John Oldham, M.D., says that when treating patients with borderline
personality disorder, therapists need to pay attention to the treatment
alliance and sustain that alliance.
Credit: David Hathcox
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,
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
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
"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
"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
"That was an enlightened insurance company," Oldham said."
There aren't many of them."
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
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
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
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
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).
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>.▪