Talking treatments are a key component of the therapy offered to people with borderline personality disorder and there are now a number of studies that point to the importance of these interventions for this complex and hard to manage condition.
A new randomised controlled trial conducted by a research team from the Centre for Addiction and Mental Health in Toronto looks at the impact that dialectical behaviour therapy and general psychiatric management can have on borderline personality disorder (BPD).
The authors randomised 180 adults with a DSM-IV diagnosis of BPD (86% female, 65% unemployed, mean age 30 years old). The trial participants had all tried to kill themselves or self-harmed at least twice in the last 5 years, with the most recent episode in the last 3 months.
People were excluded if they had:
- A diagnosis of bipolar disorder, dementia, delirium or learning disabilities
- Abused substances in the last month
- Been into hospital with another serious medical condition in the following year
The trial participants were randomised to one of two treatments:
- Dialectical behaviour therapy (DBT) – a talking therapy based on CBT that aims to balance ‘acceptance techniques’ with ‘change techniques’
- General psychiatric management (GPM) – psychodynamic psychotherapy, case management and drug therapy
It was unclear whether randomisation was adequately concealed, but outcome assessors were blinded to treatment.
Patients attended weekly therapy sessions for 1 year and were then followed-up for 2 more years (so called naturalistic follow-up). There was a significant loss to follow-up over the total 3 year period with 48% of participants completing all 4 assessments.
The main outcomes of interest were self-reported suicide and self-harm, BPD remission, use of healthcare services, general symptoms and functioning, depression, anger, interpersonal functioning and quality of life.
Here’s what they found:
- Suicide attempts were reduced in both groups:
- Dialectical behaviour therapy (DBT) – from 39.3% to 10.1%
- General psychiatric management (GPM) – from 37.5% to 6.6%
- After 2 years of follow-up these reductions were maintained and suicide attempts did not differ between the groups
- Self-harm rates also fell:
- DBT – from 84.3% to 47.8%
- GPM – 87.5% to 44.7%
- After 2 years of follow-up these reductions were maintained and self-harm rates were similar between the groups
- Remission rates were similar after 2 years of follow-up:
- DBT – 57%
- GPM – 68%
- However, the treatments appeared to have little impact on employment or disability benefit rates. Ater 2 years of follow-up:
- 53% were unemployed or not in school
- 39% were receiving psychiatric disability support
The authors concluded:
One year of either dialectical behaviour therapy or general psychiatric management was associated with long-lasting positive effects across a broad range of outcomes. Despite the benefits of these specific treatments, one important finding that replicates previous research is that participants continued to exhibit high levels of functional impairment. The effectiveness of adjunctive rehabilitation strategies to improve general functioning deserves additional study.
Link
McMain SF, Guimond T, Streiner DL, Cardish RJ, Links PS. Dialectical behavior therapy compared with general psychiatric management for borderline personality disorder: clinical outcomes and functioning over a 2-year follow-up. Am J Psychiatry. 2012 Jun;169(6):650-61. doi: 10.1176/appi.ajp.2012.11091416. [PubMed abstract]
Dialectical behaviour therapy – Mind
André Tomlin
André started the Mental Elf website in May 2011. He has worked as an Information Scientist in Mental Health since the late nineties; initially at Oxford University's Centre for Evidence-Based Mental Health and since 2002 as the Managing Director of Minervation Ltd. He loves blogging, social media and elves! He also has established interests in evidence-based healthcare, usability testing and web design.
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Hi,
It would be great if you could give us a little more information on GPM.
Thanks
Hi Romi,
In this study, GPM (general psychiatric management) consisted of psychodynamic psychotherapy, case management and pharmacotherapy, delivered once a week for one year by trained therapists.
Hope that helps.
Regards,
The Mental Elf
Thank you for your quick reply.In a nutshell is case management in this setting a person that communicates between prescriber,patient/consumer & therapist helping with planning ,review of the care program to see if changes need to be made & follow up or is there more?
Thanks
Hi Romi,
Case management is usually defined as “the coordination of community services for mental health patients by allocating a professional to be responsible for the assessment of need and implementation of care plans”.
It normally involves a number of tasks such as assessment of need, care planning, implementation and regular review.
There’s a Cochrane review on intensive case management if you are interested in reading further:
Dieterich M, Irving CB, Park B, Marshall M. Intensive case management for severe mental illness. Cochrane Database of Systematic Reviews 2010, Issue 10. Art. No.: CD007906. DOI: 10.1002/14651858.CD007906.pub2.
http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD007906.pub2/abstract
Cheers,
The Mental Elf
Sorry,I have one more question about rigorous control conditions like GPM according to the APA guidelines (McMain 2009) or community treatment by experts (CTBE) (Linehan 2006), these have no statistically significant group differences for pathology-related outcomes than DBT ,so I was wondering if you can find these in the health care system (outside of research study settings) if so,where?
Thanks
I’ve only read your blog on the matter, but am I right that the report authors’ carefully chosen words are basically saying that there were some apparent positive effects, but it still isn’t exactly clear what were the specific (combination of) contributing factors?
I hope this helps answer at least part of your question
There are some common features but quote ” the findings from this ( http://ajp.psychiatryonline.org/article.aspx?articleid=1170850 ) study that show continued Functional Impairement suggest that our current theoretical understanding of borderline personality disorder and the associated therapeutic packages is inadequate. We may have taken our eyes off the ball.”
Some common features see sources for more detail:
Has a model of pathology (disease) that is carefully explained
An atmosphere of hope and optimism
Specialized for BPD- clearly focused e.g. on problem behaviour such as self-harm or a relationship pattern…
Progress is monitored using goals (better functioning,less symptoms)
Good therapists need to be active and maintain consistent expectations of change and
participation from the BPD
Structured-the therapy has a structured manual that supports the therapist and provides
recommendations for common clinical problem.The structure encourages increased activity,
pro-activity ( taking control of situations by causing something to happen rather than waiting to respond to it after it happens such as planning Christmas shopping so you won’t get very stressed at the last minute)
A respectful, supportive ,cooperative, open and non-judgmental relationship with the BPD
Encourages a powerful attachment relationship between therapist and patient (trust and closeness with the therapist), where they validate the BPD’s distress, listen to the BPD & show empathy. This helps BPDs recognize and accept themselves as unique and worthy
Supervised therapists(for managing counter transference) are active & non-reactive
Sources
http://ajp.psychiatryonline.org/article.aspx?articleid=1170850
http://www.borderlinepersonalitydisorder.com/CME/Module_4_Treatment/player.html
http://www.ucl.ac.uk/psychoanalysis/research/mbt.htm
https://www.mja.com.au/open/2012/1/4/depression-and-borderline-personality-disorder#0_CACHCCAH
http://bgrosjean.com/BPD.html
http://www.borderlinepersonalitydisorder.com/understading-bpd/a-bpd-brief/
These features could be why strict control conditions (listed in previous comment) would be nearly as helpful as evidence-based therapies such as MBT,DBT,SFT…
Hope that helps!
Thanks for that…….
No problem,happy to help =)
I don’t understand why the authors seem so surpised that the participants still showed “high levels of functional impairment”. I mean, they had only been getting therapy for a year and it sounds like they suffered very badly and would need a lot longer than that!
Presumably the therapies made a difference but didn’t ‘cure’ completely, so the participants still struggled day-to-day. Also, the coping mechanisms they learnt may not be applicable in all situations ie. the workplace. I know I have struggled with similar issues and can ‘cope’ day-to-day with little self-harm or contact with services… but I am highly ‘functionally impaired’ as my coping mechanisms involve things like ‘time out’ so are not transferable to the workplace.
Also, there is all the talk of validating the person’s pain…. It seems to me that this is the core issue (for myself and those I’ve known *diagnosed* with BPD). If the inner pain was treated, sorted through, and ultimately banished, they’d be fine. All the talk of ‘behavoirs’ seems to miss this vital point – you are looking at someone who is in severe, unimaginable, unrelenting pain. When you take that into account, eveything they do makes sense. Of course they are screaming out in pain, of course they are trying to kill themselves to end it, of course they are going to be livid if you dismiss them – they are in agony and need help.
Get rid of the pain, and you get rid of their reaction to the pain. Using things like self-harm, contact with services, and suicide attempts to measure ‘recovery’ means they might have just found different ways of coping, rather than actually feeling much better inside. Of course, better coping skills are good, and stop the feedback-loop making things worse, but ultimately if the pain is still there they will still be impaired.
They are trying to help functioning with a new therapy called DBT-ACES (wrote about it on my blog here (near the end) :http://reducingourmentalillnesses1atatime.blogspot,com/2012/06/new-treatments-for-bpd-easy-to.html ) because some BPDs still committed suicide after completing DBT,but you’re right, there is still a very long way to go treating the root cause(s) & the pain.MBT is good as it stops the process before the emotions or physical feelings kick in by changing your interpretation rather than the DBT approach that takes action once the emotion is felt..
There’s also energy psychology but that has no research studies yet.
Yes it is sad that quality of life doesn’t seem important,the focus is on reducing money spent on hospitalization,ER visits…Stage 1 DBT is offered but the other stages you often have to pay yourself/they’re not available,DBT ACES is difficult to find as its quite new & few therapists have been trained in it.The term recovery can be misleading.