SAN FRANCISCO – Borderline personality disorder is often treated with long-running psychotherapy, but this could be a disservice to patients. Instead, stepped-care models may offer more benefit in a shorter period of time, conserving resources and potentially expanding the reach of therapeutic interventions.
“There is this legacy of psychoanalysis, this idea that if you’ve had a condition for 20 years, it’s going to take 20 years of therapy to get rid of it – which is not true,” Joel Paris, MD, said in an interview. Dr. Paris moderated a session on stepped-care interventions for borderline personality disorder at the annual meeting of the American Psychiatric Association.
He also pointed out that psychoanalysis can prove self-sustaining: “There’s something to talk about, so it can go on and if there’s money to pay for the service, why stop?”
But psychoanalysis can have diminishing returns, and that in turn can strain resources. “Some people won’t get better or won’t go beyond a certain point. You help them to a certain extent, and then you have to be able to say, ‘That’s enough; stop there. If you get in to bad trouble, you can always come back,’ ” said Dr. Paris, professor of psychiatry at McGill University, Montreal.
That realization has led Dr. McGill to introduce a stepped-care model, which has provided a 12-week program for 15 years. Dr. Paris presented a retrospective look at the program, including 479 patients who received individual and group therapy. The dropout rate was high at 30%, but only 12% of patients returned asking for more therapy. A total of 145 patients deemed to be more chronic or who did not respond to the short-term program had the option of completing additional individual or group therapy over a period of 6-24 months.
“ There are also dropouts; maybe a quarter will not complete the program,” Dr. Paris said. “But that means 75% do, and most of them get better. There’s also good evidence that short therapy can help many people with substance abuse.”
Lois W. Choi-Kain, MD, assistant professor psychiatry at Harvard Medical School, Boston, presented evidence from several studies showing that shorter- and long-term courses of dialectical behavior therapy led to similar improvements, but that brief courses were associated with more rapid improvement. The short course consisted of weekly 1-hour individual sessions, while the longer course involved weekly 2-hour group sessions. The individual approach was associated with an 89% faster improvement in symptoms in the first 3 months (P less than .0001).
These kinds of findings underscore the need for shorter courses of therapy, at least for most patients, in order to conserve resources and broaden the availability of therapy, particularly in less affluent settings. “We saw in today’s symposium that most improvement takes place at the beginning of therapy, and you should quit while you’re ahead,” Dr. Paris said. “You should not try to do impossible things and make everybody into paradigms of mental health.”
Dr. Paris reported no relevant financial disclosures.