What may matter more than the type of specialized therapy are the elements of coherence, consistency, and continuity.

Specialized psychotherapies—especially psychodynamic psychotherapy and dialectical behavior therapy (DBT)—appear to be effective for alleviating some of the most debilitating symptoms of borderline personality disorder (BPD), but effects are small and studies are plagued by methodological problems, according to a meta-analysis published in JAMA Psychiatry.

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Psychodynamic psychotherapy and DBT demonstrated efficacy for treating self-harm, suicidal behavior, and general psychopathology as well as reducing health service use in patients with BPD. However, the treatment effects were only modestly superior to usual care, suggesting that the type of psychotherapy used to treat BPD, per se, may not be as important as certain underlying shared mechanisms of therapy that are conducive to improvement.

In an editorial accompanying the study, Peter Fonagy, Ph.D., Patrick Luyten, Ph.D., and Anthony Bateman, M.A., suggest that those important mechanisms include coherence, consistence, and continuity. As these elements have steadily been incorporated into psychotherapeutic approaches to treating patients with BPD, the gap in effectiveness between specialized therapies and “treatment as usual” has likely diminished, they suggested.

The treatment characteristics of coherence, consistency, and continuity “are critical because they provide cognitive structure for a patient group that lacks in metacognitive organization,” they wrote. “The importance of structuring of subjective experience as part of treatment has influenced how therapists—including the therapists in the treatment-as-usual (TAU) arm of trials—work with patients with BPD, so outcomes may have improved in TAU because iatrogenesis is likely to have decreased with the waning of unfocused exploratory and supportive interventions.”

In the study, Ioana Cristea, Ph.D., of the Babes-Bolyai University in Romania and colleagues from several international institutions searched PubMed, PsycINFO, EMBASE, and the Cochrane Central Register of Controlled Trials using the terms “borderline personality” and “randomized trial.” Thirty-three trials with 2,256 participants were included.

Standardized mean differences in efficacy were calculated using all outcomes reported in the trials for borderline symptoms including self-harm, suicide, health service use, and general psychopathology.

The results showed significant but small posttest between-group effect sizes in all outcome categories. For borderline-relevant outcomes and psychopathology, effects were small to medium. Most trials focused on DBT and psychodynamic approaches, and both types generated significant but still small effects compared with comparison interventions.

Statistical analysis suggested that the results may be inflated by risk of bias (greater attention paid to patients in experimental arms) and publication bias (the likelihood that trials would be published when results were favorable to the experimental arm).

The researchers noted that further study is needed and that prospective registration in clinical trial registries is necessary to address methodological problems in research on psychotherapy for BPD.

John Oldham, M.D., an expert on BPD and a former APA president, reviewed the report for Psychiatric News. He said that aside from the shortcomings and methodological problems in existing research, the news is generally good for the psychotherapeutic treatment of BPD.

Oldham agreed with Fonagy and colleagues that the type or “brand” of specialized therapy is not as important in psychotherapeutic treatment of BPD as are certain crucial elements that are shared by all effective therapies.

“An unfortunate byproduct of recent progress in the field has been the ‘horse-race’ attitude sometimes heard from advocates of a particular treatment approach—that studies will one day ‘prove’ their favored approach to be the winner,” Oldham said. “I don’t think so, and I believe the Cristea report supports this broader view. Some therapies work well for some patients with BPD, and others may work well for others.”

Oldham added, “I have argued that there are four essential ingredients for effective psychotherapy for BPD: a strong therapeutic alliance; availability of capable, well-trained therapists of many stripes; enough time to do the job right; and money—that is, somebody’s got to pay for it. These are tough conditions to meet, especially in many parts of the country.”

Oldham concluded that the Cristea report is good news. “A number of types of psychotherapy for BPD, examined carefully, can be effective, just as treatment as usual can be—especially, as emphasized by Fonagy and colleagues in the accompanying editorial, when it is carried out in a structured way by well-informed clinicians who understand deeply the nature of the illness,” he said. ■