How are expert therapists similar, different, and integrative in the treatment of borderline personality disorder?

Abstract

This study examined the use of therapeutic skills by different, well-known experts in psychology who have published extensively on the treatment of borderline personality disorder to ascertain areas of technique similarity, difference, and integration. Initial videotaped sessions from these expert therapists working with the same patient were independently rated, using an established measure, on cognitivebehavioral and psychodynamic-interpersonal techniques by 6 trained clinicians. These raters also independently identified what they believed were the most clinically significant segments of each session. The 6 raters demonstrated excellent levels of reliability. Results of this empirically based comparative process analysis suggest significant similarity, integration, and common focus across these 7 expert therapists in the specific techniques they used and in the themes and issues explored during the most clinically significant segments. All therapists took an active stance in exploring areas of clinical focus and initiating topics of discussion in this first meeting. Therapists tended to focus on the patient's pattern of romantic relationships ending abruptly and his lack of understanding why they ended, or his role in them ending. Almost all these segments included the therapist providing the patient with an alternative way to understand his experiences not previously recognized. Moreover, several of the therapists tended to both explore his irrational thoughts (e.g., all-or-nothing thinking, being incomplete without a partner) and relate perceptions of these relationships (e.g., being a victim, minimizing his anger/violence) to his interpersonal difficulties. Likewise, therapists often used the information gained from this process to provide psychoeducation regarding treatment approach and rationale. Finally, therapists would often return to key specific themes and issues that were clinically significant within the session in order to further explore and work through their meaning with the patient. Clinical Impact StatementQuestion: How do expert therapists from various theoretical orientations approach treatment of borderline personality disorder? What are the differences and commonalities, and are they integrative? Findings: Several techniques may be helpful in the treatment of borderline personality disorder, such as taking an active stance and initiating clinical focus as well as offering alternative perspectives to understand experiences not previously recognized and exploring irrational thoughts. Meaning: Across the various theoretical orientations, there were many similarities across the work of the expert therapists, suggesting the clinical utility of integration when treating borderline personality disorder. Next Steps: Future steps include examining how integrative and traditional therapies differ at the level of technique with various types of patients at different points across the treatment process.