Halliwick Psychotherapy Unit, St Ann's Hospital, London
Psychoanalysis Unit, University College London
Correspondence: Dr A.W. Bateman, Halliwick Psychotherapy Department, Haringey Healthcare NHS Trust, St Ann's Hospital, St Ann's Road, London N15 3TH
See editorial, pp. 93-94,
this issue.
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ABSTRACT |
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Aims To investigate the evidence for effectiveness of psychotherapeutic treatment for personality disorder.
Method Systematic literature review.
Results There is evidence for the effectiveness of psychotherapy for personality disorder. Problems of case identification, comorbidity, randomisation, specificity of treatment and outcome measurement are inadequately addressed. Authors mainly relied on cohort studies. Evidence neither suggests superiority of one type of therapy over another nor indicates which subgroups of patients should be offered psychotherapy as in-patient, day patient, or out-patient.
Conclusions New research strategies are needed to show that personality change is both measurable and clinically meaningful. Effectiveness studies using randomised controlled designs are required. The literature suggests that effective treatment should be long-term, integrated, theoretically coherent and focused on compliance.
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INTRODUCTION |
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METHOD |
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OUTCOME RESEARCH |
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In-patient treatment
Prolonged in-patient admission has been the mainstay of treatment of
personality disorder.
Cohort studies
Most in-patient studies are prospective, using pre-test-post-test designs
on one group. Tucker et al
(1987) assessed the outcome
after 1 and 2 years of 40 of 62 borderline patients treated for between 6
months and 1 year in a specialised unit. Treatment included individual, group
and milieu therapies. Improvement in global function, reduction in
self-destructive behaviour and suicide attempts, decreased use of
hospitalisation, and the development of more constructive relationships were
all found. Najavits & Gunderson
(1995) and Blatt & Ford
(1994) reported similar
results. Copas et al
(1984) retrospectively
followed up 194 psychopathic patients after 3-5 years, and McGlashan
(1986) retrospectively
followed up 89 borderline patients after a mean of 15 years, both finding
improvements in symptoms and in behaviour. Stone's
(1993) report of up to 20
years' follow-up of 550 in-patients indicated that 66% of them were
functioning well. Such studies fail to rule out other plausible alternative
reasons for change, such as the passage of time or subsequent out-patient
treatment. Rosser et al
(1987) suggested, in a
naturalistic 5-year follow-up of individuals receiving in-patient treatment at
the Cassel Hospital in London, that caution should be exercised in ascribing
any benefits observed to that treatment. Patients with borderline personality
disorder (BPD) had a less favourable outcome than those with a combination of
neurotic pathology, depression, high intelligence and lack of chronic
out-patient history.
Longer-term follow-ups are hard to interpret because events, other therapies, etc. may have intervened; it could be argued that these studies really document the long-term course of the disorder.
Controlled interventions
Barley et al (1993)
evaluated the effectiveness of dialectical behaviour therapy (DBT) for the
treatment of BPD in an in-patient setting. DBT includes techniques at the
level of behaviour (functional analysis), cognitions (e.g. skills training)
and support (empathy, teaching management of trauma). They found that during
and following implementation there was a significant fall in rates of
parasuicide when compared to a period before implementation. There was no
significant fall during an equivalent time period in another unit offering
standard psychiatric care. However, it is not clear that the two groups of
patients were comparable, the psychiatric care was not described and there was
no randomisation of patients. Other structured inpatient treatments may have a
similar effect, for example wellness and lifestyle groups, in
which topics such as hobbies and fitness are discussed
(Springer et al,
1996) or insight-oriented therapy
(Liberman & Eckman,
1981).
Dolan et al (1997) used a non-admitted comparison sample as a control to assess the effectiveness of specialist in-patient treatment on core symptoms of personality. This is one of the few studies to attempt assessment of syndromal change. They studied 137 patients, of whom 70 were admitted and 67 not admitted either for clinical or for financial reasons. One year after treatment there was significantly greater reduction in the core features of personality disorder on the Borderline Syndrome Index (BSI; Conte et al, 1980) in the treated group than in the non-admitted group. But in a UK study using the Personality Assessment Schedule (Tyrer et al, 1988) as the criterion measure, the BSI was found to lack validity and to be susceptible to distortion from current symptoms (Marlowe et al, 1996).
Limited data on cost suggests that in-patient admission may yield significant savings after completed treatment (Dolan et al, 1996), particularly in the use of criminal justice services in those with forensic histories. The true value of long-term in-patient treatment remains unclear, but in reviewing the literature on effectiveness, it is found that the patients likely to benefit are those showing: (a) substance misuse; (b) severe suicide risk; (c) forensic history; (d) transient difficulties in reality testing; (e) failure to respond to repeated short-term hospitalisation and out-patient intervention; and (f) evidence that destructive living and hopelessness has been incorporated into the personality.
Day hospital treatment
Cohort studies
Karterud et al
(1992) studied prospectively
97 patients treated in a psychodynamically oriented day hospital, of whom 76%
had an Axis II DSM-III-R diagnosis
(American Psychiatric Association,
1987). After a mean treatment time of 6 months, the outcome on
measures of global symptoms and overall mental health was found to be best for
anxious-avoidant personality disorder, with only modest gains for BPD. Dick
& Woof (1986), using a
similar programme, found that after 12 weeks of treatment a small subgroup of
patients diagnosed retrospectively as having BPD increased their use of
services, possibly indicating that a longer term of treatment was necessary
for this group.
There is little evidence of specificity of treatment programmes. A feminist, psychodynamically informed programme with a socio-political dimension was effective in reducing symptoms and health service usage in 31 patients with personality disorder treated in day and semi-residential facilities. Gains were sustained over a 2-year follow-up (Krawitz, 1997). Use of a socio-political dimension may be highly pertinent, given the breadth of social adaptational difficulties of most patients.
Controlled studies
In a prospective study, using a design of treatment v. control
(delayed treatment), Piper et al
(1993) found significant
effects of 18 weeks of day hospital treatment in 79 patients with both
affective disorder and long-standing personality disorder. Interpersonal
functioning, symptoms, selfesteem, life satisfaction and defensive functioning
all improved after 4 months of treatment when compared with the control group,
and gains were maintained at the 8-month follow-up.
Recently, Bateman & Fonagy (1999), in a controlled trial of 38 patients with BPD, randomly allocated to a psychoanalytically informed day hospital or to treatment as usual (TAU), reported a substantial reduction in parasuicidal behaviour, self-harm and hospitalisation over an 18-month period of treatment. The severity of self-reported mood and psychiatric symptoms also improved substantially relative to the control group. Drop-out was low (12%). Improvement occurred later in treatment, emphasising that admission to day hospital needs to be for a relatively long term. Follow-up data are not yet available, nor is it clear which of a number of potentially effective components (the therapy, the milieu, or contact with staff) may have been responsible for the improvements.
There are no data to suggest that the mere inclusion of psychotherapy within a day hospital is sufficient to ensure good outcome. All studies use an integrated and organised treatment programme within a singular, coherent (and to the patients understandable) system. Only such integrated programmes, with clinicians with various tasks and functions working to the same strategic goals, permit patients with severe problems in understanding human motives (Fonagy, 1998) to feel sufficiently safe to engage effectively with the treatment.
Since there are no comparative outcome studies of different contexts of treatment, clinical impressions generated in the course of this review, rather than empirical data, are the only guide to indications for day hospital treatment. These are similar to those for in-patient treatment.
Out-patient treatment
Cohort studies
Data on both cognitivebehavioural (CBT) and psychodynamic treatment
come primarily either from single-case series or from theory-oriented methods,
which makes it difficult to generalise the results. Older studies of
psychodynamic treatment reporting long-term follow-up suggest that some
patients do well while others, particularly those with comorbidity, do badly
(Wallerstein, 1986). More
recently, Stevenson & Meares
(1992,
1999) reported on 48 patients
with BPD treated with psychoanalytic psychotherapy twice a week for one year.
Significant improvements in the number of episodes of self-harm and violence,
length of hospital admissions, and other measures were observed in the 30
patients who completed therapy; and 30% of patients no longer fulfilled the
criteria for BPD at the end of treatment. Improvement was maintained over 1
year, and continued over 5 years, with substantial saving in health care
costs.
Davidson & Tyrer (1996) found important changes in maladaptive behavioural and cognitive patterns after a 10-week course of CBT in 12 out-patients with antisocial disorder or BPD. Turkat & Maisto (1985) formulated 35 patients from a cognitivebehavioural perspective and, using a single-case design, tested their formulations. Of the 16 cases for which outcome data were available, only four had a positive outcome.
The results of these studies must be treated with circumspection. There were no independent ratings, no comparison groups, and no discussion of the possibility of improvement over time.
Controlled studies
In one of the few randomised controlled trials of out-patient treatment of
BPD, Linehan and colleagues
(1991) show that DBT was
partially effective in helping women patients with BPD. Therapy was conducted
weekly, and offered both individually and in groups over one year.
Interventions received by patients under the TAU regime were not controlled.
Twenty-two women patients were assigned to DBT and 22 to the control group.
Assessment was carried out during, and at the end of, therapy, and again after
1 year follow-up (Linehan et al,
1993). The drop-out rate was low (16%). Control patients were
significantly more likely to make suicide attempts, spent longer as
in-patients over the year of treatment, and were more likely to drop out of
those therapies to which they were assigned. However there were no differences
between groups on measures of depression, hopelessness or reasons for living.
Follow-up at 1 year found no differences between groups.
Only recently have controlled studies of out-patient psychoanalytic therapy been instigated. Clarkin et al (1999) have reported preliminary data on a small sample of 10 patients with BPD treated for 1 year. A number showed significant improvements. Patients with antisocial features seem particularly likely to do badly. A comparative trial of relationship management group therapy and individual dynamic treatment for BPD indicated, at the end of treatment and at follow-up, that these were equally effective (Monroe-Blum & Marziali, 1995), suggesting a need for costbenefit analysis to be included in future research.
Results from controlled studies of avoidant personality disorder suggest that both dynamically oriented and behavioural packages are useful (see Roth & Fonagy, 1996, for review). But many patients do not achieve normal functioning. Alden & Capreol (1993) suggest that patients with avoidant personality disorder are either distrustful and angry, or underassertive. In a trial of 76 patients, angry patients benefited from exposure but not from skills training, while the unassertive improved with both. Subdividing diagnostic categories helps to focus treatment more effectively, as may recognising interactions between aptitude and treatment. Deconstructing descriptions of personality disorders into personality style and disordered function components may be appropriate for future research. Beutler et al (1991) suggest that clients who are reactant (resistant) benefit more from non-directive therapy or paradoxical interventions than from cognitivebehavioural interventions.
Summary
In summarising studies of out-patient treatment, it should be noted that
there is relatively little compelling evidence that individuals with
personality disorders and low levels of functioning can be successfully
treated on an out-patient basis, although they may be supported. The best
evidence so far from Linehan et al's
(1991) DBT trial is relatively
disappointing in terms of long-term outcome. There are preliminary indications
that individuals with predominantly avoidant personality disorders may be
helped by either dynamic or behavioural methods.
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PROBLEMS OF RESEARCH |
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Case identification
There are problems of case identification in this literature, since
subjects may be grouped either by categories based on DSMIV and
ICD10 (World Health Organization,
1992), or by a theory-oriented method. Both methods present
problems. There is no predictive value to categories. Forming three clusters
of oddeccentric, impulsiveerratic, and anxiousavoidant
has only face validity. No cohort studies have been carried out to confirm the
stability of such groupings (Mulder &
Joyce, 1997). There is poor cross-classificatory reliability
(Sara et al, 1996),
making comparison of research findings, difficult. If this method is to be
improved, future research may have to identify personality disorder from the
perspectives of both the patient and an informant
(Zimmerman, 1994). It is not
possible to generalise the findings of theory-oriented evaluations (see, e.g.
Beck & Freeman, 1990, for
cognitive; Benjamin & Benjamin,
1994, for interpersonal; and
Kernberg, 1984, for a
psychoanalytic perspective), and their use to compare the relative
effectiveness of alternative clinical approaches is problematic. But they
offer a practical way of refining conceptualisations of specific personality
disorders.
Dimensional approaches are of limited value in clinical outcome studies. There is agreement neither on traits nor on whether they represent extremes of normal personality or are qualitatively different, and the two are often conflated by assessing traits which are abnormal in quantity (e.g. sociability) alongside personality dispositions which are unlikely to be found in non-clinical subjects (e.g. self-mutilation). Recently, a method for revising and measuring Axis II categories has been developed that is both psychometrically and clinically meaningful (Westen & Shedler, 1999). This offers potential for future research.
Comorbidity
Often several personality disorders are reported in one individual, and
interaction between the personality disorder and Axis I diagnosis could result
in either an exaggeration or an obscuring of a genuine treatment effect. In
the majority of studies, measured change in personality may be an artefact
related to improvement in symptoms, which itself may be due to a change in the
manifestation of the personality disorder, rather than improvement: for
example, a patient with BPD may avoid intense relationships and so show fewer
symptoms. In general, studies confound treatment effects related to
personality change with improvement in symptoms.
Randomisation and control
Problems of implementing RCTs for assessing the efficacy of
psychotherapeutic treatments have been discussed elsewhere
(Roth & Fonagy, 1996). But
problems specific to personality disorder may account for the dearth of
controlled studies identified for this review. First, keeping an RCT running
for a long time period with an adequate number of patients is expensive and a
formidable logistical problem. Attrition rates were high in many studies, due
to the chaotic lifestyles of the subjects and their social mobility, although
this can be ameliorated (Linehan et
al, 1991; Stevenson &
Meares, 1992; Bateman &
Fonagy, 1999). The therapist's investment in the initial treatment
contract and maintenance of an alliance improves compliance
(Yeamans et al,
1994). Recent studies suggest that younger patients who are
initially hostile are the most likely to withdraw
(Smith et al, 1995).
Second, intercurrent treatment is inevitable and confounded all long-term
follow-ups. Third, patients' expectations are an important factor for therapy
outcome (Horowitz et al,
1993): randomisation to different treatments may lead to
allocations incongruent with these expectations, and this may be particularly
problematic for patients whose lack of flexibility is almost a defining
feature of their disorder (Bleiberg,
1994). Waiting-list controls cannot be used to control for change
over long periods of time, and so are of limited use. The most stringent
control group without ethical problems is TAU which should be used in future,
even though heterogeneity of intervention and differential responsiveness
within groups may obscure results.
Specificity of psychotherapies
Evaluation of outcomes is hampered by the lack of specificity in
psychotherapeutic approaches. There is so much variance within each treatment,
and overlap between treatments, that differential treatment effects are likely
to be masked (Goldfried & Wolfe,
1998). Thus comparative outcome studies are unlikely to produce a
yield commensurate with their effort. In long-term therapy, practitioners make
complex choices in selecting interventions that take account of both
behavioural and dynamic factors. In order to enhance specificity and to assess
fidelity of application, researchers have manualised treatments.
These include psychoanalytic psychotherapy
(Kernberg et al,
1989; Clarkin et al,
1999), DBT (Linehan,
1993), and object relations/interpersonal approaches
(Dawson, 1988). The manual for
cognitiveanalytic therapy is as yet untested
(Ryle, 1997).
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OUTCOME MEASUREMENT AND FOLLOW-UP |
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The necessity for long-term follow-up in studies of the effectiveness of treatment of personality disorder is widely acknowledged. The outcome of therapy may not be fully evident at discharge (Hogland et al, 1993).
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DISCUSSION |
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Effective ingredients of treatment
Treatments shown to be moderately effective have certain common features.
They tend: (a) to be well structured; (b) to devote considerable effort to
enhancing compliance; (c) to have a clear focus, whether that focus is a
problem type of behaviour such as self-harm or an aspect of interpersonal
relationship patterns; (d) to be theoretically highly coherent to both
therapist and patient, sometimes deliberately omitting information
incompatible with the theory; (e) to be relatively long term; (f) to encourage
a powerful attachment relationship between therapist and patient, enabling the
therapist to adopt a relatively active rather than a passive stance; and (g)
to be well integrated with other services available to the patient. While some
of these features may be those of a successful research study rather than of a
successful therapy, the manner in which clinical treatment protocols are
constructed and delivered is probably as important in the success of treatment
as the specific, theoretically driven intervention itself.
Pathway to effectiveness
One way of interpreting these observations might be that part of the
benefit which individuals with personality disorder derive from treatment
comes through experience of being involved in a carefully considered, well
structured and coherent interpersonal endeavour. What may be helpful is the
internalisation of a thoughtfully developed structure, the understanding of
the interrelationship of different reliably identifiable components, the
causal interdependence of specific ideas and actions, the constructive
interactions of professionals, and above all the experience of being the
subject of reliable, coherent and rational thinking. Social and personal
experiences such as these are not specific to any treatment modality but,
rather, indicate the level of seriousness and the degree of commitment with
which teams of professionals approach the problem of caring for this group,
who may be argued on empirical grounds to have been deprived of exactly such
consideration and commitment during their early development and quite
frequently throughout their later life (see review by
Zanarini & Frankenburg,
1997). While this suggestion is speculative, it may also be
helpful in distinguishing successful from unsuccessful interventions and
pointing the way to the creation of more efficacious protocols in the
future.
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CLINICAL IMPLICATIONS AND LIMITATIONS |
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LIMITATIONS
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Received for publication December 18, 1998. Revision received December 3, 1999. Accepted for publication December 7, 1999.