Prognosis Positive

I’m hoping some readers might catch the Seinfeld reference in the title here! I’ve made somewhat of a New Year’s resolution to spend more time reading the literature in my area of expertise, including DBT, borderline personality disorder, and other related topics. There’s so much happening that it’s hard to keep up on the literature, let alone fit in regular reading amidst all of my other activities. I decided to try to fit this reading into my life in the same way that I fit in my morning exercise routine, primarily by doing it before I let myself do anything else – other words, before I check my email and fall down the rabbit hole. In any case, I finally got around to reading an article I have been meaning to read for a while now, focused on things that predict outcome in treatment for borderline personality disorder.

This article, authored by Barnicot and colleagues (Barnicot et al., 2012), reported a review of studies examining factors that predict outcome across various treatments for BPD. They conducted a comprehensive review, checking out the quality of the studies, and so on, and ended up with 33 studies to review. These studies included a variety of different treatments, such as DBT, schema focused therapy, mentalization based treatment, and so on. To cut to the chase, the findings flew in the face of some common misconceptions.

First, there was no evidence that sociodemographic factors, such as age, ethnicity, and so on, had anything to do with treatment outcome. In particular, the finding that age was not related to outcome counters the idea that you can’t teach an old dog new tricks! For those of us who do work in this area, that finding was not particularly surprising. Other research has found that, when there is a relationship between age and outcomes in psychotherapy, it’s usually a positive one. I’ve also found personally that older clients don’t do any worse DBT than younger clients.

A second interesting finding was that, If people had more severe symptoms at the beginning of treatment, this did not mean that they did any worse in treatment. In fact, in some cases, higher severity of symptoms predicted a larger amount of change in symptoms throughout treatment. Of course, the first thing that many people in the research world might think when they read these findings is that they are simply due to what’s called “regression to the mean.” This means that people who started off worse off have more room to move down, and their scores are more to get closer to average. Fortunately, the researchers looked into this and found no evidence that these findings were simply due to regression to the mean.

A third finding I wanted to comment on was that therapeutic alliance, or a good working relationship with the therapist, was a fairly consistent, good predictor of outcome. This may seem like a no-brainer, but the finding suggests that, when therapists and clients can develop a good working relationship, clients with BPD have better outcomes. The reason I think this finding is worth commenting on is that people often think people with BPD are hard to work with, difficult to establish a good working relationship with, and so on. There’s no doubt that, if you struggle with BPD, there may have been times when you have experienced rocky relationships, even with your therapist. That makes sense: Relationship problems are a symptom of BPD. If you have BPD and are looking for treatment, you might want to pay close attention to whether your therapist seems like she or he will be able to help you work through some of these relationship challenges.

The take home message, in my opinion is the following: Don’t avoid seeking treatment because your symptoms are severe and you don’t think you can change, or because you’re older and afraid you can’t learn new things, or because you have problems in relationships. With a therapist you can work well with, you might be surprised to see the positive changes you can make in therapy. ~ Alexander L.Chapman, Ph.D., R.Psych.