I Hate You--Don't Leave Me - Jerold J. Kreisman [86]
One study compared the results of yearlong outpatient treatments for borderline patients with three different approaches: DBT, TFP, and a psychodynamic supportive therapy.17 Patients in all three groups demonstrated improvement in depression, anxiety, social interactions, and general functioning. Both DBT and TFP showed significant reduction in suicidal thinking. TFP and supportive therapy did better in reducing anger and impulsivity. TFP performed best in reducing irritability and verbal and physical assault.
A three-year Dutch study compared results of treating borderline patients with SFT versus TFP.18 After the first year, both treatment groups experienced comparable significant reductions in BPD symptoms and improvement in quality of life. By the third year, however, SFT patients exhibited significantly greater improvement and had fewer dropouts. A later study from the Netherlands compared cost-effectiveness of these two psychotherapy designs.19 This investigation attempted to measure cost of treatment with improvement in quality of life over time (determined by a self-administered questionnaire). Although quality of life measures after TFP were slightly higher than after SFT, the overall cost for comparable improvement was significantly more efficient with SFT.
Although these studies are admirable attempts to compare different treatments, all can be criticized. Patient and therapist selection, validity of measures used, and the plethora of uncontrolled variables that impact on any scientific study make attempts to compare human behavioral responses very difficult. Continued studies on larger populations will illuminate therapeutic approaches that will be beneficial for many patients in aggregate. But given the complex variations rooted in our DNA, which make one person so different from another, unveiling the “best” treatment that will be ideal for every individual is surely impossible. The treatment that demonstrates superiority in a majority of patients in a study may not be the ideal choice for you. This is no less true in the area of medications, where we find one size does not fit all.
Thus, the primary point to be gleaned from these studies is not which treatment works best, but that psychotherapeutic treatment does work! Unfortunately, psychotherapy has been figuratively and literally devalued over the years. Psychological services, in general, are reimbursed at a remarkably lower rate than medical services. Insurance payment to a clinician for an hour of noninterventional interaction with a patient (diet and behavioral adjustments to diabetes, instruction on caring for a healing wound, or psychotherapy) is a fraction of the payment for a routine medical procedure (minor surgical intervention, steroid injection, etc.). For one hour of psychotherapy, Medicare and most private insurance companies pay less than one-tenth of the reimbursement rate directed for many minor outpatient surgical procedures.
As the United States continues its quest to provide health care to more people in more affordable ways, there will be temptations to mandate treatments that are shown to be grossly equivalent, but less expensive. It will be important to maintain flexibility in such a system, so that we do not denigrate the art of medicine, which allows individuality in the sacred relationship between doctor and patient.
Future Research and Specialized Therapies for BPD
In the future, advances in genetic and biological research may suggest how therapies can be “individualized” for specific patients. Just as no single medicine is recognized as better than the others in treating all BPD patients, no single therapeutic approach can be better for all, despite attempts to compare approaches. Therapists should direct specific therapy approaches to different patient needs, rather than try to apply