Gabbard Weds Neurobiology Psychodynamics in BPD Treatment

"You have become just like my parents," the young woman announced. "You are acting like a cop trying to police what I do instead of understanding me."

It was a startling statement from a patient who was habitually cutting herself—a dangerous behavior not uncommon in someone with borderline personality disorder (BPD)—and the young psychiatrist, early in his career, had only expressed what might be considered a normal concern for her safety.

"Her harming herself made me feel like I was failing in my treatment of her," recalled Glen Gabbard, M.D. "I was becoming increasingly frustrated and controlling, wanting to somehow force her to stop cutting herself."

Credit: Ellen Dallager

For Gabbard, it was a striking lesson in the importance of transference and countertransference, the powerful feelings that develop over time between patient and therapist, reflective of a BPD patient's sometimes troubled pattern of relating to early parental figures and to people generally.

Later in his career, Gabbard would become involved in a study of long-term psychodynamic psychotherapy in which he and colleagues at the Menninger Clinic attempted to measure, using audiotape recordings, how the therapeutic alliance improved or deteriorated as a function of what the therapist said or did.

In a paper titled "Transference Interpretation in the Psychotherapy of Borderline Patients: A High-Risk, High-Gain Phenomenon" in the Harvard Review of Psychiatry in 1994, Gabbard and colleagues revealed a remarkable finding: that transference interpretations tended to have a greater impact—both positive and negative—than other interventions made with patients with BPD.

The interpretation can be therapeutically beneficial or disastrous—hence, "high-risk, high-gain"—depending on the timing and the sensitivity of the therapist's approach. "What we concluded is that it is very important for the therapist to pave the way for the interpretation with empathic, supportive comments that make the patient feel understood, valued, and cared about," he told Psychiatric News. "Just as a surgeon needs anesthesia to operate, so a therapist needs a therapeutic alliance to be able to interpret something going on in the relationship."

Otherwise the patient may feel attacked—not unlike the self-harming patient of Gabbard's early training. "But if there is a sense that the patient is feeling validated and understood, over time the therapist may be able to say ‘I can appreciate that having grown up with a critical father, you might be very likely to hear me as critical.’"

Knack for Building an Alliance

Gabbard's remarks reflect a career-long interest in the value of psychodynamic psychotherapy—and the psychoanalytic principles of transference and countertransference—in the treatment not only of BPD, but of psychiatric illness in general. A familiar speaker at APA meetings and one of the most recognized figures in American psychiatry, Gabbard has excelled in uniting psychodynamic and psychoanalytic insights with the most up-to-date findings in genetics and neurobiology.

Today, he is the Brown Foundation Chair of Psychoanalysis and Professor of Psychiatry at Baylor College of Medicine and director of the Baylor Psychiatry Clinic.

He credits his interest in BPD in part to his early exposure as a resident and later as a clinician to the emphasis on psychodynamic principles at the Menninger Clinic, where Otto Kernberg, M.D., a pioneer in describing borderline personality organization, had been medical director.

"It was a long-term-treatment facility where we had many patients with BPD," Gabbard recalled. "In some ways it was the specialty of the house, and there was a good deal of experience and expertise."

Gabbard said he was struck by how often patients who came to Menninger recounted previous disastrous experiences with clinicians, some of which included gross violations of boundaries—a consequence, he said, of countertransferential instincts to heroically rescue apparently desperate patients. "I wanted to treat this group of patients, and I had a particular knack for knowing how to build a therapeutic alliance and to enlist their collaboration, so I had some early success.

"We used a modified form of psychodynamic therapy often in the context of a partial-hospital setting," he said. "One of the ideal things about Menninger was that you had a team of therapists working together, so when you ran out of ideas, you weren't the ‘Lone Ranger.’ This was a great atmosphere in which to train, and I learned a lot about the value of constructively examining one's own countertransference reactions to patients, as a way of getting to know the patient."

Talking to the Brain

Since his days at Menninger, Gabbard has been a leader in the development and teaching of psychotherapies that "speak" to the unique neurobiological characteristics of BPD. Such characteristics include evidence from functional magnetic resonance imaging showing that patients with BPD have hyperactivity in the limbic areas of the brain, especially the amygdala, and hypoactivity in the prefrontal cortex.

Such anomalies, in complex interaction with childhood trauma common among borderline patients, can result in the phenotypic behavior recognized as the symptoms of BPD: impulsive aggression, lack of affective control, and a profound mistrust born out of early disruption in the development of emotional attachment. In a 2005 article in the American Journal of Psychiatry, "Mind, Brain, and Personality Disorders," Gabbard offered a sweeping review of how theories of the mind inform—and are informed by—genetic and neurobiological research on personality disorders.

Today, transference-focused psychotherapy, developed by Kernberg and emphasizing interpretation of the transference as an agent of behavioral change, is one of several psychotherapies proven effective for BPD. Others include dialectical-behavior therapy, schema-based therapy, mentalization-based therapy, supportive psychotherapy, systems training for emotional predictability and problem solving, and general psychiatric management with dynamically oriented therapy (see Using Psychotherapy for BPD).

"From the perspective of neuroscience, we would say that all of the psychotherapies for BPD help patients use their prefrontal cortex to think through and process the highly emotional and impulsive currents that are generated by an overactive amygdala," he said. "In this way, psychotherapy is talking directly to the brain."

"A Different Kind of Brain"

Also distinctive in Gabbard's contributions to treating BPD—and a byproduct of the advances he has helped to foster over three decades in biopsychosocial understanding of the disorder—is an extraordinary sensitivity and empathy for the person behind the disorder.

"One of the reasons why the research data identifying neurobiological differences in borderline patients is so important for patients and their families is that we can say to them with certainty that the patient is not a bad person but has a different kind of brain that reacts to stress differently," Gabbard said.

He cites as evidence of the progress that has been made the formation of a patient support, education, and advocacy group—the Treatment and Research Advancements Association for Personality Disorder.

"In the 35 years I have been involved in psychiatry, we have gone from viewing these people as a chronically mentally ill subgroup to a group that has an eminently treatable condition with a relatively good prognosis," Gabbard said. "Today, we can approach patients and families with considerable hopefulness."

An abstract of "Transference Interpretation in the Psychotherapy of Borderline Patients: A High-Risk, High-Gain Phenomenon" is posted at <www.ncbi.nlm.nih.gov/pubmed/9384884>. "Mind, Brain, and Personality Disorders" is posted at <http://ajp.psychiatryonline.org/cgi/content/full/162/4/648>. The Web site of the Treatment and Research Advancements Association for Personality Disorder is <www.tara4bpd.org>.