To address this problem, thanks to philanthropic support in 2013 McLean launched what is now the Gunderson Personality Disorders Institute. The institute teaches workshops on effective therapies for BPD, like GPM and mentalization-based treatment (MBT), which focuses on helping people to differentiate and separate their own thoughts and feelings from those around them. Workshops provide interactive training exercises as well as a wide range of materials that clinicians and residents can bring back to their organizations.
According to institute director, Lois W. Choi-Kain, MEd, MD, the most common response from clinicians who attend the workshops is that they are “more hopeful and clearer about what they can do at the entry level.”
“Part of the stigma is that clinicians would treat people with BPD with methods that worked for other disorders, and when those treatments didn’t work they blamed the patient and called the patient untreatable,” said Choi-Kain. “A more general approach like GPM teaches us that the first step is identifying BPD as something that is diagnosable. GPM is an organizational framework with which clinicians can approach these very complex patients.”
“An increasing number of institutions are showing interest in learning how to better address and treat this disorder, which we hope will raise more awareness and increase much-needed resources in addressing BPD,” added Choi-Kain.
Research Helps to Make BPD Care More Accessible
In just the past few decades, a number of highly specialized psychotherapies entered the clinical scene as effective evidence-based therapies for BPD. The spread of these intensive therapies—dialectical behavior therapy (DBT), mentalization-based treatment (MBT), schema-focused therapy (SFT), transference-focused psychotherapy (TFP), and systems training for emotional predictability and problem solving (STEPPS)—have collectively helped turn the tide of the notion that BPD was an untreatable condition.
While this increase in effective treatment options has been good news, still many in the field were convinced that BPD should be primarily treated by specialists, which dramatically limits access to care. More recently, however, structured generalist management approaches, such as general psychiatric management (GPM) and structured clinical management (SCM), have also been proven to work for patients with BPD.
In a research review published in the March 2017 issue of Current Behavioral Neuroscience Reports, Choi-Kain and colleagues summarized care advances for adults with BPD, including a better understanding of the effectiveness of BPD treatments both old and new. According to their research, there are merits to specialized and generalized approaches.
Unfortunately, findings about BPD medication are not as positive. Compared to growing evidence that a variety of psychotherapies can be effective for treating BPD, the search for a reliable medication treatment has been less successful. However, this may be due, in part, to a lack of research.
To date, no medication has been approved by the U.S. Food and Drug Administration for BPD or proven to definitively manage its primary symptoms—interpersonal impairments and functional difficulties. Clinical application of the available evidence is hampered by the limited number of studies, small sample sizes, brief observation periods, and exclusion of co-occurring diagnoses—in a population for whom both psychiatric and medical diagnoses are the rule rather than an exception.
Psychotherapy-based research, however, has addressed these co-occurrences. Such investigations have found that both generalist and specialist approaches are not only effective at treating the primary symptoms of BPD, but also its most common co-occurring disorder, depression.
While generalist approaches to BPD treatment are already expanding access to evidence-based care, researchers have also been working to find the most essential ingredients of DBT, the most well-researched treatment for BPD.
A recent study has shown that a pared-down version of DBT—involving a skills training group combined with weekly case management—effectively reduced risk of self-harm, suicidality, and hospitalization. As compared to standard DBT treatment, such a simplified model could be more easily taught to mental health providers. This suggests that many more patients could be reaping the same core benefits provided by standard DBT treatment.
Specialized care, of course, still has its place. For certain complex forms of BPD, it appears that specialized therapies and adaptations of specialized therapies may be the best approach. For instance, research shows that slightly modified forms of standard DBT are effective at simultaneously treating the primary symptoms of BPD and certain other coexisting conditions, such as alcohol and drug misuse, eating disorders, and PTSD.
Today, researchers are evaluating methodologies for determining which patients should receive generalized care vs. specialized care, while others continue to study further treatment adaptations for patients with complex dual diagnoses. However, while we wait for these results, it is heartening to know that effective borderline personality disorder treatments are already available.