Searching in the dark: Shining a light on some predictors of non-response to psychotherapy for borderline personality disorder

Abstract

Background Borderline Personality Disorder (BPD) is a prevalent and serious mental health condition. People can experience recovery or remission after receiving psychotherapy for BPD; however, it is estimated that about 45% of people in well conducted treatment trials do not respond adequately to current psychological treatments. Aim To further advance psychotherapies for BPD by identifying the factors that contribute to the problem of non-response. Method 184 consecutive participants with BPD in community treatment were naturalistically followed up over 12 months and measures of personality and social functioning were examined. Logistic regressions were used to determine which baseline factors were associated with the likelihood of being a non-responder after 12 months of psychotherapy. After 12 months, 48.4% of participants were classed as non-responders due to a lack of reduction in BPD symptoms according to the Reliable Change Index (RCI) method. Results At baseline intake, patients who endorsed an adult preoccupied attachment relationship style and increased anger were more likely to be a non-responder regarding BPD symptoms at 12 months. In addition, those with preoccupied attachment patterns in their adult relationships were more likely to be non-responders regarding general psychological distress at follow up. Higher baseline levels of paranoia and endorsement of a dismissive adult relationship style was associated with being a non-responder in regard to global functioning. Conclusions Consistent with previous research, almost half of the sample did not achieve reliable change at 12-month follow up. A relationship style characterised by preoccupied insecurity and high anger seemed to be particularly challenging in being able to benefit from psychotherapy. This style may have affected both relationships outside, but also inside therapy, complicating treatment engagement and alliance with the therapist. Early identification and modification of treatment based on challenges from these relationship styles may be one way to improve psychotherapy outcomes for BPD.

To love and work: A longitudinal study of everyday life factors in recovery from borderline personality disorder

“…Internal consistency of this approach was excellent ( α = 0.90). Validity was demonstrated in previous studies of process–outcome (Hashworth et al, 2021 ; Huxley et al, 2019 ; Miller et al, 2018 ; Woodbridge, Reis, et al, 2021 ). The McLean Screening Instrument (MSI) (Zanarini et al, 2003 ) cut‐off of 7 was used to group participants as described below.…”

“…Increasingly, dominant diagnostic and classification systems are moving towards classification of personality within a spectrum of severity (e.g., personality functioning, American Psychiatric Association, 2013 ; personality organisation, Lingiardi & McWilliams, 2017 ; and personality severity, World Health Organization, 2019 ). While there currently exists a number of effective and evidence‐based treatments for personality disorder (Bateman et al, 2015 ), a subgroup of patients remain unwell despite therapeutic intervention (Woodbridge, Reis, et al, 2021 ; Woodbridge, Townsend, et al, 2021 ). As reflected by the ‘functioning poorly’ group, our results highlight a group of severely unwell patients with unique challenges.…”

“…The field of personality disorder has evolved considerably, particularly with the growing body of evidence for improved health professional attitudes (Day et al, 2018 ) (albeit stigma still remains; Ring & Lawn, 2019 ), as well as the development and availability of evidence‐based treatments (Bateman et al, 2015 ) and improved treatment trajectories (Biskin, 2015 ). Yet at present about a half do not respond to current treatment after about a year of therapy (Woodbridge, Reis, et al, 2021 ; Woodbridge, Townsend, et al, 2021 ). Thus, a more nuanced contemporary understanding of the lived experience of BPD is required.…”

The effect of attachment style on long-term outcomes in psychogenic nonepileptic seizures: Results from a prospective study

“…In patients with borderline personality disorder, it has been shown that those having a preoccupied attachment style were more likely to not respond to intervention. It has been argued that preoccupied attachment style might complicate the engagement in the therapeutic treatment and the alliance with the therapist [46].…”

Attachment style of patients diagnosed with psychogenic non-epileptic seizures at a tertiary Epilepsy Center in the Czech Republic

“…It has been also argued that preoccupied attachment style might complicate the engagement in the therapeutic treatment and the alliance with the therapist ( 35 ).…”