Treatment for Personality Disorder: are there effective strategies?

1. Treatment for Personality Disorder: are there effective strategies? Prof Anthony W Bateman Bristol 2005

2. Therapeutic Nihilism About BPD • 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

3. Re-mapping the course of borderline personality disorder

4. Remissions and Recurrences Among 275 Patients with BPD Percent Source: Zanarini et al. (2003) Am. J. Psychiat.160, 274-283

5. Time to 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 criteria for MDD

6. 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

7. Summary of Remission Findings • 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

8. Differential improvement rates of BPD symptom clusters • 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

9. What works? What does not work?

10. Summary of what works and clinical implications • 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

11. Summary of what works and clinical implications • 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

12. Psychopharmacological studies • 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

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

14. Psychopharmacological studies: Practice • 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).

15. Halliwick Referrals and medication

16. The outcome paradox in BPD

17. The paradox of the outcome of BPD • 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

18. Suggestive evidence for the reality of iatrogenic harm • 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

19. Process of Change • “…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

20. What induces change in BPD? • 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

21. How change occurs in therapy with BPD • 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

22. 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)

23. Reduced appreciation of mind  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

24. 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

25. 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

26. 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?

27. Elements of effective psychotherapies for BPD:framework, format, frippery (intervention) Framework FormatIntervention For the whole treatmentindividual/GroupMoment-to moment mentalizing

28. Framework

29. Format

30. Interventions: Directive, Non-directive, Self-directive

31. Interventions:Interpersonal/systemic ‘v’ intrapersonal/individual

32. Interventions:Insight orientated ‘v’ Symptom/skill building

33. Abreactive ‘v’ emotionally supportive

34. Training

35. Structural principles • 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

36. Therapist principles • 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

37. Therapist Stance • 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

38. General Principles (1) • 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

39. General Principles (2) • 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

40. Thank you for mentalizing! For further information anthony@abate.org.uk

41. The mentalizing therapist

42. Therapist Stance ….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

43. The therapist choice • 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?

44. The hierarchy of relationship involvement - BPD Best friend Partner self Most involved Colleague Least involved self Intensity of emotional investment Mother Daughter Teacher Centralised - Unstable

45. The hierarchy of relationship involvement - BPD Best friend Partner self Most involved Colleague Least involved self Intensity of emotional investment Mother Daughter Teacher Distributed – Relatively stable

46. Interventions: Spectrum Interpretive mentalizing Supportive/empathic Most involved Clarification and elaboration Basic mentalizing Least involved Mentalizing the transference

47. Interventions: Spectrum (1) • 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 ”

48. Interventions: Spectrum (2) • 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”

49. Conclusions • 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

50. A question of Technical Neutrality • 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”