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IntegratedModular TreatmentforBorderline PersonalityDisorder

IntegratedModular Treatmentfor BorderlinePersonality Disorder

APracticalGuidetoCombiningE

ective TreatmentMethods

W.JohnLivesley DepartmentofPsychiatry,UniversityofBritishColumbia

UniversityPrintingHouse,CambridgeCB28BS,UnitedKingdom

CambridgeUniversityPressispartoftheUniversityofCambridge.

ItfurtherstheUniversity’smissionbydisseminatingknowledgeinthepursuitof education,learningandresearchatthehighestinternationallevelsofexcellence.

www.cambridge.org

Informationonthistitle:www.cambridge.org/9781107679740

©W.JohnLivesley2017

Thispublicationisincopyright.Subjecttostatutoryexception andtotheprovisionsofrelevantcollectivelicensingagreements, noreproductionofanypartmaytakeplacewithoutthewritten permissionofCambridgeUniversityPress.

Firstpublished2017

PrintedintheUnitedKingdombyClays,StIvesplc

AcataloguerecordforthispublicationisavailablefromtheBritishLibrary ISBN978-1-107-67974-0Paperback

CambridgeUniversityPresshasnoresponsibilityforthepersistenceoraccuracyof URLsforexternalorthird-partyinternetwebsitesreferredtointhispublication, anddoesnotguaranteethatanycontentonsuchwebsitesis,orwillremain, accurateorappropriate.

Everyefforthasbeenmadeinpreparingthisbooktoprovideaccurateand up-to-dateinformationwhichisinaccordwithacceptedstandardsandpractice atthetimeofpublication.Althoughcasehistoriesaredrawnfromactualcases, everyefforthasbeenmadetodisguisetheidentitiesoftheindividualsinvolved. Nevertheless,theauthors,editorsandpublisherscanmakenowarrantiesthatthe informationcontainedhereinistotallyfreefromerror,notleastbecauseclinical standardsareconstantlychangingthroughresearchandregulation.Theauthors, editorsandpublishersthereforedisclaimallliabilityfordirectorconsequential damagesresultingfromtheuseofmaterialcontainedinthisbook.Readers arestronglyadvisedtopaycarefulattentiontoinformationprovidedbythe manufacturerofanydrugsorequipmentthattheyplantouse.

TomywifeAnn,withlove

Section7 – Constructingan

21 BuildingaMoreCoherentSelf 231

22 PromotinganAdaptive Self-NarrativeandFlexibleWorking Selves 242

23 GettingaLife,Constructing aPersonalNiche 255

Section8 – Retrospect andProspect

24 TerminationandOverview: TheTreatmentProcessacross Time 263 References 273 Index 289

Preface

Thisbookdescribesanintegrat ed,evidence-basedapproach tothetreatmentofborderlinepersonalitydisorder.Myintentionistostateassimplyaspossiblethebasic principlesneededforcomprehensivetreatmentbytryingtostripthetreatmentof borderlinepersonalitydisordertoitsessenti alsanddescribetheseessentialsinstraightforward,common-senselanguagethatisasfreeaspossiblefromjargonandunnecessary theoreticalspeculation.Thevolumeisinte ndedtobereadbyanyonewithaninterestin treatingborderlinepersonalitydisorder. Althoughdesignedprimarilyformentalhealth professionalsfromalldisciplinesrangingfromthosewithmodesttrainingtoseasoned therapists,thevolumemayalsobeofinteresttoinformedfamilymembers,signi fi cant others,andthosewiththedisorder.

Forsometimenow,Ihavebeenconvincedoftheneedtoradicallyrethinkhow borderlinepersonalitydisorderistreated.Thedevelopmentofeffectivetreatmentsfor thisdisorderisoneoftheunheraldedsuccessesofcontemporarymentalhealth.Itiseasy toforgetthatlessthanagenerationago,itwaswidelyassumedthatpersonalitydisorderwas untreatable.Wenowknowthatthisisnotthecase – patientscanbehelpedwithappropriate treatmentandsomeimprovewithout.However,westilldonotknowtheoptimalwayto treatborderlinepersonalitydisorder,andevenaftersuccessfultreatment,manypatients continuetohavesubstantialresidualdifficulties.

Untiltheearly1990s,treatmentwaslargelydominatedbypsychoanalytictherapies,and fewempiricalstudieswereavailabletoguidepsychotherapistswhowantedtopursue evidence-basedtreatment.Thesituationhaschangeddramaticallyoverthatlasttwo decades,withthepublicationofmorethanhalf-a-dozenmanualizedtreatmentsandthe emergenceofrandomizedcontrolledtrialstestifyingtotheirefficacy.Theseachievements encouragedtheideathattreatmentshouldbebasedononeofthespecializedtherapies showntobeeffective.Ihaveneverfoundthisideaconvincing.Noneofthesetherapiesoffers comprehensivecoverageofthediverseproblemsofmostpatients.Eachtherapyisbasedon atheoryofthedisorderthatshapesthetreatmentmethodsused.Theproblemisthatmost theoriesfocusonalimitedaspectofborderlineproblemsandhencecurrenttreatmentsare notcomprehensive.Also,eachtreatmentcontainseffectiveinterventions.Relianceon asingletherapymeansthatmanyeffectivemethodsarenotusedsimplybecausetheyare partofadifferentmodel.Underthesecircumstances,itseemsmoresensibletoadoptan eclecticandintegratedapproachthatcombinestheeffectiveingredientsofalltreatments ratherthanselectingoneofthem.

AnotherreasonwhyI findintegrationappealingisthatitmakesiteasiertotailortreatment totheproblemsandneedsofindividualpatients.Iamstruckbythesheerdiversity,heterogeneity,andindividualityofthepatientsIhavetreated.Althoughallwouldhavemetdiagnostic criteriaforborderlinepersonalitydisorder,theydifferedwidelyinseverity,inhowthedisorder wasmanifested,andinotherpersonalitycharacteristicsthatcontributedtotheclinicalpicture. Thesedifferencesusuallyhadabigeffectontreatment.Thisledmetoquestionthemeritsofthe one-approach-fits-allstrategyofmanualizedandspecializedtreatments.Theseconsiderations ledtoaninterestinhowtointegrateeffectiveinterventionstocreateamorecomprehensive treatmentthatcouldbetailoredtothedifferingproblemsandpersonalitiesofmypatients.

Althoughmyinterestinintegrationwasinitiallybasedonthenatureofborderline pathologyandtheconceptuallimitationsofcurrenttherapies,empiricalresearchbeganto supporttheidea.Currentevidencesuggeststhatthedifferentspecializedtherapiesproduce similarresultsandthattheywerenotsubstantiallybetterthaneithergoodclinicalcareor supportivetherapy.Thisaddednewimpetustotheideaofaunifiedtrans-theoretical approachandthedevelopmentofatrans-diagnosticmodelthatcouldbeusedtotreatall formsofpersonalitydisorder.Thereseemslittlepointinpursuingexpensiveandhighly specializedtreatmentsthatdonotdifferineffectivenessorproducebetteroutcomesthan goodclinicalcareorless-expensivesupportivetherapy.Amoreeffective,andcertainlyless expensive,strategywouldbetointegrateinterventionsthatworkfromalltreatments regardlessoftheirtheoreticalorigins.

Theframeworkprovidedforunderstandingandtreatingborderlinepersonalitydisorder isintendedtobeusedbyclinicianswithdifferingdegreesoftrainingandexperience, includingsupportstaff,nurses,socialworkers,occupationaltherapists,psychotherapists, clinicalandforensicpsychologists,andpsychiatrists.Theframeworkisalsoapplicableto mosttreatmentsettings,includingcommunitymentalhealthservices,privateofficepractice,hospitalinpatientandoutpatientservices,andthefullrangeofforensicmentalhealth services.Importantcomponentsoftheframeworkcanbeimplementedbymentalhealth supportstaff withrelativelylittleprofessionaltraininggivenmodestinstructionand ongoingsupport.Thisisimportantbecauseborderlinepersonalitydisorderisarelatively commonconditionandourhealthcaresystemscannotaffordexpensivespecializedcare deliveredbyhighlytrainedprofessionals.

Thebookisdesignedtobereadintwoways.First,itprovidesanarrativeabouthowto treatborderlinepersonalitydisorderusinganintegratedapproach.Thenarrativebeginsby describingthenatureofthedisorderbecauseanuancedunderstandingisneededfor effectivetreatment.Itthenoffersastep-by-stepdescriptionofthetreatmentprocess organizedaroundinterventionsbasedonmechanismsofchangecommontoalleffective treatments.Morespecificinterventionsdrawnfromalleffectivetherapiesarethenaddedto thiscoretoaddressspecificproblemsandimpairments.Second,thebookisalsointendedto beaworkbookthattherapistscandipintoandre-readwhendealingwithagivenproblemor impairmentintheirpatients.Tomakethebookeasiertouseinthisway,chaptersare relativelyshort,andeachdealswitharelativelyspecificissue.

OneofthecentralproblemsthatIhavegrappledwithinwritingthisbookisthevery term “borderlinepersonalitydisorder.” Idonotlikethetermandwouldbehappytoseeit replacedbysomethingmoredescriptive.Myconcernsarethree-fold.First,theterm “borderline” iscommonlyusedasapejorativeandastigmatizinglabel.Second,theterm isnotdescriptiveofthesepatients’ problems.Originally,itwasusedtodescribepatients whoshowedfeaturesatthebordersofpsychosisandneurosis.However,thismeaningwas lostlongagoandbecamemeaninglesswhenpsychiatricnosologyabandonedtheconceptof neurosis.Third,thetermisinvariablyusedtorefertopatientswhomeettheDSMcriteria forthediagnosis.However,I findtheDSMcriteriasetinadequate.Sincetheywereoriginally designedtoensurereliablediagnosis,theytendtofocusonthemoresuperficialaspectsof thedisorderandneglectmanyofthesubtletiesandcomplexitiesoftheconditionincluding theconflictednatureofmostpatients’ experience.Nevertheless,althoughIdonotlikethe term,Ihavenodoubtsabouttheimportanceoftheproblem.Thereareclearlyalarge numberofpatientswhoshowhighlevelsoflabilityandinstabilitythatisdisablingand profoundlyaffectstheiremotionalandinterpersonallivesandtheirsenseofselfand

identity.Thequestioniswhattermwouldbestcapturethisconstellationoffeatures.Since analternativeisnotreadilyavailable,Idecidedregretfullytostickwiththetraditionalterm butwiththeunderstandingthatIamdefiningitslightlydifferentlyfromtheDSMcriteria set,althoughthetwodefinitionsarehighlyoverlapping.

Ihavemanydebtsandobligationstoacknowledge.Myoverridingdebtofgratitudeisto themanypatientsthatIhaveworkedwithovertheyears.Borderlinepersonalitydisorderis notsomethingreadilylearnedfrombooks.Weknowsolittleaboutitthatthereislittle substitutefortalkingwithpatientsabouttheirexperiences,problems,andconcerns.Ihave learnedmuchfromsuchtalksandfrommypatients’ remarkableinsightsintotheir problems.Mypatientsmorethananythingoranyonehavestructuredmyunderstanding ofborderlinepersonalitydisorderanditstreatmentandatdifferenttimesinthelastforty years;thethingstheyhavetoldmehaveradicallychangedmythinking.

Sincetheframeworksdescribedforunderstandingandtreatingborderlinepersonality disorderareintendedtoofferaneclecticandintegratedperspective,thereisnothingnewto theintegratedmodularapproachdescribed.RatherIhavedrawnextensivelyonthewritings ofmanyauthorsbothonthetreatmentofpersonalitydisorderandonnormaland disorderedpersonality,andIneedtorecognizetheircontributions.However,inthe interestsofhavingareadabletextthatcanbeeasilyreferredtowhentreatingspecific patients,Idecidedagainsthaveextensivecitationsinthetextandoptedinsteadforendnotes todocumentmysourceswithmoredetailedcitationsinareferencessection.

IamalsoverygratefultothelateRichardMarleyandhiscolleaguesatCambridge UniversityPress.IgreatlyappreciatedRichard’ssupport,hispatience,andhisremarkable toleranceofmysomewhatidiosyncraticapproachtowritingthisbook.Sadly,Richarddied beforetheprojectwascompleted.MychildrenDawnandAdrianalsoprovidedhelpful commentsonhowreadablethemanuscriptwas.Finally,butnotleast,Iamenormously gratefultomywife,Ann,whoisawonderfulandconstantsourceofsupport.Shehas toleratedmyobsessionwithtryingtounderstandpersonalitydisorderformanydecadesand herattentivenessandcaringhelpedensurethecompletionofthisvolume.

Chapter

1 Introduction

Thisbookdescribesadifferentwaytotreatborderlinepersonalitydisorder(BPD).Rather thanusingoneofthemanualizedtreatmentsdevelopedinrecentyears,atrans-theoretical approachisproposedthatcombinesprinciples,strategies,andinterventionsfromall effectivetreatments.Reluctantly,Idecidedthatanamewasneededforthisapproachand decidedonintegratedmodulartreatment(IMT).However,myintentionisnottodevelop yetanothertherapydescribedbyathree-letteracronymbutrathertoshowhowtherapists canmakeuseofeffectivemethodsfromalltherapieswithoutadoptingeitherthetotal treatmentpackageortheunderlyingtheory.

ThisisnothowBPDiscurrentlytreated.Treatmentisusuallybasedononeormoreof thefollowingspecializedtreatmentsshowntobeeffectiveinrandomizedcontrolledtrials: dialecticalbehaviourtherapy(DBT),transference-focusedtherapy(TFT),schema-focused therapy(SFT),mentalizing-basedtherapy(MBT),cognitive-behaviouraltherapy(CBT), cognitive-analytictherapy(CAT),andsystemstrainingforemotionalpredictabilityand problem-solving(STEPPS).1 Sincethesetreatmentsdonotdifferineffectiveness,however, therearenoscientificgroundsforselectingoneapproachoveranother.Nordothey producebetteroutcomesthangoodclinicalcareorsupportivetherapy.Hence,itmaybe moreeffectivetocombinetheeffectiveingredientsofalltherapiesratherthanchoose amongthem.

Thereareotherreasonstopursueintegration.Currenttreatmentsarenotcomprehensive:mostarebasedontheoriesthatexplainBPDlargelyintermsofasingleimpairment, whichthenbecomesthemainfocusoftherapywithotherimpairmentsreceivingless attention.Thus,DBTconsidersemotionaldysregulationtobetheprimaryproblem.MBT assumesthatitisimpairedmentalizing(difficultyunderstandingthementalstatesofself andothers).SFTfocusesprimarilyonearlymaladaptiveschemas – beliefsthatoriginatedin dysfunctionalrelationshipswithsignificantothersduringearlydevelopment.Finally,TFT assumesthatproblemsarelargelyduetodisturbancesinthestructureofpersonality.Each explanationhasmerit:BPDdoesindeedinvolveemotionaldysregulation,dysfunctional cognitions,impairedmentalizing,andstructuralproblemswithpersonality,butpatientsdo nothavejustoneoftheseimpairments,theyhaveallofthem.Hence,atrans-theoretical approachmakesmoresense.

Currenttherapiesarealsolimitedbytheuseof “ onemethod fi tsallpatients ” approachthatneglectstheenormou sheterogeneityofBPD:patientsdi ff ersubstantiallyinseverity,co-occurrin gdisorders,andcoex istingpersonalityc haracteristics, andthesedi ff erencesimpacttreatment.Thissuggeststheneedforamorepatientfocusedapproachwithtreatmenttailoredto needsandpsychopathologyofindividual patients.

Thischapterprovidesabroadoverviewofanintegratedapproach.Itbeginsby describingbrieflythemainfeaturesofBPDfollowedbyadiscussionoftheimplications oftreatmentoutcomestudies.Finally,itprovidesanoverviewofIMTtoorientatethereader totheapproach.

1.1BorderlinePersonalityDisorder

BPDoccursin0.5to3.9percent(median1.4percent)ofthepopulation.2 Estimatesvary becauseofdifferencesinsamplesandindefinitionandassessmentmethods.Alsodiagnostic thresholds – theDSM-5requiresthepresenceof fiveoutofninecriteria – arearbitraryand adifferentthreshold(fourorsixcriteria)wouldleadtodifferentprevalencerates. Nevertheless,itisobviouslyacommondisorder.

IndividualswithBPDtendtohavesignificanthealthandsocialproblemsleadingto heavydemandsonsocialandhealthcareservices.Interestingly,healthproblemsarenot confinedtomentalhealthdifficulties:BPDisassociatedwithahigherincidenceofmedical conditionsthatdonotappeartobedirectlyrelatedtothedisorder.Theconditionisalso associatedwithincreasedmortality.Someofthisincreaseisduetosuicide – approximately 9percentcompletesuicide.3 However,suicidedoesnottotallyexplainincreasedmortality –otherfactorscontributeaswell,includingalcoholandsubstancemisuse.

1.1.1MajorCharacteristics

Throughoutthisbook,BPDisconceptualizedasapervasivepatternofinstabilityand dysregulationinvolvingunstableemotions,unstableandconflictedrelationships,unstable senseofselforidentity,unstablecognitiveprocesses,andbehaviouralinstabilitythat isassumedtoresultfromtheinteractionofgeneticpredispositionsandmultipleenvironmentalinfluences.Theinstabilityissopervasiveandconsistentthatpatientswiththe disorderhavebeendescribedas “stablyunstable.”4 However,instabilityisnottheonly pervasivefeature.Thedisorderisalsocharacterizedbyintenseconflictandequallyintense rigidity.Theconflictisbothexternalintheformofconflictedrelationshipsandinternal inthesensethatthesepatientsareoftenatwarwiththemselvesastheystrugglewith inconsistentfeelingsandtosuppresspainfulfeelingsandmemoriesanddenyimportant aspectsoftheirpersonalityandexperience.Theyarealsorigidinthoughtandaction.Events areinterpretedinrelatively fixedwaysanditisdifficulttochangeperspectiveandseethings fromalternativeviewpoints.Theirmodesofactionarealsorigid:theypersistentlyrespond tosituationsinthesamewaydespitetheseresponsesbeingunproductive.Thefeaturesof BPDaredescribedindetailinChapter3.Itshouldbenoted,however,thatthedisorderis describedalittledifferentlyherethaninDSM-5largelybecausetheDSMdescriptionis basedprimarilyoncommitteedecisionswhereasheregreateremphasisisgiventoresearch findings.5

Emotionaldysregulationisacentralimpairmentthatinfl uenceshowotherfeatures areexpressed.LifeforpeoplewithBPDisarollercoasterofunstable,intense,andchaotic emotions.Crisesarecommonandtypicallyi nvolveacollageofanxiety,fearfulness, threat,despair,sadness,anger,rage,andshame.Interpersonalproblemslargelyrevolve aroundcon fl ictbetweenstrongattachmentanddependencyneedsandfearofabandonmentandrejection.Thiscreatesunstablerela tionshipsbecauseintenseneedinessleadsto anurgentneedforcontactwithsigni fi cantotherswhenstressed,whichthenactivates fearofrejection.Instabilityinselforidentityisshownbyapoorlydevelopedandan

unstablesenseofself.Manyindividualsalsoshowatendencyfortheirthinkingto becomedisorganizedwhenstressed,whichmayprogresstosuspiciousnessandbrief stress-relatedpsychoticepisodes.Behaviou ralinstabilitytypica llyoccursinthecontext ofemotionalcrisesandusuallyinvolvesdeliberateself-harm,suicidality,andsometimes regressiveanddissociativebehaviours.

1.1.2Heterogeneity

AlthoughdiagnosticsystemssuchasDSM-5treatallindividualswhomeetdiagnostic guidelinesasthesame,patientsdifferextensivelyinwaysthataffectoutcomeandtreatment planning.Differencesinseverityofpersonalitypathology,forexample,aremoreimportant thanthetypeofdisorderinpredictingoutcome.6 Severityalsoinfluencestreatmentplanning:ingeneral,increasingseveritysuggestslessintensetreatment,moremodestgoals,and greaterrelianceonsupportivemethods.

ThefeaturesofBPDdonotoccurinisolationbutratherinthecontextofavarietyof otherpersonalitydispositionsthatinfluencetreatmentbothpositivelyandnegatively. Theco-occurrenceofcompulsivity,forexample,isusuallybeneficialbecauseitleadsto greaterdiligenceinpursuingtreatmentgoals.Traitssuchassensationseekingandrecklessness,ontheotherhand,hindertreatmentbecausetheyinvolveintoleranceofboredom andacravingforexcitementthatmaycontributetointerpersonalcrisesandvarious maladaptivebehaviours.Incontrast,socialapprehensivenessmayhindertheformationof aneffectivetreatmentrelationship.Thissuggeststhatalthoughcontemporarytherapies neglectheterogeneity,ithasimportantconsequencesthatneedtobetakenintoaccount whenplanningandimplementingtreatment.

1.2TreatmentOutcome

AmajorachievementinthestudyofBPDinrecentyearsistheaccumulationofevidence thattreatmentiseffectiveandthatthemagnitudeofoutcomechangecomparesfavourably withthatforothermentaldisorders.Thisisaremarkableachievementgiventhetherapeutic nihilismthatexistedpreviously.

1.2.1ResultsofOutcomeStudies

Evidenceofthee ff ectivenessofspeci fi ctherapiesisgenerallytakentoimplythat evidence-basedtreatmentshoulduseoneorm oreofthesetherapies.Initially,the ideaseemedreasonablebecausethesetreatmentsaremoree ff ectivethantreatment asusual.However,recentresearchpointstoadi ff erentconclusionforthreereasons. First,thesetherapiesdonotdi ff ersigni fi cantlyinoutcome. 7 Onestudysuggestedthat SFTismoree ff ectivethanTFT.However,di ff erencesinoutcomeweresmalland largelyo ff setbyconcernsthatthequalityoftherapywasnotcomparableforthetwo treatments. 8

Second,thespecializedtherapiesdonotproducebetteroutcomesthangoodclinicalcare designedspecificallyforBPD.Thusfar,onlyDBT,MBT,andCAT9 havebeencomparedto generalcarebutthereisnoreasontoassumetheotherspecializedtherapieswouldfare better.Also,thefactthatthesestudiesinvolveddifferenttherapiesandwereconducted bydifferentinvestigatorsindifferentcountries(Canada,England,andAustralia)lends confidencetotherobustnessofthe findings.

Third,thespecializedtherapiesarenotbetterthansupportivetherapy.Onestudy comparedshort-termCBTwithshort-t ermRogeriansupportivetherapy. 10 Althoughthe authorsinterpretedtheir fi ndingsasindicatingthatcognitivetherapywasmoree ff ective, di ff erencesweresmallandunlikelytobeclinicallysigni fi cant.Moreimportantly, outcomewaspoorforboththerapies,suggestingthatshort-termtherapylasting adozenorsosessionsmaybeunhelpfulintr eatingthisdisorder.Alonger-termstudy comparingnearlytwoyearsofMBTwithpsy chodynamicsupportivetherapyfound fewdi ff erences 11 despitethatfactthatthesupportivetherapygroupreceivedonlyabout one-thirdtheamounttotherapyastheMBTgroup.Theresultsareconsistentwithan earlierstudyshowingthatthelong-termsupportivetherapywasase ff ectiveasmore intensiveTFTandDBT. 12

1.2.2ImplicationsofOutcomeStudies

OutcomestudiesclearlyshowthatBPDcanbetreatedeffectivelywithoutusingaspecialized therapy.Theyalsosupportanintegratedapproach:sincealleffectivetherapiesincorporate treatmentmethodsthatwork,amorerationalstrategyistocombinetheeffectivecomponentsofalltherapiesratherthanuseasingletherapyandtherebyfailtouseeffective componentsofothermethods.Integrationisparticularlypertinentgiventhelimited focusofmostspecializedtherapies:althoughindividuallynoneofthespecializedtherapies addressallfeaturesofBPD,whentakentogethertheycovermostimpairments.Thishas promptedsuggestionsthatcombinationsofthesetherapiesshouldbeused – common suggestionsareDBTandMBT,andDBTandTFT.However,thisisacumbersomeand expensiveoption.Itwouldbesimplerandlessconfusingtoselectinterventionsthatwork fromallapproacheswithouttryingtocombinethedifferenttheoriesandconceptsonwhich thesetherapiesarebased.13

Therationalefortrans-theoreticaltreat mentisfurtherstrengthenedbyevidence thatsimilaroutcomeacrosstreatmentsarisesfromchangemechanismscommontoall e ff ectivetherapies.Evaluationsofthesemechanisms 14 pointtotheimportanceofsuch factorsasastructuredapproach,acollaborat ivetherapeuticrelationship,anempathic andvalidatingstance,andaco nsistenttreatmentprocessth atfacilitatesmotivationfor changeandencouragesself-re fl ection.Thesearethekindsoffactorsemphasizedin treatmentsbasedongoodclinicalc arethatwereusedtoevaluatethee ff ectivenessof thespecializedtherapies.Sincethesege neralfactorsaccountformostofoutcome change,itseemsmostappropriatetoorganizeevidence-basedtreatmentaround genericmechanisms.

Nevertheless,eachspecializedtherapycontainsinterventionsspecifictothatapproach thatprobablycontributetotheireffectiveness.Wecannotbesurebecausecurrentstudies donotprovideinformationonthemechanismsresponsibleforpositiveoutcomes. However,theneedtouseacomprehensivesetofinterventionsthataddressallcomponents ofBPDsuggeststhatIMTshouldalsoincludeaneclecticarrayofspecifictreatment methods.

1.3WhatIsIntegratedModularTreatment?

IMTisapatient-focused,evidence-basedapproachtotreatingBPD(andotherpersonality disorders)thatusesabroadarrayoftreatmentprinciplesandmethodsselectedtomeetthe needsandproblemsoftheindividual.Theterm “integration” iswidelyused:proponentsof

mosttherapiescommonlyclaimthattheirapproachisintegratedeventhoughitrelieson alimitedconceptualmodel.Whenusedinthisway,thetermusuallymeansthatthetherapy inquestionalsousesinterventionsusedbyothertreatments.Inpractice,mostexperienced therapistsareintegrativeinthissense:theyuseinterventionsfromvarioustherapiesthat theyhavefoundusefuleventhoughtheyprimarilysubscribetoaparticularschool.IMT simplytakeswhatexperttherapistsdoastepfurtherbyusinganeclecticcombinationof interventionsselectedonthebasisofeffectivenessandrelevancefortreatingagiven problem.

However,integrationinIMTgoesbeyondadoptingatrans-theoreticalapproach. Integrationisalsoatreatmentgoal.BPDinvolvesnotonlyunstableemotionsandrelationshipsbutalsodifficultyintegratingexperiences,thoughts,feelings,andactionsandconstructingacoherentsenseofself.Hence,acentraltreatmenttaskistofostermoreintegrated andcoherentpersonalityfunctioning.

Thesecondtermwarrantingexplanationis “ modular. ” Thisreferstothefactthat treatmentusesofanarrayofmodules,eac hconsistingofasetofinter-related strategiesandinterventionsthatseektoestablishaparticulartreatmentprocess(e.g., thetreatmentalliance)ortargetaspeci fi cimpairment(e.g.,unstableemotions).Based ontheanalysesofoutcomestudies,IMTusestwokindsofinterventionmodules: (i)generalinterventionmodulesthatimplementcommonchangeprinciplesand (ii)speci fi cinterventionmodulesbasedonstrategiesandinterventionsselected fromalltreatmentstotreatspeci fi cimpairments.Thismodularstructurepermits individualizedtherapy.

1.4TheStructureofIntegratedModularTreatment

Theevidenceindicatesthattreatmentismosteffectivewhenbasedonaclearlydefined modelthatspecifieshowtherapyisorganizedanddelivered.15 Thisprincipleledtothe developmentoftwoconceptualframeworksforIMTthatdescribethenatureofBPDand thestructureandprocessoftreatment,respectively.

1.4.1FrameworkforDescribingBorderlinePersonalityDisorder

TheframeworkforunderstandingBPD,describedindetailinChapters2–4(seeBox1.1),is usedtoorganizeclinicalinformation,plantreatment,andselectinterventions.16 Itisalso intendedtoprovideaframeworkforteachingpatientsabouttheirdisorder.Patientsare oftenpuzzledaboutwhytheyaresoupset,whichaddstotheirdistressandmakes psychoeducationanecessarypartoftreatment.

Theframeworkhasthreecomponents.The fi rstisbasedontheideathatpersonality isacomplexsystemwithmultipleinteractingcomponents:traits,regulationandmodulationmechanismsthatcontroltheexpressi onofemotionsandimpulses,interpersonal structures,andself/identity.BPDa ff ectsallpartsofthesystem.Thisideaisusedto organizethemultiplefeaturesofBPDinto fourdomainsofproblemsandimpairments (seeChapter2):

1.Symptoms:anxiety,fearfulness,emotionaldistress,rapidmoodchanges,self-harming behaviour,quasi-psychoticsymptoms,dissociativebehaviour

2.Regulation:impairedemotionalcontrol,tendencytoactwithasenseofurgencyleading toself-harmingbehaviour

BOX1.1 TheStructureofIntegratedModularTreatment

I. FrameworkforDescribingBorderlinePersonalityDisorder

1.Personalityasacomplexsysteminvolvingthetrait,regulationandmodulation, interpersonal,andselfsubsystemsthatgiverisetofourdomainsofimpairment:

a.Symptoms

b.Regulationandmodulation

c.Interpersonal

d.Self

2.Two-componentstructure:

a.Corefeaturescommontoallpersonalitydisorders:

i.Interpersonalproblems:

• Inabilitytoestablishlastingintimateattachmentrelationships

ii.Selfproblems:

• Poorlydevelopedsenseofself

• Unstableandfragmentedselfsystem

b.Emotionaldependencyconstellationoftraits:

i.Emotionaltraits:

• Anxiousness

• Emotionallability

ii.Interpersonaltraits:

• Insecureattachment

• Submissivedependency

• Needforapproval

iii.Cognitivetraits:

• Cognitivedysregulation

3.Originsanddevelopment:

a.Biological:

i.Geneticpredispositions

ii.Otherbiologicalfactors

b.Psychosocial:clinicallyimportantfactors

i.Attachmentproblems

ii.Invalidatingenvironments

4.Clinicalconsequencesofaetiologicalanddevelopmentalfactors:

a)Impairedregulationandmodulationmechanisms

b)Maladaptiveschemas

c)Maladaptivecognitiveprocesses

d)Coreinterpersonalconflict

e)Distresswithoutresolution

f)Selfsystemproblems

g)Conflictandfunctionalincoherence

3.Interpersonal:attachmentinsecurity,submissive-dependentbehaviours,conflictedand unstablerelationships;maladaptiveinterpersonalrelationships;maladaptive interpersonalbeliefs

4.Self-Identity:boundaryproblems,poorlydevelopedsenseofself,unstableselfand identitystructure,maladaptiveself-narrative,maladaptiveself-schemas(e.g., “Iam unlovable”),andproblemswithself-directedness.

Domainsorganizeapatient’sdiverseimpairmentsinawaythatfacilitatestreatment planninganddelivery.Ingeneral,eachdomainistreatedwithadifferentsetofspecific interventionmodules.Forexample,symptomsmaybetreatedwithmedication,andspecific cognitiveinterventionsandproblemsintheregulationdomainarebesttreatedwith cognitive-behaviouralmodulesthatenhanceskillsinself-regulatingemotionssuchas emotionrecognition,distresstolerance,andattentioncontrol.

Thesecondcomponentoftheframeworkisbasedontheideathatanypersonality disorderisbestunderstoodfordiagnosticpurposesashavingtwocomponents:(i) core features commontoallformsofpersonalitydisorderand(ii)a constellationoftraits that differentiatesagivendisordersuchasborderlinefromotherpersonalitydisorders(see Chapter3).Thisdistinctionreflectsacurrenttrendinthediagnosticclassificationto distinguishthefeaturesofgeneralpersonalitydisorderfromthetraitsthatdifferentiate thevariouskindsofdisorder.Thefeaturescommontoallpersonalitydisordersarechronic interpersonaldysfunctionandanimpairedsenseofselfandidentity.WithBPD,thesecore featuresareexpressedasdifficultyinestablishinglastingintimate,attachmentrelationships andproblemsestablishingastableandcoherentsenseofselforidentity.

ThreekindsoftraitsdefineBPD:(i)emotionaltraitssuchasemotionallabilityand anxiousness,whichgiverisetounstableemotionsandmoods;(ii)interpersonaltraitssuch asinsecureattachment,submissiveness,andneedforapproval/fearofdisapproval,which giverisetotheconflictbetweenneedinessandfearofabandonmentandrejection;and(iii) cognitivedysregulation – thetendencyforthinkingtobecomedisorganizedwhenstressed, whichmayprogresstoquasi-psychoticsymptomsanddissociation.Interactionamong thesetraitsgivesrisetothevariouskindsofinstabilitydescribedearlier.

Thethirdcomponentoftheframeworkisadescriptionoftheoriginsanddevelopment ofBPDandtheirimplicationsfortreatment(Chapter4).Finally,anunderstandingofthe lastingeffectsofadversityisusedtodefinemajorimpairmentsthatarelikelytobe encounteredintreatmentandsomeofthemajortreatmentstrategiesofIMT.

1.4.2FrameworkforOrganizingTreatment

IMThastwomaincomponents:(i)interventionmodulesand(ii)astagemodelofhow personalitypathologychangesduringtherapy(seeBox1.2).Asnotedearlier,intervention modulesconsistof generaltreatmentmodules basedonchangemechanismscommontoall effectivetherapiesand specifictreatmentmodules consistingofinterventionsdrawnfromthe variousspecializedtherapiesthattargetspecificproblemsandimpairments.Thedistinction betweengeneralandspecificmodulesisimportant.Generalmodulesformthebasic structureoftreatment:theyareusedwithallpatientsthroughouttreatmentwhereasspecific modulesvaryaccordingtotheneedsofindividualpatientsandtheproblemsthatarethe focusoftherapeuticeffortatanygivenmoment.

Thisdistinctionimpliesahierarchyofinterventions.Priorityisgiventointerventions neededtoensuresafetyofthepatientandothers.17 Oncesafetyisassured,generaltreatment

BOX1.2 TheStructureofIntegratedModularTreatment

II. FrameworkforOrganizingTreatment

1.Treatmentmodules:

a.Generaltreatmentmodules:

i.Structure:establishastructuredtreatmentprocess

ii.Relationship:buildacollaborativeworkingrelationship

iii.Consistency:maintainaconsistenttreatmentprocess

iv.Validation:establishavalidatingtreatmentprocess

v.Self-reflection:increaseself-knowledgeandself-reflection

vi.Motivation:buildandmaintainacommitmenttochange

b.Specificmodules:

i.Crisismodules

ii.Regulationandmodulationmodules

iii.Interpersonalmodules

iv.Selfmodules

2.Phasesofchange:

a.Safety:primaryfocusonthesymptomdomain

b.Containment:primaryfocusonthesymptomdomain

c.Regulationandmodulation:primaryfocusonthesymptomandregulationand modulationdomain

d.Explorationandchange:primaryfocusontheinterpersonaldomain

e.Integrationandsynthesis:primaryfocusontheselfandidentifydomainandon buildingasatisfyinglife

methodsareusedtoengagethepatientintherapy,buildaneffectivealliance,andestablish conditionsforchange.Whentheseconditionsaremet,specificinterventionsareusedas neededtotreattheproblemathand.Thisisanimportantpracticepoint:specificinterventionsareonlyusedwhenthereisagoodtreatmentrelationshipandamotivatedpatient. Theonlyexceptionsarewhenactionisneededtoensuresafetyandwhenmedicationis indicatedtoaddressanimmediateproblem.

Thesecondcomponentofthetreatmentframework,the phasesofchangemodel, proposesthattreatmentprogressesthough fivephases:(i)safety,(ii)containment, (iii)regulationandmodulation,(iv)explorationandchange,and(v)integrationand synthesis.Eachphaseaddressesadifferentdomainofborderlinepathology.Henceeach phaseinvolvestheuseofadifferentsetofspecificinterventionmodules.

1.4.2.1GeneralTreatmentModules

Genericstrategiesandinterventionsareorganizedintosixgeneraltreatmentmodules: (i)structure,(ii)treatmentrelationship,(iii)consistency,(iv)validation,(v)self-reflection, and(vi)motivation.The firstfourmodulesareprimarilyconcernedwithestablishingthe within-therapyconditionsnecessaryforchangewhereasthelasttwomodulesaremore concernedwithestablishingthewithin-patientconditionsneededforchangetooccur. Thefollowingsectionprovidesabroadoverviewofthesestrategies(Chapters7–12describe eachmoduleindetail).

Module1:EstablishaStructuredTreatmentProcess: AlleffectivetreatmentsforBPD emphasizetheimportanceofastructuredprocessbasedonanexplicittreatmentmodeland awell-definedtreatmentframeconsistingofthetherapeuticstanceandtreatmentcontract. Thestancereferstotheinterpersonalbehaviours,attitudes,responsibilities,andactivities thatdeterminehowthetherapistrelatestothepatient.Basedoncurrentevidence,IMT adoptsasupportive,empathic,andvalidatingstance.18 Akeyingredientofstructureisthe therapeuticcontractestablishedpriortotreatmentthatdefinescollaborativetreatment goalsandthepracticalarrangementsfortherapy.

Module2:EstablishandMaintainaCollaborativeTreatmentRelationship: Ifthereis anessentialingredienttosuccessfultreatment,itistheestablishmentofacollaborative workingrelationshipbetweenthepatientandthetherapist.Thisisgivenprioritybecause acollaborativerelationshipprovidessupport,buildsmotivation,andpredictsoutcome. WithmostpatientswithBPD,ittakestimeandefforttobuildatrulycollaborativerelationship:inmanywayscollaborationismoretheresultofeffectivetreatmentthanaprerequisite fortreatment.

Module3:MaintainaConsistentTreatmentProcess: E ff ectiveoutcomesalsodepend onmaintainingaconsistenttreatmentprocess.Consistencyisde fi nedsimplyasadherencetotheframeoftherapy.Thisiswhythetreatmentcontractissoimportant:it providesaframeofreferencethathelpsthet herapisttomonitortr eatmentandidentify deviationsfromtheframebyeitherthepatie ntorthetherapist.Violationsoftheframe arerelativelycommonwhentreatingBPDanditisimportantthattheyareaddressed promptlyandsupportively.

Module4:PromoteValidation: Validationisde fi nedasrecognition,acceptance,and a ffi rmationofthepatient ’ smentalstatesandexperiences.Validatinginterventions makeanimportantcontributiontotreat mentbyprovidingtheempathyandsupport neededtobuildacollaborativealliance. Atthesametime,theycountertheselfinvalidatingwayofthinking,whichisoften instilledbyinvalidatingdevelopmental experiences.

Module5:EnhanceSelf-KnowledgeandSelf-Reflection: Mosttherapiesencourage patientstodevelopabetterunderstandingofhowtheythink,feel,andact,andbecome moreawareofthelinksbetweentheirmentalstatesandproblembehaviour.Theextentand depthofself-knowledgeandself-understandingdependonself-reflection:thecapacityto thinkaboutandunderstandone’sownmentalstatesandthoseofothers.Impairedselfreflectionhindersthedevelopmentofimportantaspectsoftheselfthatareconstructedby reflectingindepthonone’sownmentalprocesses.Self-reflectionalsounderliesthecapacity forself-regulationandeffectivegoal-directedaction.

Module6:BuildandMaintainMotivationforChange: Asecondwithin-patientfactor necessaryfore ff ectiveoutcomesismotivationofch ange.Patientsneedtobemotivated toseekhelpandworkconsistentlyontheirpr oblems.Unfortunately,passivityandlow motivationarecommonconsequencesofpsychosocialadversity.Forthisreason, motivationcannotbearequirementfortreatment.Instead,therapistsneedtobecome skilledinbuildingmotivationandtomake extensiveuseofmotivation-enhancing techniques.

Implementationofthegeneralmodulesmeansthattreatmentisorganizedaround astrongtherapeuticrelationshipcharacterizedbysupport,empathy,consistency,and validation.Priorityisgiventotherelations hipduetotheseriouspr oblemsmostpatients haveexperiencedwithattachmentrela tionshipsandtheirconsistentdi ffi cultieswith

interpersonalrelationships.Theobjectiveistoestablishatreatmentprocessthatprovidesacontinuouscorrect ivetherapeuticexperiencetocounterthelastinge ff ectsof psychosocialadversity.Thisisanimportantaspectoftherapy:cha ngeisbroughtabout notonlybyinterventionsofonekindoranotherbutalsobythewaytherapyisorganized anddelivered.

PhasesofChangeModel: Theoverallcourseoftreatmentisdividedintosafety, containment,regulationandmodulation,explorationandchange,andintegrationand synthesisphasesthatareusedtoguidetheuseofspecificinterventionmodules. Achallengeforintegratedtreatmentishowtocoordinatetheuseofspecificinterventions soastoavoidconfusionarisingfromtheuseofmultipleinterventions.Thephasesofchange modelreducesthisproblembecauseeachphaseaddressesadifferentdomainofimpairment andhencerequiresdifferentspecificinterventionmodules.Thusthemodeldescribesthe sequenceinwhichproblemsareaddressedandspecificinterventionsareusedwithageneral progressionfrommore-structuredtoless-structuredmethods.

The firsttwophases,safetyandcontainment,primarilydealwiththesymptomdomain. Thethirdphase,controlandmodulation,continuesthefocusonsymptomresolutionbut dealsprimarilywithemotionaldysregulationandassociatedsuicidalandself-harming behaviour.Phasefour,explorationandchange,focusesprimarilyontheinterpersonal domainusingadiversearrayofinterventions,andphase five,integrationandsynthesis, dealswiththeself/identitydomain.

Thesequenceforaddressingdomainspartlyreflectstheclinicalprioritygivento symptomsincludingsuicidalityandself-harmandpartlythedegreetowhichproblems associatedwithagivendomainareamenabletochange.Ingeneral,thesequenceof symptoms,regulationandmodulation,interpersonal,andself/identityreflectsincreasing stabilityandresistancetochange.

Phase1.Safety: Whentreatmentbeginswiththepatientinadecompensatedcrisisstate, theimmediateconcernistoensurethesafetyofthepatientandothers.Thisislargely achievedbyprovidingstructureandsupportthatmaybedeliveredthroughoutpatient treatmentandacrisisinterventionservice,oroccasionallythroughbriefin-patienttreatment.Interventionsarelargelygenericandnon-specific – providingthesupportand structureasneededtokeepthepatientsafeuntilthecrisisresolves – althoughmedication mayalsobeusedwithsomepatients.

Phase2.Containment: Thebriefsafetyphaseusuallygiveswayquicklytocontainment wherethegoalistocontainandsettleemotionalandbehaviouralinstabilityandrestore behaviouralcontrol.Theobjectivesaretoreturnthepatienttothepre-crisislevelof functioningasquicklyaspossibleandlaythefoundationforfurthertreatment.Aswith thepreviousphase,changeisachievedthroughsupport,empathy,andstructure,supplementedifnecessarywithmedication.

Phase3.RegulationandControl: Crisisresolutionandincreasedstabilityareusually accompaniedbyanimprovedtreatmentrelationship.Thismakesitpossibletobegin focusingonimprovingemotionaldysregulationandreducingsymptomsincluding deliberateself-harm,suicidality,andtheconsequencesoftrauma.Specificinterventions areusedto:(i)providepsychoeducationaboutemotionsandemotionaldysregulation; (ii)increaseawareness,acceptance,andtoleranceofemotions;(iii)improveemotion regulation;and(iv)enhancethecapacitytoprocessemotions.Emphasisisplaced oncognitive-behaviouralinterventionsbecauseofevidenceoftheeffectivenessofthese interventionsinreducingdeliberateself-harmandincreasingemotion-regulatingskills.19

However,skilldevelopmentisnotconsideredsufficient:itisalsoimportanttoimprovethe abilitytoprocessemotionsmoreadaptively.Althoughcognitive-behaviouralinterventions arealsousefulforthispurpose,theyusuallyneedtobesupplementedwithmethodsthat helppatientstoconstructmeaningfulnarrativesabouttheiremotionallife.Inevitably,this workbeginstoinvolveinterpersonalimpairmentslinkedtointenseemotionsandhence treatmentgraduallymovestothenextphase.

Phase4.ExplorationandChange: Thefocusofthisphaseistoexploreandchangethose aspectsofpersonalitythatunderliesymptomsanddysregulatedemotions,especiallyinterpersonalproblems.Particularattentionisgiveninitiallytoselfandinterpersonalschemas associatedwithemotionalinstabilityanddeliberateself-harm.Thisfocusgraduallyextends tothecoreinterpersonalconflictbetweenneedinessandfearofabandonmentandrejection andtheinterpersonalexperiencesthatcontributedtothedevelopmentofthisconflict. Discussionoftheseproblemsusuallygeneratesconsiderabledistress,whichiswhyconsistentworkonthesethemesisdeferredifpossibleuntilemotionregulationincreasesandthe patientisabletotoleratethestressinvolved.Changeisachievedthroughthecontinueduse ofcognitiveinterventionstoexploreandrestructuremaladaptiveschemas,buttheseusually needtobesupplementedwithmethodsdrawnfrominterpersonalandpsychodynamic therapy.Duringthisphase,thetreatmentrelationshipbecomesamajorvehicleforexaminingandrestructuringinterpersonalschemasinvolvingdistrust,rejection,abandonment, self-derogation,andshameforgedbyearlyadversity.Atthesametime,therelationshipwith therapistprovidesthepatientwithanewinterpersonalexperiencethatchallengesmanyof themaladaptiveschemasthathaveshapedtheirinterpersonallives.

Phase5.IntegrationandSynthesis: The finalphaseoftreatmentdealsprimarilywiththe self/identitydomain.Broadlyspeaking,thegoalistohelppatientsto “getalife”– todevelop amoreadaptivelifescript,createamoresatisfyingandrewardingwayofliving,andacquire greaterpurposeanddirectiontotheirlives.Althoughonlyafewpatientsreachthisstage,all patientsneedhelpwithbuildingamorecongeniallifestyletohelpthemtomaintainchanges madeintreatment.Throughouttreatment,therapistsneedtobemindfuloftheimportance ofhelpingpatientstoconstructapersonalnichethatallowsthemtoexpresstheirpersonal aspirations,talents,interests,andtraitsandavoidsituationsandrelationshipsthatactivate vulnerabilitiesandconflicts.Nevertheless,theformulationofamoreadaptivesenseof identityislargelyachievedinthelatterpartoftreatmentwhenmoredistressingproblems movetoresolution.Thedevelopmentofamorecoherentself-structureisoftendifficultto achieveandthereislittleempiricalresearchtohelpidentifyeffectivestrategies.However, consistentapplicationofthegeneraltherapeuticstrategiescreatesatreatmentenvironment thatchallengescoreschemasandpromotesself-understandingbyprovidingconsistent andveridicalfeedback.Narrativemethodsalsoseemusefulinbuildingamoreadaptive selfstory.20

1.5TheOtherIngredientofIntegratedModularTreatment

Thusfarthefocushasbeenonthestructureoftherapy – whattodoandwhen.However, thereisanotheraspectoftherapythatisjustasimportant:whatmightbereferredtoasthe toneoftherapy.Whatmattersisnotjustwhattherapistsdobuthowtheydoit.Thisismore nebulousanddifficulttodescribe.Itiscapturedinpartbytheemphasisonanempathic, supportive,andvalidatingtherapeuticstance.Butthisisonlypartofwhatmatters. Otherfeaturesofthetherapeuticinteractionthattherapistsneedtocreatearethe

following:respect,compassion,acceptance,attentiveness,involvement,andempathicattunement.Thesefeaturescharacterizeatreatmentprocessthatoffersnewexperiencesto challengeoldwaysofinteractingwiththeinterpersonalworld.Weneedtogetthispartof therapyright:technicalcompetencemaybenecessarybutitisnotsufficient.

1.6Comment

TheIMTframeworkisdesignedtoprovidethestructureneededtodeliverthecohesiveand consistenttreatmentneededforsuccessfuloutcomeswhilealsobeingsufficiently flexibleto allowtherapiststotailortreatmenttotheirspecificstyle,patientneed,treatmentsetting,and themodalityoftreatmentdelivery.Consequently,theprinciplesofIMTarerelevantto short-termcrisisinterventionlastingatmostafewmonths;medium-termtreatmentlasting perhapsayearorso,whichisprimarilyconcernedwithincreasingemotionregulationand decreasingself-harmingbehaviour;andlong-termtreatmentlastingseveralyears,whichis intendedtochangeinterpersonalpatternsandpromotemoreintegratedpersonality functioning.

Notes

1.Fortreatmentmanualsanddescriptionsofthesetherapies,see:DBT(Linehan,1993),TFT(Clarkinetal., 1999),SFT(Youngetal.,2003),MBT(BatemanandFonagy,2004,2006),CBT(Becketal.,1990,2004; Davidson,2008),CAT(Ryle,1997),andSTEPPS(Blumetal.,2012).Therandomlycontrolledstudies supportingthesetreatmentsinclude:DBT(Linehanetal.,1991,1993),TFT(Clarkinetal.,2007;Doeringetal., 2010;Levyetal.,2006),SFT(Bamelisetal.,2014;Giesen-Blooetal.,2006),MBT(MBT,BatemanandFonagy, 1999,2000,2001,2008,2013),CBT(Davidsonetal.,2006),CAT(Chanenetal.,2008),andSTEPPS(Black etal.,2004;Blumetal.,2002,2008).

2.TheprevalenceestimatesnotedarefortheDSM-IV/DSM-5diagnosis(seeMorganandZimmerman,in press).EstimatesforDSM-III-Rdiagnosesdifferslightly.SeealsoreviewbyTorgensen(2012).

3.Parisetal.(1987);ParisandZweig-Frank(2001).

4.Schmideberg(1947).

5.ThetraitcomponentofBPDasdescribedinthisvolumeisbasedonempiricalstudiesofpersonalitydisorder traits.ThismeansthatalthoughthereissubstantialoverlapbetweenthewayBPDisdescribedhereandin DSM-IV/DSM-5,thereareseveraldifferences.First,theDSMcriterionofaffectivelabilityisdividedhereinto emotionallabilityandanxiousnesstoreflecttheresultsofempiricalstudies.Second,thecriteriondescribing apatternofunstableandintenserelationshipsisreplacedbyadescriptionofacoreconflictbetweenneediness andfearofrejectionbecausethiscapturesthecoreinterpersonalproblemassociatedwithBPDbetter.This conflictisnotreferencedintheDSMcriteriaalthoughitiscentraltounderstandingtheinterpersonal behaviourofthesepatients.Third,herereferenceisalsomadetothedependent-submissivefeaturesofthese patients,whichareoftenexpressedinahostile-dependentway.Thesedifferencesarereflectedintreatment strategiesthattargetbehavioursthatarenotincludedintheDSMcriteriaset.However,theapproach describedisequallyapplicabletotreatingBPDdiagnosedonthebasisofDSMcriteria.

6.Crawfordetal.(2011),Verheuletal.(2008),TyrerandJohnson(1996),Hopwoodetal.(2011).

7.SeereviewsbyBartaketal.(2007),Budgeetal.(2014),LeichsenringandLeibing(2003),Leichsenringetal. (2011),andPiperandJoyce(2001).

8.ThisoutcomestudybyGiesen-Blooetal.(2006)reporteddifferencesbetweenSFTandTFT.However,these differenceswererelativelysmallandlargelyoffsetbyconcernsthatthequalityoftherapywasnotcomparable acrossthetwotreatments(Yeomans,2007).

9.Threespecializedtherapiescomparedwithgoodclinicalcareare:DBT(McMainetal.,2009)MBT(Bateman andFonagy,2009),andCAT(Chanenetal.,2008;Clarkeetal.,2013).

10.Cottrauxetal.(2009).

11.Jorgensenetal.(2013),despitethatfactthatthesupportivetherapygroupreceivedonlyaboutone-thirdthe amountoftherapyastheMBTgroup:one90-minutegroupsessioneverytwoweeksversus90minutesof grouptreatmentand45minutesofindividualtherapyeachweek.

12.Theresultsofthisstudyarealsoconsistentwithanearlierstudyshowingthatthelong-termsupportive therapywasaseffectiveasthatofmoreintensiveTFTandDBT(Clarkinetal.,2007).

13.Livesley(2012).

14.CastonguayandBeutler(2006b).

15.CritchfieldandBenjamin(2006).

16.ThisframeworkisanextensionandelaborationofthemodeldescribedinLivesley(2003),andthebox modifiesthegeneralmodeldescribedbyLivesleyandClarkin(2015a)totreatBPD.

17.Mosttherapiesprioritizeinterventionsrequiredtoensuresafety(seeLinehan,1993;Clarkinetal.,1999).

18.Livesley(2003).

19.RandomizedcontrolledtrialsoftreatmentssuchasDBT(Linehanetal.,1991),STEPPS(Blumetal.,2008), andCBT(Davidsonetal.,2006;Evansetal.,1999)demonstratetheeffectivenessofcognitive-behavioural interventionsintreatingdeliberateself-harmandemotionaldysregulation.Inaddition,evidencesuggeststhat specificproblembehavioursarebesttreateddirectlywithcognitive-behavioralinterventions(seeLipsey,1995, 2009).

20.Seeforexample,cognitiveanalytictherapydevelopedbyRyle(1997).

2 UnderstandingNormal andDisorderedPersonality

Thischapterbeginstodevelopaframeworkforunderstandingborderlinepersonality disorder(BPD)bydescribingthestructureofnormalpersonalityandhowthisstructure isimpairedinBPD.However, firstIamgoingtointroducethecaseofAnna,whichwillbe usedthroughoutthebooktoillustrateassessment,treatmentplanning,andintervention strategies.Herethecaseisusedtodiscusstherangeofproblemsandpsychopathologyseen inBPD.

2.1TheCaseofAnna

Annawas36yearsold,marriedwiththreechildren,whenshewasassessedfollowingabrief hospitalstayduetoaseriousdrugoverdose.Annasaidthattheoverdosewastriggeredby a fightwithherhusbandthatcausedintensedistressandshebecameafraidthathewould leaveher.Feelingoverwhelmedandunabletocope,shetookanoverdose.Suchcriseswere commonandshehadseveralpreviousadmissionsforself-harmingbehaviour.Mostofthe timeherfeelingswere “allovertheplace,” andshefeltdepressedandpersistentlyworried “abouteverylittlething.” Although,thereweretimeswhenshewonderedifthesefeelings werereal.Shealsohaduncontrollablerages,especiallywithherhusband.Shealsohad chronicthoughtsofsuicide.

Anna’supbringingwascharacterizedbyfamilydysfunction,physicalandemotional abuse,andchildhoodsexualabuse.Hermarriagewasunstable.Sheandherhusbandfought constantlyandhewasemotionallyabusive.Therelationshipwastypicalofmanyprevious relationships.Annacommentedthatshealwaysseemedattractedtothewrongkindofmen butshewasunabletoleaveherhusbandbecauseshedidnothavethe financialresources. Shelaterexplainedthatshewasalsoafraidtolivealoneandthatshewasterrifiedofbeing abandonedandneededtofeelloved.Asaresult,shebecameverydependentonthemenshe wasinvolvedwith.Currently,shewasafraidofbeingabandonedandconstantlysoughther husband’sreassurancethathewouldnotleave.Thisfearcausedhertosubmitreadilytohis demandsandgooutofherwaytoplacatehim.

Annahadfewfriendsandshefeltuncomfortablewithpeoplebecausesheworriedthat theyfoundheruninteresting.Thiswasaproblembecauseshewaseasilyboredandneeded company.Despitethisneedforexcitement,Annaalsohadmildobsessionaltraits – sheliked thingstobetidyandorganized.Annahadnorealplansforherlifeapartfromcaringforher children.Shenotedthatshehadalwaysdriftedthroughlifeunsureaboutherselfandwhat shereallywanted.

Anna’smultipleproblemsincludedsymptomssuchasanxiety,suicidality,unstable emotions,interpersonalproblems,maladaptivetraits,andself/identityproblems.Totreat

thisarrayofproblems,itisnotsufficientsimplytodiagnoseBPDbasedonDSM-5criteria. Instead,weneedaschemethatwouldhelpustomakesenseofherdiverseproblemsand organizetheminasystematicwaythatcanbeusedtoplantreatment,selectinterventions, andhelpAnnatodevelopanewunderstandingofherlifeandcircumstances.Thischapter beginstodevelopsuchaframeworkbydescribingthemainfeaturesofnormalpersonality. AlthoughthismayseemanunusualstartingpointbecausemostconceptionsofBPDpay littleattentiontonormalpersonality,itreflectstheassumptionthatwecannotfullyunderstandpersonalitydisorderwithoutunderstandingnormalpersonality,muchas acardiologistcannotunderstandheartproblemswithoutknowledgeofthenormalcardiovascularsystem.Also,asIhopetoshow,knowledgeofnormalpersonalitycanenrichour understandingofBPDandguidetreatmentstrategies.

2.2TheNormalPersonalitySystem

WecanbeginimposingstructureontoAnna’sproblemsbythinkingofpersonalityas acomplexsystemofinteractingcomponents.1 Thisideaisusefulbecauseitforcesusto thinkaboutpersonalityasawholeratherthanalistofcriteriaandabouthowAnna′s problemsinteractwitheachother.Weneedtodothistoachievetheintegratedmodular treatment(IMT)goalofpromotingmoreintegratedpersonalityfunctioning.Fourcomponentsorsubsystemsofpersonalityareimportantinunderstandingtheclinicalfeaturesof BPD:(i)theregulatoryandmodulatorysystemusedtomanageemotionsandimpulses;(ii) thetraitsystem;(iii)theinterpersonalsystem;and(iv)theselfsystem(seeFigure2.1). Theselfandinterpersonalsystemsoverlapmorethanothersystemsbecausebothare

influencedbythesamedevelopmentalexperiences.Bothareessentiallyknowledgesystems thatstoreandprocessslightlydifferentdomainsofinformation.

Anna ’ sproblemsencompassallsubsystems.Besidessymptomssuchasanxiety, suicidality,anddeliberateself-injury,herpersonalityproblemsincludedi ffi cultyin self-regulatingemotionsandimpulses,mal adaptivetraitssuchasemotionallability andinsecureattachment,interpersonaldi ffi cultiesincludingattachmentandintimacy problems,andapoorlydevelopedsenseofselforidentity.Beforediscussingthe personalitysubsystemsindetail,Ineedtoi ntroduceanotheridea thatisfundamental totheconceptualframeworkofIMT:that eachpersonalitysubsystemconsistsof cognitivestructuresthatare usedtoorganizeinformation,interpretexperience,and guideaction.

2.3TheCognitiveStructureofPersonality

ThevarioustheoriesofBPDdescribethesecognitivestructuresusingtermssuchas “schemas,”“earlymaladaptiveschemas,”“objectrelationships,” and “workingmodels.” Despitethedifferentlabels,alltheoriessharetheideathatthesecognitivestructuresare thebasicunitsofpersonalityandthattreatmentislargelyconcernedwithrestructuring them.

Despitethiscommona lity,theoriesdi ff erinoneimportantrespect – whetherthese constructsarepurelycognitiveinnature,asassumedbycognitive-behaviouraltherapy (CBT),orwhethertheyalsohaveanemotion alcomponentasassumedbyobjectrelationshiptheory;objectrelationshipsareconsideredcognitiveandemoti onalrepresentations ofthecharacteristicrelationshipsestablishedbetweenselfandothers.Here,these fundamentalunitsofpersonalitywillbereferredtoaspersonalityschemasorschemas forbrevity.Theterm “ schema ” isusedbecauseithasalongtraditioninpsychologyand cognitivescience.InIMT,schemasareconsideredcognitive-emotionalpersonality systems – constellationsofrelatedideas,expectations,memories,andemotions. Theemotionalcomponentisintegraltotheconcept,andemotionsareassumedtoplay animportantroleinschemaactivationandexpression.Hencetheconceptofschemaas usedinIMTdi ff ersfromthatusedincognitivetherapy.

ThebriefaccountofAnna’sproblemssuggeststhatshehasawidevarietyofmaladaptive schemasinvolvingattachmentanddependencyneeds,rejectionfears,submissivenessand theneedtoplacateothers,theimportanceoforderandstructure,ideasaboutrisk-taking andexcitement-seeking,andsoon.

Thepersonalityschemaisanimportanttrans-theoreticalconstructthatisassumedtobe thebasicbuildingblockofthetrait,regulatory,interpersonal,andselfsystems.Theideathat schemasarebasictoourinterpersonalandselfsystemsisprobablyreadilyunderstandable –ineverydaylifeweuseawiderangeofconstructstodescribeourselvesandothers.Theidea thatschemasarealsointegraltotraitsandregulatorymechanismsmaybelessobviousbut thiswillbediscussedlater.

Severalaspectsofschemasareimport anttobearinmindwhentreatingBPD. First,schemasareboth “ frames ” and “ cages. ” 2 Likealens,schemasframeandcolour ourunderstandingoftheworld.However,s chemascanalsocageusin,forcingusinto rigidwaysoflookingatourselvesandothersandhencetostereotypedbehaviours. In fl exibilityiscommoninpeoplewithBPD:theyhavealimitedrepertoireofschemas thattheyusein fi xedways.ThisisillustratedbytherigidwaythatAnna ’ sintense

sensitivitytoabandonmentin fl uencedhowsheperceivedandunderstoodtherelationshipsthatdominatedherlife.

Second,peopledifferinthenumberofschemastheyhave.Generally,themoreschemas wehave,themoreadaptiveourbehaviour,becausewehavemoreoptionsinhowwe construeandrespondtoevents.Havingtoofewschemaslimitsourunderstandingof ourselvesandothers.ThisisaproblemwithpeoplewithBPD – manyhaverelativelyfew schemas.Hencetheirunderstandingofselfandothersisoftenlimited.Third,schemasdiffer inimportance.Somearecoreconstructsthatplayacentralroleinhowweperceiveandreact toeventsandhowwethinkaboutourselvesandothers,whereasothersaremoreperipheral andhavelessinfluenceonouractions.

Fourth,schemasareorganizedintosystemssuchasthetrait,regulatory,interpersonal, andself-schemas.Withineachsubsystem,schemasarefurtherorganizedintomorespecific systems.Inthecaseofthetraitsystem,schemasareorganizedaroundindividualtraitsand theyinfluencethewaythetraitisexpressed.Withintheselfsystem,self-schemasare organizedintodifferentimagesoftheself.Similarly,interpersonalschemasareorganized intodifferentrepresentationsofothers.

Therichnessofconnectionsamongschemasisimportant:themoreextensivethe interconnectionsamongschemas,thegreatertheintegrationand flexibilityoftheoverall structure.Peripheralschemashaverelativelyfewconnectionswithotherschemas,whereas coreschemashaveextensivelinkageswithotherschemas.Consequently,coreschemasare moredifficulttochangeandanychangeisusuallyanxietyprovoking.Forexample,Anna’ s abandonmentschemashadextensiveconnectionswithmultipleinterpersonalandselfschemas.Asaresult,theywerefrequentlyactivatedbyinterpersonalevents,andthey structuredmanyofherinteractionswithothersanddefinedimportantaspectsofher senseofself.

Giventheimportantroleschemasplayinallaspectsofpersonalityfunctioning,Iwill discussindetailtheschemasassociatedwithdifferentpersonalitysubsystemsandhow schemasareshapedbydevelopmentalexperiences.Thecentralroleofschemasmeansthat ageneraltreatmenttaskistohelppatientstorecognizeandrestructuremaladaptive schemasacrossthedifferentsubsystemsofpersonalityandtounderstandhowthese schemasarelinkedtosymptomsandrecurrentproblems.However,thisisnotthewhole story.Aswewillseelater,schemasarealsousedtoconstructnarrativesthatgivemeaning andstructuretoourexperience.Thusanimportantpartoftherapyisalsotohelppatients constructmoreadaptivenarrativesaboutallaspectsoftheirexperience.Butnowwereturn toexploringthesubsystemsofpersonalitywiththeconceptofpersonalityschemainmind asanintegrativeconstruct.

2.4TraitSystem

Itisconvenienttobegindescribingthepersonalitysystemwithtraitsbecausetraits arefamiliarconceptsthatareusefulindescribingclinicallyimportantdifferencesamong patients;thisisbecausetraitshaveamajorinfluenceonadjustment,health,andwell-being, andonthedevelopmentofotherpersonalitystructures.Traitsareenduringcharacteristics thatchangelittleafterearlyadulthood.Theyarealsouniversalcharacteristics – like heightandweight,theyapplytoeveryonealthoughtodifferentdegrees.Hencethetraits delineatingBPDarethesameasthosethatcharacterizenormalpersonality,althoughthey differindegreeandhowtheyareexpressed.