FRIEDMAN AND DOWNEY EDITORIAL

Editorial: Therapeutic Factors in Treatment of Patients with Borderline Personality Disorder Richard C. Friedman and Jennifer I. Downey Abstract: In this issue of Psychodynamic Psychiatry, Michael Stone discusses therapeutic factors in the treatment of patients with Borderline Personality Disorder (BPD). He emphasizes the great diversity of borderline patients and points out that a number of manual-based therapies, each described by an acronym, generally achieve positive therapeutic results in the short term. Many borderline patients require years of psychotherapy, pharmacotherapy and additional treatments, however. Stone observes that patients with this disorder invariably have other personality characteristics and disorders. Suicidality is common among borderline patients, particularly those who also suffer from major depressive episodes. Stone emphasizes the usefulness of a contextual therapeutic model and a flexible clinical stance.

KERNBERG AND STONE Four decades ago Otto Kernberg suggested that the concept of “borderline” could most helpfully be conceptualized dimensionally and that patients with personality disorders could be described according to the level of their character structural integration (Kernberg, 1967, 1977). At the highest level of integration, Kernberg suggested that repression is a core defense, the representational world is stable, and the sense of identity is solid. Primitive idealization and devaluation do not occur. At the lowest level of character structural integration, the full borderline syndrome occurs. Here, splitting is a core defense, the representational world is unstable, identity is diffused, primitive idealization and devaluation occur. Although contemporary, clinicians tend to use the diagnostic system of the DSM for practical reasons. Kernberg’s perspective provides insight into unusually complex psychiatric phenomena.

Psychodynamic Psychiatry, 44(4) 497–504, 2016 © 2016 The American Academy of Psychoanalysis and Dynamic Psychiatry

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Equally creative and useful is the concept of a diagnostic cube proposed by Stone himself (1980). Stone distinguished between psychostructural level and type of character defense. He proposed that one side of a cube could represent psychostructural level, another side, type of character defense (e.g., hysterical, obsessive, etc.), and the third side genetic predisposition to affective disorder or schizophrenia. Stone’s prescient insights into the complex nature of borderline phenomena complement Kernberg’s, and like Kernberg’s, is different from that described in the DSM nomenclature. SUICIDALITY IN BORDERLINE PATIENTS Stone emphasizes the importance of assessing suicidality among patients with BPD. Many of these patients attempt suicide and the severity of the attempt varies widely across individuals. Patients with BPD often make serious suicide attempts and the frequency of suicide among patients with BPD is elevated compared to the general population. Borderline patients are dramatic and sometimes use suicidal threats as a way of sending messages to others that are meant to provoke caring, guilt, and remorse. That is to say that their suicidal behaviors are (more or less) transparent cries for help (and revenge) but not meant to actually murder the self. On the other hand, other patients who express apparently similar guilt-provoking messages to others, actually do wish to murder the self. The hopelessness that these patients feel may be unconscious and therefore hidden, even from themselves. Assessing suicidal intent in borderline patients, therefore, calls for cautious, careful, and exceptionally thoughtful clinical assessment. Patients that may seem “manipulative” and may trigger countertransference reactions even in experienced therapists may nonetheless be seriously suicidal. According to the DSM-IV, 75% of borderline patients are likely to be young women. Our clinical experience suggests that this may provoke the same types of countertransference responses as (so-called) “hysterical” women used to in the past. The younger patients may stimulate similar negative responses from authority figures as (so-called) “acting out” adolescents often do. Provocative threats of suicide expressed to authority figures such as hospital and clinic staff members and therapists for example, may seem “manipulative” but may actually camouflage truly lethal intent. Also, given the impaired judgment often found among younger psychiatric patients and probably associated with the incomplete cerebral cortical myelinization that Stone discusses (Giedd, 2015), some borderline patients who attempt suicide are likely to do so by mistake. These patients

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may non-verbally cry out for help but misjudge the dangerousness of their actions and “accidentally” die as a result. Stone also discusses borderline patients who also meet diagnostic criteria for Major depressive episode. As might be expected, the likelihood of attempted suicide in such patients is elevated above those of other BPD patients (Friedman, Aronoff, Clarkin, Corn, & Hurt, 1983; Friedman et al., 1982; Friedman & Corn, 1987). ACRONYM THERAPIES Stone’s summary of the so-called “acronym therapies” illustrates fundamental problems present in psychiatry today. Clinicians and researchers are perpetually in search of the best treatment for specific disorders. Unfortunately, there is no best treatment of BPD patients even in the short term, and not infrequently one treatment seems as good as another. The list of acronym therapies is lengthy and includes the following: • Cognitive Behavior Therapy (CBT) • Dialectical Behavior Therapy (DBT) • Interpersonal Therapy (IPT) • Mentalization-Based Therapy (MBT) • Schema-Based Therapy (SBT) • Transference-Focused Psychotherapy (TFP) • Dynamic Deconstructive Therapy (DDT) Stone notes that in addition to the acronym therapies, supportive psychotherapy may be helpful in the treatment of a wide range of patients including those with BPD. The principles of Supportive Therapy (ST) have been summarized by Rockland (1992), Winston et al. (2004), and Appelbaum (2005) among others. The acronym therapies achieved (and continue to achieve) popularity in Stone’s opinion for the following two reasons: (1) They operationalize principles that may be tested by RCTs (randomized controlled trials). Initially used to test outcome of drug efficacy, RCTs are favorably viewed today (particularly by funding agencies) because they assess standardized treatments, and are usually time limited and quantifiable outcomes that fit into a “medical model” of psychiatric disorders. (2) They express different (but overlapping) models of behavior generated by influential clinical-investigator-scholars, each of whom advocates her or his own perspective about optimal therapeutic interventions.

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An additional point is that a specific “acronym therapy” might be helpful in an individual case. Throughout clinical medicine treatment decisions about individuals are not necessarily clearly based on the studies that have compared groups. To put this differently, individual differences may be lost in group comparisons. The first and arguably most influential acronym therapy—CBT—was introduced in the 1960s by Aaron Beck, a psychoanalyst. Beck found that traditional models of psychoanalytic intervention for depression were not as effective as the behavioral therapy approach he pioneered. His therapeutic innovations were not only directly helpful to depressed patients, but they cast doubt on classical psychoanalytic beliefs about the treatment of depression (Beck & Freeman, 1990). Soon after, Marsha Linehan developed DBT, a therapy especially tailored to treat patients with borderline personality disorder (Linehan, 1993). Once again, classical psychoanalysis, which emphasized helping unconscious conflicts become conscious, facilitating free association and achieving insight, was not as helpful as Linehan’s structured and behaviorally oriented approach. The same was true of the other therapeutic acronym approaches Stone discusses. In thinking about the similarity in outcome of the different acronym therapies an analogy with exercise training comes to mind. Exercise clearly has positive effects on physical and mental health. Swimming, jogging, brisk walking, and cycling are all beneficial as are many other types of exercise (Trost et al., 2002). Quantitative fitness measures do not differ between swimmers, joggers, walkers or cyclists. Everyone improves although each type of exercise has advocates, all of whom provide reasons that their methods are “best.” Lewis Carroll has been given credit for characterizing this as a “Dodo” effect (in another context). The Dodo effect has achieved fame in discussions of psychotherapeutic interventions since similar therapeutic results tend to be achieved by therapists from different psychotherapeutic schools, who use somewhat different therapeutic techniques. In Carroll’s Alice in Wonderland, Alice and her newfound animal companions enter a race with no beginning or end. After a while they ask the race organizer, a Dodo, to announce the winner. The Dodo concludes that since every runner has won, all must have prizes (Carroll, 2009)! Long-term follow-up, however, reveals that after time has passed many patients stop exercising across all groups. People lose motivation as a result of diverse life circumstances, including feelings about the self, and the quality of interpersonal relationships. Exercise facilitators seem to help some people and outcome of interventions is being investigated. This scenario is at least somewhat analogous to the story of the psychotherapeutic treatment of borderline patients. A crucial difference

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of course concerns the never-to-be-underestimated unique features of long-term psychotherapeutic relationships. This adds a specific feature of long-term psychotherapeutic treatment that is different from an activity like exercise training. LONG-TERM CARE OF BORDERLINE PATIENTS Clinicians who work psychotherapeutically with borderline patients emphasize that acute symptom remission, although critically important, should not be equated with adequate treatment of the whole person which tends to be prolonged. Patients and their families should expect extended treatment that is labor intensive, financially expensive, and long-term. Some patients require intermittent care during the entire course of their lives, much as patients with chronic (and often multiple) serious physical disorders do. Given the limitations of modern health care mental health delivery services, particularly in the United States, this obviously poses substantial and presently unsolved therapeutic problems. Ideally, patients who suffer from the more severe borderline syndromes should be hospitalized as needed and treated with as many psychotherapy sessions per week as are necessary in the judgment of the clinician/clinical team responsible for care. Sometimes multiple modalities are required either simultaneously or sequentially. This is particularly so for combined treatment with psychotherapy (of some type) and medication, which should be prescribed according to clinical judgment. Sometimes clinical judgment necessitates drug trials outside of those definitively supportive by an established database. Many therapeutic issues involving borderline (and other) patients have not been systematically investigated to date. Algorithms cannot solve clinical problems in areas that have not been investigated! INCOME INEQUALITY AND BPD In today’s American socioeconomic climate, where therapists are routinely required to negotiate with for-profit insurance companies, ideal care is clearly more available for those with financial resources than those who are pressed financially. Wealthy patients are less likely to be subject to rationed care in the United States. Clinicians treating patients with severe BPD, therefore, must work within the limitations of the societies where they and their patients live. Difficulties obtaining

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parity for mental health services in the United States, added to many other impediments imposed by demands made by for-profit insurance companies, are creating a situation in which implementation of best practices is virtually impossible for patients with limited economic resources (Lazar & Yeomans, 2014). Because of the diverse psychological and psychosocial problems of borderline patients, they are likely to be especially prone to the deleterious effects of inadequate care as a result of inadequate resources. This inference is made on the basis of clinical experience. Systematic research investigation of this phenomenon has yet to be carried out. Despite limitations in care delivery, however, Stone points out time is on the side of improvement in psychological functioning of patients with BPD. Maturity and positive interpersonal relationships (which sometimes occur apparently by chance) may open a pathway to mental health for some even without long-term psychotherapy and management. Long-term naturalistic studies sometimes uncover a “luck” factor in improvement that RCTs generally don’t detect. THERAPEUTIC ALLIANCE VERSUS PSYCHODYNAMICALLY INFORMED LONG-TERM MANAGEMENT Stone observes that a sound therapeutic relationship is a positive influence on outcome. A positive therapeutic relationship however usually refers to one that is experienced and expressed during psychotherapeutic sessions. Psychodynamically informed long-term management refers to something different. Experienced clinicians such as Stone, for example, who have followed borderline patients for years, or even decades, have been available for all sorts of interactions that may not usually be formally considered “treatment.” A congratulatory note from the therapist upon the birth of a child for example may not be technically considered “treatment,” or appearing at the funeral of a patient’s beloved mate, or consoling a patient after the death of a pet. Patients and therapists construct a fabric of caring communications over years and these may contribute to a patient’s stability. They also are deeply valued by therapists as symbols of how important the relationships with patients over time are to them as well. This dimension of patient care and patient treatment remains to be systematically investigated. Understanding borderline patients requires a bio-psycho-social developmental model. In fact, this particular syndrome illustrates the need for understanding interactions between biological-psychological and social levels of behavioral organization in a unique way.

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CONCLUSION A relatively small group of clinician/investigators have written extensively about the borderline syndromes over a period of many years. Michael Stone credits them in his article and is prominent among them. His perspective is particularly appreciated in this volume of Psychodynamic Psychiatry. Perhaps his most important point concerns the enormous diversity among borderline patients and the importance of a comprehensive, therapeutic perspective. This perspective includes the attributes of patients as well as therapists, the vicissitudes of the life cycle, the socio-cultural influences on behavior, and the entire range of events that can influence someone’s life. Stone (appropriately) gives great weight to the contextual model of psychotherapy as discussed by Wampold and Imed (2015). Stone’s methodical outline of the many factors that may influence therapeutic outcome and the need for therapeutic flexibility should be taken to heart by all therapists working with borderline patients.

REFERENCES American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing. Appelbaum, A. (2005). Supportive psychotherapy. In J. M. Oldham, A. F. Skodol, & D. S. Bender (Eds.), Treatment of personality disorders (pp. 335-346). Washington, DC: American Psychiatric Press. Beck, A. T., & Freeman, A. (1990). Cognitive therapy of personality disorders. New York: Guilford. Carroll, L. (2009). Alice’s adventures in wonderland and through the looking-glass. New York: Oxford University Press. Cutler, S. E., & Nolen-Hoeksema, S. (1991). Accounting for sex differences in depression through female victimization: Childhood sexual abuse. Sex Roles, 24(7), 425-438. doi: 10.1007/BF00289332 Friedman, R. C., Aronoff, M. S., Clarkin, J. F., Corn, R., & Hurt, S. W. (1983). History of suicidal behavior in depressed borderline patients. American Journal of Psychiatry, 149(8), 1023-1026. Friedman, R. C., Clarkin, J. F., Corn, R., Aronoff, M. S., Hurt, S. W., & Murphy, M. C. (1982). DSM-III and affective pathology in hospitalized adolescents. Journal of Nervous and Mental Disease, 170, 511-551. Friedman, R. C., & Corn, R. (1987). Suicide and the borderline depressed adolescent. Journal of the American Academy of Psychoanalysis, 15(4), 429-448. Giedd, J. N. (2015). The amazing teen brain. Scientific American, 312, 33-37. Kernberg, O. F. (1967). Borderline personality organization. Journal of the American Psychoanalytic Association, 15, 641-685.

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Kernberg, O. F. (1977). The structural diagnosis of borderline personality organization. In P. Hartocollis (Ed.), Borderline personality disorders: The concept, the syndrome, the patient (pp. 87-122). New York: International Universities Press. Lazar, S. G., & Yeomans, F. E. (2014). Special issue: Psychotherapy: The Affordable Care Act and mental health parity: Obstacles to implementation. Psychodynamic Psychiatry, 42(3), 339-573. Levendosky, A. (2013). Drawing conclusions: An intergenerational transmission of violence perspective. Psychodynamic Psychiatry, 41(2), 351-360. Linehan, M. M. (1993). Cognitive-behavioral treatment of borderline personality disorder. New York: Guilford. Rockland, L. (1992). Supportive psychotherapy for borderline patients: A psychodynamic approach. New York: Guilford. Stone, M. H. (1980). The borderline syndromes. New York: McGraw Hill. Trost, S. G., et al. (2002). Correlates of adults’ participation in physical activity: Review and update. Medicine and Science in Sports and Exercise, 34(12), 1996-2001. Wampold, B. E., & Imel, Z. E. (2015). The great psychotherapy debate: The evidences for what makes psychotherapy work. New York: Routledge. Winston, A., Rosenthal, R.N., & Pinsker, H. (2004). Introduction to supportive psychotherapy. Washington, DC: American Psychiatric Press.