Case Analysis – Treatment Format

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Borderline Personality

Disorder

JOEL R. SNEED, ERIC A. FERTUCK, DORA KANELLOPOULOS, AND MICHELLE E. CULANG-REINLIEB

OVERVIEW OF DISORDER

The origin of borderline personality disorder

(BPD) dates back to the original use of the term

borderline as delineating a group of patients

who were neither neurotic nor psychotic

(Stern, 1938). While early descriptions clari-

fied similarities and differences between the

phenomenology of BPD and other disorders, it

was the advent of DSM-III criteria that

allowed for reliable diagnosis and the facili-

tation of research into the disorder (Fertuck,

Lenzenweger, Clarkin, Hoermann, & Stanley,

2006). BPD is currently defined by frantic

efforts to avoid abandonment, unstable inter-

personal relationships, emotional lability,

intense and inappropriate anger, impulsivity

that is self-destructive (including drug use,

indiscriminant sexual relations, and suicidal

and parasuicidal behavior), stress-related dis-

sociation and paranoia, and chronic feelings of

emptiness (American Psychiatric Association,

2000). Recurrent suicidal behaviors, along

with self-mutilation (i.e., cutting, burning,

etc.), are often referred to as parasuicidal and

are defined as nonfatal, intentional self-injuri-

ous behaviors with intent to cause bodily harm

or risk death (Linehan, 1993a).

The burden and suffering caused by BPD

is profound. BPD is associated with an up to

10% rate of completed suicide (Black, Blum,

Pfohl, & Hale, 2004), which is similar to the

rate for major depression and schizophrenia,

and 400 times greater than the suicide rate of

the general population. Nonsuicidal self-injury

(Simeon et al., 1992), intense and chronic

emotional pain (Stiglmayr et al., 2005), and

chronic physical illnesses (Frankenburg &

Zanarini, 2004) are also prevalent.

The symptoms characteristic of BPD have

been categorized in several ways. For

example, Linehan (1993a) argued that the

DSM-IV criteria can be reorganized according

to five domains of dysregulation: emotional

(the primary disturbance), interpersonal, cog-

nitive, behavioral, and self. Others have sug-

gested that the symptoms fall along three

primary dimensions: interpersonal and identity

disturbance, emotional instability, and impul-

sive and aggressive behaviors (Sanislow,

Grilo, & McGlashan, 2000). While individuals

with BPD may vary in the severity of these

features, they are highly intercorrelated in

BPD, and cohere into a unitary syndrome

(Clifton & Pilkonis, 2007).

In clinical settings, nearly three quarters of

those diagnosed with BPD are female (Swartz

et al., 1989); however, epidemiological studies

of representative community samples indicate

an equal sex ratio (Lenzenweger, Lane,

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Loranger, & Kessler, 2007; Torgerson, Krin-

glen, & Cramer, 2001). Population prevalence

estimates for BPD range from 0.3% to 1.6%

(Lenzenweger et al., 2007), which is compa-

rable to other major psychiatric disorders, such

as schizophrenia. Given these associations, it

is not surprising that BPD is associated with

extensive health-care utilization (Bender

et al., 2001). It is estimated that approximately

11% of psychiatric outpatients and 19% of

psychiatric inpatients meet criteria for BPD

(Marshall & Serin, 1997). There is also a

substantial co-occurrence between BPD and

other Axis I disorders, such as major depres-

sion (Joyce et al., 2003; Stanley & Wilson,

2006), substance abuse (Trull, Sher, Minks-

Brown, Durbin, & Burr, 2000; Wilson et al.,

2006), anxiety disorders (Skodol et al., 2002),

posttraumatic stress disorder (Heffernan &

Cloitre, 2000; Landecker, 1992), eating dis-

orders (Zanarini, Frankenburg, Hennen,

Reich, & Silk, 2004), and—to a lesser

degree—bipolar mood disorder (Atre-Vaidya

& Hussain, 1999; Deltito et al., 2001;

Gunderson et al., 2006; Henry et al., 2001;

Paris, Gunderson, & Weinberg, 2007). Suicide

attempts increase dramatically in borderline

patients with co-occurring major depression

and substance abuse (Fertuck, Makhija,

& Stanley, 2007; Jacobs, Brewer, & Klein-

Benheim, 1999; Tanney, 2000).

Traditionally, clinicians have considered

BPD a difficult-to-treat condition with a

negative long-term prognosis (Stern, 1938;

Stone, Hurt, & Stone, 1987); however, a more

recent meta-analysis suggests that psycho-

therapeutic treatment for BPD is associated

with a sevenfold greater rate of recovery

compared to the natural history of the disorder

(Perry, Banon, & Ianni, 1999). In addition,

the long-term prognosis for individuals with

BPD appears more positive than previously

appreciated (Lenzenweger, 2008; Zanarini,

Frankenburg, Hennen, & Silk, 2003). Impor-

tantly, in the last two decades, clinicians

and researchers have developed and evalu-

ated targeted, BPD-specific psychosocial and

pharmaceutical treatment options that have

preliminary support from randomized con-

trolled trials (RCTs). Consequently, many

clinicians now express a cautious but founded

optimism for the efficacy of psychosocial

treatments for BPD (Gabbard, 2007).

The aim of this chapter is to review and

summarize empirically supported psycho-

social treatments for BPD. In addition, we

delineate the emerging trends and challenges

for the future of empirically supported treat-

ment including multimodal, integrative

treatments, treatment mechanism research,

and patient–treatment matching by BPD

subtypes and stage of recovery.

EMPIRICALLY SUPPORTED

TREATMENTS

We will use the principles established by the

American Psychological Association (Levant,

2005) on Evidence-Based Practice in Psy-

chology (EBPP) to evaluate whether a given

treatment has been demonstrated to be effec-

tive. According to the Policy Statement on

Evidence-Based Practice in Psychology

(EBPP), “The purpose of EBPP is to promote

effective psychological practice and enhance

public health by applying empirically sup-

ported principles of psychological assessment,

case formulation, therapeutic relationship, and

intervention” (p. 5). This statement was

inspired by the debate and controversy over the

original criteria put forth by Division 12 of the

APA to rigorously define empirically validated

treatments (Chambless & Hollon, 1998). The

original definition has two levels: well estab-

lished and probably efficacious. To be well

established, a treatment must have support

from at least two well-conducted randomized

clinical trials (RCTs) with active control

groups conducted by at least two indepen-

dent groups of researchers. Probably effica-

cious treatments require only one RCT with

an active control or two RCTs with wait-list

controls. Additionally, the original criteria

508 Specific Disorders

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require thatthe treatmenthavea well-articulated

manual and that the diagnostic characteristics

of the patient group samples be clearly specified

by DSM-IV criteria.

CONSENSUS PANEL

RECOMMENDATIONS

The American Psychiatric Association pub-

lished guidelines in 2001 for the treatment

of BPD that advocate for a combined psy-

chotherapy and targeted pharmacotherapy

approach with psychotherapy being the

primary treatment component and pharma-

cotherapy the adjunctive component (Oldham,

2005). Although the majority of RCTs involve

treatment of BPD with DBT, the updated

guidelines noted a number of new manualized

psychotherapy approaches being examined in

open treatment trials. Since the publication of

the update, several RCTs have been published

that we have reviewed (see the following).

Augmenting psychotropic agents, such as

SSRIs, atypical antipsychotics, and mood

stabilizers, are also recommended to treat

targeted symptoms such as affective dysregu-

lation, cognitive-perceptual disturbances, or

impulse dyscontrol in BPD.

There are now several psychosocial treat-

ments for BPD with varying empirical support

from RCTs (see Table 22.1). In the following

section, we summarize the nature and research

support for the most established approaches.

The section is divided into treatments that

are comprehensive and treatments that are

adjunctive.

COMPREHENSIVE TREATMENTS

Dialectical Behavior Therapy

Dialectical behavior therapy (Linehan, 1993a)

is a flexible, cognitive behavioral treat-

ment characterized by weekly individual

sessions, weekly skills training groups, and

telephone coaching to help generalize newly

learned skills beyond therapy sessions. The

central focus of DBT is on the dialectical

tension between accepting the patient’s

emotional experience and effecting adaptive

change through the use of chain analyses,

self-monitoring diaries, and contingency

management, particularly with respect to life-

threatening and therapy-interfering behaviors.

It also emphasizes education, role playing, and

problem solving strategies. DBT’s focus on

mindfulness, dialectics, and the therapeutic

relationship distinguish it from standard CBT.

According to the theoretical underpinnings

of DBT, the emotional dysregulation that

typifies BPD has its etiology in the interaction

between biology and environment. The bio-

logical underpinnings of emotional dysregu-

lation are high sensitivity and high reactivity

to painful affect, as well as a slow return to

emotional baseline after arousal. As a result,

borderline patients are primed for high emo-

tional reactivity because the biological con-

comitants of negative affectivity are still

active and have not returned to premorbid

levels. In conjunction with biological vulner-

ability, borderline patients are often subjected

to invalidating environments. Typical features

of the invalidating environment are being

exposed to caregivers or significant others

who: (a) respond erratically and inappropri-

ately to private emotional experiences, (b) are

insensitive to people’s emotional states,

emotional experiences, (d) emphasize control

over negative emotions, and (e) have a ten-

dency to trivialize painful experiences and/

or attribute such experiences to negative

traits, such as lack of motivation or disci-

pline. It is theorized that the interaction

between emotional vulnerability and invali-

dating environments results in not being able

to label and modulate emotions, tolerate

emotional or interpersonal distress, or trust

private experiences as valid.

According to DBT, parasuicidal behaviors

that have been traditionally thought of as

Borderline Personality Disorder 509

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TABLE 22.1 Summary of RCTs of Psychotherapy for Borderline Personality Disorder (BPD)

Article Sample Treatment Groups Duration Outcomes

Bateman and Fonagy (1999) Psychiatric inpatients with

BPD (N ¼ 38; ages 16 to 65) MBT in partial

hospitalization (N ¼ 19) versus TAU (N ¼ 19)

18 months MBT showed greater decreases in self-mutilation, suicide attempts,

anxiety, depression, and severity of symptom reports than TAU.

Reduction in hospital admissions and length of stay for MBT group

in last 6 months of study; in the TAU group, there was an increase

in the same time period.

Bateman and Fonagy (2008) Follow-up of patients with

BPD in partial hospitalization

setting from 1999 study

(N ¼ 38; ages 16 to 65)

MBT group received

additional 18 months of

outpatient treatment versus

TAU

5-year

postdischarge

follow-up

Fewer MBT patients met criteria for BPD compared to TAU. MBT

patients had less use of services and medication had longer duration

of employment than TAU.

Blum et al. (2008) BPD patients with no

previous participation in

STEPPS (N ¼ 124; Mean age ¼ 31.5; SD ¼ 9.5)

STEPPS þ TAU (N ¼ 65) versus TAU (N ¼ 59)

20 weeks Differences in affective, cognitive, impulsive, affective, and

interpersonal domains of Zanarini Rating Scale for BPD as well as

improvements in global functioning favoring the STEPPS group.

Clarkin, Levy, Lenzenweger,

and Kernberg (2007)

Patients with BPD (N ¼ 90; ages 18 to 50)

TFP (N ¼ 23); DBT (N ¼ 17); and ST (N ¼ 22)

1 year TFP and DBT were significantly associated with improvement in

suicidality. TFP and ST were associated with improvement in

anger. TFP was associated with improvement in Barratt Factor 2

Impulsivity as well as irritability, verbal assault, and direct assault.

ST was predictive of improvement in Barratt Factor 3 Impulsivity.

Davidson et al. (2006) Patients with BPD who had

received emergency

psychiatric services in past

year (N ¼ 106; ages 18 to 65)

CBT þ TAU (N ¼ 54) versus TAU only (N ¼ 52)

1 year treatment;

1 year follow-up

No differences between the groups in suicidal acts, inpatient, or

emergency hospitalization. There was a statistically significant

difference in the mean number of suicide acts (small effect size) as

well as lower anxiety and BPRS distress favoring CBT at the end of

2 years.

Giesen-Bloo et al. (2006) Patients with BPD (N ¼ 86; ages 18 to 60)

TFP (N ¼ 42) versus SFT (N ¼ 44)

3 years Both treatments related to significant increases in quality of life,

reduction in all BPD symptoms, and reduction in general

psychopathologic dysfunction. SFT group had greater reduction in

BPD symptoms, general psychopathology than TFP. Higher

dropout rate for TFP than SFT.

Gregory et al. (2008) Patients with BPD and active

alcohol abuse/dependence

(N ¼ 30; ages 18 to 45)

DDP (N ¼ 15) versus TAU (N ¼ 15)

12–18 months Significant improvement in parasuicide, alcohol misuse, and

institutional care over time for DDP but not for TAU.

Koons et al. (2001) Women with BPD recruited

from a VA clinic (N ¼ 20; ages 21 to 46)

DBT (N ¼ 10) versus TAU (N ¼ 10)

6 months DBT patients had greater reductions in suicidal ideation,

depression, hopelessness, and anger compared to TAU at

posttreatment.

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Levy, Meehan, et al. (2006) Adults with BPD (N ¼ 90; ages 18 to 50)

TFP (N ¼ 31) versus SPT (N ¼ 30) versus DBT (N ¼ 29)

1 year Reflective function, attachment coherence, and security of

attachment had a significantly greater increase over the year of

treatment for the TFP group versus the other two therapy groups.

There were no significant changes across groups for resolution of

loss or trauma.

Linehan, Armstrong, Suarez,

Allmon, and Heard (1991)

Chronically parasuicidal

women with BPD recruited

from outpatient clinic

(N ¼ 44; ages 18 to 45)

DBT (N ¼ 22) versus TAU (N ¼ 22)

1 year DBT patients had significant reductions in parasuicidal behavior,

were significantly more likely to start and to complete treatment,

stayed in treatment longer, and had significantly fewer inpatient

hospital days compared to TAU. Findings were maintained

throughout the posttreatment follow-up year.

Linehan, Heard, and

Armstrong (1993)

Women with BPD and at least

two instances of parasuicidal

behavior (N ¼ 39; ages 18 to 45)

DBT (N ¼ 19) versus TAU (N ¼ 20)

1 year Parasuicide repeat rate and the likelihood of any psychiatric

hospitalization were lower for DBT versus TAU completers; this

difference remained during the 12–18 month follow-up period.

During the follow-up year, DBT patients reported significantly

better Global Assessment Scale scores and employment

performance than TAU.

Linehan, Tutek, Heard, and

Armstrong (1994)

Women with BPD (N ¼ 26; ages 18 to 45)

DBT (N ¼ 13) versus TAU (N ¼ 13)

1 year DBT was more effective than TAU in the community in improving

interpersonal and general adjustment in women with BPD. DBT

patients rated selves better on trait anger scores and on overall

social adjustment posttreatment.

Linehan et al. (1999) Women with BPD and

substance use disorder

(N ¼ 28; ages 18 to 45)

DBT (N ¼ 12) modified for substance abuse versus TAU

(N ¼ 16)

1 year Significant reduction in substance abuse, improvements in social

and global adjustment, and greater retention rates for DBT versus

TAU. Improvements in social and global adjustment greater for

DBT versus TAU at follow-up. Greater adherence of therapists to

DBT treatment manual resulted in better outcomes.

Linehan et al. (2002) Heroin-dependent women

with BPD (N ¼ 23; ages 18 to 45).

DBT (N ¼ 11) modified for substance users versus

CVT þ 12S (N ¼ 12). Both groups also received opiate

agonist therapy.

1 year Both treatments when combined with opiate agonist treatment were

effective in reducing opiate use and maintaining the reduction to

4-month posttreatment. CVT þ 12S had greater retention rate than DBT. DBT group was more accurate in self-recording opiate use.

Linehan et al. (2006) Women with BPD (N ¼ 103; ages 18 to 45)

DBT (N ¼ 52) versus CBTE (N ¼ 49)

1 year DBT group had half the rate of suicide attempts, was more effective

at reducing emergency room visits, and inpatient psychiatric care

for suicide ideation compared to the CTBE group. DBT was more

than twice as effective as CTBE in keeping subjects in treatment.

(Continued)

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TABLE 22.1 Summary of RCTs of Psychotherapy for Borderline Personality Disorder (BPD) (Continued )

Article Sample Treatment Groups Duration Outcomes

Linehan, McDavid, Brown,

Sayrs, and Gallop (2008)

Women with BPD and high

levels of irritability and anger

(N ¼ 24; ages 18 to 60)

DBT þ placebo (N ¼ 12) versus DBT þ olanzapine (N ¼ 12)

6 months Irritability, aggression, and self-injurious behavior improved

significantly during treatment for both conditions. Irritability and

aggression tended to decrease more rapidly for olanzapine, while

self-inflicted injury tended to decrease more placebo group.

Spinhoven, Giesen-Bloo,

van Dyck, Kooiman, and

Arntz (2007)

Patients with BPD (N ¼ 78; ages 18 to 60)

SFT (N ¼ 44) versus TFP (N ¼ 34)

3 years The quality of the therapeutic alliance increased for patients for

both SFT and TFP but therapist frustration decreased for SFT while

it increased for TFP. Compared to SFT significantly more patients

in TFP dropped out early.

Turner (2000) Patients with BPD (N ¼ 24; Mean age ¼ 22)

DBT (N ¼ 12) with no separate skills group versus

CCT (N ¼ 12)

1 year DBT group showed a greater reduction in global mental health

functioning, self-harm behaviors, and hospitalization days at both

6 and 12 months. DBT had lower impulsivity than CCT at 12

months.

Van den Bosch, Koeter,

Stijnen, Verheul, and van

den Brink (2005)

Women with BPD with and

without substance abuse

(N ¼ 58; ages 18 to 45)

DBT (N ¼ 27) versus TAU (N ¼ 31)

6-month follow-up DBT had a significantly greater decrease in impulsive and self-

mutilating behavior and alcohol consumption than TAU. The

treatment effects were sustained for the 6-month period after

termination of treatment.

Van Den Bosch, Verheul,

Schippers, and van den

Brink (2002)

Women with BPD with and

without substance abuse

(N ¼ 58; ages of 18 to 45)

DBT (N ¼ 27) versus TAU (N ¼ 31)

1 year Substance abuse was not effectively targeted by either treatment.

DBT had greater retention rate and showed greater reductions of

self-mutilating behavior and self-damaging impulsive acts than

TAU. Beneficial effect of DBT on self-mutilating behaviors was

greater for those patients that had higher baseline behaviors.

Verheul et al. (2003) Women with BPD (N ¼ 64; ages 18 to 70)

DBT (N ¼ 31) versus TAU (N ¼ 33)

1 year DBT had a decrease in self-mutilating behaviors and a greater

retention rate than TAU. Impact of DBT was more pronounced for

participants who reported higher baseline frequencies of self-

mutilating behaviors.

Weinberg, Gunderson,

Hennen, and Cutter (2006)

Women with BPD (N ¼ 30; ages 18 to 40)

MACT þ TAU (N ¼ 15) versus TAU (N ¼ 15).

6 to 8 weeks The MACT group had significantly greater decrease in frequency

and severity of deliberate self-harm (DSH) at both 6–8 weeks and at

the 6-month follow-up. No significant differences between groups

were observed for suicidal ideation and time to repeat DSH.

Note: MBT ¼ Mentalization-Based Therapy; TAU ¼ Treatment As Usual; STEPPS ¼ Systems Training for Emotional Predictability and Problem Solving; TFP ¼ Transference Focused Psychotherapy; DBT ¼ Dialectical Behavioral Therapy; ST ¼ Supportive Therapy; CBT ¼ Cognitive Behavior Therapy; SFT ¼ Schema Focused Therapy; DDP ¼ Dynamic Deconstructive Psychotherapy; MPSP ¼ Modified Psychodynamic Supportive Psychotherapy; CVT ¼ Comprehensive Validation Therapy; CBTE ¼ Community-Based Treatment by Experts; CCT ¼ Client Centered Therapy; MACT ¼ Manual-Assisted Cognitive Therapy

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manipulative and controlling are reframed

as maladaptive attempts at problem solving

and emotion regulation. Linehan argued

that a dialectical perspective looks for the

wisdom or the adaptiveness of the parasuicidal

gesture; that is, although the gesture is

dysfunctional, it has been shaped by an

environment that actively teaches emotional

invalidation. As such, this model posits that

parasuicidal gestures serve self-regulatory

functions and also serve to elicit responses in

significant others who have not responded

appropriately to the patient’s emotional

needs. According to Linehan (1993a), what

maybe viewed as dysfunctional, distorted, and

destructive, may actually be adaptive, accu-

rate, and constructive.

Weekly skills training groups (Linehan,

1993b) aim to replace the maladaptive prob-

lem-solving strategies characteristic of BPD

patients with more constructive and adaptive

strategies that help the patient build a life

worth living. The four areas of skills training

include core mindfulness, interpersonal effec-

tiveness, emotion regulation, and distress

tolerance. Mindfulness strategies integrate

Zen meditation practices and epitomize the

acceptance versus change dialectic, which lies

at the heart of DBT. The core mindfulness

module distinguishes between rational mind,

emotion mind, and wise mind. The wise mind

represents an integration of rational and emo-

tion mind and can be thought of as the indi-

vidual’s intuition. Mindfulness exercises form

the core of the module and aim to decrease

impulsivity and allow for the implementation

of more adaptive strategies learned in the other

modules. The interpersonal module provides

strategies and techniques for dealing with and

negotiating difficult interpersonal interactions

based on a clear understanding of the priorities

in a given situation. Emotion regulation

provides the patient with an organizing

framework for understanding emotions, and

exercises that aim to enhance the capacity to

label and understand the antecedents, conse-

quences, and function of emotional expression.

Finally, distress tolerance aims to provide the

patient with various crisis strategies in order to

prevent maladaptive coping that historically

has hindered the individual from living a

meaningful and productive life.

Randomized clinical trials of DBT. We

identified 11 RCTs of DBT in patients meeting

criteria for BPD. Eight of these studies were

with patients meeting BPD criteria alone

whereas three examined the efficacy of DBT in

BPD patients meeting criteria for comorbid

substance abuse or dependence. Following, we

summarize their main findings.

Linehan et al. (1991) randomized 44 women

aged 18 to 45 years with BPD to either DBT

(N ¼ 22) or to treatment as usual (TAU) (N ¼ 22) for 12 months. The DBT program was comprehensive and included individual

psychotherapy, 150-minute group skills train-

ing including training in interpersonal skills,

distress tolerance/reality acceptance skills, and

emotion regulation skills. Patients were

exposed to all skills teaching twice within this

12-month trial. The TAU patients were given

alternative therapy referrals from which they

could choose. The DBT-treated patients

showed statistically significant reductions in

parasuicidal behavior. They were more likely

to start (100% vs. 73%) and remain in treat-

ment (83% vs. 42%) longer than TAU patients.

Additionally, DBT participants had signifi-

cantly fewer inpatient hospital days compared

to TAU patients. These findings were main-

tained throughout the posttreatment follow-up

year.

Linehan et al. (1993) randomized 39 women

aged 18 to 45 years old with BPD to DBT

(N ¼ 19) or TAU (N ¼ 20) for 1 year. Partici- pants were also assessed 6 and 12 months after

treatment termination. Throughout the treat-

ment year, the rate of parasuicidality and the

likelihood of any psychiatric hospitalization

were lower for DBT than TAU completers.

During the 6-month follow-up period, DBT

completers continued to have fewer episodes

of parasuicidality and fewer medically treated

episodes than TAU completers. During the

Borderline Personality Disorder 513

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12-month follow-up period, there was no

difference between groups on parasuicide

measures, but inpatient psychiatric days were

lower in the DBT group than the TAU group.

During the posttreatment follow-up, DBT

subjects reported significantly better Global

Assessment Scale scores and employment

performance than TAU subjects.

Linehan and colleagues (1994) randomized

26 women with BPD aged 18 to 45 years to

either DBT (N ¼ 13) or TAU (N ¼ 13). The DBT treatment was compared to TAU in

which participants received alternative therapy

referrals and participation in any type of

treatment available in the community. Results

indicated that DBT was more effective than

TAU in improving interpersonal and general

adjustment and DBT patients reported lower

scores on anger and overall social adjustment

at 12 months; however, there were no differ-

ences between the groups at 1 year with regard

to general satisfaction.

Verheul et al. (2003) randomized 64 women

with BPD aged 18 to 70 years to either DBT

(N ¼ 31) or TAU (N ¼ 33). Retention was found to be higher for DBT than TAU at 12

months. Although the frequency and course of

suicidal behaviors were not significantly dif-

ferent across treatments, the DBT group had a

greater decrease in self-mutilation compared

to the TAU group. Participants in the DBT

group showed greater improvement over time

compared to the TAU group in self-damaging

impulsive behaviors. Differences between

groups could not be explained by use of psy-

chotropic medication because both groups

included a similar number of patients on anti-

depressants. The impact of DBT was more

pronounced for participants who reported

greater frequency of self-mutilating behaviors

at baseline. Additionally there was a non-

significant trend toward greater effectiveness

of DBT compared to TAU in patients with

severe suicidal behavior at baseline.

Koons et al. (2001) randomized 20 women

with BPD aged 21 to 46 years from a VA clinic

to either DBT (N ¼ 10) or TAU (N ¼ 10) for

6 months of treatment. All of the components

of standard DBT were utilized; however,

because of shorter treatment duration com-

pared to the recommended 12-month DBT

treatment contract, skills training was con-

ducted only once. Patients in the DBT condi-

tion showed greater reductions in suicidal

ideation, depression, hopelessness, and anger

compared to TAU patients posttreatment.

Turner (2000) randomized 24 patients with

modified BPD (mean age ¼ 22 years) to DBT (N ¼ 12) or Client Centered Therapy (CCT; N ¼ 12). Assessments were conducted at pretreatment, and 6- and 12-month time points.

The DBT was modified in the two ways:

Psychodynamic techniques were incorporated

to conceptualize patient behavioral, emotional,

and cognitive relationship schemas, and skills

training was conducted during individual

therapy. Twice weekly CCT emphasized

empathy and provided a supportive environ-

ment that facilitated individuation. Although

parasuicidality decreased for both groups,

decreases in parasuicidality were greatest for

those randomized to modified DBT. Although

both groups showed reductions in impulsivity

and depression, there were no differences

between the groups at 6 months; however,

modified DBT showed greater reduction in

impulsivity and depression than the CCT-

treated group at 12 months. Anger ratings were

also significantly lower for the modified DBT

group than for the CCT group at 12 months.

The DBT-treated patients showed a greater

improvement in global mental health func-

tioning as assessed by decreases in Brief

Psychiatric Rating Scale (BPRS) scores at

12 months, as well as by a greater reduction in

hospitalization days at both 6 and 12 months.

Linehan et al. (2006) randomized 101

patients with BPD aged 18 to 45 years to either

DBT (N ¼ 52) or Community Treatment by Experts (CTBE) (N ¼ 49). The CTBE thera- pists were community psychotherapy experts,

but did not include CBT experts. The CTBE

therapists received equivalent fees for their

services but were not required to attend

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biweekly supervision as did DBT therapists.

The DBT-treated patients had half the rate of

suicide attempts as the CTBE group (23.1% vs.

46%) at 2-years postrandomization. The DBT

was more effective at reducing emergency

room visits and inpatient psychiatric care for

suicide ideation. The DBT was also more than

twice as effective as CTBE in retaining sub-

jects. The dropout rate among DBT-treated

patients was 25% compared to 59% among

CTBE-treated patients.

Linehan and colleagues (2008) randomized

24 women with BPD aged 18–24 years to

either 6 months of individual and group DBT

plus daily placebo (N ¼ 12) or 6 months of individual and group DBT plus daily olanza-

pine (N ¼ 12). Olanzapine, an atypical anti- psychotic that may be beneficial in reducing

anger, irritability, and assaultive behaviors,

was chosen to complement DBT treatment for

patients with irritability and anger features of

BPD. Self-injurious behavior decreased sig-

nificantly for both groups, as did irritability

and verbal and physical aggression. Patients in

the DBT plus olanzapine condition showed a

more rapid decrease by week 7 and through the

third month compared to the DBT plus placebo

condition. There was also a greater decrease in

depression scores in the DBT plus olanzapine

group than the DBT plus placebo group.

Linehan et al. (1999) randomized 28 women

aged 18 to 45 years who met criteria for BPD

and substance use disorder to DBT (N ¼ 12) or TAU (N ¼ 16). The DBT treatment lasted for 1 year and was modified for use with people

with substance abuse by incorporating a set of

organized interventions designed to increase

the positive valance of the therapy and ther-

apist, and by adopting a dialectical stance on

drug use that focused on skills for preventing

relapse after drug use. The TAU consisted of

community mental health counselors and pro-

grams or individual psychotherapy. Assess-

ments were conducted at 4, 8, and 12 months

during treatment, and also 4 months post-

treatment at 16 months. Patients treated with

DBT showed greater reductions in Substance

Abuse compared to TAU. Additionally, drop-

out rates were much lower in the DBT group

(36%) as compared to the TAU group (73%).

There were no differences between the treat-

ment groups on measures of psychopathology

at endpoint; however, at the 4-month follow-

up assessment, DBT subjects showed better

global and social adjustment. Significant

reductions in parasuicidal episodes and anger

were found for both groups; however, within

the DBT condition, treatment adherence by the

therapist predicted greater improvement.

Van den Bosch and colleagues (2002) ran-

domized 58 women with BPD aged 18–65

years with or without comorbid substance

abuse to DBT (N ¼ 27) or TAU (N ¼ 31). No treatment differences were observed between

groups with regard to number of days of

alcohol, medication, or cannabis use or overall

severity scores for alcohol and drug problems.

Dropout rates were lower in the DBT group

(37%) compared to the TAU group (77%). The

DBT-treated patients also showed greater

reductions in self-mutilation and self-dam-

aging impulsive acts compared to the TAU

group. The beneficial effect of DBT on self-

mutilating behaviors was greater on those that

had higher baseline self-mutilating behaviors.

In a follow-up study these differences between

DBT and TAU were sustained 6 months after

DBT treatment was discontinued despite the

continuation of TAU (van den Bosch et al.,

2005). In addition, the DBT group showed

greater reductions in alcohol consumption than

the TAU group 6 months after discontinuing.

Linehan et al. (2002) randomized 23 women

with BPD and comorbid heroin dependence to

either DBT (N ¼ 11) or Comprehensive Val- idation Therapy plus Narcotics Anonymous

(CVT þ 12S; N ¼ 12). CVT þ 12S consisted of nondirective individual psychotherapy that

proscribed CBT problem-solving strategies and

included DBT acceptance-based strategies

and weekly attendance at Narcotics Anony-

mous meetings. Both treatments were aug-

mented using opiate agonist therapy (Orlaam).

Both treatments were effective in reducing

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opiate use and maintaining that reduction at the

4-month posttreatment follow-up; however,

the DBT group maintained the reduction in

opiate use throughout the treatment trial, while

the TAU group significantly increased drug

use during the final 4 months of treatment. The

CVT þ 12S group had much higher retention rates compared to the DBT group (100% vs.

36%). Improvements on global adjustment

were observed in both treatments although

there were no differences between conditions;

however, the DBT group was more accurate in

self-recording opiate use.

Summary of DBT. In the early studies that

established DBT as the first treatment for

BPD supported in an RCT, Linehan and col-

leagues showed that DBT treatment over

1 year significantly reduces parasuicidality and

decreases hospitalization and dropout from

therapy (Linehan et al., 1991, 1993). Subse-

quent studies by other independent groups

have supported these findings (Koons et al.,

2001; Verheul et al., 2003) making DBT the

only treatment meeting criteria for a well-

established treatment for BPD.

Studies have also extended DBT to BPD

with comorbid substance abuse or dependence

(Linehan et al., 1999, 2002; van den Bosch

et al., 2002). The results of these studies have

been mixed. One showed greater improvement

in substance abuse compared to TAU (Linehan

et al., 1999) whereas two showed no difference

between groups in substance abuse (Linehan

et al., 2002; van den Bosch et al., 2002);

however, since the TAU groups received

various active forms of treatment, the failure to

detect a difference may reflect the lack of

power of studies with relatively small numbers

of participants to detect differences between

treatments. Dropout rates in two of the studies

were lower in the DBT group (Linehan et al.,

1999; van den Bosch et al., 2002) whereas in

one of the studies dropout rates were higher

in DBT (Linehan et al., 2002); however,

dropout rates tended to be lower in DBT,

which may be attributable to the pretreatment

contracting phase.

Two important issues emerge from this

review with respect to DBT. First, it is unclear

whether the gains made in DBT are sustained

over long periods of time. While some studies

suggest that treatment gains are sustained

(Linehan et al., 2006), other studies have

shown that after 2 years, there is no difference

between groups with regard to parasuicidal

behaviors (Linehan et al., 1993). Of course, the

failure to detect a difference between treat-

ments may reflect a lack of power of studies

with relatively small numbers of participants.

Second, although a large number of RCTs

support the effectiveness of DBT in BPD

patients, none of these studies compare DBT

to another specific mode of psychotherapy. In

the one study to date that compared DBT to

Transference Focused Psychotherapy (TFP,

see later), the two treatments were comparable

with respect to suicidality at outcome (Clarkin

et al., 2007).

Schema-Focused Therapy

Schema-focused therapy (SFT) (Young, 1994)

was developed to treat patients with per-

sonality disorder diagnoses that would other-

wise not respond well to traditional cognitive

therapy. It is an integrative therapy that

combines cognitive, behavioral, interpersonal,

and experiential techniques to identify and

change maladaptive schemas and their asso-

ciated ineffective coping strategies (McGinn

& Young, 1997). SFT predominantly differs

from traditional cognitive therapy because of

its focus on early childhood experiences

in treatment, the use of the therapeutic rela-

tionship to facilitate change, and the active

confrontation of maladaptive behavioral and

belief patterns (McGinn & Young, 1997).

Schemas are psychological constructs that

are comprised of memories, bodily sensa-

tions, emotions, and cognitions that develop

during childhood and are elaborated through

one’s life. These schemas or core beliefs are

expressed in enduring and chronic patterns

of thinking, feeling, and behaving. These

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overdeveloped behavioral patterns are thought

to impair adaptive functioning. The SFT

defines 18 potential schemas, which can be

grouped into five domains: disconnection and

rejection, impaired autonomy and perfor-

mance, impaired limits, other-directedness,

and overvigilance and inhibition. The sets of

schema modes, groups of schemas that are

active at a particular moment, common and

specific to BPD include detached protector,

punitive parent, abandoned/abused child, and

angry/impulsive child. BPD patients are

assumed to spontaneously and repeatedly flip

from one schema mode to another in an attempt

to cope with their difficulties. Moreover, the

modes of patients with BPD are dissociated

from one another so that when one mode is

active, the patient does not have access to other

modes, limiting their ability to modulate active

modes. The therapeutic goal is to develop and

maintain healthy schema modes while chang-

ing or eliminating maladaptive ones.

The putative mechanism of change in SFT is

to help the patient to become less influenced by

these pervasive schemas through the use of the

therapy relationship, homework assignments,

and the exploration of past traumas. The

behavioral, cognitive, experiential, and inter-

personal techniques focus on establishing a

positive therapeutic alliance, increasing emo-

tional awareness, developing an effective

individualized distress management plan, and

helping patients modify their maladaptive

schemas. In this way, it is believed that patients

will develop new, more adaptive beliefs about

themselves and other important people in their

life. Simultaneously, they will develop those

underdeveloped behavioral strategies that

facilitate better functioning in life and promote

emotional well-being.

The goal of SFT for BPD is to help the

patient internalize the Healthy Adult Mode,

which is modeled by the therapist, in order to

regulate their emotional and behavioral pat-

terns and effectively express their needs and

emotions. SFT for BPD patients consists of

three main phases that correspond to early

childhood development: the Bonding and

Emotional Regulation, Schema Mode Change,

and Autonomy stages. The Bonding and

Emotional Regulation stage consists of mutual

bonding between patient and therapist and

educating the patient about effective emotion

regulation. In this stage, the therapist actively

encourages the patient to express their needs

and emotions while providing empathy and

validation. The therapist also teaches coping

techniques that enable the patient to stabilize

their own emotions. In the Schema Mode

Change stage, the therapist uses limited

reparenting to model the Healthy Adult Mode,

which provides patients with the power to fight

against their own maladaptive coping modes

and perform appropriate and adaptive adult

functions. Patients will gradually internalize

this model as their own Healthy Adult Mode.

In the Autonomy stage, the therapist helps the

patient learn to develop healthy relationships

outside of therapy and let go of past destructive

relationships. The therapist teaches the patient

to follow natural inclinations in regard to

important life decisions. Finally, the therapist

gradually terminates the therapy to promote

further individuation.

Giesen-Bloo et al. (2006) compared the

effectiveness of SFT compared to TFP, a

psychoanalytically based, twice weekly treat-

ment (see following). This study included

patients with BPD, aged 18 to 60 years, ran-

domized to TFP (N ¼ 42) or SFT (N ¼ 44) for 3 years. Therapy in both conditions was con-

ducted during 50-minute, twice weekly ses-

sions for 3 years. Dropout rates were higher

among TFP patients (54.8%) compared to SFT

patients (38.6%). Significant reductions in all

BPD symptoms and general dysfunction and

increases in quality of life were observed for

both treatment groups; however, SFT patients

showed significantly greater reductions in

BPD symptoms, general psychopathology, and

in changes in personality constructs related to

the focus of SFT and TFP.

In subsequent analyses examining quality of

the therapeutic relationship, the therapeutic

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alliance was rated higher for SFT than TFP by

both therapist and patient (Spinhoven, et al.,

2007). The quality of the therapeutic alliance

increased for patients for both SFT and TFP,

but therapist frustration decreased for SFT

while it increased for TFP. The authors pos-

tulated that the greater rates of dropout

observed in their previous study (Giesen-Bloo

et al., 2006) may be due to poor alliance in the

TFP condition.

Summary of SFT. One seminal study has

demonstrated promising initial support for

SFT in the long-term (up to three years)

treatment of BPD. To date, this is the longest

trial of a psychosocial treatment for BPD, and

its duration conforms more closely to what is

observed in clinical practice and naturalistic

studies in the treatment of BPD (Perry et al.,

1999). It is unclear how SFT compares to other

established treatments for BPD, particularly

since the quality of TFP adherence has been

criticized (Yeomans, 2007).

Cognitive Behavior Therapy

Cognitive behavior therapy (CBT) for BPD

developed by Davidson and colleagues

(Davidson, Tyrer, et al., 2006) is similar to

SFT in that it purports to help “. . . patients

develop new, more adaptive beliefs about self

and others and work on developing under-

developed behavioral strategies to promote

improved levels of social and emotional

functioning” (p. 452). The goal of CBT is to

help the patient identify maladaptive core

beliefs, which are linked to emotions and

overdeveloped behavioral patterns, and impair

the patient’s ability to function in an adaptive

manner (Davidson, 2007). In personality dis-

orders, these dysfunctional beliefs inhibit the

expression of more adaptive beliefs and are

activated across many situations, persistently

biasing the interpretation of life experiences.

Core beliefs, or conceptions of self and others,

are thought to have developed as a result of

recurring negative childhood experiences and

are associated with behaviors that serve as

coping mechanisms. Although these behaviors

may have been adaptive in childhood, they

become dysfunctional later in life as the patient

is exposed to new environments and relation-

ships and serve to maintain maladaptive

beliefs, or cognitive schemas. The core beliefs

and behaviors that arise from negative child-

hood experiences are thought to contribute to

the formation of characteristics that are com-

mon in personality disorders such as poor

interpersonal relationships.

In therapy, the patient and therapist should

not only work toward changing dysfunctional

beliefs, but the patient should also gain an

understanding of how these negative beliefs

developed (Davidson, 2007). Taking a com-

prehensive family, developmental, and social

history and then using the data to formulate the

core problems of the patient accomplish this.

Following this step, they can then work to

change dysfunctional beliefs and behaviors

using various cognitive and behavioral strat-

egies so the patient can more effectively deal

with everyday life problems as they arise.

One of the tenets of CBT is that each session

of therapy follows a specific pattern so that

both patient and therapist can effectively

engage in therapy, control crises, keep track of

assignments, and focus on the goals of therapy

(Davidson, 2007). Five phases of CBT for

personality disorders have been outlined.

Phase one consists of educating the patient

about the structure and process of therapy. The

therapist assesses and formulates patient

problems within the cognitive model to help

the patient understand the connection between

maladaptive behavioral patterns and core

beliefs. Also in this stage, the specific goals of

treatment are developed based on the pre-

senting problems of the patient. In phase two,

the therapist and patient work together to

prioritize the problems and reduce the occur-

rence of behaviors that can cause harm to

self and others. The goal of phase three is

to develop more adaptive and less rigid core

beliefs and behaviors and, in phase four, these

new beliefs and behaviors are reinforced. In

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the final stage, the patient and therapist review

and reflect on the progress they have made and

focus on the gradual termination of therapy

and relapse prevention.

Davidson and colleagues (Davidson, Norrie,

et al., 2006; Davidson, Tyrer, et al., 2006)

conducted a multicenter study that randomized

106 BPD patients aged from 18 to 65 years

to either CBT plus TAU (N ¼ 54) or TAU only (N ¼ 52) for 1 year of active treatment and a subsequent follow-up at 1-year post-

treatment. There were no significant differ-

ences between groups on the primary outcome

measures of suicidal acts, inpatient psychiatric

hospitalization, or accident and emergency

room attendance at the end of active treat-

ment (1 year) or the 1-year posttreatment

follow-up; however, there was a significant

difference between the groups at the 1-year

posttreatment follow-up in the mean number

of suicidal acts.

Summary of CBT. In the only trial of

Davidson’s CBT approach to BPD, there were

no differences between the groups in the

primary outcomes but the authors noted

differences between the groups at the 1-year

posttreatment follow-up in the mean number

of suicidal acts; however, the effect size

corresponding to this difference was small

by conventional standards (Cohen, 1988;

Cohen, 1992).

Mentalization-Based Therapy

Mentalization-based therapy (MBT) for BPD

is a psychoanalytically oriented treatment

delivered in the context of a partial hospital

setting. MBT focuses on increasing mentali-

zation, which entails making sense of the

actions of oneself and others on the basis of

intentional mental states, such as desires,

feelings, and beliefs. MBT posits that indi-

viduals with BPD have a core instability or

inhibition of mentalization, particularly in

the context of relationships with significant

others. The focus of therapy is on the patient’s

moment-to-moment state of mind. The

therapist and patient identify prementalizing

modes of experience and transform them into

more adaptive modes. The focus is not on

relationship patterns per se, but on the way in

which patients think, feel, and understand their

interpersonal experiences. Because the treat-

ment takes place as part of a partial hospital

program, there are individual and group psy-

chotherapy components, as well as expressive

therapy using art and writing groups as well as

medication management.

Bateman and Fonagy (1999) randomized 38

participants with BPD to an 18-month trial of

MBT (N ¼ 19) or TAU (N ¼ 19). There was a significant decline in self-mutilation in the

MBT group and no decline in self-mutilation

in the TAU group. Separation between the two

treatment groups with regard to self-mutilation

occurred at 12 months and was statistically

significant at 18 months. There was also a

statistically significant difference between the

groups in average length of inpatient hos-

pital stays (3 days vs. 21 days for MBT

and TAU, respectively). Self-reported state and

trait anxiety scores and Beck Depression

Inventory scores significantly decreased for the

MBT group but not for TAU. In addition,

the MBT group showed a significant reduc-

tion relative to the TAU group in the severity

but not number of symptoms reported.

In a landmark follow-up study, Bateman and

Fonagy (2008) demonstrated that there was a

significant difference between the MBT and

TAU groups in number of suicide attempts at

5-year follow-up. Consistent with this finding,

there were more emergency room visits and

greater use of polypharmacy among those in

the TAU group. The number of hospital days

was also higher among the TAU group as

compared to the MBT group. At the end of the

follow-up period, only 13% of the MBT group

met diagnostic criteria for BPD as compared to

87% in the TAU group. Similarly, 46% of the

MBT group and 11% of the TAU group had

GAF scores above 60 indicating that the level

of overall functioning was significantly higher

in the MBT group.

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Summary of MBT. MBT is a psychodynam-

ically informed, comprehensive, partial day

hospitalization program for the treatment of

BPD. Only one RCT has been published that

has evaluated the effectiveness of this treat-

ment for BPD, thus MBT is a promising

treatment for BPD, which awaits replication.

One issue that emerges from this review is the

length of time for MBT to take effect as

treatment gains did not emerge until 1 year;

however, the 5-year follow-up suggested that

the gains are sustained over long periods.

Transference-Focused Psychotherapy

Transference-focused psychotherapy (TFP)

(Clarkin, Yeomans, & Kernberg, 2006) is the

first manualized, psychoanalytic treatment for

BPD and other personality disorders. TFP is

a twice-weekly outpatient therapy with the

option of auxiliary treatments to target specific

problems. By combining structure and limit-

setting with an approach that focuses on

mental and emotional experiences with the

therapist (i.e., the transference), TFP aims to

improve the underlying psychological struc-

ture that drives the symptoms of BPD. TFP

is organized into two main phases. Phase I

aims to reduce and control suicidal and self-

destructive behaviors. Phase II includes the

core of the treatment that endeavors to foster

the development of a coherent sense of self and

others, or, improved quality of object relations,

in the individual with BPD. Phase II is

accomplished through: (a) fostering reflection

on mental states of self and other; and (b)

delineating, elaborating, and integrating the

individuals with BPD’s emotions, motivations,

and expectations of self and other in the con-

text of the therapeutic relationship, or, the

transference.

TFP is based on object relations theory

(Kernberg, 1996), a psychoanalytic model of

psychological structure that posits core

impairments in the conceptions of self and

significant others (i.e., object relations) in BPD

and other personality disorders. TFP aims

to increase the coherence of these concep-

tions of self and other to effect stable, long-

term reductions in suicidality and aggressive

behaviors, emotional turbulence, the capacity

to have satisfying and meaningful relation-

ships, and to improve the capacity for work and

career.

The mechanisms of therapeutic action of

TFP (Levy, Clarkin, et al., 2006) occur in the

context of a clear and mutually agreed upon

framework for treatment that defines the

expectations and roles of the patient and ther-

apist. With this in place, the patient is provided

a safe haven to express emotionally charged

and disparate conceptions of self and others

within the therapeutic relationship. By delin-

eating these conceptions of self and other as

they unfold in the therapeutic relationship, the

therapist aims to integrate polarized and con-

tradictory emotional experiences of self and

significant others in the individual with BPD.

This integration is posited to faciliate the

patient’s experience of themselves into forms

that are richer, more coherent, and more real-

istic. Change in these psychological structures

is posited to cause a toning down of emotional

turbulence and an improvement in the stability

and quality of interpersonal relationships.

Improvement in TFP occurs when the patient

attends to the therapist’s delineation and

elaboration of the patient’s understanding of

self and other. Ideally, in the course of TFP, the

individual with BPD develops their own abil-

ity to reflect upon their sense of self and others

both independently and in collaboration with

the therapist. In TFP, the ability to step outside

of one’s immediate, emotionally charged

experience and observe it without feeling

totally immersed facilitates an integration of

the contradictory conceptions of self and

other that are seen to be at the core of BPD

symptoms.

Clarkin et al. (2007) randomized 90 patients

with BPD aged 18–50 years to 1 year of treat-

ment of TFP (N ¼ 23), DBT (N ¼ 17), or sup- portive psychodynamic psychotherapy (SPT;

N ¼ 22). SPT is a psychodynamically oriented

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supportive psychotherapy that is different

from TFP in that it does not focus upon the

therapeutic relationship itself. Analyses were

conducted using data on patients with at

least three assessment points. All treatments

resulted in broad positive changes in sub-

jects with BPD; however, only TFP and

DBT resulted in improvement in suicidality,

whereas only TFP and SPT were associated

with improvement in anger. Impulsivity was a

primary outcome of interest measured in this

study, using the Barratt Impulsiveness Scale,

which consists of three main factors. Only

TFP produced improvement on Barratt Factor

2, a measure of motor impulsivity and perse-

verance; this factor is composed of indicators

of behavioral impulsivity. Additionally, only

TFP demonstrated improvement in irritability

as well as verbal and direct assault, whereas

only SPT produced improvement on Barratt

Factor 3, a measure of nonplanning impul-

siveness; this factor is composed of indicators

of self-control and cognitive complexity. All

three treatments resulted in improvements in

depression, anxiety, global functioning, and

social adjustment.

At 12 months of treatment, Levy, Meehan,

et al. (2006) examined differences in attach-

ment organization and reflective function

(RF), the capacity to coherently understand the

mental states of self and other in the three

treatment groups. The study hypothesized that

TFP would significantly increase RF and nar-

rative coherence and significantly reduce lack

of resolution of loss and trauma in attachment

interviews compared to SPT and DBT. The

TFP group showed greater improvements in

reflective function, attachment coherence, and

security of attachment after 1 year compared to

the DBT and SPT groups. There were no

significant changes across groups for reso-

lution of loss or trauma.

Summary of TFP. TFP is an ambitious

treatment that aims to improve the symptoms

of BPD by improving the coherence and inte-

gration of concepts of self and other. In one

trial, TFP performed comparably to DBT at

1 year, and there were some indications of

superiority over SPT; however, TFP has yet to

be compared to TAU. Further, long-term

follow-up and cost-effectiveness studies are

necessary to gauge the durability and effi-

ciency of treatment gains. Given the intensity

and focus of TFP, the treatment developers

have argued that the gains are more dura-

ble than other treatments based on clinical

experience; however, there are no systematic

data to support these claims as of yet. Further,

TFP is a sophisticated and intensive treatment,

and it is unclear how readily and rapidly

psychotherapists can develop competence in

the delivery of TFP. It may turn out that TFP

is a highly specialized treatment for a subset

of BPD patients who are highly motivated,

intelligent, and able to demonstrate some ini-

tial control over the most self-destructive and

impulsive behaviors they display.

Dynamic Deconstructive Psychotherapy

Dynamic deconstructive psychotherapy (DDP)

is a time-limited, manualized treatment de-

veloped for very challenging BPD cases such

as those that have co-occuring substance abuse

or additional personality disorders. The DDP

involves individual weekly sessions over 12 to

18 months. Adjunctive group therapy is

encouraged, but not required. The treatment

model of DDP is based on the belief that

symptoms of BPD, such as identity distur-

bance, are related to core neurocognitive

deficits in processing of emotional experi-

ences. Specifically, deficits in association (i.e.,

trouble relating emotions to their verbal

labels), attribution (i.e., polarized all-or-noth-

ing attribution of experiences to self or others),

and alterity (having a reference point outside

the subjectivity of the self). These neurocog-

nitive processes form the basis for a coherent

sense of self, one that is differentiated from

others. Further examples of these deficits

include difficulties identifying and verbal-

izing specific emotions, incoherent narrative

accounts of interpersonal experience, unstable

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and polarized attributions that are poorly

grounded in reality, and use of compen-

satory maladaptive behaviors and/or ideal-

ized attachments to self-soothe. DDP aims to

remediate these deficits by helping patients

label their emotions, integrate polarized attri-

butions of self and others, and develop alterity

by providing self-other experiences in the

context of therapy (Gregory et al., 2008).

Treatment is structured into 45- to 50-minute

individual weekly sessions for a duration of 12

to 18 months. In addition to individual psy-

chotherapy, DDP encourages but does not

require group therapy participation. Overall,

DDP aims to activate specific neurocognitive

functions that are impaired through a primary

focus on current interpersonal interactions

while de-emphasizing the exploration of past

trauma (Gregory et al., 2008).

Gregory et al. (2008) randomized 30 adults

between the ages of 18 and 45 years with BPD

and active alcohol abuse or dependence to

DDP (N ¼ 15) or TAU (N ¼ 15) for 1 year. There were no differences between groups in

parasuicide, alcohol use, or institutional care

during the course of the study but there was a

significant improvement in these symptoms

over time for DDP but not TAU patients. The

proportion of DDP subjects reporting para-

suicidal behavior decreased from 73% at

baseline to 30% at 12 months, which corre-

sponded to a 21% absolute risk reduction for

DDP compared to TAU. Absolute risk reduc-

tion is the difference in probability between the

two treatment groups in the proportion of

participants manifesting a behavioral outcome

(e.g., parasuicidal behavior). The proportion of

DDP subjects reporting alcohol misuse

decreased from 67% at baseline to 30% at the

end of treatment. The absolute risk reduction

for alcohol misuse for DDP relative to TAU

was 15%. The proportion of DDP participants

needing institutional care decreased from 67%

at baseline to 10% at 12 months, which cor-

responded to a 12% absolute risk reduction for

DDP relative to TAU. Additionally, unlike

TAU, DDP improved core symptoms of BPD,

depression and dissociation, compared to

pretreatment.

Summary of DDP. DDP is a relatively new

treatment that targets a particularly vulnerable

BPD population, those with co-occurring

substance abuse or dependence. DDP has some

preliminary support from a small sample RCT.

One potentially important aspect of this treat-

ment is that it can be disseminated relatively

easily as relatively inexperienced therapists

can be trained to administer DDP competently

(Gregory et al., 2008). If the observed reduc-

tions in suicidality and alcohol abuse are rep-

licated in a larger sample, it may represent an

important treatment for a particularly difficult

to treat subgroup of individuals with BPD;

however, the absolute risk reductions esti-

mates were small and whether it is worth the

allocation of significant resources to train and

implement this form of treatment for this

modest gain is unclear.

ADJUNCTIVE PSYCHOSOCIAL

TREATMENTS FOR SPECIFIC

SYMPTOMS

Several treatments for symptoms dimensions

of BPD have been developed that are designed

to be adjunctive to TAU or other psycho-

therapeutic or medication treatments. These

treatments may be particularly important in

geographic areas that do not have access to

therapists trained in the comprehensive ther-

apies. These treatments target the most dan-

gerous aspects of BPD and may be able to be

taught and disseminated more efficiently.

Two adjunctive psychosocial treatments have

garnered empirical support from RCTs,

Manual-Assisted Cognitive Therapy (MACT)

and Systems Training for Emotional Predict-

ability and Problem Solving (STEPPS).

Manual-Assisted Cognitive Therapy

Manual-Assisted Cognitive Therapy is a six-

session therapy that incorporates elements of

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DBT, CBT, and bibliotherapy, a therapy that

focuses on reading self-healing, educational

material. Each session is structured around a

chapter of a booklet, covering functional or

behavioral analysis of episodes of parasuicide,

emotion regulation strategies, problem-solving

strategies, management of negative thinking,

management of substance use, and strategies

aimed at preventing relapse.

To evaluate the effectiveness of this short,

adjunctive treatment, Weinberg and col-

leagues (2006) randomized 30 women with

BPD between the ages of 18 and 40 years

with a history of at least one instance of

deliberate self-harm to treatment with either

MACT þ TAU (N ¼ 15) or TAU (N ¼ 15) for 6 to 8 weeks. Because MACT is an adjunctive

therapy to TAU, patients also received ad-

ditional forms of mental health care such

psychotropic medications and individual and

group psychotherapy as needed. Level of sui-

cide ideation and deliberate self-harm (DSH)

were assessed at baseline, 6–8 weeks, and at

6 months posttreatment. The MACT group had

significantly greater decrease in frequency and

severity of deliberate self-harm at both 6–8

weeks and 6 months follow-up; however, a

greater amount of concurrent treatment was

associated with a greater decrease in deliberate

self-harm, although concurrent treatment was

a smaller contributor to improvement than

MACT. No significant differences between

groups were observed for suicidal ideation and

time to repeat deliberate self-harm.

Systems Training for Emotional

Predictability and Problem Solving

STEPPS is a 20-week group therapy treatment

for patients with BPD that is meant to sup-

plement TAU. A systems element of this

treatment involves educating family members

and therapists about BPD and instructing them

on constructive ways of interacting with indi-

viduals with BPD. STEPPS consists of three

components: A psychoeducational component

that reframes BPD as an emotional intensity

problem, an emotion management component

that teaches effective strategies for managing

the intense emotions that are characteristic

of the disorder, and a behavioral management

component that teaches goal setting, healthy

eating behaviors, sleep hygiene, regular exer-

cise, leisure activities, health monitoring

(e.g., medication adherence), avoidance of

self-harm, and interpersonal effectiveness.

Blum et al. (2008) randomized 134 BPD

patients to either STEPPS plus TAU (N ¼ 65) or TAU alone (N ¼ 59). Treatment lasted for 20 weeks and subjects were assessed

throughout a 1-year follow-up time period

after treatment had ended. There were no dif-

ferences between the groups in suicide

attempts and self-harm, although STEPPS was

superior to TAU with regard to depression and

the cognitive, impulsive, affective, and dis-

turbed relationship domains of the Zanarini

Rating Scale for Personality Disorder.

META-ANALYSES OF GROUP

DESIGNS

Several meta-analyses have been conducted

examining the efficacy of psychotherapy for

the treatment of personality disorders. Leich-

senring and Leibing (2003) examined the

effectiveness of psychodynamic therapy and

CBT in the treatment of personality disorders

in a meta-analysis of 25 studies, 13 of which

included patients with BPD. Improvement in

symptom severity and personality measures

was observed in BPD patients following both

psychodynamic therapy and CBT. McMain

and Pos (2007) reviewed psychotherapy stud-

ies with a focus on personality disorders. They

concluded that psychotherapy was success-

ful in the treatment of BPD. Patients receiving

CBT, including specialized skills-based inter-

ventions such as MACT and STEPPS,

showed an improvement in BPD symptoms

and psychopathology and a decrease in fre-

quency of suicide attempts. DBT in particular

led to a reduction in suicidal behaviors,

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hospitalizations, and self-mutilating behaviors

and an improvement in treatment retention and

general psychopathology. Moreover, BPD

patients receiving schema-focused therapy

showed improvement in symptom severity and

psychopathologies. Finally, Binks et al. (2006)

included seven RCTs in a meta-analysis of

psychological treatments in patients with BPD

and found that DBT led to a decrease in self-

harm, suicidal ideation, parasuicidal behavior,

and general psychiatric severity. From these

reviews, it appears that psychotherapy is

an effective intervention in the treatment of

BPD. While DBT has received the most sup-

port, psychodynamic, cognitive behavioral,

and schema-focused psychotherapies were

also found to be effective.

WHAT WORKS FOR BORDERLINE

PERSONALITY DISORDER?

At this point, DBT has the most consistent

support in reducing suicidality and para-

suicidality in RCTs for BPD and is the only

treatment meeting criteria as a well-estab-

lished treatment for BPD. DBT consistently

demonstrates reductions in parasuicidality,

hospitalizations due to suicidal behavior,

decreases in anger, impulsivity, and depres-

sion, as well as lower rates of drop out, com-

pared to TAU and treatment by experts;

however, DBT has not demonstrated supe-

riority over other forms of specialized treat-

ments, such as TFP, and has not been

compared to other specialized treatments such

as MBT and SFT. DBT has also been modified

substantially in different studies and remained

effective, which bodes well for its use in dif-

ferent settings and populations. For example,

in Turner (2000), treatment was conducted in 6

rather than 12 months, psychodynamic con-

ceptualization was used, and skills training

was conducted in individual rather than group

sessions. In addition, DBT modified for the

treatment of BPD with comorbid substance

abuse appears effective, although one study

showed no improvement in drug use behavior

(van den Bosch et al., 2002). Thus, DBT

appears to be an effective and flexible treatment

for BPD with and without substance abuse.

Our review also reveals a number of other

comprehensive treatments for BPD that show

promise and meet criteria for being probably

efficacious. With regard to SFT and CBT,

Giesen-Bloo et al. (2006) and Spinhoven

et al. (2007) suggest that SFT is superior to

TFP with regard to reducing certain psychi-

atric symptoms and retaining patients over

time; however, the implementation of the

TFP arm in this study has been questioned.

Yeomans (2007) argued that the therapists

in the TFP arm were not adequately trained,

that the treatment was more consistent with a

general psychodynamic approach to BPD, and

that the BPD-tailored aspects of TFP were

missing. The two additional studies comparing

SFT and CBT to TAU were somewhat incon-

sistent. One study did not show any differences

between SFT and CBT and TAU in reducing

parasuicidality but did show differences in the

mean number of suicide attempts, although

the effect size was small (Davidson, Norrie,

et al., 2006).

With regard to psychoanalytically informed

treatments, there is growing evidence that

manualized forms of these treatments are also

probably efficacious. In one trial, TFP per-

formed comparably to DBT at 1 year, and there

were some indications of superiority over sup-

portive psychotherapy. TFP-treated patients in

a subsequent paper showed greater improve-

ments in reflective function, attachment

coherence, and security of attachment after 1

year compared to the DBT and SPT groups.

MBT showed decreases in self-mutilation

compared to TAU but these differences did not

emerge until after 18 months of treatment

(Bateman & Fonagy, 1999); however, long-

term follow-up suggested that these gains are

maintained and perhaps even improved over a

5-year time span (Bateman & Fonagy, 2008).

No other treatment has demonstrated this level

of long-term efficacy for BPD.

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One possibility that the MBT data support is

the notion of an incubation effect in which

short-term gains are relatively modest,

whereas long-term gains are more robust and

stable. This appears to be the opposite of what

has occurred in DBT trials. For example, DBT

treatment was associated with greater reduc-

tions in parasuicidality and psychiatric hospi-

talization at 12 and 18 months compared to

TAU, but at 24 months from baseline, there

were no longer any differences between the

groups in parasuicidality whereas psychiatric

hospitalizations remained lower in the DBT

group (Linehan et al., 1993). This suggests that

DBT may be more beneficial in the short term

but for long-term gains more dynamically

oriented approaches may be preferred. Of

course, it is possible that this particular RCT of

DBT lacked the statistical power to detect true

differences that were actually present at 24

months due to small sample sizes. Neverthe-

less, one possibility is to implement a

sequential treatment approach to BPD that

uses DBT initially for 1 year to develop skills

and reduce behavioral dysregulation and then

transition to a more dynamically informed

treatment for long-term gains. Future research

should examine this possibility.

Another theme that emerges from this

review is that different treatments may have

different effects on different symptom dimen-

sions in BPD. For example, DBT is clearly

effective in reducing affective instability and

parasuicidality whereas TFP demonstrates

greater improvements in areas like aggression,

reflective functioning, and attachment orga-

nization. Thus, perhaps different treatments

are perhaps acting in different ways to improve

different sets of systems in quite possibly dif-

ferent subgroups of BPD patients. This possi-

bility is supported by research indicating that

there are distinct subgroups of BPD. One study

applied finite mixture modeling to a sample of

90 subjects with BPD and found three distinct

groups: One group was characterized by low

levels of antisocial, paranoid, and aggressive

features, another group was characterized by

high levels of paranoid features, and a third

group was characterized by high levels of anti-

social and aggressive features (Lenzenweger,

Clarkin, Yeomans, Kernberg, & Levy, 2008).

An area of potential confusion is the number

of CBT treatments that we reviewed. For

example, DBT, SFT, and CBT are all identified

as CBT treatments. In general, cognitive

behavior therapies fall on a continuum rang-

ing from the more behavioral to the more

cognitive. In this regard, DBT falls much

more on the behavioral than the cognitive end

of the spectrum. There is very little if any

challenging of automatic thoughts or use of

thought records in DBT, which are staples of

cognitive behavioral treatments. In fact, from a

DBT perspective, identifying and challenging

dysfunctional thoughts could easily be con-

sidered invalidating. The emphasis in DBT

is much more on behavior analysis of skills

deficits, skills training, and validation. SFT

predominantly differs from traditional cogni-

tive therapy because of its focus on early

childhood experiences in treatment, the use

of the therapeutic relationship to facilitate

change, and the active confrontation of

maladaptive behavioral and belief patterns

(McArdle, 2001). SFT and CBT are most alike

in that both are essentially cognitive behav-

ioral treatments with a focus on identifying

maladaptive thoughts and core beliefs. Perhaps

one way they differ from each other is that SFT

places more emphasis on working with core

beliefs as well as incorporating the therapeutic

relationship than does CBT.

Demonstrating efficacy in an RCT does not

elucidate why or how the change came about.

Therefore, it is important that we begin

addressing questions such as, “Under what

conditions and for which patients is treat-

ment most helpful?” and, “Why and how do

effective treatments work?” (Kazdin, 2007;

Kraemer, Wilson, Fairburn, & Agras, 2002).

Treatment mechanism studies are designed to

answer these how and why and for whom

treatment works questions (Kraemer et al.,

2002). Mechanism studies move beyond

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efficacy and effectiveness studies by generat-

ing knowledge about how a treatment impacts

basic cognitive, emotional, and neurobio-

logical processes and symptoms of a given

disorder. Mechanism research can support

strong, causal inferences about what inter-

ventions work for which patients under what

conditions. In doing so, mechanism studies can

contribute to improvements of existing treat-

ments. For example, are the reductions in

parasuicidality observed in several DBT stud-

ies mediated by improved emotion regulation

as DBT theory suggests? This is a crucial step

for an efficacious treatment, as it may be

effective, but not through the mechanisms

theorized to subserve therapeutic change

(Longmore & Worrell, 2007). Moreover, is the

sequence of changes in cognitive, emotional,

and social processes important in the treatment

of BPD? For example, does change in inter-

personal behavior precede changes in impul-

sivity and emotion regulation? Alternately, do

all these processes change concurrently in

BPD? Do changes in basic processes always

precede symptom change? Or, do changes in

symptoms and functioning occur in tandem

with changes in emotion, cognition, and

behavior? Does treating some symptoms, such

as severe depression, pave the way for chang-

ing other processes such as emotion regulation?

Which processes are the most resistant to

change? Are there particular treatment strat-

egies that are more effective in changing some

basic processes than others? Does knowledge

of pretreatment status in basic processes (e.g.,

low levels of impulse control) inform who

responds to what treatments and treatment

combinations?

It is interesting, but not too long ago, the pre-

vailing view was that patients with BPD were

untreatable (Stern, 1938; Stone et al., 1987). For

example, in describing different approaches to

handling a patient who walked out in a rage on

her therapist in midsession, Basch (1980) writes:

Had the therapist diagnosed Miss Banks’s

behavior as clinically borderline, there can

be no doubt of his next steps: He would have

to contact her, if necessary take the blame

for her leaving and apologize for upsetting

her, induce her to return for treatment, give

up at least for the moment, any notion

of conducting an insight-oriented psycho-

therapy, do his best to shore up her defenses

against her inner turmoil, and help her adapt

to the limitations of a psychologically mar-

ginal existence. (pp. 60–61)

Today, the outlook is not so grim (Gabbard,

2007; Lenzenweger, 2008; Perry et al.,

1999; Zanarini et al., 2003). As our review

shows, there are a range of well-established

(e.g., DBT) and probably efficacious (e.g.,

MBT, TFP, SFT) treatments that exist, and

patients with BPD no longer need to fear living

a psychologically marginal existence.

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