Chapter Eight

Specific Psychotherapeutic Approaches

There is a Monster in me. . . . It scares me. It makes me go up and down and back and forth, and I hate it. I will die if it doesn’t let me alone.

—From the diary of a borderline patient

 

True life is lived when tiny changes occur.

—Leo Tolstoy

 

 

 

Borderline Personality Disorder is the only major psychiatric illness for which there are more evidence-based studies demonstrating efficacy from psychosocial therapies than for pharmacological (drug) treatments. Thus, unlike the treatment for most other disorders, medications are viewed as secondary components to psychotherapy. Not only have several psychotherapy approaches been shown to be effective, the arduous and sometimes extensive endeavor of psychotherapy has also been shown to be cost-effective for the treatment of personality disorders.¹

Psychotherapy as a treatment for BPD has come a long way since the publication of this book’s first edition. Spurred by rigorous research and constant refinement by clinicians, two primary schools of therapy have emerged—the cognitive-behavioral and psychodynamic approaches. In each category several distinct strategies have been developed, each supported by its own set of theoretical principles and techniques. Several psychotherapy strategies combine group and individual sessions. Though some are more psychodynamic, some more behavioral, most combine elements of both. All embrace communication that reflects SET-UP features that were developed by the primary author and discussed in detail in chapter 5: Support for the patient, Empathy for his struggles, confrontation of Truth or reality issues, together with Understanding of issues and a dedication to Persevere in the treatment.

Proponents of several therapy approaches have attempted to standardize their therapeutic techniques by, for example, compiling instructional manuals to help guide practitioners in conducting the specific treatment. In this way, it is hoped that the therapy is conducted consistently and equally effectively, irrespective of the practitioner. (An obvious, though perhaps crass, analogy may be made to a franchise food company, such as Starbucks or McDonald’s, which standardizes its ingredients so that its coffee or hamburgers taste the same regardless of where it is purchased.) Standardization also facilitates gathering evidence in controlled studies, which can support, or refute, the effectiveness of a particular psychotherapy approach.

The underlying theory of standardization is that, just as it would make little difference who physically gives the patient the Prozac (as long as he ingested it), it would make little difference who administered the psychotherapy, as long as the patient was in attendance. However, interpersonal interactions are surely different from taking and digesting a pill, so it is probably naive to presume that all psychotherapists following the same guidelines will produce the same results with patients. Indeed, John G. Gunderson, MD, a pioneer in the study of BPD, has pointed out that the original developers of these successful techniques are blessed with prominent charisma and confidence, which followers may not necessarily possess.² Additionally, many therapists might find such a constrained approach too inflexible.³

Although the different psychotherapy strategies emphasize distinctions, they possess many commonalities. All attempt to establish clear goals with the patient. A primary early goal is to disrupt self-destructive and treatment-destructive behaviors. All of the formal, “manualized” therapies are intensive, requiring consistent contact usually one or more times per week. All of these therapies recognize the need for the therapist to be highly and specially trained and supported, and many require supervision and/or collaboration with other team members. Therapists are more vigorously interactive with patients than in traditional psychoanalysis. Because these therapies are time and labor intensive, usually expensive, and often not fully covered by insurance (e.g., insurance does not cover team meetings between therapists, as required in formal DBT—see page 179), most of the studies exploring their efficacy have been performed in university or grant-supported environments. Most community and private treatment protocols attempting to reproduce a particular approach are truncated modifications of the formal programs.

It is no longer simply a matter of “finding any shrink who can cure me” (though it is possible, of course, to get lucky this way). In our complex society, all sorts of factors are, and should be, considered by the patient: time and expense, therapist’s experience and specialization, and so on. Most important, the patient should be comfortable with the therapist and her specific approach to treatment. So the reader is advised to read the remainder of this chapter with an eye toward at least becoming familiar with specific approaches, as she will likely see them (and their acronyms) again at some point during the therapeutic process.

Cognitive and Behavioral Treatments

Cognitive-behavioral approaches focus on changing current thinking processes and repetitive behaviors that are disabling; this type of therapy is less concerned about the past than psychodynamic approaches (see page 183). Treatment is more problem-focused and often time-limited.

Cognitive-Behavioral Therapy (CBT)

A system of treatment developed by Aaron Beck, CBT focuses on identifying disruptive thoughts and behaviors and replacing them with more desirable beliefs and reactions.⁴ Active attempts to point out distorted thinking (“I’m a bad person”; “Everyone hates me”) and frustrating behaviors (“Maybe I can have just one drink”) are coupled with homework assignments designed to change these feelings and actions. Assertiveness training, anger-management classes, relaxation exercises, and desensitization protocols may all be used. Typically, CBT is time-limited, less intensive than other protocols, and therefore usually less expensive. The following treatment programs are derived from CBT.

Dialectical Behavioral Therapy (DBT)

Developed by Marsha M. Linehan, PhD, at the University of Washington, DBT is the derivation of standard cognitive-behavioral therapy that has furnished the most controlled studies demonstrating its efficacy. The dialectic of the treatment refers to the goal of resolving the inherent “opposites” faced by BPD patients; that is, the need to negotiate the borderline’s contradictory feeling states, such as loving, then hating the same person or situation. A more basic dialectic in this system is the need to resolve the paradox that the patient is trying as hard as she can and is urged to be satisfied with her efforts, and yet is simultaneously striving to change even more and do even better.⁵

DBT posits that borderline patients possess a genetic/biological vulnerability to emotional over-reactivity. This view hypothesizes that the limbic system, the part of the brain most closely associated with emotional responses, is hyperactive in the borderline. The second contributing factor, according to DBT practitioners, is an invalidating environment; that is, others dismiss, contradict, or reject the developing individual’s emotions. Confronted with such interactions, the individual is unable to trust others or her own reactions. Emotions are uncontrolled and volatile.

In the initial stages of treatment DBT focuses on a hierarchical system of targets, confronting first the most serious, and then later the easiest, behaviors to change. The highest priority addressed immediately is the threat of suicide and self-injuring behaviors. The second-highest target is to eliminate behaviors that interfere with therapy, such as missed appointments or not completing homework assignments. The third priority is to address behaviors that interfere with a healthy quality of life, such as disruptive compulsions, promiscuity, or criminal conduct; among these, easier changes are targeted first. Fourth, the focus is on increasing behavioral skills.

The structured program consists of four main components:

1. Weekly individual psychotherapy to reinforce learned new skills and to minimize self-defeating behaviors.

2. Weekly group skills therapy that utilizes educational materials about BPD and DBT, homework assignments, and discussion to teach techniques to better control emotions, improve interpersonal contacts, and nurture mindfulness— a term to describe objective consideration of present feelings, uncontaminated by ruminations on the past or future or by emotional lability.

3. Telephone coaching (a unique feature of DBT) to help patients work through developing stresses before they become emergencies; calls can be made to on-call coaches at any time, but are deemed inappropriate if made after a patient has acted out in a destructive manner.

4. Weekly meetings among all members of the therapist team to enhance skills and motivation, and to combat burnout. Each week, patients are given a DBT “diary card” to fill out daily. The diary is meant to document self-destructive behaviors, drug use, disruptive emotions, and how the patient coped with such daily stresses.

Systems Training for Emotional Predictability and Problem Solving (STEPPS)

Another manual-based variation of CBT is STEPPS, developed at the University of Iowa. Like DBT, STEPPS focuses on the borderline’s inability to modulate emotions and impulses. The unique modifications of STEPPS were partly built on a wish to develop a less costly program. STEPPS is a group therapy paradigm, without individual sessions. It is also designed to be shorter—consisting of twenty two-hour weekly groups (compared to the typical one-year commitment expected in DBT). This program also emphasizes the importance of involving the borderline’s social systems in treatment. Educational training sessions “can include family members, significant others, health care professionals, or anyone they regularly interact with, and with whom they are willing to share information about their disorder.”⁶ STEPPS embodies three primary components:

1. Sessions educate about BPD and schema (cognitive distortions about oneself and others, such as a sense of unlovability, mistrust, guilt, lack of identity, fear of losing control, etc.).

2. Skills to better control emotions, such as problem management, distracting, and improving communication, are taught.

3. The third component teaches basic behavioral skills, such as healthy eating, healthy sleep regimen, exercise, and goal setting.

A second phase of STEPPS is STAIRWAYS (Setting goals; Trusting; Anger management; Impulsivity control; Relationship behavior; Writing a script; Assertiveness training; Your journey; Schemas revisited). This is a twice-monthly one-year extension of skills-training “seminars,” which reinforce the STEPPS model. Unlike DBT, which is designed to be self-contained and discourages other therapy contributions, STEPPS is designed to complement other therapy involvement.

Schema-Focused Therapy (SFT)

SFT combines elements of cognitive, Gestalt, and psychodynamic theories. Developed by Jeffrey Young, PhD, a student of Aaron Beck’s, SFT conceptualizes maladaptive behavior arising from schemas. In this model, a schema is defined as a worldview developed over time in a biologically vulnerable child who encounters instability, overindulgence, neglect, or abuse. Schemas are the child’s attempts to cope with these failures in parenting. Such coping mechanisms become maladaptive in adulthood. The concept of schemas derives from psychodynamic theories. SFT attempts to challenge these distorted responses and teach new ways of coping through a process denoted as re-parenting.⁷

Multiple schemas can be grouped into five primary schema modes, with which borderline patients identify and which correlate with borderline symptoms:

1. Abandoned and Abused Child (abandonment fears)

2. Angry Child (rage, impulsivity, mood instability, unstable relationships)

3. Punitive Parent (self-harm, impulsivity)

4. Detached Protector (dissociation, lack of identity, feelings of emptiness)

5. Healthy Adult (therapist’s role to model for the patient—soothes and protects the other modes)

Specific treatment strategies are appropriate for each mode. For example, the therapist emphasizes nurturing and caring for the Abandoned and Abused Child mode. Expressing emotions is encouraged for the Detached Protector mode. “Re-parenting” attempts to supply unmet childhood needs. Therapists are more open than in traditional therapies, often sharing gifts, phone numbers, and other personal information, projecting themselves as “real,” “honest,” and “caring.” Conveying warmth, praise, and empathy are important therapist features. Patients are encouraged to read about schema and BPD. Gestalt techniques, such as role-playing, acting out dialogue between modes, and visualization techniques (visualizing and role-playing stressful scenarios) are employed. Assertiveness training and other cognitive-behavioral methods are utilized. A possible danger in SFT is the boundary confrontation in “re-parenting.” Therapists must be extremely vigilant regarding the risk of transference and countertransference regression (see chapter 7).

Psychodynamic Treatments

Psychodynamic approaches typically employ discussion of the past and present, with the goal of discovering patterns that may forge a more productive future. This form of therapy is usually more intensive—with sessions conducted several times a week—than the cognitive-behavioral approach. The therapist should implement a structured, consistent format with clear goals, yet be flexible enough to adapt to changing needs.

Mentalization-Based Therapy (MBT)

Mentalization, a term elaborated by Peter Fonagy, PhD, describes how people understand themselves, others, and their environment. Using mentalization, an individual understands why she and others interact the way they do, which in turn leads to the ability to empathize with another’s feelings.⁸ The term overlaps with the concept of psychological mindedness (understanding the connection between feelings and behaviors) and mindfulness (a goal in DBT; see above). Fonagy theorizes that when the normal development of mentalization beginning in early childhood is disrupted, adult pathology develops, particularly BPD. This conceptualization is based on psychodynamic theories of a healthy attachment to a parenting figure (see chapter 3). When the child is unable to bond appropriately with a parent, he has difficulty understanding the parent’s or his own feelings. He has no healthy context on which to base emotions or behaviors. Object constancy cannot be sustained. The child develops abandonment fears or detaches from others. This developmental failure may arise either from the child’s temperament (biological or genetic limitations) or from the parent’s pathology, which may consist of physical or emotional abuse or abandonment, or inappropriate smothering of independence, or from both.

MBT is based on the supposition that beliefs, motives, emotions, desires, reasons, and needs must first be understood in order to function optimally with others. Confirming data on the effectiveness of this method has been documented by Bateman and Fonagy, primarily within a daily partial hospital setting in England.^9,10 In this design, patients attend the hospital during the day, five days a week for eighteen months. Treatment includes psychoanalytically oriented group therapy three times a week, individual psychotherapy, expressive therapy consisting of art, music, and psychodrama programs, and medications as needed. Daily staff meetings are held and consultations are available. Therapists, employing a manual-based system, focus on the patient’s current state of mind, identify distortions in perception, and collaboratively attempt to generate alternative perspectives about himself and others. While much of the behavioral techniques recalls DBT, some of the psychodynamic structure of MBT overlaps with Transference-Focused Psychotherapy (TFP).

Transference-Focused Psychotherapy (TFP)

TFP is a manual-based program that Otto Kernberg, MD, and colleagues at Cornell have developed from more traditional psychoanalytic roots.^11,12 The therapist focuses initially on developing a contract of understanding of the roles and limitations in the therapy. Like DBT, early concerns revolve around suicide danger, interruption of therapy, dishonesty, and so on. Like other treatment approaches, TFP acknowledges the role of biological and genetic vulnerability colliding with early psychological frustrations. A primary defense mechanism seen in borderline patients is identity diffusion, which refers to a distorted and unstable sense of self and, consequently, others. Identity diffusion suggests a perception of oneself and others as if they were fuzzy, ghostlike distortions in a fun-house mirror, barely perceptible and insubstantial to the touch. Another feature of BPD is persistent splitting, dividing perceptions into extreme and opposite dyads of black or white, right or wrong, resulting in the belief that oneself, another, or a situation is all-good or all-bad. Accepting that a good person could disappoint is difficult to comprehend; thus, the formerly good person mutates into an all-bad person. (The professional reader will note that distortions in MBT’s mentalization would include the concepts of identity diffusion and splitting; the difficulty with dyadic extremes recalls the dialectical paradoxes theorized in DBT.)

TFP theorizes that identity diffusion and splitting are early, primary elements in normal development. However, in BPD, normal, developing integration of opposite feelings and perceptions is disrupted by frustrating caregiving. The borderline is stuck at an immature level of functioning. Feelings of emptiness, severe emotional swings, anger, and chaotic relationships result from this black-and-white thinking. Therapy consists of twice-weekly individual sessions, in which the relationship with the therapist is examined. This here-and-now transference experience (see chapter 7) allows the patient to experience in the moment the splitting that is so prevalent in his life experience. The therapist’s office becomes a kind of laboratory, in which the patient can examine his feelings in a safe, protected environment, and then extend his understanding to the outside world. The combination of intellectual understanding and the emotional experience in working with the therapist can lead to the healthy integration of identity and perceptions of others.

Comparing Treatments

A vignette may help demonstrate how therapists utilizing these various approaches might handle the same situation in therapy:

Judy, a twenty-nine-year-old single accountant, arrived at her therapist’s office quite upset, after having an intense argument with her father, during which he called her a “slut.” When her doctor inquired about what prompted his slur, Judy became more upset, accusing the therapist of taking her father’s side and throwing a box of tissues across the room.

A DBT therapist might focus on Judy’s anger and physical outburst. He might empathize with her frustration, accept her impulsive gesture, and then work with her to vent her frustration without becoming violent. He might also discuss ways to deal with her frustration with her father.

The SFT therapist might first try to correct Judy’s misperception of him and reassure her that he is not angry at her and is totally on her side.

In MBT, the doctor may try to get Judy to relate what she is feeling and thinking at this moment. He may also attempt to direct her to thinking (mentalizing) about what she supposed her father was reacting to during their conversation.

The TFP therapist may explore how Judy is comparing him to her father. He might focus on her severely changing feelings about him at that moment in therapy.

Other Therapies

A number of other therapy approaches, less studied, have also been described. Robert Gregory and his group at the State University of New York in Syracuse have developed a manual-based protocol, Dynamic Deconstructive Psychotherapy (DDP), specifically directed toward borderline patients who are more challenging or have complicating disorders such as substance abuse.¹³ Weekly individual, psychodynamically oriented sessions are directed toward activating impaired cognitive perceptions and helping the patient develop a more coherent, consistent sense of self and others.

Alliance-Based Therapy (ABT) developed at Austen Riggs Center in Stockbridge, Massachusetts, is a psychodynamic approach that focuses specifically on suicidal and self-destructive behaviors. ¹⁴ Much like TFP, the emphasis is on the therapeutic relationship and how it impacts the borderline’s self-harming actions.

Intensive Short-Term Dynamic Psychotherapy (ISTDP), designed for the treatment of patients with borderline and other personality disorders, has been elaborated by a Canadian group.¹⁵ Weekly individual sessions concentrate on unconscious emotions that are responsible for defenses and the connections between these feelings and past traumas. Treatment is generally expected to continue for a period of around six months.

Practitioners from Chile, recognizing the difficulty of providing intensive individual care for borderline patients, developed a group therapy system, Intermittent-Continuous Eclectic Therapy (ICE).¹⁶ Weekly ninety-minute group therapy sessions are conducted in ten-session cycles. Patients may continue with further rounds, as they and their therapists choose. A psychodynamic viewpoint guides understanding of the patient, but interpretations are minimized. The first part of each session is an open, supportive period in which unstructured discussion is encouraged; the second half is arranged like a classroom, in which skills are taught to handle difficult emotions (as in DBT and STEPPS).

Which Therapy Is Best?

All of these “alphabet-soup” treatment designs endeavor to standardize the therapy, most utilizing manual-based programs, and have attempted to develop controlled studies to determine efficacy. All have evolved studies demonstrating the superiority of the formalized therapy over a comparative, nonspecific, supportive “treatment as usual.” Some research has studied comparative results among these treatments.

One study compared the results of yearlong outpatient treatments for borderline patients with three different approaches: DBT, TFP, and a psychodynamic supportive therapy.¹⁷ Patients in all three groups demonstrated improvement in depression, anxiety, social interactions, and general functioning. Both DBT and TFP showed significant reduction in suicidal thinking. TFP and supportive therapy did better in reducing anger and impulsivity. TFP performed best in reducing irritability and verbal and physical assault.

A three-year Dutch study compared results of treating borderline patients with SFT versus TFP.¹⁸ After the first year, both treatment groups experienced comparable significant reductions in BPD symptoms and improvement in quality of life. By the third year, however, SFT patients exhibited significantly greater improvement and had fewer dropouts. A later study from the Netherlands compared cost-effectiveness of these two psychotherapy designs.¹⁹ This investigation attempted to measure cost of treatment with improvement in quality of life over time (determined by a self-administered questionnaire). Although quality of life measures after TFP were slightly higher than after SFT, the overall cost for comparable improvement was significantly more efficient with SFT.

Although these studies are admirable attempts to compare different treatments, all can be criticized. Patient and therapist selection, validity of measures used, and the plethora of uncontrolled variables that impact on any scientific study make attempts to compare human behavioral responses very difficult. Continued studies on larger populations will illuminate therapeutic approaches that will be beneficial for many patients in aggregate. But given the complex variations rooted in our DNA, which make one person so different from another, unveiling the “best” treatment that will be ideal for every individual is surely impossible. The treatment that demonstrates superiority in a majority of patients in a study may not be the ideal choice for you. This is no less true in the area of medications, where we find one size does not fit all.

Thus, the primary point to be gleaned from these studies is not which treatment works best, but that psychotherapeutic treatment does work! Unfortunately, psychotherapy has been figuratively and literally devalued over the years. Psychological services, in general, are reimbursed at a remarkably lower rate than medical services. Insurance payment to a clinician for an hour of noninterventional interaction with a patient (diet and behavioral adjustments to diabetes, instruction on caring for a healing wound, or psychotherapy) is a fraction of the payment for a routine medical procedure (minor surgical intervention, steroid injection, etc.). For one hour of psychotherapy, Medicare and most private insurance companies pay less than one-tenth of the reimbursement rate directed for many minor outpatient surgical procedures.

As the United States continues its quest to provide health care to more people in more affordable ways, there will be temptations to mandate treatments that are shown to be grossly equivalent, but less expensive. It will be important to maintain flexibility in such a system, so that we do not denigrate the art of medicine, which allows individuality in the sacred relationship between doctor and patient.

Future Research and Specialized Therapies for BPD

In the future, advances in genetic and biological research may suggest how therapies can be “individualized” for specific patients. Just as no single medicine is recognized as better than the others in treating all BPD patients, no single therapeutic approach can be better for all, despite attempts to compare approaches. Therapists should direct specific therapy approaches to different patient needs, rather than try to apply the fictional best approach to everyone. For example, borderline patients who are significantly suicidal or engaged in serious self-mutilating behaviors may initially respond best to cognitive/behavioral approaches, such as DBT. Higher functioning patients may respond better to psychodynamic protocols. Financial or scheduling limitations may favor time-limited therapies, whereas repeated destructive life patterns might dictate a need for longer-term, more intensive protocols.

Just as most medical specialties (e.g., ophthalmology) have developed subspecialty areas for complicated situations or for the parts of the organ involved (e.g., retina, cornea), optimal treatment of BPD may be heading in the same direction. Specialized centers of care for BPD, for example, featuring experienced, specially trained professionals could offer more efficient treatment regimens.