Visions Journal, 2011, 7 (1), p. 21
The big four in current use
The treatment of choice for borderline personality disorder (BPD) is psychotherapy. Currently, four forms of psychotherapy have been found to be effective in treating those with BPD.1
Two of these treatments—mentalization-based therapy and transference-focused therapy—are viewed as psychodynamic in nature. This means that they focus on identifying recurring patterns in relationships, discussing past experiences, exploring emotions, and bring into awareness mental processes of which the person was not previously aware.
A third—dialectical behavioural therapy—is viewed as more cognitive-behavioural in nature. This means that it focuses on unhelpful thinking styles that are believed to affect how a person feels and behaves.
The fourth treatment—schema-focused therapy—combines cognitive-behavioural and psychodynamic elements.
Mentalization-based therapy (MBT) has been designed to specifically promote the capacity for mentalization in people with borderline personality disorder (BPD).2 Mentalization refers to the ability to think about internal events such as thoughts, feelings, desires and needs in oneself and in other people. It also includes seeing that these internal events may have an impact on the actions taken by oneself and by others, while being clear that such internal events are separate from actions. People with BPD are often unable to consistently mentalize. This leads to difficulties in containing negative emotions and in understanding interpersonal interactions. Impaired mentalization is thought to develop from problematic relationships with caregivers during childhood and/or from childhood trauma.
The object of treatment is to increase the person’s ability to reflect; that is, to think about mental experiences in oneself and others. Treatment helps the person to understand that one’s own thoughts, feelings and behaviours can be different from those of other people and that these internal events influence what happens in relationships with other people. This understanding is believed to lead to better control over one’s emotions and a stronger sense of self.
Transference-focused therapy (TFP) emphasizes the use of the transference, which is the patient's moment-to-moment experience of the therapist. It is believed that the patient lives out his or her usual, everyday way of experiencing oneself and others when in relationship with the therapist. These everyday ways of experiencing are derived from one's relationships with caregivers during childhood.3
The core task in TFP is to identify the patient's usual patterns of experiencing that have 'transferred' from everyday life to the therapist's office. These patterns of experiencing determine how the person thinks, feels and behaves with other people. So, it is believed that the information that unfolds within the patient's relationship with the therapist provides access to understanding the patient's internal world.
The therapist helps the patient understand the reasons—the fears and anxieties—that support his or her fragmented sense of self and others. The patient can then develop a more integrated sense of their own identity and experience of others. With a more integrated psychological state, patients will be more emotionally stable and less impulsive and will experience less interpersonal chaos. They are better able to make mature choices in work and relationships.
Dialectical behavioural therapy (DBT) is based on the theory that the core problem in BPD is dysregulation of emotions. That is, the person has a poor ability to adapt his or her emotional responses appropriately to new situations.4 It is believed this maladaptive regulation results from a combination of one's biology (e.g., genetic and other biological risk factors) and an emotionally unstable childhood environment. Examples of the latter would be an environment where caregivers punish, trivialize or respond inconsistently to the child's expression of emotion.
The focus of DBT is on helping the patient learn and apply skills to deal with strong emotions more effectively. DBT involves four modes of therapy: 1) individual, in which the therapist oversees treatment integration and manages life-threatening behaviours and crises; 2) group skills training, which includes mindfulness, distress tolerance, emotion regulation and interpersonal effectiveness; 3) skills generalization through telephone contact outside of normal therapy hours, e.g., checking in with one’s therapist to discuss how to take what is being learned in therapy into everyday life; and 4) a consultation team to support therapists in their work with BPD clients.
Schema-focused therapy (SFT) brings together elements of cognitive-behavioural, psychodynamic and experiential (i.e., focusing on what is being done, thought and felt at the present moment) therapies. It focuses on a patient's pervasive patterns of thinking, feeling and behaving. These patterns (i.e., schemas) are developed during childhood and are associated with problems in one's identity and sense of self, interpersonal functioning and emotion control.5 In this approach, BPD is thought to involve regression into early problematic ways of being that are tied to specific thought patterns and associated with intense emotional states.
Therapy involves identifying—and changing—processes that maintain maladaptive schemas. Changing schemas involves both experiential and cognitive work, such as re-parenting, which emphasizes acceptance and validation by the therapist, as well as confronting unrealistic thoughts and problematic behaviours.
Two more approaches look promising
There are other promising psychological treatments for BPD. Included among these are: Systems Training for Emotional Predictability and Problem Solving (STEPPS) and nidotherapy.
STEPPS is a treatment program designed to supplement whatever approach to ongoing care a patient is receiving.6 It combines elements of cognitive-behavioural therapy (CBT) and skills training with an emphasis on understanding how one's environment contributes to maintaining problematic behaviours. This actively involves people the patient interacts with regularly, such as family, significant others, and health care professionals. The goal is to change how a person interacts with his or her environment.
Nidotherapy refers to making systematic changes to a patient's physical and social environment to achieve a better fit for the person.7 ("Nido" is adapted from the Latin word nidus, which means "nest.") There are five essential principles of nidotherapy: 1) seeing the environment from the patient's point of view; 2) setting clear goals for changing the environment; 3) improving the patient's social function; 4) improving personal adaptation and control; and 5) involving other people in making the changes.
Relative effectiveness and availability
There is no data to suggest that any one of these therapies is better than the others. To date, results for each therapy suggest similar effects among the treatments. The therapy with the most comprehensive outcome data (i.e., data focused on the broadest range of success indicators) is mentalization-based therapy (MBT), which has been shown to lead to very good improvements that are maintained for at least seven years. No other treatment for BPD has produced such impressive lasting effects.
There is also no data to suggest that certain types of patients with BPD respond better or worse to any of these therapies. The selection of treatment will depend on the skills of the therapist. Patient preference should also be taken into account. It is unlikely, though, that any one therapist will be skilled and experienced in all of these therapies.
These therapies, except for dialectical behaviour therapy (DBT) which was developed in the early '90s, are fairly recent developments. Although psychodynamic therapy has been around for a long time, it has only recently been developed into specific models for BPD that have been tested in rigorous research. Thus, relatively few therapists have been trained in these approaches. And, while DBT as a specific therapy for BPD has been around for some time, there remains a shortage of therapists who have been properly trained to provide this treatment.
Despite the shortage of therapists formally trained to provide these specific treatments, help is available. Patients with BPD should seek treatments that are long-term (i.e., at least one year in duration). Patients should also make sure that the prospective therapist is experienced in treating the complicated problems associated with BPD. Finally, patients should consider seeking a therapist who practises within a psychodynamic orientation. Three (MBT, TFP, SFT) of the four therapies discussed above have a clear focus on considering the relevance of past experiences on present behaviour—a hallmark of psychodynamic therapy.
To find practitioners in BC who offer these psychotherapies, contact:
About the authorJohn is an Associate Professor and is Associate Director of the Psychotherapy Program in Psychiatry at the University of British Columbia. In addition to his research, he teaches medical students and psychiatry residents, serves as a journal editor, and consults with mental health clinics about service provision and evaluation
Hadjipavlou, G. & Ogrodniczuk, J.S. (2010). Promising psychotherapies for personality disorders. Canadian Journal of Psychiatry, 55(4), 202-210.
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Clarkin, J.F., Yeomans, F.E. & Kernberg, O.F. (2006). Psychotherapy for borderline personality: Focusing on object relations. Arlington, VA: American Psychiatric Publishing.
Linehan, M.M. (1993). Cognitive-behavioral treatment of borderline personality disorder. New York: Guilford Press.
Kellogg, S.H. & Young, J.E. (2006). Schema therapy for borderline personality disorder. Journal of Clinical Psychology, 62(4), 445-458.
Blum, N., St. John, D., Pfohl, B. et al. (2008). Systems Training for Emotional Predictability and Problem Solving (STEPPS) for outpatients with borderline personality disorder: A randomized controlled trial and 1-year follow-up. American Journal of Psychiatry, 165(4), 468-478.
Tyrer, P. & Bajaj, P. (2005). Nidotherapy: Making the environment do the therapeutic work. Advances in Psychiatric Treatment, 11(3), 232-238.