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Practitioners Corner
Intermittent-Continuous Eclectic
Therapy: A Group Approach for
Borderline Personality Disorder

ANTONIO MENCHACA, MD
ORIETTA PREZ, MA
ASTRID PERALTA, OT

Psychotherapies recommended for borderline personality disorder (BPD) can be difficult to implement in public hospitals. For example, in Chile, patients with BPD generally receive only pharmacotherapy, which is far
from sufficient. This report describes a group psychotherapy approach called Intermittent-Continuous
Eclectic Therapy (ICE) developed to treat patients with BPD. Results are presented from a small pilot study in
which 15 outpatients with BPD between 15 and 40 years of age treated with ICE were followed for 1 year. In
this small group of patients, improvements were seen in self-aggression and general symptoms. These preliminary findings suggests that ICE may be a useful option for treating BPD in real-world clinical settings and
that more research in this area is warranted. A case report illustrating the implementation of ICE is also presented. (Journal of Psychiatric Practice 2007;13:XXXXXX)

KEY WORDS: borderline personality disorder, psychotherapy, pharmacotherapy, intermittent-continuous eclectic

therapy (ICE)

In 2001, the American Psychiatric Association (APA)

published its Practice Guideline for the Treatment of
Patients with Borderline Personality Disorder (BPD).1
The APA guideline recommended psychotherapy as the
primary, or core, evidence-based treatment for BPD, a
recommendation reiterated in a subsequent Guideline
Watch.2 Although no specific type of psychotherapy was
endorsed, randomized controlled trials of dialectical
behavior therapy3 and psychodynamic psychotherapy 4
for BPD were presented. The guideline has been influential and helpful, but not without controversy. Some
authors suggested that the evidence was not substantial
enough to justify the guideline recommendations.5,6
Even for patients who might benefit from psychodynamic or cognitive-behavioral psychotherapy, these
treatment options are often unavailable, especially in
developing countries where psychotherapeutic options
are limited. Under these circumstances, patients with
BPD often receive only pharmacotherapy.
BPD is a severe, handicapping, and potentially fatal
condition, but its long-term prognosis is relatively
good. Data from long-term follow-up of patients with
BPD shed light on how a more flexible, pragmatic, and
less expensive treatment approach can be implemented. A 15-year follow-up report showed that, at followup, most of the patients with BPD were autonomous
and had jobs and that some were with partners and
even had children, outcomes very different from those
seen in patients who suffered from schizophrenia.7 The
Journal of Psychiatric Practice Vol. 13, No. 4

interpersonal relationships of these patients showed a

bimodal outcome: some of the patients had achieved a
good level of functioning and had established and were
maintaining stable significant relationships, while others had avoided deep social relationships in order to
maintain their psychological equilibrium. Although
patients showed evidence of persistent psychopathology, they had generally developed strategies to prevent
their symptoms from hindering their ability to function, although this was less successful in the social
area. The nature of the patients symptoms was concordant with their diagnosis, with depressive symptoms and substance abuse both common. Three
variablesintelligence, affective instability, and length
of previous hospitalizationsconsistently emerged as
indicators of long-term outcome. Other valuable predictors of outcome were work functioning, social functioning, intimate relations, symptomatology, and global
functioning.8 Recent follow-up studies have shown that
more severe symptomatology tends to decrease over a
10-year period 9,10 Based on these findings, it is clear
MENCHACA: Universidad del Desarrollo, Santiago, Chile;
PREZ and PERALTA: Instituto Psiquitrico Jos Horwitz
Barak, Santiago, Chile.
Copyright 2007 Lippincott Williams & Wilkins Inc.
Please send correspondence and reprint requests to: Antonio
Menchaca, MD, El Trovador 4280, Of. 316, Las Condes, Santiago, Chile.
amenchac@vtr.net
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PRACTITIONERS CORNER
that the following factors are important in treating
BPD:
1. An attitude of optimism and patience;
2. A commitment to providing protection, encouraging
work, and discouraging intense interpersonal
involvement,
3. The pragmatic application of an eclectic range of
interventions.7
Based on these considerations, we developed a treatment approach called Intermittent-Continuous Eclectic
Therapy (ICE). This approach involves eclectic group
therapy that is available continuously but used only
intermittently.11

DESCRIPTION OF ICE
In ICE treatment, patients with BPD are referred for
group meetings that are held once a week. Patients
can attend these meetings any time they deem it necessary, as long as they adhere to certain rules, such as
committing to stay for 10 sessions each time they come
back to the group. When patients finish a cycle of 10 sessions, they are invited to stay for 10 more sessions or to
leave and come back when they feel the need. Of course
the therapist can recommend that the patient stay or
take a vacation from group attendance, but the final
decision belongs to the patient. Most patients also need
pharmacotherapy, which can be provided by the group
therapist or by a psychiatrist in close contact with the
therapist.12 Although a variety of psychotherapeutic
techniques are used in a pragmatic way, a psychodynamic viewpoint focused on understanding the patients
mental functioning guides treatment.13
Sessions last for an hour and a half, broken up by a
10-minute break. The first half of the session, 55 minutes in length, is an open session in which patients can
talk about anything they want without much structure.
Techniques used are empathic listening, abreaction,
advice, clarification, confrontation, support, and encouraging use of rational mechanisms. Group dynamics are
not commented on, unless they interfere with the work.
Positive transference is encouraged and used; negative
transference is handled through rational explanations
linked to a common view of reality.14 Interpretation is
discouraged due to unforeseen consequences that are
impossible, in many cases, to handle in a group of
patients with personality disorders.
The second part of the session, which lasts 25 minutes, is structured like a class, in which techniques and
skills for handling aggression, anxiety, and interpersonal relations are taught. The structure of the second part
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helps to diminish the regressive effects that the first

part of the session may have elicited; it reduces the
intensity of the negative affects in the group, and it
allows the therapist to handle any other difficulty that
could threaten the patients or their treatment.
The two key concepts involved in ICE are described in
the following sections.
Intermittent-Continuous Format
It is explicitly stated that treatment can be interrupted
and then resumed by a patient when he or she deems it
necessary, following minimum conditions of participation and payment each time the patient re-enters therapy. Antisocial tendencies and secondary gain should be
evaluated to be sure these are not the only reasons that
are causing the patient to stay in the group. This
approach helps these patients deal with intimacy, which
is a central problematic issue for them,15 allowing them
to regulate it to a level at which they are comfortable
without destroying the therapeutic relationship. This
concept may be applied in both individual and group
therapy, but the group format provides a better setting
for achieving continuity along with intermittence,
because patients feel that they belong to the group even
if they do not attend sessions.16
Support Provided Through Eclectic and
Pragmatic Interventions
A variety of techniques, extracted from different theoretical frameworks that have shown some benefit for
patients with BPD, are applied. These include supportive psychodynamic techniques,14 cognitive-behavioral
techniques, in particular a dialectical behavioral
approach,17 and psychoeducation. Each sessions internal structure is designed to provide support as
described above.

PILOT DATA ON ICE

We hypothesized that patients with BPD who were
treated in an ICE group would show better adherence to
treatment and achieve better outcomes than patients
who received treatment as usual. We undertook a pilot
study in the outpatient department at the Instituto
Psiquitrico Jos Horwitz Barak (IP), which is state
owned and is the largest psychiatric institution in Chile.
The outpatient department serves roughly 2,000,000
individuals in the northern area of Santiago.
Inhabitants of this area include individuals who are
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lower middle class, poor, and indigent. Most patients
who come to the IP do not have any other treatment
options, and IP cannot refuse to treat them.
The investigator requested that psychiatrists in the
outpatient department refer patients for this treatment
protocol. An initial interview with two of the principal
investigators was performed to explain the purpose and
aims of the study to the patient. A second interview was
scheduled within a week for patients who accepted.
Patients were eligible for the study if they were between
15 and 40 years of age and met at least five DSM-III-R
criteria for BPD as assessed by the International
Personality Disorder Examination, Spanish Version
(IPDE).18 Patients were excluded from the study if they
had a chronic psychotic, organic, or bipolar disorder.
They were also excluded if they had an active major
depressive episode, or if they refused to participate.
Exclusion criteria were assessed by a psychiatric interview performed by the principal investigator. Patients
were consecutively evaluated for entry into the study
until the quota was filled.
Patients were assigned to the ICE group, with the
number of patients determined by the investigators
capacity to treat patients in one ICE group and by the
raters capacity to follow-up and assess the patients
afterwards. Patients were assessed for self-aggression,
general symptomatology, depressive symptoms, anxiety
symptoms, anger expression, and general social functioning using the following measurement tools:
Parasuicidal History Interview (PHI),3 the Symptom
Checklist-90-Revised (SCL-90-R),19 Hamilton Rating
Scale for Depression (Ham-D),20 the Hamilton Anxiety
Rating Scale (HARS),21 the State-Trait Anger
Expression Inventory (STAXI),22 and the Grningen
Social Disability Scale (GSDS).23 A single assessor who
was trained by the principal investigator performed all
the interviews at baseline and then at the 6-month and
1-year follow-up visits. She was not a therapist and was
not blind to the treatment assignment.
Twenty patients (16 women and 4 men) were assigned
to receive ICE therapy; their average age was 26.7 6.0
years. At 6-month follow-up, 13 patients (11 women and
2 men) were available for interview, while 12 patients
(11 women and 1 man) were available for interview at
the 1-year follow-up. Three patients who were followed
up at 6 months were not interviewed at 1 year, while 3
patients who were not interviewed at 6 months were
interviewed at 1 year. Thus, data for 15 patients treated
with ICE were available (data were carried forward
from the 6-month evaluation for the 3 patients not
interviewed at 1-year follow-up).
Journal of Psychiatric Practice Vol. 13, No. 4

In the 15 patients who received ICE and were followed up, scores on the SCL-90-R decreased by 40.3
69.0. Of the 14 patients who had self-injurious behavior
at baseline, only 7 had active self-injurious behavior at
follow-up. No significant differences were found on the
other measures we assessed.

CASE VIGNETTE
The following vignette illustrates how ICE therapy can
be adapted to the patients pathology and can allow the
patient to seek help in a crisis.
Ms. A, a 23-year-old female, entered an ICE group after
she attempted suicide for the fifth time due to a quarrel
with her boyfriend. The patient had a history of going
from therapist to therapist. A year before entering the
group, she had been evaluated and the therapist had
recommended weekly psychotherapy plus pharmacotherapy. However, after 3 months, Ms. A had dropped
out of treatment without giving a reason. Later, she
said that she had left because she had felt well and
because she thought her therapist was not taking her
difficulties seriously. After a period of time, Ms. A again
began to feel very depressed and started thinking of suicide. She wanted to call her therapist but was afraid to
do so because she had dropped out of treatment without
notice. Her situation became unbearable and she took
an overdose.
After this suicide attempt, Ms. A attended an ICE
group regularly for 3 months until she let the therapist
know through another patient that she had found a job
and could not continue attending therapy sessions. The
therapist called Ms. A to congratulate her on the new
job and told her that she could come back anytime she
felt she needed to in the future. Six months later, Ms. A
approached the therapist in the hallway and asked if
she could come back to the group because she was feeling worse and the therapist agreed. The patient stayed
in the group for another 2 months and did not injure
herself. She then stopped going to group sessions in a
very similar way as before. At follow-up, she reported
feeling relatively well and said that she did not feel the
need for help at that moment, but that she would come
back to the ICE group if she needed help again.

DISCUSSION
Given the very limited number of patients, the high percentage of patients lost to follow-up and the lack of a
control group, and the fact that assessments were perJuly 2007

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formed by an interviewer who was not blinded to the
treatment intervention, it is not possible to draw any
definite conclusions from the pilot data presented here.
Nevertheless, given the promising nature of our preliminary findings, it appears that ICE group treatment
may be an option to consider for patients with BPD
being treated in busy public hospitals or in developing
countries where there are limited resources. Further
research concerning ICE in larger samples and under
controlled conditions is needed.

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