Question: What are the effects of psychological interventions for borderline personality disorder (BPD)?
Outcomes: Overall BPD severity, BPD symptoms (DSM-IV criteria), psychopathology associated with, but not specific to, BPD, attrition from the study and adverse effects.
Design: Systematic review and meta-analysis.
Data Sources: A comprehensive search of 15 databases was undertaken. See online notes for details.
Study Selection and Analysis: Randomised controlled trials (RCTs) comparing specific well-defined, theory-driven psychotherapeutic interventions against control interventions or other specific psychotherapeutic interventions in adults with BPD were included. Interventions were categorised as comprehensive psychotherapies if they included individual psychotherapy as a substantial part of the treatment programme, or as non-comprehensive if they did not.
Studies Identified: Twenty-eight RCTs (n=1804) met the inclusion criteria. The comprehensive psychotherapies assessed by the trials included: dialectical behaviour therapy (DBT), mentalisation-based treatment in a partial hospitalisation setting (MBT-PH), outpatient MBT (MBT-out), transference-focused therapy (TFP), cognitive behavioural therapy (CBT), dynamic deconstructive psychotherapy (DDP), interpersonal psychotherapy (IPT), interpersonal therapy for BPD (IPT-BPD), client-centred therapy (CCT), schema-focused therapy (SFT) with or without therapist telephone crisis support and cognitive therapy (CT). Non-comprehensive psychotherapeutic interventions included: DBT-group skills training only (DBT-ST), emotion regulation group therapy (ERG), schema-focused group therapy (SFT-G), systems training for emotional predictability and problem solving for borderline personality disorder (STEPPS), STEPPS plus individual therapy (STEPPS+IT), manual-assisted cognitive treatment (MACT) with or without therapeutic assessment and psychoeducation (PE). The overall quality of the RCTs ranged from moderate to low.
Results of Meta-analysis: This was only possible for the comparison of DBT versus treatment as usual (TAU) for four outcomes. DBT showed significant benefit over TAU for anger, parasuicidality and mental health (anger: 2 RCTs, n=46, SMD −0.83, 95% CI −1.43 to −0.22; parasuicidality: 3 RCTs, n=110, SMD −0.54, 95% CI −0.92 to −0.16; mental health: 2 RCTs, n=74, SMD 0.65, 95% CI 0.07 to 1.24).
Results From Individual RCTs: All remaining comparisons were based on results of single RCTs. Compared with control, the following interventions showed significant benefits for BPD core pathology and associated psychopathology: DBT, DBT adapted for people with comorbid PTSD, MBT-PH, MBT-out, TFP and IPT-BPD. IPT was only effective in the treatment of associated depression. CBT and DDP did not significantly affect BPD core pathology and associated psychopathology. For comparisons between different psychotherapies, DBT improved core and associated pathology more than CCT, and SFT improved BPD severity and treatment retention compared with TFP. No information on adverse effects of any psychotherapy was available.
Both comprehensive and non-comprehensive psychotherapies have shown some benefit for borderline personality disorder core pathology and associated general psychopathology, with dialectical behaviour therapy being the most studied technique. However, the evidence base is not very robust.
This review is meticulously done, and transparently reported. Selection criteria are strict with the exclusion of many studies. Some may prefer meta-analytic studies that are more inclusive of studies with various qualities, with overall results and investigation of the influence of variables such as design attributes.
One can ask what impact the review has on clinicians who are actually treating borderline patients, as well as what impact it has on other powerful constituencies, such as insurance companies and training programmes.
Training programmes in psychology are currently heavily biased towards cognitive behavioural therapy (CBT), and this review will simply reinforce that orientation. The review will probably have the least impact on practising clinicians—probably changing few minds. Dialectical behaviour therapy (DBT) has already had an impact on insurance companies in the USA. Those trained in DBT will continue with that orientation. Those in systems of care that are conscious of cost containment might opt for the clinical management investigated in the McMain study.1 The evidence suggesting that many structured treatments significantly reduce symptoms in borderline patients will urge clinicians to integrate various techniques across the specific treatments to enhance the life of the individual patient.
Clinical researchers have responded with several concerns. There is recognition of the tremendous heterogeneity among borderline patients, both in terms of borderline symptoms, comorbid conditions and severity of dysfunction. The research to date is of no help on this issue. There are serious limitations in the randomised clinical trial design. These designs as executed so far provide little about the treatment mechanisms of action. Nor do they provide data on the individual patient.
This review is a stark statement of where psychotherapy stands with regard to BPD patients. Multiple treatments significantly reduce symptoms, but what are the mechanisms of change? There is little research focus on change beyond symptoms, such as progress in work and intimate relationships. Whereas meticulous reviews of the RCT data are essential for the field, one can only hope that they do not stifle clinical flexibility and actually stimulate future research creativity.