learned that BPD is found in 1.6 percent of the general population, 6 percent of primary care patients, and 10 percent of psychiatric outpatients and is associated with a lifetime suicide risk of 5 to 10 percent.

Although personality disorder diagnosis is often overlooked or “deferred,” the psychosocial burden of BPD is considerable. For example, comparing BPD and bipolar disorder, Zimmerman and colleagues reported in the April 2015 British Journal of Psychiatry that patients with BPD had more comorbidity, suicidal ideation and attempts, more substance use disorders, and poorer social functioning than bipolar patients. Further, as a comorbid condition, BPD “robustly predicts the persistence” of major depression and was associated with worse outcomes and greater suicide risk, according to Skodol and colleagues in the March 2011 American Journal of Psychiatry.

Although psychiatrists are now doing less therapy, the APA Practice Guideline for the Treatment of Patients With Borderline Personality Disorder notes that psychotherapy is the mainstay of treatment for BPD. Several evidence-based therapies for suicidal patients with BPD have emerged, including behavioral (Dialectical Behavior Therapy, or DBT; and Schema Therapy, or ST), psychodynamic therapies (Mentalization-Based Therapy, or MBT; and Transference-Focused Psychotherapy, or TFP), and a combined approach (Good Psychiatric Management, or GPM).

Two other therapeutic approaches lack randomized-trial evidence of efficacy: Cognitive Behavioral Therapy, or CBT, and the psychodynamic Alliance-Based Intervention for Suicide, or ABIS.

Behavioral therapies rectify deficits in skills needed to tolerate intense affects and correct distorted thinking, while psychodynamic therapies view suicide as a behavioral expression of conscious and unconscious mental processes driven by intense and unbearable affects.

Although most clinicians will be called upon to treat suicidal patients with BPD, few will master an evidence-based manualized treatment, leaving clinicians unprepared to provide optimal treatment for such patients and leaving patients with unmet treatment needs. Given this situation and with growing recognition that parity implementation should increase access to psychotherapy as research shows its effectiveness, in July 2015 the Institute of Medicine (IOM) published the report “Psychosocial Interventions for Mental and Substance Use Disorders: A Framework for Establishing Evidence-Based Standards” (Psychiatric News, August 7, 2015). The IOM report calls for research into specific and nonspecific “elements” (common factors) across schools of therapy that are associated with desired outcomes.

Sharing this perspective and using the available research, GAPCOP intensively reviewed behavioral and psychodynamic therapies for suicidal patients with BPD, extracted a list of six common factors, and then compared these with other comparable reviews including the Boston Suicide Study Group “candidate interventions,” Links’ “common principles,” and Bateman’s “common characteristics.” We found substantial areas of agreement, while using the limited areas of disagreement to add a seventh element to our list. Here we offer a single, integrated list of shared elements across treatments for suicidal BPD patients:

• Negotiate a clear frame for treatment.

• Recognize and insist on the patient’s responsibilities within the therapy.

• Work from a conceptual framework that guides therapist understanding and interventions. Use the therapeutic relationship to engage and address suicide actively and explicitly.

• Attend to the patient’s affect and connect it with his or her actions.

• Prioritize suicide as a topic in sessions.

• Provide support for therapist (for example, supervision).

This approach is consistent with the IOM’s interest in identifying nonspecific elements across therapies and offers a number of advantages, including (1) decreasing competition between schools of therapy, (2) allowing therapists from multiple schools to speak in a common voice to the larger field, (3) defining teachable skills for clinicians short of mastery of a manualized therapy, (4) providing introductory-level mastery that will lead some clinicians to pursue greater proficiency, and (5) improving outcomes in suicidal patients with BPD—including those for whom it is a comorbid condition that complicates treatment.

The members of the GAP Committee on Psychotherapy Expert Consensus Panel are William Sledge, M.D., Eric Plakun, M.D., Stephen Bauer, M.D., Beth Brodsky, M.D., Eve Caligor, M.D., Norman Clemens, M.D., Serina Deen, M.D., Jerald Kay, M.D., Susan Lazar, M.D., Lisa Mellman, M.D., Michael Myers, M.D., John Oldham, M.D., and Frank Yeomans, M.D. ■