Personality and Mental Health 9: 79–80 (2015) Published online 22 January 2015 in Wiley Online Library (wileyonlinelibrary.com) DOI 10.1002/pmh.1288
Commentary Discussion of emotional processing in a ten-session general (good) psychiatric treatment for borderline personality disorder
BRIAN A. PALMER, MD, Mayo Clinic 200 First St. SW Rochester, MN, USA
In their analytic description of emotional processing in a ten-session general (‘good’) psychiatric treatment for BPD (GPM) (Gunderson & Links, 2014), the authors present a compelling description of a patient with BPD who has struggled to begin a treatment. They note that emotional distress increased in treatment with few measurable positive benefits. If anything, this case appears to be failing, with markers of alliance unchanged and an increase in emotional distress in session. In attempting to consider both why this case is not progressing as expected and what might be done to help right the course, I note that I have neither access to what was done in session nor— what may be especially useful in a GPM model— the perceptions of the therapist about the quality and problems in the relationship and if and how they were addressed. From a GPM perspective, the initial phase of treatment is marked by alliance building (generally through validation and working to address the specific problems that brought the patient to treatment), psychoeducation about BPD and the interpersonal nature of symptoms, and a therapeutic stance of curiosity: your life is important, has meaning, and can be understood.
Copyright © 2015 John Wiley & Sons, Ltd.
An important role of the therapist is that of case manager, and progress in life outside of treatment is expected. In the first few weeks of treatment, we would expect to see a reduction in subjective distress (including reduced emotional distress and increased reflective capacity), aided in part by homework that expects the patient to make greater sense of her experience: an autobiography, chain analyses around cutting urges/behaviors, self-assessments, etc. We would also expect that a crisis plan is developed that both fosters agency in managing periods of high distress and helps direct appropriate help-seeking in these periods. The material provided suggests a patient in crisis. Her distress is high, cutting is active, vocational identity is threatened, and capacity to make sense of the experience is limited. Feeling angry at her brother likely evokes considerable guilt and belief in her own badness (fueling cutting), independence means loss of the parents she both needs and resents (and resents herself for needing), and her temporary sense of control through restricting food or cutting is no longer useful in managing intolerable affects. She clearly needs a new approach.
9: 79–80 (2015) DOI: 10.1002/pmh
80
Palmer
I would have expected GPM to be an excellent fit for this case. With its focus on making sense of the interpersonal nature of symptoms, active case management, practical approaches to reduce distress, and a treatment that is grounded in life progress, the approach would hold steady curiosity about the symptoms and their origins in a way that would be expected to increase Advanced Meaning Making. In looking carefully at Figure 2, there is much about the first three weeks that is typical of GPM, with a marked decrease in distress and intense negative affects. The increase in distress by weeks 6 and 7 suggests that something happened in the treatment or that something happened in the patient’s life that treatment insufficiently addressed. Treatment-wise, this could be that the therapist became much more important to the patient than either were able to discuss—a glimpse of hope that treatment could actually address her problems was seen early, only to crash down. To the extent this theory is useful, it would have been helpful to have the patient consider what about the treatment lowered her distress over the first three weeks (high suspicion that it was the therapist). The authors provide a very succinct and accurate summary of GPM, and to their credit include a description of case management as an important function of the treatment. The review of the case, however, does not mention anything about Rachel’s functioning aside from the fact that she is considering stopping her apprenticeship. The case material provided does not indicate if Rachel was (1) able to collaborate to make goals for treatment (making goals for treatment may be a goal), and (2) willing to continue her apprenticeship or substitute an appropriate alterative day structure (a plan the therapist would insist on). The grounding of treatment in goals and making improvements in the patient’s work and relational life helps mitigate the repetition of growing close to a therapist and then having no improvement in functioning. In my experience (apologies to the patients who helped me learn this), when the therapy does not have sufficient grounding in
Copyright © 2015 John Wiley & Sons, Ltd.
life, what happens in the room becomes overly important and the initial relief at feeling ‘held’ invokes hopelessness and shame when it is inevitably threatened. That this can happen early in a BPD treatment is a challenge, since understanding it in real time requires sufficient alliance and knowledge of the patient’s relational patterns. Then again, this is a reason for GPM’s emphasis on psychoeducation about the interpersonal nature of the disorder and on vocational recovery. At the same time, we all have had cases that did not go well or at least did not start well. The key, from a GPM perspective, is actively addressing this with the patient and wondering together what is not working. Holding out the possibility that the therapist may be inadequately helpful is a useful way to begin important conversation. I am unsure of the conclusion that emotional processing may play a lesser role than thought in the early phase of treatment. It is clear from the material that the relationship did not meaningfully progress and the patient did not develop appropriate sense-making mechanisms for her experience of intense emotion (including her rage and guilt at her brother and parents). Based on the available data, I attempted to offer a theory about why this may be the case and wondered about elements of the treatment. At the same time, while I practice GPM and help train clinicians in the approach, it does not claim to be a cure-all for BPD. Patients who do not do well with GPM may need more sustained treatment by experts, and I appreciate the analysis of the treatment and the authors’ willingness to place the case in the literature for all of us to continue to learn. Reference Gunderson, J. G., & Links, P. (2014). Handbook of good psychiatric management for borderline personality disorder. Washington, DC: American Psychiatric Publishing, Inc.
Address correspondence to: Brian A. Palmer, MD, Mayo Clinic 200 First St. SW Rochester, MN 55905, USA. Email: [email protected]
9: 79–80 (2015) DOI: 10.1002/pmh
Commentary Discussion of emotional processing in a ten-session general (good) psychiatric treatment for borderline personality disorder
BRIAN A. PALMER, MD, Mayo Clinic 200 First St. SW Rochester, MN, USA
In their analytic description of emotional processing in a ten-session general (‘good’) psychiatric treatment for BPD (GPM) (Gunderson & Links, 2014), the authors present a compelling description of a patient with BPD who has struggled to begin a treatment. They note that emotional distress increased in treatment with few measurable positive benefits. If anything, this case appears to be failing, with markers of alliance unchanged and an increase in emotional distress in session. In attempting to consider both why this case is not progressing as expected and what might be done to help right the course, I note that I have neither access to what was done in session nor— what may be especially useful in a GPM model— the perceptions of the therapist about the quality and problems in the relationship and if and how they were addressed. From a GPM perspective, the initial phase of treatment is marked by alliance building (generally through validation and working to address the specific problems that brought the patient to treatment), psychoeducation about BPD and the interpersonal nature of symptoms, and a therapeutic stance of curiosity: your life is important, has meaning, and can be understood.
Copyright © 2015 John Wiley & Sons, Ltd.
An important role of the therapist is that of case manager, and progress in life outside of treatment is expected. In the first few weeks of treatment, we would expect to see a reduction in subjective distress (including reduced emotional distress and increased reflective capacity), aided in part by homework that expects the patient to make greater sense of her experience: an autobiography, chain analyses around cutting urges/behaviors, self-assessments, etc. We would also expect that a crisis plan is developed that both fosters agency in managing periods of high distress and helps direct appropriate help-seeking in these periods. The material provided suggests a patient in crisis. Her distress is high, cutting is active, vocational identity is threatened, and capacity to make sense of the experience is limited. Feeling angry at her brother likely evokes considerable guilt and belief in her own badness (fueling cutting), independence means loss of the parents she both needs and resents (and resents herself for needing), and her temporary sense of control through restricting food or cutting is no longer useful in managing intolerable affects. She clearly needs a new approach.
9: 79–80 (2015) DOI: 10.1002/pmh
80
Palmer
I would have expected GPM to be an excellent fit for this case. With its focus on making sense of the interpersonal nature of symptoms, active case management, practical approaches to reduce distress, and a treatment that is grounded in life progress, the approach would hold steady curiosity about the symptoms and their origins in a way that would be expected to increase Advanced Meaning Making. In looking carefully at Figure 2, there is much about the first three weeks that is typical of GPM, with a marked decrease in distress and intense negative affects. The increase in distress by weeks 6 and 7 suggests that something happened in the treatment or that something happened in the patient’s life that treatment insufficiently addressed. Treatment-wise, this could be that the therapist became much more important to the patient than either were able to discuss—a glimpse of hope that treatment could actually address her problems was seen early, only to crash down. To the extent this theory is useful, it would have been helpful to have the patient consider what about the treatment lowered her distress over the first three weeks (high suspicion that it was the therapist). The authors provide a very succinct and accurate summary of GPM, and to their credit include a description of case management as an important function of the treatment. The review of the case, however, does not mention anything about Rachel’s functioning aside from the fact that she is considering stopping her apprenticeship. The case material provided does not indicate if Rachel was (1) able to collaborate to make goals for treatment (making goals for treatment may be a goal), and (2) willing to continue her apprenticeship or substitute an appropriate alterative day structure (a plan the therapist would insist on). The grounding of treatment in goals and making improvements in the patient’s work and relational life helps mitigate the repetition of growing close to a therapist and then having no improvement in functioning. In my experience (apologies to the patients who helped me learn this), when the therapy does not have sufficient grounding in
Copyright © 2015 John Wiley & Sons, Ltd.
life, what happens in the room becomes overly important and the initial relief at feeling ‘held’ invokes hopelessness and shame when it is inevitably threatened. That this can happen early in a BPD treatment is a challenge, since understanding it in real time requires sufficient alliance and knowledge of the patient’s relational patterns. Then again, this is a reason for GPM’s emphasis on psychoeducation about the interpersonal nature of the disorder and on vocational recovery. At the same time, we all have had cases that did not go well or at least did not start well. The key, from a GPM perspective, is actively addressing this with the patient and wondering together what is not working. Holding out the possibility that the therapist may be inadequately helpful is a useful way to begin important conversation. I am unsure of the conclusion that emotional processing may play a lesser role than thought in the early phase of treatment. It is clear from the material that the relationship did not meaningfully progress and the patient did not develop appropriate sense-making mechanisms for her experience of intense emotion (including her rage and guilt at her brother and parents). Based on the available data, I attempted to offer a theory about why this may be the case and wondered about elements of the treatment. At the same time, while I practice GPM and help train clinicians in the approach, it does not claim to be a cure-all for BPD. Patients who do not do well with GPM may need more sustained treatment by experts, and I appreciate the analysis of the treatment and the authors’ willingness to place the case in the literature for all of us to continue to learn. Reference Gunderson, J. G., & Links, P. (2014). Handbook of good psychiatric management for borderline personality disorder. Washington, DC: American Psychiatric Publishing, Inc.
Address correspondence to: Brian A. Palmer, MD, Mayo Clinic 200 First St. SW Rochester, MN 55905, USA. Email: [email protected]
9: 79–80 (2015) DOI: 10.1002/pmh
