Psychotherapy and Borderline Personality Disorder

Psychotherapy is widely regarded as the primary form of treatment for Borderline Personality Disorder (BPD), and has been indicated as such in practice guidelines (Gunderson, 2011; NCCMH, 2009; Oldham et al., 2001). The implementation of psychotherapy in the treatment of BPD has received considerable research attention in recent times. Leichsenring and colleagues (2011) identified 24 randomized controlled trials (RCT) examining psychotherapy for BPD.

A number of labels have been given to distinguish among the array of therapies that have been studied in RCTs. In general, however, these therapies may be broadly characterized as either cognitive-behavioural or psychodynamic. To some extent this distinction is largely a heuristic one – a matter of emphasis – as most treatments incorporate elements from different approaches. These treatments are all structured and guided by treatment manuals.

Cognitive-behavioural approaches to BPD include Dialectical Behaviour Therapy (DBT) and Schema-Focused Therapy (SFT). Psychodynamic approaches include Mentalization-Based Treatment (MBT) and Transference-Focused Psychotherapy (TFP). Although several therapies have been found to be more effective than treatment-as-usual, there is no evidence to suggest that either CBT or psychodynamic therapies are superior to the other. Indeed, the evidence to date suggests roughly equivalent outcomes between these different approaches. Consequently, a major question confronting researchers in this field is whether common factors among these approaches are responsible for therapeutic outcome (See section on Common Features), or whether different mechanisms between these approaches are operating along different therapeutic pathways, with equivalent results (See section on Change Mechanisms).

Clinicians seeking to provide an empirically-supported treatment for BPD will likely be confronted by more practical questions. One such question is the degree to which a treatment follows the protocol studied in clinical trials. Most of the treatments in RCTs for BPD involve two to three hours per week of patient contact, over a period of one or more years, and with ongoing weekly supervision. Therapy is often delivered in a combined group therapy and individual therapy format, with provisions for between-session emergency contact. In settings where such resources do not exist, clinicians may be faced with implementing a less-intensive version of an empirically-supported approach. There is some limited research support for this: one recent trial found that BPD patients receiving once-weekly psychodynamic therapy plus medication management achieved equivalent outcomes as did those who were treated with the more intensive dialectical behaviour therapy (McMain et al., 2009). However, clinicians should be cautious in expecting the same pace of change in a treatment offered less-adherently or less-intensively than the treatments examined in RCTs. Furthermore, the outcomes reported in RCTs typically involve measures of symptom severity concerning self-harm and suicidality, rather than recovery from BPD itself. Most treatment developers and expert clinicians acknowledge that a longer course of therapy – beyond the one year duration typical of RCT studies – is likely required to achieve other psychosocial recovery indicators.