Complex disorders, complex treatments
Oct 20, 2012
Borderline Personality, Complex Trauma, and Postrraumatic Stress Disorder (PTSD) have numerous features in common. In fact, if the PTSD is a product of childhood trauma, or if the individual with Borderline symptoms suffered Childhood Emotional Abuse, then the resulting patterns of symptoms can be very, very, much alike, calling into question whether or not the disorders can be differentiated at all. One attempt to address these diagnostic difficulties has been the in many ways excellent review by Lewis and Grenyer (2009). [LINK]
Unfortunately, one of the shortcoming of that paper is the limited conceptualization of what constitutes "treatment". I have reviewed experts' recommendations for the treatment of complex trauma on my website [LINK] Often these treatments are tailored to "disorders" rather than underlying psychological processes. Acceptance and Commitment Therapy (ACT) has identified some of the psychological processes its researchers / practitioners believe (in some cases have found, particularly in the case of Experiential Avoidance) to be of importance in the onset and maintenance of psychological distress. I have had several problems being one of the ACT Apostles, such as its adherents discomfort with looking for replication results, and the apparent need to view everything withintheACT theoretical model; in my view needlessly leaving behnd a great degree of other psychological reseearch, including valuable research looking into other underlying psychological processes, and treatments targeting those underlying processes. One of the most studied has been "emotion regulation", another has been "distress tolerance" , and Professor Kim Gratz, of the University of Mississippi, has been one researcher developing and refining treatment programs for psychological processes underlying Borderline Personality Disorder and often co-morbid conditions, such as substance use disorder, and self-harm. I have provided Prof Gratz treatment manual for emotion regulation difficulties of those who deliberately self-harm (DSH) [LINK]
A recent paper by Prof Gratz [LINK] has looked at extending research on the utility of an adjunctive emotion regulation group therapy for deliberate self-harm among women with borderline personality pathology. The purpose of this study was to further develop ERGT (Emotion Regulation Group Therapy) by examining its utility across other settings, a more diverse group of patients, a wider range of outcomes, and group leaders other than the principal investigator (Gratz). Twenty-three women received this ERGT in addition to their ongoing treatment in the community. Self-report and interview-based measures of DSH and other self-destructive behaviors, psychiatric symptoms, adaptive functioning (including social and vocational impairment and quality of life), and the proposed mechanisms of change (emotion dysregulation and experiential avoidance) were administered pre- and posttreatment. Results indicate significant changes over time (accompanied by large effect sizes) on all outcome measures except quality of life and self-destructive behaviors (although the latter was a large-sized effect). Further, 55% of participants reported abstinence from DSH during the last two months of the group.
Clearly, mechanisms in addition to difficulties with lack of mindfulness skills, and difficulties with emotion regulation, must be examined if the significant personal and interpersonal problem of deliberate self-harm is to be fully and successfully overcome and recovery from this problem is to be maintained. Perhaps, more extensive, broader range treatments need to be implemented, at least for those who do not benefit satisfactorily (complete cessation of DSH and improved quality of life) is to be achieved. This is where, I believe, the more comprehensive formulations, and treatment programs, conceptualized by those such as Barrett in Essentials for Effective Trauma Treatment [LINK] can come into their own.