I stumbled across this article from 2006 in the Health section of the NY Times regarding treatment and BPD. I think it illustrates that certain treatments can be more traumatic on the patient than others (or no treatment at all). Personally, I think it also could make the case for CBT/DBT (or another behavioral treatment) because those treatments are generally focused on effective skill-building for the here and now, rather than dredging up the past right away, which could cause more trauma to the patient.

May 30, 2006

Behavior

A Case in Point for the Maxim ‘Do No Harm’

By RICHARD A. FRIEDMAN, M.D.

Everyone knows that talking about your feelings is supposed to be good for you. In part, that’s probably why psychotherapy is widely viewed as a healthy pursuit. Conventional wisdom has it that self-knowledge is always a boon, and, like wealth, you can never have too much of it.

That’s what I thought until I met Helen.

Helen was a successful 52-year-old professional who had been married for 30 years. After watching “The Celebration,” a movie in which the family patriarch is publicly unmasked as a sexual predator by his children, Helen recovered what she believed were memories of sexual abuse by her father.

Over the course of several months, she felt depressed and angry and decided to start psychotherapy for the first time. Her therapist recommended twice-weekly sessions and encouraged her to discuss her childhood and memories of sexual abuse.

She became more depressed and anxious during the initial treatment, hardly unexpected given the traumatic material she had to deal with. But then something alarming began to happen.

Helen began to abuse alcohol, something she had never done before, and to cut her wrists superficially, an old behavior that she had stopped in her 20’s.

Helen was confused. If therapy was supposed to help her, why did she feel so much worse? What could explain the fact that this previously high-performing professional woman had become a serious alcohol abuser who was cutting her wrists several times a week with a razor?

The problem was that Helen had what psychiatrists call borderline personality disorder, and therapy had encouraged a process of self-exploration that proved toxic to her.

She did not have the psychological resources to deal with the intense emotions that this kind of therapy unleashed.

Borderline patients frequently use alcohol or drugs to try to stabilize their overly reactive moods, and they often injure themselves to relieve unbearable psychic pain.

In hindsight, it’s easy to see that this was just the wrong treatment for this particular patient. Yet even when she was given a more supportive treatment, aimed at helping her cope rather than delve into her feelings, she still floundered and didn’t function nearly as well as she did before having any therapy.

It will sound heretical coming from a psychiatrist, but there are some patients who feel worse and get worse when they are in psychotherapy. For some, the problem is getting the wrong type of treatment; for others, it may be the relationship with the therapist that is problematic, regardless of the specific treatment.

In an analysis of psychotherapy studies, Dr. Michael Lambert, a professor of psychology at Brigham Young University and a well-known expert in psychotherapy research, found that about 5 percent to 10 percent of patients deteriorated with psychotherapy.

This is not a trivial problem considering that 3.5 percent of all Americans were in psychotherapy each year from 1987 to 1997, according to a 2002 study published in The American Journal of Psychiatry by Dr. Mark Olfson of the College of Physicians and Surgeons of Columbia.

Although we are not very good at predicting which patients are likely to get worse with treatment, it’s not that hard to spot them once they are in therapy and things aren’t going well.

A few years back, one of my residents was treating a young man in psychotherapy who had great difficulty deciding what he wanted to do with his life.

He wasn’t depressed, but he was a very passive person.

It became clear that the patient was using the treatment not to understand his passivity, but to indulge it; he enjoyed talking about what he should do, but made no steps outside of therapy despite many attempts to address his behavior. We stopped his psychotherapy and referred him for vocational counseling.

The possible benefits of no treatment go beyond just patients who get worse in therapy. Some patients have been in psychotherapy for so long that it isn’t clear what the advantage of treatment is; in some of these cases, stopping therapy gives patients a chance to discover that they might do fine without it.

Others might seek treatment during a crisis or when they are grief-stricken. As painful as these situations can be, if people are generally healthy and have good social supports, they are likely just to feel better with time and probably don’t need any treatment at all.

At first blush, it might sound paradoxical — even uncaring — but sometimes the best treatment is no treatment at all.