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How does psychodynamic theory explain borderline personality disorder

How does psychodynamic theory explain borderline personality disorder

Originally conceived of in psychodynamic terms, emphasizing deficits in representations of the self and others, some of the first treatments for borderline personality disorder (BPD) used approaches that emphasized unconscious processes, defense mechanisms, and attachment style.

By helping BPD patients rework some of these underlying issues stemming from their early development, psychodynamic therapists took on what they could anticipate as involving a lengthy process. Newer approaches within the psychodynamic model provide more focused treatment aimed at resolving shorter-term issues.

In a new meta-analysis of 16 controlled studies (with 519 patients), culled from an original pool of 199 published and unpublished clinical trials, John Keefe, of New York City’s Weill Medical College of Cornell University, teamed up with an international group of personality disorder researchers (2020) to appraise psychodynamic therapy’s potential to evaluate the evidence base for the psychodynamic treatment of PDs. The Keefe et al. study compared other forms of treatment, such as dialectical behavior therapy, a well-established method that focuses on regulating emotions and living in the moment. Ten of the investigations in the meta-analysis included BPD patients only.

As background to the meta-analysis, the Cornell-led research team noted that personality disorders (PD) in general are more treatment-resistant and have lower rates of positive outcomes than other forms of psychological disorders, difficulties that “bespeak the need for PD-focused treatments” (p. 158). The authors go on to observe that, in contrast to therapies that target the symptoms associated with mood and anxiety disorders, these PD-focused approaches “have the aim of helping patients ameliorate personality functioning and pathological ways of relating to self and other” (p. 158).

The methods used in psychodynamic approaches attempt to help patients become better able to “mentalize,” encouraging them to explore their views of self and others in ways that can help them make meaning of these views. PD-focused psychodynamic treatment also employs transference, in which patients can gain insight into their interactions with people in their actual lives on the basis of interactions with their therapists. Reality-testing, in which patients check out their interpretations of experiences against a less biased view, becomes another important PD-focused aspect of treatment.

People with PDs also tend to use defense mechanisms considered “maladaptive,” such as denial, “splitting” (seeing others as all good or all bad), and projection (attributing to others your own undesirable qualities). Consequently, another focus of psychodynamic therapy can help patients develop less dysfunctional ways of handling negative affect. Finally, given the role of attachment style (ways of thinking about close relationships), PD-oriented treatment, particularly for people with BPD, involves reworking those disturbed patterns of self-other relationships.

Perhaps you are close to an individual with BPD and, through your interactions with this person, have learned just how pervasive the symptoms of this disorder can be. Known to be associated with greater life stress, social and occupational dysfunction, and unstable relationships, their disorder puts strains on you as well. You hear about how psychotherapy is going for this person and wonder why it does not have any beneficial effects. Rather than conclude that treatment can never work, however, you may consider the alternative possibility that the therapist isn’t focusing specifically on those BPD symptoms.

Based on the Keefe et al. study, it would appear that your hunch may be correct. Psychodynamically-focused treatment, the authors concluded, was as effective as other approaches that target PDs specifically, particularly for BPD and another set of the so-called “Cluster C” PDs (avoidant, dependent, and obsessive-compulsive). In one key BPD symptom area in particular, however, psychodynamic therapies seemed to have their largest impact: namely, suicidality (suicide attempts and incidents of self-harm). Noting, however, that the other main treatment for BPD, dialectical behavior therapy, had similar effects on suicidality, the authors believe that more studies may be needed to establish any specific advantages to pure psychodynamic therapy.

You might be wondering, given that psychodynamic treatment doesn’t go as much “by the book,” or according to a manual, as do shorter-term, cognitively focused treatments, how it’s possible to establish similarity of an intervention given across multiple studies with multiple therapists, and with varying types of patients. Indeed, this was a limitation that the authors note. Additionally, most of the studies included in the meta-analysis in which a control group was used typically did not report any long-term follow-up. Those that did were on small samples, but they did report benefits for BPD patients.

With only 16 studies available for analysis, even though these were conducted on over 500 patients, it would be difficult to come up with large and consistent effects in a statistical sense. As much as possible, the authors attempted to tease out the differences between patient samples according to a variety of possible influences on the results, including the nature of the PDs represented in the patients, diagnostic measures used to assess patients, types of control (active vs. waitlist), length of treatment, length of follow-up, number of sessions, and actual version of psychodynamic treatment offered.

Given these methodological issues, the authors were, therefore, appropriately circumspect in coming up with wholehearted support for dynamically-oriented treatments. Each favorable finding needed to be qualified by a series of “but’s” showing how measurement issues further complicated the picture. As the authors note, “study-level meta-analyses cannot inform as to what specific treatments for PDs may be most appropriate for particular PD patients” (p. 166).

Instead of prescribing a one-size-fits-all approach, then, Keefe and his colleagues suggest a more tailor-made therapeutic strategy. Given that psychodynamic treatment wasn’t all that different from other theoretically-driven methods, “moving to questions of ‘what works for whom’ in (BPD’s) treatment may be warranted” (p. 166).

An implication of this finding is that, for example, people whose everyday lives are functioning at a relatively high level may be better candidates for so-called “object relations therapy,” which is more focused on long-standing issues relevant to disturbances in attachment style. In contrast, BPD patients who are more impaired could benefit more from gaining insight into the meaning of their inner experiences or mentalization therapy. Finally, people higher on the personality trait of agreeableness may be better candidates for DBT, in which they work together with their therapists to take more directed steps necessary to change their behaviors.

To sum up, there’s no reason to leave behind the longest-running treatment of BPD in favor of newer approaches without considering the specific nature of the individual. Psychodynamic therapy, particularly that which is informed by its more recent variations, could prove to be an important way to help those with BPD find their own path to fulfillment.

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