No “One Size Fits All” treatment for Borderline Personality Disorder

The February 2012 issue of the Journal of Personality Disorders explores the benefits of therapists taking an integrated approach in the treatment of personality disorders. What is meant by "integrated approach" is the use of more than one treatment framework or theory (i.e. Dialectical Behavioral Therapy, Cognitive Behavioral Therapy, Mentalizing-Based Therapy, etc.) with the same client. There is research that shows that treatments that focus specifically on the treatment of BPD are more effective than "treatment as usual", that is, therapy where the interventions are not BPD specific[1]. I see this regularly in my work...clients who have had years of therapy, have learned coping skills, stress-management skills, how to challenge negative self-talk, but have not improved significantly. These clients are understandably skeptical of therapy and of their ability to change and recover.

While research shows that a BPD-specific therapy is more effective than a generic therapy, there is little research-based evidence to help us understand which aspects of each modality bring about positive change. In addition, all the BPD-specific treatments appear to produce comparable amounts of change (Leichsenring and Leibing, 2003) indicating that no one treatment can be identified as working better than others across the board. [2] This makes sense to me. There are 9 different personality traits that make up the criteria for BPD, and several hundred ways these can be combined to form a BPD diagnosis. Mix in other personality traits a person possesses, the typical mix of related mental illnesses often present (depression, anxiety, PTSD, substance abuse, eating disorders, etc.), and the strengths and weaknesses of the therapist doing the treatment, and it should be obvious that no one treatment method could be equally effective for every person and every symptom.

If all BPD-specific treatments produce comparable and significant change, it follows that there are strategies in each treatment approach that are effective. The difficulty is in discovering which components of treatment work, and which of the different aspects of BPD are positively impacted by the different components. There is little research available at this point to answer these questions.

At Tidelands, we have utilized strategies from many different arenas to address the issues that have come up for clients during individual and group therapy. For example, one very painful issue that many of our clients deal with is an overpowering feeling of self-loathing. This horribly intense, emotionally painful feeling can drive self-destructive, emotion-numbing, and suicidal behaviors. To work with this we have drawn on the work of Kristen Ness, PhD, and her concept of Self-Compassion[3] and her process for learning how to be compassionate and gentle with ourselves. This has been very helpful for many of our clients, not just clients dealing with BPD.

We also integrate Jon Kabat-Zinn's work on mindfulness, resources on self-forgiveness, skills from dialectical behavioral therapy, cognitive therapy techniques, schema therapy assessments for identifying core maladaptive beliefs that are causing distress, communication and assertiveness skills, relationship building skills including identifying and staying out of unhealthy relationships[4], and take a "whatever works" approach to help clients cope effectively with the issues they are facing. And to be perfectly honest, our clients have been instrumental in introducing us to many of the approaches and resources, sharing what has worked for them, and encouraging us to share what they have learned with others. We continue to challenge ourselves to explore new, different and exciting ideas, skills and techniques that can help our clients return to wellness.

[1]Dimaggio and Livesley. Introduction to ...The Integrated Treatment of Personality Disorders. Journal of Personality Disorders 26(1), 1-6, 2012.

[2]Nelson, et. al. Psychotherapy Integration in the Treatment of Personality Disorders: A Commentary. Journal of Personality Disorders (26)1, 7-16, 2012.

[3]Ness, Kristin. Self-Compassion (2011) William Morrow.

[4]Brown, Sandra L. (2005) How To Spot a Dangerous Man Before You Get Involved. Alameda, CA. Hunter House.