17b
Andrea L. Gold and Shirley Yen
In their review of cognitive and behavioral approaches for personality disorders (PDs), Rosenthal, Wyatt, and McMahon (this volume) provide an excellent, comprehensive summary of cognitive behavioral therapies (CBTs) and related research spanning over 30 years. The authors conceptualize CBTs as a family of interventions collectively defined by their application of empirically supported principles stemming from basic science to promote behavioral, emotional, and cognitive change. Although the evidence supporting cognitive and behavioral approaches to the treatment of PDs is relatively sparse compared to the abundant literature on randomized controlled trials (RCTs) for mood and anxiety disorders, it is nonetheless encouraging to see the breadth of CBTs for PDs.
As reviewed in this chapter, interventions showing some empirical support for the treatment of PDs include dialectical behavior therapy (DBT), schema focused therapy (SFT), cognitive therapy for personality disorders, emotion regulation group therapy (ERGT), and systems training for emotional predictability and problem solving (STEPPS). However, as the authors acknowledge, most of this work is restricted to borderline personality disorder (BPD), and strong empirical support for other PDs is lacking. There are many reasons why cognitive and behavioral psychotherapy development has been limited to BPD. Of note, BPD is unique among the PDs in terms of its inclusion of suicidal behaviors or non-suicidal self-injury (NSSI) as a diagnostic criterion, which translates into higher rates of suicide attempts and risk for psychiatric hospitalizations within this population. In the community, the presence of suicidal and self-injurious behaviors among individuals with BPD reflects a higher level of risk and associated healthcare costs, as well as heightened urgency for intervention and priority for clinical research (Bender et al., 2001; Yen et al., 2003; Zanarini, Frankenburg, Khera, & Bleichmar, 2001; Zanarini et al., 2008). Similarly, this diagnostic criterion of BPD provides an outcome variable that is easier to measure and operationalize relative to the criteria for other PDs. Indeed, the focus within DBT treatment research on specific behavioral outcomes, such as the frequency of NSSI events and suicide attempts and the use of hospital-based crisis services, facilitates outcome assessment and increases the likelihood of observable improvements. In this sense, it is understandable that outcome research for BPD has outpaced other PDs. More work is needed to evaluate how and when CBTs promote clinical improvements across PD diagnoses. Indeed, despite the fact that other PDs are also associated with high rates of suicide and suicidal behaviors (Ansell et al., 2015; Giner et al., 2013; Links, Gould, & Ratnayake, 2003), as well as significant impairment and disability (Skodol et al., 2005), they are disproportionately understudied with respect to treatment.
Similar to the way in which BPD stands out among all PDs as having the most treatment outcome research, the authors note that DBT stands out among established CBTs as the “gold standard” BPD treatment. DBT clearly appears to be the most widely implemented intervention when it comes to CBTs for PDs. Why might this be the case? One possibility is that DBT has the most empirical support for its utility, ranging from RCTs (Koons et al., 2001; Linehan, Armstrong, Suarez, Allmon, & Heard, 1991; Linehan et al., 2006) and meta-analyses (Kliem, Kröger, & Kosfelder, 2010; Panos, Jackson, Hasan, & Panos, 2014) to quasi-experimental research (Bohus et al., 2004; Rathus & Miller, 2002) and program evaluation studies (Bohus et al., 2000; Comtois, Elwood, Holdcraft, Smith, & Simpson, 2007; Yen, Johnson, Costello, & Simpson, 2009). Moreover, DBT has ample training programs, including the Behavioral Tech organization that helps clinicians establish and monitor DBT programs. Additionally, the DBT-Linehan Board of Certification (DBT-LBC) evaluates and identifies providers and programs that deliver DBT with fidelity to the model, serving to confirm that implementation adheres to the evidence-based research. At the same time, the DBT-LBC is a relatively new organization, founded within the last five years. Thus, many implementations of DBT in the community reflect adaptations of the outpatient model investigated in RCTs, but with varying degrees of modifications. Indeed, treating PDs in real world settings often requires clinicians to make necessary adaptations to fit the needs of the clinic or community. For example, DBT has been adapted to match levels of care available in the environment, including residential, inpatient, partial hospital, and intensive-outpatient levels of care, as well as outpatient services provided in community mental health centers and Veterans Affairs medical centers.
Moreover, DBT-based interventions are sometimes implemented ahead of the science. For example, DBT clinics geared toward adolescents developed before the completion of efficacy trials. The first DBT-A RCT (Mehlum et al., 2014) was published over half a decade following the publication of the first DBT-A treatment guide (Miller, Rathus, & Linehan, 2006) and concurrently with the DBT-A treatment handbook (Rathus & Miller, 2014). The second RCT for DBT-A, a multi-site study, was only recently published (McCauley et al., 2018) – over a decade following the initial treatment guide. Furthermore, brief guides describing the follow-up to standard DBT-A treatments, the so-called phase 2 or graduate group treatments have been published for adolescents (Miller et al., 2006; Rathus & Miller, 2014) and implemented in clinical communities without the research to demonstrate their efficacy.
These repeated trends for DBT applications for adolescents to be implemented ahead of the science clearly suggest a dire need for adolescent interventions that cannot wait for the science. As evidenced in Rosenthal et al.’s review, studies of cognitive behavioral approaches to PDs tend to focus on adults. Yet, in the case of BPD, there is ample evidence it can be reliably diagnosed in adolescence, and the DSM-5 (APA, 2013) allows for the diagnosis before adulthood. Indeed, the National Education Alliance for BPD (NEA.BPD) recently began a global initiative to support collaborative work advancing developmental approaches to BPD: the Global Alliance for the Prevention and Intervention of BPD (GAP; www.borderlinepersonalitydisorder.com/what-is-gap/). Clearly, clinicians are faced with challenges surrounding the presentation of PD symptoms, particularly BPD, in high-risk adolescent populations, and cognitive and behavioral intervention efforts for this population must take into account developmental perspectives, family systems, and pediatric approaches.
Even when cognitive and behavioral approaches to treating PDs are available, there may be challenges to implementing them. First, diagnostic heterogeneity – a problem for any PD – is a particular problem when considering treatments targeting all PDs. Comorbidity appears to be the rule rather than the exception, reflecting comorbidity among multiple PDs (Hyler, Kellman, Oldham, & Skodol, 1992) and with disorders other than PDs, such as mood and anxiety disorders (Kaufman & Charney, 2000). Indeed, oftentimes what brings individuals with PD diagnoses into treatment is their comorbid depression or anxiety. Although comorbidity leads to challenges in treatment implementation, CBTs reflect a family of interventions that may be particularly well suited to handle such heterogeneous and comorbid clinical presentations. CBTs for both PDs and mood and anxiety disorders reflect and apply the same principles, such as exposure, cognitive restructuring, and behavioral activation. This allows clinicians to flexibly deploy and tailor CBTs to address a range of symptom presentations. Although the authors note that CBTs for transdiagnostic personality dysfunction are not yet established, such work is under development (Mulder & Chanen, 2013) and has a precedent in existing CBT approaches, such as the Unified Protocol for emotional disorders developed by Barlow and colleagues (Barlow et al., 2017). Furthermore, although implementing CBTs for PDs in the context of psychiatric comorbidity is further compounded by the issue of dual diagnosis (or comorbid substance use disorders), DBT has addressed this issue through the adaptation of DBT for substance using populations (Linehan et al., 1999), which may present a model for other CBTs.
As the authors note, there are few “branded CBTs” for PDs, particularly for PDs other than BPD. This may be due to a host of factors that make it exceedingly challenging to conduct psychotherapy development and outcome research for PDs. For example, a longer time course is often needed to address the more pervasive and longstanding patterns of maladaptive intra- and interpersonal behaviors associated with PDs relative to other psychiatric disorders. Treatment settings such as Veterans Affairs medical centers may be in an ideal position to conduct such work, given the presence of large systems and interdisciplinary treatment teams that allow longer courses of treatment in the absence of barriers linked to insurance. Indeed, treatment of PDs requires time and resources; thus, affordability is a barrier for many patients in need of treatment. It is thus not a surprise that much of the research on treatments for PDs has been conducted outside of the United States, where healthcare costs and barriers to healthcare are generally lower. Given that adaptations for DBT and other types of CBTs are often required to match the needs of the clinic or community, an investment in effectiveness research beyond DBT for BPD is necessary to develop, evaluate, and disseminate promising interventions.
In conclusion, although it is promising that there are several CBTs for PDs, the focus of research has been predominantly on BPD and DBT. Although evidence for the effectiveness of DBT is accumulating, there is a need to reach a broader spectrum of PD patients. A CBT targeting common symptom presentations may be a promising approach, and is in need of further development and research.
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