Borderline Therapy: No Uniform Mass

4. March 2013
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The trend is towards "disorder-specific psychotherapy". Psychologists however show using a small, but intensive study on borderline patients that it is important that the psychotherapist aligns his method specifically for the individual patient.

Hardly any mental disturbance has aroused so much discussion as borderline personality disorder (BPS, ICD-10: F.60.31, emotionally unstable personality disorder, borderline type, DSM-IV 301.83). A typical trait of borderline personality disorder is severe relationship problems; those affected show an enormous degree of black and white thinking (splitting) and easily become enraged. Their relations are fragile, however the close relationships themselves very intense, because the patient strongly idealises his or her counterpart or “demonises” the other – typical here is that these aspects can change very quickly. Many patients injure themselves or are suicidal. Most borderline patients report of having a traumatic childhood, often during which sexual abuses have taken place. It is not always easy to make the diagnosis – often the condition is only apparent when typical relationship difficulties make themselves noticeable in the psychotherapeutic relationship.

Disorder specific treatment for borderline disorder

Behaviour therapies which are valid as disorder-specific therapies for borderline disorder include Dialectical Behavioral Therapy (DBT) and Schema-Focused Psychotherapy (SFT) and the two psychodynamically oriented methods Transmission Focused Psychotherapy (Transference-Focused PsychotherapyTFP) and Mentalisation Based Therapy (MBT) (Sollenberger & Walter, 2010). Guides for the treatment of borderline patients can be helpful – but psychoanalysts Geoff Goodman (International Psychoanalytical Association (IPA)) and his colleagues at the University of Long Island, New York USA, show in their recent study that matters still come down to the individual design of the therapeutic relationship.

The authors analysed the therapy sessions of five female borderline patients who due to a crisis were in in-patient treatment. The patients were aged 26 (patient 1), 31 (patient 2), 29 (Patient 3), 35 (patient 4) and 41 years (patient 5). All were taking medication for depression or bipolar disorder. For 6 months 3 times per week they received individualised psychodynamic therapy (Psychodynamic Therapy, PDT). The therapists were trained to carry out therapy according to a manual from Kernberg and colleagues from the year 1989. The most important therapeutic techniques are clarification, confrontation and transference interpretation. This method is the original form of the later, more detailed Transmission Focused Psychotherapy (Transference Focused PsychotherapyTFP, Clarkin et al. 2006).

Weekly completion of questionnaires overwhelmed some patients

All therapy sessions were recorded and transcribed from recordings by academic staff. Then trained doctoral graduates coded every third hour of therapy. So-called “Psychotherapy Process Q-Sort” (PQS) was used as the coding system. This system consists of 100 items which describe the therapy session. The statements look like this for example: “The patient is introspective and explores his inner thoughts and feelings” (Item No. 97) or “The therapist is sensitive to the feelings of the patient, he adapts to the patient and is empathetic” (Item No. 6). In order to capture the symptom severity of patients over time, they were asked once a week to fill out Symptom Checklist SCL-90-R. Patients 1, 3 and 5 agreed, while patients 2 and 4 were not prepared to declare to doing this – the authors interpreted this rejection as an excessive challenge. This shows how difficult it is to carry through intensive studies with borderline patients.

Nevertheless, the team coded the sessions of all five patients to investigate the actions of the therapist. Overall, the team coded 127 therapy sessions. From these codings, four structures of interaction were picked out that occurred in each treatment. The authors classified these structures (in condensed form) as follows: Interaction structure (IS) 1 = collaborative relationship with supportive elements, IS 2 = empathic state of agreement of the therapist to his or her patient; IS 3 = eroticised relationship, reflecting the attempts of the patient to be emotionally intimate with the therapist; IS 4 = directive therapist and cooperative and assisting patient.

The mental tension eased in all three patients

The authors expected that the mental stress of patients would subside over time. The results confirmed their hypothesis: the three patients studied responded positively to the six-month residential treatment, each having her own psychotherapy interaction pattern. A moderate degree of effect was shown, whereby the greatest improvement was seen in the patient who was at the beginning of the study the worst affected (patient 5). All five therapist-patient relationships differed markedly in their interaction patterns. The authors conclude: What helps Patient “X” might not by any means be seen by Patent “Y” as helpful. An example: An empathic state of attentiveness (Interaction structure 2) in the case of patient number 3 correlated with a large decrease in psychological pressure, while with patient No. 5 the opposite was the case. The authors refer to a contribution from the psychoanalyst Judy L. Kantrowitz (2001), who compares a psychotherapeutic relationship with a snowflake. Each of these relationships is unique and yet there is a common framework – in relation to the existing study the basic framework is built from the four structures of interaction which the authors were able to establish.

Interesting here was the fact that the very same therapist who treated two patients (patient 4 and 5) proceeded by using two completely different treatments. The reason for the different approach could be traced back to the different personalities of the patients, the authors note. But it could also be that patients respond to different aspects of personality in the therapist. The study clearly demonstrates that individual interaction structures for different therapist-patient pairs can have different meaning and that one and the same structure of interaction between patients can correlate with differing outcomes, say the authors.

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Medicine, Psychiatry

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