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Treatment for Personality Disorder: are there effective strategies?. Prof Anthony W Bateman Bristol 2005. Therapeutic Nihilism About BPD . Early follow-up studies inexorable progression of the ‘disease’ “burnt out” borderlines Condition resistant to therapeutic help

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Treatment for personality disorder are there effective strategies l.jpg

Treatment for Personality Disorder: are there effective strategies?

Prof Anthony W Bateman

Bristol 2005


Therapeutic nihilism about bpd l.jpg
Therapeutic Nihilism About BPD strategies?

  • Early follow-up studies

    • inexorable progression of the ‘disease’

    • “burnt out” borderlines

  • Condition resistant to therapeutic help

    • intensity and incomprehensibility of emotional pain

    • dramatic self-mutilation

    • ambivalence in inter-personal relationships

    • wilful disruption of any attempt at helping


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Re-mapping the course of strategies?

borderline personality disorder


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Remissions and Recurrences Among 275 Patients with BPD strategies?

Percent

Source: Zanarini et al. (2003) Am. J. Psychiat.160, 274-283


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Time to 12 Month Remission for DIPD Positive Cases strategies?(The CLPS Study)

Proportion not remitting

Time from intake in months

Grilo et al., (2004)

JCCP, 72, 767-75.

Remission is defined as 12 months at 2 or fewer criteria for PDs;

Remission is defined as 2 months at 2 or fewer criteria for MDD


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Time to GAF 12 Month Remission for DIPD Positive Cases (The CLPS Study)

Proportion not remitting

Time from intake in months

Grilo et al., (2004)

JCCP, 72, 767-75.

Remission is defined as 12 months at 2 or fewer criteria for PDs;

Remission is defined as 2 months at 2 or fewer for MDD


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Summary of Remission Findings CLPS Study)

  • After six years 75% of patients diagnosed with BPD severe enough to require hospitalisation, achieve remission by standardised diagnostic criteria.

  • About 50% remission rate has occurred by four years but the remission is steady (10-15% per year).

  • Recurrences are rare, perhaps no more than 10% over 6 years.

  • Treatment has no (or only negative) relationship to outcome


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Differential improvement rates of BPD symptom clusters CLPS Study)

  • Impulsivity and associated self mutilation and suicidality that show dramatic change

    • The dramatic symptoms (self mutilation, suicidality, quasi-psychotic thoughts) recede (? respond to treatment)

  • Affective symptoms or deficits of social and interpersonal function are likely to remain present in at least half the patients.

    • anger,

    • sense of emptiness,

    • relationship problems,

    • vulnerability to depression


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What works? CLPS Study)

What does not work?


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Summary of what works and clinical implications CLPS Study)

  • Modified rather than ‘pure’ psychotherapeutic treatments for BPD are most extensively researched

  • Evidence from randomized trials that structured treatments employing DBT, TFP, MBT, SFT have efficacy over routine care

  • Because contrast is commonly to routine care, difficult to ascertain whether outcomes are due to the structured nature of the programs or their therapeutic orientation

  • Since clinicians working in this area are clear about the importance of offering structure for these patients, disaggregation of structure from orientation is clearly not an option.

  • More realistically, studies need to contrast one orientation against another in the context of high levels of structure, and also against routine care.

  • This will require a much larger sample size than has been mustered by any extant trial, and there are practical problems in achieving this


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Summary of what works and clinical implications CLPS Study)

  • Competence and training of senior clinicians who can offer supervision is especially important

  • ‘Nonspecific’ issues may be especially pertinent when considering the performance of evidence-based treatments in routine practice e.g. context

  • Since systemic factors may be as relevant to success as type of treatment, pragmatic trials would be useful to indicate the conditions required to implement evidence-based therapies in routine services

  • Therapist factors are increasingly considered as important for outcomes


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Psychopharmacological studies CLPS Study)

  • Medication usually aims to manage specific symptomatic manifestations of personality disorders

  • There is evidence for the efficacy of this approach, but there is no drug treatment of choice for personality disorders

  • Patients vary markedly in the domains in which impairment is presented, and hence the extent to which medication is indicated

  • A wide range of medications are used in clinical practice, including neuroleptics, antidepressants and mood stabilizers


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Psychopharmacological studies CLPS Study)

  • Recent reviews indicate that there is relatively little research evidence on which to base treatment recommendations (Roy & Tyrer, 2001; Sanislow & McGlashan, 1998; Soloff, 1994)


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Psychopharmacological studies: Practice CLPS Study)

  • Waldinger and Frank (1989) surveyed 40 American clinicians in private practice with experience of psychotherapy with borderline patients

    • 90% prescribed medication

    • 87% reported that patients abused their medication at some time

  • Many PD patients have specific problems with dependency on drugs and on individuals, and have a potential for abusing both (Elkin, Pilkonis, Docherty et al, 1988a, 1988b; Perry, 1990).

  • Trials of long-term maintenance therapy have shown little additional benefit beyond the acute phase (e.g., Cornelius, Soloff, Perel, & Ulrich, 1993).

  • Short-term adjunctive use of medication may be important in the management of these patients (Soloff, 1994).




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The paradox of the outcome of BPD CLPS Study)

  • Many treatments show some effectiveness

    • 97% of patients receive outpatient of care

    • average of 6 therapists

  • The disorder has a positive natural progression, irrespective of treatment

  • Historically, experts agreed about the treatment-resistant character of the disorder

  • TAU is only marginally effective (Lieb et al, 2004)

  • Unmodified psychoanalytic and cognitive treatments probably don’t work


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Suggestive evidence for the reality of iatrogenic harm CLPS Study)

  • Classic follow-up of patients treated in the 1960s and 1970s (Stone, 1990)

    • 66% recovery only achieved in 20 years

    • 4 times longer than recent studies

  • One year hospitalisation is significantly less effective than 6 months hospitalisation (Chiesa et al, 2003)

    • The iatrogenic effects of hospitalisation persist at 72 months follow-up

  • Brief manual-assisted cognitive therapy slightly increases the likelihood of self harm relative to treatment as usual with PD patients (Tyrer et al, 2004)

  • Improvements in treatment outcome may be a consequence of the changing pattern of healthcare in the US

    • reduced the likelihood of iatrogenic deterioration associated with damaging side effects of lengthy psycho-social treatment


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Process of Change CLPS Study)

  • “…very little support for the view that any one class [of interventions and techniques] is particularly effective.”

  • “quite likely that all procedures have an effect when used on a compatible patient…

  • “Because the field has been so preoccupied with finding a treatment or cluster of procedures that work across patient groups,…work remains to identify the patient factors that determine compatibility.” Beutler, et al., 2005

  • % variance accounted for by techniques is small; therapist variance is larger (Wampold)

  • Need research on therapist, patient, interaction (Beutler)

  • In BPD “it is difficult to ascertain whether outcomes are attributable to the structured nature of the programs or the therapeutic orientation and models which they employ.” Roth & Fonagy, 2005, p.318


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What induces change in BPD? CLPS Study)

  • Validation in DBT as a mechanism of change – results were inconclusive (Linehan, Dimeff, Reynolds, et al, 2002; Linehan & Heard, 1993; Shearin & Linehan, 1992)

  • Adding a DBT skills training group to ongoing outpatient individual psychotherapy does not seem to enhance treatment outcomes

  • Given that DBT is described as primarily a skills-training approach (Koerner & Linehan, 1992) this finding indicates that the central skills training component of DBT may not be of primary importance

  • Assessment of pre and post skills ability unavailable

  • No evidence of change mechanism in MBT


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How change occurs in therapy with BPD CLPS Study)

  • Interpersonal mechanism of change

    • Change occurs not through insight, catharsis, or negotiation

    • Change occurs through new emotional experience in the context of attachment salient interactions

    • Indicative evidence that Reflective Function changes in TFP

  • Not the content of therapy but the process of treatment


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Adverse reactions and ordinary mechanisms of therapeutic change

  • Psychotherapies interface with a range of processes associated with technique (distorted cognitions, coherence of narrative, expectations of the social environment, expectations of the self – hope)

  • A generic factor in common to all these:

    • Consideration of one’s experience of ones own mental state alongside that which is presented through therapy (by the therapist, by the group)

  • Assumes appreciating the difference between ones experience of ones own mind and that presented by another person

  • We assume that the integration of current experience of mind with alternative views is foundation of the change process (Allen and Fonagy, 2002)


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Reduced appreciation of mind change vulnerability to therapy

  • Individuals with BPD have impoverished model of mental function

    • Own and others’

    • Schematic, rigid, extreme ideas about states of mind

  • Creates vulnerability to

    • Emotional storms

    • Impulsive actions

    • Problems of behavioural regulation

  • Consequently unable to compare

    • A self-generated model

    • Model presented by ‘mind expert’

  • Maladaptive consequences

    • Accept alternatives uncritically, without integration, (un-therapeutic)

    • Reject them wholesale  drop-out of therapy


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The danger of ‘psychotherapies’ for BPD is provision of mind states by a ‘mind expert’

  • The therapist’s general stance may often in itself be harmful, however well-intentioned

    • ‘I think what you are really telling me …..’

    • ‘It strikes me that what you are really saying…’

    • ‘I think your expectations of this situation are distorted’

    • ‘I think what you should do is…’

  • A person who cannot discern the subjective state associated with anger cannot benefit from

    • Being told that they are feeling angry

    • And what the underlying reasons for the anger might be


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The fate of ‘mind expert’ view about the inner world of BPD patients

  • It can only be accepted as true or rejected outright

  • Dissonance between patient’s inner experience and external perspective is not appreciated  bewilderment  instability by challenging and undermining the patient’s own enfeebled representation of inner experience  more rather than less mental and behavioural disturbance


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So, given the pathology, What Tasks Does Every Treatment Face?

  • Minimizing iatrogenic effects

    • Assessment:

      • Symptoms, other key variables

      • Severity

      • Treatment tailored to the individual

    • Structuring the treatment:

      • Contract?

      • Responsibilities of patient and therapist?

    • Defining techniques for therapist

    • Protecting the therapist

      • Group consultation?

    • Containing the patients’ dangerous behaviours: positive regard is not enough

    • Therapists’ qualities – what is required?

    • Goals: symptom relief? Beyond symptoms?


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Elements of effective psychotherapies for BPD: Face?framework, format, frippery (intervention)

Framework FormatIntervention

For the whole treatmentindividual/GroupMoment-to moment mentalizing


Framework l.jpg
Framework Face?


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Format Face?



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Interventions: Face?Interpersonal/systemic ‘v’ intrapersonal/individual


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Interventions: Face?Insight orientated ‘v’ Symptom/skill building



Training l.jpg
Training Face?


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Structural principles Face?

  • Therapeutic change is maximized by

    • Structured therapy – agreement on format, goals, modalities

    • Relational focus

    • Agreed intervening targets that are achievable

    • Understanding of treatment strategies

    • Links between therapy and generalization to everyday life

    • Therapist supervision


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Therapist principles Face?

  • Therapist activity and clarity

  • Understanding of problems and pathway to improvement

  • Flexibility of therapist – availability in crisis

  • Appropriate self-disclosure

  • Convey non-judgemental and not-knowing stance

  • Recognize difficulty of changing

  • Address therapeutic impasse


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Therapist Stance Face?

  • Not-Knowing

    • Neither therapist nor patient experiences interactions other than impressionistically

    • Identify difference – ‘I can see how you get to that but when I think about it it occurs to me that he may have been pre-occupied with something rather than ignoring you’.

    • Acceptance of different perspectives

    • Active questioning

  • Monitor you own mistakes

    • Model honesty and courage via acknowledgement of your own mistakes

      • Current

      • Future

    • Suggest that mistakes offer opportunities to re-visit to learn more about contexts, experiences, and feelings


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General Principles (1) Face?

  • Balance between empathy and insistence on change – use of non-directive and directive procedures

  • Focused and theoretically coherent approach – avoid eclecticism – DO NOT USE Therapy-LITE

  • Intensive and applied over time

  • Ideographic approach to formulation

  • Therapist stance – explicit and honest about limits of ability


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General Principles (2) Face?

  • Intrapersonal and interpersonal and understand interaction between them and be able to specify those to the patient in an understandably way

  • Insight procedures when developed capacity to tolerate affect

  • Establish level of emotional and cognitive capacities (no assumptions) –the danger is supposing greater emotional capacity than is present

  • Focus on current state rather than past


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Thank you for mentalizing! Face?

For further information

anthony@abate.org.uk



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Therapist Stance Face? ….Highlighting alternative perspectives

  • I saw it as a way to control yourself rather than to attack me (patient explanation), can you think about that for a moment

  • You seem to think that I don’t like you and yet I am not sure what makes you think that.

  • Just as you distrusted everyone around you because you couldn’t predict how they would respond, you now are suspicious of me

  • You have to see me as critical so that you can feel vindicated in your dismissal of what I say


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The therapist choice Face?

  • Patient attacks you verbally talking about how useless you are – what do you say/do?

    • Nod?

    • Defend yourself or even attack back?

    • Interpret the actualization of a past dominant object relationship manifest in present?

    • Link to patient/therapist relationship at that moment

    • Attempt to understand internal state of patient and how his experience has come about within the context of therapy?

    • Other?


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The hierarchy of relationship involvement - BPD Face?

Best friend

Partner

self

Most involved

Colleague

Least involved

self

Intensity of emotional

investment

Mother

Daughter

Teacher

Centralised - Unstable


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The hierarchy of relationship involvement - BPD Face?

Best friend

Partner

self

Most involved

Colleague

Least involved

self

Intensity of emotional

investment

Mother

Daughter

Teacher

Distributed – Relatively stable


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Interventions: Spectrum Face?

Interpretive mentalizing

Supportive/empathic

Most involved

Clarification and elaboration

Basic mentalizing

Least involved

Mentalizing the transference


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Interventions: Spectrum (1) Face?

  • Supportive & empathic

    • “I can see that you are feeling hurt”

  • Clarification & elaboration

    • “I can see that you are feeling hurt, I wonder how come?”

  • Basic Mentalising

    • “I can see that you are feeling hurt and that must make it hard for you to come and see me/be with me today” (depending on amount affect arousal that you want to allow)

  • Interpretive Mentalising

    • Transference tracers: “I can see that you are feeling hurt and that there is something you feel I am doing to make you feel like that. Perhaps I am not doing exactly what you want me to do about your incapacity benefit ”


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Interventions: Spectrum (2) Face?

  • Mentalisingthe transference

    • “I can see how you can end up feeling hurt by what is happening here” (empathy), “and then you are not sure if you want to be here or not” (outcome of feeling - experience near), “In the end I think that the only way you feel you can get me to do what you want is to suffer more and more until I understand that you need to be looked after as a disabled person who has a right to treatment and care (motivation)”.

  • Non-mentalising interpretations – to use with care

    • Dyadic transference interpretation (Kernberg): “You need to create a relationship in which you feel the victim of someone who is cruel and hurtful to you”

    • Triadic transference (Strachey): “You felt victimised as a child and now with me and with other people you feel compelled to recreate relationships where you are the person who is hurt by those who do not care for you enough”

    • Historical (past blaming, trauma focused): “Your feeling of hurt at the moment is because you have been reminded of how you felt rejected by your mother”


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Conclusions Face?

  • A therapeutic treatment will be effective to the extent that it is able to enhance the patient’s mentalising capacities without generating too many iatrogenic effects

  • Therapist awareness of mentalizing may minimize likelihood of iatrogenic effects of any therapy

  • Focus on mentalizing within well-defined structure may not only be anti-iatrogenic but also balance affective and cognitive processing harmoniously to effect change

  • Mentalizing as core of therapy defines patient/therapist relationship as one in which a mind has a mind in mind

  • Mentalizing may be the key aspect of effective psychotherapeutic process


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A question of Technical Neutrality Face?

  • A therapist who intervenes from a position of technical neutrality avoids siding with any of the forces involves in the patient’s conflicts

  • Neutrality means maintaining the position of a neutral observer in relation to the patient and his difficulties

  • When working from a position of technical neutrality the therapist is aligned with the patient’s “observing ego”


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Functions of Technical Neutrality Face?

  • Encourages redirection of patient’s conflicts into the therapy

  • Allows therapist to diagnose internal object relations dominant at any given moment

  • Strengthens the patient’s observing ego

  • Interpretations presented from a position of neutrality facilitate integration of split off internal object relations


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Deviations from Technical Neutrality Face?

  • Deviations are part of the treatment strategy

  • Deviations attempt to control dangerous acting out that cannot be contained by confrontation and interpreation

  • Indications:

    • Threat to safety of patient or others

    • Threat to continuation of treatment

    • Confrontation and interpretation fail to contain acting out


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Neutrality and MBT Face?

  • Neutrality versus ‘reflective enactment’

  • Therapist’s occasional enactment is necessary concomitant of therapeutic alliance

    • The therapist is essential vehicle for the alien part of patient’s self so that therapist can perceive and reflect the patient’s constitutional self

    • For the patient to tolerate the relationship the therapist needs to become what the patient needs her to be

  • Beyond enactment, the therapist must be able to preserve a part of her mind that is able to accurately mirror the patient’s internal state following successful projective identification


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Therapist Stance Face? Implicit Mentalization

  • The therapist is continually constructing and reconstructing an image of the patient, to helpthe patient to apprehend what he feels

  • Mentalizing in psychotherapy is a process of joint attention in which the patient’s mental states are the object of attention

  • Neither therapist nor patient experiences these interactions other than impressionistically


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Therapist Stance Face? Explicit Mentalization

  • Not directly concerned with content but with helping the patient

    • to generate multiple perspectives on the fly 

    • to free himself up from being stuck in the “reality” of one view (primary representations and psychic equivalence) 

    • to experience an array of mental states (secondary representations) and 

    • to recognize them as such (meta-representation).

  • Explication draws attention back to implicit representations—feelings for example

    • use language to bolster engagement on the implicit level of mentalization

    • highlight the experience of “feeling felt” (mentalized affectivity)


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Design of study of out-patient MBT Face?

Eligible consecutive patients

SCID I&II plus Clarkin Severity

(N=56)

Patients randomised (N=50)

Patients not randomised

due to refusal (N=6)

Minimisation for:

Age (18-25, 26-30, >30)

Gender

Antisocial PD

3:2 Experimental – control ratio

Naturalistic follow-up

Where consent to research

now or later

Mentalization Based Treatment

Individual and Group

Psychotherapy 18-months

(N=30)

Non-manualised therapies:

Individual or group

‘supportive’ psychotherapy

18-months plus normal care

(N=20)


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Pilot Study out-patient MBT Face?

Patients in treatment

(N=50)

Expert supportive psychotherapy

Individual + group

plus normal care

18-months (N=20)

Mentalization Based Treatment:

Individual and group psychotherapy

18-months (N=30)

3-months: SCL-90, BDI, SpielS&T, IIP, SAS

6-months: Sui & Self-harm Inventory

Hospital Admission

Service Usage e.g.A&E

3-months: SCL-90, BDI, SpielS&T, IIP, SAS

6-months: Sui & Self-harm Inventory

Hospital Admission

Service Usage e.g.A&E

Drop-out=3

Drop-out=7

Intention to treat analysis(N=)

Intention to treat analysis (N=)

18 Months Follow-up (N=?)

18 Months Follow-up (N=?)


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Comorbid Disorders: Axis II Face?

  • Avoidant: 12.1%

  • Paranoid: 36.6%

  • Histrionic: 24.4%

  • Antisocial: 42.1%

  • Narcissistic: 41.8%

  • Obsessive-C 12.4%

  • Dependent 5.1%

  • Schizotypal 2.3%

  • Schizoid 0.0%

  • Mean number of Axis II diagnoses: 3.29 (SD = 1.13): Max = 6, Min = 1.


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    Pilot Study: % Attempted Suicide (NNT=3.8) Face?

    *

    PH outcome

    * p < .05

    ** p < .01

    *** p < .001

    Trend O/P MBT: W=.45, Chi squared= 38.7, df=3, p<.001

    Trend Control: W=.16, Chi squared= 9.33, df=3, p<.05


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    % Self-Mutilating Behavior (NNT=6.7) Face?

    n.s.

    PH outcome

    * p < .05

    ** p < .01

    *** p < .001

    Trend O/P MBT: W=.20, Chi squared= 17.5, df=3, p<.001

    Trend Control: W=.08, Chi squared= 4.5, df=3, n.s.


    Self rated depression bdi l.jpg

    Pair-wise Face?

    comparisons

    * p<.05

    ** p<.01

    *** p<.001

    Self Rated Depression (BDI)

    **

    PH outcome

    ANOVA: Significance of interaction term: F2.4, 83 = 6.6, p<.01



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    CBT for BPD: Controlled trials Treatment

    • Tyrer et al., 2003

      • report outcomes from a large multicentre trial in which 480 individuals who presented to emergency services after self-harm were randomized either to brief manualized CBT (MACT) (five sessions over three months), or to TAU

      • Though approximately 40% of individuals in this study had a PD, their actions rather than their diagnosis formed the basis for trial entry, and the relevance of these results for personality disorder per se is unclear

      • No differences in the rate of self-harm or suicide over 12 months follow up.

      • Some indications of greater cost effectiveness for active treatment (related largely to the costs of hospital, social and criminal justice services), but these were significant only at up to six month follow-up (Byford et al., 2003).

      • Borderline patients showed increased costs if received CBT


    Dbt for bpd controlled trials l.jpg
    DBT for BPD: Controlled trials Treatment

    • Linehan, Armstrong, Suarez et al, 1991

      • Contrasted DBT with TAU

      • Therapy was conducted weekly, and treatment was offered both individually and in groups over 1 year

      • Patients were admitted to the trial if they met DSM-III-R criteria and had at least 2 incidents of parasuicide in the 5 years preceding (with 1 in the immediately preceding 8 weeks)

      • 22 women were assigned to DBT and 22 to the control condition.

      • Assessment was carried out during and at the end of therapy and again after 1-year follow-up (Linehan, Heard, & Armstrong, 1993)

      • Controls were significantly more likely to make suicide attempts ( mean 33.5 vs 6.8 attempts) and spent significantly more time as inpatients over the year of treatment (mean 38.8 and 8.5 days).

      • Controls were significantly more likely to drop out of the TAU therapies —attrition from DBT was 16.7%, contrasted with 50% for other therapies


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    Iatrogenesis, psychotherapy and BPD Treatment

    • Pharmacological studies assume the possibility of and test for adverse reactions

    • Psychotherapy is assumed to be at worse inert

    • No systematic studies of adverse reactions to psychotherapy

      • No theory of adverse reaction

    • Adverse reaction must link to mechanisms of change



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    Key Constructs Treatment


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    Therapist Stance Treatment

    • Reflective enactment ‘v’ neutrality

      • Therapist’s occasional enactment is acceptable concomitant of therapeutic alliance

      • Own up to enactment to rewind and explore

      • Check-out understanding

      • Joint responsibility to understand over-determined enactments


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