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Overview and Thoughts on Future Directions in the Treatment of Personality Disorder: 

Overview and Thoughts on Future Directions in the Treatment of Personality Disorder

Question: 

Question If this meeting were to take place 20 years from now, would the discussion focus on the relative merits of dialectical behaviour therapy, transference-based therapy, cognitive therapy, mentalizing-based therapy, or any of the other dozen or so therapies currently available to treat personality disorder? Or, more bluntly, are any of these therapies likely to survive?

Trends in the Treatment of Personality Disorder: 

Trends in the Treatment of Personality Disorder Phase I: pre-1990 Psychoanalytical-based therapies Milieu treatments: largely in forensic settings Few evaluations except modest attempts to evaluate the treatment of psychopathy Phase II: 1990 to now Proliferation of treatments Currently about 12 reasonably well-developed therapies are available Modest outcome studies available Phase III: future developments Integrated, eclectic approaches

Conclusions (1): 

Conclusions (1) Personality disorder responds to treatment: Various therapies including psychodynamic, cognitive, and cognitive-behavioural therapy and medication are associated with significant change in at least some components of personality pathology Different modalities – individual, group therapy, and day therapy programmes – are effective

Conclusions (2): 

Conclusions (2) Change does not differ significantly across different therapeutic models: Cognitive and psychodynamic treatments yield similar amounts of change (Leichsenring andamp; Leibing. 2003) No single therapy appears to be more effective than the rest This finding is similar to the results of meta-analyzes of the efficacy of psychotherapy generally Points to the importance of generic change mechanisms RCTs suggest that Dialectical Behaviour Therapy (DBT) and Mentalizing-Based Therapy (MBT) lead to change DBT and MBT effective in reducing deliberate self-harm and hospital admissions; also some improvement in level of functioning Specificity of these treatments has not been demonstrated

Conclusions (3): 

Conclusions (3) Change appears to be domain specific: That is, there is some evidence that some interventions are more effective for some problems than others. Specific problem behaviours respond to cognitive-behavioural techniques Limited evidence suggests that outcome varies across disorders: Borderline PD appears to do better than antisocial, cluster A, and cluster C disorders This does not mean, however, that these disorders do not respond to treatment

Conclusions (4): 

Conclusions (4) Premature termination is lower for cognitive-behavioural therapies (especially in comparison to psychoanalytic therapy) An important finding because early drop-out is common – up to 50% for some psychoanalytic treatments The results of milieu treatments including the results of well-designed studies of day treatment programmes point to the value of: Combinational treatments using different intervention strategies and modalities Group treatment

Conclusions (3): 

Conclusions (3) Medication is effective in changing some aspects of personality pathology: Evidence supports a targeted approach to treat: Impulsivity Cognitive dysfunction: transient psychotic episodes, quasi-psychotic symptoms Affective lability: evidence is less consistent than for impulsivity and cognitive dysfunction Little evidence that medication has a substantial impact on core features of personality disorder Currently there is stronger evidence for the effectiveness of psychotherapy than for medication especially in the treatment of borderline personality disorder (Paris, 2005)

Where do we go from here?: 

Where do we go from here? What do we not need? Comparative (horse race) trials Current treatments are not comprehensive Different therapies focus on different targets Current treatments are not is based on a comprehensive, and evidence-based theory of personality disorder What is needed to develop an effective treatment? More outcome studies To determine long-term outcome To evaluate the efficacy specific interventions We need to go beyond a partisan approach that argues for the merits of different treatments with similar but modest outcomes Development of eclectic and integrated treatments based on a coherent framework for understanding personality disorder and evidence of treatment efficacy

Rationale for an Eclectic and Integrated Model: 

Rationale for an Eclectic and Integrated Model Outcome is similar across treatment: This finding is similar to that for psychotherapy generally Implication: treatments incorporate common elements associated with successful outcome Outcome is modest for all treatments Most effective therapies appear to contain specific interventions that are potentially useful Given these considerations the most rational and evidence-based approach would be to combine effective interventions from different treatment models

Toward an Integrated Treatment Model: Commonalities Among Current Treatments : 

Toward an Integrated Treatment Model: Commonalities Among Current Treatments Generic mechanisms Structured approach to treatment Theoretical similarities

Commonalities: 2. Structured Approach to Treatment: 

Commonalities: 2. Structured Approach to Treatment Effective treatments use a highly structured approach to: Establish treatment including the treatment contract Delivery of interventions 'Structured' in this context refers to a systematic and explicit framework for establishing and organizing treatment NOT the type of intervention used

Commonalities: 3. Theoretical and Conceptual Similarities: 

Commonalities: 3. Theoretical and Conceptual Similarities The advocates of the various therapies tend to emphasize the 'unique' features of 'their' model Because different therapies are offered as alternatives, clinicians tend to think that their task is to select among them Thus PD is variously considered an object relations problem, mentalizing deficiency, emotional dysregulation disorder, an interpersonal disorder, the result of maladaptive cognitions, and so on Knowledge about PD remains fragmented and useful interventions are not used because they 'belong' to a different school The problem is not that some of these models are wrong but that all are right, although to differing degrees To develop an integrated treatment approach and an integrated theory of PD, we need to integrate these perspectives

Integrating Different Theoretical Perspectives: 

Integrating Different Theoretical Perspectives Two ways to integrate different theoretical perspectives: Develop an integrated framework to organize information about personality disorder: Ideally an integrated theory is needed but we are probably a long way from having the knowledge base required for theory construction The alternative in a systematic framework for organizing information about personality disorder, for example, conceptualizing personality as a system and developing systematic accounts of the different components Develop a framework for organizing treatment that incorporates the common elements

Cognitive Structure as an Integrating Concept: 

Cognitive Structure as an Integrating Concept Psychoanalytic, cognitive, cognitive-behavioural, and constructionist therapies share the idea that the cognitive structures used to interpret information about the self, others, and the world are core features of personality disorder This structure is variously labeled object relationships, working models, self and object representations, self and interpersonal schemata Greater process would occur if the different approaches adopted a common language The term 'schema' are used in cognitive science (not cognitive therapy) seems the most appropriate term

Personality Disorder:A Systems Perspective: 

Personality Disorder: A Systems Perspective Symptoms and problem behaviours Regulation and control mechanisms Trait system Knowledge systems: Interpersonal system: Person constructs Grammar of behaviour (theory of mind) Self system: Cognitive component: Self attributes Autobiographical self or self script Conative or self-directed component

Framework for Organizing Treatment: 

Framework for Organizing Treatment Generic component: Structured approach Explicit treatment frame Consistency and programme integrity General therapeutic strategies based on generic interventions focused on building a collaborative treatment relationship Specific interventions: Selected systematically to address the different domains of the personality system’ Selection guided by: What works Rational consideration of the kinds of change that may reasonably expected for each domain Incorporates a rehabilitative component

Personality Disorder:A Systems Perspective: 

Personality Disorder: A Systems Perspective Symptoms and DBT, CBT, medication problem behaviours Regulation and DBT, CBT, Medication control mechanisms Trait system None directly, CBT Knowledge systems: Interpersonal system: Person constructs IPT, CBT, P-analytic Grammar of behaviour (T of M) MBT Self system: Cognitive component: CBT Self attributes P-analytic Autobiographical self or self script Constructionism Conative or self-directed component P-analytic

Phases of Change : 

Phases of Change Safety: Interventions to ensure safety of patient and others Containment: Interventions to contain affective and behavioral instability Control and Regulation: Interventions to reduce symptoms, control affects and impulses, and improve self-management of affects and impulses Exploration and Change: Interventions to change the cognitive, affective, and situational factors contributing to problem behavior Integration and Synthesis: Interventions designed to address core pathology and forge a new sense of self and more integrated and adaptive self and interpersonal systems

Sequence of Interventions: 

Sequence of Interventions 1: Safety: Provision of structure and support 2: Containment: Generic supportive and containing interventions Medication 3: Control and regulation: Medication Cognitive-behavioural interventions 4: Exploration and change: Cognitive, interpersonal, and psychodynamic interventions 5: Synthesis: Cognitive and psychodynamic interventions Structured Less Structured

Sequence of Interventions: 

Sequence of Interventions Phase 1: Safety Phase 2: Containment Phase 3: Control and regulation: Phase 4: Exploration and change Phase 5: Integration and Synthesis General Specific Strategies Interventions Medication Generic Mechanisms Specific Support, Validation Psychosocial Interventions