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Brief Therapeutic Approaches for Personality Disorders

Katherine L. Dixon-Gordon, Lindsey C. Conkey, and Sherry E. Woods

Introduction

Personality disorders (PDs) are longstanding patterns of maladaptive cognition, affect, and behavior that lead to substantial distress and impairment (American Psychiatric Association, 2013). These disorders affect approximately 9 percent of the population (4.4–14.8 percent; Quirk et al., 2016; Samuels et al., 2002). Relative to these modest prevalence rates, PDs incur disproportionately great societal costs. Individuals who suffer from PDs use more treatment resources (Quirk et al., 2016), rely more heavily on disability and social services (Østby et al., 2014), and have reduced life expectancies (Fok et al., 2012). The fifth revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) delineates ten distinct forms of PDs that are classified into three clusters based on similar patterns of maladaptive behaviors (American Psychiatric Association, 2013). Schizoid, paranoid, and schizotypal PDs are classified in Cluster A and involve odd or eccentric patterns of behavior. Antisocial, borderline, narcissistic, and histrionic PDs are classified in Cluster B, and involve dramatic and impulsive patterns of behavior. Avoidant, dependent, and obsessive-compulsive PDs are classified in Cluster C, and involve anxious or fearful patterns of behavior. In addition to these categorical distinctions that distinguish the presence or absence of PDs based on diagnostic thresholds, PDs may also be observed on a continuum (Trull, Distel, & Carpenter, 2011). Consequently, the DSM-5 provides an alternative model that characterizes PDs as maladaptive variants of normative personality dimensions.

The presence of PDs often complicates the treatment process, a particularly concerning problem since these disorders occur at high rates (up to 45 percent) in clinical settings (Zimmerman, Rothschild, & Chelminski, 2005). The presence of PDs often indicates a more severe symptom presentation. For instance, patients with emotional disorders and co-occurring PDs were more severely depressed at intake than their counterparts without PDs (Lis & Myhr, 2016). Additionally, PDs have been associated with greater treatment drop-out (Schindler, Hiller, & Witthöft, 2013), and Cluster B PD traits specifically have been linked to poorer working alliance in treatment (Olesek et al., 2016). These factors may have fueled some of the historical concerns about the amenability of PDs to treatment (Lewis & Appleby, 1988).

The late twentieth century welcomed the emergence of several psychotherapies for PDs (see Dixon-Gordon, Turner, & Chapman, 2011). The most well-studied of these treatments have predominately focused on borderline PD, including dialectical behavior therapy (DBT; Linehan, 1993), mentalization-based therapy (MBT; Fonagy & Bateman, 2008), and schema-focused therapy (SFT; Giesen-Bloo et al., 2006). Apart from these borderline PD-specific treatments, meta-analytic evidence supports the efficacy of PD psychotherapies broadly when compared to treatment-as-usual (TAU; Budge et al., 2013). The implementation and reach of these treatments has so far been limited, due in part to their length (one to three years) and intensity (two to six hours per week). Public healthcare systems often lack the resources to develop and sustain PD treatment programs (Carmel, Rose, & Fruzzetti, 2013; National Collaborating Centre for Mental Health, 2009). Although longer-term treatment is recommended for patients with PDs (Crits-Christoph & Barber, 2007), promoting uptake of evidence-based strategies would be enhanced by an understanding of patient populations, settings, and services in which briefer treatments are effective. Briefer programs would be less costly, easier to implement and sustain, and more accessible to larger numbers of patients. In an effort to address this public need, researchers have focused their efforts on developing and assessing the utility of brief interventions.

The following review will detail recent advances in brief treatments for PDs. As such, the objectives of the present review are to: (1) provide a summary of the extant literature on briefer treatments for PDs, and (2) provide recommendations for future research and clinical practice.

An Update of Brief Psychosocial Treatments for PDs

The present chapter provides an update on the empirical literature related to brief treatments of PDs.¹ In line with treatment guidelines, we focused on psychosocial therapies for PDs (National Collaborating Centre for Mental Health, 2009). To ensure that these treatments were designed to target the problems associated with PDs, we focus herein on trials that were specifically designed for PD samples. Of note, this approach excluded trials that examined PDs as potential moderators of treatment response for other conditions. Although brief treatments have been defined with many durations (e.g., 1–40 sessions; Center for Substance Abuse Treatment, 1999), given the lengthy duration of many existing PD treatments, we have reviewed interventions involving less than one year of therapy. See Figure 20.1 for our selection process and excluded articles. A total of 66 articles are summarized below. The studies included in the final review are presented in Table 20.1. Only a minority of these studies were randomized controlled trials (RCTs; n = 25). Nearly half focused on borderline PD (n = 32). We have organized this literature broadly by treatment approach.

Figure 20.1

Selection process diagram

Table 20.1Summary of studies meeting inclusion criteria

Reference	Sample	Diagnosis	Treatment	Length	Design
Dynamic
(Amianto et al., 2011)	N = 35	BPD	SB-APP+STM (n = 18) vs. STM (n = 17)	12 months	RCT with 1-year follow-up
(Andreoli et al., 2016)	N = 170	BPD and depression	AP-Clinicians (n = 70) vs. AP-Nurses (n = 70) vs. TAU (n = 30)	3 months, 2x a week	RCT with 3-month follow-up
(Berggraf et al., 2014), secondary analyses of (Svartberg et al., 2004)	N = 47	Cluster C PD	STDP (n = 23) vs. cognitive therapy (n = 24)	40 sessions	RCT
(Hellerstein et al., 1998)	N = 49	PD	STDP (n = 25) vs. BSP (n = 24) – other arms of this trial were not reported	40 sessions	RCT with 6-month follow-up
(Horn, Verhuel, et al., 2015)	N = 134	PD	STIP-TA (n = 67) vs. other psychotherapies (n = 67)	3 months	Non-randomized controlled trial
(Muran et al., 2005)	N = 128	Cluster C PD or PDNOS	STDP (n = 16) vs. CBT (n = 19) vs. BRT (n = 21)	30 weekly sessions	Non-randomized controlled trial
(Ryle & Golynkina, 2000)	N = 27	BPD	Cognitive analytic therapy	24 sessions	Uncontrolled trial
(Schanche et al., 2011), secondary analyses of (Svartberg et al., 2004)	N = 50	Cluster C PD	STDP (n = 25) vs. cognitive therapy (n = 25)	40 sessions	RCT
(Svartberg et al., 2004)	N = 50	Cluster C PD	STDP (n = 25) vs. cognitive therapy (n = 25)	40 sessions	RCT with 2-year follow-up
(Ulvenes et al., 2012), secondary analyses of (Svartberg et al., 2004)	N = 46	Cluster C PD	STDP (n = 23) vs. cognitive therapy (n = 23)	40 sessions	RCT
(Vinnars et al., 2005)	N = 156	PD	Manualized dynamic supportive-expressive psychotherapy (n = 80) vs. community dynamic therapy (n = 76)	40 sessions	RCT with 1-year follow-up
(Westerman et al., 1995) secondary analyses of Winston et al., 1991	N = 59	PD, primarily Cluster C	BAP (n = 21) vs. STDP (n = 21) vs. waitlist (n = 17)	40 weeks BAP/STDP, 15 week waitlist	RCT with 1.5-year follow-up for subsample (n = 38)
(Winston et al., 1991)	N = 47	PD, primarily Cluster C	BAP (n = 17) vs. STDP (n = 15) vs. waitlist (n = 17)	40 weeks BAP/STDP, 20-week waitlist	RCT
(Winston et al., 1994)	N = 81	PD, primarily Cluster C	BAP (n = 30) vs. STDP (n = 25) vs. waitlist (n = 26)	40 weeks BAP/STDP, 15-week waitlist	RCT with 1.5-year follow-up for subsample (n = 38)
Cognitive-behavioral
(Alden, 1989)	N = 76	APD	CBT exposure vs. CBT exposure and interpersonal skills training vs. CBT exposure and interpersonal skills with a focus on close relationships vs. waitlist	10 weeks	RCT with 3-month follow-up
(Andreasson et al., 2016)	N = 108	BPD	DBT (n = 57) vs. CAMS (n = 51)	16 weeks	RCT
(Blum et al., 2002)	N = 52	BPD	STEPPS	20 weeks	Uncontrolled trial
(Bohus et al., 2000)	N = 24	BPD inpatients	Inpatient DBT	3 months	Uncontrolled trial
(Bohus et al., 2004)	N = 50	BPD inpatients	Inpatient DBT (n = 31) vs. waitlist (n = 19)	3 months	Non-randomized controlled trial
(Bos et al., 2010)	N = 79	BPD	STEPPS (n = 42) vs. TAU (n = 37)	18 weeks	RCT
(Chugani et al., 2013)	N = 19	Cluster B PD diagnosis or traits	DBT skills training (n = 11) vs. TAU (n = 8)	11 weeks	Non-randomized controlled trial
(Davidson et al., 2009)	N = 52	ASPD+aggression	CBT+TAU (n = 25) vs. TAU (n = 27)	6 or 12 months	RCT
(Davidson et al., 2014)	N = 20	PD (with recent episode of self-harm)	MACT (n = 14) vs. TAU (n = 11)	6 sessions	RCT
(Dixon-Gordon et al., 2015)	N = 19	BPD	DBT emotion regulation (n = 7) vs. DBT interpersonal effectiveness (n = 6) vs. psychoeducation (n = 6)	6 sessions	RCT
(Doyle et al., 2013)	N = 126	ASPD traits	ETS (n = 70) vs. TAU (n = 26)	5 weeks	Non-randomized controlled trial
(Emmelkamp et al., 2006)	N = 62	APD	CBT (n = 21) vs. BDT (n = 23) vs. waitlist (n = 18)	20 weeks	RCT
(Evans et al., 1999)	N = 32	Recent self-harm and Cluster B PD traits	MACT (n = 18) vs. TAU (n = 16)	Max 6 months + bibliotherapy	RCT
(Feliu-Soler et al., 2014)	N = 35	BPD	DBT mindfulness skills training + GPM (n = 18) vs. GPM (n = 17)	10 weeks	RCT
(Gratz & Gunderson, 2006)	N = 22	BPD females with recent and recurrent self-injury	ERGT (n = 12) vs. TAU (n = 10)	14 weeks	RCT
(Gratz & Tull, 2011)	N = 23	BPD females with recent and recurrent self-injury	ERGT	14 weeks	Uncontrolled trial
(Gratz et al., 2014)	N = 61	BPD females with recent and recurrent self-injury	ERGT immediately (n = 31) vs. waitlist+later ERGT (n = 30)	14 weeks	RCT with uncontrolled 9-month follow-up
(Harvey et al., 2010)	N = 38	BPD	STEPPS	20 weeks	Uncontrolled trial
(Huband et al., 2007)	N = 176	PD	Problem-solving group sessions (n = 87) vs. waitlist (n = 89)	16 sessions	RCT
(Kleindienst et al., 2008), Secondary analyses from (Bohus et al., 2004)	N = 60	BPD	Inpatient DBT (n = 40) vs. waitlist+TAU (n = 20)	3 months with 21-month follow-up	Uncontrolled trial
(Kröger et al., 2013)	N = 1423	BPD	Inpatient DBT	3 months	Uncontrolled trial
(McMain et al., 2017)	N = 84	BPD and recent self-injury	DBT skills (n = 42) vs. waitlist (n = 42)	20 weeks	RCT
(Meaney-Tavares & Hasking, 2013)	N = 17	BPD	DBT skills-training sessions	8 sessions	Uncontrolled trial
(Pasieczny & Connor, 2011)	N = 90	BPD	DBT (n = 43) vs. waitlist+TAU (n = 47)	6 months	Non-randomized controlled trial
(Perroud et al., 2010)	N = 447	PD (94% BPD)	Intensive DBT	3-4 weeks	Uncontrolled trial
(Rizvi et al., 2017)	N = 50	BPD	DBT	6 months	Uncontrolled trial
(Sahlin et al., 2017)	N = 95	Women with BPD or BPD features and recurrent self-injury	ERGT	14 weeks	Uncontrolled naturalistic trial with 6-month follow-up
(Soler et al., 2009)	N = 59	BPD	Brief DBT skills (n = 29) vs. standard group (n = 30)	13 weeks	RCT
(Soler et al., 2012)	N = 59	BPD	DBT-mindfulness group + GPM (n = 40) vs. GPM alone (n = 19)	8 sessions	RCT
(Springer et al., 1996)	N = 31	PD	Brief DBT inpatient (n = 16) vs. wellness activity-control (n = 15)	10 daily-sessions	RCT
(Stanley et al., 2007)	N = 20	BPD	Brief DBT	6 months	Uncontrolled trial
(Thylstrup et al., 2015); (Thylstrup et al., 2017)	N = 176	ASPD and substance use	ILC (n = 96) vs. TAU (n = 80)	6 sessions, 11 weeks	RCT with 15-month follow-up
(Yen et al., 2009)	N = 50	BPD	Brief inpatient DBT	5 days	Uncontrolled trial with 3-month follow-up
(Weinberg et al., 2006)	N = 30	BPD and recurrent NSSI	MACT (n = 15) vs. TAU (n = 15)	6 sessions	RCT with 6-month follow-up
Integrative
(Ball et al., 2005)	N = 52	PD in homeless adults	DFST (n = 26) vs. substance abuse counseling (n = 26)	6 months	RCT
(Ball, 2007)	N = 30	PD	DFST (n = 15) vs. 12FT (n = 15)	6 months	RCT
(Nenadić et al., 2017)	N = 9	BPD or Cluster C PD	GST	12–15 weeks	Uncontrolled trial
(Pabst et al., 2011)	N = 21	BPD+PTSD	Narrative exposure	Meansessions = 14 (11–19)	Uncontrolled trial with 6-month follow-up
(Prunetti et al., 2013)	N = 51	PD (71%BPD)	CET	3 weeks	Uncontrolled trial with 3-month follow-up
(Renner et al., 2013)	N = 26	Cluster B or C PD or features	Schema CBT	20 sessions	Uncontrolled trial
(Skewes et al., 2015)	N = 8	PD (n = 7 APD)	GST	20 sessions	Uncontrolled trial with 6-month follow-up
Multi-component Programs
(Amianto et al., 2011)	N = 35	BPD	SB-APP+STM (n = 18) vs. STM (n = 17)	12 months	RCT with 1-year follow-up
(Bartak et al., 2010)	N = 371	Cluster C PD	Long-term outpatient treatment (n = 68), short day hospital treatment (n = 77), long-term day hospital treatment (n = 74), short inpatient treatment (n = 59), long-term inpatient treatment (n = 93)	Various	Non-randomized naturalistic trial
(Gratz et al., 2006)	N = 36	BPD	Integrative, step-down treatment program for BPD	Hospitalization average of 8 weeks; outcomes measured at 1- and 3-months	Uncontrolled trial
(Horn, Bartak, et al., 2015)	N = 205	PDNOS	Short-term outpatient (n = 17), long-term outpatient (n = 50), short-term day-hospital (n = 26), long-term day-hospital (n = 36), short-term inpatient (n = 52), long-term inpatient (n = 36)	Various (short-term <6 months, long-term >6 months)	Non-randomized naturalistic trial
(Ogrodniczuk et al., 2011)	N = 197	PD	Day treatment program including art, exercise, vocational, interpersonal, and cognitive behavioral groups	18 weeks	Uncontrolled trial
(Petersen et al., 2008)	N = 66	PD	Day treatment including individual and group psychodynamic and cognitive therapy (n = 38) vs. TAU+waitlist (n = 28)	5 months	Non-randomized controlled trial
(Sollberger et al., 2015)	N = 44	BPD inpatients	DST (n = 32) vs. TAU (n = 12)	12 weeks	Non-randomized controlled trial

Note: 12FT = 12 step facilitation therapy; AP = abandonment psychotherapy; APD = avoidant personality disorder; ASPD = antisocial personality disorder; BAP = brief adaptive psychotherapy; BDT = brief dynamic therapy; BPD = borderline personality disorder; BRT = brief relational therapy; BSP = brief supportive psychotherapy; CBT = cognitive behavioral therapy; CET = cognitive evolutionary therapy; CAMS = collaborative assessment and management of suicidality; DFST = dual-focused schema therapy; DST = structured disorder-specific inpatient treatment; ERGT = emotion regulation group therapy; ETS = enhanced thinking skills intervention; GPM = general psychiatric management; GST = group schema therapy; ILC = impulsive learning counseling; MACT = manual-assisted cognitive therapy; NSSI = non-suicidal self-injury; PD = personality disorder; PDNOS = personality disorder not otherwise specified; RCT = randomized controlled trial; SBPP = Sequential Brief Adlerian Psychodynamic Psychotherapy; STDP = short term dynamic psychotherapy; STIP-TA = short-term inpatient psychotherapy based on transactional analysis; STM = structured team management; STEPPS = systems training for emotional predictability and problem solving; TAU = treatment as usual.

Dynamic Approaches

A recent surge in research on psychodynamic treatments has yielded support for time-limited versions of these treatments for PDs. Building off prior work (Davanloo, 1980), short-term dynamic psychotherapy (STDP) draws on traditional psychoanalytic theory and emphasizes an active role of the therapist through elicitation of affect and use of the therapeutic relationship. Several RCTs have compared brief (i.e., 40 sessions) STDP to other treatments for PD. For instance, patients with any PD randomized to receive STDP reported significant improvements in patient-identified target complaints and symptom severity (N = 49; Hellerstein et al., 1998). In addition, after completing STDP, patients with a Cluster C PD (N = 50) exhibited improvements in general psychiatric symptoms, PD symptoms, interpersonal problems (Svartberg, Stiles, & Seltzer, 2004), social adjustment (N = 81; Winston et al., 1991, 1994), emotional and identity symptoms (Berggraf et al., 2014), and self-compassion (Schanche, Stiles, McCullough, Svartberg, & Nielsen, 2011). In addition, both STDP and brief adaptive therapy demonstrated superiority to a waitlist control (Winston et al., 1991, 1994), but this waitlist was only 15–20 weeks in duration, confounding the treatment conditions with time. There were no other significant differences between STDP and comparison conditions. Given the lack of a matched control condition, the efficacy of STDP warrants further study.

In terms of specificity, there is little evidence that STDP outperforms other treatments for PDs. No significant differences emerged between STDP and brief supportive psychotherapy (Hellerstein et al., 1998), brief adaptive therapy (a more cognitively oriented dynamic treatment; Winston et al., 1994), or cognitive therapy (Berggraf et al., 2014; Schanche et al., 2011; Svartberg et al., 2004). Among patients with a Cluster C PD or PD not otherwise specified (N = 128), a 30-session STDP with weekly half-hour sessions had a higher proportion of treatment drop-outs relative to brief relational therapy in a non-randomized controlled trial, and a lower rate of patients who achieved reliable improvements in interpersonal functioning than the CBT condition (Muran, Safran, Samstag, & Winston, 2005).

Examinations of the processes associated with outcomes in STDP shed light on putative mechanisms of this treatment. In secondary analyses evaluating process in STDP (Ulvenes et al., 2012; Westerman, Foote, & Winston, 1995), there was evidence of differential processes across treatments. Whereas avoidance of affect was associated with less symptom reduction in STDP, it was associated with more symptom reduction in cognitive therapy (Ulvenes et al., 2012). In addition, the strength of the therapeutic alliance was associated with outcome in STDP (Westerman et al., 1995).

Other trials have compared a range of other dynamic approaches to TAU for PDs. For instance, an RCT compared supportive-expressive dynamic psychotherapy, a time-limited (i.e., 40-session) manualized treatment designed to alter maladaptive interpersonal patterns characteristic of PDs, to TAU for patients with PDs (N = 156; Vinnars, Barber, Norén, Gallop, & Weinryb, 2005). Although there were no between-group differences in PD severity, psychiatric symptoms, or global functioning post-treatment, the supportive-expressive treatment was associated with significantly fewer visits to community mental health centers than TAU at the one-year follow-up. In addition, a non-randomized trial compared the utility of a three-month inpatient psychotherapy program based on transactional analysis (involving both psychodynamic and cognitive behavioral principles and tailored for personality pathology) to TAU (Horn, Verhuel, et al., 2015). Patients with PDs (N = 67) were matched with patients in other Dutch treatment programs. Patients in the treatment condition improved significantly more in terms of general psychiatric symptoms and quality of life, and had higher recovery rates (68 percent vs. 48 percent in the control). Effect sizes were large, and improvements persisted over the three-year follow-up period. These data offer preliminary support for the potential utility of these brief dynamic interventions, although replication is needed.

Several dynamic interventions were designed to treat borderline PD in particular. Some of these studies compared time-limited dynamic treatments to a less resource-intensive control condition. For instance, one RCT compared abandonment psychotherapy as delivered by certified psychotherapists to the same treatment delivered by nurses and to TAU (Andreoli et al., 2016). Abandonment psychotherapy is a three-month, twice-weekly manualized intervention designed to target abandonment fears characteristic of borderline PD by cultivating emotional understanding and insight about maladaptive patterns. Integrating principles of MBT and DBT, this approach also directly targets therapy interfering and safety-interfering behaviors. Among patients with an admission due to self-injury who met criteria for major depression and borderline PD (N = 170), the experimental conditions did not significantly differ, and both resulted in reduced suicidal ideation, suicide attempts, and a lower likelihood of a psychiatric hospitalization at the three-month follow-up, relative to TAU. Therefore, formal training in psychotherapy does not appear to be associated with better outcomes, further increasing the accessibility of this treatment.

Likewise, another study compared a time-limited psychodynamic treatment, Sequential Brief Adlerian Psychodynamic Psychotherapy (SB-APP), to a less resource-intensive clinician-training condition for participants with borderline PD (N = 35) and a history of high treatment use (Amianto et al., 2011). In 40 weekly sessions, SB-APP focuses on strengthening identity, increasing validation of the self and emotions, and reducing idealization. Based on the notion that one aspect of effective treatments for PDs involves providing staff with training in a cohesive view of the disorder, SB-APP was compared to staff simply receiving supervised team management. All patients demonstrated improvements in global functioning and reductions in anger. The SB-APP showed greater decreases in borderline PD symptoms, including suicide attempts, feelings of emptiness, impulsivity, and relationship disturbance, than the control condition. Thus, individual psychotherapy contributed more than additional clinician training and support.

Finally, cognitive analytic therapy is a dynamic treatment that aims to diagram and reflect on the fragmented emotion-dependent “self-states” experienced by individuals with borderline PD (Ryle & Golynkina, 2000). In an uncontrolled trial of 24 sessions of cognitive analytic therapy for patients with borderline PD (N = 27), 52 percent of patients no longer met PD criteria following treatment (Ryle & Golynkina, 2000). This study remains to be replicated.

Together, the 14 studies reviewed in this section document nine trials examining brief dynamic treatments for PDs (see Table 20.1). Although patients receiving treatment in most of these controlled trials exhibited within-group symptom improvements, only a handful outperformed comparison conditions. The transactional analysis inpatient program (Horn, Verhuel, et al., 2015) and STDP (Winston et al., 1991, 1994) resulted in greater improvement in symptoms and functioning than TAU for PDs. Abandonment psychotherapy (Andreoli et al., 2016) and SB-APP (Amianto et al., 2011) outperformed TAU or an enhanced staff-training, respectively, in reducing suicide attempts and symptoms of borderline PD. None of these results have been replicated, providing only preliminary support for the efficacy of these treatments. Although many studies of STDP fell within our initial search criteria, it is worth noting that several trials allowed for variable duration of treatment and were therefore not included in the present study. Thus, this review likely underestimates the evidence base of STDP.

Cognitive-Behavioral Approaches

The time-limited, problem-focused nature of cognitive behavioral therapy (CBT) lends itself to briefer applications for PDs. Generally, these approaches aim to modify dysfunctional patterns of thinking and behaving by providing psychoeducation, managing contingencies, and improving self-management and social skills deficits (e.g., Doyle et al., 2013; Huband, McMurran, Evans, & Duggan, 2007; Linehan, 1993). Given the prominence of interpersonal problems across PDs, improving social skills in this population was expected to alleviate many of the symptoms and functional impairments associated with a range of PDs (Huband et al., 2007). Based on this premise, Huband and colleagues developed a 16-session problem-solving group therapy as both a brief intervention and a prelude to additional treatment (Huband et al., 2007). In an RCT comparing this intervention to a waitlist control for patients with PDs (N = 176), those who received the intervention had significantly better problem-solving skills, overall higher social functioning, and lower anger expression than controls, although there were no differences in utilization of mental health services.

Preliminary evidence suggests that brief cognitive-behavioral treatments are useful for the treatment of avoidant PD. One RCT compared 20 sessions of CBT to a brief dynamic therapy or a waitlist control for patients with avoidant PD (N = 62; Emmelkamp et al., 2006). Although both active conditions led to decreases over treatment in social anxiety, avoidance, and both avoidant and obsessive-compulsive PD symptoms (albeit not dependent PD symptoms), CBT outperformed the brief dynamic treatment on all these outcomes. These improvements were maintained at a six-month follow-up.

In an effort to identify the relative efficacy of different cognitive-behavioral interventions for avoidant PD, an RCT compared a no-treatment control condition to ten weeks of group therapy containing effective elements of treatments for interpersonal problems for patients with avoidant PD (N = 76; Alden, 1989). In particular, this study compared the no-treatment control to three different 10-week groups focused on (1) graduated exposure only; (2) exposure plus interpersonal skill training; or (3) exposure, interpersonal skills, and the development of intimacy in close relationships. The treatment conditions demonstrated greater improvement than the control condition across interviewer-rated and self-report measures of social inhibition, anxiety, self-esteem, and relational functioning. Further, the intimacy condition outperformed the other social skills condition with regard to the frequency of and satisfaction with social activities (although there were no significant differences between the exposure condition and the other group treatment conditions). The improvements found across the treatment conditions were maintained over the three-month follow-up. Despite these improvements and the fact that half of the participants rated their specific targets as “improved,” few participants (9 percent) rated these targets as completely satisfactory, and symptom scores remained in the clinical range. Thus, although even brief CBT is effective in reducing avoidance and improving social activities for avoidant PD, particularly if the treatment directly targets close relationships, full remission of symptoms was rarely seen.

Two controlled trials have evaluated brief cognitive behavioral interventions for antisocial PD. One pilot RCT directly compared 6 or 12 months of CBT to TAU for males with antisocial PD and a recent act of aggression (N = 52; Davidson et al., 2009). No differences emerged at the 12-month follow-up with respect to anxiety, depression, alcohol abuse, anger, acts of aggression, or social functioning. The authors noted that patients who received 6 months of CBT showed greater improvement in social functioning than those who received TAU, although this difference was non-significant. Another approach, enhanced thinking skills, consists of 20 group sessions over five weeks that teach impulse control, flexible thinking, interpersonal problem-solving, and reasoning (Doyle et al., 2013). In a non-randomized controlled trial for inmates with antisocial PD (N = 126; 49 completers), ETS outperformed the waitlist TAU in reducing anger and antisocial PD symptoms and improving problem-solving.

Another RCT examined a psychoeducation-based adjunctive treatment to a substance use treatment program for antisocial PD. Patients with antisocial PD (N = 176) were randomly assigned to receive six sessions of impulsive lifestyle counseling (ILC) psychoeducation over 11 weeks or TAU (Thylstrup, Schrøder, Fridell, & Hesse, 2017; Thylstrup, Schrøder, & Hesse, 2015). Across both groups, patients reported a decrease in aggression, although no significant difference emerged between conditions. However, relative to TAU, ILC was associated with increased abstinence (Thylstrup et al., 2017) and decreased drug use in the three-month follow-up (Thylstrup et al., 2015). Together, these studies suggest the utility of even shorter-term cognitive-behavioral interventions in reducing some of the symptoms of antisocial PD.

The vast majority of brief cognitive-behavioral treatments were developed to focus on Cluster B PDs, particularly borderline PD. In some cases, these treatments were also evaluated for patients with a range of PDs. For instance, an adjunctive manual-assisted cognitive therapy (MACT) that focuses on understanding the precipitants and advantages and disadvantages of problem behaviors and provides psychoeducation about adaptive coping strategies was originally evaluated for borderline PD, but has been implemented for a range of other PDs. One RCT examined the utility of a six-session adjunctive MACT or TAU only for patients with borderline PD and recent self-injury (N = 30; Weinberg, Gunderson, Hennen, & Cutter, 2006). The MACT condition resulted in significantly greater decreases in the frequency of non-suicidal self-injury during treatment, as well as greater decreases in self-injury severity and frequency over the six-month follow-up. There were no significant differences in change in suicidal ideation. Another study expanded the application of MACT to a sample of inpatients with PDs (N = 20) who were admitted to the hospital for an episode of self-injury (Davidson, Brown, James, Kirk, & Richardson, 2014). Patients who received six sessions of MACT reported lower anxiety, depression, and suicidal ideation than those who received TAU at the three-month follow-up. There were no significant differences in alcohol use, and differences in the frequency of self-injury over the treatment period were not reported.

Further enhancing the accessibility of MACT, an RCT compared a modified MACT protocol involving fewer sessions (i.e., 0–6) plus MACT-based bibliotherapy to TAU for patients with a Cluster B PD and a history of self-injury (N = 34; Evans et al., 1999). Participants in the MACT condition were given a manual and the option of attending up to six sessions; however, participants attended an average of only 2.7 sessions, and five participants did not attend any sessions. Even with this lower level of care, the MACT condition had significantly greater reductions in depressive symptoms and non-significantly reduced suicidal acts and costs of care. This approach may therefore be a model for increasing accessibility of care in other skills-based interventions.

Many studies have examined briefer cognitive-behavioral interventions for borderline PD and its associated problem behaviors. Systems training for emotional predictability and problem solving (STEPPS) is a manualized group-based cognitive-behavioral skills program developed for individuals with borderline PD (Blum, Pfohl, John, Monahan, & Black, 2002). In two uncontrolled studies, participants with borderline PD (N = 52; Blum et al., 2002; N = 38; Harvey, Black, & Blum, 2010) reported significant improvements in mood, clinical symptoms, and PD symptoms after 20 weeks of STEPPS. Another RCT comparing 18 weeks of STEPPS to TAU for patients with borderline PD (N = 79; Bos, van Wel, Appelo, & Verbraak, 2010) found that participants in the STEPPS condition had significantly greater improvements in general and borderline PD-specific symptomology as well as quality of life; however, there were no differences in impulsive behaviors or instances of non-suicidal self-injury. Further, although treatment gains were maintained at six-month follow-up, there were no significant group differences in recovery rates (i.e., overall psychological distress below the clinical cut-off).

Based on empirical research suggesting that self-injury primarily functions to regulate intense distress, emotion regulation group therapy (ERGT) was developed to enhance emotion regulation among women with prominent borderline PD symptoms and recurrent self-injury (Gratz & Gunderson, 2006). Specifically, this group-based, time-limited treatment targets one particularly concerning aspect of borderline PD – non-suicidal self-injury – and its proposed underlying mechanism of emotion regulation difficulties. Over 14 weekly group sessions, ERGT focuses on providing psychoeducation and skills training focused on increasing understanding of the functions of self-injury, increasing emotional awareness and understanding, teaching adaptive emotion regulation strategies, and encouraging willingness to experience emotions in the service of long-term goals. An uncontrolled trial found that ERGT resulted in reductions in self-injury, symptoms of BPD, depression, and anxiety, and improvements in vocational functioning in a sample of women with borderline PD and recent, recurrent self-injury (Gratz & Tull, 2011). A preliminary RCT compared ERGT to TAU for women with borderline PD and recent, recurrent self-injury (Gratz & Gunderson, 2006). ERGT outperformed TAU in reducing self-injury, emotion dysregulation, and symptoms of borderline PD, anxiety, and depression. Findings were replicated in a larger RCT among women with threshold or subthreshold borderline PD and recent, recurrent self-injury (N = 61), and gains were maintained over a nine-month follow-up (Gratz, Tull, & Levy, 2014). In addition, a naturalistic uncontrolled trial for women with borderline PD symptoms and self-injury (N = 95) from outpatient clinics across Sweden revealed that ERGT resulted in improvements in self-injury, other self-destructive behaviors, emotion dysregulation, and psychiatric symptoms (Sahlin et al., 2017). Of particular note, clinicians in this study had no prior exposure to ERGT, aside from completing a brief workshop and related readings. Despite the short-term nature of this treatment, gains were maintained over the six-month follow-up. The replication of these findings across multiple trials provides among the most consistent support for the efficacy of a brief treatment for borderline PD. Furthermore, the implementation of this treatment by clinicians with minimal prior experience in naturalistic settings underscores the probable effectiveness of this treatment. Additional work is needed to ascertain whether ERGT includes specific ingredients that will outperform other bona fide treatments for borderline PD.

Dialectical behavior therapy (DBT) is a comprehensive treatment that balances cognitive behavioral strategies of change with the acceptance-based philosophy of Zen Buddhism (Linehan, 1993). This approach typically involves one year of weekly group skills training to teach mindfulness, interpersonal effectiveness, emotion regulation, and distress tolerance skills, along with weekly individual psychotherapy and telephone coaching. The complex, resource-intensive nature of DBT has prompted many clinicians to implement briefer versions of this treatment program. DBT has been streamlined in many ways by different groups; for instance, by truncating the duration of treatment or providing only one mode of treatment (e.g., just the skills group). Empirical evaluations of these abbreviated forms of DBT are just emerging.

Data from uncontrolled trials suggest that shortened versions of DBT may be useful for borderline PD. For instance, six months of DBT for patients with borderline PD yielded improvements in depression, self-injury (N = 20; Stanley, Brodsky, Nelson, & Dulit, 2007; N = 50; Rizvi, Hughes, Hittman, & Vieira Oliveira, 2017), suicidal ideation (Stanley et al., 2007), emotion regulation, symptoms of borderline PD, and overall adjustment (Rizvi et al., 2017). Despite the brief nature of these treatments, effect sizes were comparable to other trials of DBT (Rizvi et al., 2017). Further supporting the feasibility of short-term DBT, one of these trials relied on training clinicians as study therapists (Rizvi et al., 2017), suggesting that beneficial treatment provision does not require extensive experience.

Controlled trials likewise support the utility of abbreviated standard DBT for borderline PD. An RCT evaluated six months of DBT compared to TAU plus a waitlist for Australian females with borderline PD (N = 73; Carter, Willcox, Lewin, Conrad, & Bendit, 2010). There were no differences between groups on the primary outcomes of self-injury or treatment utilization, although both groups had significant reductions in these metrics. However, the DBT group improved significantly more than the control group on measures of disability and quality of life. In a slightly larger sample, patients with borderline PD (N = 90) were randomized to either six months of standard outpatient DBT or a waitlist control (Pasieczny & Connor, 2011). The DBT condition showed a greater reduction in self-injury (suicidal and non-suicidal) and treatment use (e.g., emergency department and psychiatric admissions and days of hospitalization) than the waitlist control. However, several other findings from this RCT warrant consideration. In particular, additional DBT was offered as indicated and, in this case, additional gains were achieved, suggesting that more treatment could confer greater benefit. In addition, patients who had intensively trained therapists demonstrated greater reductions in self-injury, suggesting that DBT may not be as effective when administered by someone without extensive training in and experience with the treatment.

In addition to reducing the duration of treatment, the week-to-week time commitment of DBT has also been streamlined by focusing on only the DBT group skills training component. As such, an RCT compared 20 weeks of DBT skills training groups to a waitlist control for patients with borderline PD and recent self-injurious behaviors (N = 84), with a 12-week follow-up (McMain, Guimond, Barnhart, Habinski, & Streiner, 2017). Findings revealed that the DBT arm had greater reductions in suicidal and non-suicidal self-injury and anger, as well as greater improvements in distress tolerance and emotion regulation. Another RCT compared 13 weeks of standalone DBT group skills training to standard group therapy for patients with borderline PD (N = 59; Soler et al., 2009). The DBT group had greater decreases in reported depression, anxiety, and borderline PD symptoms of anger and affect lability.

In another adaptation of standard DBT, an intensive program condensed the standard format of one weekly 2-hour group session to four weekly 2–4 hour group sessions for three to four weeks in an uncontrolled study of outpatients with a PD (N = 447; predominantly borderline PD; N = 418; Perroud, Uher, Dieben, Nicastro, & Huguelet, 2010). Despite the relatively high (19.9 percent) drop-out rates, there were significant pre- to post-treatment improvements in depression, hopelessness, and symptom distress. Of note, a substantial proportion of the sample (N = 103) underwent a second course of DBT, and although hopelessness and depression did not improve in this round, symptom distress was significantly further reduced.

Another truncated form of DBT has been compared to an established short-term treatment for suicidality, collaborative assessment and management of suicidality (CAMS; Andreasson et al., 2016). Patients with two or more borderline PD criteria and a recent suicide attempt (N = 108) were randomized to either 16 weeks of DBT or CAMS. CAMS is a flexible, atheoretical approach to target and manage suicidality in a collaborative and empathic manner. No significant differences emerged in borderline PD symptoms, depression, non-suicidal self-injury, or suicidal behavior frequencies. As such, this brief form of DBT was not superior to another established treatment for suicidality.

The short-term nature of inpatient hospitalization has also led to an increased need for abbreviated forms of DBT in inpatient contexts. An uncontrolled naturalistic trial evaluated the utility of three months of DBT for inpatients with borderline PD (N = 24; Bohus et al., 2000). This abbreviated model of DBT involves (1) developing a functional analysis of target behaviors, (2) providing psychoeducation, (3) providing training in emotion regulation and distress tolerance skills, (4) managing contingencies of target behaviors, and (5) engaging in discharge planning. Results suggested decreases in self-injury frequency, dissociation, depression, anxiety, and overall symptoms over the course of treatment. In a non-randomized controlled trial, this three-month inpatient DBT program was compared to a waitlist control for inpatients with borderline PD (N = 50; Bohus et al., 2004). Results revealed that DBT outperformed the waitlist comparison in reducing depression symptoms, anxiety symptoms, general psychiatric symptom severity, and self-injury and enhancing interpersonal functioning, with 42 percent of participants exhibiting clinically-significant improvements in general psychiatric symptom severity. Furthermore, these improvements were sustained over the 21-month follow-up (Kleindienst et al., 2008). A large-scale naturalistic trial of three months of DBT for inpatients with borderline PD (N = 1423) also found significant improvements in depression, borderline PD, and general psychopathology symptoms and global functioning (Kröger, Harbeck, Armbrust, & Kliem, 2013).

Two studies have examined even more condensed formats of DBT in inpatient contexts. In an uncontrolled trial, a five-day inpatient DBT program for patients with borderline PD (N = 50) yielded improvements in general psychopathology, depression, hopelessness, anger expression, and dissociation over a three-month period (Yen, Johnson, Costello, & Simpson, 2009). Additionally, an RCT examined an abbreviation of DBT to ten daily sessions compared to an activity control “wellness and living” group for inpatients with a PD (N = 31; Springer, Lohr, Buchtel, & Silk, 1996). Although all participants demonstrated significant decreases in depression, hopelessness, and suicidal ideation, there were no between-group differences. Given the absence of any documentation of superiority over comparison conditions, there is no evidence that such condensed inpatient forms of DBT are efficacious.

Abbreviated formats of standard DBT have also been developed to accommodate the time demands imposed by the semester structure of universities and colleges. An uncontrolled trial examined the utility of eight two-hour DBT group skills-training sessions for college students with borderline PD (N = 17; Meaney-Tavares & Hasking, 2013). Participants demonstrated significant reductions in depression, borderline PD symptoms, and self-blame, although no significant change in anxiety was seen. Another trial included a non-randomized TAU control condition, and examined the relative utility of an 11-week DBT skills training class for college students with Cluster B PDs or PD traits (N = 19; Chugani, Ghali, & Brunner, 2013). Those in DBT showed significantly greater increases in skills use and decreases in maladaptive coping than the TAU group. Although both conditions demonstrated decreases in emotion regulation difficulties, there was no significant difference between conditions. Evidence of the superiority of DBT skills training over a non-randomized TAU control condition, albeit preliminary, provides suggestive support for the possible utility of brief DBT skills training for PD traits in college students.

Another strategy for abbreviating DBT is to focus on specific skills modules. A non-randomized controlled trial assigned consecutive hospital patients with borderline PD (N = 35) to either general psychiatric management (GPM) alone or GPM plus a 10-week DBT mindfulness skills training group (DBT-M; Feliu-Soler et al., 2014). No differences were found in terms of self-reported mindfulness or laboratory-assessed biological or subjective indices of emotional reactivity. However, the DBT-M condition resulted in greater improvements in observer-rated depressive symptomology and psychiatric severity. Another RCT revealed that eight sessions of DBT mindfulness group plus GPM outperformed GPM alone in improving impulsivity on a behavioral task among patients with borderline PD (N = 59; Soler et al., 2012). In another small pilot RCT, women with borderline PD (N = 19) were assigned to six weeks of group therapy involving DBT interpersonal effectiveness skills, DBT emotion regulation skills, or psychoeducation (Dixon-Gordon, Chapman, & Turner, 2015). The emotion regulation condition resulted in significantly greater reductions in self-injury than the other conditions. Although preliminary, these findings support the utility of specific DBT skills modules, namely mindfulness and emotion regulation, in the reduction of BPD-relevant symptoms.

Taken together, these 33 studies describe 31 trials of CBT for PDs (see Table 20.1), particularly borderline PD (n = 23) and related problems (i.e., self-injury; n = 2). Over half of the trials (n = 21) were controlled. The only trials that were replicated focused on borderline PD. Although 17 studies evaluated variations of DBT, many of these implementations were idiosyncratic, and only a few of the trials of these versions were replicated. The three-month inpatient DBT program showed promising results in uncontrolled trials (Bohus et al., 2000; Kröger et al., 2013), and outperformed a waitlist condition in reducing self-injury and depression, anxiety, and general psychiatric symptoms and increasing global functioning. (Bohus et al., 2004). Likewise, six months of DBT yielded improvements in self-injury in both uncontrolled trials (Rizvi et al., 2017; Stanley et al., 2007) and when compared to waitlist controls (McMain et al., 2017; Pasieczny & Connor, 2011). Controlled studies also demonstrated the superiority of MACT to TAU in reducing self-injury (Weinberg et al., 2006), suicidal behaviors (Evans et al., 1999), and suicidal ideation (Davidson et al., 2014) among patients with Cluster B PDs and self-injury. In addition, both uncontrolled (Harvey et al., 2010) and controlled (Bos et al., 2010) evaluations of STEPPS support its utility in reducing symptoms of borderline PD. Finally, open trials of ERGT reveal improvements in self-injury, borderline PD and other psychiatric symptoms, and emotion regulation difficulties from pre- to post-treatment (Gratz & Tull, 2011; Sahlin et al., 2017), and RCTs demonstrate the superiority of ERGT to TAU in reducing self-injury, emotion regulation difficulties, and other symptoms of borderline PD and depression, and improving quality of life (Gratz & Gunderson, 2006; Gratz et al., 2014).

Integrative Approaches

Several interventions for PDs integrate principles from diverse theoretical orientations. For instance, schema-focused therapy (SFT) is an integrative approach informed by cognitive-behavioral, attachment, and psychodynamic perspectives (Giesen-Bloo et al., 2006) and is predicated on the theory that a failure to meet early attachment needs results in maladaptive relational and intra-personal schemas. SFT targets these deficits through limited reparenting, experiential imagery and dialogue, cognitive restructuring, and behavioral exercises. An uncontrolled trial aimed to examine the utility of 12–15 sessions of group SFT among inpatients with borderline PD or Cluster C PDs (N = 9; Nenadić, Lamberth, & Reiss, 2017). Patients who underwent this brief group showed significant reductions in symptom severity and maladaptive schema modes. Of note, effect sizes (ds = 0.69–0.86) were judged to be smaller than other applications of this treatment. Likewise, two uncontrolled trials demonstrated the utility of a 20-session group SFT for patients with a Cluster B PD, Cluster C PD, or prominent PD features (N = 26; Renner et al., 2013) and patients with Cluster C PDs (N = 8; Skewes, Samson, Simpson, & van Vreeswijk, 2015) in reducing general symptom severity, maladaptive schemas, and dysfunctional coping.

In recognition of the frequent co-occurrence of PD and substance use disorders, efforts have been made to combine SFT and relapse prevention strategies for drug dependence, resulting in dual-focus schema therapy. In one RCT, homeless adults with a PD (N = 52) were randomized to six months of dual-focus schema therapy or substance abuse counseling three times weekly, but high drop-out (N = 40) precluded an evaluation of the efficacy of the intervention (Ball, Cobb-Richardson, Connolly, Bujosa, & O’Neall, 2005). In another RCT, outpatients with a PD and methadone-maintained opioid dependence (N = 30) were randomized to either six months of dual-focus schema therapy or 12-Step Facilitation Therapy (Ball, 2007). Across both conditions, patients reported decreases in alcohol problems, psychiatric symptoms, and dysphoria. Dual-focus schema therapy yielded a steeper decline and overall less substance use than the 12-Step condition, whereas the 12-Step condition had greater decreases in dysphoria. Although promising, dual-focus schema therapy did not demonstrate clear superiority over the comparator in these trials.

Interpersonal group psychotherapy is another integrative treatment for borderline PD that focuses on providing a context for interpersonal interactions, and works to clarify and develop boundaries, allow for grief, and encourage more balanced views of self in relation to others (Munroe-Blum & Marziali, 1995). This manualized treatment consists of 30 1 ½ hour sessions (25 weekly, then 5 biweekly). An RCT for patients with borderline PD (N = 110) compared interpersonal group psychotherapy to individual TAU (individual dynamic psychotherapy). Although patients showed improvements in depression, general symptoms, and social adjustment, there were no significant between-group differences at post-treatment or one-year follow-up. Consequently, extant data do not currently support the efficacy of this treatment for PDs.

Cognitive evolutionary therapy focuses on enhancing meta-cognitive functioning and highlighting the evolutionary functional influences on meta-cognition. In an inpatient setting including patients with a PD (N = 51; 71 percent borderline; 35 percent avoidant PD), participants underwent three weeks of cognitive evolutionary therapy including 20 hours a week of both individual and group therapy, as well as some skills training from DBT (Prunetti, Bosio, Bateni, & Liotti, 2013). Significant improvements were observed in general psychiatric symptom severity, depression, anxiety, paranoia, interpersonal sensitivity, subsequent hospital admissions, and attendance in outpatient therapy. Without a control condition, however, the efficacy of cognitive evolutionary therapy remains unclear.

Narrative exposure therapy is an exposure-based treatment that aims to change the autobiographical associations of event memories thought to underlie borderline PD (Pabst et al., 2011). One uncontrolled feasibility study examined the utility of narrative exposure therapy for women with borderline PD and co-occurring posttraumatic stress disorder (PTSD) without a stabilization period (N = 12; n = 10 completers). From pre-treatment to the six-month follow-up, significant reductions were found in depression, PTSD symptoms, and dissociation, whereas the reductions in borderline PD symptoms were non-significant. Consequently, although these data provide preliminary support for the utility of this treatment for PTSD, they are not particularly promising with regard to PD symptoms.

These seven trials constitute a variety of integrative approaches for PDs (see Table 20.1). Four of these treatments were informed by SFT, which was associated with improvements in PD symptoms (Nenadić et al., 2017; Skewes et al., 2015) and symptom distress (Renner et al., 2013) in uncontrolled trials. In addition, relative to a 12-Step condition, dual-focused schema therapy demonstrated improvements in substance use outcomes (Ball, 2007), suggesting this may be a promising, potentially efficacious treatment with some specific ingredients that outperform other active treatments for PD and substance use. Replication in controlled trials will instill more confidence in these results.

Multi-Component Programmatic Approaches

Although the interventions offered in psychiatric programs are often heterogeneous, it is fruitful to consider how varied lengths of such programs may affect outcomes in PDs. Indeed, several studies of PD treatment programs suggest that significant improvements can be seen much sooner than one year. One such uncontrolled naturalistic trial of a day-treatment program involving a range of groups (vocational, cognitive-behavioral, art, etc.) for patients with PDs (N = 197, 125 completers) revealed significant improvements in interpersonal problems, social adjustment, general psychiatric severity, dysfunctional behaviors, and overall quality of life after only 18 weeks of treatment (Ogrodniczuk et al., 2011). Likewise, another intensive outpatient treatment program designed for patients with prominent borderline PD features or a borderline PD diagnosis (N = 36) yielded significant improvements with large effect sizes in borderline PD-relevant behaviors and symptoms after three months (Gratz, Lacroce, & Gunderson, 2006). Specifically, improvements were seen in emotion regulation, self-injury, symptom severity, and quality of life at one month, and significant changes with large effect sizes were observed in all outcome variables except for self-injury between one and three months. Despite demonstrating improvements in some domains, there were no significant changes in global functioning or quality of life, and the majority of the sample did not reach normative levels of functioning. These studies provide preliminary evidence for the utility of these relatively brief, heterogeneous programs, but the absence of control conditions precludes any conclusions regarding their efficacy.

Two non-randomized controlled studies evaluated the utility of specialized treatment programs relative to control conditions. One of these studies compared outcomes among PD patients (N = 66) enrolled in a Danish day-treatment to a waitlist-control (Petersen et al., 2008). The day treatment comprised five months of both psychodynamic and cognitive therapy in group and individual settings for 11 hours each week. Those who received the intervention demonstrated lower rates of psychiatric hospitalizations and suicide attempts than the waitlist, as well as significant decreases in symptom severity and global functioning (albeit not interpersonal functioning). Similarly, a 12-week, structured, disorder-specific inpatient treatment combining psychodynamic treatment with DBT skills training was compared in a non-randomized controlled trial to inpatient TAU for patients with borderline PD (N = 44; Sollberger et al., 2015). The disorder-specific condition showed significant decreases in identity diffusion and instability and depression. Both of these programs demonstrated utility for PDs over control conditions.

A non-randomized naturalistic study compared outcomes for patients (N = 205) across six different treatment modalities (Horn, Bartak, et al., 2015). Specifically, short- (≤6 months) and long- (>6 months) term outpatient treatment, short- and long-term day-hospital treatment, and short- and long-term inpatient treatment. Outcomes were assessed yearly up to 60 months after baseline, and participants in all treatment modalities showed improvements in symptom severity and social functioning. At the one-year follow-up, short-term and long-term outpatient treatments outperformed inpatient treatment in reducing psychiatric symptom severity, but these differences became non-significant over time. Thus, these treatments showed comparable benefits by the follow-up. Likewise, another non-randomized naturalistic study compared these treatment modalities for patients with Cluster C PDs (Bartak et al., 2010). All groups showed improved psychiatric symptoms and psychosocial functioning one year later; short-term inpatient treatment (<6 months) showed more improvement than the other groups.

Despite their heterogeneity, these six studies underscore the utility of brief, multi-componential treatment programs for PDs (see Table 20.1). The two controlled trials suggest that disorder-specific treatments result in greater reductions in PD symptoms than TAU (Sollberger et al., 2015) or waitlist-controls (Petersen et al., 2008).

Discussion

This emerging literature documenting brief interventions for PDs constitutes a dramatic shift in the approach to treating these disorders. The advent of efficacious treatments for PDs (e.g., Fonagy & Bateman, 2008; Linehan, 1993) has cast off prior beliefs about the intractability of PDs. Moreover, prior recommendations that PDs require longer-term treatments than other disorders (Crits-Christoph & Barber, 2007) have been confronted by pragmatic demands from under-resourced communities. Consequently, accumulating research has been dedicated to developing briefer, more accessible interventions for patients with PDs.

The present review has yielded encouraging results. Interventions lasting less than one year have yielded promising outcomes in the treatment of PDs, underscoring the utility of even relatively brief psychosocial interventions for these disorders. It is worth noting that the effect sizes from some of these treatments (e.g., DBT) were comparable to longer forms of the treatment (Rizvi et al., 2017). These interventions cut across theoretical orientations (e.g., Hellerstein et al., 1998; Rizvi et al., 2017; Winston et al., 1994), suggesting that the effectiveness of brief treatments is not circumscribed to a particular approach. These findings are consistent with work identifying transtheoretical aspects of effective treatments for borderline PD (Weinberg, Ronningstam, Goldblatt, Schechter, & Maltsberger, 2011). Specifically, research indicates that longer borderline PD treatments share a structured time-limited approach based on a biopsychosocial model, elements of safety planning, attention to treatment motivation and compliance, a focus on the here and now, an emphasis on the therapeutic relationship, and a group component. Many of these transtheoretical features may also contribute to the utility of briefer treatments for PDs.

The pressure for increased access to treatments for PDs may also be addressed by reducing the resources needed to deliver such treatments. For instance, data from some of these trials suggest that interventions delivered by trainees (Rizvi et al., 2017) or nurses (Andreoli et al., 2016) were beneficial, increasing the accessibility of treatments. Similarly, the group-based nature of many of these brief psychotherapies (e.g., Blum et al., 2002; Gratz & Gunderson, 2006) further facilitates patient access.

The brief nature of these treatments necessitates a precise and strategic approach to targeting the problems central to PDs. It is worth noting that many of these possibly efficacious briefer treatments for PDs directly targeted proposed mechanisms hypothesized to underlie the presenting problems, most prominently emotion regulation and interpersonal functioning. Consistent with the notion that emotion regulation difficulties underlie many of the problem behaviors in borderline PD (Gratz & Gunderson, 2006; Linehan, 1993), briefer treatments that focus on enhancing mindfulness of emotions and emotion regulation generally outperformed comparison conditions. For example, predicated on the notion that the self-injury characteristic of borderline PD serves an emotion regulatory function, both ERGT (Gratz & Gunderson, 2006; Gratz & Tull, 2011; Gratz et al., 2014; Sahlin et al., 2017) and MACT (Davidson et al., 2014; Evans et al., 1999; Weinberg et al., 2006) directly focus on enhancing adaptive emotion regulation capacities. Likewise, training in DBT emotion regulation (Dixon-Gordon et al., 2015) and mindfulness (Feliu-Soler et al., 2014; Soler et al., 2012) skills outperformed comparison conditions. In addition, in line with views that interpersonal difficulties contribute to many PDs (Westerman et al., 1995), interpersonally-focused treatments were efficacious for avoidant PD (Alden, 1989), and a strong therapeutic relationship emerged as a prospective mechanism of STDP (Westerman et al., 1995). A clearer understanding of the mechanisms of action of larger, more comprehensive treatments for PDs may suggest other avenues for further streamlining treatments for these disorders. This review also highlights important directions for future research. First, many of the evaluations of brief treatments were uncontrolled, and among those that included control groups, few have been replicated. Only a few treatments have garnered sufficient empirical support to be considered efficacious for the treatment of PDs. Among these include STDP, especially for Cluster C PDs, although there is not yet evidence for the specificity of this treatment for PDs relative to factors common to many forms of psychotherapy (Hellerstein et al., 1998; Winston et al., 1994). Likewise, a number of cognitive-behavioral interventions have been shown to be efficacious for borderline PD and/or self-injury in controlled trials, including ERGT (Gratz & Gunderson, 2006; Gratz et al., 2014), six-month DBT (McMain et al., 2017; Pasieczny & Connor, 2011), and MACT (Davidson et al., 2014; Evans et al., 1999; Weinberg et al., 2006). However, many of the abbreviations of PD treatments such as DBT were idiosyncratic truncations of treatments. Further work evaluating similar versions of abridged treatments would bolster the confidence in these initial results.

Second, most treatment development efforts have thus far focused on borderline PD and other Cluster B disorders. Although these efforts are reasonable in light of the tremendously high rate of treatment utilization among those with borderline PD, even relative to other PDs (Ansell, Sanislow, McGlashan, & Grilo, 2007), there remains scarce work on brief treatments for other PDs. Therefore, additional research is needed on efficacious treatments for mixed PD presentations and other PDs.

Third, findings from some of these studies underscore the need for longer interventions in some cases. For instance, effect sizes in some of these briefer treatments were judged to be smaller than longer versions of these treatments (e.g., Nenadić et al., 2017). In addition, when patients opted to undergo additional courses of DBT after the briefer treatments, they derived further benefits (Pasieczny & Connor, 2011; Perroud et al., 2010). Accordingly, although even short-term treatments may stabilize acute symptoms, many patients may require longer term treatment. Yet, only a few studies have compared the cost and clinical utility of different durations or “doses” of treatments (Davidson et al., 2009). Whereas two trials found continued improvement with longer durations of therapy for borderline PD (Pasieczny & Connor, 2011; Perroud et al., 2010), another trial did not find significant differences in patients who received 6 versus 12 months of treatment (Davidson et al., 2009). Since bona fide interventions may yield considerable benefit early on, differences between different “doses” of treatment are likely to be small and trials will need to be powered for equivalence (Christensen, 2007). Only a few studies to date have confronted the most important question facing these abbreviated treatments: namely, is it worth it? Economic evaluations will be an important component of future comparisons of durations of treatment.

Likewise, research will need to investigate moderators to determine who is likely to benefit most from briefer versus longer treatments. Such work has the potential to inform an empirical examination of a stepped care model (Paris, 2013, 2015). In this model, patients with positive prognostic indicators could be offered a brief streamlined intervention first, whereas those who require more intensive intervention could be identified early and matched with appropriate programs. Those who do not derive sufficient benefit from brief front-line interventions could then be offered a “stepped up” treatment.

The arrival of streamlined treatments has the potential to revolutionize PD treatment and management. Given the enormous toll these disorders pose to individuals, the health system, and society (Quirk et al., 2016; Zimmerman et al., 2005), more efficient and accessible treatments have the potential to address an urgent public health need. Attention to increased accessibility must be balanced by an acknowledgment that many of these patients will require more comprehensive or longer treatments. A stepped care approach addressing both of these needs may represent a path forward.

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¹This review involved a search of PsychInfo; search terms were: [(brief or “short-term”) AND (treatment or intervention or therapy or “dialectical behavior”) AND (“personality disorder” or “personality disorders”)]. We also identified articles that were cited within any reviewed full-text to ensure comprehensive coverage of this area. To be included in this review, research needed to be (1) an empirical primary source, (2) peer-reviewed literature, (3) written or translated into the English language, (4) published prior to the date the most recent search was conducted for the present manuscript (December 4, 2017), (5) conducted in human samples, (6) quantitative, (7) a study of a sample that included PD symptoms (defined dimensionally or categorically) as an inclusion criterion for the sample, and (8) a study of a brief (i.e., <1 year) psychosocial therapeutic approach.