Other Psychodynamic Therapies for Borderline Personality Disorder
Supportive psychotherapy is likely one of the most widely practiced therapies, yet it is commonly misunderstood as consisting simply of an encouraging form of active listening. Supportive psychotherapy, however, is a conceptually coherent treatment that draws heavily on psychodynamic principles and a hierarchy of specific interventions (Werman, 1984). The goal of supportive therapy is largely similar to that of other psychodynamic approaches: to promote optimal personality functioning in the face of stresses to the patient’s capacity for affective and self regulation. Supportive therapy handles this task differently from more exploratory approaches. One of the most distinguishing features of supportive therapy is its de-emphasis on transference elaboration and interpretation (in contrast to traditional insight-oriented psychoanalytic therapy). In supportive treatment, the therapist must maintain a thorough awareness of transference and countertransference dynamics, whilst largely avoiding the verbal interpretation of these issues (Werman, 1984). The theory of supportive psychotherapy has been developed into a specific approach for Borderline Personality Disorder (BPD; Rockland, 1992). This approach focuses on encouraging the transformation of behavioural acting out into the verbalization of psychological conflicts, and the development of adaptive outlets for emotional expression. To this end, the patient’s identification with the therapist’s helpful stance is fostered and limited advice and environmental interventions are utilized when necessary.
The only randomized clinical trial (RCT) involving supportive psychotherapy for BPD consisted of its use as a comparison treatment in the study of Trasnference-Focused Psychotherapy (TFP) and Dialectical Behavior Therapy (DBT; Clarkin, Levy, Lenzenweger, & Kernberg, 2007). The supportive psychotherapy condition was based on Rockland’s (1992) supportive therapy for BPD. In this trial, patients in the supportive therapy condition experienced improvements across a number of outcome domains. Several of these, such as depression, anxiety, and social and global functioning, were equivalent with the TFP and DBT treatments. Supportive therapy was not associated with improvement in suicidality, but was associated with improvement in anger and impulsivity.
General Psychodynamic Psychotherapy
Although psychodynamic psychotherapy has been packaged into specific treatment packages such as TFP and Mentalization-Based Treatent (MBT), a more generic and integrative version has a long tradition in general psychiatric practice, and in the care of patients with BPD. Indeed, the American Psychiatric Association includes psychodynamic psychotherapy in its Practice Guideline for the Treatment of Patients with BPD (APA, 2001). This version of dynamic psychotherapy involves the use of transference interpretations – particularly concerning resistance and negative transference – along with several other forms of intervention. Treatment priorities include management of suicidality, a focus on emotions, and the transformation of acting out into expression and reflection. Supportive principles are also central to the treatment, including the provision of empathy and validation, and attention to here-and-now problems. The APA guidelines integrate psychodynamic therapy into an overall care protocol that includes the adjunctive use of medications for particular symptom management, as well as limited hospitalization and crisis intervention where necessary.
This common-practice form of psychodynamic therapy was recently examined in a large (N = 180) RCT where it served as the primary intervention in the treatment condition known as general psychiatric management (McMain et al. 2009). In this trial, general psychiatric management was a manualized version of the APA Practice Guidelines, drawing upon Gunderson’s (2001) development of psychodynamic therapy for BPD, which emphasizes the pathogenic effects of early attachment disturbances. General psychiatric management was the comparison treatment against DBT, which was expected to produce superior outcomes. Outcomes across a range of measures were equivalent after one year of treatment. The performance of psychodynamically-informed treatment in this trial is all the more noteworthy when patient-therapist contact hours are taken into account. Patients in the DBT condition received one hour of individual therapy per week, two hours of telephone coaching per week, and two hours of group-based skills training per week. Patients receiving general psychiatric management were seen for one hour per week for individual psychotherapy and medication management. This finding suggests that a less-intensive, non-brand-name approach – perhaps more routinely available in community settings – can be effective for patients with BPD when implemented by psychodynamically-informed clinicians.