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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.

Practice Implications

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.

The Great Psychotherapy Debate: Since in April, 2015 I review parts of The Great Psychotherapy Debate (Wampold & Imel, 2015) in the PPRNet Blog. This is the second edition of a landmark, and sometimes controversial, book that surveys the evidence for what makes psychotherapy work. You can view parts of the book in Google Books.

Wampold, B.E. & Imel, Z.E. (2015). The great psychotherapy debate: The evidence for what makes psychotherapy work (2^nd edition). New York: Routledge.

In this part of the chapter on efficacy, Wampold and Imel provide convincing evidence from numerous reviews of meta analyses that the average effect size of psychotherapy across diverse treatments and patients is about d = .80. This is a reliable figure and is considered a “large” effect by commonly accepted standards. Put another way, the average psychotherapy patient is better off than 79% of untreated clients, psychotherapy accounts for 14% of the outcome variance, and for every 3 patients who receive psychotherapy, one will have a better outcome than had they not received psychotherapy. In other words, psychotherapy is remarkably efficacious. These effect size estimates are mostly drawn from randomized clinical trials that are highly controlled (i.e., therapists are highly trained and supervised, patients are sometimes selected to have no co-morbid problems, treatment fidelity to a manual is closely monitored, etc.). Some argue that the context of these trials renders them artificial, and that findings from these trials reveal little about psychotherapy practiced in the real world with complex patients. How do findings from controlled clinical trials compare to everyday clinical practice? Wampold and Imel review the evidence from three areas of research: clinical representativeness, benchmarking, and comparisons to treatment as usual. With regard to clinical representativeness, a meta analysis (k > 1,000 studies) coded the studies for type of treatment setting, therapist characteristics, referral sources, use of manuals, client heterogeneity, etc. The meta analysis found that therapies that were most representative of typical practice had similar effects to what is observed in highly controlled studies. With regard to benchmarking, a large study (N > 5,700 patients) compared treatment effects observed in naturalistic settings to clinical trial benchmarks. Benchmarks were defined as scores on an outcome (e.g., on a depression scale) that are within 10% of scores reported in clinical trial research. Treatment effects in naturalistic settings were equivalent to and sometimes better than those achieved using clinical trial benchmarks. Further, therapists in practice settings achieved the same outcomes in fewer sessions than in clinical trials. With regard to comparisons to treatment as usual, a meta analysis (k = 30 studies) for personality disorders looked at studies that compared evidence-based treatments tested in clinical trials to treatment as usual. The meta analysis found that evidence-based treatments were significantly more effective than treatment as usual with moderate effects. These results suggest that when it comes to personality disorders, special training and supervision, which are common in clinical trials, might be beneficial.

Practice Implications

Wampold and Imel argue that psychotherapy as tested in clinical trials is remarkably effective such that the average treated patient is better off than 79% of untreated controls. The evidence also suggests that psychotherapy practiced in clinical settings is effective and probably as effective as psychotherapy tested in controlled clinical trials. It is possible that therapists who treat those with personality disorders may benefit from additional training and supervision to improve patient outcomes in everyday practice.

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.

Practice Implications

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.

Budge, S.L., Moore, J.T., Del Re, A.C., Wampold, B.E., Baardseth, T.P., & Nienhuis, J.B. (2013). The effectiveness of evidence-based treatments for personality disorders when comparing treatment-as-usual and bona fide treatments. Clinical Psychology Review, 33, 1057-1066.

Personality disorders (PD) are more stable and enduring than other mental disorders and are characterized by pervasive, serious, and rigid self-destructive patterns in affect, cognition, interpersonal relations, and impulse control that reduce psychological well-being. PD are associated with higher rates of self injury, suicide, and health care costs. The prevalence of PD in the population ranges from 6% to 13%. The presence of PD in a patient often reduces the effectiveness of psychological treatments for Axis I disorders (e.g., depression, anxiety) that the patient may have. Psychotherapy may be more effective than other interventions, such as pharmacotherapy, for treating PD. In their meta analysis, Budge and colleagues (2013) addressed two questions. First, are manualized evidence-based treatments (EBT) as provided in clinical trials superior to treatment as usual (TAU), presumably as offered in naturalistic settings, for treating PD? Second, are there differences between bona fide treatments (i.e., psychotherapy administered by trained therapists and based on sound psychological theories) for PD? (A note about meta analyses: meta analyses are a statistical method to combine the findings of a large number of studies while accounting for the sample sizes, quality of the studies, and size of the effects. Meta analyses provide us with much more dependable results than any single study could provide). Regarding the first question, 30 studies were included in the meta analysis. Evidence-based treatments included psychodynamic therapies, cognitive behavioral therapies, and dialectical behavior therapy, among others. Overall, EBTs were more effective than TAUs, and the effect was medium sized. The positive effects in favor of EBT over TAU were larger for patients with borderline personality disorder. For the second study comparing bona fide treatments, only 12 studies were found and included in the meta analysis. Only three of the studies indicated that one bona fide therapy was more effective than another. It is also important to note that the average duration of treatment in the EBT studies was 1 year and peaked at 40 sessions.

Practice Implications

As Budge and colleagues (2013) concluded, with sufficient training, supervision, and dose hours, it appears that evidence based treatments (EBT) are more effective than treatments as usual (TAU) for personality disorders (PD). The results of the meta analysis suggested that training in evidence based psychotherapies may be necessary to achieve the best possible outcomes for patients with PD, especially those with borderline personality disorder. Are there differences in between EBTs for PD? The literature on this issue is quite small, so that 12 studies are not enough to make many conclusions. There is previous evidence that psychodynamic therapies and CBT yield very large effects for PD. The pervasiveness and complexity of PD symptoms make it so that effective treatments are necessarily longer term, which is consistent with previous research on this topic.

Colli, A., Tanzilli, A., Dimaggio, G., & Lingiardi, V. (2013). Patient personality and therapist response: An empirical investigation. American Journal of Psychiatry.

Therapist emotional responses to patients may refer to emotional reactions or to countertransference. Emotional responses can inform therapeutic interventions if therapists view their responses as informative about the patient’s feelings, perspectives, and relationship patterns. Clinicians have an intuitive sense that specific patient characteristics tend to evoke distinct emotional reactions (i.e., countertransferences) in the therapist. However, there are very few studies that examine the association between patient personality features and therapist emotional responses. A study Colli and colleagues examined this issue. They sampled 203 therapists from two theoretical orientations (psychodynamic = 103; cognitive-behavioral = 100). Among the therapists, 58% were women, mean age was 43 years, average experience was 10 years, average time spent providing psychotherapy was 16 hours per week, and 78% were in private practice. Each therapist was asked to randomly select a patient in their caseload, and complete a validated personality assessment questionnaire about the patient. Three weeks later, and immediately following a therapy session with the patient, the therapist completed a validated therapist emotional response questionnaire. Half of the patients were women (53%), mean age was 34 years, average length of treatment was 5 months (once per week), and 72% were diagnosed with a personality disorder (either comorbid or as a primary diagnosis). Patient paranoid and antisocial features were associated with therapists feeling criticized/mistreated. Patient borderline personality features were associated with therapists feeling helpless/inadequate, overwhelmed/disorganized, and special/overinvolved. Patient narcissistic features were associated with therapists feeling disengaged. Patient dependent personality features were associated with therapists feeling both parental/protective and special/overinvolved. The results were not affected by clinicians’ theoretical orientation. That is, psychodynamic and cognitive-behavioral therapists showed similar emotional responses to each patient personality pattern.

Practice Implications

The results do not appear to be an artifact of therapist theoretical orientation, and so the authors argue that patient interpersonal patterns are quite robust in evoking specific therapist countertransference. A therapist’s emotional responses that are not primarily related to the therapist’s own issues could be an important source of information about the patient’s emotional and interpersonal patterns. Therapist emotional responses can also impede the therapist’s work if the responses are not well understood. Therapists who treat those with borderline personality features may avoid their own experience of negative thoughts and feelings during a session and this may unwittingly manifest as a sudden confrontation of the patient. With patients who have narcissistic features, therapists may feel disengaged, unempathic, and emotionally mis-attuned, which could lead to an impasse or premature termination. Therapists who treat patients with dependent features may be overprotective and may avoid exploring the patient’s painful feelings.

Author email address: antonello.colli@uniurb.it

Ulvenes, P. G., Berggraf, L., Hoffart, A., Stiles, T. C., Svartberg, M., McCullough, L., & Wampold, B. E. (2012). Different processes for different therapies: Therapist actions, therapeutic bond, and outcome. Psychotherapy, 49(3), 291-302.

One of the few truisms of psychotherapy is that the therapeutic alliance is important to treatment outcomes. But does the alliance work similarly in Cognitive Behavioral Therapy (CBT) and in Psychodynamic Therapy (PDT)? Therapeutic alliance is defined by three elements: the bond between client and therapist, agreement on tasks, and agreement on goals. Compared to PDT therapists, CBT therapists tend to focus more on cognitions and focus less on emotions, and so the bond may be less important in CBT than agreement on tasks and goals. Will the bond between client and therapist be differentially affected by the differing focus on emotions between CBT and PDT? A study by Ulvenes and colleagues (2012) looked at this question. This study is a follow up study of a randomized controlled trial comparing CBT to PDT for the treatment of cluster C personality traits (i.e. individuals who have trouble in experiencing and expressing emotions, and in developing close relationships). Fifty clients were randomized to either CBT or PDT, therapy was short term, and therapists were experienced and competent in delivering their therapy. In the previous study the authors reported that CBT and PDT were both equally effective in treating clients with cluster C personality disorder. In the current study, the authors found that therapist avoidance of affect was associated with developing a greater bond with patients in both CBT and PDT. That is, Cluster C patients liked their therapists better if the therapists avoided talking about the clients’ feelings. However, focusing on affect in PDT was also associated with positive outcome. In other words, therapists who avoided talking about emotions in PDT helped the patient like the therapist better, but this was counterproductive for good outcome. PDT therapists had to manage to create a bond despite their focus on affect in order to achieve good outcomes. On the other hand, focusing on affect in CBT was associated with poorer outcome. That is, therapists who avoided affect in CBT, which is consistent with the treatment model, had clients who experienced both a better bond and better outcomes. Therapeutic alliance is important for all therapies, but may operate quite differently depending on how much the therapy focuses on affect (PDT) or on cognitions (CBT).

Practice Implications

PDT therapists working with cluster C patients have to negotiate a complex task of maintaining a bond despite the treatment model’s focus on emotions in order to achieve good outcomes. CBT therapists will do well to be consistent with the treatment model and focus primarily on cognitions to help with the bond and promote good outcomes. CBT therapists in particular may need to develop a strong bond before agreeing on tasks and goals, which are also keys to a therapeutic alliance.

Author email: pal.ulvenes@modum-bad.no