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Psychoanalytic Treatment of Borderline Personality Disorder: Page 2 of 3

Psychoanalytic Treatment of Borderline Personality Disorder: Page 2 of 3

RCT of Psychoanalytically Oriented Treatment

With all this in mind, we set about developing a randomized controlled trial (RCT) of a psychoanalytically oriented treatment of BPD (Bateman and Fonagy, 1999). The severity of the patients' symptoms, many of whom had received compulsory treatment in secure settings and most of whom had made serious attempts on their life in the six months prior, meant that treatment in a partial-hospitalization program was necessary. Forty-four patients were randomized either to a psychoanalytically informed partial-hospitalization program or routine general psychiatric care. Treatment included individual and group psychoanalytic psychotherapy for a maximum of 18 months. Outcome measures included frequency of suicide attempts and acts of self-harm, number and duration of inpatient admissions, use of psychotropic medication, and self-report measures of depression, anxiety, general symptom distress, interpersonal function and social adjustment. Patients in the partial-hospitalization program showed a statistically significant decrease on all measures in contrast to the control group, which showed limited change or deterioration over the same period. Improvement in depressive symptoms, decrease in suicidal and self-mutilatory acts, reduced inpatient days, and better social and interpersonal function began after six months and continued to the end of treatment at 18 months. The dropout rate was low at 12%.

Long-term follow-up was built into the study, and patients who participated in the original study were assessed every three months after completion of the treatment phase (Bateman and Fonagy, 2001). Patients who completed the partial-hospitalization program not only maintained their substantial gains but also showed a statistically significant continued improvement on most measures in contrast to patients treated with standard psychiatric care, who showed only limited change during the same period. Their continued improvement in social and interpersonal functioning suggests that longer-term changes were stimulated. The control group used more of all types of health and social care monitored in the study including attendance at emergency rooms, particularly following impulsive acts of self-harm. The maintenance of a reduction in episodes of self-harm and suicide attempts (Figures 1 and 2) and low rates of hospital admission in the patients with BPD who completed a psychoanalytically oriented partial-hospitalization program (compared with those patients who received standard psychiatric care) reduced to a minimal level the need for costly emergency treatment and expensive inpatient care. This suggests considerable cost savings following treatment.

Effective Components of Psychoanalytic Treatment

The program offered in this study was complex and no process measures were used, making it difficult to identify the effective components of the treatment. But similar criticisms apply to all other treatments of BPD, including DBT. The treatment was organized around BPD as a disorder of attachment and mentalizing capacity--a difficulty in thinking about others as having an inner world with feelings and conceptions different from one's own--and targeted four main areas: identification and appropriate expression of affect, development of stable internal representations, formation of a coherent sense of self, and capacity to form secure relationships. Interventions were structured according to a hierarchy. The first aim was to help the patient to improve affect control, followed by targeting internal representations through a focus on mentalizing capacity. Finally the sense of self and the detail of the dynamics of the relationship were investigated through transference exploration in the individual and group sessions.

This program and other treatments shown to be moderately effective, including DBT, have the following common features: 1) are well-structured; 2) devote considerable effort to enhancing compliance; 3) have a clear focus, whether that focus, is a problem behavior or an aspect of interpersonal relationship patterns; 4) are highly coherent to both therapist and patient, sometimes deliberately omitting information incompatible with the theory; 5) are relatively long term; 6) encourage a powerful attachment relationship between therapist and patient, enabling the therapist to adopt a relatively active rather than a passive stance; and 7) are well-integrated with other services available to the patient.

One way of interpreting these observations might be that part of the benefit that personality-disordered individuals derive from treatment comes through the experience of being involved in a carefully considered, well-structured and coherent interpersonal endeavor. What may be helpful is the internalization of a thoughtfully developed structure, the understanding of the interrelationship of different reliably identifiable components, the causal interdependence of specific ideas and actions, the constructive interactions of professionals, and, above all, the experience of being the subject of reliable, coherent and rational thinking. Social and personal experiences such as these are not specific to any treatment modality. Rather, they are correlates of the level of seriousness and the degree of commitment with which teams of professionals approach the problem of caring for this group who, it may be argued on empirical grounds, has been deprived of exactly such consideration and commitment during their early development and, quite frequently, throughout their later life (see review by Zanarini and Frankenburg, 1997). While this suggestion is speculative, it may also be helpful in distinguishing successful from unsuccessful interventions and pointing the way to more effective services.

Conclusions and Future Research Considerations

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