Tuesday, September 18, 2012

Psychotherapy Outcome Research and Treatment for Borderline Personality Disorder, Part I

The purveyors of Cognitive-behavioral psychotherapy (CBT), one of the large number of “schools” of thought in the fields of psychology and psychiatry, like to tout their randomized controlled outcome studies (RCT’s) as proof that theirs is the most “evidenced based” type of psychotherapy. When it comes to the psychotherapy of borderline personality disorder (BPD), which provides a microcosm for almost every type imaginable of behavioral/relationship issues that are confronted by psychotherapists, two of the most studied paradigms are actually related more to what many psychologists consider to be the opposite type of psychotherapy: humanistic/psychodynamic psychotherapy.  Those models are called transference-focused psychotherapy, TFP, and mentalization-based treatment, MBT.  

A third “empirically validated treatment” called schema-focused therapy (SFT), while based initially on some CBT concepts, takes quite a detour from those and employs techniques adapted from a number of alternate psychotherapy schools.

Actually, the one type of RCT-studied therapy for BPD that is most associated with CBT, dialectical behavior therapy (DBT), also borrows considerably from other schools of thought.  Not only that, but it really has been shown to be effective only for a couple of BPD symptoms, most notably self-injurious behavior (SIB) such as self-cutting.

John F. Clarkin is a highly respect psychotherapy researcher who has perhaps the most experience of anyone in the field.  He recently published an article in the Journal of Personality Disorders (Vol, 26 (1), Feb. 2012, pp. 43-62) entitled, “An Integrated Approach to Psychotherapy Techniques for Patients with Personality Disorder.  In it, he makes what I consider several extremely important and crucial points in the debate about the various treatment ideologies.

John Clarkin, Ph.D.

First, he points out, the empirically "validated" models often focus only on symptoms and not on the more important and enduring aspects of personality. In fact, in longitudinal studies of affected individuals, the personality disorder criteria and symptoms change over time, often all by themselves, while their interpersonal dysfunction does not change very much at all.  This implies that that, while symptom reduction is important, it is the interpersonal issues that should be the major long term focus in therapy. The heart of the matter in personality disorders is the patient’s conception of self and others.  The ultimate goal of treatment should be interpersonal functioning that allow for pleasure, interdependence, and intimacy in relationships.

Second, the literature on outcome studies is based on average scores on symptom-based outcome measures. This covers up the obvious fact that in any treatment, some patients change and some do not.  This is further complicated by the issues of “comorbidity.”  Patients with BPD, for instance, often meet criteria for one or more additional personality disorders, not to mention additional psychiatric disorders. And even within the definition of a single personality disorder, many different combinations of traits are possible to arrive at the diagnosis. Much more so than in any other field of medicine, patients with personality disorders are highly unique. Therefore, no one treatment can or will work for everyone.

Third, as Clarkin states, “A close examination of the treatment manuals…suggests that each manual contains some strategies that are unique and essential to the treatment, and some that are common (sometimes with different jargon) with other approaches."

A fourth important point he makes is that all of these therapies consist of multiple interventions, and the studies do not show which ones are important and which ones are not, or even more importantly, which ones may even be counterproductive: “…most probably contain low doses of effective practices, ancillary but important aspects that make delivery of the treatment more palatable, superstitious behaviors (those we think that matter but do not), and factors that impede or fail to optimize therapeutic change.”

A fifth point he makes that I would like to mention is that it is the delivery of the techniques that is often more important than the techniques themselves.  Techniques can be done skillfully, “…or in an abrasive, authoritarian, or uninterested aloof way.  There is plenty of research data that suggests that the skill of the therapist can be, in many instances, far more important to good results that an individual techniques."  Clarkin adds, “The therapist is not a technique-dispensing machine. Many of the techniques are applied common sense, and could be read out of a book."

Last, let us not forget that the receptivity of the patient is another major factor in whether or not therapy is successful.  If patient factors are not taken into account, the effectiveness of any technique “approaches zero.”  Furthermore, despite the rejection of the concept of transference by CBT therapists, “Some patients with severe needs for attachment with no relationships outsider of treatment may become intensely attached to and preoccupied with the therapist in ways that are detrimental to growth.”

In short, it makes a lot more sense to integrate the various techniques across treatment strategies from the treatment manuals in a way that tailors them to the particular patient in front of the therapist.  Throughout treatment, individual decisions must be made, which takes a skillfull therapist indeed. 

Of the four treatment paradigms that have been subjected to RCT’s, in my opinion schema focused therapy does the best job. Of course, the concepts of "mental schemas" and “mentalization” share much in common. (I will not be defining them in this post).  

My own model, unified therapy, has not been subjected to an outcome study. I applied for an “exploratory” grant to get some initial (pilot) data and was of course turned down by the National Institute of Mental Health. That may or may not have something to do with the fact that the only family-systems-oriented reviewer on my NIMH review committee was replaced at the last minute by DBT founder Marsha Linehan. Someone on the panel accused me of not being “mindful” enough.  I wonder who that might have been?
But maybe I’m just being paranoid. As Nassir Ghaemi says, the NIMH's " funding is sparingly distributed: the highly conservative, non-risk-taking nature of NIH peer review is well-known." The study most likely to be accepted by the NIMH is one that has either already been done, or whose outcome is not really in doubt.

To be fair, doing meaningful psychotherapy outcome studies is diabolically difficult. In my book, How Dysfunctional Families Spur Mental Disorders, I went into great detail about a lot of the reasons for this. I’ll summarize what I said in part II of this post.

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