An editorial in the January 2006 issue of the British Journal of
Psychiatry concludes that mental health professionals should be
optimistic about improvements in the treatment of borderline
personality disorder (BPD).
People with BPD tend to have unstable and intense relationships,
and to exploit and manipulate others. They may find it difficult or
impossible to recognise the effects their behaviour has on other
people, to 'put themselves in other people's shoes' and to
empathise with others (known as reduced 'mentalisation';).
They may have rapidly changing moods, and make recurrent
attempts to self-harm, or to commit suicide. Subjectively, they
have a pervasive inner feeling of emptiness and boredom.
In the past, psychiatrists tended to believe that personality
disorders were intractable, and could not be effectively treated.
Recently, howevre, there have been advances in understanding of the
condition, and the development of psychosocial interventions, such
as psychodynamic psychotherapy and dialectical behaviour therapy,
which have been shown to be effective in BPD.
A review of recent research shows that the majority of patients
with BPD experience a substantial reduction in their symptoms far
earlier than previously assumed. After six years, 75% of patients
with BPD severe enough to require hospitalisation, recover.
Recurrences are rare, perhaps only 10% over six years, far fewer
than with other more common mental disorders, such as
depression.
Could the apparent improvement in the course of BPD be accounted
for by harmful treatments being less frequently offered? The
authors of the editorial comment that there may be particular
disorders, including BPD, where psychotherapy represents a
significant risk to the patient.
Traditional psychotherapeutic approaches depend for their
effectiveness on the capacity of the individual to integrate their
experience of their own mental state with the alternative
perspective presented by the therapist. Mentalisation (the capacity
to understand behaviour in terms of the associated mental states in
self and others) is essential for the achievement of this
integration.
However, people with reduced capacity for mentalisation, such as
those with BPD, are unlikely to benefit from traditional
psychological therapies. The difference between the patient's inner
experience and the perspective given by the therapist, in the
context of feelings of attachment to the therapist, leads to
bewilderment and instability in the patient.
Unsurprisingly, this leads to more, rather than less, mental and
behavioural disturbance. The problem is compounded by the fact that
attachment and mentalisation are loosely linked psychological
systems. Recent intriguing neuroscientific findings have
highlighted how activation of the attachment system tends
temporarily to inhibit the normal adult's capacity to
mentalise.
It has been proposed that people with BPD have hyperactive
attachment systems as a result of their history and/or biological
predisposition, which may account for their reduced capacity to
mentalise. They would be particularly vulnerable to side-effects of
psychotherapeutic treatments that activate the attachment
system.
Yet without activation of the attachment system, these patients
will never develop a capacity to function psychologically in the
context of interpersonal relationships, which is at the core of
their problems.
More effective treatment lies in balancing these two components
of therapy without inducing side-effects, such as arousal and
disturbance in the patient. This will require more specific
treatment protocols, and better focused training, if psychotherapy
for borderline personality disorder is to be provided free from
harm.
For further information, please contact Liz Fox or Deborah
Hart in the Communications Department.
Telephone: 020 7235 2351 Extensions. 6298 or 6127
References:
Reference:
Fonagy P. and Bateman A (2006), Progress in the treatment of borderline personality disorder.
British Journal of Psychiatry, 188, 1-3.