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Treatment Approaches to Help Them Heal Janice R. Morabeto M.Ed. L.S.W. C.H.T.

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Presentation on theme: "Treatment Approaches to Help Them Heal Janice R. Morabeto M.Ed. L.S.W. C.H.T."— Presentation transcript:

1 Treatment Approaches to Help Them Heal Janice R. Morabeto M.Ed. L.S.W. C.H.T.

2 Review the particular therapeutic challenges with which these individuals present. Discuss the APA guidelines for effective treatment management for individuals suffering from BPD. Discuss the treatment approaches which show promise in helping individuals who suffer from BPD as well as their family members.

3 The Challenge of BPD: A brief review APA Guidelines For Effective Treatment Pharmacological Interventions Dialectical Behavior Therapy Philosophy Principles and Practices Psychodynamic and Pscyhoanalytic Modalities

4 Most common personality disorder in clinical settings. 10% of individuals seen in outpatient mental health clinics, 15%–20% of psychiatric inpatients 30%–60% of clinical populations with a personality disorder. It occurs in an estimated 2% of the general population (1, 136). Borderline personality disorder is diagnosed predominantly in women, with an estimated gender ratio of 3:1. The disorder is present in cultures around the world. Five times more common among first-degree biological relatives

5 Research suggests that 1 out of 10 individuals with BPD complete suicide Chronic Suicidality Among Patients With Borderline Personality Disorder Joel Paris, M.D. 8-10% Does not reflect those in the treatment groups

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7 Abandonment Emotional Dysregulation Impulse Dyscontrol Relationship Polarities Suicidality Substance Abuse/Prom iscuity Crisis and Crazy Making

8 Suicidality Attempted SuicideSuicide CrisisThreats

9 Impulsivity Substance Use/Abuse/Dependency Self HarmRecklessness

10 Affective Instability AngerDysphoriaAnxiety

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12 American Psychiatric Association PRACTICE GUIDELINE FOR THE Treatment of Patients With Borderline Personality Disorder Originally published in October 2001.

13 Monitor patients carefully for suicide risk and document this assessment; be aware that feelings of rejection, fears of abandonment, or a change in the treatment may precipitate suicidal ideation or attempts. Take suicide threats seriously and address them with the patient. Taking action (e.g., hospitalization) in an attempt to protect the patient from serious self-harm is indicated for acute suicide risk

14 to take responsibility for his or her actions). If a patient with chronic suicidality becomes acutely suicidal, the clinician should take action in an attempt to prevent suicide by: Chronic suicidality without acute risk needs to be addressed in therapy (e.g., focusing on the interpersonal context of the suicidal feelings and addressing the need for the patient

15 Hospitalization Wrap around services Increasing outpatient visits plus family watches until the suicide crisis is over

16 Involve the family (if otherwise clinically appropriate and with adequate attention to confidentiality issues) when patients are chronically suicidal. For acute suicidality, involve the family or significant others if their involvement will potentially protect the patient from harm.

17 A promise to keep oneself safe (e.g., a suicide contract) should not be used as a substitute for a careful and thorough clinical evaluation of the patients suicidality with accompanying documentation. However, some experienced clinicians carefully attend to and intentionally utilize the negotiation of the therapeutic alliance, including discussion of the patients responsibility to keep himself or herself safe, as a way to monitor and minimize the risk of suicide.

18 Monitor the patient carefully for impulsive or violent behavior, which is difficult to predict and can occur even with appropriate treatment. Address abandonment/rejection issues of anger, and impulsivity in the treatment. Arrange for adequate coverage when away; carefully communicate this to the patient and document coverage.

19 The following are risk management considerations for boundary issues with patients with borderline personality disorder: Monitor carefully and explore countertransference feelings toward the patient. Be alert to deviations from the usual way of practicing, which may be signs of countertransference problemse.g., appointments at unusual hours, longer-than- usual appointments, doing special favors for the patient.

20 Always avoid boundary violations, such as the development of a personal friendship outside of the professional situation or a sexual relationship with the patient.

21 If the patient makes threats toward others (including the clinician) or exhibits threatening behavior, the clinician may need to take action to protect self or others. Get a consultation if there are striking deviations from the usual manner of practice.

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23 What the caterpillar calls the end of the world, the master calls a butterfly Richard Bach, Illusions: The adventures of a reluctant Messiah

24 Psychotropic Medications Dialectical Behavior Therapy DBT Transference Focused Psychotherapy TFP

25 Affective Dyscontrol Symptoms Impulsive-Behavioral Dyscontrol Symptoms Cognitive-Perceptual Symptoms

26 Serotonin Selective Reuptake Inhibitors FluoxetineProzac SertralineZoloft Venlafaxine Effexor Affective dysregulation, Impulsive-behavioral dyscontrol Cognitive-perceptual difficulties

27 Aggression, Irritability, Depressed mood, Self-mutilation Some somatic complaints (headaches/PMS)

28 AmitriptylineElavil, Endep ImipramineNorpramin, Pertofrane DesipramineJanimine, Tofranil Decreased depressive symptoms and indirect hostility Enhanced attitudes about self-control

29 Effective for the associated symptoms Depersonalization, Paranoid symptoms, Obsessive-compulsive symptoms Helplessness Hopelessness

30 Lithium Mood-stabilizing Anti-aggressive effects

31 DivalproexDepakote, Epival Carbamazepine Tegretol, Epitol May be useful in treating behavioral dyscontrol and affective dysregulation in some patients with borderline personality disorder, although further studies are needed

32 HaloperidolHaldol Perphenazine Etrafon, Trilafon Thiothixene Navane Improvement in impulsive-behavioral symptoms, global symptom severity, and overall borderline psychopathology. Similar efficacy found in the adolescent population

33 Marsha Linehan (1993)

34 SuicidalBehaviors interferingwith therapyBehaviorsinterfering withquality of life

35 1. Enhance and maintain the clients motivation to change 2. Enhance the clients capabilities 3. Ensure that the clients new capabilities are generalized to all relevant environments 4. Enhance the therapists motivation to treat clients while also enhancing the therapists capabilities 5. Structure the environment so that treatment can take place.

36 Interpersonal DysregulationSelf Dysregulation Cognitive DysregulationBehavioral Dysregulation Emotional Dysregulation

37 Synthesis Thesis Antithesis

38 Radical Acceptance Of the Client Teach to the Client Self Environment Others

39 Giving Self Up to the moment Focused Consciousness Breathing Thought Stopping Radical Acceptance

40 Radical Acceptance of Others Point of View Listening Skills Repeating back Self-Assertion Making a Request Saying No Expressing Self, Using I statements Conflict Resolution Skills

41 Teach and Use Socratic Discussion Identifying Differences between Thoughts Evaluations Behavioral/Emotional Reactions ABCs of CBT

42 TFP is an intense form of psychodynamic psychotherapy designed particularly for patients with borderline personality organization (BPO) a minimum of two and a maximum of three 45 or 50-minute sessions per week. It views the individual as holding unreconciled and contradictory internalized representations of self and significant others that are affectively charged.

43 The distorted perceptions of self, others, and associated affects are the focus of treatment as they emerge in the relationship with the therapist (transference). The consistent interpretation of these distorted perceptions is considered the mechanism of change. Kernberg designed TFP especially for patients with BPO. According to him, these patients suffer from identity diffusion, primitive defense operations and unstable reality testing.

44 Suicidal or homicidal threatsOvert threats to treatment continuityDishonesty or deliberate withholdingContract breachesActing out in sessionsActing out between sessionsNonaffective or trivial themes

45 Allmon, D., Armstrong, H. E., Heard, H. L., Linehan, M. M., &.Suarez, A. (1991). Cognitive-Behavioral Treatment of Chronically Parasuicidal Borderline Patients. Archives of General Psychiatry, 48, Koons, C. R., Robins, C. J., Tweed, J. L., Lynch, T. R., Gonzalez, A. M., Morse, J. Q., Bishop, G. K., Butterfield, M. I., & Bastian, L. A. (2001). Efficacy of Dialectical Behavior Therapy in Women Veterans with Borderline Personality Disorder. Behavior Therapy, 32, Linehan, M. M. (1993). Cognitive Behavioral Treatment of Borderline Personality Disorder. New York: Guilford Press. Linehan, M. M., Schmidt, H., Dimeff, L. A., Kanter, J. W., Craft, J. C., Comtois, K. A., & Recknor, K. L. (1999). Dialectical Behavior Therapy for Patients with Borderline Personality Disorder and Drug-Dependence. American Journal on Addiction, 8, Verheul, R., Van Den Bosch, L. M. C., Koeter, M. W. J., De Ridder, M. A. J., Stijnen, T., & Van Den Brink, W. (2003). Dialectical Behaviour Therapy for Women with Borderline Personality Disorder, 12-month, Randomised Clinical Trial in The Netherlands. British Journal of Psychiatry, 182,

46 1. Clarkin, JF, Yeomans, FE, & Kernberg, OF (1999). Psychotherapy for Borderline Personality. New York: J. Wiley and Sons. 2. Kernberg, OF, Selzer, MA, Koenigsberg, HA, Carr, AC, & Appelbaum, AH. (1989). Psychodynamic Psychotherapy of Borderline Patients. New York: Basic Books. 3. Koenigsberg, HW, Kernberg, OF, Stone, MH, Appelbaum, AH, Yeomans, FE, & Diamond, DD. (2000). Borderline Patients: Extending the Limits of Treatability. New York: Basic Books. 4. Yeomans, FE, Clarkin JF, & Kernberg, OF (2002). A Primer of Transference-Focused Psychotherapy for the Borderline Patient. Northvale, NJ: Jason Aronson. 5. Yeomans, FE, Selzer, MA, & Clarkin, JF. (1992). Treating the Borderline Patient : A Contract-based Approach. New York: Basic Books

47 Borderline personality disorder: The treatment dilemma. Author(s): Oldham, J.M. Published: 1997 Source: Journal of the California Alliance for the Mentally Ill Number of Pages: Cognitive-Behavioral Treatment of Borderline Personality Disorder Author(s): Linehan, M. Published: 1993 Dialectical behavior therapy for borderline personality disorder. Author(s): Linehan, M.M. Published: 1987 Source: Bulletin of the Menninger Clinic Volume: 51 Number of Pages:

48 PRACTICE GUIDELINE FOR THE Treatment of Patients With Borderline Personality Disorder WORK GROUP ON BORDERLINE PERSONALITY DISORDER John M. Oldham, M.D., Chair Glen O. Gabbard, M.D. Marcia K. Goin, M.D., Ph.D. John Gunderson, M.D. Paul Soloff, M.D. David Spiegel, M.D. Michael Stone, M.D. Katharine A. Phillips, M.D. (Consultant) Originally published in October A guideline watch, summarizing significant developments in the scientific literature since publication of this guideline, may be available in the Psychiatric Practice section of the APA web site at


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