20a
Lars Mehlum
Although emotional and behavioral symptoms of personality disorder (PD) vary considerably across specific disorders, impairment and suffering caused by affective, cognitive, and interpersonal dysfunction in people with PD is, by definition, severe. Since those who are affected often have extensive use of health and social services and less than average productivity, the costs of these disorders to society are very large (Soeteman, Hakkaart-van Roijen, Verheul, & Busschbach, 2008). However, PDs, even the most challenging forms such as borderline personality disorder (BPD), are treatable conditions; over the last decades, several empirically validated psychotherapeutic approaches have emerged, giving rise to treatment optimism in clinicians and hope in patients and their families (see Rosenthal, Wyatt, & McMahon, Chapter 17 this volume; Fonagy, Bateman, Luyten, Allison, & Campbell, Chapter 18 this volume). Furthermore, economic evaluations have shown that these treatments have good potential for significant cost savings, since they are more effective and, contrary to what is often believed, usually less expensive than traditional treatments when all costs are taken into consideration (Haga, Aas, Groholt, Tormoen, & Mehlum, 2018; Meuldijk, McCarthy, Bourke, & Grenyer, 2017).
Still, most evidence-based psychotherapeutic approaches for PD are lengthy (one to three years) and intensive (several sessions per week), and they rely heavily on access to extensively trained and highly skilled therapists. These are resource requirements that can hardly be met by treatment providers in the average routine clinical setting, even in high-income countries. And, even in cases where economic and human resources are not an issue, lengthy and intensive treatments may still be infeasible for large proportions of people in need of treatment, who may not be able to match the high level of patient compliance and commitment required. These major obstacles to large-scale implementation of evidence-based treatments for PD constitute some of the background for the attempts to develop brief interventions or abbreviated versions of existing approaches that have emerged over recent years.
Dixon-Gordon and coworkers’ comprehensive review of advances made in the field of brief treatments for PDs clearly demonstrates that there is not a lack of creative approaches to developing such treatments. However, despite this creativity, the relatively high amount of research in this field, and some promising results that have emerged, we still have many unresolved questions. In this commentary, we will discuss some of the questions and challenges that seem to remain for the task of developing and validating brief interventions for PD.
Brief Interventions for PD: Is This a Realistic Approach?
Most of the brief treatments that have been proposed so far seem to be based on the assumption that long-term treatments could be shortened or simplified while still retaining approximately the same effectiveness. However, given the way we conceptualize PD as an inflexible, pervasive, and enduring pattern of experiencing or behaving that deviates markedly from common expectations causing significant distress and impairment, what are the odds we are going to succeed in developing interventions for such disorders that are both effective and brief? These are not episodic or time limited syndromes and they typically do not affect only some mental functions; they affect most areas of functioning. Many patients with PD, particularly those who have BPD, are perceived by their clinicians as “multi-problem” patients with an extremely large number of life problems and treatment needs. These are some of the reasons why patients with PDs are usually regarded as hard to treat and thus requiring high doses of treatment. However, more treatment or longer lasting or more intensive treatment does not necessarily mean more effective treatment.
The problem is that to develop brief treatments with approximately the same or even better effects as the longer or more intensive interventions, we would need more knowledge than we currently have on how treatments produce change and growth. Without knowing the mechanisms of therapeutic change and treatment component(s) responsible for this change, modifying treatments to make them briefer and less resource demanding – while still retaining the same treatment effects – is a risky business. Conversely, with a better understanding of which treatment elements are key to change, we could probably concentrate our efforts on delivering only these elements and thus save resources.
The most extensively researched treatment for BPD, at least in terms of number of randomized controlled trials published, is Dialectical Behavior Therapy (DBT), but it is only recently that high-quality dismantling or component studies have emerged. In their recent comparison of different DBT treatment modalities, Linehan and coworkers demonstrated that interventions that included skills training were more effective than DBT without this treatment modality (Linehan et al., 2015). For some patients, this could mean that important treatment needs (e.g., reductions in suicidal and self-injurious behaviors) could possibly be met through skills training alone or skills training combined with a brief initial number of individual therapy sessions. Support for this is found in a number of less sophisticated studies of skills training of varying length as a stand-alone intervention; these are highlighted in Dixon-Gordon et al.’s review.
This leads us to the question of not only what are the most effective, and thus indispensable, treatment components, but what treatment components work best for whom. Treatment trials have, to date, largely been able to demonstrate overall effectiveness of the interventions in relatively heterogeneous clinical samples. Studies with samples large enough to allow for analysis of treatment moderators will likely give us more precise information on who is benefiting the most from the treatments. For some patients, certain outcomes of certain aspects of the treatment will probably be even better than for the average patient group, whereas for others it will probably be weaker, absent, or even negative. There is a great need to tailor and optimize treatments to individual patients, but to do so we need more knowledge.
The need to avoid harming patients through our interventions is another important concern. Since psychotherapeutic interventions are powerful tools, there is a real danger that some patients will have side-effects or adverse outcomes. As pointed out by Fonagy and Bateman (2006), patients with BPD are particularly vulnerable to side-effects of treatments that activate their attachment system. Most treatments regard such activation necessary for a therapeutic relationship to evolve and for the patient to improve her or his psychological functioning in interpersonal relationships. But, in the context of brief treatments for BPD – where attachment would typically soon be followed by separation – the treatment should, as a consequence, include strategies to protect patients against the potential dangers of attachment system overactivation.
Brief Interventions: Should They Have a Different Focus?
Since we may lack much of the knowledge needed to realistically expect brief treatment approaches to PD to be comparable to longer term treatments in their effectiveness, a relevant question is whether the focus for brief treatments should be entirely or partly different from the original or longer term treatments. Brief treatments could focus on stabilizing the patient to make other and/or subsequent treatments feasible. Brief treatments could, for example, include strategies to improve patients’ distress tolerance and interpersonal functioning just enough to allow them to tolerate receiving and benefiting from other help. These interventions could focus on building or maintaining some supportive social relationships or staying employed. People with PD often have treatment interfering behaviors that reduce their capacity for staying in treatment or responding to the treatment. Brief interventions could have a limited focus on reducing such behaviors. Or, rather than targeting the PD itself, brief interventions could focus on symptoms and problems often experienced by people with PD, such as depressive symptoms, substance abuse, anxiety, or other co-occurring conditions. Effectively delivering treatments for these symptoms and problems to people with PD may necessitate development of strategies that are different from those required for treatment of people without PD. Brief interventions for PD could build on positive experiences from e-mental health tools developed for other psychiatric disorders, such as depression, through the use of therapist guided internet-based self-help interventions. Brief interventions could also focus on teaching patients coping skills and helping them practice these skills through the use of interactive web-based computer programs.
An important additional focus for brief interventions for “hard to treat” patients with PD is to address the negative transactions that often evolve between clinicians and patients and, thus, the stigma still experienced by many people with PD when seeking treatment. Clinicians’ notions of what is “hard to treat” in these patients could, in reality, be less strongly associated with the PD itself and more strongly associated with certain learned illness behaviors or adaptations patients have made to their environments, secondary effects of the disorder, or even iatrogenic effects of past treatments. Brief interventions aimed at avoiding these perils would have a potential of substantially improving the treatment gains for many patients with PD across a wide range of treatment settings.
Future Research Directions
Dixon-Gordon et al.’s review leaves a clear impression that, despite the multitude of approaches to developing brief interventions for PD, too many studies have lacked the adequate research design, methodological rigor, and statistical power to provide any firm conclusions about treatment effects. Too often, “brief treatment” seems to have been paired with “brief study,” creating more confusion than clarity. Furthermore, there is currently no agreement as to what should be the criteria for determining treatment response or remission in PD. A lack of consensus regarding core outcome measures makes systematic reviews and meta-analyses more difficult. There is also a lack of conceptual clarity; most studies published so far have been unclear about what brief interventions really mean. Is it low-dose we are talking about, or treatment of brief duration?
Obviously, there is a need for carefully designed studies of brief interventions that are clearly defined as to the level of the disorder they aim to treat (i.e., the PD itself or its associated symptoms and/or problems), the aspect of the disorder they will focus on, the mechanism(s) of change they will utilize, the specific patient group the treatment will target, and the treatment response criteria with which the outcome will be evaluated. Since the main rationale for developing and evaluating such brief interventions for PD is to save resources and make treatments accessible to more people, an aspect of economic and implementation evaluation should probably always be included in future empirical studies. As virtually no brief intervention for PD has been convincingly replicated so far, future studies should preferably be conducted in a collaborative way to facilitate replications. This calls for stronger national and international collaborations between clinical researchers. Recently, PD researchers in Europe have formed an alliance to address the need for speeding up research on and dissemination of PD-specific treatments on this continent (Mehlum et al., 2018). This alliance organizes training seminars for young PD clinical researchers to promote high-quality research in more European countries, and offers workshop conferences for clinicians to speed up the dissemination of evidence-based treatments in underserved regions. Finally, the alliance organizes research congresses and offers members and affiliates opportunities to develop their research collaborations on specific topics through an increasing number of thematic sections. Hopefully, such alliances will lead to a more systematic building of the evidence base needed to deliver evidence-based and affordable treatments in a sustainable way to the people who need them.
References
Fonagy, P., & Bateman, A. (2006). Progress in the treatment of borderline personality disorder. British Journal of Psychiatry, 188, 1–3.
Haga, E., Aas, E., Groholt, B., Tormoen, A. J., & Mehlum, L. (2018). Cost-effectiveness of dialectical behaviour therapy vs. enhanced usual care in the treatment of adolescents with self-harm. Child and Adolescent Psychiatry and Mental Health, 12, 22. doi:10.1186/s13034-018-0227-2
Linehan, M. M., Korslund, K. E., Harned, M. S., Gallop, R. J., Lungu, A., Neacsiu, A. D., … Murray-Gregory, A. M. (2015). Dialectical behavior therapy for high suicide risk in individuals with borderline personality disorder: A randomized clinical trial and component analysis. JAMA Psychiatry, 72(5), 475–482.
Mehlum, L., Bateman, A., Dalewijk, H. J., Doering, S., Kaera, A., Moran, P. A., … Bohus, M. (2018). Building a strong European alliance for personality disorder research and intervention. Borderline Personality Disorder and Emotion Dysregulation, 5, 7. doi:10.1186/s40479-018-0082-z
Meuldijk, D., McCarthy, A., Bourke, M. E., & Grenyer, B. F. (2017). The value of psychological treatment for borderline personality disorder: Systematic review and cost offset analysis of economic evaluations. PLoS One, 12(3), e0171592. doi:10.1371/journal.pone.0171592
Soeteman, D. I., Hakkaart-van Roijen, L., Verheul, R., & Busschbach, J. J. (2008). The economic burden of personality disorders in mental health care. Journal of Clinical Psychiatry, 69(2), 259–265.