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THE PSYCHOLOGY OF PERSONALITY DISORDERS
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Author Topic: BPD: Treatments, Cures, and Recovery  (Read 57296 times)
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« on: June 23, 2008, 09:29:57 AM »

Borderline Personality Disorder - Treatment and Cures

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

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

  • What works?


  • How does it work?


  • What is the role of the family member?


  • What is 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 is 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 need 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 expereinces of the membership on this subject.

Skippy
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« Reply #1 on: June 23, 2008, 09:53:19 AM »

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]. More information is posted here
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« Reply #2 on: December 29, 2008, 10:00:53 PM »

One thing you might want to keep in mind is that all the research on treatments showing improvements have been done on low functioning, inward acting BPs who primary issues are staying alive and not hurting themselves--especially DBT. They all require a major commitent on the part of the patient.We don't really have any research on any other types of patients. Randi Kreger
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« Reply #3 on: January 05, 2009, 01:35:07 PM »

One thing you might want to keep in mind is that all the research on treatments showing improvements have been done on low functioning, inward acting BPs who primary issues are staying alive and not hurting themselves--especially DBT. They all require a major commitent on the part of the patient.

We don't really have any research on any other types of patients.

This makes me wonder ... especially because high functioning BPDs often are not even diagnosed as BPD but as something else, for reasons of insurance, increased compliance from the patient, stigma avoidance, etc.

Sounds like it would be quite difficult to do effective studies of treatments for high-functioning BPDs.
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« Reply #4 on: March 28, 2009, 03:42:13 PM »

One thing you might want to keep in mind is that all the research on treatments showing improvements have been done on low functioning, inward acting BPs who primary issues are staying alive and not hurting themselves--especially DBT. They all require a major commitent on the part of the patient.

We don't really have any research on any other types of patients.

This makes me wonder ... especially because high functioning BPDs often are not even diagnosed as BPD but as something else, for reasons of insurance, increased compliance from the patient, stigma avoidance, etc.

Sounds like it would be quite difficult to do effective studies of treatments for high-functioning BPDs.

Linehan's DBT research has been replicated and expanded upon since the first publication... so though it might not be as plentiful as the original validating studies, I'd say that just about every group and sub-type of borderline individual has been studied under this type of treatment.  Within the last few years, it's even been modified for children and adolescents.

I think the biggest issue with treatment of the highest functioning borderlines would be the fact that they aren't seeking treatment.  If they are truly high functioning, they won't be forced into treatment by circumstances that typically lead people to seek help with their symptoms.  They play "well" with others...  get it, double meaning... "well" as in "healthy" and "well" as in "get along gang happy." 

I would think it would be a reasonable leap to generalize results of the components of the treatments to the high funct BPD's.  All treatment modalities are interconnected and either build upon previous theory or have theories shooting forth from it.  While the beginning research for methods like DBT did focus on individuals with overt borderline behaviors and past history of serious symptoms, the theories and related treatments have been researched on multiple populations of individuals with varying symptomology.

Some of the aspects, like mindfulness in DBT, have been around for millenia.  More time tested than empiracally so... but definitely the exposure to multiple levels of pathology and functioning exist and the method still persists as reliable... if only through folklore and tradition until disproven by data. 

My personal belief is that the lines are so blurry between diagnoses and criteria that research on populations/diagnostic categories isn't as effective as research on symptoms/behaviors.  Of course, there are hundreds of scientists with decades of experience who would slap me in the face for taking such a stand.  I'm just a fraction fan and always try to find that least common denominator and start from there...
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« Reply #5 on: December 11, 2009, 01:02:19 PM »

 I just saw an article in a local paper about Schema therapy being 60% effective in people with BPD within 6 months. Sounds too good to be true. Can someone explain the difference between DBT and Schema and is one more effective that the other?

thanks,

Morgause
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« Reply #6 on: February 10, 2010, 11:35:53 AM »

You know, as much as this is interesting, you'd be hard pressed to find schema therapy anywhere local. It's only being offered in NYT, as far as I know.If I had to say the difference in a nutshell, I would say that schema has the focus on skills like DBT, but with much more of an emphasis on psychotherapy to the point where the therapist helps nurture the patient. I think that makes a lot of sense. 
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« Reply #7 on: February 10, 2010, 12:11:48 PM »

Here is a link that can be used to search for therapists by therapy type:

www.goodtherapy.org/find

It's not a huge database.  For Philadelphia, it lists 23 therapists (all types) of which 3 are DBT therapists listed, 2 are Schema therapists.

In Chicago,  4 DBT therapists listed, 1 Schema. In San Francisco, 10 DBT therapists listed, 2 Schema.
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« Reply #8 on: February 10, 2010, 01:40:42 PM »

You know, as much as this is interesting, you'd be hard pressed to find schema therapy anywhere local. It's only being offered in NYT, as far as I know.

If I had to say the difference in a nutshell, I would say that schema has the focus on skills like DBT, but with much more of an emphasis on psychotherapy to the point where the therapist helps nurture the patient. I think that makes a lot of sense. 


Randi Kreger

Author, "The Essential Family Guide to Borderline Personality Disorder "

Thanks for the answer. I live in Netherlands where for some reason there seems to be large number of people with BPD despite the small population. Therapy is covered under most insurance policies, and they seem to favor Schema therapy for BPD over DBT here. Is it true that Schema therapy is more effective and recovery is faster? I was a bit skeptical of the 6 month recovery prognosis myself..(in a study done by the Vrije Universiteit Medisch Centrum) But it was written in a top newspaper (NRC)

If schema therapy is so effective, why aren't more BPD treated by it instead of DBT?
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« Reply #9 on: February 11, 2010, 11:27:03 AM »

You know, as much as this is interesting, you'd be hard pressed to find schema therapy anywhere local. It's only being offered in NYT, as far as I know.If I had to say the difference in a nutshell, I would say that schema has the focus on skills like DBT, but with much more of an emphasis on psychotherapy to the point where the therapist helps nurture the patient. I think that makes a lot of sense. 

Thanks for the answer. I live in Netherlands where for some reason there seems to be large number of people with BPD despite the small population. Therapy is covered under most insurance policies, and they seem to favor Schema therapy for BPD over DBT here. Is it true that Schema therapy is more effective and recovery is faster? I was a bit skeptical of the 6 month recovery prognosis myself..(in a study done by the Vrije Universiteit Medisch Centrum) But it was written in a top newspaper (NRC) If schema therapy is so effective, why aren't more BPD treated by it instead of DBT?

Right now there is a lot of competition between various researchers as to see whose therapy is more effective, nanny nanny na na na, "MY therapy is better than YOUR therapy, so there!" I am reading through the lined about this, but that is generally how things go. There are other therapies such as transference focused therapy (www.borderline-personality.suite101.com/article.cfm/transferencefocused_psychotherapy) and mentalization (www.BPD.about.com/od/treatments/a/mentalize.htm) and I think it's fair to say that everyone wants a piece of the pie. Studies showing effectiveness are necessary to getting reinbursed, which is why these studies are so critical. My personal belief was borne out by this study: Highly Structured Therapies Prove Their Efficacy in BPD                         Any structured, symptom-focused treatment for borderline personality disorder is likely to be better than the unstructured care patients typically get in the community. www.pn.psychiatryonline.org/content/45/2/22.1.fullI think it's kind of obvious that therapists who are specially treated and focus in on BPD and take an interest in this population and their special needs are going to be better. But DBT takes the cake right now simply because it's been around the longest--Marsha Linehan published her seminal text and workbook in 1993 and it has a big head start at providing training. Take a look at Behavioraltech.com. Her courses and products are very expensive. It takes a great deal of money to train clinicians in new techniques and put new programs in clinical settings. I don't remember which therapy in the Netherlands is available. But whatever it is, it's going to better than treatment as usual IF your BP is a good match for what they offer. Remember they're all focused on the lower-functioning conventional BP.
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