http://hdl.handle.net/10401/5491
Avances en Salud Mental Relacional
Advances in Relational Mental Health
ISSN 1579-3516 - Vol. 11 - Núm. 1 - Mayo 2012
Órgano Oficial de expresión de la Fundación OMIE
Revista Internacional On-Line / An International On-Line Journal
PSYCHOSOCIAL FUNCTIONING IN PATIENTS WITH BORDERLINE
PERSONALITY DISORDER TREATED WITH INTENSIVE DYNAMIC
BRIEF GROUP THERAPY
José Guimón, Aizpea Boyra, Wendy Dávila, Andrés Mascaró, Claudio Maruottolo. Departmental Section
of Psychiatry, School of Medicine, University of the Basque Country (UPV/EHU), Spain.
jose.guimon@ehu.es, wendydavilawood@hotmail.com
SUMMARY
In the present paper we have carried out a naturalistic study of the outcome of 106 patients in two of
the four day units which Avances Médicos S.A. (AMSA) has progressively been developing since 2003. Of
this sample, 64.2% are diagnosed of Borderline Personality Disorder (BPD), and the remaining 35.8 %
have other diagnoses (Non-BPD).
We have compared different patient variables and found that, in contradiction to our initial hypothesis,
the BPD group demonstrated an adherence to treatment similar to the Non- BPD group. Furthermore,
the dropout rate of BPD patients during treatment was less than that of the Non-BPD patients.
Regarding symptomatology, there were general significant improvements with no difference between
the two groups, though BPD patients seem to have a greater range of improvement. More specifically,
they showed greater improvements in the variables of anxiety, depression and suicide risk. In the one
year follow-up those who accepted to come for evaluation (32, 7%) sustained the improvements seen at
program discharge, in both patient groups. In view of these promising results we consider that the
"Intensive Dynamic Brief Group Psychotherapy" (IDBGT) approach that we use on our day unit shortstay programs, is highly recommendable to patients with BPD.
Key words: Borderline personality disorder. Group psychotherapy. Therapeutic community.
RESUMEN
En este trabajo hemos llevado a cabo un estudio sobre la evolución y respuesta al tratamiento de 106
pacientes en dos de las cuatro unidades que Avances Médicos S.A., ha ido implementando desde el
2003. De esta muestra el 64.2% tiene diagnóstico de Trastorno Límite de la Personalidad (TLP) y el 35.8%
restante tiene otros diagnósticos (No-TLP).Hemos comparado diferentes variables y encontrado que, en
© 2012 CORE Academic, Instituto de Psicoterapia
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Psychosocial functioning in patients with borderline
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contradicción con nuestra hipótesis inicial, el grupo de TLP muestra una mayor adherencia al
tratamiento que el grupo de No-TLP. En lo que respecta a la sintomatología hallamos una mejoría
significativa en ambos grupos, aunque los pacientes límite parecen tener un rango de mejoría mayor.
Concretamente esta mejoría se ha reflejado en las variables de ansiedad, depresión y riesgo de suicidio.
En el seguimiento que se realizó tras un año de tratamiento se observó en aquellos pacientes, tanto del
grupo de TLP como del grupo de No-TLP que accedieron a ser evaluados (32,7%), una mejoría sostenida.
A la luz de estos resultados consideramos que la psicoterapia dinámica de grupos breve, utilizada en los
programas de corta estancia de nuestras unidades, es una abordaje muy recomendable para tratar la
patología límite de la personalidad.
Palabras clave: Trastorno límite de la personalidad. Psicoterapia grupal. Comunidad terapéutica.
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1. INTRODUCTION
Several meta-analytic reviews [1] conclude that randomized control trials (RCT) on
the psychotherapeutic treatments of patients with borderline personality disorder (BPD)
are too small and too scarce to inspire full confidence in their results. Groups and
therapeutic communities have been considered as privileged approaches to the social
adaptation of people with severe mental disorders. There are still fewer studies on timelimited day hospital approaches concerning patients with BPD [2, 3, 4, 5, 6].
In the present paper we refer to our holistic emergency program created in 2003 in Bilbao. This
program was developed in AMSA, an institution that integrates different services. There is an
emergency center; a 25 bed short-term unit, with a 14 day average stay; the four short-stay day units
and an outpatient clinic. Each of these four units attends a certain profile of patients. One unit centers
on patients within the psychotic spectrum; another unit on patients with severe substance abuse, and
the last two units attend to patients with mood and personality disorders and are the units we refer to
in this paper.
We worked with a sample of 106 patients (64,2% BPD and 35,8% non-BPD) that were attending
the above mentioned day units for treatment. These day units run for five days a week, four hours a
day, using Intensive Dynamic Brief Group Therapy (IDBGT) as the main approach for treatment. The
average stay is of 50 days (ranging from 10 to 90 day stay), and there is a maximum of 30 patients
among the two units. On the whole, our private network serves 250.000 people from the area of Bilbao
and its province (1.100.000 inhabitants).
The results of our naturalistic study show the evolution of certain clinical and social variables of
the 68 patients with the DSM-IV-TR BPD diagnosis compared to 38 patients with other non-BPD
diagnoses. The patients were evaluated at their admission, at the time of discharge and twelve months
after discharge.
2. METHOD
Table 1. Characteristics of the Patient Sample.
VARIABLES
SEX
BORDERLINE
NON-BORDERLINE
Male
54,50%
28,90%
Female
45,50%
71,10%
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MARITAL STATUS
ECONOMICAL STATUS
FAMILY CONTEXT
EDUCATIONAL LEVEL
REGULARITY OF
Psychosocial functioning in patients with borderline
personality disorder treated with intensive dynamic brief group therapy
Single
65,20%
26,30%
Married
24,20%
52,60%
Divorced
10,60%
7,90%
High
25,80%
18,40%
Medium
57,60%
73,70%
Low
16,70%
7,90%
Functional
3%
31,60%
Dysfunctional
97%
47,40%
Undergraduate
33,30%
28,90%
High school
48,50%
36,80%
Basic education
18,20%
34,20%
Non attendance
13,60%
5,30%
Irregular
24,20%
21,10%
Regular
62,20%
73,70%
Less than 1 month
22,10%
18,40%
1-2 months
23,50%
23,70%
2-3 months
27,90%
18,40%
More than 3 months
26,50%
39,50%
Active
59,10%
10,50%
Inactive
49,90%
63,20%
ATTENDANCE
LENGTH OF STAY
EMPLOYMENT STATUS
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Entering the study we found some significant differences among the 106 patients (64,2% BPD
and 35,8% non-BPD). The BPD patients seemed to have a different profile compared to the 35, 8% of the
sample with other non-BPD diagnoses. Patients with BPD were more frequently male (p=0.012), single
(p=0.000), of a younger age (p=0.01), came from disfunctional families (p=0.000), were employed
(p=0.05), had existing diagnostic co-morbidity (p=0,021), showed previous self-harm behaviour and
history of suicidal attempts (p=0.09) and frequently presented mild substance and alcohol abuse
(p=0.000), (p=0.000).
Evaluation
Several instruments were implemented in this study. On the clinical side, we used the SCID II
(Structured Clinical Interview for DSM IV) [7], the BSI (Brief Symptoms Inventory) [8], the HS (Beck
Hopelessness Scale [9], the STAI (State-Trait Anxiety Inventory) [10], and the BDI (Beck's Depression
Inventory) [11].
In addition, the degree of severity of all patients was evaluated using the Spanish version of the
scale for the Severity of Psychiatric Illness (SPI) [12]. This instrument includes the following items: suicide
risk, danger to others, severity of symptoms, difficulty with self-care, medical problems, drug problems,
job problems, family disruption, home instability, treatment compliance, family involvement, and
premorbid disfunction. We have also evaluated the severity of the BPD patients with the scale of Asnani
[13] that counts the number of DSM IV items existent in the patients and then classifies them in four
groups, (group 1 fulfills up to five DSM diagnostic criteria; group 2 fulfills up to six criteria, group 3 fulfills
up to seven criteria and group 4 fulfills up to eight/nine criteria of the diagnostic manual).
On the psychosocial side, we used three instruments that we had developed and validated in
previous works: the ERA (the Spanish version of the Questionnaire d`évaluation des relations avec les
autres,) [14]; the QFS (Spanish version of the Questionnaire de fonctionement sociale) [15]; and an
adaptation of the Scherer & Scherer Coping Index [16].
The different evaluations were done at the beginning of the program, at the time of discharge
and 12 months after discharge.
The Therapeutic Programs
Our therapeutic programs, developed by our team over the past 30 years [17], steer towards
community therapy [18, 19]. As such, treatment revolves around therapy through the group, more
specifically Intensive Dynamic Brief Group Therapy or IDBGT. In a dozen different care units (short-stay
units in general hospitals, rehabilitation units, and day hospitals in Spain and in Switzerland [18] we have
worked with patients with severe mental disorders.
In particular in the programs we refer to the average length of stay was of 50 days, (22, 7%: less
than 1 month, 25%: more than 3 months), for five days a week, during four hours a day.
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The two therapeutic teams include psychiatrists, psychologists, social workers, occupational
therapists and psychomotor therapists, trained in individual group and family dynamic therapy. This
multidisciplinary team allows for an integrative treatment and throughout their stay patients'
medication is individually controlled and supervised. The service users attend three small verbal therapy
groups per day (medium sized staff-patient groups once a week, small sized dynamic groups 5 days a
week, and small sized cognitive oriented groups 5 days a week) and several group activities (artistic and
body expression 4 days a week, relaxation once a week, and daily activities 5 days a week) (See Table2)
[19]. In addition, a dynamic multifamily group meets once every week and the staff team attends a daily
process group to work through and analyze the day's events.
After participating in these programs most patients choose to either continue treatment in our
out-patient units or to continue treatment in other services. Thus, our programs act as a therapeutic
experience that facilitates a further, deeper and longer personal development [20].
Table 2. Day Unit Schedule.
Monday
Tuesday
Wednesday
Thursday
Friday
9.30 - 9.45
Reception
Reception
Reception
Reception
Reception
9.45 - 10.45
Dynamic Group
Dynamic Group
Dynamic Group
Dynamic Group
Dynamic Group
10.45 - 11.15
Break 1
Break 1
Break 1
Break 1
Break 1
11.15 - 12.15
Relaxation
Tecniques
Art Therapy
Dance and
Movement Therapy
Art Therapy
Dance and
Movement
Therapy
12.15 - 12.30
Break 2
Break 2
Break 2
Break 2
Break 2
12.30 - 13.30
Discussion Group
Psychoeducational
Workshop
DiscussionGroupl
Conflict focused
Group
DiscussionGroup
3. RESULTS
Our BPD patients appear to be as severe as the hospitalized BPD patients according to the
scores obtained in the Asnani severity. As for the patients at the moment of medical discharge, there
was an overall significant improvement of the symptoms. Specifically, there was a significant
improvement in the 9 factors of the BSI (Somatization, Obsessive-compulsive, Interpersonal sensibility,
Depression, Anxiety, Hostility, Phobic anxiety, Paranoid thinking and Psychoticism). These results showed
no statistical differences between BPD and non-BPD. However BPD patients had a larger range in
symptoms.
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Psychosocial functioning in patients with borderline
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The results regarding treatment attendance contradict existing literature, and thus, our initial
hypothesis which defended that the BPD patients would have a more irregular attendance. There were
no differences in type of discharge and length of stay between the BPD and the non-BPD group and so it
appears that both groups have a similar attendance rate.
The satisfactory treatment compliance among patients with BPD is difficult to achieve in all
treatments settings. Nevertheless, our study reported a drop-out rate during the treatment smaller in
the BPD group than in the non-BPD group (p=0,499, not statistically significant). Overall, it seems that
patients were actively employed, remained occupied, and did not prematurely abandon treatment.
The strongest predictor of drop out was the substance abuse. Substance abusers had a drop out
rate of 46%. Family stability also seemed to be related to the drop-out rate as patients with a good
family implication tended to fully complete the established treatment.
Concerning the psychosocial functioning there was an improvement in several QFS items:
Increase in the Daily life activities (t.4) Global social functioning (p=0,001), Frequency of relations (p=
0,001), Satisfaction in the activities (p= 0,003). In the ERA questionnaire there was a positive correlation
between symptom improvement in the BSI and the items Openness to others (p= 0,073), Relational
distance (p= 0,000), Personal insight (p=0,035) Pleasure in relations (p= 0,139) and Global activities (p=
0,031). Both the BPD and non-BPD group showed a statistically significant improvement after the
program.
Evaluation 12 months later
In the one year follow up we continued to observe, in those who accepted to come for
evaluation (60% of the initial sample), an improvement similar to that seen at the moment of discharge
of the program [21], both in the BPD and Non-BPD patient group. A relevant number of patients (40%)
entering the program were unreachable at the one year follow-up and could not be evaluated. We were
able to reach a significantly smaller percentage of BPD patients than non-BPD patients (39% vs. 61%).
Among the coinciding characteristics of those who were non-attainable was the diagnosis of
BPD (especially those with higher symptom severity), a higher presence of males, and frequent history
of substance abuse. (Only some data was obtained of this patient group through the interview of first
degree relatives).
Symptom evaluation
We observed a significant improvement in all the factors of the BSI: Somatization (p=0,05),
Obsessive-compulsive (p=0,000), Interpersonal sensibility (p=0,000), Depression (p=0,000), Anxiety
(p=0,002), Hostility (p=0,014), Fobic anxiety (p= 0,000), and Psychoticism (p=0,001).
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4. DISCUSSION
Limitations of this study
Our study has several limitations. The most important one is that we have not been able to
make a randomized controlled study for obvious clinical and administrative reasons and our research
design is naturalistic. However, it should be noted that the few controlled studies published in this area
were conducted in rather artificial settings and so the possibility of generalizing the results is
diminished.
Some meta-analytical evaluations on the results of programs made in day centres for patients
with BPD are quite optimistic. However, a Cochrane Review [6, 22] concludes that, although some of the
problems frequently encountered by people with borderline personality disorder may be amenable to
talking/behavioural treatments, all therapies remain experimental. This sceptical conclusion highlights
other limitations of empirically supported psychological treatments with BPD: they have not been
effectively disseminated to the mental health professionals; they are not readily available to the public
who require them; and they have only a remote resemblance to what goes on in actual clinical practice.
The question then is how to surpass these difficulties. Many authors emphasize the need to
overcome the problems of rigid manuals and to avoid forcing clinicians to adhere to theories and
practices that are outside their interest. Most proclaim the need of naturalistic psychotherapy studies
such as the one we have presented here.
Clinical and social improvement
At the end of the program there was a significant improvement in the 9 factors of the BSI,
showing no statistical differences between the BPD and non-BPD group. As was previously mentioned,
in the one year follow up an important percentage of the patients entering the program were not
reachable so only a little data was obtained through contact with their relatives. Nonetheless, the
number of non-available patients was not larger than the figures mentioned in existing literature. For
example: of 100 prospective clients contacting a mental health clinic, only 50 will attend the initial
evaluation, 33 will attend the first treatment session, 20 will remain by Session 3, and fewer than 17 will
remain by Session 10. [23]
In our sample, social functioning improved equally in BPD and in non-BPD patients, both at the
end of the program and after one year. This last finding can, of course, be questioned because of a less
severe psychopathology in those patients who were reachable in the follow up.
A similar tendency was found in our previous study with Zanello [24], when comparing QFS
scores with self-rated symptom severity. The lower levels of social functioning were significantly
associated with more severe symptoms. Moreover, a research from Ullrich [25] suggests that, although
most personality disorders are associated with impaired psychosocial functioning and life-failure, some
personality disorder traits (even when considered pathological) can contribute positively to one
important aspect of life-success: status and wealth.
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We have found a significant improvement of social functioning in patients with moderately
severe BPD, 12 months after their participation in our program, which remain relatively independent to
their clinical changes. In particular, there was a positive correlation between symptom improvement in
the BSI and the ERA.
In contrast, most authors found a poor improvement in social functioning in BPD patients after
treatment [26, 27, and 28]. However, Jovev and Jackson [29] found that some patients with BPD who
experienced change in personality psychopathology did show a mild improvement in social functioning.
Symptom alleviation and improved social functioning, in fact, have always been considered to be related
[30]. Nevertheless, as symptoms and social adjustment sometimes appear relatively independent, no
accurate conclusion concerning the patients' social functioning should be driven on the basis of our
data.
The mechanisms involved in Intensive Dynamic Brief Group Therapy
In Intensive Dynamic Brief Group Therapy medication and different kinds of psychotherapy are
combined. This procedure is frequently called «combined pharmacological and psychotherapeutic
treatment» [31]. In our programs combined psychotherapy is seldom carried out by the same clinician.
On most cases a collaborative treatment model is used among two or three different clinicians [32]. In
fact, the triangle is a well-known situation for containing conflict and anxiety as has been shown by
couple and family therapists. It is, however, well known that transference and counter-transference
issues can seriously deteriorate collaborative treatment [33]. Apart from the type of profession,
intergenerational differences can add to the difficulties. In these circumstances, patients can be
transformed into narcissistic objects. If triangular relations are usually difficult, the collaborative group
psychotherapy and pharmacological treatment creates additional problems because they tend to elicit
rivalry among some members, stigmatization of some others and other group phenomena.
From our IDBGT work frame several therapeutic factors must be noted as, in our opinion, they
represent the quintessence of therapeutic communities and explain their therapeutic effect [34]. In our
work, we emphasize the role played in our units of containment (in Bion's sense). Containing furnishes a
feeling of security in the face of the infantile pain, rage and despair that is frequently re-experienced by
the patients. It is related to the `mothering element' of these units and is coupled with a `paternal
element' present in the establishment of limits and rules and the reinforcement of boundaries. This is
achieved through the structuring of the environment to make it less uncertain and to facilitate
modifications in the ill-adapted behavior of the patients.
In our units the patients have to deal with a high degree of stress. Intensive Dynamic Brief Group
Therapy, with its particular emphasis on the here and now and on inter-member cohesiveness, has
shown itself to be, in our experience, a useful stabilizing buffer tool. It fosters involvement and supports
and allows a controlled expression of anger and aggressiveness. The patient-staff group is the key
holding element of our programme, due to its basic contribution to creating a container for the anxieties
arising in the ward. It is also of invaluable help because of the information it provides concerning each
patient. The other groups also provide the patient with orientation and emotional support and, within
the staff, tensions among the therapeutic team are reduced and incoming nursing personnel notice how
their previous fears and apprehensions diminish.
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Attachment is of very low quality in many of our patients and can be improved through these
therapeutic experiences. In our units, a «multiple treatment setting» is the rule, with a great variety of
professionals being involved in different activities. This multiple treatment setting has many advantages.
The therapeutic relationship between staff and severely pathological patients makes for a potentially
positive ambiance where reenactments of internal object relations can be interpreted. The therapeutic
team offers itself as an alternative family able to provide a corrective emotional experience which can
help the patient, as was conceptualized by Adshead [35] (1998) in terms of attachment theory [36].
However, therapeutic teams do not always behave as an ideal family. Certain manifestations signal
negative counter-transference reactions.
A continuous challenge is to improve communication, in the form of contacts with other
patients and therapists through the use of `symbolic representations' and the process of identification.
For this to occur, a communal identity [37] should ideally be achieved. This is forged through the
participation of all the members in therapeutic, social, and informal activities. Stable, protected groups
with well-defined boundaries can support this process.
Another factor specific to therapeutic communities is the compromise obliging patients to
accept that all interpersonal interaction belongs to all the members of the community. Effectively,
everything that goes on in the community can theoretically be utilized from a therapeutic point of view,
leading then to an inseparable union between living and learning [38].
In this kind of units the lack of symmetry between the therapist and the patient is accepted, but
the automatic assumption of the therapist's superiority tends to be rejected. This attitude fosters
accountability in patients, who assume responsibility for their own therapeutic process. Borderline
patients have, as other severe mental ill patients, a disorganization of their identity. They project their
difficulties onto the community that surrounds them and introject some elements of the organization
offered by the ward atmosphere. The internalization of object relations [39] is a phenomenon always
taken into account by the professionals.
5. CONCLUSIONS
The present study shows important improvements in symptoms after the discharge from the
day program in patients with BPD. In our sample symptoms improved as much in the BPD as in the NonBPD group. In addition, results showed a non-expected good attendance of BPD patients to the program
when compared with the data mentioned in literature. Furthermore, twelve months after their
participation in the program, an improvement of social functioning was found in patients with
moderately severe BPD. This improvement was, in many cases, independent to their clinical changes.
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Acknowledgements
This study has received the support of the Board of the University of the Basque Country. "Los
grupos psicoeducativos en los pacientes psiquiátricos crónicos, UPV/EHU".
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