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New Treatments for Borderline Personality Disorder
For many years, Marsha Linehan's Dialectical Behavior Therapy (DBT) has been widely recognized as the model for developing an effective therapeutic treatment by marrying painstaking research and clinical practice. Dozens of research studies have made DBT the field's most recognized and empirically supported treatment for borderline personality disorder (BPD). But although DBT remains by far the most researched therapy for BPD, other therapies have done as well in comparison trials of treatment outcomes.
In the latest study, reported in the September 15 online edition of the American Journal of Psychiatry, a team of researchers, led by psychologist Shelley McMain from the University of Toronto, has used the American Psychiatric Association (APA) guidelines for treating BPD to develop a more psychodynamic psychotherapy called General Psychiatric Management (GPM). Like DBT, it's a manualized, structured therapy, and it did as well on every symptom of BPD, including the most serious—suicidal and self-harming attempts.
GPM and DBT both share some common principles. Both acknowledge the client's suffering, make it clear that treatment will be difficult and slow, teach clients to take responsibility for their actions, and set clear goals in a structured therapy setting. Both emphasize decreasing impulsivity and increasing reflection, moderating black and white thinking, identifying and moderating inappropriate behaviors and feelings, and promoting more effective interpersonal relationships. But GPM differs from DBT in some important ways.
DBT deemphasizes medications, whereas GPM guidelines recommend them for distressing comorbid conditions or symptoms, such as impulsivity, depression, or anxiety. DBT therapists organize the hierarchy of treatment targets (suicidal, treatment-interfering, and quality of life interfering behaviors); in GPM the patients choose the hierarchy. DBT uses behavioral assignments, such as keeping diary cards, to handle negative transference, whereas the psychodynamic therapy focuses on addressing the negative transference in session.
Two other psychodynamic therapies, Transference-Focused and Emotionally Supportive, have shown effectiveness in treating BPD (see Clinician's Digest, November/December 2007).
Interpersonal Therapy, which straddles the line between psychodynamic and behavioral, is acquiring a promising track record. Anthony Bateman and Peter Fonagy's mentalization therapeutic approach, which, like DBT, focuses on helping clients develop the capacity to think about themselves in relation to others and to understand others' states of mind, has also proven effective.
The emergence of several effective treatments for BPD offers considerable hope for treating what, in the days before Marsha Linehan's innovative work, was widely considered an untreatable condition. Often we think of research as narrowing the road ahead. But Linehan's careful research, while solidly validating DBT, has also helped illuminate some common treatment philosophies and approaches and paved the way for the development of new ones.
AAMFT: Doherty's video may be viewed at www.youtube.com/watch?v=tmNfyCkKAW8; MFTers for Change Facebook page: MFT's For a More Dynamic, Inclusive, and Effective AAMFT. Depression: American Journal of Psychiatry 165, no. 10 (October 2008): 1272-80. Therapists and Scientists: Psychological Science in the Public Interest 9, no. 2 (November 2008): 67-103. Borderline Personality Disorder: American Journal of Psychiatry Online (September 15, 2009) doi: 10.1176/ appi.ajp.2009.09010039.