Interventions with Borderline Personality Disorder

Interventions with Borderline Personality Disorder
By Jonathan B Singer
Publisher: Loyola eCommons
Year: 2009

Borderline personality disorder (BPD) is one of 10 personality disorders in the DSM-TV-TR (American Psychiatric Association [APA l, 2000). Personality disorders are characterized by inflexible and maladaptive personality traits that cause significant functional impairment of subjective distress in social, occupational, or other areas of functioning (APA, 2000). BPD is one of three personality disorders (along with histrionic and narcissistic personality disorders) that are characterized by dramatic, emotional, or erratic individual;. The essential feature of BPD is “a pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity that begins by early adulthood and is present in a variety of contexts” (APA, 2000, p. 706).

BPD is a severely disabling condition that has one of the highest suicide rates and higher mental health utilization than ony other disorder (McClough Clarkin, 2004). The challenges posed by BPD the professional lore that has grown up around the disorder has resulted Ln it being perceived by professiomls and the public as the most difficult and problematic of all disorders to assess and treat Brodsky, Stanley, 2006). BPD vs also the most researched and best understood of all axis II diagnoses (mcClough & Clarkin, 2004). This chapter presents an overview of empirically validated and promising approaches to the assessment and treatment of BPD.


According to the DSM-IV- TR (APA, 2000), prevalence rates for BPD are 1 percent to 2.5 percent in the general population, 10 percent in outpatient settings, and between 20 percent and 5O percent in inpatient settings. Diagnosis of BPD is complicated by the challenges of distinguishing it from other diagnoses, such bipolar disorder or post traumatic stress disorder (PTSD); the frequency of co-occurrence with other axis I and axis II diagnoses; and the impact of negative emotional responses that clinicians have to the label BPD (Avirara et al., Mayo, 2006; Presley, 2005).

There no standard assessment protocol for BPD, and most assessments are associated with the chosen treatment approach. However,there are a few issues that should be addressed in all assessments.

Because problems associated with BPD are inherently social, assessment should establish how interpersonal instability manifests in interpersonal behaviours and affects relationship quality (McClough Clarkin, 2004).

Assessments shouid also establish which types of symptoms result in th emost significant impairment or distress; cognitive symptomatology, affect dysregulation, or lack of impulse control (Oldham, 2004). Possible assessment  questions could include “How do you deal with conflict? Who can you rely on for support? Tell me about a long-term friend whom you feel is ‘in your corner’? What do you do when someone makes you mad? Describe to me your ideal relationship.”


Untii the 1950s, few if any treatments demonstrated effectiveness in reducing core symptoms of BPD. Since then, a number of treatments have demonstrated success in addressing specific features of BPD.

Three treatments, dialectical behavior therapy (DBT; Linehan, 1993a„ 1993b), mentalization based treatment (MBT; Bateman & Eonagy, 2001; Fonagy Bateman, 2007) and cognitive-behavioral therapy (C B T; Davidson, Norrie, et al., 2006; Davidson, Tyrer, et al., 2006), have demonstrated better outcomes than treatment-as-usual (TAU) in randomized controlled trials (RCTs).

One randomized trial compared the effects Of a CBT and a psychodynamic treatment (Giesen-B100 et al., 2006). The following is a brief review of empirically validated and promising treatments for BPD.

Dialectical Behavior Therapy

Marsha Linehan and colleagues originally developed DBT as g treatment for women who engage in self-harming behaviors, but they found that a significant number of their clients met criteria for BPD (Linehan, 1993a). Although DBT is the treatment for BPD with the most empirical support, its efficacy has been demonstrated primarily for women with BPD who self-harm (Feigenbaum, 2007).

There is emerging empirical support for the use of DBT with adolescents with BPD, comorbid substance use disorders and BPD, binge eaters, depressed elderly patients, and even families of people with BPD (Chapman. 2006; Hoffman, Fruzzeti & Bateau, 2007; Hoffman et al., 2005; Rathus Miller, 2002).

In response to criticism that existing research on DBT simply reflects the benefits of having small caseloads, targeted supervision, and e controlled environment, Linehan and colleagues tested DBT against six expert in a setting (Linehan et al 2006).

The authors reported that compared to the expert treatment condition, cfients receiving DBT reported fewer and less severe suicide attempts, used crisis services less;, had fewer psychiatric hospitalizations, end had fewer dropouts than the expert treatments.

DBT is a combination of CBT and Zen mindfulness training (Linehan, 1993b). Unique features of DBT include

(1) interventions based on mindfullness and acceptance (e.g., finding a balance between emotion and rationality, known as wise mind”);

(2) emphasis the dialectic (i.e., reality is comprised of ever-changing opposing forces);

(3) focus on emotions and the biopsychosocial model (i.e., BPD ig understood to be a dysfunction of the emotional regulation system which is part of a biopsychosocial system);

(4) addressing five specific processes of therapy (Chapman, 2006).

The five processes and their corresponding treatment modalities are

(1) motivating the client to change and rehearsing cognitive and behavioral skills that help clients regulate their emotions in I-hour weekly individual therapy;

(2) enhancing behavioral skills: mindfulness, interpexsonal skills, regulation of emotions, and distress tolerance in 2-hour weekly skills training groups;

(3) ensuring the generalization of these skills to activities of daily living using as-needed phone consultalions with outpatient treatment or milieu therapy for inpatient programs;

(4) enhancing therapist capabilities and motivations in I-hour weekly DBT consultation team meeting;

(5) structuring the treatment environment to support client and therapist capabilities (Linehan, 1993b).

DBT is a highly structured treatment, and clinicians might wonder if anything less than strict adherence to model will be effective in treating people with BPD. A recent study reported success in using a modified version of DBT in uncontrolled environment and incorporating the skills training group with non-DBT individual therapy (Harley, Baity, Blais, & Jacobo, 2007).

Mentaiization-Based Treatment

Peter Fonagy and Anthony Bateman dewe!oped MBT as a day hospitalization treatment for peopie diagnosed with BPD (Fonagy Bateman, 2007). In the only evaluation of the model, MBT demonstrated significant and enduring changes in mood states and interpersonal functioning (Bateman & Fonasy, 1999, 2001).

Increased benefits of MBT were reported at 3-rnonth follow-up, and significant difference between the experimental and control groups were veported at a 5-year follow-up (Fonagy & Bateman, 2007).

The developers noted that alFhough MBT resulted in no cost savings during the evaluation, improved functioning resulted in considerable after treatment cost savings. BPD has its origins in psychoanalytic and psychodynamic theory (McClough & Clarkin, 2004).

Howewer, there are only few psychodynamic rrcatmcnts with empirical support (Korner, Gecull, Meares, Stevenson, 2006). MBT is a psychodynamic developmental model for understanding BPD in which mentalizing is the key to treatment.

According to Fonagy and Bateman (2007), “Mentalization is the capacity to make sense of self and of others in terms of subjective states and mental processes” (p. 83). The model assumes that people with BPD cannot understand the thoughts and feelings associated with the behaviors of self and others because

(1) their own infant mental states were not understood by their caregivers, and

(2) as a result, they never developed emotional regulation skills.

MBT targets three higher order social cognitive functions that are important in attachment contexts: “affect representation and regulation; attentional control, also with strong links to the regulation of affect; and finally mentalization, a system for interpersonal understanding within the attachment context” (Fonag & Bateman, 2007, p. 84).

The challenge for the clinician is to help the client develop emotional regulation without stimulating the attachment system. One way MBT achieves this by eschewing the role of insight and affective exploration in therapy. The developers contend that therapists can do harm to clients who have significant difficulty regulating emotion and who have poor conceptions of self and others by insisting on using traditional insight-oriented psychodynamic treatment.


A recent RCT compared TAU with TAU plus CBT (Davidson, Norrie et aL 2006; Davidson, Tyrer et al., 2006). The treatment was based on cognitive-behavioral principles and therefore the interventions focused on the patient’s beliefs behavior thar impair social and adaptive functioning. The study results suggested that all participants showed reductions in suicidal ideation, and hospitalintion. The TAU + CP,T group also showed reductions in dysfunctional beliefs state enxiety, and distress censed by psychiatric symptorn.

Schema-Focused Therapy versus Transference-Focused Psychotherapy

A recent study comporcd a cognitive-based treatment (schema-focused therapy; SFU and a psychodynatnic treatment (transference-focused psychotherapy; T P P) in a 3-year randomized trial of 82 men and women with BPD (Giesen-Bloo et al., 2006). Giesen-Bloo and colleagues noted that whereas empirically validated treatments such as DBT, CBT, and MBT target specific symptoms, such as self-harm behavior or interpersonal functioning, both SFT and TFP were developed to restructure clients’ personalities.

Results of the study indicated that participants from both treatments improved significantly on all DSM-IV BPD Criteria, all effects were apparent after the first year, and there was significant improvement in the quality of life {or the majority of participants.

Promising Treatments

With the exception of the treatments in the study by Geisen-Bloo and colleagues, no single pharmacological or psychosocial treatment has demonstrated efficacy in addressing all aspects of BPD. However, there are a number of treatments that hold promise for addressing specific symptoms,populations, or for specific treatment settings (listed in alphabetical order):

  1. EMDR. Brown and Shapiro (2006) presented a case study of treating BPD using eye movement desensitization and reprocessing (EMDR), a recognized trauma therapy. This individual treatment holds promise in addressing trauma issues for people with BPD using a treatment that has some empirical support in other populations.
  2. Intermittent-continuous eclectic therapy (ICE). ICE is a group approach developed in Chile. Mcnchaca, Perez, and Peralta (2007) described a I-year pilot study of men and women ages 15 to 40 in an outpatient setting.  The authors reported improvement in self-aggression and general symptoms. ICE is one of the few group treatments for  BPD. Group treatment holds promise as a cost effective treatment (Marziali, 2002).
  3. Interpersonal group psychotherapy (IGP). IGP is a group approach developed by Marziali and Munroe-Blum (1994, cited in Marziali, 2002). The developers compared 30 sessions of IPC with open-ended, long term, individual psychoanalytic  psychotherapy. Results indicated at posttreatment and at 1-year follow-up,  participants in both the experimental and the comparison treatments made gains.
  4. Interpersonalt psychotherapy (IPT-BDP). Research is currently being conducted on a version of modified for people with BDP (JPT-BPD; Markowitz, Bleiberg, Pessin & Skodol, 2007). IPT is an empirically supported individual treatment for people with moderate to severe depression that focuses on the bidirectional influence of interpersonal problems and depressive symptoms. IPT-BDP targets the interpersonal instability and depressed affect commonly encountered in people with BDP  (Markowitz, Skodol, & Bleiberg, 2006). An RCT is currently under way.
  5. Pharmacotherapy. Despite recent advances in addressing core symptoms of mood, anxiety, and childhood disorders, pharmacotherapy is not recommended in the treatment of BPD. Treatment guidelines recommend the use of medications to address temporary psychosis and other discrete symptoms (Oldham, 2004), but the evidence to support the use of medications alone, or in combination with psychotherapy is equivocal (Paris, 2005; Paton Okocha, 2005).
  6. ST EPPS (Systems Training for Emotional Predictability and Problem Soloing) (Blum,Pfohl, St. John, Monahan, & Black 2002; Van Wel et al., 2006). STEPPS is a group treatment based on Minuchin’s structural family therapy model. Two pilot studies suggest treatment efficacy. RCTs are currently under way (Van Wel et al., 2006).
  7. Supportive therapy. Aviram, Hellerstein, Gerson, and Stanley (2004) used supportive individual therapy with an outpatient population with BPD who engaged in self- harming behaviors. Thc authors suggested that the approach appeared to be efficacious in engaging people with BPD and minimizing the frequency and intensity of self-harming behavior. However, because this was an open and uncontrolled trial, its findings must be interpreted with caution.


There is cause for hope among clinicians and clients that effective treatment of BPD is possible.

Recent empirical findings have challenged the long-held belief that BPD is treatment-resistant and follows a chronic disease model (Fonagy Bate- man, 2006; Zanarini, Frankenbuyg, Hennen, Silk, 2003).

Most treatments leviewed in this chapter conceptualize the root cause of BPD differently, have different targets for c.h2nge, and thus propose different treatments. However, meta-analyses of BPD treaunents suggest there are similar outcomes across therapies (Livesley, 2007).

Given the heterogeneity of client characteristics for people with BPD and the variety of approaches used by clinicians in the field (Sharp et al), the best  practices approach to treating BPD is likely to be an integration of treatments rather than a single evidence-based treatment.

Livesley (2007) proposed an integrated model for treating BPD, one rhat is based on three common treatment factors:

A structured approach with a clearly defined treatment model, an explicit treatment frame and contract, and careful adherence to the model; General change strategies based on the relationship component of the common factors; and Generic aspects of the specific interventions used by various therapies” (p. 133).

Integrated approaches are recommended because of noted limitations of any one treatment, and as a way of increasing treatment allegiance by clinicians with different treatment frameworks. The combination of treatment technique and treatment allegiance has been shown to account for 38 percent of treatment outcome (Wampold, 2001). The best treatments will help clients express emotions without causing harm to self or others, establish fulfilling and stable relationships, and develop a sense of personal mastery.

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