Borderline Personality Disorder: Therapeutic Factors

Mechanisms of Change in Treatments of Personality Disorders: Commentary on the Special Section

Considerable progress has been made in the psychotherapeutic treatment of patients with personality disorders (PDs). Once engendering a pervasive therapeutic nihilism, PDs are starting to be viewed as treatable with a much better prognosis than previously thought. Evidence from several randomized controlled trials demonstrating the effectiveness of various forms of psychotherapy, coupled with findings from several longitudinal studies, suggests that such increased clinical optimism is warranted. However, the persistent focus on treatment brands obscures our understanding of the mechanisms through which benefits are actually realized. This article considers emerging trends in PD treatment research, exemplified by the series of articles contained within this special section, that attempt to identify more precisely the mechanisms of therapeutic change. It is only through such work that we will be able to accomplish further refinement of effective strategies, create possibilities for true integration of therapies, and achieve real progress in the field for the betterment of our patients.

Borderline Personality Disorder: Treatment from the Contextual Perspective

In relation to the psychotherapy of borderline personality disorder (BPD), the contextual model embraces the subjective components that operate alongside the more readily objectifiable elements of the medical model. The latter include the guidelines of the various psychodynamic and cognitive approaches, the randomized control trials of these approaches, follow-up studies, and data from MRI and other neurophysiological tests. The contextual model focuses on less easily measurable factors that comprise the real relationship between therapist and patient, including the heterogeneity in the BPD domain. Another component consists of patient expectations at the outset, the placebo effect of having an ally in the person of the therapist, and the nature of the patient's primary unconscious conflicts. These combined elements exert a major influence vis-à-vis the efficacy of treatment, such that the precise nature of the therapeutic method emerges as of less importance in the eventual outcome-so long as the method is a bona fide theory-driven intervention, conducted by therapists with sufficient knowledge of alternative approaches and with the flexibility to utilize other approaches temporarily, in accordance with the exigencies of the patient's current life. This amounts to an integrated approach.

Borderline Patients: 25 to 50 Years Later: With Commentary on Outcome Factors

The current study concerns the long-term follow-up of 40 patients with borderline personality disorder. Sixteen were patients from the PI-500 study, formerly hospitalized at the New York State Psychiatric Institute. Twenty-four had been from the author's private practice 25 to 50 years ago. Twenty-one of the combined group had first been in treatment 50 years ago. This is believed to be the longest follow-up period recorded for borderline patients. The main results are that two-thirds of the patients eventually reached the level of either clinical remission or clinical recovery. Reaching recovery, in the patients now in their 60s and 70s, was associated with having life-long personality traits, as described in the Five-Factor Model, of Agreeableness and Conscientiousness. These traits conduced to better outcome in forming lasting relationships and in workplace success. In some of the patients, genetic vulnerability to mood disorder (recurrent unipolar depression; bipolar disorder) was associated with slower improvement or to poorer outcome. Incest by an older-generation relative appears as another negative prognostic factor. Psychotherapy for most of the patients had originally been psychoanalytically oriented ("expressive"), though circumstances and life crises often led to the use of supportive, psychopharmacological, and behavioral interventions as well.