14 Borderline personality disorder in women: treatment approaches

Most clinicians working with borderline personality disorder (BPD) take a pragmatic multimodal approach to treatment. Historically, patients were managed within general adult psychiatric services, and often considered problematic, untreatable, and only reluctantly accepted as suffering from a mental illness. There were, nonetheless, important treatment developments in therapeutic community settings. Over the past decade there has been increasing recognition and understanding of personality disorder as a disorder (Department of Health 2003) with inspiring new developments in psychological treatments and an expansion of specialist services The National Institute for Clinical Health and Excellence (NICE) guidelines for the treatment and management of BPD in the United Kingdom will further influence the range of National Health Service services and treatment approaches available. It emphasizes the role of psychological treatments, complex interventions, and crisis management, and recommends developing a care pathway for people with BPD (2009). It also reviews cost-effectiveness of psychological treatments (Brazier et al. 2006).

There is no specific medication for BPD, though it can help some patients through targeting specific symptoms and support psychotherapy work when integrated within an overall treatment programme. It is useful to consider whether the patient’s symptoms are primarily in relation to affect control (mood lability, rejection sensitivity, intense anger, mood crashes, chronic emptiness, dysphoria, social anxiety), impulsivity and sensation seeking (aggression, self-harm, bingeing, risk-taking), or cognitive perceptual disturbance. Any comorbid axis 1 disorders should be adequately treated. Please see NICE guidelines (2009) and American Psychiatric Association practice guideline (Gunderson 2001) for further details and review of evidence.

In prescribing, clinicians should consider transference and countertransference issues and the possibility of splitting (Gabbard 2005). Patients and clinicians can get caught up in idealizing medication as a solution to difficulties at a moment of intense need, despair, or suicide threat. Patients may experience prescribing concretely as the therapist giving or withholding care, though it may have value as a transitional object. Unfortunately BPD patients typically end up taking a number of drugs intermittently—each of questionable value and increasing the risk of overdose. Prescribing should occur within a stable therapeutic relationship, with clearly agreed target symptoms and trial period, and regular review of efficacy. Drugs which are not clearly helping should be stopped. Comorbid drug and alcohol use will also impact on efficacy and safety. Prescribing in women is further complicated by pregnancy, breastfeeding, and weight gain. As always, patients should be properly advised of the benefits and risks to make an informed treatment choice. Prescribing should be discussed with the whole team working with the patient to minimize splitting between clinicians and between psychotherapy and pharmacotherapy.

Antipsychotics can be helpful in women with paranoid ideas, transient psychotic episodes, or stress-induced hallucinations, illusions, derealization, and depersonalization. This can support psychotherapy for patients who are easily triggered to paranoid states in groups or intensely socially anxious (with anxiolytic doses).

The use of olanzapine to reduce paranoia, anxiety, interpersonal sensitivity, anger, and hostility in women with BPD is supported by a 6-month double-blind placebo controlled trial (Zanarinii and Frankenberg 2001). Zanarini et al. (2004) suggested a combination of olanzapine and fluoxetine as superior to fluoxetine alone in an eight-week trial of 45 women. A recent small trial suggests benefit from aripiprazole (Nickel et al. 2006),

Antidepressants are commonly prescribed in BPD, frequently for comorbid depression. A specific role for selective serotonin reuptake inhibitors (SSRIs) in BPD in reducing anger, impulsive-aggressive behaviour, and affective lability is supported by a number of double blind randomized controlled trials (RCTs) such as the Rinne et al. (2002) study of 38 women, and consistent with the aetiological hypothesis of serotonergic dysfunction. Some patients require increased doses up to 80 mg/day of fluoxetine. It is thought SSRIs may stimulate neurogenesis in the hippocampus and reduce hyperactivity of the hypothalamic–pituitary–adrenal (HPA) axis by reducing hypersecretion of corticotrophin releasing factor. A study of 30 borderline women given 150 mg/day fluvoxamine found a significant reduction of adrenocorticotropic hormone (ACTH) and cortisol response to combined dexamethasone and corticotrophin-releasing hormone in women with childhood abuse (Rinne et al. 2003).There is also evidence for venlafaxine, though this is more dangerous in overdose. Some women may benefit from the additional anxiolytic effect of mirtazapine.

Carbamazepine and sodium valproate are sometimes used to reduce impulsive outbursts. Though there is some supporting evidence (Frankenberg and Zanarini 2002), it is weak and both carry risk of teratogenicity. Some small recent RCTs of topiramate and lamotrigine showed reduction in anger in women with BPD (Nickel 2004; Tritt 2005; Loew 2006). The NICE guideline highlights this as an area for further research.

Women with BPD frequently suffer insomnia and should be given basic sleep hygiene advice. Any hypnotic medication should be prescribed for short periods only, to restore sleep routine and limiting potential for abuse. A sedative antihistamine can be a useful alternative.

From Bateman and Fonagy (2004):

Psychoanalytic thinking informs most current conceptualizations and psychotherapeutic work with women with BPD. The capacity to use psychoanalytic psychotherapy is complicated by reduced ego strength and reflective capacity, affective instability, and difficulty working with ‘as if’ interpretations. Though patients tend to be help-seeking and form intense relationships with their therapist, there are high drop-out rates (60%) and difficulty forming a therapeutic alliance (77%) (Frank 1992). The attachment context of ongoing treatment stirs up intense feelings and is typically complicated by acting out such as self-harm, substance misuse, and violence, and high demands of therapists with pressure to ‘special treatment’ and boundary violations.

Intensive psychoanalytic psychotherapy can be beneficial and contribute to lasting change in some patients, but needs to be long term and is extremely challenging for both therapist and patient, and should be done by experienced therapists or with expert supervision. Interpretations can be particularly problematic. In presenting an alternative view, the therapist can be experienced as abandoning or critical, amplifying anxiety and threat of fragmentation, and increasing the pressure to splitting and projection in an attempt to preserve psychic equilibrium in the face of overwhelming affects and fantasies—with the danger of a rapidly escalating disturbed paranoid state and behavioural outburst. Managing this requires attention to countertransference–transference factors and flexibility of technique while working within the analytic frame. Analysts have also emphasized the importance of non-verbal factors in working with patients with such early developmental difficulties (Stewart 1992).

Valuable thinking about psychotherapy with BPD emerged from the Menninger project, a 25-year prospective study of psychoanalysis and supportive psychotherapy for patients with personality disorder (Wallerstein 1986). It suggested patients with low ego strength did better in supportive therapy and that the most disturbed patients (with borderline, paranoid features, drug and alcohol addiction) required a modified analytic approach using supportive-expressive therapy with attention to negative transference, focus on here and now interactions, a network of informal support, and periods of hospitalization (Kernberg 1972). Attention to the therapeutic alliance and transference emerge consistently as important in achieving good treatment outcomes in working with BPD (see Gabbard 2005). These insights are reflected in newer psychotherapies developed specifically for BPD, all of which offer a structured, supportive, here and now therapeutic approach, with attention to the therapeutic alliance and flexibility that can incorporate periods of hospital admission.

A number of studies support the usefulness of psychoanalytically-based treatment for BPD in individual, group, day hospital, and therapeutic community settings.

A trial of twice-weekly psychodynamic-interpersonal psychotherapy showed significant improvements in 48 patients with BPD, with reduction in episodes of self-harm and violence, time off work, number and length of hospital admissions, frequency of drug use, and self-report symptom index. This was sustained at five-year follow-up which also demonstrated substantial healthcare cost savings (Meares et al. 1999). Guthrie (2001) demonstrated the effectiveness of 12-month psychodynamic-interpersonal therapy in an RCT for patients who self-harm.

Mentalization-based treatment (MBT) was developed by Bateman and Fonagy (2004). In their model, unstable or reduced capacity to mentalize is a core feature of BPD, explaining the observed clinical characteristics. Fostering the development of this capacity is believed to underlie all effective treatments of BPD, and is the primary focus in MBT. This approach can be applied in individual, group, and family therapy, and its effectiveness has been demonstrated in a partial day-hospital setting.

The relatively safe attachment relationship with a therapist and the therapeutic milieu is crucial in providing a secure base relationship context in which the individual can start to find their own mind through representations in the mind of the other. Feeling understood itself generates a sense of security which fosters further mental exploration. Therapists typically construct in their minds an image of the patient’s mind, naming feelings and cognitions and spelling out implicit beliefs. For the patient this is a crucially different experience from that of a parent who is unresponsive or imposes their own disturbed or reactive experience. Therapists work collaboratively to foster mentalization in patients and sustain this in the face of inevitable challenges. Importantly, affective arousal can trigger a loss of mentalizing capacity and this is often marked in therapeutic contexts. Both mentalization and the failure to mentalize are understood as normal occurrences—and exploration of therapist failures to mentalize (alongside patient struggles) and the restoration of this—is a valuable aspect of therapy. Though personal history and experiences remain important in formulation, in MBT the key to improvement is promoting the capacity to mentalize rather than resolving problematic experiences or understanding unconscious conflict.

MBT applied in an individual or group setting involves a spectrum of interventions from supportive and empathic—through clarification and elaboration to basic mentalizing, interpretative mentalizing, and mentalizing the transference.

From Bateman and Fonagy (2006):

A randomized controlled trial of 38 patients with BPD demonstrated the effectiveness of MBT applied in a psychoanalytically-orientated partial day-hospital programme for 18 months (Bateman and Fonagy 1999). The partial hospitalization included once weekly individual psychotherapy, thrice weekly group psychotherapy, once weekly expressive therapy, a weekly community meeting, and regular meetings with care coordinator and psychiatric medication review. The control group included regular psychiatric review with medication and admission as appropriate and outpatient and community follow-up. In the treatment group, the study showed significant reduction in suicide and self-harm attempts, number and duration of hospital admissions, use of psychotropic medication, self-report depression, anxiety, general symptom distress, and improvements in interpersonal function and social adjustment. In comparison, the control group showed limited change or deterioration in these variables. These improvements began after six months and continued to the end of treatment.

A follow-up study (Bateman and Fonagy 2001) showed these gains were maintained over 18 months after completing treatment and showed statistically significant continued improvement—suggesting that treatment enabled patients to better negotiate stresses and strains of everyday life without resorting to old coping strategies. For example, suicide attempt in the previous six months fell from 95% on admission to 5.3% at 18-month follow-up in the treatment group. Assessment of service utilization costs showed no difference between groups pre- and during treatment, but a trend for costs to decrease during the 18-month follow-up in the treatment group. This shows that the intensive day-hospital treatment is not only significantly more efficacious—but no more costly than psychiatric care with predicted long-term savings longer term (Bateman and Fonagy 2003).

A more recent trial is investigating MBT applied in an outpatient twice weekly setting with patients receiving one individual and one group session per week for an 18-month treatment period. This is compared with patients randomly allocated to a control treatment of one individual and one group session per week supportive psychotherapy. The results are not yet available.

There have been interesting recent developments and applications of MBT in family work (SMART; Fearon et al. 2006) and mother–infant work (Minding The Baby; Sadler et al. 2006).

Transference-focused psychotherapy (TFP) is a structured, manualized, time-limited outpatient psychodynamic psychotherapy based on Kernberg’s psychoanalytic object relations-based conceptualization of borderline personality (Clarkin et al. 1999).

The treatment aims to contain suicidal and split-off behaviours, and to resolve identity diffusion through integrating projected aspects of self-fostering the development of a coherent sense of self and others. In psychoanalytic language this constitutes a move from paranoid-schizoid to depressive position functioning. This is done through promoting reflection on the mental states of self and other through active exploration of feelings, motivations, and beliefs as they arise in the therapeutic relationship, and within the safety of the therapeutic frame. These typically reflect activated, characteristic pathological object relations dyads in reference to the therapist (such as Abuser–Victim or Gratifying provider-dependent child). Clarification of the cognitive content of intense associated affective states provides containment, reduces acting out, and helps develop a capacity for reflection and affect modulation. It involves therapist awareness and containment of countertransference. Importantly, the therapist confronts contradictions in the patient’s perceptions and affects in relation to themselves, and starts to interpret role reversals as they manifest in the here and now of the session. The therapist will interpret splitting and defensive motivations for this (e.g. defence against depressive anxieties or paranoid fear), alongside interpretation of underlying object relations dyads. The woman becomes increasingly aware of contradictions and oscillations between idealized and persecuting images of the therapist—and begins to accept the full range of her internal experience. This facilitates the gradual integration of idealized and persecutory experiences with a toning down of the intensity of affect and consolidation of self and object representations. The therapist generalizes experiences in therapy to relations outside, consolidating self and object representations and facilitating the woman’s capacity to reflect, experience, and relate to self and others in a more healthy way.

An initial study of 23 borderline women treated for 12 months showed low drop out (19%) and significant reduction in suicide attempts and severity of self-harm. Women had fewer inpatient admissions, emergency room attendance, and inpatient days, and showed reduction in global symptoms with improved social functioning in friendships and work (Clarkin et al. 2001). More recently, a randomized controlled study of 90 patients with BPD comparing TFP with DBT and dynamic supportive therapy for one year showed significant improvements in depression, anxiety, global functioning, and social adjustment in all three groups. It showed significant improvement in suicidality with TFP and DBT only, and significant improvement in anger and impulsivity with TFP and supportive treatment. TFP was also significantly predictive of change in irritability and ratings of verbal and direct assault (Clarkin et al. 2004, 2007).

Dialectical behavioural therapy (DBT) is an adaptation of CBT developed by Linehan (1991) working with parasuicidal women with BPD. It is manualized with supportive, behavioural, and cognitive components and an emphasis on developing a positive therapeutic alliance (Linehan 1993). Typically, treatment is outpatient twice weekly for one year with one individual session (with homework) and one group session for educational skills training.

In Linehan’s model, biological emotional vulnerability interacts with an invalidating family environment leading to core difficulties with emotional regulation and uncertainty about the validity of inner experience. DBT advocates a supportive and empathic therapeutic relationship, validating the woman’s experience of themselves and building a positive therapeutic alliance.

DBT targets problem behaviours in BPD which are formulated using a behavioural functional analysis; an initial trigger leads to emotional dysregulation in the subject, who resorts to behaviours such as self-harm, drug, and alcohol use, binging and purging, isolation, suicidal ideas, or reckless behaviour to reduce or avoid painful emotions. This provides temporary relief—however, the continued use of this strategy reinforces emotional and behavioural problems. This vicious cycle is addressed collaboratively using a problem-solving approach to help the patient recognize the sequence and learn specific skills to interrupt the cycle at particular points.

DBT teaches new ways to manage emotional distress through improved capacity for self-recognition (as angry, sad, alone), greater tolerance of distress, and alternative strategies to regulate feelings without recourse to problem behaviours; stopping the problem behaviour stops the reinforcement. Vulnerability to cues triggering emotional dysregulation is addressed through behavioural exposure and stimulus control. Problem solving may suggest specific skills training such as strategies to improve interpersonal effectiveness.

Mindfulness training (developed out of Zen Buddhist mediation) has been developed as a core skill in DBT. Exercises include attention to the immediacy of experience, such as observing or describing thoughts or feelings as they arise, helping develop a capacity for self awareness and reflection and a tolerance of the experience of emotion. Importantly, arising mental contents are related to non-judgementally in contrast with an automatic ‘bad—need to get rid of’ attitude. Mindfulness is approached as a skill that will improve with practice—and it can be very positively reinforcing for women who feel at the mercy of uncontrollable mental experience to discover that their focus, concentration, and self-awareness can improve with regular practice over time.

The dialectical approach considers problem behaviours and the application of new skills within the wider system, recognizing the complexity of change. Factors within the patient and in their relationships that may impede change are understood in terms of inevitable dialectical tensions between contradictory positions. There is an explicit focus in DBT on the recognition of these, and the need to find a synthesis.

Linehan (1991) showed DBT to be effective in a randomized controlled trial of 44 women with BPD who had made at least two suicide attempts in the past five years, one within eight weeks. The control group (TAU) showed significantly increased rates of suicide attempts, inpatient days, and drop out. However, there were no differences in measures of depression, hopelessness, or reasons for living, and at one-year follow-up the treatment control differences were not sustained. Subsequent studies have confirmed efficacy in reducing parasuicide in outpatient and inpatient settings, but clinically significant change was not sustained at follow-up.

In cognitive therapy BPD patients are formulated in terms of characteristic basic assumptions, dichotomous thinking, and a weak sense of identity leading to characteristic affects and behaviour that reinforce core beliefs in self-perpetuating cycles resistant to modification by individual experiences. Beck emphasizes the interaction between childhood environment and biological predispositions (temperament) resulting in the development of maladaptive cognitive, affective, motivational, action, and self-regulatory schemas, driving behavioural strategies that are dysfunctional in certain situations (Beck et al. 2004).

In women with BPD, typical basic assumptions include ‘the world is dangerous and malevolent’ with core beliefs such as ‘I am powerless and vulnerable’, ‘I cannot cope alone’, resulting in avoidance tackling problems and overdeveloped help-seeking and dependence behaviours, reinforcing vulnerability. These core beliefs, such as ‘I am inherently unacceptable’ and ‘no one will ever love me’, lead to chronic anxiety in relationships and self-punishment. These are intensified by dichotomous thinking, and rapid switches between extreme views compounding an unstable sense of identity. Goal confusion leads to ineffectiveness and poor motivation, further reinforcing helplessness, unacceptability, and dependence. For Beck, the borderline dilemma is feeling helpless in a hostile world without a source of security, vacillating between dependence and avoidance of others—unable to trust, rely, or feel safe in either position. Safran and Segal (1990) emphasize the interpersonal context, showing how schemas drive behaviours that provoke responses from others that confirm underlying assumptions.

Beck (2004) delineates standard cognitive and behavioural strategies to address dysfunctional schemas and behaviours including identifying goals, identifying and confronting schemas and core beliefs, and explicitly linking them to maladaptive behaviours. Dichotomous thinking is addressed through cognitive restructuring of beliefs associated with childhood and past traumas to help the patient develop more appropriate and adaptive behaviours to situations they currently face. Self-destructive behaviours and issues such as impulse and emotional control are specifically targeted.

Cognitive therapy has been adapted for working with BPD with longer treatments (often over a year) and availability for crisis contact between sessions. There is considerable attention to building a collaborative therapeutic alliance which is inevitably complicated by the patient’s interpersonal difficulties. The therapeutic relationship may be used as a ‘relationship laboratory’ where powerful emotional reactions to the therapist are explored and ‘transference’ is understood cognitively in terms of underlying generalized beliefs and expectations. Misconceptions and misunderstandings are openly explored and therapists are encouraged to attend to countertransference feelings of anger, frustration, or attribution of malevolent intent. There is also explicit attention to issues stirred up by endings and breaks (Davidson 2000).

Young (1999) developed the concept of Early Maladaptive Schemas (EMS) that develop in response to unmet emotional needs in early dysfunctional family relationships, and are continually elaborated. Events activate these schemas, leading to distortions in thinking, powerful affect and problematic behaviour, and threatening a sense of identity. This results in schema coping behaviour as the patient’s best attempt to stabilize. He also emphasizes schema maintenance, schema avoidance, and schema compensation.

Schema-focused therapy (SFT) has been developed as an intensive longer-term cognitive treatment for BPD (Young 2003). The model identifies four schema modes specific to BPD: detached protector, punitive parent, abandoned/abused child, and angry/impulsive child. It addresses these through a range of behavioural, cognitive, and experiential techniques that focus on the therapeutic relationship, daily life outside therapy (including homework assignments), and past (traumatic) experiences. The aim is to facilitate the development of alternative schemas so that a patient’s experience and behaviour is no longer dominated by dysfunctional schema.

Studies have demonstrated the benefits of manual assisted cognitive therapy and problem-solving therapy developed as brief crisis interventions after deliberate self-harm, and adapted for personality disorder (Evans et al. 1999; Huband et al. 2007). Other studies suggest benefits of cognitive therapy for BPD, with some evidence for improvement maintained at 18-month follow-up (Tyrer et al. 2003; Brown et al. 2004; Weinberg 2006).

Most recently, the BOSCOT trial (Davidson et al. 2006) randomized 106 BPD patients with BPD to 30 sessions of CBT plus TAU or TAU control group. The CBT focused on maladaptive core beliefs and over-/underdeveloped behavioural strategies (e.g. self-punishment/self-nurturance). Both treatment and control groups showed improvement at one year sustained after a further year follow-up in outcomes including inpatient hospitalization, suicidal behaviour, and use of accident and emergency treatment facilities. Patients with CBT had significantly less suicidal acts over the two years, dysfunctional beliefs, state anxiety, and symptom distress. No significant difference between groups was demonstrated in cost effectiveness or improvement in quality of life.

An interesting RCT of 88 BPD patients compared SFT with TFT, each delivered twice weekly for three years. This showed significant treatment effects with both treatments, with improved quality of life, reduction in BPDSI scores, and reduction in psychopathology and personality pathology with all effects apparent after one year. Survival analysis showed a significant effect in favour of SFT with greater improvement on abandonment fears, relationships, identity disturbance, impulsivity, parasuicidal behaviour, and dissociative and paranoid ideation (Giesen-Bloo et al. 2006)

Cognitive analytic therapy (CAT) was developed by Ryle as an integration of psychoanalytic and cognitive therapy. Like CBT it is time limited, problem orientated, structured and collaborative and uses behavioural methods and specific cognitive tools. Ryle revised and developed his original model specifically for patients with BPD (1997).

The therapist and patient work collaboratively to formulate the patient and set goals for therapy. The first four sessions identify target problems (TPs) (e.g. worthlessness, cutting, relationships) and target problem procedures (TPPs) which perpetuate them. TPPs include traps (vicious circles where negative beliefs generate behaviours with consequences that reinforce the beliefs), dilemmas (actions based on falsely dichotomous choices), and snags (ways in which the patient undermines their own fulfilment of aims). These are understood as dysfunctional ways of coping with feelings that perpetuate core pain, and are thought to originate in early relationship experiences which form a blueprint for subsequent relationships. These are conceptualized as reciprocal roles based on early relationships (neglecting–neglected) or on compensatory fantasy (perfectly caring–perfectly cared for) and recurrently manifest in the patient’s relationships—including the therapeutic one. Each pole of the reciprocal role has an associated mood and self state. Patients move between these in response to internal and external triggers.

The therapist’s understanding of the patient is shared through the reformulation letter explicitly linking target problems, target problem procedures, childhood experiences, and core pain. This narrative reconstruction of the patient’s story from childhood to current difficulties can be very moving for patients who may feel truly heard, thought about, and understood for the first time. The therapy uses a wide range of techniques including diary writing, imagery, no-send letters, cognitive behavioural experiments, and reciprocal role interpretations to promote insight and behavioural change.

BPD is understood primarily in terms of rapidly switching dissociated self states that explain the characteristic intense unstable relationships, affect instability, and identity disturbance. For example, an idealizing–idealized pattern with behaviours seeking perfect care (and to avoid abandonment), precarious, and prone to switch to an abused-abusing state. Self-harm may be in a self-abusing or self-punishing role, or an attempt to escape an emotionally void blank state, or reclaiming an active role when faced with powerlessness. Anger may be the rage of an abused child or identification with an aggressive abuser role. Chronic feelings of emptiness are understood in terms of early unresolved deprivation, continuing failure to get emotional needs met, and ongoing insecurity.

This understanding of the patient is presented diagrammatically in the self states sequential diagram (SSSD) which plots the patient’s self states, the transitions between them, and the behavioural procedures generated by each. This can be used by the therapist to reflect on events and mood shifts both outside the session and within. Typically a state shift may be triggered in the session so that the therapist is acutely and suddenly experienced as depriving or abusive at that moment threatening the therapeutic alliance. The SSSD becomes a valuable tool at this point for therapist and patient together to work out where they are on the map and reflect on the process and precipitant. As the patient becomes practised at recognizing her own states, state shifts, and identifying precipitants, the SSSD is something she can increasingly use outside sessions to help make sense of her subjective experience in relationships more widely. It is hoped that the continued self-monitoring will develop the patient’s own capacity for reflection, reduce acting out associated with state/mood switches, and facilitate a more integrated sense of self.

Ryle understands BPD patients’ difficulties as arising from deficits at three levels of development originating in childhood experiences of neglect, unpredictability, and commonly sexual or physical abuse. In combination with temperament and life events, these result in a restricted and distorted reciprocal role repertoire; dissociation between split-off aspects of self and limited capacity for self-reflection.

Ryle believes CAT provides a corrective emotional experience alongside intellectual understanding in promoting insight and behavioural change. He emphasizes the therapeutic relationship and explicit attention to transference and countertransference and issues stirred up by termination. The therapy for BPD is 24 sessions, with follow-up at one, two, three, and six months. The reformulation letter, the SSSD, and the goodbye letter are tools the patient takes away to help hold on to the work achieved in therapy. Ryle believes CAT helps patients develop a more integrated sense of themselves and their past, enabling a greater sense of control and responsibility for their lives supported by an internalized sense of the therapist.

A descriptive study of 27 patients offered 24 sessions plus four follow-up sessions over a year showed significant improvement in symptom and interpersonal outcome at six months post treatment (Ryle and Golynkina 2000), indicating the value of further randomized-controlled research to demonstrate efficacy.

This time-limited supportive therapy was developed for patients with depression and. focuses systematically on interpersonal sensitivity, role transitions, interpersonal disputes or losses, linking each to changes in mood. It has been recently adapted for patients with BPD with a small trial suggesting improvement in symptoms of depression and mental distress (Markowitz 2006). A trial comparing fluoxetine plus IPT for 39 patients (62% women) with BPD and comorbid MDD showed efficacy compared to fluoxetine alone in reducing depressive symptoms and self-rated psychological and social functioning quality of life measures (Bellino 2006).

Groups are very helpful in working with women with BPD. The group becomes a microcosm in which object relations and primitive phantasies and defences such as splitting and projection are externalized. Within the containment and facilitation of an ongoing group, patients can learn from each other and develop their reflective skills—often being very acute in their observations. It may be easier to accept confrontation and interpretation from fellow members than the therapist, and they can titrate their level of contact. Therapist interpretations may be more tolerable as part of a group theme, and with a dilution of dependency needs. Patients are encouraged to be responsible for thinking about themselves and each other and the ‘group’ as whole. In an outpatient psychotherapy setting, BPD patients are often seen in a mixed group with patients with neurotic or other personality disorder features where their immediacy of affect and directness of expression, and willingness to express dependency needs or feelings of rejection can be extremely valuable to others. See Garland (in press) for a thoughtful and coherent account of psychoanalytic work with borderline patients in a slow open long-term outpatient group. A randomized controlled trial by Munroe-Blum and Marziali (1995) showed significant improvement after 25 weekly sessions of interpersonal group therapy followed by five biweekly sessions. Gains were sustained at 12- and 24-month follow-up, and equivalent to the individual dynamic therapy 40 sessions control group. Group therapy is an important component in most specialist treatment programmes for personality disorder in therapeutic community, day hospital, and intensive outpatient settings. Patients usually have ongoing additional individual therapeutic contact which can help work through issues stirred up in the group context.

Family work may be important for couples or younger women or adolescents still living with their families. Relationships may be highly conflictual and it is important any professional contact with the wider family is with the explicit consent of the patient. The clinician needs to be sensitive in exploring family dynamics, giving space to the views of all family members—which may vary hugely. Characteristic interpersonal interactions may homeostatically maintain a pathological system in which the women or girl with BPD is ‘ill’ or ‘bad’. Parental disturbance may be split off and projected into an adolescent who becomes projectively identified and expresses symptoms. Parents may have been neglectful or abusive and failed to provide structure or guidance required for healthy development. Or there may be over involvement with the daughter crucial in meeting parental needs, and lacking support to develop as an individual. Gunderson (2001) has also suggested a role for psychoeducational work with families of BPD patients to help them appreciate the complexities of the patient’s struggle in relationships and in treatment.

Short-term mentalization and relational therapy (SMART) is a recently developed integrative family therapy that addresses problems in family relationships in terms of difficulties in mentalizing, exacerbated by stress and emotional arousal and setting up repetitive negative cycles of non-mentalizing interactions. The therapist fosters mentalizing in the family through modelling, active questioning, structured games, and homework. See Fearon et al. (2006).

The therapeutic community was first described by Main as an institution in which the setting itself restores morale and promotes psychological treatment. The most well-known example is the Henderson Hospital whose structure and working practices demonstrate characteristic features of permissiveness, reality confrontation, democracy, and communalism. Permissiveness encourages the enactment of disturbed feelings and relationships which can then be examined by staff and patients alike. Staff/patient differences are minimized with patients having the majority vote in decision making—particularly regarding admission, disciplining, and discharge. There is daily large group therapy alongside a range of occupational activities. Dolan et al. (1992) showed a reduction in global severity index scores in 95 patients with severe personality disorder (est. 87% BPD). Though this was considered a costly residential setting, Dolan et al. (1997) demonstrated the cost-effectiveness of one year of residential treatment through reducing inpatient admissions, self harm, psychological distress, and improving self-esteem in the year after treatment.

Main himself developed the Cassel Hospital, a residential psychodynamic psychotherapy setting offering a combination of intensive individual and once weekly group psychotherapy alongside community meetings, work groups, and structured activities, with psychotropic medication as required. A recent prospective study at the Cassel Hospital compared one-stage inpatient treatment with a two-stage step down programme consisting of 6 months of residential followed by 24–28 months of psychosocial outpatient/community treatment (Chiesa and Fonagy 2000). This involved continuing twice weekly group psychotherapy, once weekly psychosocial outreach nursing, regular psychiatric review, and networking with other healthcare agencies. Subjects allocated to the two-stage model showed significantly better improvement on most measures including self-harm, attempted suicide, psychiatric readmission rates, and more cost effective (Chiesa 2002), compared with both inpatient-only treatment and psychiatric outpatient treatment as usual. They also did significantly better at follow-up at one, three, and six years on global measures of mental health and social adjustment (Chiesa et al. 2006).

Recently there has been a move away from residential therapeutic community treatments to intensive psychodynamic day hospital services for the treatment of BPD.

A number of trials have demonstrated the efficacy of this approach with significant reductions in symptoms and health service utilization that are sustained at follow-up (Bateman and Fonagy 1999, 2001; Karterud et al. 2003). These typically provide a structured therapeutic milieu with a combination of individual and group psychodynamic treatments, other expressive groups (e.g. art therapy), and activity groups (e.g. gardening). There are clear rules about drug, alcohol use, and violence, and patients are involved in community responsibilities and decisions. There is an emphasis on ongoing supervision and team reflection on dynamics within the staff–patient group as a whole to contain working with patients. Based within psychiatric services, patients will have CPA review, psychotropic medication, and liaison with wider services working with the patient as required.

Hospital admissions of BPD patients tend to be complicated by intense interpersonal dynamics with strong countertransference responses and splitting within staff teams. There is frequently a degree of acting out by staff as well as patients in the context of powerful projective processes. Patients may be given special care by some and hated and deprived by others. They may become attacking or refuse to engage in an overall treatment plan—resulting in hopelessness and futility amongst staff and pressure to discharge. For such reasons it is advisable for women with BPD to work through crises with increased outpatient or community support whenever possible. This may include daily contact with a home treatment or crisis resolution team and can help foster the patient’s autonomy while staying sensitive to their level of distress and monitoring risk.

However, for some patients working in ongoing outpatient or partial hospital treatment, brief crisis admission may be necessary to manage acute risk if they become acutely suicidal, self-destructive, or transiently psychotic. The staff and hospital milieu can provide important concrete containment and an auxiliary ego function. Reflective practice groups are important in containing the emotional impact on staff of working with disturbed patients to preserve a thoughtful, therapeutic milieu. Although controlling strategies such as restraint, medication, and one-to-one monitoring may be required at times, the aim is to help the patient take responsibility for self-control. Staff can help patients identify precipitants of crisis, delay impulsive action, explore alternatives, and anticipate consequences of actions. Suicide attempters are often experienced as manipulative, but they are at increased risk of actual suicide. It is useful to engage patients actively in considering risk and criteria for safe discharge. During an admission, open communication between ward staff, and ongoing liaison with the wider team working with patients in the community is essential.

See Gabbard (2005):