Iconic Therapy for the treatment of borderline personality disorder

Borderline personality disorder (BPD) consists of a pattern of instability in interpersonal relationships, self-image, and emotions. This is accompanied by marked impulsivity.

There are various therapies for the treatment of BPD, although we do not yet have any whose effectiveness is well established. Most therapies are experimental or probably effective. Currently, the iconic therapy is being studied to establish its level of effectiveness.

It is an integrative therapy that brings together different therapeutic principles. Soledad Santiago, director of the San Juan de Dios Assistance Center, is the creator of the iconic therapy. Since 2004, it has been studying its effectiveness for the treatment of emotional instability and BPD.

After several years applying it in hospital admission, An iconic therapy program has recently been started in outpatient clinics. Read on to learn more about this promising therapy.

How does BPD manifest and who does it affect?

As stated in the DSM-5, BPD consists of a pattern of instability in interpersonal relationships, self-image, and emotions.. This is usually accompanied by intense impulsivity. It usually begins at the beginning of adulthood and is manifested by at least five of the following characteristics:

efforts for avoid abandonmentwhether real or imagined.Pattern unstable or intense interpersonal relationshipscharacterized by an alternation between the poles of idealization and devaluation.Identity alteration: intense and persistent instability of self-image and sense of self.Impulsiveness in two or more potentially self-harming areas.Recurrent behavior, activity, or threats of suicide or self-harming behaviors.emotional instability due to a notable reactivity of mood.Chronic feeling of emptiness.Inappropriate and intense anger or difficulty controlling anger.Transient paranoid ideation related to stress or severe dissociative symptoms.

Studies estimate that the prevalence may be 2% in the general population, up to 40% in the psychiatric population, and between 30 and 60% in clinical populations diagnosed with personality disorders.

Among the most used treatments, we find Marsha Linehan’s dialectical behavioral therapy. Its use is widespread due to its effectiveness in reducing suicidal behavior and ideation, reducing days spent in hospital and reducing visits to the emergency room. In addition, it is also effective in improving emotional instability, like Iconic Therapy.

What is iconic therapy?

As mentioned previously, iconic therapy It is an integrative treatment modality. It starts from a cognitive-behavioral orientation, but is completed with principles from other orientations.

The name of the therapy is due to the fact that it uses images (icons). These icons are used to symbolically represent both the principles of therapy and the coping strategies taught. This makes it easier to understand and apply in times of stress.

It is available 32 icons representing important aspects of therapy. We find, among others, some such as perception, self-realization, self-esteem, attribution, validation, feeling of emptiness, life goal and interpersonal relationships.

The objective is reduce vulnerability, in addition to facilitating insight o awareness and increasing frustration tolerance. These icons are also useful for understanding the origin and feedback mechanisms of emotional instability.

Therapy structure

The educational block of this therapy explains what the most frequent maladaptive behaviors are. in unstable people and the possible causes of them, as well as their consequences. Among them we find:

Primary maladaptive behaviors: self-aggressive, heteroaggressive or escape behaviors that arise as an immediate response to frustration or non-achievement of a vital goal. These maladaptive behaviors are the origin of new problems that, in turn, cause frustration.Secondary or compensatory behaviors: idealization and/or manipulation behaviors that, in the short term, reduce frustration, but in the long term they cause it again.

As can be seen, it is also an important objective for the patient to understand that these behaviors contribute to the creation of a vicious circle around frustration.

The therapeutic block constitutes the bulk of the therapy and it is where the therapeutic principles of the different currents and their corresponding strategies are collected. These are ordered sequentially to facilitate their learning and application:

At first you can use the “key phrase”an effective self-instruction that can be used in the first moments after exposure to a situation that generates discomfort. If the key phrase is not enough and greater control is required, you can resort to “emotional cooling” in order to control impulses. To do this, techniques such as “giving yourself time” can be used, which allows you to postpone making decisions to carry them out at another time in a less hasty manner. Making an unconsidered decision can cause new problems that, once again, end in frustration. Once you are prepared to face the solution, One technique or another will be used depending on the patient’s specific problem.

In what format is iconic therapy applied?

This therapy is designed to be applied in group format, individual format and family format, for 12 weeks approximately. Sessions are led by a therapist and a co-therapist and last approximately 90 minutes.

The group format is similar to a theoretical-practical course in which patients learn to become aware of their behavior and learn to develop coping strategies. The therapist presents different concepts represented in icons and helps patients relate them to situations in which they could be useful.

In the individual format, the aim is to help the patient apply the knowledge learned to real life.. The patient explains his personal problem to the therapist and the therapist, if the patient is not able to identify any icon that could be useful, will help him evoke and adapt an icon to his specific situation.

It is important to validate and acknowledge the patient and show them that they are understood, as well as help them increase their perception of self-efficacy. We must focus attention on the patient and we must avoid the dependent, demanding relationship and prevent attempts at manipulation by the patient.

The objective of the family format is for family members to understand the problem and accept it. They must have a collaborative attitude and must know the guidelines for establishing limits and looking for solutions to improve the family environment as much as possible.

For the study of this therapy, a 12-week program was applied, with a frequency of one group session and one individual session per week, and one family session every fifteen days or a month. After the first 12 weeks, the sessions are spaced out and there is a group session and an individual session every 3 months, until reaching 12 months of treatment.

Future perspectives

This therapy has been applied for 15 years. The first pilot study took place with 12 patients with a diagnosis of BPD admitted to the San Juan de Dios Care Center. The results reflected a significant improvement in the level of maladaptive behaviors and greater global adaptation up to two years later. (Santiago, Castro, Cañamero, Godoy, Valverde & Marcos, 2005).

Currently, a first clinical trial is underway that compares the experimental group (to which Iconic Therapy is applied) with a control group. It has taken place with young people between 15 and 25 years old with a diagnosis of BPD and suicidal tendencies. Its protocol can be consulted in the journal BMC of Psychiatry and the results are pending publication.

It is expected that patients who undergo Iconic Therapy will show a greater reduction in symptoms, this improvement being verifiable at 12 months of follow-up. Additionally, a reduction in suicidal ideation, suicidal behavior, maladjustment in daily life, and use of services is expected as a consequence of BPD symptoms.

There were already useful therapies for the treatment of borderline personality disorder, however, its greatest limitation is its long duration and complexity. Thanks to its brief and intensive nature, iconic therapy could become a very valuable alternative for BPDin case the proposed hypotheses are met.

We should be attentive to the publication of the research results, since a favorable result may shed some light on the difficult treatment of people with BPD.

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