CLINICAL GUIDELINES FOR PSYCHOTHERAPY FOR PATIENTS WITH BORDERLINE PERSONALITY DISORDER

BORDERLINE PERSONALITY DISORDER

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CLINICAL GUIDELINES FOR PSYCHOTHERAPY FOR PATIENTS WITH BORDERLINE PERSONALITY DISORDER Michael H. Stone, MD

The term borderline has been in psychiatric parlance for more than 100 years. Elsewhere, the author has traced the evolution of the term during this long span, which began with a loosely defined usage signifying “between neurotic and psychotic” (in level of severity), and changed over the years to its present connotation of extreme moodiness, 37 For approximately impulsivity, rage, and self-destructive tenden~ies.~~, 60 years, roughly from the 1920s to the publication of DSM-111,’ borderline was spoken of primarily in psychoanalytic circles, rarely in those of conventional psychiatry. The definition tightened from the imprecise descriptors of Stern,35emphasizing emotional collapse under stresses with which ordinary people could cope effectively, to the more precise but broad criteria of Kernberg,16 to the narrower and more readily objectifiable criteria of Gunderson and Singer.14When DSM-I11 incorporated borderline personality disorder (BPD) into its new Axis 11, the eight-item set was an amalgam of the definitions by Kernberg and Gunderson. The current definition in DSM-IV3is similar, except for the addition of an item (derived from Gunderson) concerning brief psychotic episodes. Because of the widespread use of the DSM, the now standard definition of BPD demarcates a typically sicker patient population than that captured by the Kernberg criteria. This relates to the fact that BPD

From the Department of Psychiatry, Columbia College of Physicians & Surgeons; and MidHudson Forensic Hospital, New York, New York

THE PSYCHIATRIC CLINICS OF NORTH AMERICA

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VOLUME 23 NUMBER 1 * MARCH 2000

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is a subset of the larger number of patients who would meet the Kernberg criteria. These patients include those with identity diffusion, adequate reality testing capacity, impulsivity, poor stress tolerance, and a poor capacity to deal with strong stresses by healthy sublimatory pursuits. Kernberg16calls this constellation Borderline Personality Organization (BPO). The DSM definition of BPD has become the standard in general psychiatry, although many in the psychoanalytic community continue to use the broad Kernberg16criteria. Most BPD patients exhibit inordinate anger, manipulative suicidal acts, and striking degrees of unreasonableness in their dealings with others (especially with intimates). A patient may lack these qualities and still meet the criteria for BPO. Patients with BPD, however, almost invariably meet the criteria for BPO. These distinctions have important clinical implications. The treatment approaches to BPD recommended in the psychoanalytic literature (as advocated by clinicians such as Deut~ch,~ SchmideKnight;* Frosch,lo Kernberg,15,l6 Waller~tein,~~ and Clarkin et a17) typically answer to a patient population that is less extravagantly selfdestructive and rageful than is the BPD population. By and large, the patients depicted in this literature presented a clinical picture similar to what Kernberg16was eventually to describe under the heading of BPO in his 1967 article, only a portion of whom mutilated themselves (e.g., wrist-cutting or burning their skin with cigarettes) or made flamboyant suicide gestures. The psychoanalytic literature focused on patients who, as a group, enjoyed better educational and socioeconomic backgrounds, on average, than did patients with BPD, who are to be found in every educational and economic level. These differences will become relevant later, when the various therapeutic approaches in contemporary usesome of which seem more effective with one group of patients with BPD than with another-are discussed. HETEROGENEITY WITHIN THE BORDERLINE POPULATION

Before the specific techniques of therapy that are in common use are discussed, clinical heterogeneity within the borderline domain must be addressed. Even within the narrower realm of BPD, let alone that of BPO, one confronts considerable heterogeneity in etiological factors, cultural factors, and clinical subtypes, all of which affect treatment strategy and necessitate different tactics tailored to the particularities of each patient with BPD. As for the etiological factors, some patients with BPD have impulsive and tempestuous personality characteristics that have developed chiefly in response to intense early traumata, especially incest. Women are much more likely to have been incest victims than are men, which accounts for much of the gender disproportion within BPD, where women may outnumber men 2:l or, in some samples, 5:1, or 6:1.3O, 39, 48 Another factor helping to account for the gender disparity is the greater

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propensity of women to depression. Depression, combined with irritability, may also create the clinical picture of BPD. In the New York State Psychiatric Institute long-term follow-up study,38 for example, many female patients with BPD who were not incest victims presented with major depression and often had strong family histories of manic-depressive spectrum illnesses. In other groups of BPD patients, genetic factors, such as those predisposing to attention-deficit hyperactivity disorder with hyperactivity, to "episodic dyscontrol" (more common in male adolescents4), or to affective disorder (such as bipolar I1 manic depression1,38), appear as the prime causative agents. Prescribing an optimal treatment plan for patients with BPD is further complicated by the admixture in most patients (almost all of those meeting DSM-IV criteria for BPD) of various symptom-disorders (i.e., Axis I comorbidity). Major affective disorder is probably the most common of these and may present as major depression or bipolar I1 manic depression. In female more than in male patients, eating disorders, including anorexia nervosa, bulimia nervosa, or alternating bouts of both, another common accompaniment. Premenstrual aggravation of symptoms (e.g., depression and irritability) is common among women with BPD.40Panic disorder, obsessive-compulsive disorder (OCD), posttraumatic stress disorder (PTSD), and dissociative disorder may also be comorbid conditions in patients with BPD, although these are encountered less commonly. Also, substance-abuse disorder is present in half or more patients with BPD and is occasionally limited to alcohol or marijuana but often involves "hard" drugs (e.g., cocaine, LSD, PCP, and heroin). For almost all of these conditions, special treatment methods are required over and above what might be considered ideal simply for the therapy of the underlying BPD. Many of these symptom-conditions represent abnormal cravings for food or drugs and are best handled by one of the various 12-step programs dedicated to each such craving, such as Alcoholics Anonymous in the case of alcoholism, Narcotics Anonymous in the case of heroin or cocaine addictions, and Overeaters Anonymous for bulimia. Programs for compulsive gambling and compulsive sex (i.e., Sexaholics Anonymous) also exist. For most of the other conditions, medications are available. For patients with BPD and with affective disorder, antidepressants, or mood stabilizers are often helpful singly or in combination. The selective serotonin reuptake inhibitors (SSRIs) have proven useful in patients with BPD with concomitant PTSD, OCD, or d e p r e s s i ~ n . ~ ~ Patients with BPD often show "impulsive aggression," which has been found amenable to SSRIS.~Female patients who experience symptom intensification around the time of the menses may respond to a variety of medications, including antidepressants, anxiolytics, and bromocryptine, that must be fitted empirically to each patient. In the same way that. BPD rarely occurs without accompanying symptom disorders, "pure" cases of BPD (or even of BPO), in which no other Axis I1 personality disorder is present, are also rare. As Oldham et alZ9demonstrated, patients with BPD may be comorbid for three or

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more other personality disorders, as listed categorically in the DSM. Because of the ”dramatic” nature of BPD, comorbid disorders are most often Cluster B disorders, which, in addition to BPD, include narcissistic, histrionic, and antisocial personality Other personality traits also can be present, including OCD and dependent, avoidant, or paranoid personality disorders. Awareness of this characterologic diversity was adumbrated in Kernberg’sI6 1967 article, in which he outlined certain common subtypes within the BPO domain, such as the ”infantile” (akin to DSMs ”histrionic”), hypomanic, paranoid, and depressive-masochistic. Patients with BPD and with depressive-masochistic characteristics enjoy a typically better prognosis than those with hypomanic or paranoid tendencies. This is true whether one is using the DSM or BPO criteria. The notion of a spectrum of BPD types was also incorporated in the schema sketched by Grinker, et all2 who spoke of As-If and Anaclitic-Depressed subtypes, among others. The Anaclitic-Depressed subtype carried the best prognosis and was nearest in general function to the otherwise higher-level Neurotic patients. In the author’s longterm follow-up study of patients with BPD,38 which centered on 299 patients with BPD, of whom 206 met DSM-I11 criteria, several patients had other personality trends, such as the Irritable / Explosive, whose outcome was poorer than those for all the other comorbid subtypes, except the Antisocial (whose outcome was, not surprisingly, the worst of all). In general, patients with BPD and with persistent anger and hostility have poor outcomes and respond less well to treatment (regardless of type) than patients with BPD who are not persistently angry, if for no other reason than that they alienate those on whom they most depend, whether relatives, intimate friends, or therapists. Clinicians should be aware of certain other patient factors, some unrelated to personality, that affect outcome and, to an extent, the choice of therapy approaches. In McGlashan’sZ8Chestnut Lodge study and the author’s PI-500 long-term follow-up studies, for example, high intelligence was a positive prognostic factor. Physical attractiveness, artistic talent, and self-discipline were also highly correlated with good longterm outcomes. Similarly, patients with BPD who had abused alcohol but who eventually enrolled in AA and remained faithful to it uniformly did well. Patients also had good self-discipline, together with high motivation to conquer their illness (an illness they were willing to acknowledge rather than deny). Self-discipline and motivation may be seen as (favorable) personality factors; the other qualities relate more to natural endowment and good luck. All of these qualities may be understood as facilitators of therapeutic efforts (whatever form these efforts may take). THERAPEUTIC APPROACHES TO BORDERLINE PERSONALITY DISORDER

Several verbal therapies are widely used in the treatment of patients with BPD. Although no one approach is universally applicable, several

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of the main techniques can be used exclusively, or almost so, with selected patients. For other patients with BPD, therapists may rely predominantly on one approach (most therapists are trained to master one particular technique during their training) but with the introduction of other methods from time to time as the occasion may demand. This admixture is most apt to be relevant with hospitalized patients with BPD whose clinical picture is especially complex, such as patients with, multiplicity of symptom disorders, frequent suicide threats, marked impulsivity, or drug-abuse disorder, for whom the continuity of treatment or the life of the patient seem constantly to hang in the balance. The main technical approaches fall into three broad categories: (1) supportive psychotherapy, (2) psychoanalytically informed psychotherapy, and (3) cognitive-behavioral psychotherapy. Each of these categories may be subclassified. Psychoanalytically informed psychotherapy, for example, embraces several approaches, such as Gunders~n’sl~ exploratory therapy, kern berg'^'^ transference-focused psychotherapy (TFP), Kohut’sZ3self-psychological therapy, and earlier techniques developed by Zet~el,~O S~hmideberg,~~ and others. Because one of the defining features of borderline psychopathology is impulsivity (it is the one trait ~ ) ,which the that is common to any and all definitions of b ~ r d e r l i n e ~for proper antidote is limit setting, all schools of thought emphasize this aspect of treatment. In his book Supportive Therapy for Borderline Patients, R o ~ k l a n dlists ~ ~limit setting as one of the important supportive interventions. Kernberg17underlines the importance of limit-setting in speaking of TFP, as does Gunderson13as part of analytically oriented therapy. In her treatise of dialectic behavior therapy (DBT), LinehanZ5stresses the importance of setting appropriate limits. Although limit-setting is intrinsically a behavioral tactic, its importance in the treatment of patients with BPD is such as to defy neat categorization in just one of the earliermentioned overarching therapy types. SUPPORTIVE INTERVENTIONS

Rockland3*mentions several supportive interventions in addition to limit setting. Supportive therapy is more directly goal-oriented than is psychoanalytic therapy. The importance of establishing a therapeutic alliance is crucial to all forms of psychotherapy. This need may be addressed within the context of supportive therapy by direct comments at the beginning of treatment, such as, “We are going to be working together, you and I, on your problems,” emphasizing to the patient that the therapist means to be supportive of the patient and is actively interested in being helpful and creating a bond with the patient by reducing the patient’s feelings of being alone and helpless. Among the other supportive interventions relevant to work with patients with BPD are contract setting (carried out at the beginning of treatment by establishing the ground rules for therapy), encouragement, giving hope and reassurance, giving suggestions and advice, being a

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“container” (as emphasized by WinnicotP7) for the strong emotional storms of the patient, environmental intervention (e.g., speaking with relatives about urgent matters or recommending a day hospital), reframing the patient’s words in a more clear or realistic fashion (akin to the clarifications of psychoanalytic therapy), giving praise where praise is due, strengthening defenses, giving intellectual interpretations (which may help shed light on some conflict but without going into ” d e p t h analysis that might be overwhelming), and supplying at times an ”inexact interpretation” (in cases in which a not-quite-accurate interpretation may nevertheless alleviate anxietyll). Although it may come under the heading of suggestions and advice, education is another important element of supportive therapy. On many occasions, patients with BPD may be somewhat ignorant of how the world works (e.g., of the need to be on time at the office, to dress appropriately for various occasions, or to forestall investment in a get-rich-quick scheme). Patients with BPD may be woefully ignorant about sexually transmitted diseases and about which behaviors are risky. In these cases, education is a necessary intervention. Supportive psychotherapy for patients with BPD is typically carried out in 1 session (the length might vary from a half hour to a full hour) each week, although two sessions in 1 week may be needed at the beginning. Given the traumatic experiences that many patients with BPD have experienced in their early years, the chaos of their contemporary life, and their fragility, a ”quick cure” is out of the question. Under ideal circumstances, therapy lasting many 5 to 10 years is required to fully stabilize these patients, regardless of the therapeutic approach that is used. COGNITIVE AND BEHAVIORAL INTERVENTIONS

Cognitive and behavioral therapies as they apply to patients with BPD make use of several underlying assumptions and strategies that distinguish these therapies from supportive and analytically oriented therapies. The general philosophy and the techniques of cognitivebehavioral therapy have been well explicated by Beck and Freeman6 in the book Cognitive Therapy of Personality Disorders. Whereas cognitive and psychoanalytic therapists feel the need to ”identify and modify core problems” (p 4), the two schools go about these tasks in different ways. Psychoanalysts see the core problems and conflicts as subconscious (and therefore not readily accessible); cognitive therapists see these problems as mostly in the realm of consciousness, and cognitive therapy is directed at bringing even more of these underlying problems into awareness. As Beck and Freeman6 point out, cognitive therapists “work at the dual levels of the symptom structure (manifest problems) and underlying schema (inferred structures)”. One’s schemas are understood as directing rule-guided behavior, including the maladaptive behavior of personalitydisordered patients.

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Several maladaptive schemata stem from childhood and typically plague patients with BPD. Beck and Freeman6 outline nine such schemata, as follows: (1) abandonment and loss (which may express themselves in the “here and now” as feelings that the patient will always be alone and unsupported by others, (2) unlovability (the feeling that ”no one would want to be close to me if they really got to know me”), (3) excessive dependence, (4)subjugation (the belief that one must acceed to the desires of others or else face abandonment), (5) mistrust (with the accompanying fear that people are poised to hurt and take advantage), (6) inadequate self-discipline (impulsivity and an inability to control oneself), (7) fear of losing emotional control, (8) guilt (the conviction of being a “ b a d person), and (9) emotional deprivation (the feeling that ”no one can ever meet my needs”). Patients with BPD, more than most patients with other personality disorders, regularly exhibit what Beck5refers to as dichotomous tkinkinga cognitive distortion in which the experiences of everyday life are assessed as either all good or all bad. Unable to understand the many shades of gray that exist between the extremes, patients with BPD habitually overreact to minor shortcomings on the part of a relative or significant other as though the ”offending” person were suddenly horrible and worthless; most good moments throughout the long past of the relationship are forgotten in the heat of an argument or disappointment. This tendency is repeated in therapy. At other moments-the good ones-patients with BPD idealize in a manner just as unrealistic as the hatred that was engendered by a negative experience. Meantime, extreme reactions give rise to extreme emotions and, often, to extreme behaviors (i.e., impulsive, destructive acts, e.g., promiscuity, binge drinking, and throwing or smashing objects), which are the hallmark of the diagnosis of BPD. The goals of cognitive-behavioral interventions are to help patients to see the shades of gray and to learn to react in a more modulated and less disruptive fashion to the negative occurrences in their day-to-day experience. In recent years, LinehanZ5has emerged as an important spokesman of this form of therapy. She devised a carefully worked-out methodology for helping patients with BPD who engage (as most of them do) in selfmutilative and in parasuicidal acts to give up these destructive tendencies, gradually, in favor of more adaptive ways of interacting with others. The interventions she proposes are described in her book, DiaIectic Behavior A manual containing guidelines for DBT is also available. DBT relies on a program involving, customarily, one session per week with the therapist, one group session per week, and as-needed telephone calls to the therapist if the patient is about to perform a selfdestructive act. Such calls are permitted only if the act has not already been carried out; the intention is to help these patients to find a more adaptive solution to their predicaments. Patients are made to understand from the beginning (part of the contract setting) that such calls are not permitted when the self-destructive act has already been performed. This plan serves as a conditioning mechanism. Self-restraint is rewarded

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(with a call to the therapist), and impulsivity is discouraged. Linehan et a P a have reported beneficial results from DBT in that DBT-treated patients have performed significantly fewer self-mutilative or parasuicidal acts over the course of 1 or 2 years compared with the number of such acts by a control group of patients with BPD given treatment as usual (a form of supportive therapy used at the site where the study is being carried out). The "treatment as usual" alluded to in the Linehan study involved significantly less time per week with the therapist. Whether the apparent superiority of DBT is a function of the technique or whether the key factor is the time spent each week with the therapist (who might have as good results using a supportive or an analytically oriented approach offering equivalently intense therapy) is unclear. Also, the long-term outcome for patients with BPD treated with DBT is unclear because long-term (10 y or more) follow-up studies focusing on the Linehan model have not been reported. If limit-setting is considered a supportive intervention, then DBT (as any effective form of therapy for patients with BPD) also partakes of tactics borrowed from the supportive approach. Ordinarily, little attention is paid to feelings of transference and countertransference within the domain of cognitive-behavioral therapy (including DBT). Linehan, nevertheless, effectively uses countertransference interpretations in her work. She gives an example concerning a woman who spoke of wanting to kill herself because of severe stress at work, implying that Linehan could not appreciate how stressful her situation was because Linehan was clearly a successful professional who was "above" such stressful experiences. Linehan replied, "Oh, but I do understand. I have to live with a similar amount of stress much of the time. You can just imagine how stressful it is for me to have a patient constantly threatening to kill herself." This kind of paradoxic response forms a part of the DBT armamentarium. Other DBT strategies are outlined elsewhere and include such interventions as the use of metaphor, playing the devil's advocate, advocating the middle path (to typical patients with BPD who react only at the extremes), and making synthesizing statements (akin to the interpretive work of the analytically oriented therapies). PSYCHOANALYTICALLY ORIENTED INTERVENTIONS

The psychoanalytically oriented approach to the psychotherapy of patients with BPD has the longest history, with respect to the literature on this subject, of all of the approaches. The many different names used to label this approach, dating back to the 1920s, are outlined elsewhere.36 The terms exploratory psy~kotkerapy,'~expressive p s y c h o t k e r ~ p y and , ~ ~ transference-focused psychotherapy7 are currently used. The similarities of these approaches much outweigh the differences. All rely on parameters (i.e., techniques that depart from the classic analytic model) such as conducting sessions with patients sitting rather than lying down; talking more readily on the part of therapists, who often make the first comment

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rather than to let a patient with BPD continue in a long silence at the beginning of a session; relying on the techniques of clarification and interpretation while focusing more on the ”here and now” rather than on early childhood; intervening more readily in the face of dangerous signs and symptoms; and taking a more active stance than is customary with better-integrated patients (functioning at what Kernberg15has called the neurotic, as opposed to the borderline, level of personality organization). Other analytic approaches to therapy for patients with BPD include the interpersonal approach, championed by Sullivan42and his successors, most notably, Searle~,3~ and the self-psychological approach, promulgated by K o h ~ t These . ~ ~ authors used definitions of borderline that are less tightly constructed than those by Kernberg or the DSM but are closer to the broad definition by Kernberg. Kohut tended to define borderline not from initial interview (as is standard in all diagnostic work) but rather from a failure on the patient’s part to respond adequately to analysis after several months of treatment. Searles’ approach is remarkable for its attention to countertransference as an index to the wardedoff emotions of patients with BPD cast into the person of the therapist (by the defense mechanism of projective identification). Case Example

A young woman with BPD was consumed with jealousy toward her older, beautiful, and emotionally healthy sister but was in denial of this jealousy. She spoke endlessly to her therapist about how handsome, attentive, and wonderful her boyfriend was, scarcely letting the therapist get a word in edgewise. This had the effect of making the therapist jealous of this supposed paragon of male virtues, who meant so much more to the patient than did her seemingly insignificant therapist. When the therapist finally identified his own jealous reaction, he recognized it as a “foreign emotion” induced in him purposely by his patient. %s in turn made it possible to broach the subject of jealousy (by a comment e.g., ”I wonder if the jealousy you make me feel in eulogizing your boyfriend has any relevance to your own life?”), whereupon the patient for the first time began to talk about the long-denied and painful subject of her jealousy concerning her much-advantaged sister.

TRANSFERENCE-FOCUSEDPSYCHOTHERAPY

The expressive psychotherapy evolved by Kernberg et all5,2o has developed still further in their most recent set of detailed guidelines for conducting this form of treatment,7 now called transference-focused psychotherapy. The foundation of TFP is in the Object-Relations theory elaborated by Kernberg15,16, 2o in many of his contributions since the mid-1960s. Patients with BPD or BPO, although able to differentiate self from others (unlike persons with psychotic organization, who fail at this task), cannot form an integrated mental picture of the self, in both its good and bad

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aspects, nor of the important other(s) in their lives. One posits a mechanism of ”splitting” as the primitive defense mechanism, which interferes with the ability to achieve realistic, integrated mental representations of self and other. Clinicians see this mechanism in operation when confronting patients with BPD who relate to others and to their therapists as all good (i.e., idealized) or all bad (i.e., devalued), hugging the attitudinal extremes, and blind to the shades of gray in relationships. Clinicians also confront the rapid attitudinal shifts of patients with BPD, such as when they suddenly vilify someone whom they were idolizing only the moment before. Unwanted, unacceptable feelings may be denied (subconsciously); disavowed (i.e., acknowledged in consciousness but not openly admitted); or, as with the jealous woman in the earlier example, projected onto someone else, such as the therapist. Recognition of this defensive scaffolding characteristic of patients with BPD helps clinicians to set the tone for the goals of therapy. TFP seeks to undo the splitting of affects such that patients come to achieve integrated views of self and others. This fosters more harmonious relationships with the important people in the patient’s life, including relatives, spouses, close friends, anri work associates, given that these are the crucial relationships that were threatened as long as the attitudinal extremes and rapid shifts of emotions dominated the patient’s life. All of these extremes and shifts soon manifest themselves in the transference situation, as the patient oscillates between idealization and contempt, love and hatred, dependence and rejection-toward the therapist. Many patients with BPD ”actualize the transference” rather than understand the transference, that is, they try to convert the professional therapistpatient relationship into a friendship, or love relationship, or antagonistic relationship from which they must flee. The therapeutic antidote to these tendencies is to help patients move from action proneness to the verbal expression of the tumultuous feelings that were pressing for (inappropriate) action. Among the inappropriate actions to which patients with BPD are prone include self-mutilation; parasuicide (as mentioned earlier in connection with DBT); sexual promiscuity (e.g., picking up strangers in bars who turn out to be abusive); alcohol and drug abuse; anorexia; bulimia; and creating tensions with therapists by not leaving when the session is over, throwing objects, canceling without notice, not paying the bill, behaving seductively, or quitting therapy prematurely. Under ideal circumstances, TFP relies on a schedule of two or three sessions per week. The therapeutic work begins by setting a meaningful contract with the patient (i.e., governing the number of meetings, how telephone calls are to be handled, and how suicidal threats and acts are to be handled). The therapist establishes priorities concerning the hierarchy of issues to be dealt with. The most pressing and potentially threatening issues are dealt with first, and the therapist keeps attuned to affects surfacing in the course of each session that are most significant. TFP encourages attention by tuning in to verbal, nonverbal (i.e., gestures), and countertransferential cues.

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As an aid to creating such a hierarchy, Linehan, in her discussion of DBT, and Kernberg, in his formulations of TFP, offer similar guidelines. Each set constitutes an algorithm that is fundamental to all forms of therapy, not just TFP or DBT. Linehan’s outline assigns first priority to suicide threats or acts (because these, if unattended, may compromise the life of the patient); next, to threats to discontinue the therapy impulsively and prematurely; third, to severe symptoms that could endanger the patient, such as drug abuse, unprotected sex, anorexia, or marked depression; fourth, to moderate or mild symptoms, such as dysthymia, premenstrual irritability, bulimia, and social phobia, that are less lifethreatening); fifth, to the various maladaptive personality traits that interfere with optimal function; and sixth, to the patient’s ambitions, hopes, and goals, sorting out which are realistic and which are not. The priorities used in TFP begin also with suicidal (or homicidal) threats. Absent such threats, the next most important issue is an overt threat to the continuity of treatment. Then, dishonesty, lying, or withholding (any of which make a mockery of the therapeutic effort) are addressed. A contract breach becomes the next issue. An example is a failure to take a prescribed medication. Next, symptomatic behavior during the sessions, such as refusing to leave when the session is over, arriving late, or behaving seductively, are addressed. Between-session acting out is the next important issue, and trivialization of the session by talking only of unimportant themes is the last issue. These last few issues pertain more directly to the analytically oriented aspects of TFP, but therapists engaged in this form of treatment are also attentive to severe and less severe symptoms that patients with BPD may present, as alluded to in the DBT algorithm. As Clarkin et a17 mention, TFP shares many features in common with most forms of psychodynamic psychotherapy, including emphasis on the stability of the frame of treatment, more active involvement than would be characteristic in work with neurotic analysands, ”containing” a patient’s hostile emotions, discouraging self-destructive behavior by confrontation, the use of interpretations that help to connect feeling and actions, limit setting, focus on the ”here and now,” and careful attention to countertransference feeli11gs.4~ In contrast to the self-psychological approach of Kohut, TFP avoids, insofar as possible, providing advice or support interventions. TFP also pays more attention to the negative transference than would be routine with the Kohutian approach. Because TFP emphasizes not only the techniques of clarification and interpretation but also of confrontation (e.g., about glaring discrepancies of professed attitudes, polar opposite assertions concerning important others, or threats to behave in selfdestructive or treatment-threatening ways), TFP differs from most other forms of psychotherapy for patients with BPD. Confrontation does not mean giving the patient the “third degree” as by a hostile cross-examining attorney. Rather, it represents a technique in which the therapist invites the patient to reexamine some conflicting statements, the paradoxic nature of which the patient had hitherto been unaware. A therapist

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might, for example, say, ”I notice that you told me in one breath that you felt as though you’d lost the most precious person on earth when your father died, yet in another breath you had mentioned he had been molesting you sexually throughout most of your early teens. I wonder whether ’precious’ is the only way in which you remember him.” Some of the important strategies of TFP, as delineated by Clarkin et al,7 include spelling out the patient’s dominant object-relationship attitudes, as they become apparent in the transference situation; analysis of role reversals as these unfold in the course of therapy; and integration of the formerly sharply polarized positive and negative images of self and others. Role reversals are characteristic in work with patients with BPD. One day, a patient may behave submissively to the therapist as though the therapist is an implacable and hostile authority. The next day, the patient may upbraid the therapist in the most withering terms, as though the patient is now the “scolding parent,” with the therapist suddenly cast into the role of the ”patient” as he or she was, years earlier, the victimized child. By helping the patient to take a step back from such vehement reenactments and to understand the nature and, ultimately, the sources of such role reversals and other displays of uncontrolled emotion, the TFP therapist fosters the integrative process that is the linchpin of successful treatment. This paves the way toward more modulated and harmonious relationships-a crucial step in the recovery process of patients with BPD, in view of their exquisite sensitivity to feelings of being alone or abandoned. GROUPPSYCHOTHERAPY

Various forms of group therapy are widely practiced as part of the treatment program for patients with BPD. Often, group therapy is advocated as an important supplement to a program that includes individual psychotherapy (usually one of the approaches outlined earlier) and, especially in the early phases, when Axis I1 symptoms are 41 Group therapy may be congenerally prominent, pharma~otherapy.~~, ducted along supportive, cognitive-behavioral (as in DBT), or expressive lines. The latter is often used within the context of TFP or other analytically oriented approaches. In the expressive groups, the focus is usually on the dominant affects that pervade the group as a whole, rather than on just one patient. The first (or most vocal) patient to speak in the group can often be understood as being (without at first realizing it) the ”spokesman” for these dominant affects that also engulf the as-yet silent members of the group. In this way, feelings of resentment (e.g., of a new member), envy, rejection, or loss and abandonment (e.g., if the therapist will be leaving for some time) all become grist for the expressive and analytic mill. Although the author’s preference is to work with groups of diagnostic homogeneiety (e.g., all BPD), not all clinicians share this view. In the author’s experience, mixtures of BPD and schizophrenic patients in a group works to the detriment of the less well-functioning

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schizophrenic patients. Also, mixtures of BPD and neurotic patients may put the less well-functioning patients with BPD at a disadvantage. Some clinicians whose primary professional identify is as group psychotherapist work with patients with BPD in this context only, omitting individual therapy. In addition to the various 12-step programs mentioned earlier are incest-survivor groups geared to patients (almost always women) with BPD who had endured incest experiences in their early years. These groups may be of therapeutic value in diminishing the shame that often haunts incest victims, as though each was utterly alone in having experienced incest and as though each had “willed,” and thus been responsible for, the patient’s victimization. COMMENTS

Many decades and voluminous literature have been spent in attempting to determine which form of psychotherapy is best for patients with BPD. Debate between competing philosophies has often been acrimonious, partly because the heterogeneity of other personality types and symptom disorders in any large sample of patients with BPD renders the design and implementation of rigorous, controlled studies next to impossible (or impossible, if one considers cost). This is not to say that controlled studies of drug-efficacy or of short-term effects of psychotherapy on discrete symptoms, such as self-cutting, are impossible to perform. Linehan et a126have shown that DBT can reduce self-cutting and parasuicidal acts in patients with BPD over the course of 1 or 2 years more successfully than can supportive ”treatment as usual.” Controlled studies, however, comparing DBT with supportive or analytical therapy of similar intensity have not been conducted. In work thus far with patients with BPD treated by Kernberg’s colleagues at New York Hospital’s Personality Disorder Institute, the incidence of self-cutting and parasuicidal acts decreased over 1 year to levels similar to what Linehan et a126reported (P. Foelsch, unpublished observations, 1999). The New York Hospital study did not include a control group treated with an alternative approach. Ideally, the TFP approach should be studied using a randomized method, in which a similar group of patients with BPD are treated with DBT or a supportive therapy. The comparison should not be limited to a focus merely on the number of self-damaging acts before and after treatment (probably any intensive approach would enable BPD patients to harm themselves less often). A more genuine comparison of psychotherapies would be gained only by long-term follow-up (i.e., 2 5 y), but such an endeavor would be painstaking and costly. The elimination of self-destructive acts is obviously a crucial first step in the treatment of patients with BPD, but to assume that even such symptom amelioration constitutes a ”cure” is quixotic. Most patients with BPD, for example, have experienced traumata-often repeated and

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of multiple types-the effects of which have been to derail grossly the course of early development, conducing to stormy, sadomasochistic relationships and to a distorted and embittered view of life and its possibilities. These malformations of habit and thought are not overturned in a day. Long-term follow-up, ideally of prospective design, of 10 to 20 years is necessary just to understand the natural history of the personality of patients with BPD. In such long intervals, however, sufficient intervening variables confound the attempts to find compelling answers about the optimal form of therapy. In the present state of our knowledge, the author finds it realistic to address the question, Which form of psychotherapy, conducted by therapists of which orientation, is optimal for which subtypes and varieties of borderline patients? Some tentative answers are already available. Frances (personal communication, 1993) speaking impressionistically, suggested that “therapists of average skills, working with average borderline patients-would best serve their patients with a supportive approach; talented and highly motivated patients can benefit from an expressive therapy carried out by talented therapists who have been well trained in that school.” Independent of the training and orientation of the therapists available to any given patient with BPD, a large proportion of such patients (including those with BPD by latest DSM criteria) could reasonably be well handled by a therapist competent in supportive, cognitivebehavioral, or analytical therapy, but a “remainder” group of patients would flourish best under the guidance of a therapist skilled in only one of these approaches. To forecast which approach would be ideal for each patient in this group would not be easy. The answer will depend on variables such as a patient’s educational and socioeconomic level and cultural background. Even the generational issue may become important. At times, the author has been referred patients with BPD who, for example, belong to the generation of the 1950s or 1960s, when psychoanalysis was king, and who insist on analytic therapy (this having the greatest cachet in their family and community) despite not having an idea of the psychological mindedness or motivation necessary to use this therapy. The author’s efforts to carry out a more cognitive approach, which seemed more compatible with their mindset, met with scornful rebukes that ”this isn’t analysis.” Conversely, some patients with BPD with good psychological mindedness and motivation, although seemingly ideal candidates for TFP, were eager for a ”quick cure” in the form of hypnosis or some other unconventional (with respect to BPD) modality. The issue of consistent applicability also needs to be addressed. Although many patients with BPD can improve gratifyingly within the context of one approach used consistently throughout the length and breadth of their treatment, there are many exceptions to this puristic model. Gunders~n’~ and Waldinger and G ~ n d e r s o nhave ~ ~ written about the need of many patients with BPD (especially those in residential treatment) to have several months of largely supportive treatment before exploratory therapy can productively be undertaken.

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In moments of crisis, which crop up frequently in the lives of most patients with BPD (especially during the 1 or 2 y of treatment), supportive measures are often in order, no matter what a therapist’s preferred orientation may have been. Deaths of, or rejections by, loved ones; serious accidents; job loss; illness in the patient or family; and prolonged separation from the therapist all may call for brief supportive interventions. Also, supportive ”interlude,” by furthering some goal of the therapy, may be desirable. Case Example

A married woman with two small children presented a clinical picture of BPD, together with major depression and dissociative tendencies. She had made a recent suicide attempt requiring a brief hospitalization. Generally feeling hopeless, as though ”marking time” until her death relieved her of her burdens (most notably, her two unusually difficult children), she nevertheless urged her therapist to visit her home, ostensibly to get a first-hand view of how unruly and disruptive the chldren were. The therapist made the home visit-the only time he had done so in 33 years of practice. While at her home, he discovered (besides the two unruly children) impressive art objects scattered everywhere throughout the house, all of which had been fashioned by the patient some years ago. She had never mentioned her talents to the therapist and had abandoned them in response to criticisms from her relatives about the ”mediocrity” of her work. The therapist expressed his admiration and, convinced it would enhance her will to live, urged her to resume her creative efforts. These obviously supportive measures proved to be a turning point in her treatment. The patient went back to her artwork and did so with such good results as to win acclaim from several outside observers. Their praise had the paradoxic (although all too typical for patients with BPD) effect of making her feel acutely ill-at-ease, as though she could not live up to people’s expectations. Her “success avoidance” then became an important theme in the otherwise primarily transferencefocused nature of the therapeutic work.

Some evidence suggesting that clinicians cannot make firm pronouncements stating that a patient BPD could improve only with one particular approach has already begun to accumulate. Wallerstein,& in his comprehensive report on 42 patients from the Menninger Study,1g mentioned that patients with BPD (diagnosed before the DSM-I11 era) had been earmarked for expressive therapy but that many had improved substantially at long-term follow-up, whether their treatment had been, in retrospect, mostly supportive or mostly expressive. A similar finding emerged in the author’s long term follow-up study, based on a much larger number of patients with BPD38treated at the New York State Psychiatric Institute (i.e., the PI500 study). Most of the patients in these studies, as in McGlashan’s Chestnut Lodge studp2*were from middleclass or upper-class families and enjoyed educational advantages. Even with this socioeconomic status and educational background, a hierarchy can be established among patients with BPD, concerning their amenability to analytically oriented therapy. In his classic 1967 article, KornbergI6 wrote that, other factors being equal, BPO patients with otherwise

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depressive-masochistic (akin to Grinker’s anaclitic-depressed group or DSMs dysthymia patients) and infantile (akin to DSMs histrionic personality disorder) personalities usually fared better with expressive therapy than did those whose other personality features were largely paranoid, hypomanic, or antisocial. These impressions were borne out in the author’s PI500 study also. Patients exhibiting BPD who come from educationally and socioeconomically disadvantaged backgrounds and who cannot afford private care tend to come from families that had been abusive; their level of impulsivity and the chaos of their daily lives exceeds that of their better-off counterparts. Amenability to the analytic modes of psychotherapy is often lacking, as are the time and resources to come for sessions with the optimal frequency. Patients with BPD from severely destructive and chaotic families are more prone to develop dissociative phenomena (sometimes with the distinct ”alters” of multiple personality disorder but more often with other stigmata that fall short of ”alters”), as described by K1uft,21 or the symptoms of PTSD, as who was impressed by the co-occurrence of BPD highlighted by K1-011,~~ and PTSD as though they might be two sides of the same coin. The degree of comorbidity in these situations is highly sample dependent, but in certain groups of BPD patients, such comorbidity exists, and when it does, special treatment interventions, usually of supportive and psychopharmacologic, are necessary. The use of SSRIs, such as fluoxetine, has proven of value in ameliorating the symptoms of traumatized persons, including those with BPD who have developed PTSD,43,44 In an earlier article, the autho1.38discussed a pragmatic approach to patients with BPD, acknowledging the roles of analytically oriented, behavioral, cognitive, and drug modalities (“A, B, C, and D ) as equaling “E-the eclectic treatment of this patient group. These modalities remain the important ingredients of the therapeutic armamentarium. Whether optimal treatment of a patient with BPD can be confined to just one of the verbal approaches and whether a patient’s needs would be better served by a judicious admixture of approaches, in accordance with the shifting circumstances of the patient’s life, is a matter of clinical judgment and a function of each therapist’s primary orientation. Absent the elusive controlled studies that might provide scientifically more respectable answers, clinicians must make do with expert opinion and clinical experience, which requires juggling the important variablescomorbid personality disorders and traits; accompanying symptoms; cultural, socioeconomic, and educational factors; cognitive style; motivation; and perseverance-relevant to each patient. The complexity of the clinical picture in BPD, especially in patients with the poorest function and severest symptoms, can only in selected cases be encompassed by TFP or DBT alone. Periodic consultations with psychopharmacologists and other specialists is often necessary, at least in the early stages. The therapy of patients with BPD remains one of the most challenging assignments. Clinicians try to make their treatment as scientific as possible, but the room for art is generous.

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