Single session treatment of a borderline personality disorder

Debbie, a patient in ongoing therapy, volunteered to assist in a workshop by participating in an interview. The goals of the session were to identify some small, discrete problem that could be worked on in the limited time available, and to demonstrate how a short-term treatment can be used.The issues considered revolved around Debbie's schema. Her early abuse set several schemas that have directed Debbie's life. The goals of the therapy would be to help modify those rules. The single session was a microcosm of a longer-term therapy. Overall, from the reports of the patient and her therapist, on follow-up, she was able to do the homework with the the therapist's assistance and found that it was helpful in countering the negative thoughts. This led to a lifting of the concomitant depression and a diminution in the self-injurious behavior.Many sessions would be needed to reinforce and strengthen the exercise strated in this session. Overall, I would see this session as both a successful treatment session and a demonstration of how identifying discrete, proximal goals can benefit patients with long-standing Axis II problems. The hypotheses and questions led to data gathering and hypothesis testing. Throughout the session, it was essential to be aware of the likely schemas so that some could be used in the session, while others were clearly avoided. By developing a conceptualization or model of the problem(s), a set of interventions could be mobilized within the session and as homework between sessions. By working toward a coping model of treatment rather than attempting to cure long-standing problems, brief cognitive behavioral interventions can be successful.     

Introduction to the special feature on the integrated treatment of personality disorder

The solid evidence that personality disorders can be treated effectively goes side by side with, on the one hand, sparse evidence for disorders other than borderline and for personality disorders co-occurrent with one another, and, on the other hand, with a relative lack of knowledge about the actual effective mechanisms of change that underpin successful psychotherapies. In this introduction we present the rationale for this special feature, advocating for an integrated treatment of personality pathology in which empirically-supported strategies and techniques are selected from different traditions on the basis of the pragmatic principle of what works.     

Psychotherapy integration in the treatment of personality disorders: a commentary

Whereas research on the treatment of personality disorders over the past several decades has focused primarily on comparing the efficacy of various treatment packages associated with different theoretical models, there is increasing evidence that the field would benefit from focusing more attention on developing integrative treatments that are both informed by research and capable of scientific verification. The articles assembled for this special section each propose a different approach to integrative treatment for personality disorders. In this commentary, we outline a number of reasons for making such a shift to more integrative treatments, consider some of the potential challenges to integration, and discuss the different approaches to integration illustrated in these articles. We highlight some of the difficult tradeoffs that must be made in developing an integrative approach and discuss similarities and differences in the response to such challenges by the contributors to this special section. Finally, we point to several areas for future research that we believe will contribute to the development of increasingly effective treatments for individuals with personality disorders.     

Six-year follow-up of three treatment programs to personality disorder

Previous studies of long-term outcome for personality disorder (PD) were either retrospective in design or did not include a control condition. In this paper we report results for three PD cohorts (N = 111) treated in two different specialist psychosocial programs (step-down and long-term inpatient) and in general psychiatric treatment as usual (TAU), which were prospectively followed up for 72-months after intake. The three PD samples were compared on symptom severity, social adjustment, global functioning and other clinical indicators (self-mutilation, parasuicide and readmission rates) at intake, 6, 12, 24, and 72 months. Results indicated that a specialist step-down model showed significantly greater change than a purely inpatient model and TAU in most key dimensions of functioning, a difference maintained at 72-months follow-up. Improvement in the samples was not associated with amount of intercurrent treatment received in the year prior to the follow-up assessment. This study confirms that a step-down program retains significant improvement associated with a specialist psychosocial approach for PD. However, this conclusion should be qualified by design limitations. The samples were not randomly allocated to the three conditions and the naturalistic geographical allocation used in the study created a potential for a number of confounds. Whilst we used extensive statistical controls, the possibility that the differences found between the groups may be due to population differences cannot be discounted.     

Motivation for treatment in patients with personality disorders

The primary objective of the present study is to investigate the association between DSM-IV personality disorders and motivation for treatment in a large sample of patients admitting for a variety of psychotherapeutic programs (n = 1083). Second, we examine whether and to what extent this association is accounted for by other relevant patient variables (i.e., demographics, subjective distress, and treatment history). We developed a brief questionnaire to measure the motivation for treatment: the Motivation for Treatment Questionnaire (MTQ-8). The MTQ-8 consists of two subscales, i.e., Need for help and Readiness to change. The results show that patients with various personality disorders were significantly more motivated for treatment than those without. No differences across specific personality disorders were apparent. The association between personality disorders and motivation for treatment appeared to be partly accounted for by the level of symptom distress. It is concluded that, among treatment-seeking patients, personality disorders are associated with motivation for treatment and this association can best be understood by the higher symptom distress in patients with personality disorders as compared to those without personality disorders.     

Integrated treatment: a conceptual framework for an evidence-based approach to the treatment of personality disorder

Evidence that various therapies are effective in treating personality disorder and that outcome does not differ substantially across treatments suggests that it is time replace concerns about the efficacy of specific therapies and which form of therapy to use with an evidence-based approach that combines methods that work from all therapies. A framework is proposed for selecting and combining eclectic treatment methods and delivering them in a coordinated way. The framework has two components: (1). a system for conceptualizing personality disorder based on empirical knowledge about the structure, etiology, development, and stability of personality pathology to use as a guide to selecting interventions and planning the sequence in which they will be used; and (2), a model of therapeutic change based on the general literature on psychotherapy outcome and specific studies of PD treatments. The framework proposes that integrated treatment be organized around general principles of therapeutic change common to all effective therapies supplemented with more specific treatment methods taken from the different therapies as needed to tailor treatment to individual patients and treat specific problems and psychopathology. The coordinated delivery of such a diverse array of interventions is achieved by using a phases of treatment scheme that proposes that treatment focus on specific symptoms and problems is a systematic and orderly way according to their stability and potential for change.     

On the renaissance of personality assessment and personality theory

Both personality assessment and personality theory have experienced a significant decline in the past two or three decades, giving way to alternate professional interests by some, and being attacked as both empirically unsupportable and devoid of conceptual merit by others. Several tangible signs suggest that a resurrection is underway owing to position reversals by former critics, the changing character of patient populations, refinements in personality-oriented psychometric techniques, the refurbishing of analytic, interpersonal, and learning theories of personality, and the central role assigned personality disorders in the multiaxial format of the DSM-III. Looking toward the future, the paper proposes a series of comprehensive and parallel diagnostic criteria for the personality disorders to be included in either DSM-IIIR or DSM-IV.