1. health and fitness
2. therapy

4/28/2015
Mantosh J. Dewan, MD
SUNY Distinguished Service Professor
Upstate Medical University
Syracuse, NY
Book royalties: Am Psychiatric Press, Inc
-The Art & Science of Brief Psychotherapies

-The Difficult to Treat Psychiatric Patient




Editing fees: John Wiley, Inc
Writing honorarium: Taylor & Francis
Consulting: Streufert Consulting LLC.
Clinakos LLC, Cyberdoctor LLC
Grants: NIMH, HRSA
For therapists:
-Often only evidence-based,effective treatment
- Emerging model for psychotherapy
 For psychiatrists:
- Axis II defeats medication treatment for
easy-to-treat Axis I disorders; making it
“difficult to treat” or “treatment resistant”

(Dewan & Pies 2001)
-**improves med mngmt, adherence**
1
4/28/2015









What makes brief therapy brief?
long term vs brief dynamic therapy
What makes Personality Disorders difficult to
treat?
Generic, ‘plain ol’ English’ model (POEM) of
brief therapy for PD (including med mngmt)
Application to Borderline PD
(doing the impossible quickly!)
What makes brief therapy brief?
long term vs brief dynamic therapy
What makes Personality Disorders difficult to
treat?
Generic, ‘plain ol’ English’ model (POEM) of
brief therapy for PD (including med mngmt)
Application to Borderline PD
(doing the impossible quickly!)
Brief dynamic psychotherapy is allied to
long-term dynamic therapy
just as
lightning chess is allied to regular chess
Steenbarger, Greenberg, Dewan 2012
2
4/28/2015







Common emphasis on:
- frame, boundaries
- techniques (resistance, transference, CT)
- phases: alliance/engagement
working through/discrepancy
termination/consolidation
Less severe pathology
Good object relations
Rapid alliance formation
Narrow problem focus
Increased therapist activity
Here-and-now focus
More severe
Poor to good
Gradual
Broad range
Moderate
Past & present
Dewan et al 2009


# of sessions:
-preset, < than 24;
Time limit:
-preset, 6 m or less;
*1 yr eg DBT, DDP

Focus:
-strictly ltd to 1 or 2;
open ended, > 24
open ended, > 6m
broad exploration
Gabbard 2010; Dewan et al 2014
3
4/28/2015




What makes brief therapy brief?
long term vs brief dynamic therapy
What makes Personality Disorders difficult to
treat?
Generic, ‘plain ol’ English’ model (POEM) of
brief therapy for PD (including med mngmt)
Application to Borderline PD
(doing the impossible quickly!)
Understanding PD
Neurosis:
-ego-dystonic
‘something wrong’
-normal personality
with flexible, adaptive,
varied pattern of
responses &
relationships
N
Personality disorder:
-ego-syntonic
’nothing wrong with
me’ (change the
others)
-fixed, narrow range
of
-maladaptive
responses and
relationships.
Understanding PD
Neurosis:
-ego-dystonic
‘something wrong’
-normal personality
with flexible, adaptive,
varied pattern of
responses &
relationships
Personality disorder:
-ego-syntonic
’nothing wrong with
me’ (change the
others)
-fixed, narrow range
of
-maladaptive
responses and
relationships.
Neurosis
Personality
disorder
N
Neurosis
therapist
Personality
disorder
prescriber
4
4/28/2015




Ego-syntonic (they do not want treatment)
Narrow (same response to all situations)
Fixed (think of changing a habit you have)
Maladaptive (sometimes troubled;
often troubling)
Schizotypal
Schizoid
Paranoid
Borderline
Antisocial
Histrionic
Narcissistic
O-C
Dependent
Avoidant


Psycho
+
++
+
++
++
++
++
Socio
+/+
++
+
+
+
Skodol et
Pharmaco
+
+/+
+/al 2014
Most psychotherapy studies are short term
Dynamic and CBT are effective
(Leichsenring & Leibing, 2004)
Specific therapies for BPD eg
-Dynamic Deconstructive Psychoth (Gregory ’10)
-Mentalization-based Th (Bateman & Fonagy 99)
-Schema-focused Therapy (Giesen-Bloo et al 2006)
- Dialectic Behavior Therapy (DBT; Linehan 2006)
***If trained, skilled in formal EB brief therapy,
excellent. If not (for most of us), try POEM…

5
4/28/2015




What makes brief therapy brief?
long term vs brief dynamic therapy
What makes Personality Disorders difficult to
treat?
Generic, ‘plain ol’ English’ model. (POEM) of
brief therapy for PD (including med mngmt)
Application to Borderline PD
(doing the impossible quickly!)
Patient selection
quick, correct, narrow focus (1 or 2)
 Rxic alliance- warmth, accurate empathy
- quick, firm, so watch for stress/rupture
 Contract: # of sessions or Time?
 “psychoeducation”

-
*If MD, pressure from pt to add medication.
**Psychological meaning … (Dewan 1992)
6
4/28/2015
I: Comprehensive evaluation 2-3 sessions
II: Pattern recognition
2-5 sessions
 III: Making it ego-dystonic,
noting -ve consequences 3-5 sessions
 IV: Historical normalization
2-3 sessions
 V: Options and practice
5-10 sessions
 VI: Termination
3-5 sessions
Total
17-31 sessions
*Reminder for me: Keep It Simple (KIS)



-
Standard history, with particular attention to:
Repetitive ways of behaving, thinking
Hurtful consequences to patient, others
Examples of when this does not happen eg.,
with feared boss
When did it start; detailed circumstances
7
4/28/2015
Best if you think, speak in plain English
(rather than defenses, schemas, etc)
 Pick one (two at most) repetitive, maladaptive
behavior
 Almost always, there will be examples of the
same behavior with a variety of people.
 Use simple phrase (preferably theirs) to
underscore this behavior pattern.
Understanding PD
Neurosis:
-ego-dystonic
‘something wrong’
-normal personality
with flexible, adaptive,
varied pattern of
responses &
relationships
Personality disorder:
-ego-syntonic
’nothing wrong with
me’ (change the
others)
-fixed, narrow range
of
-maladaptive
responses and
relationships.
N
Neurosis
therapist
Personality
disorder
prescriber
Pattern  -ve consequences- hurt
Pattern -ve consequences- unhappy
 Pattern -ve consequences- paid a high
price
--Diff people same response & -ve result
 For how long?
 Look for exception to pattern +ve result.
Worth trying something different?


8
4/28/2015









May have been best (even wise) of the few
bad choices when young
Now, more choices; feared people not as
powerful and patient is stronger (clearly in at
least some relationships)
Fixed to flexible response
One primary response to many options
Mal- to adaptive: Consider both extremes,
choose middle with predictable consequences
Hint: what would Mary do?
Try several different ‘styles’ of behavior
Practice in sessions; then try with least
threatening person/situation
Reminder: may not work the first time!
9
4/28/2015














Do nothing
Do it- but poorly [passive aggressive]
Do it, then be overtly angry at unconnected
others [displacement]
Plead illness [somatization]
Politely refuse this time
Later, discuss this matter calmly
Scream at boss/ quit job [acting out]
Kill him for constantly taking advantage
What would Mary do?
Fixed to flexible, many options
Mal- to adaptive: Consider both extremes
and middle with predictable consequences
Hint: what would Mary do?
Try several different ‘styles’ of behavior
Practice in sessions; then try with least
threatening person/situation
Reminder: may not work the first time!
10
4/28/2015









Consolidation: applaud courage to change,
gains are yours to keep, can apply newly
learnt strategy to other situations
If distressed/regressed after termination,
note ‘old’ pattern,
consider ‘new’ options,
think it through, then act
Termination: final? Or primary care model? Or
graduation…
What makes brief therapy brief?
long term vs brief dynamic therapy
What makes Personality Disorders difficult to
treat?
Generic model of brief therapy for PD
Application to Borderline PD
(doing the impossible quickly!)
Reminder to myself: KIS* x 2!
Therapy based on understanding, not s/s
(meds are based on s/s)
* Keep It Simple
11
4/28/2015



Stable instability
Border between oral phase (needy, dependent
with micropsychotic) and anal phase (control)
Object relations: all good OR all bad Self and
Other
ORAL
-narcissism/fragments
-dependent/helpless

micro- psychotic
desperate, needy
----------B O R D E R L I N E--------ANAL
-control/aggression

controlling, hostile
(Therefore, “stable instability”)

Phallic: histrionic/narcissistic= high level BPD
Borderline object
relations:
-ALL good or bad
-over- or de-value
-’All good’ SELF +
‘All good’ other
euphoria
-’All bad’ SELF + ‘All
bad’ other
hopeless, desperate,
suicidal
Mature obj relations:
Both good and bad
in self and other
Self
Other
Good
Good
Bad
Bad
Good+Bad
Good+Bad
Understanding BPD
12
4/28/2015
Pattern:
Beware therapist response
-Micropsychotic
-needy, dependent
Need to rescue
-controlling; hostile
Harsh, rejecting

-ALL good 
or ALL bad [extremes]
Seduced
Hateful (Groves ’78)
1. Don’t take it personally: provide stable, nonreactive, mature relationship with corrective
emotional experiences.
2. Challenge ALL GOOD OR ALL BAD:
-consistently integrate G AND B for pt and self
3. Dampen quick, impulsive, extreme responses
-by modeling
-by asking pt to consider moderate options.
Meds often ineffective in PD, therapy needed
Brief, focused therapy proven effective
 If trained in proven therapies, it is preferred
 If not, consider KIS and POEM based therapy
1. Point out one ‘old’ fixed pattern
2. Note –ve consequences, make it dystonic
3. Range of common options, try the middle
4. Practice & Termination are imp in brief work

Can improve psychopharm adherence

Brief therapy is gratifying for Dr and patient


13
4/28/2015








Dewan MJ: Adding medication to ongoing psychotherapy: Indications and
pitfalls. Am J Psychotherapy 1992; 46:102-110.
Dewan M, Pies R. The difficult to treat psychiatric patient. Am Psychiatric
Publishing, 2001
Dewan M, Weerasekera P, Stormon L: Techniques of Brief Psychotherapy. In
Gabbard G (Ed)Textbook of Psychotherapeutic Treatments in Psychiatry, Am
Psychiatric Publishing, 2009
Dewan M, Steenbarger B, Greenberg R. The Art and Science of Brief
Psychotherapies. Am Psychiatric Publishing, 2014.
Gabbard G. Long term psychodynamic therapy: a basic text. Am Psychiatric
Publishing, Inc 2010.
Leichsenring F, Leibing E. The effectiveness of psychodynamic therapy and
CBT in the treatment of personality disorders. Am J Psychiat 2003;160:1223.
Skodol A, et al. Personality disorders. In Hales et al (Eds) Am Psych Publishing
Textbook of Psychiatry, 6th ed. 2014, p851.
Steenbarger B, Greenberg R, Dewan M: Doing therapy, briefly: Overview and
synthesis. In The Art & Science of Brief Psychotherapies. APPI, 2014
14
4/28/2015






Bateman A, Fonagy P: Effectiveness of partial hospitalization in the treatment
of PPD: a randomized controlled trial. Am j Psychiatry 1999; 156: 1563-69.
Clarkin J, Yeomans F, Kernberg O. Psychotherapy for BPD. Wiley, 1999. 63:
649-658.
Giesen-Bloo J,et al. Outpatient psychotherapy for BPD: randomized trial of
schema-focused therapy vs transference focused therapy. Arch Gen
Psychiatry 2006;
Gregory RJ, DeLucia-Deranja E, Mogle JA. Dynamic deconstructive
psychotherapy versus optimized community care for borderline personality
disorder co-occurring with alcohol use disorders: a 30-month follow-up.
J Nerv Ment Dis. 2010;198:292-98
Groves J. Taking care of the hateful patient. NEJM 1978; 298:883-887
Linehan M, et al. Two year randomized controlled trial and follow up of
dialectical behavior therapy vs therapy by experts for suicidal behaviors and
BPD. Arch Gen Psychiatry 2006; 63: 757-766.
Thank you.
I’d be happy to hear your thoughts and
take brief questions
for focused discussion…!
15