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Disruptive Innovation

Debranding Treatment for Borderline Personality Disorder: A Call to Balance Access to Care with Therapeutic Purity

Choi-Kain, Lois W. MD, MEd

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Harvard Review of Psychiatry: 5/6 2020 - Volume 28 - Issue 3 - p 143-145
doi: 10.1097/HRP.0000000000000256
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Not so long ago, a reputable psychiatrist traced the beginning of wisdom to never calling a patient borderline.1 Around that time, Marsha Linehan2 reported on the effectiveness of a new treatment called dialectical behavior therapy (DBT) designed to treat suicidal and treatment-nonresponsive patients diagnosed with borderline personality disorder (BPD). Starting with Linehan, a potent clinical revolution occurred. Since then, many other psychotherapeutic approaches—including mentalization-based treatment, transference-focused psychotherapy, and schema-focused therapy—joined DBT as empirically validated treatments for BPD.3 These new, evidence-based brands of psychotherapeutic treatment, spanning the gamut from behavioral to psychodynamic approaches, innovated both BPD treatment and psychotherapy at large by providing effective care for one of psychiatry’s most challenging syndromes, which up until that point was regarded as not treatable.

Over time, our scientific community has put these brands of evidence-based BPD therapies to more stringent test, starting in the first wave of trials against treatment as usual, evolving through subsequent comparisons to nonmanualized treatments by community experts, as well to structured clinical-management approaches by informed generalists. These rigorous comparisons have legitimized these treatments and further validated BPD as a constructive diagnosis. Now, the beginning of clinical wisdom is diagnosing a patient with BPD since we now know that treatments as usual—not focused on BPD and its core symptoms—do not yield the same clinical gains as the treatments specifically targeting BPD. Each brand formulates BPD from different bases (e.g. emotional dysregulation, skills deficits, mentalizing instability, split object relations, dysfunctional schemas). The problem is that these specialized psychotherapies all apply complex techniques foreign to the skill set of most general mental health practitioners. Furthermore, there is no proof that the varying formulations and techniques of the specific brand-name treatments confer advantages one against another.4

In the pharmaceutical industry, brand-name medications hold patents on the physical appearance of their pills down to their flavor, aroma, shape, and color. The brand’s packaging makes it distinguishable from other brands and from generics. These trademarked, nonfunctional elements of the treatment’s packaging comprise its trade dress, which is strongly associated with the treatment for its consumers as well as its prescribers.5 When it comes to treatment for BPD, we need to ask ourselves, to what extent do the varying theoretical formulations and techniques of the different brands of BPD treatment share a common core mechanism of action, with the rest being peripheral trade dress?

Andrew Chanen commented at the 2019 annual meeting of the American Psychiatric Association that these brands of therapy, like brands of laundry detergent, make different claims, but pragmatically, all yield the same desired result, since the central ingredients responsible for the mechanism of action remain the same. These central ingredients include an informed focus on BPD, a coherent formulation of what causes its symptoms, and a consistent therapeutic approach organized around its proposed formulation. The specialized psychotherapies employ different concepts and techniques that overlap significantly. Psychotherapy research more broadly demonstrates that various approaches yield similar results. What is common and central, and what is non-essential packaging, is not known empirically, but understanding this core of effective treatment may pave the way for wider accessibility of care.

I would propose that new generics of the BPD treatment market are the generalist variants of BPD care. Generalist approaches, such as general psychiatric management (GPM), were developed by expert clinicians based on national guidelines for the care of patients with BPD. In the largest outpatient trial to date for BPD, pitting DBT against GPM, there were no differences in outcomes after one year of treatment or in three years of follow-up.6 Slimmer on psychotherapeutic content and heavier on clinical case management, generalist approaches boil down what works in the brand-name comparators into pragmatic interventions more likely to become a regular fixture in all mental health settings. Other brief, pared-down treatments, such as the 20-group psychoeducational skills–based intervention Systems Training for Emotional Predictability and Problem Solving (STEPPS), also offer a lower dosing of treatment that may be more tolerable for some patients and relatively easy to implement.7

Still, the notion that only brand-name psychotherapies work for BPD remains widely held. DBT, for instance, has become an iconic brand: the product has become synonymous with effective BPD care. Psychiatric licensure examinations pair “DBT” with vignettes that clearly describe patients with BPD as the correct answer. But the reality is that DBT programs typically have waitlists one year long. This dearth of care is patently mismatched with a population of patients with a highly elevated suicide rate and distinctive intolerance of aloneness and abandonment. Representatives of brand-name psychotherapies sometimes discourage the broadening of options for BPD treatment despite the absence of replicated evidence that any one treatment is superior or that any of them can be implemented affordably and sustainably in all clinical environments.

Of course, this fact makes it easy to argue for debranding treatment for BPD to increase access to care, given the estimated six thousand treatment-seeking patients with BPD per certified evidence-based psychotherapist in this country.8 If the majority of care can be redistributed to general mental health care and if more-severe cases nonresponsive to generalist care can be allocated to specialists, not only will more patients receive informed care but also more clinicians will feel capable of providing good-enough care. This new approach could help destigmatize the disorder by proving that it is just one psychiatric condition among others—and not one that is so severe that treatment should be provided only by specialists.

Nevertheless, there is a tension in the world of brand-name versus generic therapeutics that cannot be ignored. Brands are more than marketing devices; they provide a sense of value, reliability, and identity for both the product and its consumers. Brands tell stories that people use to organize their understanding of themselves and the world—which provide confidence not only in the product but even more broadly for the consumer, “shor[ing] up fragile world-views and identities.”9(p 36) It is possible that the innovative, brand-name psychotherapies changed our field by promoting the notion that BPD is in fact understandable, its symptoms manageable, its relational storms containable, and its recovery possible. This new, courageous optimism in the face of the prevalent pervasive pessimism regarding the disorder has powerfully turned the tide of stigma.

In the world of BPD treatments, each brand conveys not only a distinct core formulation and array of techniques and procedures, but also a distinct culture that instills its consumers with confidence in the face of the predictable challenges. Brands generate epistemic trust, defined by Peter Fonagy and his collaborators10 as the trust in the authenticity and personal relevance of knowledge transmitted in an interpersonal context. Epistemic trust—fueled both by authority gained through expertise and research, and by ostensive cues that convey recognition of each individual’s personal experience—is critical to learning. Whether brand-name or generic, the treatment must speak to those who will use it, and its ingredients do need to be packaged in a way that is personally relevant to its consumers. In addition, the authority and credibility of those providing treatment interact with patients’ expectancies, receptivity, and adherence to care. Little is known about the effects of where, when, and by whom these treatments are delivered; therefore, greater clarity is needed on how context and timing influence the outcomes of brand versus generic variants.

The opportunity to debrand treatments for BPD represents a critical juncture with a number of paradoxes. While the evidence from clinical trials indicates little or no difference in effectiveness between prevailing brands or between brands and generic-generalist versions, separating out the crucial ingredients, placebo effects, and trade dress of each brand is necessarily a complex process requiring further research. The practice of these brand-name treatments, along with their cultures, shapes the professional identity of practitioners—at times to shore up confidence and competence, and at times to fuel irrational, narrow-minded thinking that closes the road to just distribution of care to more patients. With many equally effective brand-name therapeutics for BPD and the rise of the new generics, a growing spectrum of options is possible. Stepped-care algorithms can guide allocation of these options according to clinical severity, with the consequence that less intensive, brief interventions would be routinely used in most cases, and more intensive, lengthy interventions used for more severe, complex cases. Earlier intervention is needed, rather than waiting until increased severity warrants the more intensive care. In order to match treatments to patients, it would also be helpful to identify through longitudinal research the clinical features associated with longer time to remission, greater risk for suicide attempts, and higher levels of comorbidity. More generally, further research will help to provide an empirical foundation for effective and judicious allocation of different steps of care. The public’s health needs demand that we come to understand what is essential, what is trade dress, and what is good enough to proliferate beyond the trench of specialist care. We need both specialists and generalists in order to address the present reality regarding BPD—the widespread suffering, morbidity, mortality, and inadequate supply of treatment to meet demand.

Declaration of interest

The author reports no conflicts of interest. The author alone is responsible for the content and writing of the article.

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© 2020 The Author(s). Published by Wolters Kluwer Health, Inc