Mental health articles

This section outlines the main treatment approaches adopted when working with people with personality disorders and discusses their relative efficacy.

Behavioural and cognitive approaches

There is evidence that behavioural and cognitive approaches can be effective in the treatment of people with personality disorders. The main approaches evaluated include schemafocused therapy, dialectical behaviour therapy  and long-term cognitive behavioural therapy.

Schema-focused therapy

Schema-focused therapy is an approach developed as a result of observations of the difficulties encountered when applying a traditional cognitive therapy model to patients with personality disorder. These difficulties included the diffuse presentation of patients with personality disorders, the high prevalence of interpersonal problems, an overly rigid style of thinking and behaviour, and a resulting avoidant pattern of coping with new situations. Young hypothesized that a wider conceptual approach was needed to engage these people that makes sense of the whole of the personality disordered patients difficulties. As such he developed a therapy that incorporates traditional cognitive therapy techniques but marries these with interpersonal and experiential interventions, using the concept of schema as the unifying element. Schema have been described as ‘the basic rules that people live by’, and are thought to develop out of early life experience. Young proposed a subset of schema that he termed Early Maladaptive Schema, and that these serve as templates for processing and defining later behaviour. The aim of schema-focused therapy, then, is to help the patient challenge these early maladaptive schemas through a range of behavioural experiments, cognitive restructuring and interpersonal techniques within the therapeutic relationship. As yet there is only weak evidence of the validity of Young’s  concept of early maladaptive schema and no strong evidence of the effectiveness of the schema-focused approach.

Dialectical behaviour therapy

Dialectical behaviour therapy is a long-term, cognitive behavioural therapy package of interventions evaluated as having some effectiveness in the treatment of patients with a borderline personality disorder. This form of therapy derives from the hypothesis that the core difficulty encountered by patients with a borderline personality disorder is an inability to self-regulate emotional arousal. This, it is suggested, is the factor that leads to the cluster of behaviours that have collectively become recognized as borderline personality disorder. This treatment approach generally lasts a minimum of 12 months and would contain individual cognitive behavioural psychotherapy focusing mainly on motivational issues, including the motivation to stay alive and remain in treatment. This therapy is conducted alongside skills training groups with the goal of teaching selfregulation of emotional states through the practising of new skills. The therapists delivering this treatment package are recommended to receive intensive clinical supervision and frequent consultation with each other. Until recently the evidence for the effectiveness of dialectical behaviour therapy was seen as promising but largely weak due to small sample sizes, and the fact that the majority of trials had been conducted by the therapy’s originator. However, a Dutch study has recently published the results of a large randomized controlled trial comparing dialectical behaviour therapy and treatment as usual for patients with borderline personality disorders. The results of this study demonstrated that dialectical behaviour therapy led to statistically and clinically significant reductions in self-mutilating behaviours and self-damaging impulsive acts. These differences could not be attributed to any differences between the treatment groups.

Cognitive-behaviour therapy

Cognitive-behavioural therapy protocols for people with personality disorder have generally agreed on the need to modify standard therapy approaches with an emphasis on a greater degree of individualized case formulation to guide and inform subsequent intervention design. To this end it is recommended that the therapist be more active than may be traditionally expected, and that the therapist should expect to tolerate a greater degree of negative transference. It is generally recommended that the therapy be longer term, with 12–20 months (or more) of treatment not uncommonly recommended. This long-term traditional approach to the treatment of personality disorder has yielded some promising early results in studies of effectiveness, but as yet these studies are statistically underpowered and as such have limited generalizability.

Psychodynamic approaches

The psychodynamic view of personality disorders is based on a developmental model of personality with the aim of helping the patient understand how the past influences the present with the use of interpretation. Treatment will generally be long term focusing on the therapeutic relationship between the patient and therapist, emotional experience and defence mechanisms. The therapist will use the relationship developed between therapist and patient, known as transference, as the means of understanding how the patient relates to other people. The evidence for the effectiveness of psychodynamic approaches to personality disorder is scarce. The few randomized studies that exist suggest that this approach may be helpful to patients with borderline personality disorder, and that a brief psychodynamic therapy may be more effective than a waiting list control.

Pharmacological approaches

Anti-psychotic, anti-depressant and mood stabilizing drugs have all been used in the treatment of personality disorders. It appears that some atypical anti-psychotic drugs can reduce symptoms such as depression, interpersonal sensitivity, anger and paranoia in patients with borderline personality disorder. However, this study was relatively small (n = 28) and so should be regarded as preliminary evidence only. Anti-depressants have also been recommended in the treatment of borderline personality disorder, being found to reduce impulsiveness, anger and depression. Mood stabilizers such as lithium and carbamazepine have been used in the treatment of mood disturbance for patients with personality disorder. However, there is little evidence that they offer any further benefits to these patients.

Principles of nursing care

There are a number of practical principles that should be considered when nursing patients with personality disorders. Issues such as the development of an appropriate therapeutic relationship, team working, supervision and support, are perhaps even more important when working with personality disordered patients, than with other patient groups.

Therapeutic relationships and engagement

The development of a therapeutic relationship is of crucial importance in the delivery of effective health care interventions to mentally disordered people. This is perhaps even more crucial when that person has a personality disorder. The centrality of an appropriate therapeutic relationship is emphasized by all three major psychological approaches to therapy. The humanistic school would propose that a therapeutic relationship is necessary and indeed sufficient in the delivery of a therapy that enables personality change. The psychodynamic therapist would encourage the development of a therapeutic relationship as a vehicle by which the patient can explore their past and current relationships with others. This knowledge, derived from the workings of the therapeutic relationship, would in turn generate insights that allow the person to change. Finally, the learning theorists have more recently come to understand that cognitive and behavioural therapies can be made more effective when delivered in the context of a strong therapeutic relationship  emphasized what he termed core conditions in the development of a therapeutic relationship, those being warmth, empathy and genuineness. The application of these skills led to the therapist having unconditional positive regard for the patient and so enabling the exploration of internal issues that would lead to a realization and change. While not all schools of psychological therapy agree with the mechanism of change proposed by Rogers, it has become widely accepted that he identified the key ingredients to developing therapeutic relationships with people. There are particular issues when developing therapeutic relationships with personality disordered patients. These are largely dependent on the observed behaviours within that individual that have attracted the diagnosis of personality disorder. As such it is important that these deficits within the personality disordered patient are recognized and do not prevent the development of a potentially otherwise helpful relationship. The nurse charged with engaging a personality-disordered patient in their care and treatment may need to accept certain behaviours within that relationship that might cause concern or be considered unusual in relationships with non-personality disordered patients. For example, a patient with a borderline personality disorder may split the nursing team into those staff that are definitely OK and those that are definitely not, resulting in behaviours such as over-dependence or overt hostility. In normal circumstances the team may wish to try to modify these behaviours but in this case it may be helpful to tolerate these extremes in order to maintain some engagement with at least a part of the nursing team.

Tags: disorder, personality, Personality Disorder, treatment