The Psychotherapy Practice Research Network (PPRNet) blog began in 2013 in response to psychotherapy clinicians, researchers, and educators who expressed interest in receiving regular information about current practice-oriented psychotherapy research. It offers a monthly summary of two or three published psychotherapy research articles. Each summary is authored by Dr. Tasca and highlights practice implications of selected articles. Past blogs are available in the archives. This content is only available in English.
…I blog about psychotherapy for borderline personality disorder, capacity to metnalize and therapy resistant depression, and negative effects of psychotherapy
Type of Research
- ALL Topics (clear)
- Alliance and Therapeutic Relationship
- Anxiety Disorders
- Attendance, Attrition, and Drop-Out
- Client Factors
- Client Preferences
- Cognitive Therapy (CT) and Cognitive-Behavioural Therapy (CBT)
- Combination Therapy
- Common Factors
- Depression and Depressive Symptoms
- Efficacy of Treatments
- Feedback and Progress Monitoring
- Group Psychotherapy
- Illness and Medical Comorbidities
- Interpersonal Psychotherapy (IPT)
- Long-term Outcomes
- Neuroscience and Brain
- Outcomes and Deterioration
- Personality Disorders
- Placebo Effect
- Practice-Based Research and Practice Research Networks
- Psychodynamic Therapy (PDT)
- Resistance and Reactance
- Self-Reflection and Awareness
- Suicide and Crisis Intervention
- Therapist Factors
- Transference and Countertransference
- Trauma and/or PTSD
- Treatment Length and Frequency
Efficacy of Psychotherapies for Borderline Personality Disorder
Cristea, I.A., Gentili, C., Cotet, C.D., Palomba, D., Barbui, C., & Cuijpers, P. (2017). Efficacy of psychotherapies for borderline personality disorder: A systematic review and meta-analysis. JAMA Psychiatry. doi:10.1001/jamapsychiatry.2016.4287.
Borderline personality disorder (BPD) is a debilitating disorder characterized by: severe instability of emotions, relationships, and behaviors. More than 75% of those with BPD have engaged in deliberate self-harm, and suicide rates are between 8% and 10%. BPD is the most common of the personality disorders with a high level of functional impairment. Several psychotherapies have been developed to treat BPD. Most notably, dialectical behavior therapy (DBT), cognitive behavioral therapy (CBT), and psychodynamic treatments like mentalization-based and transference-focused psychotherapy. This meta-analysis by Cristea and colleagues examined the efficacy of psychotherapy for BPD. Studies included in the meta-analysis (33 trials of 2256 clients) were randomized controlled trials in which a psychotherapy was compared to a control condition for adults with BPD. For all borderline-relevant outcomes (combined borderline symptoms, self-harm, parasuicidal and suicidal behaviors) yielded a significant but small effect of the psychotherapies over control conditions at post treatment (g = 0.35; 95%CI: 0.20, 0.50). At follow up, there was again a significant effect of the psychotherapies over control conditions with a moderate effect (g = 0.45; 95% CI: 0.15, 0.75). When the different treatment types were looked at separately, DBT (g = 0.34; 95% CI: 0.15, 0.53) and psychodynamic approaches (g = 0.41; 95% CI: 0.12, 0.69) were more effective than control interventions, while CBT (g = 0.24; 95% CI: −0.01, 0.49) was not. The authors also reported a significant amount of publication bias, suggesting that published results may be positively biased in favor of the psychotherapies.
The results indicate a small effect of psychotherapies at post-treatment and a moderate effect at follow-up for the treatment of BPD. DBT and psychodynamic treatment were significantly more effective than control conditions, whereas CBT was not. However, all effects were likely inflated by publication bias, indicating a tendency to publish only positive findings. Nevertheless, various independent psychotherapies demonstrated efficacy for symptoms of self harm, suicide, and general psychopathology in BPD.
Common Factors Across 5 Therapies for Suicidal Patients with Borderline Personality Disorder
Sledge, W., Plukin, E.M., Bauer, S., Brodsky, B.,... Yoemans, F. (2014). Psychotherapy for suicidal patients with borderline personality disorder: An expert consensus review of common factors across five therapies. Borderline Personality Disorder and Emotion Dysregulation, 1:16. doi:10.1186/2051-6673-1-16.
Treating patients with suicidal ideation and borderline personality disorder (BPD) can cause significant anxiety, concern, anger, and guilt in clinicians. Strong emotional reactions can lead to risky therapeutic interventions, poor clinical decisions, and professional burn out. The outcome of therapy can have serious consequences for such patients. Recently, a panel of 13 experts reviewed the efficacy of the most common treatments for suicidal ideation in BPD. As part of the review, they identified the common factors that may be useful for all clinicians who work with these clients. The five therapies they reviewed included the following. Dialectical behavior therapy, which emphasizes the role of emotional dysregulation and impulsivity in suicide. Treatment includes distress tolerance, emotional regulation, interpersonal effectiveness, and mindfulness. Schema therapy decreases suicide risk by challenging negative thoughts with cognitive and behavioral techniques while using the therapeutic relationship to improve the patient’s capacity to attach to others. Mentalization based therapy works toward improving the patient’s capacity to keep in mind the patient’s own mind and the mind of the other. This encourages new perspectives on relationships and emotion regulation. Transference focused psychotherapy views suicidal behavior in BPD as related to distorted images of the self and others. The treatment emphasizes gaining greater awareness of self in relation to others, and integrating a more realistic experience of the self. Good psychiatric management is an integrative approach that uses both psychodynamic and behavioral concepts. The approach sees BPD as a problem with interpersonal hypersensitivity, but the management tends to be more pragmatic than theoretically based. The expert panel defined six common factors among these treatments. (1) Negotiation of a frame for treatment – in which roles and responsibilities of therapist and patient are defined before the start of treatment, including an explicit crisis plan. (2) Recognition of the patient’s responsibilities within therapy. (3) The therapist having a clear conceptual framework for understanding the disorder that then guides the interventions. (4) Use of the therapeutic relationship to engage the patient and to address suicide actively and explicitly. (5) Prioritizing suicide as a topic whenever it comes up in the therapy. (6) Providing support for the therapist through supervision, consultation, and peer support.
Suicidal ideation in patients with BPD can have serious consequences for the patient and can be highly stressful for the clinician. This expert panel identified six common features of most major treatment approaches to suicidal ideation in BPD. Even if clinicians are not explicitly trained in any one of the approaches, ensuring that these six factors are present in their work will improve the likelihood that their patients will experience a good outcome.
Evidence for Psychodynamic Therapy of Personality Disorders
Barber, J.P., Muran, J.C., McCarthy, K.S., & Keefe, J.R. (2013). Research on dynamic therapies. In M.E. Lambert (Ed.), Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change, 6th Edition (pp. 443-494). New York: Wiley.
In this part of their chapter, Barber and colleagues (2013) summarize the research on the efficacy of dynamic therapies for personality disorders. As the authors indicate, dynamic therapies refer to a family of interventions that: focus on the unconscious, affect, cognitions and interpersonal relationships; use interpretations and clarifications; consider transference and countertransference; and use the therapeutic relationship to improve self understanding and self-awareness. Following Magnavity (1997), the authors describe dynamic therapies specifically for personality disorders as identifying maladaptive, recurring patterns of thinking, behaving and emotional responding with the intent of restructuring these through linking current and transference patterns to early attachment and trauma. Barber and colleagues conducted meta analyses of available research on dynamic therapies for personality disorders. They combined several outcomes based on patient and observer reports as an index of general outcome. In seven studies representing 452 patients, dynamic therapies for personality disorders were more effective than control conditions (i.e., treatment as usual, or wait-lists), and the size of the effect was moderate. They found no significant differences between dynamic therapies and other types of therapy for personality disorders. Dynamic therapies had significant advantages over control conditions for general symptomatology, interpersonal problems, personality pathology, and suicidality. These therapeutic effects were maintained to short-term follow up.
There are now several dynamic therapies for personality disorders that have substantial research evidence for their efficacy. For example, Transference Focused Psychotherapy for borderline personality disorder is considered a “well-established” treatment by the American Psychological Association Division 12. Mentalization-based treatment is also considered to be “probably efficacious”. Other “probably efficacious” dynamic therapies include: McCullough-Vaillant’s short term dynamic psychotherapy (STDP) and brief relational therapy for Cluster C personality disorders (i.e., avoidant, dependent, obsessive-compulsive); and intensive STDP for general personality disorder.