Treatment Manual: The basis for any psychotherapy study is a treatment manual that defines what the therapy prescribes and proscribes. Working from the basic IPT (Interpersonal Therapy) manual (Weissman et al., 2000), we have been developing a new manual suited to the needs and difficulties faced by patients who have BPD. Although IPT-BPD is recognizable as IPT, it necessarily modifies or departs from the standard acute treatment for major depression at points. Treating patients who have lifelong personality dysfunction, whose difficulties may include frequent threats to the stability of the therapy itself, is perforce more complicated than treating patients who have acute major depression, who may have been doing well until a few months previously.
Features of Adaptation: Among the changes involved in IPT-BPD are (1) conceptualization of the disorder, (2)
chronicity of the disorder, (3) difficulties in forming and maintaining the treatment alliance, (4) length of the intervention, (5) suicide risk, and (6) termination.
Conceptualization of BPD. As noted, researchers have remarked on the resemblance between and overlap of borderline personality disorder and mood disorders. Many—in some samples, nearly all—patients diagnosed with BPD meet criteria for major depression and/or dysthymic disorder (Akiskal et al., 1985; Zanarini et al., 1998). From a clinical perspective, the patients in our protocol for BPD have shared interpersonal patterns with many chronically depressed patients. As do depressed individuals, they often feel depressed, feel guilty, see anger as a "bad" emotion, and hence tend to avoid it when possible. Unlike most depressed patients, BPD patients periodically explode, expressing anger in a manner that frightens them and others and that does little to improve their interpersonal situations. This unhappy outcome convinces patients that anger is indeed "bad" and leads them to try to suppress it. Thus patients who have BPD seem to overlap with depressed patients in their often inhibited behavior, but differ in having explosive, impulsive, self-destructive outbursts. In treating depression, IPT therapists often validate patients’ anger as an appropriate reaction to external circumstances and encourage the inhibited patients to express this anger rather than to suppress it and feel passive and self-critical. In our experience with patients who suffer from BPD, these same dynamics often appear, but with the complication that these patients go too far, rather than not far enough, on the occasions when they do voice such feelings. The goal in either case, obviously, is a moderate and effective expression of anger. The same may be said of self-assertion, another risky interpersonal maneuver for both depressed and borderline patients. For the purposes of working with a spectrum of BPD patients who do manage to have some interpersonal relationships, we characterize BPD as a mood-inflected chronic illness similar to dysthymic disorder, but punctuated by sporadic, ineffective outbursts of anger and impulsivity. This medical model, defining BPD as a treatable illness that is not the patient’s fault, allows the patient to shift unneeded guilt from self to syndrome. Given the confusion and stigma attached to the borderline rubric, the IPT therapist provides psychoeducation about the name of the syndrome and what it does and does not mean. Our expectation is that IPT approaches similar to those for depressed patients will often be helpful.
Chronicity of the Disorder. The IPT model neatly fits acute psychiatric disorders: Symptoms arise in temporal association to life events, either preceding or postdating them. In either case, the therapist connects mood symptoms to life situations, a formulation that makes intuitive sense even to patients who have poor concentration and sometimes concrete thinking. Chronic illness, however, fits this scheme less well. If a patient has been suffering for decades, recent events seem less related to the illness and indeed may feel as if they are the patient’s personality, not an illness at all. In adapting IPT for chronic Axis I syndromes such as dysthymic disorder (Markowitz, 1998) and social phobia (Lipsitz et al., 1999), we took advantage of that patient perspective: that, precisely because of the duration of the illness, the patient confuses symptoms with him- or herself. Therapy itself then becomes an iatrogenic role transition (Markowitz, 1998). In the course of a relatively brief treatment, the patient learns to distinguish a chronic illness (understandably confused over time with personality, or self ) from self. By taking healthy actions in interpersonal encounters—rather than interpersonal actions influenced by symptoms of illness—the patient begins to see how chronic illness has inhibited his or her interpersonal skills. Symptoms and symptomatic interpersonal behaviors (e.g., passivity) become ego-alien. Developing new (i.e., nondysthymic) skills then yields success experiences (Frank, 1971), better interpersonal functioning, and better mood. The resolution of the iatrogenic role transition is the shedding of the longstanding diagnosis. In treating dysthymic disorder, therapists encourage patients that depression is not their personality, even if it feels as if it is, a process that becomes more complicated in treating a personality disorder. The usual IPT approach is applied, nonetheless: BPD is diagnosed and deemed a chronic but treatable illness that affects interpersonal functioning. The goal of treatment is to develop better, more adaptive interpersonal skills so that the patient functions better and feels better. Treatment raises the exciting expectation that the patient may be able to shed this disorder, even though he or she has had it throughout adulthood, in a relatively brief course of treatment.
Difficulties in Forming and Maintaining a Treatment Alliance. Depressed patients, who enter treatment in great pain, generally cooperate with therapists to relieve it. We anticipated that forming a therapeutic alliance with patients who have BPD would be more difficult. The IPT model is generally patient-friendly: The therapist is an encouraging, therapeutically optimistic ally in the struggle against an illness. Both because IPT focuses on improving relationships in the patient’s "real" daily life and because therapist interpretations risk making patients feel criticized or threatened, IPT focuses as much as possible on relationships external to the office. This focus minimizes the threat of a rupture in the therapeutic alliance (Safran &Muran, 2000). When conflict between patient and therapist does occur, it is addressed in here-and-now interpersonal terms, trying to understand and to optimize the way the patient is feeling and handling current patterns and communications with the therapist. Patients who have BPD notoriously tend to "split" (in psychodynamic terms) or think "dichotomously" (in cognitive terms). That is, they feel strongly positive about a person or relationship at one moment, then abruptly reverse their view to an extreme negative polarity, with seeming amnesia or at least lack of integration of their previous outlook. The goal of any helpful therapy for BPD patients must be ultimately to help patients integrate "mixed feelings," the positive and the negative aspects inherent in all relationships. IPT does not achieve this result by focusing on the therapeutic relationship but by exploring the range of feelings a patient has about significant relationships and the people in them. The therapist validates the patient’s feelings, but then probes for negative feelings in positively held relationships, and vice versa. The therapist explicitly normalizes the idea that emotional reactions tend to be complex and nuanced; that "mixed feelings" are reasonable and tolerable, for example, that a person can (and sooner or later may temporarily) hate people he or she loves, depending upon what is happening in the relationship; and that such feelings are useful signals of what is happening in the relationship. Working with patients who meet BPD criteria makes some difficulties in the therapeutic relationship are almost inevitable. If a rupture occurs, the IPT therapist validates the patient’s feelings when possible; encourages active communication of the disagreement in here-and-now, interpersonal terms; and underscores the importance of continuing to work together because this problem is precisely the kind that arises with borderline personality disorder. In resolving tensions in the therapy, IPT therapists are free to apologize and to give the patient space as judged clinically appropriate.
Length of Treatment. Sixteen weeks, the usual maximal length of acute IPT for major depressive disorder, seemed inadequate to treat BPD. There are no published studies of IPT for Axis II disorders, although the earlier, unpublished study by Gillies and colleagues had attempted a 12-week trial. Without a clear precedent in IPT research, our group decided to attempt a two-stage treatment. In the first, acute phase, the patient receives 18 50-minute IPT sessions in 16 weeks. The goals of that initial phase are to establish a therapeutic alliance, limit self-destructive behaviors, explain the IPT model, and ideally provide initial symptomatic relief. If the patient tolerates this first phase, a continuation phase of 16 sessions in as many weeks follows. (If the patient does not tolerate the initial phase, an alternative approach may be preferable.) Goals of continuation treatment involve building on initial gains, developing more adaptive interpersonal skills, and maintaining a strong therapeutic alliance as termination approaches. Thus BPD patients can receive up to 34 IPT sessions over 8 months in this open, pilot study. Patients are also offered a 10-minute telephone contact once weekly, as needed, to handle crises and maintain therapeutic continuity. Both the length and the intensity of treatment in this IPT protocol are shorter than in DBT, which comprises weekly individual and group sessions for a year (Linehan, 1993), and in the 18-month Bateman and Fonagy (2001) psychodynamic day hospital program. The extended treatment framework, as well as the reflection of patients’ chaotic lives in the content of treatment, require that the focus of IPT-BPD necessarily be loosened somewhat. Relative to acute IPT for Axis I disorders, the therapist may tolerate greater shifts in topic from session to session, although always attempting to return to the central theme (e.g., a role dispute with a significant other). These BPD patients present with a plethora of interpersonal life events; that is good from an IPT perspective, providing numerous opportunities for connecting affect to life situations. Although Angus and Gillies (1994), in adapting IPT for borderline patients, had created a fifth interpersonal problem area, self-image, and other adaptations of IPT have made equivalent additions (Weissman et al., 2000), our group has not seen the need to use this fifth category or to develop others. We had expected, and thus far have found, that most patients who have BPD have role disputes and role transitions.
Suicide Risk. Helping patients to avoid self-destructive behavior must be a key aspect of any treatment for BPD. Our experience to date has been that all patients have suicidal ideation, and some have impulses to act on it, but most have been willing to see such impulsive acts as avoidance of their feelings in relationship situations and so to suspend the behaviors during the therapy.
Termination. Because separation and abandonment are central concerns of many individuals who have BPD, termination poses a potential problem. Termination has usually not been a difficult treatment phase in IPT, in part because of its deemphasis of the therapeutic relationship and brief, clear time limit. Termination is announced well in advance and the patient reminded periodically. The termination phase is a bittersweet role transition that offers an opportunity to examine the patient’s feelings about this difficult life event, to look at the positive and negative aspects of the relationship, and ideally to integrate them.
As in standard IPT, the IPT-BPD therapist helps bolster the patient’s sense of independence as treatment ends by helping him or her to review the treatment to that point. Why has the patient been feeling better? Because he or she has made strides in the treatment, learning to handle affects and relationships differently. The therapeutic relationship may be considered another such opportunity for dealing with interpersonally linked feelings in here-and-now, nontransferential fashion.
- Markowitz, John, Andrew Skodol, and Kathryn Bleiberg; Interpersonal Psychotherapy for Borderline Personality Disorder: Possible Mechanisms of Change; Journal of Clinical Psychology; Vol. 62(4); 2006
Reflection Exercise #2
The preceding section contained information
about strategies for adapting IPT for Borderline clients. Write
three case study examples regarding how you might use the content of this section
in your practice.
What are the six changes from what IPT was originally developed for in adapting IPT for BPD? Record the letter of the correct answer