Citation

Gabbard GO. Psychiatr. Ann. 1998; 28(11): 651-656.

Copyright

(Copyright © 1998, Healio)

DOI

10.3928/0048-5713-19981101-10

PMID

unavailable

Abstract

When an impulsive or explosive temperament is adequately treated by an SSRI or another agent, the patient often finds that the negative affect states are sufficiently reduced so that collaboration with the therapist is possible. Angry transference states are diminished so that the patient can think with the therapist about the origins of difficulties in the transference. Often a reflective space is facilitated by the use of SSRIs, which build in a delay mechanism so that the patient can think before acting impulsively. There is considerable merit in having one psychiatrist conduct the psychotherapy and prescribe the medication rather than splitting those functions between two separate clinicians. The difficult characterologic dimensions that manifest themselves in the re-creation of an internal object relationship in the trasference will occur around medication prescribing in the same way that they do in the psychotherapy. It is ideal if the same clinician is involved in the delivery of both treatments so that these recurrent themes in the relationship can be addressed constantly and understood as they emerge. Although separating the two functions may also be effective there is a much greater risk of splitting,22 in which one treater is idealized and the other is devalued. Frequently the pharmacotherapist is regarded as a benign figure who is interested in symptom relief, in contrast to the therapist, who insists on discussing painful and unpleasant issues. Many BPD patients will create considerable tension between the two treaters by the way they portray one to the other. In working with both the medication and the psychotherapy, a continued focus of the clinician's effort should be to forge a solid therapeutic alliance. The development of this alliance can best be measured by monitoring how well the patient is able to collaborate with the therapist in the pursuit of commonly held goals. In this regard the alliance is both an enabling variable and a mini-outcome variable.23,24 The repeated emphasis on working together goes a long way in impressing upon the patient that, fundamentally, the doctor-patient relationship is not an adversarial one. If the patient is unable to collaborate in this manner, the clinician then has an opportunity to further interpret and clarify the patient's problematic internal object relations. There is no "quick fix" for the BPD patient. Nevertheless, long-term follow-up studies suggest that there is reason for optimism when clinicians are persistent in their efforts to help. In a recent 3-year prospective outcome study, Najavits and Gunderson25 found that BPD patients follow a course of erratic improvement in the first few years of treatment, and that their overall outcomes are better than might be expected. Some will become chronic, and somewhere between 3% and 10% will ultimately commit suicide. Nonetheless, persistent efforts at adjusting the psychotherapy and the medication are likely to pay off in improved functioning and better quality of life.

Language: en