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Katherine L. Dixon-Gordon, Lindsey C. Conkey, and Sherry E. Woods
We welcomed the opportunity to read our colleagues’ (Drs. Mehlum and Unruh) perspectives regarding our review of brief therapeutic approaches for personality disorders (PDs). These experts identified notable implications of the growing evidence base, and remaining questions for both research and treatment.
Identifying Mechanisms of Change
Both Drs. Mehlum and Unruh point to the importance of understanding the factors that contribute to change in briefer treatments for PDs. As noted by Dr. Unruh, these briefer treatments share conceptualizations of mechanisms with their parent treatments. Turning to the extant data, we can identify some of what Dr. Unruh refers to as the structural/systematic aspects of the treatment, or the ingredients that produce change. Of note, the structure of the effective treatments ranged from individual and group outpatient psychotherapy to inpatient programs.
Among these common ingredients is a focus on explicit education to enhance emotion regulation. This focus is evident across a number of treatments, ranging from the enhanced thinking skills to teach impulse control for antisocial PD (Doyle et al., 2013) to emotion regulation skills training in dialectical behavior therapy for borderline PD (e.g., Rizvi, Hughes, Hittman, & Vieira Oliveira, 2017). Indeed, standalone emotion regulation-focused groups have consistently demonstrated efficacy for borderline PD (Dixon-Gordon, Chapman, & Turner, 2015; Gratz & Gunderson, 2006). Another common element seen across theoretical approaches is a focus on interpersonal functioning, ranging from fostering balanced views of the self in relation to others (Munroe-Blum & Marziali, 1995), to teaching interpersonal skills for borderline PD (Rizvi et al., 2017), to facilitating interpersonal exposure for avoidant PD (Alden, 1989). Another shared aspect of these treatments that may separate them from treatment as usual is their insistence that treatment can work. This alone may constitute a critical mechanism of change, given that treatment credibility and expectancies have been shown to be predictors of treatment outcomes (Keuroghlian, Frankenburg, & Zanarini, 2013), and may be especially important for the frequently-stigmatized population of PD patients.
Although many of these treatment ingredients are theorized to target processes within the patient (referred to by Dr. Unruh as mental state factors), this has not been directly tested in many cases. Future studies would benefit from multimodal assessments of these putative within-patient change processes.
Understanding Moderators of Treatment Outcome
It is conceivable that distinct processes account for change across distinct outcomes. Thus, as noted by Dr. Mehlum, we also must consider the question of which treatments are best for whom. Given that patients with PDs often present with multiple problems, there are also the questions of which treatment elements are best for which outcomes and when. Different outcomes may be achievable at different timeframes, with some treatment goals lending themselves to briefer treatments. For instance, helping clients reduce out-of-control behaviors may be a nearer-term goal than improving their sense of self-worth. Indeed, one key short-term outcome to consider in this regard is the reduction of crisis behaviors that lead to hospitalization, since hospitalizations predict poor treatment response in longer-term treatments (Coyle, Shaver, & Linehan, 2018). It is also worth considering that short-term treatments may require new targets, such as preparing for the imminent conclusion of therapy, as noted by Dr. Mehlum. We recommend that future studies include repeated measures to depict the dose–response relationship across outcomes. Likewise, it is critical that we understand the long-term effects of short-term treatments.
Moving Forward
There is a pressing need to increase access to PD treatments that work. A stepped-care model akin to emerging good psychiatric management-oriented models (Choi-Kain, Albert, & Gunderson, 2016) may provide such a framework; however, we still require data to make evidence-based treatment recommendations for who needs further treatment and when. A clearer understanding of the mechanisms and moderators of treatment response over time would begin to address this gap.
References
Alden, L. (1989). Short-term structured treatment for avoidant personality disorder. Journal of Consulting and Clinical Psychology, 57(6), 756–764.
Choi-Kain, L. W., Albert, E. B., & Gunderson, J. G. (2016). Evidence-based treatments for borderline personality disorder: Implementation, integration, and stepped care. Harvard Review of Psychiatry, 24(5), 342–356.
Coyle, T. N., Shaver, J. A., & Linehan, M. M. (2018). On the potential for iatrogenic effects of psychiatric crisis services: The example of dialectical behavior therapy for adult women with borderline personality disorder. Journal of Consulting and Clinical Psychology, 86(2), 116–124.
Dixon-Gordon, K. L., Chapman, A. L., & Turner, B. J. (2015). A preliminary pilot study comparing dialectical behavior therapy emotion regulation skills with interpersonal effectiveness skills and a control group treatment. Journal of Experimental Psychopathology, 6(4), 369–388.
Doyle, M., Khanna, T., Lennox, C., Shaw, J., Hayes, A., Taylor, J., … Dolan, M. (2013). The effectiveness of an enhanced thinking skills programme in offenders with antisocial personality traits. Journal of Forensic Psychiatry and Psychology, 24(1), 1–15.
Gratz, K. L., & Gunderson, J. G. (2006). Preliminary data on an acceptance-based emotion regulation group intervention for deliberate self-harm among women with borderline personality disorder. Behavior Therapy, 37(1), 25–35.
Keuroghlian, A. S., Frankenburg, F. R., & Zanarini, M. C. (2013). The relationship of chronic medical illnesses, poor health-related lifestyle choices, and health care utilization to recovery status in borderline patients over a decade of prospective follow-up. Journal of Psychiatric Research, 47(10), 1499–1506.
Munroe-Blum, H., & Marziali, E. (1995). A controlled trial of short-term group treatment for borderline personality disorder. Journal of Personality Disorders, 9(3), 190–198.
Rizvi, S. L., Hughes, C. D., Hittman, A. D., & Vieira Oliveira, P. (2017). Can trainees effectively deliver dialectical behavior therapy for individuals with borderline personality disorder? Outcomes from a training clinic. Journal of Clinical Psychology, 73(12), 1599–1611.