The Emergence of a Generalist Model to Meet Public Health Needs for Patients With Borderline Personality Disorder
“Kevin,” a 17-year-old high school student, was brought to the emergency department by his distraught mother for having threatened to stab himself. The mother gave a history of Kevin’s cutting himself repeatedly since age 13, with a 2-year hiatus when he had his first and only girlfriend, a relationship that had ended 6 months earlier. Since then, Kevin’s alcohol use increased, seemingly unprovoked rages led to his suspension from his school’s hockey team, and he had periods of depression during which he cut himself and said he felt like he was unreal. Two months earlier, at his mother’s urging, he had seen their primary care physician, who diagnosed depression and started him on a selective serotonin reuptake inhibitor (SSRI). He became more socially withdrawn and remained easily angered, and his school functioning declined. After he told his physician that he had contemplated suicide, the physician increased his SSRI dosage. In the emergency department, Kevin looked distracted and irritated, compulsively stroking a cloth bracelet while his mother gave this history, but he seemed to relax and welcome talking when seen by the emergency department psychiatrist. When asked about the bracelet, he said it was a residual talisman of good luck made from his childhood pillow. When asked about the threat to stab himself, he said this only occurred because his stepfather had criticized him for being rude. When the psychiatrist commented that he must have been angry, Kevin looked confused and said, “Yeah, I suppose.”
The psychiatrist made the diagnoses of major depression, alcohol abuse, and borderline personality disorder. He prescribed another antidepressant to augment the SSRI, but said that borderline personality disorder would probably need to be treated by a specialist. After efforts to find him a dialectical behavior therapist failed (the emergency department psychiatrist was not aware of other evidence-based treatments for borderline personality disorder), Kevin was referred to a psychiatrist, Dr. A, who, although not a specialist, was notable for his being willing to “take on” borderline patients.
Course of Treatment
Dr. A agreed to see Kevin, but after reinforcing the emergency psychiatrist’s message about alcohol abuse, insisted that the parents would be involved. In an initial meeting, he reviewed the DSM-5 criteria for borderline personality disorder with Kevin and his mother. He told them that it had a significant heritable disposition that interacted with environmental adversities. Kevin interrupted this to describe how his parents had failed him (his stepfather’s cruelty, his mother’s wimpiness, and so on). In response, Dr. A said, “Although you may be correct, the genetics of your disorder makes it likely that your sensitivities made you a difficult child who challenged your parents’ capacities to respond optimally.” Dr. A went on to say that about 20% of patients with borderline personality disorder remit by 1 year, 45% in 2 years, and 85% by 10 years, and that once remitted, they usually remain so. But, he warned, reduction of symptoms was often not associated with attaining good work and stable partnerships; he said that these are what he hoped Kevin had as goals, because that is what his were. Kevin did.
Kevin began meeting with Dr. A once a week. He talked about his anger at his parents, especially his stepfather, whose efforts to discipline him were much resented. Dr. A expressed sympathy for this, but redirected Kevin’s attention to his more recent problems, namely, his lost girlfriend. Exploration revealed that the relationship had unraveled because she objected to how possessive Kevin was and how hostile he had become toward her other relationships. Dr. A said that placing so much hope on one relationship was unwise and bound to fail. Dr. A urged Kevin to devote his attention to school and attempt to regain friendships with members of his hockey team who didn’t drink. This proved difficult. When he encountered persisting resentments from his behaviors before being suspended, he again cut himself. His mother took him back to the emergency department, where the attending physician called Dr. A. He spoke with Kevin, saying, “I wish you hadn’t done that. If you get that upset again, I wish you’d call me.” Kevin seemed relieved and even a bit surprised by this response. He later said, “I thought you’d be angry and tell me it was stupid.”
In the months that followed, they experimented with decreasing the dosage of one of the SSRIs, and eventually Kevin was weaned from it altogether. With modest improvements in his introspection, his studies, and his trust in Dr. A, Kevin graduated from high school, although without distinction. He was invited to help teach hockey to youngsters that summer, and after initial doubts about his hockey skills and about leaving home, he accepted the offer. He did well in this role, and his schedule of appointments with Dr. A largely became “as-needed,” “touching base” by telephone.
Kevin started commuting to the local community college in the fall, and he continued to see Dr. A intermittently. Dr. A encouraged him to taper off his other SSRI, which Kevin resisted. In December, Kevin’s mother called to report that Kevin was reinvolving himself with a girl in the same preoccupied jealous way as he had done previously. Dr. A suggested that she come with Kevin to an appointment the next day. Kevin was enraged by his mother’s call and her “intrusiveness into his private life.” Still, he did come to the appointment, but not with his mother.
Dr. A began by saying, “I share your mother’s worries about the relationship you are forming with your new girlfriend,” and, after inquiring about Kevin’s perspective, kindly but firmly told him that in his opinion, hockey and school still needed to be his primary investment. “Given your borderline personality disorder condition,” Dr. A said, “you will be unlikely to attain a successful romantic partnership unless you have established other sources of self-esteem, social supports, and satisfying work.” He asked Kevin to think about this and suggested that they resume regular meetings. Kevin got very angry at this, bitterly accusing Dr. A of underestimating him and of wanting him “to be alone forever.” Dr. A said he was sorry to disappoint him as Kevin stormed out.
Not long afterward, the girl initiated a relationship with another student, after which Kevin felt “toxic” and cut himself superficially; he told no one, but he did resume seeing Dr. A. During that school year, he talked with great shame and anxiety about his father’s disappearance from his life at age 7 after having been discovered exposing himself to young girls. During this process, he became more charitable in responding to his stepfather’s efforts to father him. After his freshman year, he returned to his summer hockey teaching role. His visits to Dr. A again became “as needed.” As a college sophomore, he decided to major in education. When he ran out of his SSRI as a junior, he felt dysphoric and anxious, but with Dr. A’s support, he stayed off. About this time, he also stopped wearing his worn-down cloth bracelet: “I just decided to do it.” During his last 2 years at college, he had a few short-term romances, during which he turned to Dr. A for coaching. His visits to Dr. A became increasingly infrequent, and he once remarked that he had become somewhat ashamed about his earlier psychiatric problems and felt that such visits were unwelcome reminders. Dr. A nodded supportively, but felt a bit hurt. In the year after graduation, Kevin brought his fiancée, another junior high school teacher, to meet Dr. A. As they ended the appointment, Dr. A felt both very proud of Kevin but sad to be losing this very rewarding patient. He noted to himself that these reactions were similar to those he’d felt when his own children had successfully moved on into their adulthood.
The treatment of patients with borderline personality disorder poses a major public health issue. This patient group accounts for about 2% of the population (1, 2), 15%−20% of psychiatric hospital and clinic admissions (3, 4), 10%−15% of emergency department visits (5, 6), and about 6% of primary care visits (7). The far higher indirect costs associated with the disorder include high rates of failed work, marriages, and child-rearing, as well as high rates of medical problems (6, 8–11). Addressing these issues requires a large complement of competent providers.
Before evidence-based treatments were available, the primary model for treating patients with borderline personality disorder began with two papers written by Otto Kernberg in 1967 and 1968 (12, 13). He proposed the use of psychoanalytic therapies, which at that time typically involved three or more sessions a week. His contributions inspired a large psychoanalytic literature and encouraged a generation of psychodynamically trained clinicians to undertake long-term intensive therapies with borderline patients; during the next 15 years, more than 50 books were published on the disorder. This literature primarily documented only the array of difficulties encountered. It proved very difficult to find successful cases (14). Altogether this literature offered little reason to undertake a randomized controlled trial and largely served to reinforce the persisting stigma of how intractable this patient population is.
In this article, I describe the development of the three major empirically validated forms of treatment for borderline personality disorder, the problems they exposed, and how, after a second generation of outcome research, a generalist treatment model emerged. This model shows that nonspecialist psychiatrists and other professionals can provide effective care, which helps address the need for more clinicians to treat patients with the disorder. The vignette illustrates the practice within this model and highlights the practicality and user-friendliness of this approach for psychiatrists as well as other mental health professionals.
Evidence-Based Treatments: the “Big Three”
The second major wave of interest in treating borderline personality disorder began in 1993 when Marsha Linehan introduced dialectical behavior therapy (15). Dialectical behavior therapy was a radically different model of therapy, whose effectiveness was demonstrated by dramatic improvements compared with usual care (Table 1). This model combines once-weekly individual with weekly group therapy. It was far more supportive and didactic than the psychoanalytic model. Linehan’s model has continued to gain empirical support (with 13 confirmatory randomized controlled trials) and has become widely accepted as the standard-bearer for treatment of borderline personality disorder (16). In the recent revision of her manual, Linehan now details applications of dialectical behavior therapy for a number of other disorders as well (17). Her revelation of having spent a significant portion of her adolescence hospitalized for severe self-harm (18) has generated increased credibility for her model and even more devotion to it by patients.
| Model | Description | Intervention | Duration | Training | Randomized Controlled Trials/Trials With Supportive Results (N/N) |
|---|---|---|---|---|---|
| Dialectical behavior therapy | Clinicians are coaches who advise and teach, give patients homework diaries to complete, and actively encourage intersession interactions. The primary focus is on self-harm and suicidality. The treatment’s effectiveness was thought to derive from clinicians’ validating their patients’ painful emotions while encouraging them to learn new skills with which to manage their emotions. | Weekly individual (1 hour) and group (2 hours) sessions | 1 year | 10-day workshop, with homework and weekly group consultation | 13/13 |
| Mentalization-based treatment | Clinicians identify and respond to the patient’s emotions and misattributions as they arise within both the individual and group components. From this, patients learn to correct their developmental inability to “mentalize” (i.e., self-awareness, empathy, and knowing how they affect and are affected by others). | Weekly individual (1 hour) and group (1 hour) sessions | 1.5 years | 3-day workshop, with or without weekly individual supervision and weekly group supervision | 3/3 |
| Transference-focused psychotherapy | Clinicians attempt to resolve split object relations (their incompatible good/bad, idealized/devalued views of themselves or others) through interpretations of their disowned aggression as it emerges within the therapy (i.e., transference). From this, they consolidate a more integrated sense of self. | Twice-weekly individual sessions | 1 year | 3-day workshop, with weekly individual supervision | 3/2 |
TABLE 1. The Three Major Evidence-Based Treatment Models for Borderline Personality Disorder
The next major model for treating borderline personality disorder, mentalization-based treatment, was provided by Anthony Bateman and Peter Fonagy, both psychoanalysts, in 1999 (19) (see Table 1). Like dialectical behavior therapy, it combined a weekly individual session with group therapy. Mentalization-based treatment was based on observations of troubled parent-child interactions, which were thought to cause the borderline patients’ impairments in self/other awareness. Mentalization-based treatment initially proved successful compared with usual treatment in a partial hospital-based sample of patients with borderline personality disorder (19). The mentalization-based treatment interactions themselves are psychoanalytic-like by emphasizing inquiry (“not knowing”) and focusing on the patients’ interactions with their clinicians or with other group members. Unlike psychoanalysis, mentalization-based treatment is more supportive and discourages interpretation. Mentalization-based interventions are dialectical behavior therapy-like in being supportive and dyadic (i.e., clinicians are more “real” in showing emotions and self-disclosures), but unlike dialectical behavior therapy, mentalization-based treatment discourages directives and lacks homework. Although mentalization-based treatment has hardly replaced the dialectical behavior therapy model, it rests comfortably beside it with several confirmatory studies (20, 21), and training sites have been established in Europe and in the United States.
During the 1990s, Kernberg’s psychoanalytic model underwent multiple refinements until by 1999 it had been manualized as transference-focused psychotherapy (22), and by 2007 it had established its value in a randomized controlled trial (23) (see Table 1). That study compared an investigator-developed treatment against two controlled manualized alternatives; specifically, twice-weekly transference-focused psychotherapy was compared with dialectical behavior therapy and with once-weekly individual supportive psychotherapy. Although there were some advantages for the transference-focused psychotherapy in diminishing hostility and improving reflectiveness (related to the mentalization concept), the three treatments performed quite similarly in most outcome domains. The study offered evidence that an identifiably psychoanalytic form of therapy could be manualized, and the results were interpreted as an affirmation of the efficacy of transference-focused psychotherapy.
While the developments of these evidence-based treatments offered encouraging examples of the potential treatability of borderline personality disorder, they also brought new problems to light. Despite the fact that Kernberg, Linehan, and Bateman and Fonagy all became compelling and tireless teachers of and advocates for their respective models, they have together taught far too few clinicians to serve this highly prevalent disorder. Thus, because of the time and costs required for specialized training in these evidence-based treatments (see Table 1), they have not offered—and cannot be expected to offer—a meaningful response to the public health need for clinicians to treat patients with borderline personality disorder. Another issue is that all three models primarily target the psychological problems of the disorder, giving relatively little attention to its biogenetic sources and social adaptational failures. The significant heritability of borderline personality disorder was not discussed, family interventions were not included, medication management had an unintegrated role provided by an independent clinician, and vocational rehabilitative needs were not addressed (see the vignette for an alternative approach). These limitations are in part due to new knowledge that arrived after these therapies were developed about borderline personality disorder’s generally positive course and unexpectedly high heritability. In part, too, these therapies did not anticipate how widespread the use of psychiatric medications would become; even as these evidence-based treatments were being established, the treatment of most patients with borderline personality disorder was being initiated in psychiatric facilities or by primary care physicians, such that it became rare to find a patient with the disorder who had not already been treated with medication (24–26). Moreover, even when one of the evidence-based treatments is available, the psychiatrists’ role often becomes ambiguous; their role as medication manager might appear to be secondary, but psychiatrists often retain primary responsibility for managing crises and directing care in acute settings such as emergency departments and hospitals.
Emergence of a Generalist Model
In 2007, Gabbard (27) rhetorically asked, “Do all roads lead to Rome?” He noted that although the big three evidence-based treatments for borderline personality disorder differed, sometimes dramatically, in their theories and interactions, they all led to similar outcomes. This observation led to his and others’ efforts to identify the underlying features that effective treatments share (23, 28–31). The nonspecific characteristics they shared included the presence of a primary clinician, the establishment of goals, active responsiveness, a dyadic relationship, safety planning, and at least as-needed use of other clinicians to discuss problems.
Against this backdrop, a second generation of randomized controlled trials were conducted that now used manualized comparison treatments that for ethical reasons could assure participants that they were receiving an active treatment whose outcome would be better than treatment as usual (see Table 2). These comparison treatments generally tried to adopt the shared nonspecific characteristics of effective treatments identified above. As noted, the first such study compared transference-focused psychotherapy, dialectical behavior therapy, and supportive psychotherapy (23). Supportive psychotherapy’s manual (33) is a derivative of the supportive psychotherapy found to have been effective in the Menninger Psychotherapy Research Project (34, 35). When that study was completed, transference-focused psychotherapy’s success was so heralded that relatively little attention was paid to the fact that the considerably less intensive once-weekly supportive psychotherapy did nearly as well.
| Studiesa | Duration | Follow-Up | Outcomes |
|---|---|---|---|
| TFP (N=23) versus DBT (N=17) versus SP (N=23) (reference 23) | 1 year | NA | All patients improved significantly, but TFP was better in more domains than either DBT or SP |
| DBT (N=90) versus GPM (N=90) (reference 32) | 1 year | 1 year | All patients improved significantly, but GPM was modestly better with more comorbidity |
| MBT (N=71) versus SCM (N=67) (reference 20) | 1.5 years | NA | All patients improved significantly, but MBT was significantly better with more comorbidity |
TABLE 2. Evidentiary Base for the Generalist Model of Treatment for Borderline Personality Disorder
The second study to use a manualized comparison treatment tested the value of dialectical behavior therapy compared with general psychiatric management (32) (see Table 2). The general psychiatric management arm of this study has been characterized by Kernberg as being like supportive psychotherapy (36). General psychiatric management was a once-weekly treatment mostly offered by general (nonspecialist) psychiatrists with 5 or more years’ experience, using a manual derived from Gunderson and Links (37) and published in 2014 (31). General psychiatric management is openly psychoeducational, medicalizes the disorder, focuses more on life outside the office than on in-office interactions, and integrates medication management (see the vignette). Here too, the results from the generalist arm were very similar to the index treatment, that is, what Linehan herself recognized as high-quality dialectical behavior therapy (personal communication, 2009).
The third relevant randomized controlled trial used primarily registered nurses to test the value of mentalization-based treatment against a treatment called structured clinical management (20) (see Table 2). Like general psychiatric management, structured clinical management is a weekly supportive case management that focuses more on life outside the treatment than on the interactions within the sessions. In this trial, patients in the mentalization-based treatment arm improved more rapidly, but both conditions led to significant gains on all outcome variables. It was the subgroup with more comorbidity that benefited more from mentalization-based treatment (38). In an independent trial in which mentalization-based treatment (individual and group) was compared with biweekly supportive group therapy, few differences were observed in their effects, although again patients receiving mentalization-based treatment improved more rapidly (21).
Lest the evidentiary support for less intensive nonspecialized treatments from these studies of the “big three” be underestimated, this message gains added support from two other studies. Another weekly supportive therapy condition, called “good clinical care,” which was provided for an average of 12 sessions, proved to be as effective as a specialized treatment, cognitive analytic therapy (39), that required additional training (40). Most recently, Linehan demonstrated that when as-needed case management is combined with dialectical behavior therapy’s twice-weekly skills group, it is nearly as effective as standard dialectical behavior therapy (41). This result draws attention to the value of group therapies (as did Jorgensen and colleagues’ 2013 study with mentalization-based treatment [42]), but it also further underscores the effectiveness of less intensive, less specialized treatments.
Discussion
Altogether, these studies have now established that treatments that require less training and that are less intensive than the major evidence-based therapies can be relatively efficacious for patients with borderline personality disorder. The generalist model supported by this research centers on once-weekly sessions with a case manager/psychotherapist who is supportive, directive, and pragmatic. As illustrated in the vignette, the general psychiatric management model of treatment is initiated by unapologetically disclosing the borderline personality disorder diagnosis, which is clearly identifiable by excessive anger, interpersonal reactivity, self-harm, and impulsivity. This diagnostic disclosure is then accompanied by psychoeducation, including explicit statements about the handicaps imposed by genetic makeup. The clinician then keeps the borderline patients’ focus on their problems in daily living, while flexibly integrating family interventions, group therapies, and medications.
The emergence of this generalist model for treating borderline patients has far-reaching implications. The first is that less intensive interventions should become a first line of treatment. This most clearly applies to all first-diagnosed and first-treated borderline patients. Generalist approaches are also suitable for youths, in whom the full syndrome may not have developed but in whom early interventions may forestall that development. This model and even less intensive interventions are already being introduced in Australia (43). Only after having failed to improve in a generalist treatment should patients be referred to dialectical behavior therapy, mentalization-based treatment, or transference-focused psychotherapy. There is no reason to think that the need for borderline personality disorder specialists will be reduced, only that their expertise can be used with more discretion.
The second implication is that the treatment of borderline personality disorder need not be reserved for specialists with extensive training. This does not mean that any clinician can do this; this patient population is difficult to treat. They require clinicians with stable self-esteem, good sense, and a willingness to get personally involved. It also doesn’t mean that no training is needed; it means that the training that usually comes from many years of experience can now be expedited. Experienced clinicians who have been taught good psychiatric management typically report, “I didn’t learn much, but it’s very reassuring to know that what I’ve learned to do after all these years now has evidentiary support.” It also means that the required training can be integrated into the basic curricula for psychiatrists and possibly all mental health professions. In the future, a generalist model can and should be adapted for training primary care physicians, nurses, emergency department physicians, and family service clinicians.
A final implication concerns the negative stigma that has surrounded borderline personality disorder since its introduction into the diagnostic system. Even now, borderline patients have a reputation for being untreatable and even treatment resistant (44, 45). This prejudice is sustained despite knowing that evidence-based treatments dramatically add to the speed and level of their improvement and that longitudinal studies have shown that the majority get well and then stay well (9, 46). The mental health professions, perhaps especially psychiatrists, have unfortunately continued to underdiagnose and avoid these patients (47–49) and to disparage their treatability. Perhaps this is because most psychiatrists practice mainly psychopharmacology (50), and there are no approved medications for borderline personality disorder (44).
Knowing now that many, perhaps most, clinicians can effectively treat most patients with borderline personality disorder should encourage the mental health professions, especially psychiatrists, to embrace the challenges that these patients undeniably pose. Only by doing this can the mental health professions begin to address the public health needs of these patients. As described in the vignette, the responsibility to treat this underserved and sizable patient population offers what can become a personally rewarding experience.
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