Psychodynamic Psychotherapy and Borderline Personality Disorder: The Evidence Base


Psychodynamic Psychotherapy and Borderline Personality Disorder: 
The Evidence Base


Introduction

Personality disorders are chronic and severe conditions associated with high levels of impairment and suffering.  They present a significant challenge to health care providers because of their resistance to common treatment approaches.  The most common personality disorder in clinical settings is borderline personality disorder (APA, 2001).

Borderline personality disorder has received much attention in the psychodynamic literature over several decades, and a number of distinct theoretical approaches have emerged, each with its own account of the dynamics of the condition, of the developmental pathway that produces it, and of the psychotherapeutic strategy necessary to bring about change.  Despite this attention, there has been relatively little outcome research carried out on this patient group.  This is the case with personality disorder generally, and some of the reviews of the research make suggestions as to why this may be so.  Fernandez-Alvarez et al (2006), for example, highlight factors which make personality disorder patients a difficult population to study.  These include the high degree of co-morbidity between different personality disorders, and between personality disorders and other disorders; the need for complex and multi-faceted treatment approaches; and the logistical problems associated with long treatments and high drop out rates.

Although outcome research with borderline personality disorder may be said to be in its infancy, there is a growing body of findings which constitutes an evidence base for the effectiveness of psychodynamic psychotherapy with this patient group.  This paper provides a review of the literature.  It has been produced by the Psychodynamic Psychotherapy clinical team as part of the critique of the PCT proposal to de-commission the service.


Outcome Research

Most of the early literature on the psychodynamic psychotherapy of borderline personality disorder patients tended to be in the form of anecdotal case reports.  The first attempt to move beyond this towards a more systematised appraisal of the effects of therapy was made by Waldinger and Gunderson (1984).  This involved a survey of eleven experienced therapists, to provide a retrospective assessment of the course and outcome of therapy with seventy eight borderline patients.  Although this study has significant methodological limitations, such as the reliance on subjective and retrospective accounts, it does indicate that many patients made considerable gains during treatment.  These were in the areas of ego functioning, behaviour, object relatedness, and sense of self.  It was also found that the longer patients stayed in treatment, the more they improved.

An early prospective outcome study was carried out by Tucker et al (1987), based on in-patient treatment of borderline patients in a specialised unit.  Forty patients were assessed at admission, discharge, and one and two years follow-up, and the treatment period varied between 6 months and a year.  Treatment was psychodynamically informed, and involved individual, group and milieu therapies.  Findings included improvement in global functioning, the development of more constructive relationships, and reductions in suicide attempts, self-destructive behaviours, and use of hospitalisation.

The first prospective study evaluating the effectiveness of out-patient psychodynamic psychotherapy with patients diagnosed with borderline personality disorder was carried out by Stevenson and Meares (1992).  Thirty patients were treated with psychodynamic psychotherapy twice-weekly for a year.  At the end of treatment participants showed significant improvement on all the measures used, which included number of episodes of violence and self-harm, length of hospital admissions, length of absence from work, and symptom measures.  30% of patients no longer met the criteria for BPD.  Improvements were maintained at 1 year follow-up.  Subsequent papers showed that the improvements were maintained over 5 years (Stevenson and Meares, 1995), and that this approach to treatment had significant cost benefits (Stevenson and Meares, 1999).  One of the features of this study was that subjects acted as their own controls, with behavioural measures taken in the year following therapy being compared with measures taken in the year before therapy.  In another study an attempt was made to compare this treatment group of patients with a waiting list control group (Meares et al, 1999).  Whereas 30% of the treatment group no longer met the criteria for BPD after a year of therapy, there was no change in the diagnosis of the control group, suggesting that the treatment was responsible for the improvements in the original group.

Of lesser significance is a study by Monsen et al (1995).  This was a prospective outcome study involving 25 individuals, most of who were diagnosed with personality disorder, receiving outpatient psychodynamic psychotherapy for a mean period of about 2 years.  Measures were taken before therapy, at termination, and at a mean follow-up of 5.2 years.  At termination there was an apparent 72% reduction in the diagnoses of personality disorder, and a 75% reduction in other diagnoses.  Of 7 patients who were initially diagnosed with borderline personality disorder, 2 still met the diagnostic criteria at termination, and none did so at follow-up.

Munroe-Blum and Marziali (1995), in a controlled trial, compared 22 borderline patients in short-term interpersonal group psychotherapy with 26 borderline patients receiving individual psychodynamic psychotherapy.  Measures of social dysfunction, social performance and symptoms were taken prior to treatment, through to 24 months follow-up.  Significant improvements were made by both groups of patients, and these were maintained at follow-up.  No significant differences were found between the two treatments on any of the measures.

Dolan et al (1997) evaluated the impact of psychodynamically informed impatient therapeutic community treatment on core personality disorder symptoms.  70 patients completed measures of borderline psychopathology at the point of referral to the specialist unit, and then at 1 year after discharge.  A further 67 patients, who were not accepted for treatment, completed measures at referral and 1 year after referral.  Although the untreated group cannot be considered a formal comparison group, the reduction in borderline psychopathology was significantly greater in the treated group.  There was also a correlation between length of stay in the unit and amount of improvement.

Another study based in a therapeutic community was carried out by Wilberg et al (1998).  This was in a day patient setting, and was a naturalistic prospective study investigating, at 3 year follow-up, outcomes in patients who received day treatment alone compared with patients who were given an additional year of outpatient group psychotherapy after leaving the unit.  The results showed that the patients who received the extra outpatient treatment were significantly more improved on a range of measures.  

The first major randomised controlled trial of a psychodynamic approach to borderline personality disorder was carried out by Bateman and Fonagy (1999), in a day hospital setting.  Thirty eight patients were randomly allocated to a psychodynamically informed day hospital treatment programme or to routine psychiatric care.  The day hospital programme involved once-weekly individual psychotherapy and three times a week group therapy.  Over the 18 months of treatment the day hospital patients showed a significant reduction in parasuicidal behaviour, self-harm, and hospitalisation relative to the control group, as well as improvements in self-reported mood and psychiatric symptoms.  In a subsequent study (Bateman and Fonagy, 2001) these patients were found to have maintained their gains at 18 months follow-up, and in fact showed significant continued improvement on most measures compared to the control group.  A further report demonstrated the cost-effectiveness of the treatment programme (Bateman and Fonagy, 2003).  Another follow-up study (Bateman and Fonagy, 2008) looked at the patients 8 years after the initial entry into the trial.  This showed that the psychodynamic treatment group were continuing to do well, with benefits being maintained.  The authors note that what was striking was how badly the treatment as usual group were doing, despite receiving significant service input.

More recently, Bateman and Fonagy (2009) conducted a randomised controlled trial in an outpatient setting, comparing their manualised psychodynamic therapeutic approach, mentalization based treatment (MBT), with another protocol-driven approach, structured clinical management (SCM).  Outcome measures involved rates of suicidal behaviour, self-harm behaviour and hospitalisation.  These were taken for the 6 months prior to treatment, as a baseline, and then at 6 monthly intervals during the 18 months of treatment.  Both treatment approaches were associated with substantially reduced suicidality, self-harm and hospitalisation, and improvements on measures of symptoms, and social and interpersonal functioning, but with MBT showing superiority on most measures.

Fonagy has also been involved in a study looking at the effectiveness of hospital-based psychodynamic treatment for personality disorder (Chiesa and Fonagy, 2000).  Two treatment models were compared: in-patient treatment with no aftercare, and a shorter in-patient admission followed by outpatient psychotherapy.  Allocation to the two models was based on geographical factors, rather than randomisation.  Of 90 patients who started treatment, 75% met the criteria for borderline personality disorder.  The 12 month period covered by the study found significant improvement in patients in both treatment conditions, but patients in the two-stage model improved more quickly and more extensively, on measures such as the Global Assessment Score and the Social Adjustment Scale.  The advantage of the two-stage model was particularly marked for the borderline patients.  A further report (Chiesa and Fonagy, 2003), showed that improvements for both treatment models was maintained at 36-month follow-up, and that the two-stage model produced more stable improvements, as shown by a greater reduction in self-harm, suicide attempts and re-hospitalisation.  Chiesa et al (2004) also compared the patients in the two psychodynamic programmes with patients in general psychiatric treatment, demonstrating that the two-stage model was more effective than both long term residential treatment or general psychiatric treatment in the community.  A more recent paper (Chiesa et al, 2006), comparing the above three approaches, showed that the greater changes in the two-stage model were maintained at 72-month follow-up.  A comparative study also showed that the two psychodynamic treatment programmes were more cost-effective than general psychiatric treatment (Chiesa et al, 2002).

A similar hospital-based psychodynamic treatment programme was studied by Vermote et al (2009).  This was a naturalistic design involving 70 patients, 50% of whom were diagnosed with borderline personality disorder.  The mean length of stay in the treatment programme was 9.2 months.  Assessments were carried out on admission, at 3 monthly intervals, and at 3 and 12 month follow-ups.  A range of outcome measures were used.  The general finding was that the treatment programme was effective, with patients showing considerable and consistent improvement, which was sustained at follow-up.  The study involves an analysis which identifies different treatment trajectories for distinct groups of patients, based on their initial symptom levels and degree of improvement.  Characteristics of these subgroups indicate that better responders to treatment had higher levels of vindictiveness, and more schizoid, paranoid and narcissistic features than poor responders.

Another in-patient study was carried out by Gabbard et al (2000).  This was a prospective, naturalistic outcome study, which monitored 216 patients diagnosed with personality disorder from hospital admission through to one-year follow-up.  35% of the patients had a diagnosis of borderline personality disorder.  Two hospital settings were involved, with similar treatment programs.  These used therapeutic community principles, with a strong emphasis on group and individual psychotherapy.  Significant improvements were noted on a number of measures, such as the Global Assessment Scale, ego function scale, and symptom rating scale, which were maintained at follow-up.

In 2001 Cookson et al published the findings of the Edinburgh Project.  This was a pilot study of the effectiveness of time-limited psychoanalytic psychotherapy with borderline and other severe personality disorders.  This involved once-weekly psychotherapy over a year for 19 patients.  A number of self-report measures were used.  The Personality Diagnostic Questionnaire and the Borderline Syndrome Index were used prior to treatment and at follow-up periods up to 20 months.  The Multi-impulsivity Scale and the Brief Symptom Inventory were used at these points, and at monthly intervals during treatment.  Analysis of the results showed a significant improvement on all measures between assessment and 3 month follow-up, with the improvements being maintained at later follow-ups up to 20 months.

Clarkin et al (2001) examined the effectiveness of Transference Focused Psychotherapy (TFP) with female patients diagnosed with borderline personality disorder.  Therapy was twice-weekly individual psychotherapy for a year.  Assessments were made prior to treatment and after a year of therapy, and involved measures of suicidal behaviours and service utilisation during the previous year, and ratings of symptomatology.  Two sets of data analysis were conducted: on the seventeen patients who completed the year of treatment, and on an intent-to-treat basis which also included six patients who did not complete the year.  In both cases it was concluded that therapy produced considerable improvement in functioning in a broad range of areas.  Clarkin (2002) has also reported on a comparison study between patients treated with Transference Focused Psychotherapy and a matched untreated control group, which confirms the benefits of this treatment approach.

In a later paper, Clarkin et al (2004) report on the setting up of a randomised controlled trial for borderline personality disorder, which involved 90 participants randomised to one of three outpatient treatments: Transference Focused Psychotherapy (TFP), Dialectical Behaviour Therapy (DBT), and supportive psychodynamic psychotherapy.  Treatments were for a year, and each was to be delivered in accordance with the conventions of the particular approach.  Hence TFP was twice-weekly, supportive psychotherapy once-weekly, and DBT was once a week plus a group session.  A range of measures was to be used, before treatment, and at 4, 8, and 12 months (termination).  Preliminary findings were published in 2005 (Clarkin et al, 2005) based on analysis of three of the assessment measures: reflective function, coherence, and attachment.  Reflective function was found to have increased most dramatically for the TFP-treated group, and did not change significantly in the other two groups.  Coherence increased significantly for all three groups, as did security of attachment.  The study was eventually published in 2007 (Clarkin et al, 2007). 

An interesting feature of the research, as noted by the authors, is that it has characteristics of both efficacy and effectiveness studies.  It is similar to an efficacy study in that it used randomisation, manualised treatments, blind raters, and reliably measured outcome variables.  It is similar to an effectiveness study in that it included a range of borderline patients, therapists provided treatment in their private offices rather than a university setting, and use of medication was not standardised.

The main finding of the study was that all three approaches were associated with a broadly equivalent degree of improvement over the year of treatment.  However, there were differences in the changes produced by each therapy.  Transference Focused Psychotherapy and dialectical behaviour therapy were significantly associated with improvement in suicidality, and TFP and supportive psychotherapy were associated with improvement in anger.  Overall, TFP was predictive of significant improvement in 10 of 12 outcome variables, DBT in 5 of the 12, and supportive psychotherapy in 6 of the 12.

Transference Focused Psychotherapy also featured in a randomised trial comparing its effectiveness with that of schema-focused therapy (Giesen-Bloo et al, 2006).  Eighty-six borderline personality disorder patients completed the study, which involved twice-weekly outpatient psychotherapy for up to 3 years.  Outcome measures included 3-monthly ratings of borderline symptomatology and quality of life, and 6-monthly ratings of general psychopathologic dysfunction and personality concepts specific to each treatment model.  Both treatments were found to bring about significant change, as indicated by reduction in borderline symptoms and general psychopathologic dysfunction, increases in quality of life, and changes in personality features.  Apart from quality of life, schema-focused psychotherapy appeared superior in terms of the extent of change produced.

In 2010 Transference Focused Psychotherapy was subjected to another randomised controlled trial comparing it to treatment by community psychotherapists (Doering et al, 2010).  The study involved 104 female borderline patients who were treated with out-patient psychotherapy for 1 year.  Primary outcome measures were drop-outs and suicide attempts, along with a range of secondary measures.  The results showed that the TFP group had significantly fewer drop-outs and significantly fewer suicide attempts.  TFP was also significantly superior in terms of reduction in borderline symptomatology, improvement in psychosocial functioning, improvement in personality functioning, and reduction in psychiatric hospital admissions.

An interesting randomised controlled trial was carried out by Vinnars et al (2005), comparing two psychodynamic approaches to therapy with personality disorders.  156 patients, about a quarter of whom were diagnosed with borderline personality disorder, were randomly assigned to either 40 sessions of the established manualised approach of supportive-expressive psychotherapy or to community-delivered psychodynamic therapy.  What in effect was being compared was a manualised approach typical of efficacy studies, with a nonmanualised approach in a real clinical setting, typical of effectiveness studies.  The authors hypothesised that the former would be more successful, in accordance with a commonly held view.  What they in fact discovered was that there was no difference between the two treatments.  Assessment data were taken at intake into the study and at 1 and 2 years after intake.  At the 1 year, posttreatment, assessment 33.6% of patients no longer met the diagnostic criteria for personality disorder, and at the 2 year, follow-up, assessment this had risen to 46.8%.  Patients in both treatments also made significant improvements in terms of functional impairment, psychiatric symptoms and personality disorder severity.  In a further study using the same data, Vinnars et al (2007) examined whether particular measures predicted treatment outcome for personality disorder patients.  They found that patients with more severe levels of personality disorder had slower rates of improvement, suggesting that longer treatment may be needed for this population.  They also found, however, that patients with higher levels of vindictiveness had higher rates of improvement, and high levels of dominance were significantly related to a higher rate of improvement in the community-delivered psychodynamic therapy compared to supportive-expressive psychotherapy.

Jorgensen and Kjolbye (2007), in a naturalistic outpatient study, examined the outcome of up to 15 months of psychoanalytically oriented psychotherapy for patients with borderline personality disorder.  19 patients were involved in the study, and treatment included individual therapy, group therapy and a psychoeducational group.  A number of patients dropped out of the study, but those that remained in treatment made significant improvements in terms of levels of anxiety and depression, and general level of functioning.  Follow-up data over 32 months showed that positive changes were maintained or improved upon.  This study was a pilot study, and a further, larger scale study involving 100 patients is currently being undertaken.

Another randomised controlled trial was recently published by Gregory et al (2008).  This was a comparison of a manualised psychodynamic psychotherapy with treatment as usual, for borderline personality disorder patients with co-occurring alcohol use disorder.  30 participants were assessed every 3 months during a year of treatment, and the primary outcome measures were parasuicidal behaviour, alcohol misuse and institutional care.  Secondary measures of symptomatology were also used.  Results showed statistically significant improvement on all primary measures for the psychodynamic psychotherapy participants, but not for those receiving treatment as usual.  Most secondary outcome measures also improved significantly for the psychotherapy participants.


Meta-Analyses

Perry et al (1999) reviewed 15 studies covering a number of types of personality disorder and a range of therapies.  They found that all studies demonstrated improvement in personality disorders with psychotherapy, and that pre-post effect sizes were large.  In four studies 53% of patients had borderline personality disorder, and after a mean of 1.3 years in therapy 52% met recovery criteria.  Perry et al (1999) suggest that the recovery rate in these trials is about 7 times faster than the natural course of the disorder.

Leichsenring and Leibing (2003), in a more focused review, examine 22 studies involving either psychodynamic psychotherapy or cognitive behaviour therapy (CBT).  They found that for borderline personality disorder, the effect size for psychodynamic psychotherapy was 1.31, and for CBT 0.95.  Six psychodynamic studies that used measures oriented to the core features of borderline psychopathology yielded an effect size of 1.56.  The psychodynamic studies showed some correlation between outcome and treatment length.

Verheul and Herbrink (2007) review the evidence for different formats and settings for psychotherapy of personality disorders.  They conclude that various psychotherapeutic treatments have proven to be efficacious, in terms of reducing symptomatology and personality pathology, and improving social functioning, but this is particularly the case for outpatient individual psychotherapy.  They suggest there is also evidence for the use of long-term psychodynamic outpatient group psychotherapy, for short-term psychodynamic psychotherapy in a day hospital setting, and for psychodynamically oriented, in-patient psychotherapy programmes.  The evidence mostly applies to borderline, dependent and avoidant personality disorders.

Binks et al (2006) conducted a Cochrane review of psychological therapies for people with borderline personality disorder.  Their inclusion criteria were narrow, in that they only considered randomised controlled trials.  7 of these were included; most involving Dialectical Behaviour Therapy, but one involving a psychodynamic approach.  For the psychodynamic approach, the review concluded that the overall impression was positive, and that the findings were important and clinically meaningful.


Treatment Guidelines

Practice Guideline for the Treatment of Patients with Borderline Personality Disorder (American Psychiatric Association, 2001).

This guideline was produced following a survey of available evidence and clinical consensus.  With regard to treatment selection it states:

‘Certain types of psychotherapy (as well as other psychosocial modalities) and certain psychotropic medications are effective for the treatment of borderline personality disorder.  Although it has not been empirically established that one approach is more effective than another, clinical experience suggests that most patients with borderline personality disorder will need some form of extended psychotherapy in order to resolve interpersonal problems and attain and maintain lasting improvements in their personality and overall functioning.’

The American Psychiatric Association also publishes Guidance Watch (Oldham, 2005) which provides updates on the original guideline.  This states that ‘Evidence and opinion continue to support the recommendation of the 2001 guideline that psychotherapy represents the primary, or core, treatment for this disorder’.  It also comments favourably on the effectiveness demonstrated by recent outcome research, including that of psychodynamic psychotherapy.

Personality Disorder: No Longer a Diagnosis of Exclusion (National Institute for Mental Health, 2003)

As part of the above guidance, Bateman and Tyrer were commissioned to provide a report on the effectiveness of treatments.  Their review did not lead them to prescribe a particular approach, but rather to identify the guiding principles for effective therapy.  These were that therapy should:

‘-be well structured
-devote effort to achieving adherence
-have a clear focus
-be theoretically coherent to both therapist and patient
-be relatively long term
-be well integrated with other services available to the patient
-involve a clear treatment alliance between therapist and patient’

The guidance also states that ‘part of the benefit which severely personality disordered individuals derive from their treatment comes through their experience of being involved in a well-constructed, well-structured and coherent interpersonal endeavour.’

Borderline Personality Disorder: Treatment and Management. NICE Clinical Guideline 78 (National Institute for Health and Clinical excellence, 2009)

The NICE guideline explicitly recognises that the research for all models of psychotherapy is generally at an early stage of development.  It also acknowledges that the evidence suggests that a range of approaches, including psychodynamic, may be effective.  The main recommendation regarding psychological treatment is concerned with the service characteristics that should be in place:

‘-an explicit and integrated approach used by both the treatment team and the therapist, which is shared with the service user
-structured care in accordance with the guideline
-provision for therapist supervision’

It also suggests twice-weekly sessions may be used, and that brief interventions should not be used.

The guideline also states that the limiting factor in providing access to psychological therapies is the very small proportion of NHS staff trained to deliver them to a competent standard.


Summary

Over the past few decades there has been a developing interest in researching the effectiveness of psychodynamic psychotherapy with borderline personality disorder patients.  This has been studied in a variety of settings and modalities: group and individual, in-patient programmes, day hospitals and outpatients.  Over time there has been a progression towards designs of greater rigour: from retrospective accounts, through prospective outcome studies to controlled studies and randomised controlled studies.  Whilst most of the studies suggest that psychodynamic psychotherapy is effective, in the sense of bringing about improvement on various measures in clinical situations, of late that has been a growing interest in demonstrating efficacy, by means of randomised controlled trials (RCTs).  Whilst there is a critique that can be made about the priority given to RCTs within treatment guidelines, what is important to note is that since the publication of the NICE guideline on the treatment of borderline personality disorder the psychodynamic psychotherapy approaches of Mentalization Based Treatment and Transference Focused Psychotherapy have each demonstrated their efficacy in a second RCT.  These two approaches have now each demonstrated their efficacy and their superiority over another treatment in two RCTs.  This is the criteria that NICE regards as the ‘gold standard’, and places them alongside Dialectical Behaviour Therapy.  This should be recognised when the guideline is updated.

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John Fletcher October 2011