Psychological therapies for personality
disorder
The zeitgeist and beyond
Professor Kate Davidson
Institute of Health and Wellbeing, Glasgow
Stavanger 2014
Overview
• The therapies: what they say they do
• Do we know how therapy works?
• Are we doing well enough?
• What should we pay attention to in the
future?
Central problems in BPD
(as demonstrated in factor analytic studies)
Behavioural
regulation
Affect
Regulation
Interpersonal
Sensitivity
Cognitive
Childhood adversity
Implications for therapy
(adapted from Livesley, 2011)
• Validation
• Behavioural
competence
• Assertiveness skills
Invalidation
emotions &
experience
Threat
Powerless
Chaos
• Empathy/ trusting
relationship
• Support & Safety
• Evaluation of threat
• Consistency
Therapies developed for BPD
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Dialectical behavior therapy
Schema focused therapy
Cognitive behavioural therapy-pd
Mentalization based therapy
Transference-focused psychotherapy
Cognitive analytic therapy
STEPPS
Nidotherapy
Therapies developed for BPD
 Dialectical behavior therapy
 Schema focused therapy
 Cognitive behavioural therapy-pd
 Mentalization based therapy
 Transference-focused psychotherapy
• Cognitive analytic therapy
• STEPPS
• Nidotherapy
The picture gallery
DBT
• Marsha Linehan USA
CBT
 Aaron Beck
 Arthur Freeman USA
 Judith Beck USA
 Christine Padesky USA
 Jean Cottraux France
 Kate Davidson UK
Schema Focused Therapy
• Jeff Young
USA
Arnoud Arntz
Netherlands
mentalization
• Anthony Bateman &
Peter Fonagy
Transference Focussed Therapy
• Otto Kernberg
• Frank Yoemans
• John Clarkin
Main problem identified by theories
Borderline Personality Disorder
Therapy
Main problem
DBT
Affect regulation
CBTpd
Beliefs about self others & over-developed
behaviours
Early maladaptive beliefs and behaviours
Reflective functioning
Sense of self: Splitting of good / bad parts
SFT
MBT
TFT
DBT
• BPD results from impaired regulation of
emotions – resulting from a biological
sensitivity to an early environment lacking in
emotional validation.
CBT and Schema therapies
• Early maladaptive schema: long-standing & pervasive themes (called core
beliefs in CBTpd)
– originate in childhood and go on to define the individual’s behaviours,
thoughts and feelings and relationships with other people
– leads to maladaptive consequences
• Schemas may serve as potential solutions in childhood
BUT in adulthood, ineffective strategies to meet basic needs &
become associated with negative emotions and impaired functioning.
Mentalisation:
Reflective functioning difficulties
Psychic equivalence or concrete thinking
- think it so believe it
Pretend mode
- “cut off “ from reality
Teleological thinking.
– feel need to put something into physical action. E.g. must cut
themselves in order to relieve the distress OR don’t believe their
therapist cares about them until they see some real proof, like a phone
call or a card
Misuse of mentalising - the most disturbed type.
– deliberate attempt to perhaps control the mind of another person, to
distort the thinking of another person. Telling someone what they
think rather than asking them or listening to what they say.
– in dissociative states of extreme abuse where there is dissociated
parts of the person that then projects out extremely intense feelings
that the therapist then feels like acting on or may feel anxious about.
TFT Assumptions
Object relations dyads - parts of the self and
other are defensively separated into “all good”
and “all bad” representations.
Split is literally a defence against aggressive
impulses.
“Warring” of parts of self is thought to account
for dramatic behavioural cognitive and
emotional symptoms in BPD.
Emphasis in theoretical underpinnings:
therapies for Borderline PD
Behaviour
SFT
CBT
DBT
Affect
SFT
CBTpd
MBT
TFT
Cognition
Therapy targets
?
Targets of therapy techniques in DBT
Modify behaviours that
Mindfulness
Emotion
regulation
skills
Distress
tolerance
Behavioural
regulation
Affect
regulation
interfere quality of life
Interpersonal
sensitivity
Interpersonal
problem solving
Targets of Schema Focused therapy
Daily activity- exposure
Assertiveness in
interpersonal context
Behavioural
regulation
Affect
regulation
Schema &
schema modes
identified.
Cognitive
restructuring &
education
Interpersonal
sensitivity
Gestalt work: experiential imagery/
dialogue work
Targets of Schema Focused Therapy
Limited reparenting
Reparenting
Limited
Daily activity- exposure
Assertiveness in
interpersonal context
Behavioural
regulation
Affect
regulation
Interpersonal
sensitivity
Interpersonal
schemas or
modes identified
Gestalt work: experiential imagery/
dialogue work
Targets of CBTpd
Empathic
shared
formulation
Changes in
interpretation of
view of self &
others changes
emotional
response
Behavioural experiments to
test out beliefs about self &
others
Behavioural
regulation
Affect
regulation
Interpersonal
sensitivity
Develop new
beliefs about self
and others
Interpersonal
problem solving
CBT-pd
New CBT paradigm
• More explicit use of the therapeutic
relationship
• Based on individual case conceptualisation
• Developing new beliefs and associated
behaviours
• Behavioural experiments to test new beliefs
and aid development of new behavioural
repertoire
Targets and techniques in MBT
States of mind clarified
Behavioural
regulation
Emotional
regulation
Interpersonal
sensitivity
Feedback reflective
functioning / affect focus
Understanding causes/
consequences of emotional
states in interpersonal
interactions
Aim of MBT
 Assess developmental patterns in interpersonal
relationships in terms of stability, flexibility balance.
 Link to current relationships, behaviour & problems
 Affect focussed – on patient’s mind - current thinking and
feelings and not on behaviour.
- To spot when there is a failure of reflective functioning (RF) by
moment by moment process orientated sessions
- Use sound bites - mainly focused on affect
- Use basic mentalising to try to restore RF - validation, support,
empathy, clarifying mental states, clarifying feelings, tracing
feelings to actions.
Not insight oriented
TFT aims
More
gratifying
relationships
Behavioural
regulation
Emotional
regulation
Interpersonal
sensitivity
Modify representations
of self and others
By clarification,
confrontation &
transference
interpretations
TFT aims
Modify representations of self and others as they are enacted in
the here and now transference.
Patient learns to integrate warded off / disowned parts of self &
integrates these into internalised representations of self/others &
deal with powerful emotions that accompany them
• by clarification
• confrontation
• transference interpretations
Not target of therapy
behaviour
MBT
TFT
affect
cognition
And they all help!
Generic Structured Clinical Care
for individuals with Personality
Disorders
UCL
Expert reference group 2013
http://www.ucl.ac.uk/clinicalpsychology/CORE/competence_mentalillness.html
OR
www.ucl.ac.uk/CORE/
Comparison of trials misleading
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•
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Same diagnosis
Different patterns of problems
Self–harm vs suicidal distinction
Past vs current suicidal behaviour
Method of counting: average, any, actual n
etc.
• Severity of problems e.g. depression, anxiety
Treatment Duration (years)
TFT also delivered for 1 year (Clarkin et al, 2007)
What changes?
• Behaviour- suicidal behaviour YES
• Affect?
• Cognition/ interpersonal sensitivity?
At long term follow up
MBT 5 years: any suicide attempt N=41
– MBT 23% vs TAU 74%
CBTpd 6 years: mean number suicide attempts (N=76)
Any suicide attempt over 6 years follow up
- CBTpd 56% vs TAU 73%
DBT 36 months: (N=180) any suicide attempt
- DBT 6% vs TAU 13.3%
What changes?
• Behaviour- suicidal behaviour YES
• Affect?
• Cognition/ interpersonal sensitivity?
Summary main CBTpd findings (BOSCOT trial)
Outcome
Number of suicidal acts
Anxiety
BSI – Positive Symptoms
Distress Index
p
0.02
0.013
0.0047
Depression scores at baseline
(BDI or HRSD* mean scores )
40+: extreme depression 31-40: severe depression 17: cut off for clinical depression
baseline
45
40
35
30
25
20
15
10
5
0
Extreme
Severe
Moderate
CBTpd Davidson DBT McMain MBT B&F 2009
2006/2010
2012
Davidson and Tran 2014
*HRSD moderate depression 17-23
DBT Turner
2000
Linehan * 2006
Depression scores at baseline, end of therapy
(BDI or HRSD* mean scores )
45
40
35
30
25
20
baseline
15
end treat
10
5
0
CBTpd DBT McMain MBT B&F
Davidson
2012
2009
2006/2010
DBT Turner
2000
Davidson and Tran 2014
Linehan *
2006
Depression scores at baseline, end of therapy and follow up
(BDI or HRSD* mean scores ) FOR CONTROL TREATMENT
What changes? Depression and
suicidal behaviour
• Behaviour- suicidal behavoiur
• Affect?
• Cognition/ interpersonal sensitivity?
Summary main CBTpd findings (BOSCOT trial)
Outcome
Number of suicidal acts
Anxiety
p
0.02
0.013
BSI – Positive Symptoms
Distress Index
0.0047
Beliefs (YSQ)
0.0064
CBTpd changed behaviour and beliefs
BOSCOT study 106 patients with BPD (Davidson et al., 2006)
 Independence
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Subjugation/ lack of individuation **
Vulnerability to harm and illness
Fear of losing control
Emotional deprivation **
Abandonment & loss **
Mistrust **
Social isolation
Unlovability/ defectiveness/ badness***
Social undesirability
Guilt punishment
Incompetence / failure **
Unrelenting standards
Loss emotional control
Entitlement/ insufficient limits
BPD**
At 16 years follow up
Both groups achieved high rates of remission
• BPD: 78-99%
• Other PD: 97-99%
Symptomatic recurrence rates higher in BPD
 Recurrence 10-36% vs 4-7%
 Loss of recovery 20-44% vs 9-28%
Risk factors for a poorer long-term
outcome
(Zanarini 2005, 2007)
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Older age
Longer treatment history
Pathological childhood experiences
Temperament problems
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Comorbid substance use
PTSD
Anxious cluster disorder
Family history of psychiatric disorder
Approx 60% to 70% of patients with BPD make suicide
attempts- completed suicides far less.
Quality of Life
Euroqol (thermometer) outcomes
80
70
60
50
40
therapy
30
GPM/ tau
baseline
20
10
0
DBT 36 m
CBtpd
SFT/ TFT
What does not respond well in
therapy?
• Affective symptoms
- chronic dysphoria
feelings of emptiness
intense anger
profound abandonment
(Zanarini 2007)
New research in anhedonia
- from depression literature
Therapy for depression (CBT) has focused on understanding increase in
negative emotion experience
Neglected ways to reconnect individuals to positive experience.
• In depression, disturbances in experience of positive emotion
- anticipation (when approaching a goal or reward)
- consummation (when attaining a goal or reward)
- impaired positive emotion recognition.
Augment positivity
Capitalise on emerging insights from positive affective neuroscience.
B Dunn 2012
In psychotherapy
• May underestimate occurrence of negative
treatment effects
• May have “harmful” therapists (Kraus et al,
2011)
• Often authors/ clinicians are unclear as to
what a side effect or adverse event might be
Negative effect of psychotherapy
• Exposure therapy – coronary heart disease
• Increased suicidality with CBT (Thase et al., 2007)
• Increased anxiety from applied relaxation therapy
(Borkovec et al., 1993)
• Drop outs due to issues with the format of group
therapy (Hall et al 1998))
• Problems in the therapeutic relationship
(Leichsenring et al., 2009) )
(From Vaughn et al., 2014)
Type of therapist patient interaction in BPD
• If therapist is passive, can activate feelings of being neglected or
abandoned.
• Fostering over-reliance on therapist to allay patient’s fears of being
abandoned may not be necessary e.g. crisis phone calls to therapists
(Nadort et al 2009)
• Need to be aware of process of therapy to repair ruptures in alliance
(“what is going on here?”). Importance of “real” communication between
therapist and patient.
• Therapists who do not match the patients level of complexity in
interactions show poor outcomes (Davidson, Livingstone et al., 2007)
Adverse Events in psychotherapy
• Potential side effects well documented
acknowledged in medication
• Adverse outcomes often only apparent after
medication in common use.
• Patients and clinicians can weigh risks and
benefits
Vaughn et al 2014
Random sample of papers that mention AE (%)
Trials medication vs psychotherapy
100
90
80
70
60
50
40
30
20
10
0
medication
psychotherapy
Next steps
To develop more effective therapies
• Less trials
• More in depth understanding
- Understand process of change in behaviour
and affect regulation, thinking about self
and others
• Pay attention to factors that influence good
and poor outcomes in routine clinical practice
and under experimental conditions
Tusen Takk
Professor Kate Davidson
[email protected]