(iv) Role of therapist training and competency Psychodynamic therapy for patients with borderline personality disorder is uncommonly demanding. Consultation from an experienced colleague is highly recommended for all therapists during the course of the therapy. In some situations, personal psychotherapy can help the clinician develop skills to manage the intense transference/countertransference interactions that are characteristic of these treatments.
2. Cognitive behavior therapy a) Definition and goals Although cognitive behavior therapy has been widely used and described in the clinical literature, it has more often been used to treat axis I conditions (e.g., anxiety or depressive disorders) than personality disorders. Cognitive behavior therapy assumes that maladaptive and distorted beliefs and cognitive processes underlie symptoms and dysfunctional affect or behavior and that these beliefs are behaviorally reinforced. It generally involves attention to a set of dysfunctional automatic thoughts or deeply ingrained belief systems (often referred to as schemas), along with learning and practicing new, nonmaladaptive behaviors. Utilization of cognitive behavior methods in the treatment of the personality disorders has been described (19), but because persistent dysfunctional belief systems in patients with personality disorders are usually “structuralized” (i.e., built into the patient’s usual cognitive organization), substantial time and effort are required to produce lasting change. Modifications of standard approaches (e.g., schema-focused cognitive therapy, complex cognitive therapy, or dialectical behavior therapy) are often recommended in treating certain features typical of the personality disorders. However, other than dialectical behavior therapy (17, 144–147), these modifications have not been studied. b) Efficacy Most published reports of cognitive behavior treatment for patients with borderline personality disorder are uncontrolled clinical or single case studies. Recently, however, several controlled studies have been done, particularly of a form of cognitive behavior therapy called dialectical behavior therapy. Dialectical behavior therapy consists of approximately 1 year of manual-guided therapy (involving 1 hour of weekly individual therapy for 1 year and 2.5 hours of group skills training per week for either 6 or 12 months) along with a requirement for all therapists in a study or program to meet weekly as a group. Linehan and colleagues (8) reported a randomized controlled trial of dialectical behavior therapy involving patients with borderline personality disorder whose symptoms included “parasuicidal” behavior (defined as any intentional acute self-injurious behavior with or without suicide intent). Control subjects in this study received “treatment as usual” (defined as “alternative therapy referrals, usually by the original referral source, from which they could choose”). Of the 44 study completers, 22 received dialectical behavior therapy, and 22 received treatment as usual; patients were assessed at 4, 8, and 12 months. At pretreatment, 13 of the control subjects had been receiving individual psychotherapy, and 9 had not. Patients who received dialectical behavior therapy had less parasuicidal behavior, reduced medical risk due to parasuicidal acts, fewer hospital admissions, fewer psychiatric hospital days, and a greater capacity to stay with the same therapist than did the control subjects. Both groups improved with respect to depression, suicidal ideation, hopelessness, or reasons for living; there were no group differences on these variables. Because there were substantial dropout rates overall (30%) and the number of study completers in each group was small, it is unclear how generalizable these results are. Nonetheless, this study is a promising first report of a manualized regimen of cognitive behavior treatment for a specific type of patient with borderline personality disorder. A second cohort of patients was subsequently studied; the same study design was used (148). In this report, there were 26 intent-to-treat patients (13 received dialectical behavior therapy, and 13 received treatment as usual). One patient who received dialectical behavior therapy committed suicide late in the study, and 3 patients receiving dialectical behavior ther50
APA Practice Guidelines