Short-Term Therapy and Its Limits in Personality Disorders

People with personality disorders have long-standing symptoms that have developed over the course of their lives. Treatment of people with these disorders can be effective, but given that the disorders take time to evolve, so do the interventions.

If you know people with personality disorders who have sought therapy, you are probably familiar with the difficulties they face. Perhaps you have a sister-in-law whose constant hot-and-cold behavior leaves you confused and, at times, hurt. Out of nowhere, it seems, she becomes enraged but on other occasions, she can be attentive and affectionate. As far as you know, she’s been in therapy for quite some time, but she seems not to have shown any measurable improvement.

According to a new study by van Vreeswijk and colleagues (2019) of the G-Kracht Mental Health Care Institute, Delft, the Netherlands, personality disorders are indeed “burdensome for the patients themselves [and] their closest ties” as well as being “costly for society” (p. 1). Their chronic nature, and the fact that they often co-exist with other psychological disorders, means that the demand for treatment exceeds the available resources for them to receive this treatment, in part because therapy for these individuals is long and expensive. To overcome the shortage of available treatment options, as the authors note, “More must be achieved with less” (p. 1) especially because “the societal demands seem to stress even cheaper and faster results” (p. 2).

One way to cut down costs and provide treatment for more of those who need it, the Dutch team suggests, is to expand on the availability of group therapy using methods that cut across specific theoretical frameworks and diagnoses. If such treatment were to work, though, therapists need to have guidance in the form of pre-defined modules, with each session’s approach clearly outlined. The two frameworks that the Dutch authors chose to evaluate in this context were 8-session based schema mindfulness-based cognitive therapy (SMBCT) and competitive memory therapy (COMET). Both of these approaches have support from prior research as effective across specific personality disorder diagnoses.

In SMBCT, treatment is aimed at improving the negative, self-defeating schemas that individuals with personality disorders have about themselves that, in turn, affect their thoughts, emotions, and behaviors. Patients learn to identify these schemas while they practice mindfulness to lessen the impact of their negative self-thoughts. Ordinarily, when these schemas are triggered, patients will run almost automatically into a maladaptive emotional state. Mindfulness breaks that cycle by encouraging patients to stop and reflect on how they make these unfortunate logical leaps without giving them any thought.

COMET targets negative self-images by using counterconditioning in which patients think back on a negative situation while they simultaneously activate positive feelings about themselves. An example of such counterconditioning would involve encouraging the patient to have thoughts such as “I am a smart person who can cope with a difficult situation” while also listening to music intended to boost positive memories.

Both of these approaches are intended to reverse negative cycles that can perpetuate the underlying emotional chain of events that keep the individual’s symptoms alive. Furthermore, in keeping with their 8-week structures, they each have specific agendas for each therapy session. SMBCT involves training in mindfulness, using each session to practice mindfulness under different circumstances, such as remembering painful events from the past. COMET’s weekly sessions each give participants a chance to focus on the opposite of their negative self-image including “exercising first-aid” when their negative images pop up in their heads.

Of the 66 individuals (primarily unmarried women 25 to 40 years old) first screened for the study, 8 were excluded because they either didn’t fit the diagnostic criteria or because they declined to participate. This left 58 to be assigned randomly to treatment conditions; of these, 20 dropped out before completing therapy or the final assessments. Although loss of participants is inevitable in any follow-up study, this dropout rate suggests that therapy did not appear to be compelling enough to these patients to keep them in the study for even that 8-week period. All participants received psychiatric consultations and medication use, with no restrictions, and those who needed more treatment after participation in the study had ended were given additional therapy following the model of their own assigned condition.

To assess therapy’s effectiveness, the authors calculated a score for clinical significance of change that took into account overall symptom severity. The proportions staying the same, showing improvement, or worsening were roughly equal between conditions, with 18-20% showing recovery, 14-17% improving, 40-46% remaining unchanged, and 21-23% actually deteriorating. There were some positive effects on more specific indexes, including self-esteem and some schema indexes, and feelings of suicidality did not decrease.

As the authors concluded, “As such this study might portrait the potential limits and challenges in looking for transdiagnostical brief modular treatments for a mixed group of personality disorders” (p. 7). In other words, by bringing together individuals with different personality disorders into a group setting with treatments that were not specific to the disorder, the findings were less than impressive. However, on the positive side, 20% fit the criteria for recovery (at least within the time frame of the study), and 17% showed improvement.

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There were other nuances in the results, in that individuals with the highest levels of psychological distress showed the most improvement, and of the personality disorders included, the best results were demonstrated for people with borderline personality disorder. Somewhat surprisingly, although the treatments were focused on changes in schema or self-image as a way of producing symptom relief, the pattern of findings was actually in the opposite direction. Symptom relief produced changes in these negative schemas. As the authors note, in addition to the small sample size and diversity of diagnoses in the samples, the participants varied in their ability to perform the actual mindfulness and schema-bending strategies. There was also no control group, waitlist or otherwise, and the time frame of the follow-up was only 4 weeks. Finally, all measures of improvement were based on self-report rather than on expert ratings of symptoms.

Do these findings mean that short-term treatments delivered in a relatively economical format can never work? It seems likely that with the limitations in the study population and design, there’s no reason to dispense entirely with this option as an avenue of future research. However, the results do show the difficulty of intervening in a generic manner with people whose diagnoses and individual case formulations may present very different challenges.

To sum up, for the moment, teaching individuals with personality disorders some basic mindfulness and self-esteem boosting tactics may as yet prove to be a valuable method in an overall approach to treatment. However, the findings also show the importance of using only those methods that have shown to be proven in their effectiveness. People with personality disorders may not respond that well, at present, to the kind of short-term therapy that works with other disorders. But the goal of making treatment available on a more widespread basis is still a valuable one.

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