Patients diagnosed with Borderline Personality Disorder (BPD) may benefit from psychodynamic therapies that stress the ability to reflect on the psychological experiences of self and others. A new study published in the Journal of Counseling and Clinical Psychology reports greater improvement for patients diagnosed with DBT in psychodynamic psychotherapy compared to Dialectical Behavior Therapy (DBT).
The authors, led by John Keefe at the Albert Einstein College of Medicine, suggest differences in the outcomes of various psychotherapeutic treatments for people diagnosed with BPD depending on a patient’s reflective functioning–the ability to reflect upon their own mental states and those of others. For example, patients with lower reflective functioning at the beginning of treatment were more likely to improve in psychodynamic psychotherapies than those in DBT or the control group. On the other hand, patients with higher reflective functioning showed more improvement in DBT. According to the authors:
“Patients with normative RF [reflective functioning] may be able to take better advantage of the skills-focused approach of DBT. Without adequate [reflective functioning], it may be more difficult for an individual to effectively apply certain DBT skills—for example, in applying interpersonal effectiveness skills, normative [reflective functioning] may be helpful to accurately identify one’s own goals and the likely responses of others to best plan an effective communication to get one’s needs met. Patients with more normal [reflective functioning] may also not need as much the interpretive, mentalizing focus of the psychodynamic treatments, as factors other than [reflective functioning] may underlay their BPD… [Reflective functioning] may be a relevant prescriptive factor in matching BPD patients to treatments, such that TFP and SPT may be especially helpful for patients with low RF.”
DBT – a type of cognitive behavioral therapy (CBT) – has become the “gold standard” of treatment for people diagnosed with BPD and has been found to reduce self-harm and suicide attempts. Although DBT is often seen as a one-size-fits-all approach for treating BPD, there is evidence for the efficacy of other treatments. While some patients reap the benefits of DBT, others have spoken up against the treatment for multiple reasons, including the lack of sensitivity to trauma and understanding of difficult life circumstances.
Psychodynamic psychotherapy is among the treatments found to be as efficacious as cognitive behavioral therapies in treating psychiatric disorders in adults and adolescents, including mood disorders, anxiety disorders, and BPD. Among the evidence-based psychodynamic psychotherapies for BPD are Transference-Focused Psychotherapy (TFP), Mentalization-Based Therapy (MBT), and Supportive Psychodynamic Therapy (SPT).
Patients diagnosed with BPD often experience low reflective functioning (also known as mentalization), which the authors defined as “the capacity to understand the self and others in terms of intentional mental states, such as feelings, desires, wishes, attitudes, and goals.” The explicit aim of TFP and MBT is to improve this capacity. Research outcomes on these treatments have demonstrated that BPD patients who undergo TFP and MBT experience increased reflective functioning.
In TFP, the therapist fosters mentalization by encouraging patients to identify and understand “the motivations, thoughts, and feelings underpinning different self- and other mental states” or, in other words, help them understand their own psychological experiences and that of others. In SPT, therapists focus on creating a supportive environment for the patient in which they can freely express themselves while providing advice and emotional support. The aim is to help patients tolerate intense emotions and encourage the use of their own coping mechanisms or defenses.
The researchers of this study wanted to examine how the reflective functioning of patients at the beginning of treatment might influence the outcomes of different psychotherapeutic treatments (TFP, SPT, DBT, and eTAU) and compare their efficacy through two distinct randomized control trials (RCTs). Ninety people participated in the first RCT, while 104 participated in the second. Limited sociodemographic information was provided. In both trials, patients were seen for therapy for a year. The patients were randomly assigned to TFP, DBT, or SPT in the first trial. In the second trial, they were randomly assigned to either TFP or eTAU. The researchers measured reflective functioning and symptomatology at the treatment’s beginning and termination.
Keefe and his colleagues found that reflective functioning influenced the differences between psychodynamic psychotherapy (TFP and SPT) and other treatments (DBT and eTAU). Patients with poor reflective functioning at the beginning of therapy demonstrated more symptom reduction when partaking in psychodynamic psychotherapy compared to DBT and eTAU.
On the other hand, patients with ordinary reflective functioning saw more improvement in DBT and eTAU. It is important to note that the data might have been influenced by the higher dropout rates in DBT and eTAU and that eTAU included clinicians who engaged in cognitive-behavioral, psychodynamic, and other approaches to psychotherapy.
The results of this study might serve in the decision-making process when choosing a treatment for patients with BPD, as some patients might better benefit from psychodynamic psychotherapy. In contrast, others might benefit from DBT or eTAU.
Keefe, J. R., Levy, K. N., Sowislo, J. F., Diamond, D., Doering, S., Hörz-Sagstetter, S., Buchheim, A., Fischer-Kern, M. & Clarkin, J. F. (2022). Reflective Functioning and Its Potential to Moderate the Efficacy of Manualized Psychodynamic Therapies Versus Other Treatments for Borderline Personality Disorder. Journal of Consulting and Clinical Psychology, advanced online publication. http://dx.doi.org/10.1037/ccp0000760