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 dont 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 ones 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 therapists 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 patients inner experience and
  external perspective is not appreciated ?
  bewilderment ? instability by challenging and
  undermining the patients 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
BPDframework, format, frippery (intervention)
Framework Format
Intervention For the whole treatment
individual/Group Moment-to moment
mentalizing
28
Framework
29
Format
30
Interventions Directive, Non-directive,
Self-directive
31
InterventionsInterpersonal/systemic v
intrapersonal/individual
32
InterventionsInsight 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_at_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 dont like you and yet I
  am not sure what makes you think that.
• Just as you distrusted everyone around you
  because you couldnt 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
Supportive/empathic
Most involved
Clarification and elaboration
Basic mentalizing

• Interpretive 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)

• Mentalising the 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 patients
  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 patients 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
  patients observing ego

51
Functions of Technical Neutrality

• Encourages redirection of patients conflicts
  into the therapy
• Allows therapist to diagnose internal object
  relations dominant at any given moment
• Strengthens the patients observing ego
• Interpretations presented from a position of
  neutrality facilitate integration of split off
  internal object relations

52
Deviations from Technical Neutrality

• 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

53
Neutrality and MBT

• Neutrality versus reflective enactment
• Therapists occasional enactment is necessary
  concomitant of therapeutic alliance
• The therapist is essential vehicle for the alien
  part of patients self so that therapist can
  perceive and reflect the patients 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 patients internal state
  following successful projective identification

54
Therapist Stance Implicit Mentalization

• The therapist is continually constructing and
  reconstructing an image of the patient, to help
  the patient to apprehend what he feels
• Mentalizing in psychotherapy is a process of
  joint attention in which the patients mental
  states are the object of attention
• Neither therapist nor patient experiences these
  interactions other than impressionistically

55
Therapist Stance 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
  representationsfeelings for example
• use language to bolster engagement on the
  implicit level of mentalization
• highlight the experience of feeling felt
  (mentalized affectivity)

56
Design of study of out-patient MBT
Eligible consecutive patients SCID III plus
Clarkin Severity (N56)
Patients randomised (N50)
Patients not randomised due to refusal (N6)
Minimisation for Age (18-25, 26-30,
gt30) Gender Antisocial PD 32 Experimental
control ratio
Naturalistic follow-up Where consent to research
now or later
Mentalization Based Treatment Individual and
Group Psychotherapy 18-months (N30)
Non-manualised therapies Individual or group
supportive psychotherapy 18-months plus normal
care (N20)
57
Pilot Study out-patient MBT
Patients in treatment (N50)
Expert supportive psychotherapy Individual
group plus normal care 18-months (N20)
Mentalization Based Treatment Individual and
group psychotherapy 18-months (N30)
3-months SCL-90, BDI, SpielST, IIP,
SAS 6-months Sui Self-harm Inventory Hospital
Admission Service Usage e.g.AE
3-months SCL-90, BDI, SpielST, IIP,
SAS 6-months Sui Self-harm Inventory Hospital
Admission Service Usage e.g.AE
Drop-out3
Drop-out7
Intention to treat analysis(N)
Intention to treat analysis (N)
18 Months Follow-up (N?)
18 Months Follow-up (N?)
58
Comorbid Disorders Axis II

• 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.

59
Pilot Study Attempted Suicide (NNT3.8)

PH outcome
p lt .05 p lt .01 p lt .001
Trend O/P MBT W.45, Chi squared 38.7, df3,
plt.001 Trend Control W.16, Chi squared 9.33,
df3, plt.05
60
Self-Mutilating Behavior (NNT6.7)
n.s.
PH outcome
p lt .05 p lt .01 p lt .001
Trend O/P MBT W.20, Chi squared 17.5, df3,
plt.001 Trend Control W.08, Chi squared 4.5,
df3, n.s.
61
Self Rated Depression (BDI)

PH outcome
ANOVA Significance of interaction term F2.4, 83
6.6, plt.01
62
Change in Reflective Function as a Function of
Time and Treatment
63
CBT for BPD Controlled trials

• 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

64
DBT for BPD Controlled trials

• 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

65
Iatrogenesis, psychotherapy and BPD

• 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

66
Comparison of treatments
67
Key Constructs
68
Therapist Stance

• Reflective enactment v neutrality
• Therapists 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