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
    disorders

    •    Studies can be differentiated according to level of care, i.e.,
    outpatient, partial hospitalization (e.g., day treatment)/residential, or
    inpatient

    •    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
    psychodynamic approaches

    •    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.

References

Bateman, A., & Fonagy, P. (1999). Effectiveness of partial hospitalization in the treatment of borderline personality disorder: A randomized controlled trial. The American Journal of Psychiatry, 156(10), 1563–1569.

Bateman, A., & Fonagy, P. (2001). Treatment of borderline personality disorder with psychoanalytically oriented partial hospitalization: An 18-month follow-up. The American Journal of Psychiatry, 158(1), 36–42. doi:10.1176/appi.ajp.158.1.36

Bateman, A., & Fonagy, P. (2003). Health service utilization costs for borderline personality disorder patients treated with psychoanalytically oriented partial hospitalization versus general psychiatric care. The American Journal of Psychiatry, 160(1), 169–171. doi:10.1176/appi.ajp.160.1.169

Bateman, A., & Fonagy, P. (2008). 8-year follow-up of patients treated for borderline personality disorder: Mentalization-based treatment versus treatment as usual. The American Journal of Psychiatry, 165(5), 631–638. doi:10.1176/appi.ajp.2007.07040636

Blum, N., Pfohl, B., St. John, D., Monahan, P., & Black, D. W. (2002). STEPPS: A cognitive-behavioral systems-based group treatment for outpatients with borderline personality disorder—a preliminary report. Comprehensive Psychiatry, 43(4), 301–310. doi:10.1053/comp.2002.33497

Blum, N., St. John, D., Pfohl, B., Stuart, S., McCormick, B., Allen, J., … Black, D. W. (2008). Systems Training for Emotional Predictability and Problem Solving (STEPPS) for outpatients with borderline personality disorder: A randomized controlled trial and 1-year follow-up. The American Journal of Psychiatry, 165(4), 468–478.

Bohus, M., Haaf, B., Simms, T., Limberger, M. F., Schmahl, C., Unckel, C., … Linehan, M. M. (2004). Effectiveness of inpatient dialectical behavioral therapy for borderline personality disorder: A controlled trial. Behaviour Research and Therapy, 42(5), 487–499. doi:10.1016/S0005-7967(03)00174-8

Bos, E. H., van Wel, E. B., Appelo, M. T., & Verbraak, J. P. M. (2011). Effectiveness of Systems Training for Emotional Predictability and Problem Solving (STEPPS) for borderline personality problems in a “real-world” sample: Moderation by diagnosis or severity? Psychotherapy and Psychosomatics, 80(3), 173–181. doi:10.1159/000321793

Bos, E. H., van Wel, E. B., Appelo, M. T., & Verbraak, M. J. P. M. (2010). A randomized controlled trial of a Dutch version of Systems Training for Emotional Predictability and Problem Solving for borderline personality disorder. Journal of Nervous and Mental Disease, 198(4), 299–304. doi:10.1097/NMD.0b013e3181d619cf

Chiesa, M., & Fonagy, P. (2000). Cassel personality disorder study: Methodology and treatment effects. The British Journal of Psychiatry, 176, 485–491. doi:10.1192/bjp.176.5.485

Chiesa, M., & Fonagy, P. (2003). Psychosocial treatment for severe personality disorder: 36-month follow-up. The British Journal of Psychiatry, 183(4), 356–362. doi:10.1192/bjp.183.4.356

Chiesa, M., Fonagy, P., & Holmes, J. (2006). Six-year follow-up of three treatment programs to personality disorder. Journal of Personality Disorders, 20(5), 493–509. doi:10.1521/pedi.2006.20.5.493

Comtois, K. A., Elwood, L., Holdcraft, L. C., Smith, W. R., & Simpson, T. L. (2007). Effectiveness of dialectical behavior therapy in a community mental health center. Cognitive and Behavioral Practice, 14(4), 406–414. doi:10.1016/j.cbpra.2006.04.023

Farrell, J. M., Shaw, I. A., & Webber, M. A. (2009). A schema-focused approach to group psychotherapy for outpatients with borderline personality disorder: A randomized controlled trial. Journal of Behavior Therapy and Experimental Psychiatry, 40(2), 317–328. doi:10.1016/j.jbtep.2009.01.002

Fleischhaker, C., Böhme, R., Sixt, B., Brück, C., Schneider, C., & Schulz, E. (2011). Dialectical Behavioral Therapy for Adolescents (DBT-A): A clinical trial for patients with suicidal and self-injurious behavior and borderline symptoms with a one-year follow-up. Child and Adolescent Psychiatry and Mental Health, 5. doi:10.1186/1753-2000-5-3

Gabbard, G. O. (2005). Psychodynamic psychiatry in clinical practice (4th ed.). Arlington, VA, US: American Psychiatric Publishing, Inc.

Gratz, K. L., & Gunderson, J. G. (2006). Preliminary Data on Acceptance-Based Emotion Regulation Group Intervention for Deliberate Self-Harm Among Women with Borderline Personality Disorder. Behavior Therapy, 37(1), 25–35. doi:10.1016/j.beth.2005.03.002

Harvey, R., Black, D. W., & Blum, N. (2010). Systems Training for Emotional Predictability and Problem Solving (STEPPS) in the United Kingdom: A preliminary report. Journal of Contemporary Psychotherapy, 40(4), 225–232. doi:10.1007/s10879-010-9150-4

Huband, N., McMurran, M., Evans, C., & Duggan, C. (2007). Social problem-solving plus psychoeducation for adults with personality disorder: Pragmatic randomised controlled trial. The British Journal of Psychiatry, 190(4), 307–313. doi:10.1192/bjp.bp.106.023341

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

Kliem, S., Kröger, C., & Kosfelder, J. (2010). Dialectical behavior therapy for borderline personality disorder: A meta-analysis using mixed-effects modeling. Journal of Consulting and Clinical Psychology, 78(6), 936–951. doi:10.1037/a0021015

Leirvåg, H., Pedersen, G., & Karterud, S. (2010). Long-term continuation treatment after short-term day treatment of female patients with severe personality disorders: Body awareness group therapy versus psychodynamic group therapy. Nordic Journal of Psychiatry, 64(2), 115–122. doi:10.3109/08039480903487525

Linehan, M. M., Comtois, K. A., Murray, A. M., Brown, M. Z., Gallop, R. J., Heard, H. L., … Lindenboim, N. (2006). Two-Year Randomized Controlled Trial and Follow-up of Dialectical Behavior Therapy vs Therapy by Experts for Suicidal Behaviors and Borderline Personality Disorder. Archives of General Psychiatry, 63(7), 757–766. doi:10.1001/archpsyc.63.7.757

Lorentzen, S., Ruud, T., Fjeldstad, A., & Høglend, P. (2013). Comparison of short- and long-term dynamic group psychotherapy: Randomised clinical trial. The British Journal of Psychiatry, 203(4), 280–287. doi:10.1192/bjp.bp.112.113688

Lorentzen, S., Ruud, T., Fjeldstad, A., & Høglend, P. A. (2014). Personality disorder moderates outcome in short‐ and long‐term group analytic psychotherapy: A randomized clinical trial. British Journal of Clinical Psychology. doi:10.1111/bjc.12065

McMain, S. F., Links, P. S., Gnam, W. H., Guimond, T., Cardish, R. J., Korman, L., & Streiner, D. L. (2009). A randomized trial of dialectical behavior therapy versus general psychiatric management for borderline personality disorder. The American Journal of Psychiatry, 166(12), 1365–1374. doi:10.1176/appi.ajp.2009.09010039

Monroe-Blum, H., & Marziali, E. (1995). A controlled trial of short-term group treatment for borderline personality disorder. Journal of Personality Disorders, 9(3), 190–198.

Rivera, M., & Darke, J. L. (2012). Integrating empirically supported therapies for treating personality disorders: A synthesis of psychodynamic and cognitive-behavioral group treatments. International Journal of Group Psychotherapy, 62(4), 501–529. doi:10.1521/ijgp.2012.62.4.500

Soler, J., Pascual, J. C., Tiana, T., Cebrià, A., Barrachina, J., Campins, M. J., … Pérez, V. (2009). Dialectical behaviour therapy skills training compared to standard group therapy in borderline personality disorder: A 3-month randomised controlled clinical trial. Behaviour Research and Therapy, 47(5), 353–358. doi:10.1016/j.brat.2009.01.013

Wilberg, T., Karterud, S., Pedersen, G., Urnes, Ø., Irion, T., Brabrand, J., … Stubbhaug, B. (2003). Outpatient group psychotherapy following day treatment for patients with personality disorders. Journal of Personality Disorders, 17(6), 510–521. doi:10.1521/pedi.17.6.510.25357

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