BPD Treatments, Cures and Recovery

[lbjnltx]

Borderline Personality Disorder - Treatment and Cures

"The conventional wisdom is that behavior modification training is the best hope for people with Borderline Personality Disorder.  Some suggest that "talk therapy" is more affective.  Some will suggest the need for both.  There are also many opinions on the role of pharmaceuticals in dealing with BPD.

This workshop is to discuss the treatments available to people affected by Borderline Personality Disorder:

• What works?

• How does it work?

• What is the role of the family member?

• What should the family members "not do"?

• What to expect?

Recent consensus seems to suggest that behavior modification training is most effective with people affected by Borderline Personality Disorder.  Cognitive Behavior Therapy (CBT), or one promising offshoot, Dialectical Behavioral Therapy (DBT) is the method most heavily evaluated in population studies.  There are also several others - Transferance (a preferred method at Columbia Presbyterian in NYC, for example) and the newer Schema, and Mentalization therapies that are being evaluated.

In the simplest sense, this is mostly about recognizing maladaptive behavior in yourself (the person affected by BPD), and using behavior tools to express it more constructively. Like a diet, it works only with someone who is motivated and committed.  Like a diet, many enter, some have short term gains but can't sustain the willpower.  And like a diet, setbacks in life can easily defeat the process.  Some patients start and restart.  Some start and then give up / dismiss it.  

For these reasons, it is important that the family and environment be both structured (helping avoid falling events) and encouraging (not defeating).  The family also needs to be both patient and have boundaries with respect to digressions.

There is no "passive" cure.

The role of pharmaceuticals is mostly about:

• taking the "edge off" to help curb the extreme responses,  or to

• treat any underlying biological disease (e.g. thyroid disease, diabetes, etc) and secondary issues (e.g.,depression).

"taking the edge off" was explained to me as getting the patients "head above water" so that the work can be started... .   rather than a permanent solution or a stand alone cure.

I look forward to hearing the many diverse experiences of the membership on this subject."

Skippy

Our objective is to better understand the struggles our child faces and to learn the skills to improve our relationship and provide a supportive environment and also improve on our own emotional responses, attitudes and effectiveness as a family leaders

[lbjnltx]

Cognitive-behavioral therapy (CBT)

Cognitive-behavioral therapy (CBT), founded by Albert Ellis, Ph.D. is a combination of two therapy techniques: cognitive and behavioral. Cognitive therapy refers to an approach that focuses on a person's cognitions: their thoughts, assumptions, and beliefs. With this therapy approach a person learns to recognize and change faulty or maladaptive thought patterns. The focus is on restructuring the dysfunctional cognitions through a process of identifying, challenging, and reshaping them. Behavioral therapy focuses on changing a person's unhealthy and problematic behaviors, actions, and responses. The focus is not on "why" something happens, but changing the process to prevent, alter, or replace it with a healthier more effective behavior. Dialectical-behavioral therapy (DBT), and Schema-focused Therapy (SFT) are specialized types of CBT.


Dialectical-behavioral therapy

Developed by Marcia Linehan, Ph.D., of the Department of Psychology at the University of Washington, DBT directly targets suicidal and other dangerous, severe, or destabilizing behaviors. Standard DBT strives to increase behavioral capabilities, improve motivation for skillful behavior through management of issues and problems as they come up in day-to-day life and reduction of interfering emotions and cognitions, and structure the treatment environment so that it reinforces functional rather than dysfunctional behaviors. Therapy consists of weekly individual psychotherapy, group skills training, telephone consultation, and weekly meetings between therapist and a consultation team to enhance therapist motivation and skills and to provide therapy for the therapists. DBT skills for emotion regulation include:

   Identifying and labeling emotions

   

   Identifying obstacles to changing emotions

   

   Reducing vulnerability to emotion mind

   

   Increasing positive emotional events

   

   Increasing mindfulness to current emotions

   

   Taking opposite action

   

   Applying distress tolerance techniques

   


A recent report compares patients that DBT vs those that received treatment by community experts. The latter were therapists who were experienced in the treatment of BPD but used methods other than DBT to treat randomly assigned patients.

Subjects receiving DBT were half as likely to make a suicide attempt, required fewer hospitalizations for suicide ideation, and had lower medical risk across all suicide attempts and self-injurious acts combined. They were also less likely to drop out of treatment and had fewer psychiatric hospitalizations and psychiatric emergency department visits, according to the report.

An abstract of the study, "Two-Year Randomized Controlled Trial and Follow-Up of Dialectical Behavior Therapy vs. Therapy by Experts for Suicidal Behaviors and Borderline Personality Disorder," is posted here.


Schema Therapy Builds on CBT

Schema therapy, the newest of the psychotherapies for BPD, appears to synthesize elements of several successful therapies. Paris has described it as "CBT with a psychodynamic component."

Schema therapy founder Jeffrey Young, Ph.D., who is on the faculty of the Department of Psychiatry at Columbia University College of Physicians and Surgeons, was one of the first students of Aaron Beck, M.D., the founder of cognitive therapy.

"I found that cognitive therapy was extremely effective with many Axis I disorders, as research has since substantiated, but was much less effective by itself with Axis II personality disorders," he told Psychiatric News. "I began to look for ways to expand cognitive-behavior therapy to work with Axis II issues by integrating elements drawn from other approaches as well as CBT, including psychodynamic therapies such as object relations, emotion-focused/gestalt therapies, and attachment theory."

Young described schema therapy as an active, structured therapy for assessing and changing deep-rooted psychological problems by looking at repetitive life patterns and core life themes, called "schemas." Schema therapists use an inventory to assess the schemas that cause persistent problems in a patient's life.

"Once we have determined what schemas a patient has, we use a range of techniques for changing these schemas," Young said. "These include cognitive restructuring, limited re-parenting, changing schemas as they arise in the therapy relationship, intensive imagery work to access and change the source of schemas, and creating dialogues between the `schema,' or dysfunctional, side of patients and the healthy side."

He added that systematic behavioral techniques are also employed to change dysfunctional coping styles, especially maladaptive behaviors in intimate relationships. More information about schema therapy is posted here.

In a randomized trial of schema therapy versus transference-focused therapy published in the Archives in June 2006, statistically and clinically significant improvements were found for both treatments on all measures after one, two, and three-year treatment periods. Data on 44 schema therapy patients and 42 transference-focused therapy patients were available.

Main outcome measures included scores on the Borderline Personality Disorder Severity Index, quality of life, and general psychopat hologic dysf unction. Patient assessments were made before randomization and then every three months for three years.

Significantly more schema therapy patients fully recovered (46 percent versus 26 percent) or showed reliable clinical improvement (66 percent versus 33 percent) on the Borderline Personality Disorder Severity Index than patients receiving transference-focused therapy. They also improved more in general psychopathologic dysfunction and showed greater increases in quality of life.

Statistical analysis also revealed a higher dropout risk among transference-focused therapy (52 percent) patients than among patients receiving schema therapy (29 percent), according to the study report.

The report, "Outpatient Psychotherapy for Borderline Personality Disorder: Randomized Trial of Schema-Focused Therapy vs. Transference-Focused Psychotherapy," is posted here.

"This is the first controlled study demonstrating that a treatment is capable of reducing all of the BPD manifestations as defined by DSM-IV, reduces associated personality features and general psychopathology, and increases quality of life," study co-author Arnoud Arntz, Ph.D., told Psychiatric News.

He is with the Department of Medical, Clinical, and Experimental Psychology at the University of Maastricht, in the Netherlands.

The authors also stated that, in a separate analysis, schema therapy was found to be highly cost-effective for society, despite the length and intensity of the treatment.

Young, who was not involved in the study, said it is the first to demonstrate "deep personality change" in a high percentage of patients long considered untreatable.

"Up until now, existing therapies for BPD have proven to lead to only partial recovery or have only been able to reduce self-harming behaviors," he said. "This should be of great interest to psychiatrists because patients with BPD are usually considered the most difficult, frustrating, and risky patients within most therapists' practices.

"The second important implication for psychiatrists is that the use of a neutral stance toward the BPD patient, which is advocated in most psychody namic approaches to BPD, is clearly much less effective than the more engaged, warm, and nurturing stance of schema therapy," Young said. "This was demonstrated by the dramatic differences in dropout rates between the two treatments."


Mentalization Therapy

It has been proposed that people with BPD have hyperactive attachment systems as a result of their history or biological predisposition, which may account for their reduced capacity to mentalize. They would be particularly vulnerable to side-effects of psychotherapeutic treatments that activate this attachment system. Because the approach is psychodynamic, therapy tends to be less directive than cognitive-behavioral approaches, such as dialectical behavior therapy (DBT), another common treatment approach for borderline personality disorder. More information is posted here.

Mentalization is the capacity to understand both behavior and feelings and how they’re associated with specific mental states, not just in the client, but in others as well. It is theorized that people with Borderline Personality Disorder (BPD) have a decreased capacity for mentalization. Mentalization-based therapy, pioneered by Andrew Bateman, M.A., and Peter Fonagy, Ph.D., seeks to facilitate the capacity for "mentalization"—the ability to perceive the mind of others as distinct from one's own and hence to reconsider and reassess one's own perceptions of reality. Mentalization is a component in most traditional types of psychotherapy, but it is not usually the primary focus of such therapy approaches.

Transference-focused Psychotherapy

Transference-focused Psychotherapy (TFP), founded by Otto Kernberg, M.D., is a psychodynamic treatment designed especially for patients with borderline personality disorder (BPD). Transference-focused psychotherapy among others, is an adaptation of psychoanalysis that aims to correct distortions in the patient's perception of significant others and of the therapist.

TFP, which dates back many years, places special emphasis on the assessment and on the treatment contract between the client and the therapist. The setting up of the contract and frame has a behavioral quality in that parameters are established to deal with the likely threats both to the treatment and to the patient's well-being that may occur in the course of the treatment. The patient is engaged as a collaborator in setting up these conditions.

After the behavioral symptoms of borderline pathology are contained through structure and limit setting, the psychological structure that is believed to be the core of borderline personality is analyzed as it unfolds in the relation with the therapist as perceived by the patient [transference].

[Reality]

Hi lbjnitx,

Did you write this information yourself?  I find it very helpful to see this summary, so thank you for doing this work.

Reality

[lbjnltx]

No, Skip compiled it

It is from a workshop that is linked in the ":)iscussion: What can a parent do".

We are making the effort to direct the information on the site to be more relevant for the parents of the  Supporting Board so we need to contribute.

From the perspective of a parent who has looked for resources and evaluated the different therapies promoted to help a person with BPD, what are your thoughts?

[somuchlove]

  Thanks for putting this in a great format.  

Now to get our loved one into treatment.  Can you put a step by step together of how to understand and love them enough to stay strong and in the right way, have them walk on the yellow brick road to the Great Oz, that can fix them.  

I wish it was as simple as " follow the yellow brick road, follow the yellow brick road.

==============================

[qcarolr]

I think my DD is still in the 'taking the edge off' stage  

I do like the result statistics on Schema therapy - the overall impact in personality and not just managing the symptoms. Yet it takes a long term commitment. I also like the point about it being more engaged (less neutal emotion from t) with better chances for this longer term commitment.

So many failures that my DD experineced. She started play therapy at age 5 because of my emotional issues and how her problems triggered these. I don't know that there was much success in that therapy - DD remembers it as a waste of her time that she can never get back. Geez I hate it when she uses that phrase with me. She resisted OT at age 3 even. WHat strong defiance in that girl.

I do have to say that CBT for me 15 years ago helped a lot with my bipolar. I was an eager participant - I wanted my life back. I am not sure what DD would say about this. She seems most happy when out with her homeless friends - not too many demands most of the time. Not too deep of interpersonal r/s to maintain. If this one blows up, move on to the next one.

Gotta go - family calling.

qcr  

[vivekananda]

I thought DBT was the answer... .   the DBT that I looked into was a highly structured program based on skills training in 4 modules: Core Mindfulness, Interpersonal Effectiveness, Emotional Regulation and Distress Tolerance. This course involved 2.5 hrs weekly group sessions conducted like classes with 1 hr individual sessions each week and phone coaching where relevant. This was the second stage of a 4 stage program, the 'meaty' stage. The program lasted a year and had room for subsequent follow-up.

I thought this was just what would suit the dd. She could be 'attending class' - she is an excellent student and like her mum, loves learning. The focus on mindfulness suits her predisposition for things such as meditation etc. And, I expected it to match theory with practice because she would have to understand.

But, if she didn't get a warm, positive feedback environment - she would reject it out of hand.

The T I spoke to about a DBT program seemed to be young (a plus) and almost offhand (a big minus). It was a case of if she wanted it, it was here... .   too bad if she didn't... .   my sensitive soul was offended!

I subsequently learned that in a conference in Aust, John Gunderson (MD McLean Hosp MA) said that research showed that there were common components to successful treatment - that there was:

1) structure to the treatment

2) a good therapeutic relationship

3) a long term perspective

4) a focus on emotions

5) it as based on the here and now (not rehashing the past)

My dd32 got some treatment for PTSD and that seemed to improve her wellbeing, but her view of reality is still so skewed because her BPD aspects are not getting attended to. I am happy with anything that makes her life easier - but gee I'd love to see her 'properly' in treatment. Nowadays, it wouldn't even have to be DBT! Anything that works would do!

Vivek    

[opheliasmom]

I found a great DBT therapist last year.  My 19 year old informed me that "The T wants to change me, I just want to find someone who will listen to me, you know like a friend that understands psychology."  I am proud of myself for not laughing out loud and encouraged her to continue looking if her current T wasn't working out.  You can lead a horse to water... .  

[Nrsertcht]

My now 18 yr. old dd (BPD/Bipolar/Anxiety disorder) just finished a 7 mo. long DBT program where I also attended group therapy. The local adolescent DBT program has kids attend group with a parent.

It took many months for dd to engage and she only did so after being challenged by her private DBT therapist to engage or leave the program. Only near the end of the program did dd feel the program beneficial.

Two and a a half months later, dd has decided to leave the DBT program and return to her CBT therapist she had for 3 yrs. prior to 3 hospital stays/6 months.

We shall see

[vivekananda]

good luck Nrsertcht!

Lucky you to have had a chance to do the group therapy at the same time. Pity she pulled out, but she has returned to CBT, so that's good. I am thinking things could be looking up   I hope so,

cheers,

Vivek    

[qcarolr]

How to get my DD to engage immediately with a program - for it to be availble instantly the moment she expresses interest (the very same day she wants to make an appt would be preferred) - and somehow keep her interest past 2 months, her historic limit to any activity.  The world doesn't work this way.

So my reality is that none of these programs will get DD involved and keep her involved from where she is at right now. She gave herself a brief window (2 mos) when she first returned home in Jun 2011. She did attend everything at mental health center I could get them to offer her. It was all community group stuff - like crafts, gardening -- social experience I guess. None of it fit her needs or interests. I went with her, at her request. Much of it did not fit with her learning disability.

She would not be able to do the written work. This is a limiting factor with her probation classes where she is expected to take notes. She cannot look, listen, and write at the same time. It is hard to get anyone to understand this. And it is hard for DD to even share that she needs accomadations. She has great fears of being looked at 'stupid' or 'retarded', or experiencing anything she would perceive as humiliation.

If she had a dx of Aspergers, there would be more understanding for her. She is borderline for that with the NLD (non-verbal LD). And maybe she would be more accepting of herself.

I am lost - I have nothing left to offer her right now. I have to look after myself, and then gd.

qcr  

Our objective is to better understand the struggles our child faces and to learn the skills to improve our relationship and provide a supportive environment and also improve on our own emotional responses, attitudes and effectiveness as a family leaders

[lbjnltx]

Before we can advise or guide our loved one's to undertake a certain path towards recovery it is good to know what the options are.  When we are educated in the different treatment modalities we can present well founded advice and direction.  Through the experiences we have had in the past with our loved ones and failed treatment attempts we can see how important choosing the correct kind of treatment for our child/adult child is.

My daughter's experience with outpatient dbt was not too good.  That told me that I needed to do more research and consider other options based on who my d is.  I came to the conclusion that I would not put all my eggs in one dbt therapy basket as I looked into RTC models.

Perhaps keeping in mind that DBT was developed to treat the most severe symptoms (suicidal attempts/ideation/self harm) is it the best first step for your child/adult child?

[Nrsertcht]

Speaking on my case only, dd was referred to DBT after her 3rd hospital stay in 6 months. She was at the hospital for self harm/suicidal ideation.

**Sorry for my earlier confusing post. Dd and I did finish the 7 month long DBT program and only at the end did she engage. Wish she would repeat a module or two but she's very eager to return to her CBT therapist.

Dd also sees a DMH worker in a youth transition program. Dd is 18 and she is working on skills for "growing up"-eventual living by herself.

[qcarolr]

There was an article posted on another thread about DBT being absorbed into many other CBT based therapies today. I can't find it today. I think this is a really important point. As treatments that work for some are advanced and studied in measurable clinical trials, evolution happens. This gives me hope for all of us. It also seems to me that for a truer recovery, more than just the emotional regulation aspect of BPD needs to be incorporated - a multi-focused approach perhaps. Some of the treaments discribed in this thread are working in this direction.

I have been reading several books that incorporate how our body and brain connect internally with what we can observe externally. One key thing for me is the importance for our healthy survival as humans for interpersonal connections. Relationships that are able to provide reciprocal reinforcement of that relationship for it to grow through the stuggles that are a normal part of life. However we choose to describe or define the issues for pwBPD, the systems that support this great need are impaired. The sense of self (internal focus) and identity (external focus) does not mature in a healthy progression from infancy to childhood through adolescence into adulthood. There are many factors along this path that interfere with development of the sense of ;and identity.

Some researchers are beginning to see that if we can repair this developmental process neurologically, then the other two areas will respond as well (emotional regulation and impulsivity - much stronger issues in younger pwBPD). Here is an outline of this progression of impairment of this maturation process as compiled by my knowledge surfing mind - others are scholars and researchers. Hope it makes some sense.

Child: Environmental discord that leads to lack of sense of safety: internal effects [genetics, fetal development, sensory motor processing deficits] and external effects [unavailable caregiver/attachment issues, caregiver responsiveness to internal issues - ie. child not available for care]

Adolescent: CNS (central nervous system) inactivity/imbalance [neurological structures, neuro chemicals, hormonal impacts - both reporductive hormones and adrenal hormones]

Adult:  observed actual atrophy in brain structures, particularly in the hippocampus area - much more research needed in this area to support the cause of this. Suggestion is from long term inactivity seen in adolescents.

So how can we create or use current therapies to reverse these impacts and losses that we see as BPD behaviors?

Can the adult CNS atrophy be reversed or compensated for effectively with treatments?

How to match interventions to the stage that each unique individual presents?

I think this thread is saying a great big YES to these questions.

qcr  

             

[lbjnltx]

Here is a sampling I found when I used this site to search for DBT therapists and Schema therapists in the US:  www.goodtherapy.org

Schema Therapists  130

DBT Therapists        850

Geographic availability certainly plays a role in choosing therapy models. 

There was an article posted on another thread about DBT being absorbed into many other CBT based therapies today. I can't find it today. I think this is a really important point. As treatments that work for some are advanced and studied in measurable clinical trials, evolution happens. This gives me hope for all of us. It also seems to me that for a truer recovery, more than just the emotional regulation aspect of BPD needs to be incorporated - a multi-focused approach perhaps. Some of the treaments discribed in this thread are working in this direction.

I think this thread is saying a great big YES to these questions.

Here is an interesting post:

I am a therapist who works quite a bit with DBT, Schema therapy, and mentalization, often with folks who could be described as borderline.  These are some of my impressions off the top of my head.  Sorry to not have more detail, www.pubmed.gov is a good source for current research (coupled with a friendly librarian!).

Schema therapy is an integrated therapy, that is, it integrates from other, previously existing therapies, mostly CBT, Gestalt, psychoanalytic (particularly object relations), and attachment theory.  I haven't seen research looking at six months of treatment for BPD.  I would love to see it if someone can find a reference.  Most research I've seen has looked more at 2-3 years of usually twice a week outpatient Schema therapy.  Outcomes have been among the best for BPD research.  One notable thing to my mind, drop out has been particularly low.

DBT seems to me to focus very well on skills to manage behaviors, emotions, and relationships.  I usually integrate a lot of DBT into the Schema work I do with people.  A lot of Schema therapists seem to take this approach.  I think it may be a next step in the evolution of Schema therapy.  DBT has good outcomes in research, but may not be particularly strong in helping with some of the mood problems with BPD and drop out is higher than Schema.

Mentalization Based Therapy also has very good outcomes and lower drop out than DBT.  It seems to focus a lot on building psychological mindedness in patients with BPD -- reflecting on one's own mind, emotions, motivations, etc. and those of others.  Mentalization has been used as a stand alone treatment and has been viewed as an active ingredient of other therapies.  I use it as the later.  I think Schema therapy is an excellent mentalization therapy -- it has depth and a very accessible, understandable terminology that I think helps increase patients' (and therapists'!) mentalization very well.  Peter Fonagy and his gorup are the leaders here.  (DBT, particularly with its focus on mindfulness, can also be seen as increasing mentalization.)

The Schema Therapy Institute in NYC is probably the best place for referrals for Schema therapists.  (By the way, this post is not a personal plug, I am not certified by them so they won't be giving my name.  This is just a topic close to my heart, and, it seems to others here so I wanted to share.) www.schematherapy.com

The Netherlands seems to have embraced Schema therapy as the national insurance's therapy of choice for BPD (or that's what I can gather from my limited perspective here in the US).  There is a lot of excellent Schema research and clinical growth happening there. 

The evolution of specified treatments for pwBPD may well be an integrated model of DBT and Schema.   

[lbjnltx]

National Health and Medical Research Council. Clinical Practice Guideline for the Management of Borderline Personality Disorder. Melbourne: National Health and Medical Research Council; 2012 reports these finding from Random Clinical Trials:

www.nhmrc.gov.au/_files_nhmrc/publications/attachments/mh25_borderline_personality_guideline.pdf

Managing BPD

Clinical Practice Guideline for the Management of Borderline Personality Disorder

Functions measured in the studies were:

BPD Symptoms

General Psychopathology

Anger

Depression

Anxiety

Suicidal Ideation

Self-harm and Suicide

General Functioning

Interpersonal and Social Functioning

Hospitalization



5.1.2.4 Effects of specific psychological therapies on specific outcomes

Findings of the meta-analyses for specific psychological therapies included the following:

• CBT (one trial8) was associated with significant reductions in self-harm and suicidal behaviours, compared with treatment as usual, but no significant improvements in general psychopathology, depression, anxiety, general functioning, interpersonal and social functioning, or hospitalisation rates.

• DBT was associated with overall significant improvements in anger (four trials12, 15, 75, 195), depression (two trials14, 15), anxiety (three trials12, 15, 75), and self-harm and suicidal behaviours (five trials12, 13, 15, 19,

195), general psychopathology (two trials19, 75) and general functioning (three trials19,75,195), compared with treatment as usual, but not BPD symptoms (one trial12), suicidal ideation (three trials12, 14, 15), interpersonal and social functioning (three trials19, 75, 195), or hospitalisation rates (two trials15, 19).

• DBT skills training, a modified approach based on DBT (one trial22), was associated with

significant improvements in BPD symptoms, anger, depression, and anxiety, compared with

treatment as usual, but not general psychopathology, self-harm and suicidal behaviours, or

interpersonal and social functioning.

• DDP (one trial34) was not associated with significant improvements in any outcomes included

in the meta-analysis (BPD symptoms, depression, self-harm and suicidal behaviours, general

functioning, interpersonal and social functioning), compared with community-based care that

did not use this approach.

• MACT (one trial4) was associated with significant improvements in suicidal ideation and in

self-harm and suicidal behaviour, compared with treatment as usual.

• MBT was associated with significant improvements in general psychopathology (two trials11, 27), anxiety (one trial11), self-harm and suicidal behaviour (one trial27), and hospitalisation (one trial27), compared with treatment as usual, but no significant effect on depression (two trials11,27) or interpersonal and social functioning (two trials11, 27).

• MOTR (one trial36) was associated with a significant improvement in interpersonal and social

functioning, but not general psychopathology, compared with standardised assessment not using the motive-oriented therapeutic relationship approach.

• SFP (one trial39) was associated with significant improvements in BPD symptoms, general

psychopathology, general functioning, and interpersonal and social functioning, compared with

treatment as usual based on individual psychotherapy.

• STEPPS was associated with significant improvements in BPD symptoms (two trials5, 28) general psychopathology (two trials5, 28) and general functioning (two trials5, 28), but not in depression (one trial5) or interpersonal and social functioning (two trials5, 28), compared with treatment as usual.

• TFP (one trial32) was associated with a significant reduction in BPD symptoms, but not with

improvements in other included outcomes (general psychopathology, depression, anxiety,

self-harm and suicidal behaviour, general functioning, hospitalisation rates), compared with

treatment by an experienced community psychotherapist.



Key:

CBT: cognitive–behavioural therapy; DBT: dialectical behaviour therapy; DBT ST: dialectical behaviour therapy standard treatment Skills Training; DDP: Dynamic deconstructive psychotherapy; MACT: manual-assisted cognitive therapy;

MBT: mentalisation-based therapy; MOTR: motive-oriented therapeutic relationship; SFT: schema-focused psychotherapy; STEPPS: Systems training for emotional predictability and problem solving; TFP: transference focused psychotherapy

* If a Function is not measured in a particular treatment model the study(s) did not report finding in this area



Does the information from this Guideline for Treatment change your views on treatment options?  If so, how will that impact your decisions about searching for therapists/therapy models and offering financial help for clinical support?

[somuchlove]

This is very interesting read.  You have all done a wonderful job.  Now my big question is, and maybe it was here somewhere and I missed it... .  Where do we look, where do we find, THE RIGHT person for our BPD family member.  As some have said, it has to be a pretty successful meeting from the beginning because the mind will take over and reject.  My BPD DD has been going to a counselor that is very aware of her issues.  She and her bf have been going.  However, my dd sees it all on an attack on her.  He has suggested to her seeing someone individually for each.  Of course she sees that as his not caring, on her bf sides, etc.

I feel, however she must be getting something out of it or she wouldn't go.  She has never been willing to go before.  But I think she went in hopes of finding someone that would see the world as she sees it and all the blame of everything falls on bf.

[qcarolr]

My search found one T listed under schema in the metro area.

Not enough well trained T

That take my dd Medicaid benefit

how to get her to go to more than two appt

Good to see the research based therapies getting put out there. Now to train and retrain the vast pool T's in the current research based therapies.

How long has it taken for debt to filter into general use that it is enjoying today?

Qcr

[lbjnltx]

Where do we look, where do we find, THE RIGHT person for our BPD family member.  As some have said, it has to be a pretty successful meeting from the beginning because the mind will take over and reject.

As a carer/family member to a loved one with BPD we may find ourselves in a position to offer support by providing information to our loved ones regarding therapy models and/or therapist recommendations/funding therapy.

In order to make these recommendations we must be well informed and discerning regarding the models of therapy, effectiveness, and availability. We also need to be mindful that the outcome of our children's decisions regarding therapy attendance and efforts invested are not ours to own. We can present opportunities and must let go of the outcome.

If we review the results of the Australian study we can see that certain types of therapy have different results regarding different features.  For example, the study results indicate that MBT is more affective in improvements in self harm and suicidal behaviors than DBT Skills Training.  If our children are struggling with self harm and suicidal behaviors that would be paramount to social functioning and other features of the disorder.  Keeping that in mind we could approach our search for therapy using an MBT Therapist as our search criteria.

Because availability must be factored in this will also affect the outcome of decisions.  We do the best we can with what we have to work with.  If there are therapists available who practice the type of therapy we are seeking out for our loved one it is advisable to meet with them and do an interview along side our child if they will allow.  It is up to the therapist/patient to determine if it is a good fit or not.  

Here are the professional guidelines from the Australian study:

Principles for working with people with BPD

Be respectful.

Show empathy and a caring attitude.

Be consistent and reliable.

Listen and pay attention to the person when they describe their current experience and take it seriously.

Validate the person’s current emotional state and allow the person to express strong emotions.

Maintain a non-judgmental attitude.

Stay calm.

Communicate clearly.

Express hope about the person’s capacity for change and give encouragement, but don’t give false assurances about the ease and speed of recovery.


These guidelines apply across treatment models.  Also, it is advisable that transitions are carefully guided, boundaries are set and consistent communication between carers and other health care providers takes place... .  having a case manager to oversee all is ideal.      

 My BPD DD has been going to a counselor that is very aware of her issues.  She and her bf have been going.  However, my dd sees it all on an attack on her.  He has suggested to her seeing someone individually for each.  Of course she sees that as his not caring, on her bf sides, etc.

Being aware of issues may or may not equal awareness of diagnoses nor appropriate treatment.  If the therapist is encouraging her to go into individual treatment with a BPD specialist that is a good sign.  It will be up to her to make that decision.  

I feel, however she must be getting something out of it or she wouldn't go.  She has never been willing to go before.  But I think she went in hopes of finding someone that would see the world as she sees it and all the blame of everything falls on bf.

This is indeed progress and you are most likely correct in your assumption that she is getting something out of it as she continues to go.  Any decent therapist will stay in the middle regarding blame while expressing acceptance and empathy that is needed to build trust in a safe environment.



Source: National Health and Medical Research Council. Clinical Practice Guideline for the Management of Borderline Personality Disorder. Melbourne: National Health and Medical Research Council; 2012.

[vivekananda]

Many times on the boards I read about someone's child having done DBT and it didn't work. I often wondered what sort of DBT was it? When I read this in the Aust National Guidelines, it supported what I had heard a few months earlier after John Gunnerson had visited Aust. I think this sort of info could be helpful when we want to know if a particular therapist/therapy would be helpful.

"5.1. 2. 3 Characteristics of effective psychological treatments for BPD

Effective structured therapies share the following characteristics:

• The therapy is based on an explicit and integrated theoretical approach, to which the therapist
  
  (and other members of the treatment team, if applicable) adheres, and which is shared with
  
  the person undergoing therapy.



• The therapy is provided by a trained therapist who is suitably supported and supervised 
  
  (see Section 6.8).



• The therapist pays attention to the person’s emotions.



• Therapy is focussed on achieving change.



• There is a focus on the relationship between the person receiving treatment and the clinician.



• Therapy sessions occur regularly over the planned course of treatment. At least one session
  
  per week is generally considered necessary.

Structured psychological therapies are effective when delivered as individual therapy or as group therapy.

For the psychological approaches shown to be effective in randomised clinical trials, the duration of treatment ranged from 13 weeks to several years. In clinical practice, some therapies are usually continued for substantially longer periods."

(Source: National Health and Medical Research Council. Clinical Practice Guideline for the Management of Borderline Personality Disorder. Melbourne: National Health and Medical Research Council; 2012)

I think that when we consider the 'best' treatment for our child, that we can consider not just which could have the best research backup, but, knowing our kids so well, we might believe that one form could best suit their needs than another. Also, as is pointed out above, the relationship between the T and our kid is critical.

At the moment, my dd is seeing a T for PTSD, so she would be doing some sort of CBT I expect. Now, ultimately this will not come to grips with her BPD, but she trusts this guy and the therapy is easing her anxiety symptoms. So, it isn't the end of the world. I just hope she can stick with it. I hope also that the guy recognises she has BPD and treats her for that - which may be a possibility... .  maybe... .  

Viv   

[qcarolr]

At the moment, my dd is seeing a T for PTSD, so she would be doing some sort of CBT I expect. Now, ultimately this will not come to grips with her BPD, but she trusts this guy and the therapy is easing her anxiety symptoms. So, it isn't the end of the world. I just hope she can stick with it. I hope also that the guy recognises she has BPD and treats her for that - which may be a possibility... .  maybe... .  

One step at a time. If this gives your D a sense of success in treatment and a trust connection with a T that is such an awesome step forward. The more intense treatments for BPD criteria (symptoms) can come later. Maybe she would never be open to BPD focused treatments without first dealing with the trauma. I believe the first need is to believe you are safe before any r/s can exist at more than a superifcial and temporary level.

Just my thoughts.

qcr  

Our objective is to better understand the struggles our child faces and to learn the skills to improve our relationship and provide a supportive environment and also improve on our own emotional responses, attitudes and effectiveness as a family leaders