17c
M. Zachary Rosenthal, Kristin P. Wyatt, and Kibby McMahon
We appreciate the thoughtful commentaries about our chapter written by Gold and Yen and, separately, Hughes and Rizvi. Each pair of authors raises many excellent points about the challenges associated with drawing upon the available body of scientific research when using cognitive and behavioral therapies to treat individuals with personality disorders (PDs). Both commentaries converge on the recommendation that clinicians using cognitive behavioral therapies for patients with PDs consider using principle-driven, modular, and transdiagnostic approaches. In this brief rejoinder, we highlight and extend upon several particular comments made in both commentaries.
The authors have highlighted the limitations of the current established CBTs for PDs. For example, therapies that have demonstrated efficacy for mainly one PD are often used for other populations without sufficient empirical justification. Gold and Yen (this volume) note that DBT is the most well-studied treatment specifically for BPD. Due to its efficacy for BPD, it has been adapted for use in other populations. At times, this has occurred ahead of the pace of scientific research directly testing and supporting the efficacy within such populations. The authors note, for example, how DBT for adolescents (DBT-A) was disseminated to clinicians prior to results from rigorously conducted randomized controlled clinical trials demonstrating its efficacy (Mehlum et al., 2014). DBT-A is not alone. There are other adaptations from standard DBT (and other treatments) that have been (or are currently being) disseminated to clinicians early in the process of such approaches being directly empirically investigated.
In the absence of an evidence base for manualized interventions with strong empirical support for these other populations, what is the clinician to do when such patients present for help? We believe that branded but understudied adaptations of CBT protocols for PDs, such as DBT, have taken hold because these interventions: (a) are grounded in transdiagnostically relevant empirically supported principles of change, and (b) offer hope and a treatment plan to clinicians who otherwise may lack hope or clarity about a treatment plan. On the one hand, it makes sense why established CBT protocols have been adapted and disseminated in the absence of extensive research studies directly testing the newly adapted approach. In some ways, these adaptations are in line with procedures we have argued for in our chapter: using case conceptualization to guide selection of empirically supported procedures corresponding to the relevant clinical processes and contexts. On the other hand, we wish to emphasize the importance of clinicians being aware of and communicating to patients the limitations in the science underlying the treatment they are offering.
Looking forward, the high comorbidity and complexity of personality pathology call for a new approach to treatment. We have argued in our chapter that a reasonable approach is to move beyond branded manualized treatments to empirically supported principles of change with a case conceptualization that organizes treatment targets, processes, and outcomes. Like Gold and Yen, Hughes and Rizvi also share interesting insights in their commentary on this new approach. We appreciate the high specificity of the suggestions provided (e.g., structured case formulation, target hierarchy), in that these suggestions more clearly operationalize ways to enact empirically supported principle-driven treatment. Hughes and Rizvi’s commentary on the need for behaviorally specific targets of change is especially germane to a principle-driven approach. We agree that this may be particularly difficult to do when treating PD populations, given the heterogeneity of clinical presentations, therapeutic goals, and therapy-interfering interpersonal behaviors that can inadvertently delay treatment progress.
We also welcome their highlighting the advantages of a modular approach to the treatment of personality dysfunction, with flexible and tailored interventions using empirically supported cognitive and behavioral principles and processes. This approach is especially timely, given current national healthcare trends in payer reform that emphasize a shift to value-based care using a population health framework. More specifically, insurers and payers (e.g., Medicare, Medicaid, commercial payers) are transitioning from fee-for-service to fee-for-value and risk-based models of care. Within these value-based care models, clinicians will increasingly be required by payers to take financial risk by demonstrating value across the patients they treat. With regard to PDs, one implication of this shift is that clinicians will increasingly be incentivized with financial risk and reward to provide measurable improvements in treatment for the lowest possible cost to the payer.
As payers change to value-based models of reimbursement, it will be increasingly important to identify low-cost and flexible interventions that target specific, transdiagnostic forms of personality dysfunction. A modular approach, as suggested by Hughes and Rizvi, might include the systematic use of screening tools that capture transdiagnostic personality dysfunction and stratify patients into those needing time-limited versus longer-term care pathways. This approach could be considered a more resource-lean, lower cost way to engage specific psychological process targets (e.g., disinhibition, psychological flexibility) known to underlie personality dysfunction and to be amenable to change using empirically supported modules of interventions. Such an approach would offer measurement-based care and enhance access to services for more people by utilizing a time-limited approach.
In sum, the current “branded” CBTs for PDs are often resource heavy and are limited in their ability to meet the complexity, heterogeneity, and pervasiveness of personality dysfunction in clinical populations. We agree with the rest of the authors that we should consider modular, principle-driven approaches to conceptualization and treatment. With these approaches, we can better distinguish those patients who need to be treated with these comprehensive protocols from those who would instead benefit from a streamlined adaptation targeted to specific processes of change.
References
Mehlum, L., Tørmoen, A. J., Ramberg, M., Haga, E., Diep, L. M., Laberg, S., … Grøholt, B. (2014). Dialectical behavior therapy for adolescents with repeated suicidal and self-harming Adolescent Psychiatry, 53(10), 1082–1091.