Group Treatment of Personality Disorder
• Group treatments for patients diagnosed with personality disorders
have represented an active area of research over the last two decades
• Studies have overwhelmingly targeted Borderline Personality Disorder
(BPD) and the problems central to BPD: suicidality, parasuicidality,
depression, hopelessness, and hospital admissions—the assumption is that
effective techniques with BPD would be effective with other personality
• Studies can be differentiated according to level of care, i.e.,
outpatient, partial hospitalization (e.g., day treatment)/residential, or
• Outpatient interventions are uniformly cognitive-behavioral (CBT) in
orientation (usually Dialectical Behavior Therapy or DBT), while day
treatment/residential and inpatient programs often combine CBT and
• The evidence base regarding group treatments for other PDs is limited,
based primarily on clinical experience and anecdote
• Studies of long-term psychodynamic group therapy are difficult to do
and thus rare, but the work of Lorentzen and colleagues has demonstrated
that a long-term format, relative to a time-limited short-term format, is
more effective for patients with PD
DBT has received more attention than any other outpatient approach. Central to DBT is a skills-training group (2.5 hours/week, generally for one year of treatment) that complements twice-weekly individual therapy and telephone coaching. Evidence for the effectiveness of the skills-training group alone is mixed; one study found the DBT group out-performed a dynamic group on patient retention, psychiatric symptoms, lability, and anger (Soler et al., 2009). Evidence for the efficacy of the DBT program is strong, relative to “community treatment by experts” (Linehan et al., 2006) and particularly for suicide attempts, crisis/inpatient service use, and dropping out. However, equivalent effectiveness has been observed relative to comparison treatments that are BPD-specific (Kliem et al., 2010). For example, McMain et al. (2009) employed psychiatric management in line with the American Psychiatric Association treatment guidelines for BPD as a comparison for DBT and reported equivalent effects for most clinical outcomes. Adaptations of DBT for adolescent (Fleischhaker et al., 2011), community mental health center (Comtois et al., 2007), and inpatient groups (Bohus et al., 2004; Kleindienst et al., 2008) have been examined in preliminary studies with promising results.
Another group CBT approach, Systems Training for Emotional Predictability and Problem-Solving (STEPPS), has garnered strong evidence for efficacy with BPD patients (see Blum et al., 2002, 2008; Bos et al., 2010, 2011; Harvey et al., 2010). STEPPS employs group CBT emphasizing skills training for emotion and behavior management and a psychoeducational group for key members of the patient’s social network. Strong effects on BPD symptoms, global functioning and quality of life have been observed, but dropout rates remain an issue. Other outpatient group treatments with demonstrated effectiveness include schema-focused (Farrell et al., 2009), acceptance-based (Gratz & Gunderson, 2006), interpersonal (Munroe-Blum & Marziali, 1995), and problem-solving (Huband et al., 2007) group therapy.
A partial hospitalization approach with substantial empirical support is the 18-month Mentalization-Based Day Treatment (MBDT; Bateman & Fonagy, 1999). Relative to treatment-as-usual (TAU), MBDT proved superior on self-harm, suicide attempts, health services use, and medication compliance, with results maintained at 18-month and 8-year follow-up (Bateman & Fonagy, 2001, 2008). Cost-effectiveness has also been demonstrated (Bateman & Fonagy, 2003). Notably, after discharge MBDT patients attend a weekly maintenance therapy group for up to 2 years. Recent work evaluating integrative day treatment programs, combining psychodynamic (Transference-Focused Psychotherapy, Mentalization-Based Therapy) and cognitive-behavioral (DBT) approaches, shows these models to be quite promising for patients with BPD (Rivera & Darke, 2012).
Regarding group-oriented inpatient treatments, the Cassel Hospital study compared TAU (medication and case management in the community) with two inpatient approaches: a one-stage, 12-month, analytically-informed milieu treatment plus twice-weekly individual therapy, and a two-stage “step-down” program involving 6 months of the inpatient milieu followed by 12-18 months of outpatient dynamic group therapy and 6 months of outreach nursing (Chiesa & Fonagy, 2000, 2003). Dropout was an issue for both inpatient programs, but the rate of early terminations was higher in the one-stage program. Both programs outperformed TAU on measures of social and global functioning, psychiatric symptoms, and clinical indicators (e.g., suicide attempts). The two-stage program resulted in greater overall benefit, and this was maintained at 2- and 6-year follow-up (Chiesa et al., 2006). The outpatient group of the two-stage program helped patients make the transition to the community. The use of outpatient groups following intensive treatment as a means of maintaining treatment gains is receiving more research attention (Leirvåg et al., 2010; Wilberg et al., 2003).
Apart from BPD, evidence for the effectiveness of group approaches with other forms of personality disorder is limited; recommendations are generally based on anecdote and clinical experience. Gabbard (2005) provides summaries of these recommendations for other PDs.
Methodologically strong studies of long-term psychodynamic group therapy for patients with personality disorders are extremely difficult to accomplish. However, strong work in Norway by Lorentzen and colleagues (Lorentzen et al., 2013, 2014) has demonstrated two important findings. First, a comparison of short- (STG) and long-term (LTG) dynamic group approaches showed equivalent effectiveness for the ‘typical’ patient over a 3-year period. However, patients with PD improved significantly more, on all outcome variables, in LTG relative to STG. Rates of change in the two formats favored the shorter format during the first 6 months, but the superior effect of LTG showed clearly at 3 years. This is solid evidence for a format that has seen extensive use in the field for many years, and is an important validation of clinical experience with PD patients.
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Kleindienst, N., Limberger, M. F., Schmahl, C., Steil, R., Ebner-Priemer, U. W., & Bohus, M. (2008). Do improvements after inpatient dialectical behavioral therapy persist in the long term?: A naturalistic follow-up in patients with borderline personality disorder. Journal of Nervous and Mental Disease, 196(11), 847–851. doi:10.1097/NMD.0b013e31818b481d
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