Indian Journal of Health Social Work
INTERPERSONAL PSYCHOTHERAPY ON BORDERLINE PERSONALITY DISORDER: A CASE STUDY
Urbi Mukherjee1, Jayanti Basu2, Ushri Banerjee3
1Assistant Professor, Department of Applied Psychology, Kazi Nazrul University, Asansol, West Bengal, India, 2Professor, Department of Applied Psychology, Calcutta University, Kolkata, West Bengal, India, 3Assistant Professor, Department of Applied Psychology, Calcutta University, Kolkata, West Bengal, India
Correspondence: Urbi Mukherjee, e-mail id: mukherjee.urbi@gmail.com
ABSTRACT
Borderline Personality Disorder (BPD) is characterized by pathological attachment pattern, rapid mood fluctuations, emotional dysregulation, impulsivity, distorted aspects of self and interpersonal relatedness. Interpersonal Psychotherapy (IPT) is primarily aimed to resolution of interpersonal difficulties, improving both social functioning and psychiatric symptoms. IPT’s effectiveness in unipolar depression led investigators to enlarge the application of IPT. IPT has been proposed to treat BPD, the first among the Personality Disorders, because of its frequent comorbidity with mood disorders and the serious interpersonal issues. The present study attempted to investigate changes in differentiation of self through IPT in a single case diagnosed with BPD. Differentiation of self was measured using Differentiation of Self Inventory (DSI, Skowron & Friedlander, 1998). The four interpersonal domains, as stated in IPT, loss/ grief, role transition, interpersonal disputes and interpersonal deficits were evaluated using Interpersonal Inventory. Beck Depression Inventory (Beck et al., 1961) was also used as an additional objective measure of mood symptoms.Findings indicated that IPT may be considered useful in improving core BPD symptom clusters. Results also indicated considerable impact of therapy across domains of differentiation of self viz total score, emotional reactivity, I- position and fusion with others across baseline, middle and termination phases of therapy. The case study implied promise of IPT in improving functionality and quality of interpersonal relatedness of patients with BPD alongside mood and other core symptoms. It may be included in future researches that target time-limited, relatively shorter impactful psychotherapeutic treatment for BPD.
Keywords: BPD,IPT, Differentiation of Self.
INTRODUCTION
Borderline Personality Disorder (BPD) is characterized by pathological attachment pattern, rapid mood fluctuations, emotional dysregulation, impulsivity, distorted aspects of self and interpersonal relatedness. The low level of differentiation of self parallels the contextual, relational, and clinical experience of individuals with BPD. Theoretically, four factors influence an individual’s level of differentiation: emotional reactivity, emotional cut-off, fusion with others, and the ability to take an I Position (Kerr & Bowen, 1988). More evocatively, individuals with BPD have inability to tolerate and regulate emotion often results in dramatic overreactions and impulsivity. When internal experiences or interpersonal interactions become too intense, poorly differentiated individuals tend to characteristically engage in either emotional cutoff or fusion (Bowen, 1978; Kerr & Bowen, 1988). The inability to take an I- position in close personal relationships is equal to a lack of an integrated concept of self and an integrated concept of others. Bowen‘s (1978) views on the impact of level of differentiation of self on life experience are supported by research linking lower levels of differentiation of self with greater psychological distress (Elieson & Rubin, 2001; Peleg-Popko, 2002), marital discord (Skowron, 2000), poorer effortful control (Skowron & Dendy, 2004), and greater psychological symptoms and interpersonal problems (Skowron, Stanley, & Shapiro, 2009). These findings indicated that this core of fragmented self and self- concept tended to have pervasive influence on interpersonal dysfunctions along with fluctuating mood symptoms; this further underscored the avenue of exploration through psychotherapeutic interventions that would focus on these domains. However, BPD is one of the most contested diagnoses in terms of challenges encountered during interventions. Some of the therapies (such as Dialectical Behaviour Therapy) have shown promising results. However, certain limitations in dealing with this kind of pathology indicated need for time-limited interventions effective on functional outcomes over symptomatic improvements (Mcmain, 2015; Gratz, Tull & Levy, 2015). Interpersonal Psychotherapy (IPT) is primarily aimed to resolution of interpersonal difficulties, improving both social functioning and psychiatric symptoms. IPT’s effectiveness in unipolar depression led investigators to enlarge the application of IPT. IPT has always relied on outcome research to validate its efficacy for particular patient populations. For personality disorders, however, the empirical literature for interpersonally targeted interventions of any kind is extremely limited. Borderline Personality Disorder (BPD) is the first personality disorder for which IPT has been adapted (Angus & Gillies, 1994; Markowitz, Bleiberg, Christos & Levitan, 2006; Markowitz, Bleiberg, Pessin & Skodol, 2007). IPT has been proposed to treat BPD, the first among the Personality Disorders, because of its frequent comorbidity with mood disorders and the serious interpersonal issues.
Bateman (2012) suggested that the four foci, grief/ loss, role transition, interpersonal dispute and interpersonal skill deficits, of IPT for treating BPD need greater emphasis and modification in terms of therapeutic alliance, addressing self -related disturbances and length of therapy. The focus of IPT for BPD then becomes careful scrutiny of the effect of interpersonal interactions on the patient’s experience of their mind with concurrent work on managing emotional arousal. This is performed collaboratively with the patient following the basic model of IPT. Each session commences with a review of current relationships and interactions with others followed by a communication analysis when appropriate. Given the chronicity and complexity of borderline personality disorder, IPT sessions can be extended (Markowitz, Skodol & Bleiberg, 2006). Literature on adaptation of IPT on BPD suggested a range of 12 weeks to 34 weeks (Angus & Gillies, 1994; Markowitz, Kocsis, Bleiberg, Christos & Sacks, 2005) time- limited therapy model. Moreover, there is recommendation of treatment plan of 24 sessions using IPT, with the flexibility of reducing sessions from once per week to twice per month after 16 sessions (Bateman, 2012).
The present study attempted to study changes in differentiation of self through IPT in a single case diagnosed with BPD.
Case Description
Index client, 26 years old married female, graduate, home- maker, belonging to a joint family of middle socioeconomic strata from sub-urban area, presented with complaints of difficulty in adjusting with her in-laws and husband, frequent family discords since her marriage 4years back along with frequent anger outbursts, extreme impulses to act out on rage, hitting husband often, low mood often accompanied by crying spells, suicidal ideation with insidious onset, continuous course and deteriorating progress for last 4 years. As the condition worsened with heightened family discords, her husband thought of mental health consultation.
Family history was found to be nil contributory. However, the client reported that her father had excessive stubbornness and domination. Her husband also confirmed this impression.
No other informant was available. Past history revealed she had hobbies of creative writing. She was keen to learn various computer applications.
Mental status examination revealed presence of depressive cognitions and suicidal ideations. Personal and social judgment was poor with grade III insight.
Structure of IPT
IPT is conceptualised as consisting of three phases (initial, middle and termination), each with its own distinctive strategies and objectives.
The client was thoroughly informed about the research purpose and upon consent, she was made aware of the Interpersonal Psychotherapy as the modus of treatment. The client was encouraged to assume the sick role with the aim of reminding that the sickness is treatable that would, in turn, increase the treatment adherence. The duration and frequency of sessions were also detailed.
The client adhered to 24 weekly IPT sessions of 1 hour duration distributed into initial, middle and termination phase. Differentiation of self was measured using Differentiation of Self Inventory (DSI, Skowron & Friedlander, 1998) and it was administered at initial (baseline), middle (at session 12) and termination (at session 24) phases. The four interpersonal domains, as stated in IPT, loss/ grief, role transition, interpersonal disputes and interpersonal deficits were evaluated using Interpersonal Inventory. Degree of subjective distress was also tracked across sessions as an additional objective measure (Beck Depression Inventory, Beck et al., 1961) of mood symptoms.
The IPT formulation
The interpersonal psychotherapy formulation was done (Figure 2).
Initial Phase:
The goals of initial phase were:
– Psychoeducation
– Establishing the ‘sick role’
– Generating hope towards betterment
– Normalizing emotional set- backs
– Explaining the Interpersonal formulation
Major two areas of interpersonal disputes were identified:
i. With husband
ii. With in-laws
Detailed psychoeducation was imparted to the client and the informants. It took three sessions for the client to understand the emotional and self related disturbances as part of pathology. Labeling the pathology was not encouraged but establishing the ‘sick role’ was emphasized. Thus acknowledging the symptom clusters was focused with the help of IPT formulation. Role of interpersonal encounters were also emphasized. She was encouraged to understand and identify those problem areas that were characteristic of her and further be targeted for modification on her part. The interpersonal formulation was also repeated in subsequent sessions. After three sessions, she could compose herself better and articulated her feelings that could possibly be modified under inevitable circumstances. However, given the circumstances, it was then identified as an unmodifiable transition by the client in context of the present. Therefore, with reference to the circle of closeness, her role as mother was subsequently focused.
Review of the initial phase revealed betterment in mood, initiation of greater time spent with son, exploring the child’s needs and interests. Her outrageous impulses were toned down.
Middle Phase:
The goals of the middle phase were:
– Engagement in role- specific behaviours
– Generating alternative ways of interpersonal interactions to make the situations better through role playing during sessions, demonstrating communication and decision analysis
– Reflections on practicing
The sub-goals were, therefore, set to—
– analyze, modify role specific (as wife) expectations;
– identify faulty communication and helping client develop better communication skills so that the difference of opinion is resolved.
The client was advised to continue with monitoring each and every situation in vivid details, so the verbal as well as the non-verbal cues would also be tracked. For that time being she was advised to practice isolation and reminding herself of therapeutic goals.
The client started keeping details of interpersonal situations with her son- when and how she spent time with him, what all observations she could make as a mother. She conveyed that she never focused on mothering in such details. Making her child learnt self- help skills used to give her a better sense of fulfilment.
The detailed narration of interpersonal encounters revealed that she previously got various proposals for front- desk or sales related jobs. After her marriage, during the stay in her paternal place, she went for one such offer and got involved in a relationship with a guy within a few days. As her in-laws belonged from the same locality, her husband was informed by one of his acquaintances. The client had to face the consequence and gave up the job. This resulted in disputes with her husband, further deteriorated her emotional well-being.
In order to formulate the specific strategies to practice effective decision analysis, her responses and communications were delineated in details. Pervious relationship issue was taken as an example only. Follow-up interaction with husband was then role played. It was explained that impulses having a constitutional origin were not possible to regulate. Acting on those impulses was subject to decision analysis. Moreover, any individual or situation might arrive as provocation; effective communication strategies seemed important there. Previous ineffective communications were underlined from the role-playing. Follow-up sessions on communication and decision analysis revealed that the client became more willing to learn how she could better practice communication analysis. Modified effective communication would rather facilitate the client to ‘negotiate’ in a mature way so that she would not act on the triggers. Besides, decision analysis in the context of her engagement in some kind of job or activity was reviewed. She could correlate that these skills would also help her in other interpersonal encounters.
At this point, she herself took the decision of going with her husband, along with their son, to the place where her husband was posted. She could explore herself in the ‘role’ of the ‘mother’. She expressed that she felt a better sense of autonomy. She could explore on job prospects and found that nothing stable was readily available. Thus she discussed with her husband and both agreed that the client would start a computer coaching class at the ground floor of her paternal place. She planned to employ teachers. Being the native of the locality, both she and her husband could arrange good number of students.
Client’s efforts were thoroughly appreciated. She was explained the correlations among the roles, she being the common to every situation, and was also explained the significance of demarcations between roles.
Review revealed that she became less reactant in presence of her sister-in-law and mother-in-law.
The summary of the role-playing done was reviewed. The client employed effective communication skills and could come up with a contract with her husband that initial infrastructural investments would be borne by her husband and the client in exchange had to secure the pocket-money by herself.
Review further revealed that the client’s mood improved consistently. Impulses of self-harm subsided. She planned a routine for her where she categorically performed some household chores, took care of the son and started the marketing for her coaching centre at the local level.
After a few weeks the client reported a positive move towards inaugurating the coaching class. The client made necessary arrangements and her business venture started. She herself also started learning some higher computer applications in the class. Some of the students approached her for tuitions of a few school-based subjects. She started that too. She felt quite satisfied with this
Reviews reflected a steady improvement with normal ups and downs with which the client used the strategies that were effective for her.
Review further indicated a working rapport was established with the in-laws, mostly surrounding a need- based communication. The client reported that she felt comfortable with this pattern. She attributed her focus on the ‘role’ of a ‘mother’ as a major agent of her betterment.
Termination was planned after discussing with the client.
Termination Phase:
The goals of the termination phase were:
– Reviewing the therapy process and therapeutic change agents
– To sustain on the improved state of betterment
– Relapse prevention
– Identifying the relapse of severe symptoms and seeking immediate help
Whenever there would be any need felt and experience of failure after repeated attempt to reach to the baseline, recommendation to consult the therapist without delay was made.
Results indicated considerable impact of therapy in the total score and domains of differentiation of self across baseline, middle and termination phases of therapy. Emotional Reactivity (ER) denoted difficulty to remain calm in response to the emotionality of others. Findings revealed improvement in emotional reactivity, between baseline-middle and baseline-termination phases. Similar trend reflected in I-Position (IP) that indicated betterment in maintaining a clearly defined sense of self and thoughtfully adhering to personal convictions when pressured by others to do otherwise (Bowen, 1978). Emotional Cut-off (EC), personified by the reactive emotional distancer, and interpersonal relatedness in terms of Fusion with Others (FO) changed indicating improvement between baseline-middle and baseline-termination phases. This trend further
denoted a betterment in defining self, its convictions and values and better reliance on self -efficacy over others’ approval. DISCUSSION
IPT had shown to impact the urgency to react on emotionally toned situation, helping the patients to remain calm rather than getting disturbed. This might be assumed to improve their communication skills as exercised through ‘Communication analysis’ and ‘Decision analysis’. The focus was to help client address interpersonal difficulties, instead of reacting on it, by observing how critical interpersonal situations cause problems and dysfunctions. Subsequently the client was encouraged to determine the goal, generating potential solutions, and evaluating and selecting a strategy to try alternative mode of communication that would at least resist worsening the mood.
Findings of Dannie Mooney-Reh (2011) on intervention of BPD using individual psychodynamic therapy and group intervention based on DBT, reported reduction in psychiatric symptoms, better coping, improved differentiation, effective management of emotional distress and more psychological flexibility. Therefore, it may be said that the skills employed with respect to self as reactant, recipient and interpreter had led to improved differentiation of self. This may also be considered as an agent for improvement in affective and behavioural domains.
The differences in scores across middle and termination phase followed the usual patterns of therapeutic progress. A spurt of improvement from baseline to middle indicated reduction in symptom severity. However, personality pattern is not subject to drastic restructuring. Identification of own vulnerabilities required time to get accepted when the individual attempted further modification through various therapeutic skills. This again tended to create bouts of dysfunctions and increase symptom severity. However, by termination it could lower the propensity of the vulnerable aspects of ‘self’ to the extent that could improve the functionality of the patients. The scores as reflected were in synchrony with this conceptualization.
Findings indicated that IPT may be considered useful in improving core BPD symptom clusters as well as functionality of the client.
The case study implied promise of IPT in improving functionality and quality of interpersonal relatedness of patients with BPD alongside mood and other core symptoms. It may be included in future researches that target time-limited, relatively shorter impactful psychotherapeutic treatment for BPD. The case study also indicated need for in-depth research in this area for structuring IPT based module for treating BPD.
REFERENCES
Angus, L., & Gillies, L.A. (1994). Counseling the borderline client: An interpersonal approach. Canadian Journal of Counseling, 28, 69–82.
Bateman, A. W. (2012). Interpersonal psychotherapy for borderline personality disorder. Clinical psychology & psychotherapy, 19(2), 124-133.
Beck, A. T., Ward, C. H., Mendelson, M., Mock, J., & Erbaugh, J. (1961). An inventory for measuring depression. Archives of General Psychiatry, 4(6), 561-571.
Bowen, M. (1976). Theory and practice in psychotherapy. In P.J. Guerin (Ed.),Family therapy: Theory and practice (pp. 42–90). New York: Gardner Press.
Elieson, M. V., & Rubin, L. J. (2001). Differentiation of self and major depressive disorders: A test of Bowen theory among clinical, traditional, and Internet groups. Family Therapy: The Journal of the California Graduate School of Family Psychology, 28(3), 125-142.
Gratz, K. L., Bardeen, J. R., Levy, R., Dixon-Gordon, K. L., & Tull, M. T. (2015). Mechanisms of change in an emotion regulation group therapy for deliberate self-harm among women with borderline personality disorder. Behaviour research and therapy, 65, 29-35.
Kerr, M. E., & Bowen, M. (1988). Family evaluation. New York: Norton.
Knox, J. (2011). Self-agency in psychotherapy. New York, NY: W. W. Norton.
Markowitz, J. C., Bleiberg, K. L., Christos, P., & Levitan, E. (2006). Solving interpersonal problems correlates with symptom improvement in interpersonal psychotherapy: preliminary findings. The Journal of nervous and mental disease, 194(1), 15-20.
Markowitz, J. C., Bleiberg, K., Pessin, H., & Skodol, A.E. (2007). Adapting interpersonal psychotherapy for borderline personality disorder. Journal of mental health, 16(1), 103-116.
Markowitz, J. C., Kocsis, J. H., Bleiberg, K. L., Christos, P. J., & Sacks, M. (2005). A comparative trial of psychotherapy and pharmacotherapy for “pure” dysthymic patients. Journal of affective disorders, 89(1-3), 167-175.
McMain, S. F. (2015). Advances in the treatment of borderline personality disorder: an introduction to the special issue. Journal of clinical psychology, 71(8), 741-746.
Mooney-Reh, D. (2011). An examination of the significance of differentiation of self in the assessment and treatment of borderline personality disorder.
Peleg-Popko, O. (2002). Bowen theory: A study of differentiation of self, social anxiety, and physiological symptoms. Contemporary Family Therapy, 24(2), 355-369.
Skowron, E. A. (2000). The role of differentiation of self in marital adjustment. Journal of counseling Psychology, 47(2), 229.
Skowron, E. A., & Dendy, A. K. (2004). Differentiation of self and attachment in adulthood: Relational correlates of effortful control. Contemporary family therapy, 26(3), 337-357.
Skowron, E. A., & Friedlander, M. L. (1998). The Differentiation of Self Inventory: Development and initial validation. Journal of counseling psychology, 45(3), 235.
Skowron, E. A., Stanley, K. L., & Shapiro, M. D. (2009). A longitudinal perspective on differentiation of self, interpersonal and psychological well-being in young adulthood. Contemporary Family Therapy, 31(1), 3-18.
Stuart, S. (2006). Interpersonal Psychotherapy: A Guide to the Basics. Psychiatric Annals, 36(8), 542–550.
Weissman, M. M., Markowitz, J. C., & Klerman, G.L.(2000). Comprehensive guide to interpersonal psychotherapy. New York: Basic Books.
Weissman, M., & Markowitz, J. (2007). Clinician’s quick guide to interpersonal psychotherapy. Oxford University Press.
Conflict of interest: None
Role of funding source: None
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