14 - Skills-based therapies for personality disorder

Summary

Summary Over recent years, a variety of therapies have been developed or adapted to treat personality disorder. This chapter reviews skills-based (as opposed to insight-based) treatments. Two approaches are outlined: cognitive–behavioural therapy and dialectical behaviour therapy. The chapter details the underpinning theory and models of personality disorder used by the two approaches, and describes how the therapy is applied. Evidence of therapeutic efficacy is presented, with information about accessing training and therapy materials.

Until recently, many practitioners regarded personality disorder as untreatable. Although initially seeming to be suitable for therapy, patients with personality disorder were often difficult to engage, attended therapy sporadically, and their self-damaging and violent behaviours interrupted treatment (Warren & Dolan, 1996). Many failed to improve with treatment, often engendering anger and hopelessness in therapists (Gunderson, 1984). Some clinicians thought not only that patients failed to respond to treatment, but that their problems were amplified by their involvement in therapy, simply because of the fundamental characteristics of their disorder (Harris et al, 1994; Reiss et al, 1996). As a consequence of such opinions, patients with personality disorder were commonly considered to be ‘abusers’ of mental health services (Warren & Dolan, 1996) and personality disorder became a ‘diagnosis of exclusion’ from services (National Institute for Mental Health in England, 2003).

Certainly, personality disorder was associated with longer, more costly treatment and higher attrition rates (Goldstein et al, 1998; Blackburn, 2000) and several studies indicated that its presence predicted poorer treatment outcome (Diguer et al, 1993; Hoglend, 1993; Reich & Vasile, 1993). However, this research mostly derived from studies examining standard treatments for emotional disorders, rather than treatments specifically designed for personality disorder. It could be argued that this is akin to offering aspirin to a person with a broken leg: the treatment addresses only one symptom rather than tackling the core problem.

Over the past 15 years, several new treatments have been designed to address personality disorder. There is a growing body of evidence suggesting that patients with personality disorder can respond to therapy. This is especially true for borderline personality disorder (Linehan et al, 1991; Shea, 1993; Davidson & Tyrer, 1996; Wilberg et al, 1999; Bateman & Fonagy, 2000; Ryle & Golynkina, 2000; Verheul et al, 2003; Fonagy & Bateman, 2006).