The effectiveness of evidence-based treatments for personality disorders when comparing treatment-as-usual and bona fide treatments☆
Introduction
Personality disorders (PDs) have received substantial attention in psychological treatment literature due to the severity of symptoms, especially when compared to other classes of diagnoses (Crits-Cristoph and Barber, 2002, Soeteman et al., 2010, Soeteman et al., 2011). PDs tend be more stable and enduring than other forms of mental illness detailed in the Diagnostic and Statistical Manual of Mental Disorders and are typified by the pervasive, serious, and rigid self-destructive patterns in affect, cognition, interpersonal relations, and impulse control that impact psychological well-being (APA, 2000). PDs are associated with higher rates of self-injurious behaviors, including suicide (McMain, 2007), as well as functional impairment and extensive treatment usage resulting in higher healthcare costs (Hadjipavlou and Ogrodniczuk, 2010, Soeteman et al., 2011). Diagnostically, PDs are commonly occurring types of psychological disturbance, with prevalence rates ranging between 6 and 13% (Lenzenweger, 2008, Samuels, 2011). Additionally, PDs are highly comorbid with Axis I disorders, particularly anxiety and mood disorders (Ruegg & Frances, 1995). Often the focus of treatment is on Axis I disorders, however the presence of a PD typically attenuates the effectiveness of treatments for the Axis I disorders (Crits-Cristoph & Barber, 2002).
Although historically it was believed that psychotherapy was not effective for persons with PD (e.g., Bateman and Fonagy, 2000, Hadjipavlou and Ogrodniczuk, 2010), there is increasing evidence that psychotherapy is the treatment of choice for treating PDs (Bateman and Fonagy, 2000, Binks et al., 2006a, Gabbard, 2000, Leischsenring and Leibing, 2003, Ogrodniczuk and Piper, 2001, Perry et al., 1999, Perry and Bond, 2000, Sanislow and McGlashan, 1998, Shea, 1993, Verheul and Herbrink, 2007). Psychotherapy has shown more promising results than alternative treatments, such as pharmacological interventions (Binks et al., 2006b, Duggan et al., 2008, Gibbon et al., 2011, Paris, 2011, Stoffers et al., 2010). General aggregate effect sizes on pretreatment to posttreatment outcome measures associated with PDs range from 1.1 to 1.3 (Perry et al., 1999) and .87 to 1.79 specifically for cognitive behavior and psychodynamic therapies, respectively (Leischsenring & Leibing, 2003). Benchmarked effect sizes for depression range from .88 to 1.15 (Minami et al., 2008); when considering that effect sizes above .8 are considered large (Cohen, 1977), and that aggregated effect sizes for PD treatments surpass benchmarking studies for depression, it appears that psychotherapeutic treatments for PDs are effective. While important contributions to the field, current meta-analyses related to PDs are limited by including uncontrolled observational studies. Additionally, meta-analyses of PDs disproportionately focus on borderline personality disorder (BPD); the remaining 9 (DSM-IV-TR) PDs are studied less frequently (Hadjipavlou & Ogrodniczuk, 2010).
Research of psychotherapeutic treatments has evolved over time to delineate: (a) if treatments are effective, (b) which treatments are more effective than others, and (c) the specific ingredients of the treatments that are particularly effective. The evidence-based treatment (EBT) movement—which is now considered the paragon for ascertaining the viability of treatments (Westen, Novotny, & Thompson-Brenner, 2004)—outlines specific criteria psychotherapy trials should meet in order to establish treatment efficacy. In order for a treatment to be considered well established, it must have demonstrated that its benefits exceed those of some alternative treatment or placebo condition (Chambless & Hollon, 1998). Further, these standards also apply to effectiveness studies (e.g., studies that determine the transferability of efficacious treatments to naturalistic settings). More often than not, treatment-as-usual (TAU) is considered the alternative comparison-group-of-choice when determining if an EBT will be effective in the community.
Operationally, TAU is meant to be a psychotherapeutic treatment that is being offered in a naturalistic setting, and most likely includes integrative, non-manualized treatments provided by masters and doctoral level clinicians. For anxiety and depression, evidence based treatments (EBTs) have been found to be superior to TAU only when TAU did not include psychotherapy services (Wampold et al., 2011). One of the primary conclusions from the Wampold et al. study was that TAUs are poorly implemented as a comparison group for depression and anxiety treatments; more often than not TAU was a no-treatment group, but even when it was an actual treatment, TAU was implemented without therapist training, supervision, or support comparable to what was provided in the EBT condition.
Thus far, a multitude of studies examining PDs have utilized TAU as a comparison group—it appears that the same problems detected by Wampold et al. (2011) may be true for PD studies. Bender (2011) indicates, “Most clinicians are not adequately trained to treat BPD. Thus, in many cases, using treatment-as-usual as the comparison group is like a race between someone who carbo-loaded the night before and a person who hasn't eaten in 3 days” (p. 323–324). While psychotherapeutic treatments are considered the treatment of choice for PDs due to their purported effectiveness, it remains unknown whether the development and testing of particular EBTs for PDs has improved the quality of service. That is, does delivery of an EBT result in superior outcomes relative to other treatments or to TAU given by therapists who treat PD? To date, no comprehensive analysis of PD studies using TAU has been conducted to investigate whether TAUs used in the primary studies are adequate or to determine the effectiveness of EBTs relative to TAU.
In response to poorly implemented TAU comparison groups, critics have called for more robust control groups (Wampold et al., 2011). As it is difficult to determine how effective treatments may be when using TAU as a comparison, an alternative method is to compare two bona fide treatments. A bona fide psychotherapy is a psychotherapeutic treatment administered by trained therapists, based on psychological theories, considered to be a viable form of treatment that has been presented to the psychotherapy community (for example, via dedicated treatment manuals or books; Wampold et al., 1997). The Dodo Bird effect, a phenomenon initially coined by Rosenzweig (1936), asserts that all bona fide psychotherapies are equally effective, because there are common factors inherent within most bona fide psychotherapeutic modalities that are essential to producing positive treatment outcomes The Dodo Bird effect has been substantiated across several disorders when direct comparisons are examined (e.g., Baardseth et al., 2013, Benish et al., 2008, Clum et al., 1993, Davidson and Parker, 2001, Imel et al., 2008, Miller et al., 2008, Project MATCH Research Group, 1997, Siedler and Wagner, 2006, Spielmens et al., 2007). Taken together, there is substantial support for the common factors. However, the Dodo Bird effect has not been tested for PD and therefore it is important to note whether the results for other disorders generalize to PD.
There were two purposes of the current research, which contains two studies. The purpose of Study 1 was to examine the relative efficacy of EBTs when compared to TAU for adults diagnosed with a PD. In line with findings from other studies (e.g., Wampold et al., 2011), we hypothesized that TAU would be less effective than EBTs. However, we also hypothesized that there would be confounding variables (e.g., hours of treatment, disorder being treated, and quality of TAU) that would moderate the effectiveness of TAUs. The purpose of Study 2 was to investigate the relative efficacy of bona fide treatments. We hypothesized that the meta-analysis would yield effect sizes that did not vary significantly from zero.
Section snippets
Inclusion criteria
A number of selective processes occurred in order for a study to be included in the final analysis for Study 1. First, the study directly compared an evidenced-based treatment with TAU. Second, participants were diagnosed with at least one personality disorder or met a large portion of the diagnostic criteria for a personality disorder; studies were also included when concomitant disorders were present, though treatment of the personality disorder was required to be the primary purpose. Third,
Inclusion criteria
A number of selective processes occurred in order for a study to be included in the final analysis for Study 2. First, the study directly compared at least two bona fide treatments to one another. Second, participants were diagnosed with at least one personality disorder or met a large portion of the diagnostic criteria for a personality disorder; studies were also included when concomitant disorders were present, though treatment of the personality disorder was required to be the primary
Discussion
The current meta-analysis tested the relative efficacy psychotherapeutic treatments for personality disorders via two avenues: (a) determining the effectiveness of EBTs when compared to TAU, and (b) determining the effectiveness of bona fide treatments when compared to one another. The results provide evidence in both studies that some treatments may be more effective than others, but there were important caveats to this conclusion in both studies. In Study 1, there was significant
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This research was funded by the American Psychological Association Division 29 Charles J. Gelso Psychotherapy Research Grant.
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Marked with an asterisk (*) indicate studies included in the meta-analysis for study 1; those marked with a cross (†) indicate studies included in Study 2.