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
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