Borderline Personality Disorder (BPD) is a severe form of psychopathology. It is characterised by disturbances in mood, interpersonal relationships, sense of self and difficulties in controlling impulsive behaviours such as self-injury and substance use. Therapists have had difficulties engaging in treatment because the interpersonal disturbances associated with the disorder can affect the therapy relationship and the complexities of the client’s presentation can lead to a sense of impotence. For much of the past 50 years the disorder was considered by many to be untreatable. We now can confidently say we have treatments that work.
One of the interventions to first demonstrate effectiveness in treating BPD was dialectical behaviour therapy (DBT). The impact of DBT on BPD led Time magazine to announce in 2011 that DBT is one of the 100 greatest recent scientific discoveries. The evidence is also mounting that other therapies are also effective and work in different ways to DBT. These include schema therapy and psychodynamic approaches.
In Australia, research suggests that 1–2.3 per cent of Australian adults have BPD. People with BPD are heavy users of health services accounting for 4-6 per cent of patients in primary care services and 25 per cent in mental health services. They also attempt self-harm more than any other patient group and are second only to bipolar disorder in the frequency of suicide completion. Mortality from BPD, however, is not restricted to suicide. People with a personality disorder are likely to live 18 years less than the general population as they have a raised risk of ‘unnatural deaths’ (suicide, homicide and accidents) as well as ‘natural’ causes of death (such as infections or cardiovascular disease). They also have increased risk of developing alcohol or drug dependence and, by definition, have unstable and chronic relationship difficulties. The suffering associated with BPD is not restricted to those with the diagnosis. The disorder also has a profound impact on the person’s family and carers.
While the impact of BPD on individuals, their family and carers is well documented, it is also important to consider the societal costs of BPD. A study conducted in the Netherlands estimated the total yearly cost of BPD at 2.2 billion euros (Van Asslet, Dirksen, Arntz, & Severens, 2007). With a prevalence rate of BPD that is comparable to Australia’s, one wonders how much the annual society cost of BPD is here. The cost-savings to the community of treating individuals with BPD with an evidence-based therapy are substantial if overseas figures are compatible to our situation in Australia.
DBT as a treatment option
Marsha Linehan developed DBT in the early 1990s. At the time, she was working with women with high levels of suicidal ideation and felt that standard cognitive behaviour therapy techniques were not effective. DBT at its core is behaviour therapy combined with mindfulness and a unique way of viewing the relationship with the clinician. Linehan was one of the early pioneers to introduce mindfulness in Western therapies. Initially wary of incorporating Eastern-based philosophy into Western treatment, Linehan’s 1993 text stripped mindfulness back to its core skills. Interestingly, in the 2014 revisions to the DBT skills training manual, Linehan has reintroduced some of the now more widely accepted spiritual aspects of mindfulness.
“One of the central tenets of DBT is the focus on emotion dysregulation as the core mechanism”
One of the central tenets of DBT is the focus on emotion dysregulation as the core mechanism. This is thought to stem from the combination of a biological predisposition with environmental factors. This emotion dysregulation is manifested in an oversensitive and overly reactive emotion response system. That is, emotions are more easily triggered and when triggered, are more intense. Finally, once activated the person has trouble returning to baseline levels of arousal. The difficulty with BPD can be that the extreme emotional sensitivity prevents a treatment focused only on change strategies, and their extreme suffering is prohibitive of an approach based only on acceptance. Linehan argued that the solution is a dialectical approach that balances change and acceptance.
DBT views individuals with BPD as having a skills deficit. Each of the four core skills of DBT directly maps onto the core features of BPD and teaches skills to manage these deficits.
- Mindfulness skills increase awareness and focus and can also help reduce the confusion around what is the ‘self’.
- Interpersonal skills assist in relationship development and maintenance.
- Emotion regulation skills improve ability to regulate affect and manage anger.
- Distress tolerance skills focus on managing impulsivity and giving alternative behaviours to self-harm and suicide attempts.
These skills-focused change strategies allow the individual to create a life worth living.
To balance the change-focused strategies, DBT places a strong emphasis on the clinician/client relationship. Clinicians weave validation and acceptance into a relationship that focuses on the human and ‘real’ connection. Clinicians are encouraged to join a consultation team to support themselves and ensure adherence to the treatment.
The DBT model has also been adapted to not only focus on improving the skills of individuals with BPD, but also to assist their families and carers. Alan Fruzetti and Perry Hoffman developed a 12-week Family Connections program (Hoffman et al., 2005) which focused on increasing the skills of families and carers to reduce their own suffering. Across the 12 weeks Family Connections focuses on psychoeducation about BPD, improving skills and increasing social support. Once again the use of a skills focus serves to give families and carers tools to better manage their relationships whilst also serving the important function of decreasing stigma. With four published studies and more ongoing research into the outcomes of this program initial outcomes suggest that family members experience reductions in grief, depression, and burden, and increased feelings of mastery and empowerment. This grassroots program was gifted to The National Education Alliance of BPD, Australia, and is now running in most states.
Schema therapy in practice
Schema therapy was developed as a treatment for personality disorders and other chronic symptom disorders. It is an integrative form of psychotherapy that incorporates concepts and approaches from cognitive behaviour therapy, attachment theory, Gestalt therapy and psychodynamic perspectives. As in DBT, there is a strong emphasis on the therapeutic relationship. Although change techniques in this therapy are more directed towards experiential exercises within session rather than the practice of skills outside of session.
Schema therapy relies on two conceptual models for the formulation of clients’ issues and to understand the change process. The first is early maladaptive schemas, which are defined as pervasive and self-defeating, dysfunctional patterns of thoughts, cognitions, behaviours and affects that typically develop during childhood but become elaborated on throughout the person’s life. These early maladaptive schemas are thought to develop when there is a mismatch between a child’s basic needs and their environment. Early maladaptive schemas are classified in terms of a hierarchy that includes the need for connection, autonomy and reasonable limits.
Young recognised that individuals with borderline personality disorders often experienced rapid emotional changes with simultaneous activations of several schemas, and therefore developed a schema mode model. The mode model describes current states rather than traits and at any one point refers to the interaction between the person’s schemas and their coping style. Researchers have identified six modes relevant in patients that present with BPD. The combination of these six modes differentiate BPD from other personality disorders.
The mode that represents the core distress has been labelled vulnerable child mode. In this mode the patient’s feelings are in the rawest state. It is in this state that they feel intensely worthless, unlovable, helpless, incompetent or abandoned. They frequently feel overwhelmed and look to others for solutions. According to the theory given the adversity of such a state, the patient will typically move from this to an alternative state. In BPD, two such common modes are known as angry child mode, which represents a state where the person demands that others fix the situation, or an impulsive child mode where the person will try to change the underlying pain through self-gratification impulses without regards to consequences. An alternative way of dealing with the distress associated with the vulnerable child mode is to use dissociation or other mechanisms of detaching and these symptoms are part of a state that has been labelled a detached mode. Finally, patients with BPD have been found to experience a punitive mode, which is typically the internalisation of negative experiences throughout the life and, whilst in this mode, the person typically experiences shame and invalidation of their primary needs.
Therapy includes psychoeducation of the symptoms of BPD as they relate to modes (similar to how DBT relates BPD symptoms to skills), then the focus is on understanding how each mode plays out in the person’s life. The next phase is to provide experiences in the therapy of soothing the person’s vulnerable child mode, identifying the needs of angry and impulsive modes while setting limits on associated behaviours and helping the client fight the destructive messages of the punitive modes. The goal of therapy is to develop the client’s ability to do this for themselves by providing new experiences in session. In the theory this is strengthening a healthy adult mode which is weak at the start of therapy but increases as therapy progresses.
Using a psychodynamic approach
Similar to schema therapy, psychodynamic approaches to BPD rely more on experiences in the clinician’s office to facilitate change than teaching skills to cope with emotional dysregulation. Mentalisation based therapy (MBT), developed by Bateman and Fonagy (2010) is one such psychodynamic approach that has been found to be effective in treating BPD. Mentalising is the ability to identify our own thoughts and feelings, as well as the ability to look at another and try to figure out the thoughts and feelings behind their actions. MBT is based on the premise that individuals with BPD are poor at mentalising. MBT is a manualised approach that involves both group and individual therapy.
Through therapy, MBT assists individuals with BPD to learn to better understand themselves and others. It encourages individuals with BPD to see their interpersonal interactions through a more grounded and flexible lens. Clinicians in this model apply an open and curious stance, encouraging clients themselves to reflect on their emotional and interpersonal events. This model was developed in the National Health Service in the United Kingdom and although originally had partial hospitalisation as part of the program, subsequent versions of the program were outpatient-based only.
Current state of research
In the soon to be released Australian Psychological Society document, Evidence-based psychological interventions in the treatment of mental disorders (Fourth edition), there is Level 1 evidence for DBT and psychodynamic therapy in treating BPD. However, it is important to keep in mind that trials investigating these interventions have typically been small in number and suffer from several methodological issues. The largest number of trials have been in DBT, but most of these have compared DBT to treatment-as-usual where several important critical factors have not been controlled for such as supervision and support for clinicians. It is interesting that therapy approaches that take quite a different view on crucial mechanisms such as psychodynamic therapy and DBT can achieve equivalent outcomes that are typically better than treatment-as-usual. Recently, the Centre for Psychotherapy in the Hunter New England Mental Health Service compared a psychodynamic approach, the conversational model, with DBT. Although DBT had some advantages, surprisingly, there were no differences in reduction in self-injury behaviour despite one method making this a priority of treatment and the other method an ancillary goal.
There are a number of promising areas for future investigation. For example schema therapy, while only having had a handful of randomised controlled trials does appear to achieve large effect sizes. All three treatment approaches – DBT, schema therapy and MBT – frequently combine individual and group treatments yet we know little about whether group treatment is an advantage or disadvantage in treating BPD. Group treatment seems to offer a lot of potential as an effective delivery mode as it can be more cost effective. It may also assist in repairing some of the difficulties that people with BPD experience, such as a sense of alienation and disconnection.
However, group treatments have potential difficulties. It can be challenging to ensure that there is an appropriate sense of safety. Without the sense of safety the potential of some acting out behaviour in the group increases which could make the group treatment more problematic for some individuals. There is a study that should help answer some of these questions that will be completed in the next six months. It is the largest randomised control trial for BPD with 480 patients and involving six countries including Australia (Wetzelaer, 2014). It investigated the treatment of BPD in three conditions and amongst other things will investigate who benefits more from group versus individual treatment. The results will be presented at the Berlin World CBT Conference in 2019.
Similarly, there is the need to understand some of the key aspects of the therapies that do seem to work. Potential research questions could:
- investigate the extent to which cognitive and experiential factors produce change in individuals. Understanding this could improve how the therapy is delivered.
- test some of the fundamental assumptions within each therapy. For example, in DBT emotional dysregulation is considered a core component of the aetiology, so do changes in emotional dysregulation influence treatment outcome?
- look at whether some approaches work better for some BPD patients compared to others given that the three therapy approaches discussed differ in focus.
To paraphrase Linehan, the current evidence-based treatment approaches to BPD are ‘doing the best they can, and they need to do better’. As our understanding of these treatments improves, we will be better able to help individuals with BPD not only create a life worth living, but to experience joy.
The first author can be contacted for a more complete list of references: [email protected]