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Mentalization based treatment of borderline personality disorder
Abstract
Mentalizing is the process by which we make sense of each other and ourselves, implicitly and explicitly, in terms of subjective states and mental processes. It is a profoundly social construct in the sense that we are attentive to the mental states of those we are with, physically or psychologically. Given the generality of this definition, most mental disorders will inevitably involve some difficulties with mentalization, but it is the application of the concept to the treatment of borderline personality disorder (BPD), a common psychiatric condition with important implications for public health, that has received the most attention. Patients with BPD show reduced capacities to mentalize, which leads to problems with emotional regulation and difficulties in managing impulsivity, especially in the context of interpersonal interactions. Mentalization based treatment (MBT) is a time-limited treatment which structures interventions that promote the further development of mentalizing. it has been tested in research trials and found to be an effective treatment for BPD when delivered by mental health professionals given limited additional training and with moderate levels of supervision. This supports the general utility of MBT in the treatment of BPD within generic mental health services.
... Mentalization-based therapy is a manualized and structured psychotherapy approach, rooted in attachment and psychodynamic theory, that was originally developed specifically for patients with BPD (4,5). Mentalization refers to the capacity to reflect upon and understand one's own and other's mental states, i.e., thoughts, feelings, and desires (4). ...
... Mentalization-based therapy is a manualized and structured psychotherapy approach, rooted in attachment and psychodynamic theory, that was originally developed specifically for patients with BPD (4,5). Mentalization refers to the capacity to reflect upon and understand one's own and other's mental states, i.e., thoughts, feelings, and desires (4). According to mentalization theory, patients with BPD are more vulnerable to experience frequent and severe impairments in mentalizing, in particularly when emotionally distressed. ...
... Impaired mentalization is considered the cause of core difficulties associated with BPD, such as interpersonaland self-problems, impulsivity, and self-harm. MBT aims at promoting patients' capacity to mentalize, and to restore it, when lost (4). Importantly, MBT is the only therapy for BPD that has been shown to have long lasting effects on patients after 8-years follow-up (4). ...
Aim: The objective of this study was to explore patient experience with
short-term MBT for BPD in the Danish mental health services.
Methods: Semi-structured qualitative interviews were conducted with 12
outpatients diagnosed with BPD, who attended short-term MBT for 5 months.
The interviews were verbatim transcribed and analyzed using thematic
analysis with double coding.
Results: The analysis resulted in four subordinate themes: (1) Treatment
duration – too short or appropriately short?, (2) The group as a “safe space,” (3)
Bad experiences impacted treatment negatively, and (4) My life has changed
for the better.
Conclusion: The results suggest that most of the patients were overall satisfied
with short-term MBT, which they experienced as having a positive impact
on their lives. However, a subgroup of patients wanted more therapy. This study highlighted the strengths and limitations of short-term MBT for BPD as
experienced by the patients, and points to barriers in developing service-user
informed short-term treatment options for BPD.
... The inventory consists of three different subscales: 1) pre-mentalizing (PM), capturing non-mentalizing ways of reflecting about the child's mental states; 2) certainty about mental states (CMS), reflecting difficulties dealing with the opacity of mental states, in which parents' can be either overly confident about the child's mental states (hypermentalizing) or be unaware of the existence or excessively uncertain about what their child is thinking or feeling (hypomentalizing); and 3) interest and curiosity (IC) in the child's mental states, in which parents can either have a limited genuine interest and curiosity in the child's internal world (hypomentalizing) or be excessively interested and curious about their child's mental states to a point where it can become intrusive to the child (hypermentalizing). These three types of impairments in PRF often tend to co-occur and overlap, and PRF in parents' may be intact on some dimensions, while imbalanced i.e. impaired on other dimensions (Bateman & Fonagy, 2006). Common to all these types of loss of mentalizing, is that they may be experienced as intrusive, distant, uncaring and confusing by the child, and thus result in the child not feeling adequately understood, validated, or recognized as an individual agent with independent mental states . ...
... Impaired mentalizing is thought to constitute a core mechanism in the development and maintenance of PDs. In fact, the concept of mentalization was originally developed as an approach to understand and treat individuals with borderline personality disorder (BPD) (Bateman & Fonagy, 2006). Since then, a body of evidence supporting the notion of impairments in mentalizing in individuals with PDs has emerged (Antonsen et al., 2016;Chiesa & Fonagy, 2014;Fischer-Kern et al., 2010;Fonagy et al., 1996;Johansen et al., 2018;Levy et al., 2006). ...
... The aim of the present study is twofold: the primary aim is to investigate whether a convenience sample of adult outpatients with PD have impaired PRF, as measured with the PRFQ, compared with reported means of HCs from a previous study. In accordance with previous findings and theory (Bateman & Fonagy, 2006;Marcoux et al., 2017;Schacht et al., 2013), we hypothesized that: parents with PD would (1) report higher levels of pre-mentalizing, (2) lower levels of certainty about the mental states of the child, and (3) not differ in terms of their interest and curiosity, compared to HCs. The second aim was to investigate associations between PRF subscales and clinical core features of personality pathology, including symptoms of psychopathology and interpersonal problems in parents with PD. ...
Impaired parental reflective functioning (PRF), i.e. difficulties in understanding one's child in terms of mental states, may constitute a risk for children's development and wellbeing. Impaired PRF has been linked to parental psychopathology, however no study has investigated PRF in adult patients with personality disorders (PDs). We examined PRF in a sample of adult outpatients with diagnosed PDs compared with healthy controls (HCs), and explored associations between PRF and symptoms of psychopathology and interpersonal problems in parents with PD. A convenience sample of treatment-seeking outpatients with PDs (n ¼ 34) were assessed with questionnaires measuring PRF (The Parental Reflective Functioning Questionnaire (PRFQ)), symptoms of psychopathology (Symptom Checklist Revised (SCL-90-R)) and interpersonal problems (Inventory of Interpersonal Problems (IIP)). PRF scores were compared with reported means of HCs (n ¼ 156) pooled from a previous study. Parents with PD reported higher levels of pre-mentalizing and lower levels of certainty about mental states compared with HCs. Both groups reported high levels of interest and curiosity and did not differ significantly in this regard. Exploratory analyses showed that low levels of certainty about mental states was associated with high levels of depressive and psychotic symptoms and submissive types of interpersonal problems (social-avoidance and non-assertiveness). Our findings provide preliminary evidence that patients with PD have impairments in PRF compared with HCs. The findings stress the importance of assessing the multidimensional nature of PRF in parents with PD.
... Mentalization-based therapy is a manualized and structured psychotherapy approach, rooted in attachment and psychodynamic theory, that was originally developed specifically for patients with BPD (4,5). Mentalization refers to the capacity to reflect upon and understand one's own and other's mental states, i.e., thoughts, feelings, and desires (4). ...
... Mentalization-based therapy is a manualized and structured psychotherapy approach, rooted in attachment and psychodynamic theory, that was originally developed specifically for patients with BPD (4,5). Mentalization refers to the capacity to reflect upon and understand one's own and other's mental states, i.e., thoughts, feelings, and desires (4). According to mentalization theory, patients with BPD are more vulnerable to experience frequent and severe impairments in mentalizing, in particularly when emotionally distressed. ...
... Impaired mentalization is considered the cause of core difficulties associated with BPD, such as interpersonaland self-problems, impulsivity, and self-harm. MBT aims at promoting patients' capacity to mentalize, and to restore it, when lost (4). Importantly, MBT is the only therapy for BPD that has been shown to have long lasting effects on patients after 8-years follow-up (4). ...
Background
Mentalization-based therapy (MBT) is an evidence-supported psychotherapy approach for borderline personality disorder (BPD) that has been implemented in mental health services worldwide. Originally, MBT was developed as an 18-months program for BPD. However, a short-term (5 months) MBT program has been developed. Research into patient experiences with long-term MBT for BPD is scarce, and no studies have investigated patient experience with short-term MBT for BPD.
Objective
The objective of this study was to explore patient experience with short-term MBT for BPD in the Danish mental health services.
Methods
Semi-structured qualitative interviews were conducted with 12 outpatients diagnosed with BPD, who attended short-term MBT for 5 months. The interviews were verbatim transcribed and analyzed using thematic analysis with double coding.
Results
The analysis resulted in four subordinate themes: (1) Treatment duration – too short or appropriately short?, (2) The group as a “safe space,” (3) Bad experiences impacted treatment negatively, and (4) My life has changed for the better.
Conclusion
The results suggest that most of the patients were overall satisfied with short-term MBT, which they experienced as having a positive impact on their lives. However, a subgroup of patients wanted more therapy. This study highlighted the strengths and limitations of short-term MBT for BPD as experienced by the patients, and points to barriers in developing service-user informed short-term treatment options for BPD.
... Zudem hat sich die Psychoanalyse selbst weiterentwickelt (Mertens, 2012(Mertens, , 2014: die Bindungstheorie (Bowlby, 1976;Fonagy & Bateman, 2008), die Säuglingsforschung (Stern, 1985), das Intersubjektivitätskonzept (Stolorow et al., 1996) und der Mentalisierungsansatz (Fonagy & Bateman, 2008) sind höchst bedeutsame Meilensteine. ...
... Zudem hat sich die Psychoanalyse selbst weiterentwickelt (Mertens, 2012(Mertens, , 2014: die Bindungstheorie (Bowlby, 1976;Fonagy & Bateman, 2008), die Säuglingsforschung (Stern, 1985), das Intersubjektivitätskonzept (Stolorow et al., 1996) und der Mentalisierungsansatz (Fonagy & Bateman, 2008) sind höchst bedeutsame Meilensteine. ...
Zusammenfassung: In Deutschland wird Psychotherapieausbildung in die Hände von Wissenschaftlern gegeben und die praktische Ausbildung hintangestellt. Dies führt zur Frage, inwiefern und in welchem Ausmaß Psychotherapie Wissenschaft ist. Beginnend mit einer Diskussion von Psychologie als Wissenschaft und ihren Fehlentwicklungen und Stagnationen wird zur Frage übergegangen, ob Psychotherapie Wissenschaft ist, die von den Wissenschaftlern bejaht wird. Die praktizierenden Psychotherapeuten dagegen sagen, dass sie eine Kunst ist, die auf Wissenschaft aufbaut, aber mehr ist als diese. Sie leiten daraus ab, dass diese Kunst nicht von Wissenschaftlern gelehrt werden kann. Aber auch unter den Wissenschaftlern herrscht keine Einigkeit. Die einen forschen unter experimentellen, laborähnlichen Bedingungen, während ihre Ergebnisse von den anderen als ungültig für die reale Welt außerhalb des Labors betrachtet werden. Schließlich wird der Frage nachgegangen, wo und wie die Kunst der Psychotherapie gelernt werden kann. Psychotherapy is more than science or: From science to art Summary: In Germany psychotherapy training has been handed over to scientists and the practical training neglected. This leads to the question to what extent and in what magnitude psychotherapy is a science? Starting with a discussion of psychology as a science, its undesirable development and stagnation then becomes a question of whether psychotherapy is a science that would be accepted by scientists. Practicing psychotherapists counter this and say that it is an art, which is founded on science however, it is more than this. They deduce that this art cannot be taught by scientists. However, there is also no unanimity amongst scientists. The one group conduct research under experimental laboratory conditions , whereas the others see these findings as invalid for the real world outside the laboratory. Finally the question is pursued where and how the art of psychotherapy can be learnt. La psicoterapia è più di una scienza, ovvero: dalla scienza all'arte Riassunto: In Germania l'insegnamento della psicoterapia è affidato agli scienziati, e la formazione pratica è trascurata. Ciò conduce alla domanda fino a che punto e in che misura la psicoterapia sia una scienza. Iniziando con una discussione della psicologia come scienza, dei suoi errori e delle sue stagnazioni, si arriva alla domanda se la psicoterapia sia una scienza, a cui gli scienziati danno risposta affermativa. Gli psicoterapeuti che praticano la professione sostengono invece si tratti di un'arte, che si basa sulla scienza ma è più di essa. La conclusione che ne traggono è che questa scienza non può essere insegnata da scienziati. Ma anche tra gli scienziati non vi è una posizione unitaria: se alcuni fanno ricerche in condizioni sperimentali che riproducono quelle di laboratorio, gli altri non considerano tali risultati validi per il mondo reale al di fuori del laboratorio. Infine si approfondisce la questione di dove e come possa essere appresa l'arte della psicoterapia. Parole de chiave: Psicoterapia, scienza, teoria scientifica, basato sull'evidenza, progettazione di studi controllati randomizzati, ricerca quantitativa, ricerca qualitativa, studio sul campo, ermeneutica, fattori comuni, rapporto terapeutico, insegnamento della psicoterapia, esperienza di sé, supervisione, personalità del terapeuta Einleitung
... The provision of programmes of adequate duration (12 months or more) are likely to produce not only sustained change in symptom, process and adjustment measures but also to result in a reduction in usage of psychiatric and general medical services, coupled with an increase in employment and education (Bateman & Fonagy, 2010;Crawford et al., 2008;Davies & Campling, 2003). At the conclusion of the study, nearly half of the cohort had been discharged from mental health services, representing a significant reduction in service usage. ...
Objectives
The research aimed to evaluate an exploratory Compassion Focused Group Psychotherapy Programme and the impact on participants' experiences of self‐criticism, usage of services and general wellbeing. Participants included patients with a history of complex attachment and relational trauma (A&RT), who might attract a diagnosis of personality disorder.
Design
This study utilised a quasi‐experimental non‐randomised within subject controlled design for the evaluation of the efficacy of the programme.
Methods
Participants were recruited from tertiary care services. The programme consisted of a 12‐week Preparation and Engagement intervention (PEG) which was Compassionate Mind Training and Psychoeducation, followed by a 40‐week Compassion Focused Trauma Group intervention. The cohort was then followed up after 12 months during which period they received treatment as usual. A comprehensive selection of self‐report measures was administered at various points during the therapeutic process and following completion of the group interventions.
Results
The results of the research showed that the provision of a long‐term, slow‐paced, Compassion Focused Group Psychotherapy intervention, resulted in significant changes across all measures which were maintained at 12‐month follow‐up. These significant results were maintained following intention to treat and reliable change analyses. These data were supported by a significant reduction in service usage and a significant increase in engagement in employment and education.
Conclusions
This study has identified that within Compassion Focused Group Psychotherapy, there is a therapeutic process of establishing group‐based safeness as a necessary precursor to cultivating compassion and reworking early shame‐based trauma memories.
... Furthermore, trust impairments in BPD may manifest in adverse countertransference reactions [4], difficulties in developing and maintaining solid therapeutic alliances [12], and "splitting" clinicians into idealized or persecutory camps [13]. Different theoretical and clinical approaches have conceptualized the interpersonal domain as a particular focus of psychotherapeutic intervention [14][15][16]. Premature treatment termination may result from impaired trust appraisal of clinicians. A personality disorder (PD) diagnosis (of which BPD is the most frequent) predicts early drop-out of psychotherapy [17]. ...
Purpose of Review
Unstable relationships are a core feature of borderline personality disorder (BPD). Impairments in trust processes (i.e., appraisal and learning regarding others’ trustworthiness) can subserve interpersonal problems associated with BPD, but the determinants, mechanisms, consequences, and variations in trust impairments among individuals with BPD remain poorly characterized. Thus, a better understanding of such impairments could help target interventions that address the interpersonal problems of individuals with BPD beyond emotion dysregulation, impulsivity, and aggression.
Recent Findings
We conducted a pre-registered systematic review of empirical studies on trust processes and BPD features ( k = 29). Results are organized around a heuristic model of trust processes in BPD comprising the following stages: developmental factors, prior beliefs and dispositions, situation perception, emotional states, trust appraisal, behavioral manifestations, and trust learning.
Summary
Based on the synthesis of the findings, we recommended directions for future research and clinical assessment and intervention, such as managing trust during the early stages of therapy and considering improvements in trust processes as a central mechanism of change in treating individuals with BPD.
... Mentalization-based treatment, which has its roots in attachment theory, assumes that BPD is associated with a hyperactivation or deactivation of the attachment system (or a combination of both), leading to imbalances in the capacity for mentalizing that are often severe (Bateman & Fonagy, 2006. however, to investigate to what extent attachment is a dynamic context-bound adaptive process rather than a static personality feature. ...
Objectives:
Although treatments of patients with borderline personality disorder (BPD) were historically associated with relatively high dropout rates, dropout rates in contemporary evidence-based treatments for BPD are typically substantially lower. However, only a few studies have investigated dropout rates in mentalization-based treatment (MBT), and even fewer have investigated predictors of dropout in this type of treatment. In this study, we investigated dropout rates in two types of MBT (day hospital MBT [MBT-DH] and intensive outpatient MBT [MBT-IOP]) using data from a recent multicenter randomized clinical trial. Given the central importance of attachment considerations in MBT, we also investigated the relationship between dropout in these two treatments and attachment dimensions.
Design:
Within a multicenter randomized clinical trial, 114 BPD patients were randomized to MBT-DH (n = 70) or MBT-IOP (n = 44).
Methods:
Dropout in both types of MBT was investigated using descriptive analyses, and its association with attachment anxiety and attachment avoidance, as measured by the Experiences in Close Relationships questionnaire at baseline, was investigated using regression analyses.
Results:
Dropout rates were relatively low (10.5% across both types of MBT) and did not significantly differ between groups (11.4% in MBT-DH, 9.1% in MBT-IOP). Attachment avoidance and attachment anxiety did not impact dropout, nor did their interaction or the interaction with the type of MBT.
Conclusions:
Low dropout rates in both types of MBT indicate a high level of engagement of patients in both programmes. Attachment dimensions were not associated with dropout, consistent with the principle that MBT is tailored to each individual's needs. More research is needed, however, to investigate to what extent attachment is a dynamic context-bound adaptive process rather than a static personality feature.
... In addition to skills in critical evaluation of studies, future psychodynamic practitioners should have sound knowledge of this body of research, including its current limitations. Further, specific STPP and LTPP models that have been subjected to controlled research, such as for example Supportive-Expressive Therapy (SET; Luborsky, 1984), Intensive Short-Term Dynamic Psychotherapy (ISTDP; Abbass, 2015), Panic-Focused Psychodynamic Psychotherapy (PFPP; Milrod et al., 1997); Dynamic-Interpersonal Therapy (DIT; Lemma et al., 2011), Transference-Focused Psychotherapy (TFP; Clarkin & Kernberg, 2015) and Mentalization-Based Treatment (MBT; Bateman & Fonagy, 2006), should be introduced and integrated with teaching in general psychodynamic concepts and treatment principles. This puts pressure on psychodynamic teachers and supervisors who, in addition to having deep knowledge in the rich theoretical and clinical literature, needs to keep updated with the growing body of research in PDTs; still, if the aim of the community is to truly become 'evidence-based', this is the way forward. ...
... Empirically supported treatments are often mistakenly thought to be synonymous with cognitive behavioral therapy (CBT) interventions (Becker-Haimes et al., 2019;Dozois et al., 2014;Luebbe et al., 2007;Shedler, 2018). However, the list of ESTs promoted by APA's Division 12, also includes several psychodynamic treatments (PDTs), such as Short-Term Psychodynamic Therapy for Depression (Luborsky et al., 1995), Panic-Focused Psychodynamic Psychotherapy for Panic Disorder (Milrod et al., 1997), Mentalization-Based Treatment (Bateman, 2006), and Transference-Focused Psychotherapy (Clarkin & Kernberg, 2015) for Borderline Personality Disorder. Among youth, Mentalization-Based Treatment for Adolescents (MBT-A; Rossouw & Fonagy, 2012) for self-injury, Short-Term Psychoanalytical Psychotherapy for adolescent depression (Goodyer et al., 2017), and dyadic psychodynamic interventions for trauma-exposed children, maternal depression, and intimate partner violence have all demonstrated efficacy (Guild et al., 2017;Lieberman et al., 2006). ...
Many clinicians hold misperceptions about evidence-based practice (EBP), and evidence-based psychodynamic therapy (PDT) in particular. It is important to address these beliefs and attitudes in graduate training and help students to consider evidence-based interventions from a range of theoretical orientations. This study reports on a required 15-week course in evidence-based PDT within two graduate psychology doctoral programs. Eighty-five students completed measures of attitudes toward EBP and PDT prior to the first class and after the final class. Students who identified with different theoretical orientations—integrative, CBT, or PDT—did not differ in attitudes toward EBP, and student attitudes toward EBP remained stable. Students with a precourse CBT orientation viewed PDT less favorably than those with a psychodynamic orientation. Attitudes toward PDT improved significantly across all orientations, but CBT-oriented students reported the largest gains in positive attitudes toward PDT as compared to students with a PDT or integrative orientation. The results support the use of graduate training in evidence-based PDT to improve attitudes toward specific aspects of EBP and PDT. Findings also highlight the mutability of student attitudes and the potential for fostering an integrative approach to EBP that includes PDT. Further research is warranted to examine whether graduate courses in EBP can lead to use of a wider range of therapy interventions with clients.
... posed a question about the mutual relations between defensive activity and metacognition as processes that appear in response to the activation of a specific mental structure. While defense against conflict is indicated in the context of an early childhood attachment relationship as the cause of a weakened reflection on mental states (Bateman & Fonagy, 2006), the issue of defense seems to have been neglected in research into metacognition as an ability that actualizes itself in adult life. We wanted to better explain the differentiation and fluctuations of the level of metacognition in people with borderline personality organization in response to emotional-relational stimuli. ...
Metacognición y actividad defensiva en respuesta a estímulos relacionales-emocionales en la organización límite de la personalidad
El objetivo de este estudio es complementar la descripción del funcionamiento de individuos con organización límite de la personalidad (BPO) en términos de metacognición por adicionalmente describiendo el fenómeno de defensa contra experiencas emocional-relacional, como un posible factor que contribuye a los niveles observados de metacognición. Los participantes se dividieron en grupos limítrofes (N = 69) y no limítrofes (N = 71). Después de un procedimiento destinado a activar el sistema de apego, se les pidió que dijeran una historia relacional, que se usó para codificar una tasa de metacognición (usando la Escala de Evaluación de Metacognición-Revisada, MAS-R) y una actividad defensiva (Sistema de Codificación de Actividad Defensiva, DACS). Ambos grupos registraron bajos niveles de metacognición; principalmente, no se encontraron diferencias significativas, aunque ANCOVA revela que, a la vez que el efecto de defensa se elimina, los individuos BPO presentan un nivel más bajo de metacognición que los del grupo de control. Además, el análisis de la mediación causal confirmó el rollo mediador de la actitud defensiva en la relación entre metacognición y BPO. La actividad defensiva demostró interferir en la evaluación de la metacognición en individuos con BPO.
... The MBT treatment program consisted of introductory groups (10-12 sessions) [3], treatment (maximum of 18 months) and follow-up treatment (maximum of 18 months). Patients completed one of the three MBT conditions: 1) intensive outpatient treatment (n = 5), 2) three day day-treatment (n = 1) and 3) five day day-program (n = 4). ...
Background
Previous research has emphasized the importance of therapists giving Routine Outcome Monitoring (ROM) feedback to their patients. It has been shown that several factors influence therapists’ tendency to provide ROM feedback to their patients.
Methods
In this qualitative study, using a semi-structured interview followed by thematic analysis using Atlas.ti, we focused on experiences of therapists and patients with a disorder specific ROM instrument: the Borderline Personality Disorder Severity Index-IV (BPDSI-IV). Ten patients with a borderline personality disorder who had been in Mentalization Based Treatment (MBT) and ten MBT-therapists treating patients with a borderline personality disorder were interviewed.
Results
Qualitative analysis revealed that patients experienced benefits of ROM using the BPDSI-IV. Patients gained more insight in and recognition of their borderline personality disorder symptoms. They also felt more understood by the therapist because they got an opportunity to explain their symptoms in a different way than in a regular therapy session. Therapists shared they didn’t always use all the ROM outcomes as serious feedback for adjusting treatment. They preferred to use the BPDSI-IV over the other ROM instruments, because the BPDSI-IV is disorder specific, which gives insight into the treatment course of the patient.
Conclusions
Experiences of both patients and therapists with the BPDSI-IV were positive. It seems to be valuable and promising for healthcare institutions to evaluate treatment with a disorder specific ROM instrument.
Background
Despite the introduction of dimensional conceptualisations of personality functioning in the latest classification systems, such as Criterion A of the Alternative Model of Personality Disorders in the DSM-5, heterogeneous clinical presentation of personality pathology remains a challenge. Relatedly, the latent structure of personality pathology as assessed by the Semi-Structured Interview for Personality Functioning DSM-5 (STiP-5.1) has not yet been comprehensively examined in adolescents. Therefore, this study aimed to examine the latent structure of the STiP-5.1, and, based on those findings, to describe any unique clinical profiles that might emerge.
Methods
The final sample comprised 502 participants aged 11–18 years consecutively recruited from a specialised personality disorder outpatient service, as well as general day clinic and inpatient wards at the University Hospital University Hospital of Child and Adolescent Psychiatry and Psychotherapy, University Hospital Bern, Switzerland. Participants were assessed using the STiP-5.1, as well as a battery of other psychological measures by clinical psychologists or trained doctoral students. Variations of Factor Analysis, Latent Class Analysis and Factor Mixture Models (FMM) were applied to the STiP-5.1 to determine the most appropriate structure.
Results
The best fitting model was an FMM comprising four-classes and two factors (corresponding to self- and interpersonal-functioning). The classes differed in both overall severity of personality functioning impairment, and in their scores and clinical relevance on each element of the STiP-5.1. When compared to the overall sample, classes differed in their unique clinical presentation: class 1 had low impairment, class 2 had impairments primarily in self-functioning with high depressivity, class 3 had mixed levels of impairment with emerging problems in identity and empathy, and class 4 had severe overall personality functioning impairment.
Conclusions
A complex model incorporating both dimensional and categorical components most adequately describes the latent structure of the STiP-5.1 in our adolescent sample. We conclude that Criterion A provides clinically useful information beyond severity (as a dimensional continuum) alone, and that the hybrid model found for personality functioning in our sample warrants further attention. Findings can help to parse out clinical heterogeneity in personality pathology in adolescents, and help to inform early identification and intervention efforts.
For most residents of Europe, war is a new experience in which they find themselves both as witnesses and participants. In this paper the war in Ukraine serves as an illustration and case example. Like any unfamiliar experience, war elicits profound emotional responses which can be so overwhelming that an individual may be unable to fully process them and to create mental representations of the reality of war. When the psyche becomes entrapped in an unprocessed state, without the capacity to derive meaning from it, this results in the “fossilization” of the psyche akin to what McGinley and Segal describes as a totalitarian state of mind. Subjectivity and individual differences come under collective or personal attack, or both. This state of being prioritizes the needs of the collective psyche over the individual psyche. The image of Gorgon Medusa, who transformed living people into “fossilized” ones, is presented as a metaphor of total identification with the collective dimension. In contrast, the psyche can reveal a creative approach to resolving war‐induced trauma. This is depicted in the concept of the Alchemical Stone and its creation, which symbolizes a harmonious connection between the external and internal realms, the subjective and objective experiences, and the real and the imaginal dimension.
Introduction
Mentalization‐based therapy (MBT) and its adapted version for adolescents (MBT‐A) are repeatedly highlighted as promising treatments for reducing self‐harm, particularly in borderline personality disorder (BPD). Despite the availability of publications providing evidence of their efficacy in reducing self‐harm, recent meta‐analyses have yielded mixed results. To inform best‐practice clinical decision‐making, we conducted a systematic review and meta‐analysis. We aimed to disentangle findings for both adolescents and adults on the efficacy of MBT(‐A) in reducing self‐harm (primary outcome) and symptoms of BPD and depression (secondary outcomes).
Methods
Web of Science, Scopus, Embase, PubMed/Medline, and Cochrane Review Database were searched for eligible studies published until September 2022. In total, 14 studies were identified, comprising 612 participants from nine MBT studies (six pre–post, three RCTs) and five MBT‐A studies (two pre–post, three RCTs). Aggregated effect sizes were estimated using random‐effects models. Meta‐regressions were conducted to assess the effect of moderator variables (treatment duration, drop‐out rates, and age) on effect sizes.
Results
Overall, both MBT and MBT‐A demonstrated promising effects in reducing self‐harm ( g = −0.82, 95% CI −1.15 to −0.50), borderline personality disorder ( g = −1.08, 95% CI −1.38 to −0.77), and depression ( g = −1.1, 95% CI −1.52 to −0.68) symptoms. However, when compared to control interventions (TAU, SCM), MBT(‐A) did not prove to be more efficacious, with the exception of MBT showing superior effects on BPD symptoms in adults ( g = −0.56, 95% CI −0.88 to −0.24).
Conclusion
Although the pre–post evaluations seem promising, this analysis, including RCTs, showed no superiority of MBT(‐A) to control conditions, so that prioritizing the application of MBT (‐A) for the treatment of self‐harm is not supported. Possible explanations and further implications are discussed.
Aim: The present study was conducted with the purpose of determining the fit of the structural model of borderline personality syndrome based on the experience of childhood trauma and emotional dysregulation with the mediating role of mentalization. Method: The current research method was descriptive-correlation of structural equations type. The statistical population of the present study was all the people referred to the psychiatric clinic of Imam Hossein Hospital in Karaj. Sampling was done through convenience method and the sample size was estimated to be 330 people according to Kline (2016), and after removing the distorted information questionnaires, 319 people were analyzed. Data collection tools were Lichsenring's borderline personality scale (1999), Gratz and Romer's emotion dysregulation questionnaire (2004), Bernstein et al.'s childhood trauma questionnaire (2003), and Dimitrijoys et al.'s mentalization questionnaire (2018). Data analysis was done using structural equation modeling. Results: The results of this study showed that the presented structural model has a good fit. The results showed that childhood trauma experience has a direct effect on borderline personality syndrome (β=0.79; P<0.001). Also, emotion dysregulation has a direct effect on borderline personality syndrome (β=0.76; P<0.001). Childhood trauma experience (β=0.81; P<0.001) and emotional dysregulation (β=0.73; P<0.001) have an indirect effect on borderline personality syndromes through the mediation of mentalization. Conclusion: It can be concluded that the structural model of borderline personality syndrome based on the experience of childhood trauma and emotional dysregulation with the mediating role of mentalization has a suitable fit.
Emotion dysregulation (ED) has primarily been described in patients suffering from borderline personality disorder (BPD) and is an integral part of this diagnosis, but it is also a transdiagnostic construct that can be found in several other psychiatric disorders. The strong relationships between ED and BPD may lead clinicians to underestimate ED associated to other clinical contexts. This can lead to difficulties in diagnostic and treatment orientation, especially in the context of comorbidities. In this article, after reviewing the literature on the development and functioning of emotion dysregulation, and on the evidence for emotion dysregulation in eight disorders (borderline personality disorder, pathological narcissism with/without narcissistic personality disorder, obsessive-compulsive personality disorder, antisocial personality disorder, bipolar disorder, autism spectrum disorder, complex post-traumatic stress disorder, and adult attention deficit hyperactivity disorder), we present a transdiagnostic processual model of emotion dysregulation based on core triggers and interpersonal styles to try to address this issue and to provide a simple but technical tool to help clinicians in their diagnostic assessment and treatment orientation. By focusing more on typical patterns and interpersonal dynamics than only on categories, we believe that this model may contribute to the actual need for improvement of our current psychiatric classifications, alongside other well-studied and under-used dimensional models of psychopathology (e.g., HiTOP, AMPD), and may be useful to build more specific treatment frameworks for patients suffering from ED.
In this article we describe and reflect upon the roots of mentalization-based group therapy (MBT-G) and its relationship to group analysis. The original setting for MBT was psychotherapeutic day hospitals that were strongly influenced by group analytic thinking. The challenges from an increasing number of borderline patients initiated theoretical and therapeutic innovations that separated MBT-G from traditional group analysis who responded differently, e.g. by strengthening its ties to object-relational theories that emphasized innate destructive drives. Since then, the dialogue between the two approaches have been meagre in the UK, but more constructive in e.g. Norway and Germany. We argue that MBT-G needs group analytic competence with respect to basic group dynamics, and that group analysis needs revitalization by the theory of mentalizing. We call for dialogues between the two approaches. The authors belong to both camps and speak with reference to experiences in Norway, United Kingdom, Denmark and Germany.
Notre travail décrit l’élaboration d’hypothèses complexes concernant des vécus traumatiques précoces et chroniques chez des patients qui ont entretenu des échanges dysfonctionnels avec leur entourage et des relations nocives à leur propre corps. Ces hypothèses se sont révélées utiles pour choisir l’approche la plus adéquate à chaque phase du traitement. La parole, la relation et les approches corporelles développent tout leur potentiel thérapeutique si l’on prend soin d’évaluer comme un tout, la globalité de la personnalité du patient, ses particularités et sa situation existentielle.
This article explores the relationship between developmental trauma, dissociation, and substance abuse within the framework of the self-medication hypothesis. By means of presenting a clinical vignette, the article illustrates how substance abuse can serve as a maladaptive coping strategy for managing overwhelming emotions that stem from traumatic experiences in attachment relationships during childhood. Individuals who have undergone developmental trauma may dissociate negative attachment memories and their related emotions, which consequently leads to compartmentalization of their internal states and hinders their self-regulation abilities. In such scenario, substances can act as external regulators of distressing emotions, distancing these individuals from their traumatic memories and facilitating the adoption of an omnipotent and self-reliant attitude. Hence, it is of utmost importance for clinicians to accurately identify and address the selfmedication needs of these individuals. This is fundamental in facilitating these clients’ capacity to acknowledge, explore, and integrate their distressing memories as intrinsic elements of their identity, thereby fostering the development of a unified and cohesive self-concept.
Keywords: addiction; dissociation; developmental trauma; self-medication hypothesis
No one doubts the importance of trust in psychotherapy, but few therapists think about the complexities of trusting relationships, and the trustworthiness that would justify trusting remains far from view. Fortunately, inasmuch as trusting and trustworthiness are inherently ethical concepts, contemporary philosophers have given trust the consideration it warrants. Integrating science and philosophy, the author reviews the broad scope and multifaceted nature of trust and trustworthiness, the social-cognitive development of trust, and the development of distrust in the context of borderline personality disorder. Without questioning therapists’ character, the author makes the case for shifting the emphasis from the patient's distrust to the therapist's challenge to become trustworthy in the course of each treatment relationship and, more broadly, over the course of a professional career.
Although mentalization-based treatments have been applied to persons diagnosed with schizophrenia spectrum disorders, there is minimal literature on how mentalization-based treatment might be adapted to persons with schizotypal personality disorder (SPD). Persons with SPD often struggle to reflect upon their own mental states and the mental states of others, which can result in social anxiety, confusion, and interpersonal withdrawal. Such problems in mentalization might also be linked to early experiences of adversity and emotional abuse, experiences that are commonly reported by persons with SPD. In this chapter, some key areas of vulnerability for persons with SPD will be outlined, including impaired mentalization, emotional deficits, and social anxieties that can be addressed in the context of a secure therapeutic relationship. The authors will provide brief clinical vignettes to illustrate mentalization-informed techniques that can boost reflective functioning, enhance emotional awareness, and reduce social anxiety and confusion that can interfere with the development of meaningful interpersonal connections.
Mentalization difficulties may be one reason why individuals who experienced childhood maltreatment (CM) are at increased risk for borderline personality (BP) symptoms. The goal of this study was to identify specific aspects of mentalization associated with CM and determine their role in the short-term course of BP symptoms. A total of 253 mothers with a previous mental health diagnosis completed online surveys at three times over 9 months. A cross-lag panel model was tested to estimate reciprocal effects between mentalization measures and BP symptoms and indirect effects from CM to mentalization to BP symptoms. At baseline, women with more CM endorsed more difficulty with general mentalization, emotional clarity, and reflecting on childhood experiences. Lack of emotional clarity and disorganized responding about childhood served as indirect paths from CM to subsequent BP symptoms and showed bidirectional associations with BP symptoms over time. Thus, these may be particularly important treatment targets in this population.
Several evidence-based psychotherapies for personality disorders have been developed in recent decades, including transference-focused psychotherapy (TFP), a contemporary model of psychodynamic psychotherapy developed by Otto Kernberg. Kernberg established Group TFP (TFP-G) as an alternative or adjunct treatment to individual TFP. Although not yet manualized, TFP-G is used in publicly and privately funded mental health services, including outpatient clinics, subacute hospitals, therapeutic inpatient units, partial hospitalization services, and rehabilitation services serving people with borderline personality. Kernberg's model of TFP-G psychotherapy, its application in clinical settings, and what differentiates it from other group psychotherapy models is described as well as illustrated with some examples useful to practitioners.
La prévalence élevée des troubles de la personnalité et l’impact important de ces troubles sur le fonctionnement des individus atteints en font un enjeu majeur et incontournable des soins en santé mentale. Plusieurs traitements de psychothérapie ont démontré jusqu’à maintenant des bénéfices significatifs dans l’amélioration des difficultés liées à ces troubles. La thérapie basée sur la mentalisation (TBM), qui utilise la psychothérapie de groupe, est l’un des traitements reconnus comme efficaces. La modalité de groupe basée sur la mentalisation (TBM-G) présente toutefois des défis pour les psychothérapeutes. L’efficacité même de l’intervention de groupe repose, selon les auteurs, sur la capacité à stimuler la mentalisation, utiliser la dynamique de groupe, encourager la cohésion et permettre l’expérience d’une réappropriation réparatrice de situations conflictuelles, qui, à leur avis, sont sous-utilisées dans ce type de processus thérapeutique. Le présent article s’attarde, en ce sens, à des pistes d’interventions pour favoriser des attitudes mentalisantes dans un groupe de thérapie. Plus spécifiquement, nous tentons de réviser comment l’attention portée à ce qui se produit dans l’ici et maintenant, l’identification et la résolution du « détruit/trouvé » et le développement de métacognitions se veulent des techniques qui stimulent la cohésion et potentialisent le processus thérapeutique.
Même si l’association entre l’alexithymie et les troubles de la conduite alimentaire (TCA) est établie, on comprend mal comment une personne en vient à développer des traits de personnalité alexithymiques qui, à leur tour, prédisent les TCA. En s’inspirant de modèles psychanalytiques, cette étude approfondit les connaissances actuelles en testant deux stratégies de régulation émotionnelle comme prédicteurs de cette relation: la suppression expressive et la réévaluation cognitive. Il était attendu que la suppression constante d’une émotion prédise positivement les traits alexithymiques (indicateur de dérégulation émotionnelle), qui à leur tour, prédiraient positivement les symptômes TCA. Inversement, il était suggéré que l’usage de la réévaluation cognitive prédise négativement les traits alexithymiques et donc les symptômes TCA. Les séquences hypothétiques ont été confirmées.
Self-compassion is a powerful antidote to shame and a crucial component of healing from the impact of complex trauma. As self-compassion becomes more widespread, it is crucial that compassion-based concepts and practices are integrated in trauma treatment in a skillful and client-focused manner. This involves developing a comprehensive interpersonal and attachment-based formulation of the client’s trauma experience and its sequelae. This chapter provides guidance for therapists engaged in the treatment of complex post-traumatic stress disorder (PTSD). Evidence for the relationship between self-compassion and trauma symptoms is presented alongside findings from the intervention literature. Following this, I provide a phase-based approach to integrating self-compassion into treatment for complex PTSD. Starting with developing an attachment-based formulation for the client’s experiences, I describe principles and practices for working with self-compassion in the context of their attachment and trauma history.KeywordsPTSDTraumaAttachmentSelf-CompassionTherapy
Based on Hegel's dialectics, we argue that different psychotherapies considered monolithic such as cognitive behavioural therapy (CBT) and psychoanalysis, even though they hold radically different views on human suffering and therapy's aims, profoundly influence each other. We call this mutual influence dialectical integration (DI). DI is the result of unconscious processes that are activated by antagonism and negation for self‐constitution. In a dialectically formative process, the self‐constitution of CBT and psychoanalysis each is achieved by means of the negation of part of itself, which undergoes alienation in the other, thereby superficially taking the form of a rejection of the other approach. But whenever theoretical or practical lacunae occur in the unfolding of these disciplines, they negate this primary negation and re‐internalize the alienated self‐component. This part does not return in its original—and negated—form, but, through a sublation introducing theoretical and practical development. This is illustrated here by Hartmann's ego psychology, Beck's cognitive theory, Young's schema therapy, and Bateman & Fonagy's mentalization‐based therapy (MBT). We show how these developments incorporate elements of otherness, which are not simply extraneous to the tradition but also part of it. We conclude by showing how DI gives rise to recognition and containment of otherness in both schools.
Les recherches en psychologie au cours des dernières années mettent en lumière le rôle essentiel de la capacité de mentalisation parentale (CMP), d’une part pour prévenir l’occurrence des traumas relationnels précoces et, d’autre part pour prédire la sécurité de l’attachement de l’enfant. Les deux dyades père-enfant présentées dans cet articale visent à explorer la CMP des pères signalés pour maltraitance à la protection de l’enfance ainsi que les représentations d’attachement de leurs enfants d’âge préscolaire. Les résultats ont soulevé la présence de difficultés de mentalisation importantes chez les pères. Du côté des enfants, il est possible de constater des difficultés au niveau de la régulation émotionnelle et comportementale ainsi que des représentations d’attachement de type insécurisé.
The development and functioning of representations of God are complex processes, in which psychological and cultural factors mutually influence each other. Attachment is a psychological factor that can provide insights into the representation and communication of ideas and experiences regarding supernatural agents in children’s drawings and narratives. Our hypotheses: (1) Securely attached children will use more God representation-related symbols in their drawings than insecurely attached children, (2) These symbols will have a referring and self-transcending character. We explore children’s drawings of God and their accompanying narratives with regard to attachment styles. We describe our theoretical framework and discuss the research process, our use of theory and materials, and our findings. We also present a qualitative analysis of drawings by both insecurely and securely attached children, focusing on qualitative aspects of the drawings and their use of religious symbols. Secure attachment is associated with more God representation-related symbols. Other drawing aspects also relate to attachment. We compare the occurrence of attachment characterizations of relationships with God, the padding of the paper, and the use of anthropomorphic and non-anthropomorphic images. Finally, we focus on the concrete localization of God on the paper, and the figurative place where children imagined God to be.
This article is a presentation of mentalization-based supervision with regard to focus, goals and means. The article is based on current theory of mentalization, and clinical practice with mentalization-based supervision. It presents a dimension to be considered in mentalization-based supervision, where the goal of stimulating mentalization is always in focus. This is illustrated in a sequence from a supervision session. It is possible to determine what mentalization-based supervision is and extract what makes it different of other psychotherapy supervision.
As practitioners working within the NHS, the majority of our clients have received a psychiatric diagnostic label, for example, Borderline Personality Disorder. Whilst such labels fit neatly with the current emphasis on time-limited, evidence-based, cost-effective psychological treatments for ‘target’ issues, they tell us little about the client’sparticular emotional needs and how the more ‘destructive’ aspects of clients behaviour, particularly towards the practitioner’s attempts to work with them, can actually be understood. This paper outlines the Object Relations approach to Borderline Personality Disorder which is disadvantaged in the NHS due to its typically long-term open-ended nature.This approach focuses on the human condition as a whole and provides the practitioner, regardless of their preferred therapeutic model, with a particularly detailed framework for understanding the client’s inter-personal behaviour and their own emotional responsesto such behaviour so that the therapeutic relationship might ultimately allow practitioner and client to feel valued and empowered rather ‘trapped’ by the application of a particular label.
In this chapter, the basis for a conceptual understanding of power and powerlessness will be established. Based on the Weberʼs definition of power (extended by Luhmann), various aspects, identifying features and manifestations of power and powerlessness will be discussed. In psychotherapy we are constantly confronted and engaged with power structures of external and internal reality and also experience the challenges of our own involvement in power and powerlessness fantasies and scenarios. In order to be able to come to a reflective and empathic understanding and handling of these challenges ourselves and together with our patients, it will be developed, with reference to the theory of mentalization presented in ► Chap. 2, how the topics of power and powerlessness can be mentalized systematically, i.e. which dimensions can be considered and felt.
Introduction
Therapists’ responses to patients play a crucial role in psychotherapy and are considered a key component of the patient–clinician relationship, which promotes successful treatment outcomes. To date, no empirical research has ever investigated therapist response patterns to patients with different personality disorders from a neuroscience perspective.
Methods
In the present study, psychodynamic therapists ( N = 14) were asked to complete a battery of instruments (including the Therapist Response Questionnaire) after watching three videos showing clinical interactions between a therapist and three patients with narcissistic, histrionic/borderline, and depressive personality disorders, respectively. Subsequently, participants’ high-density electroencephalography (hdEEG) was recorded as they passively viewed pictures of the patients’ faces, which were selected from the still images of the previously shown videos. Supervised machine learning (ML) was used to evaluate whether: (1) therapists’ responses predicted which patient they observed during the EEG task and whether specific clinician reactions were involved in distinguishing between patients with different personality disorders (using pairwise comparisons); and (2) therapists’ event-related potentials (ERPs) predicted which patient they observed during the laboratory experiment and whether distinct ERP components allowed this forecast.
Results
The results indicated that therapists showed distinct patterns of criticized/devalued and sexualized reactions to visual depictions of patients with different personality disorders, at statistically systematic and clinically meaningful levels. Moreover, therapists’ late positive potentials (LPPs) in the hippocampus were able to determine which patient they observed during the EEG task, with high accuracy.
Discussion
These results, albeit preliminary, shed light on the role played by therapists’ memory processes in psychotherapy. Clinical and neuroscience implications of the empirical investigation of therapist responses are discussed.
Background:
No evidence-based support has been offered to young people (YP) who have experienced technology-assisted sexual abuse (TASA). Interventions aimed at improving mentalization (the ability to understand the mental states of oneself and others) are increasingly being applied to treat YP with various clinical issues. Digital technology use among YP is now common. A digital intervention aimed at improving mentalization in YP who have experienced TASA may reduce the risk of revictimization and future harm and make YP more resilient and able to manage distress that might result from TASA experiences.
Objective:
In this paper, we describe a protocol for determining the feasibility of the i-Minds trial and the acceptability, safety, and usability of the digital intervention (the i-Minds app) and explore how to best integrate i-Minds into existing routine care pathways.
Methods:
This is a mixed methods nonrandomized study aimed to determine the feasibility, acceptability, safety, and usability of the intervention. Participants aged between 12 and 18 years who report distress associated with TASA exposure will be recruited from the United Kingdom from the National Health Service (NHS) Trust Child and Adolescent Mental Health Services, sexual assault referral centers, and a web-based e-therapy provider. All participants will receive the i-Minds app for 6 weeks. Coproduced with YP and a range of stakeholders, the i-Minds app focuses on 4 main topics: mentalization, TASA and its impact, emotional and mental health, and trauma. A daily prompt will encourage YP to use the app, which is designed to be used in a stand-alone manner alongside routine care. We will follow participants up after the intervention and conduct interviews with stakeholders to explore the acceptability of the app and trial procedures and identify areas for improvement. Informed by the normalization process theory, we will examine barriers and enablers relevant to the future integration of the intervention into existing care pathways, including traditional clinic-based NHS and NHS e-therapy providers.
Results:
This study was approved by the Research Ethics Board of Scotland. We expect data to be collected from up to 60 YP. We expect to conduct approximately 20 qualitative interviews with participants and 20 health care professionals who referred YP to the study. The results of this study have been submitted for publication.
Conclusions:
This study will provide preliminary evidence on the feasibility of recruiting YP to a trial of this nature and on the acceptability, safety, and usability of the i-Minds app, including how to best integrate it into existing routine care. The findings will inform the decision to proceed with a powered efficacy trial.
Trial registration:
International Standard Randomised Controlled Trial Number Registry (ISRCTN) ISRCTN43130832; https://www.isrctn.com/ISRCTN43130832.
International registered report identifier (irrid):
DERR1-10.2196/40539.
There is now ample evidence from the preclinical and clinical fields that early life trauma has both dramatic and long-lasting effects on neurobiological systems and functions that are involved in different forms of psychopathology as well as on health in general. To date, a comprehensive review of the recent research on the effects of early and later life trauma is lacking. This book fills an obvious gap in academic and clinical literature by providing reviews which summarize and synthesize these findings. Topics considered and discussed include the possible biological and neuropsychological effects of trauma at different epochs and their effect on health. This book will be essential reading for psychiatrists, clinical psychologists, mental health professionals, social workers, pediatricians and specialists in child development.
This chapter starts by examining the existing parallels between the oppression of women and the unbridled domination of the ecosystem. This chapter briefly highlights the conditions under which these oppressive behaviors developed, and it argues that culpability lies in the oppressive “system,” of which all genders remain enslaved. Following a review of attachment theory, Margaret Mahler’s theory of separation-individuation, ecopsychology, and feminist psychology, this chapter suggests that oppressive antisocial and exploitive antienvironmental behaviors may be transformed into more restorative pro-environmental behaviors through mentalization, a key social cognition. Mentalization-based therapy is currently used in clinical practice to treat human relational disorders. To expand our definition of relational, we must fully acknowledge human–nonhuman dynamics. To understand the pathology underlying the climate crisis, it may be helpful to look at the underlying etiology of narcissistic personality disorder. Learning to use our capacity to mentalize the ecosystem, we can shift from our narcissistic, destructive relation to nature and develop an empathic, sustaining relation in its place.
Everybody, including those individuals with psychological problems, has their own unique personality, that is, their characteristic manner of thinking, feeling, behaving, and relating to others (John et al., Handbook of personality: theory and research, 3rd edn. Guilford, 2008). Some people are typically introverted, quiet, and withdrawn, whereas others are more extraverted, active, and outgoing. Some individuals are consistently anxious, self-conscious, and apprehensive, whereas others are routinely relaxed, self-assured and unconcerned. Personality traits are integral to each person’s sense of self, as they involve what people value, how they think and feel about things, what they like to do, and what they are like most every day throughout much of their lives. For some people, these personality traits will be maladaptive to the point that they would constitute a personality disorder. A personality disorder (PD) is defined in the Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-5) as “an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment” (APA, Diagnostic and statistical manual of mental disorders, 5th edn. Author, 2013, p. 645).KeywordsPsychopathyDiagnosisAssessmentPersonality disorderDSM-5
In dieser Arbeit werden seit langem etablierte sowie aktuelle Entwicklungen von psychoanalytischen Konzepten der Familientherapie im deutschen Sprachraum dargestellt, wobei gezeigt wird, wie sich solche Konzeptionen in den letzten Jahrzehnten, aufeinander aufbauend, entfaltet haben. Psychoanalytische Familiendynamik, Bindung und Mentalisierung werden als Grundlagen für das therapeutische Vorgehen vorgestellt. Im zweiten Teil wird der Blick gerichtet auf die Entstehungsund Entwicklungsgeschichte der psychoanalytischen Paar-, Familienund Sozialtherapie in Deutschland – und im deutschsprachigen Raum. Dies geschieht aus einer sehr persönlichen Perspektive, weil diese untrennbar verbunden ist mit der eigenen fachlichen Entwicklung.
One of the major developments of the second year of human life is the emergence of the ability to pretend. A child's knowledge of a real situation is apparently contradicted and distorted by pretense. If, as generally assumed, the child is just beginning to construct a system for internally representing such knowledge, why is this system of representation not undermined by its use in both comprehending and producing pretense? In this article I present a theoretical analysis of the representational mechanism underlying this ability. This mechanism extends the power of the infant's existing capacity for (primary) representation, creating a capacity for metarepresentation. It is this, developing toward the end of infancy, that underlies the child's new abilities to pretend and to understand pretense in others. There is a striking isomorphism between the three fundamental forms of pretend play and three crucial logical properties of mental state expressions in language. This isomorphism points to a common underlying form of internal representation that is here called metarepresentation. A performance model, the decoupler, is outlined embodying ideas about how an infant might compute the complex function postulated to underlie pretend play. This model also reveals pretense as an early manifestation of the ability to understand mental states. Aspects of later preschool development, both normal and abnormal, are discussed in the light of the new model. This theory begins the task of characterizing the specific innate basis of our commonsense "theory of mind.".
The Menninger Clinic This article is based on a patient education program the authors are conducting in the Professionals in Crisis program at The Menninger Clinic. This program is designed to foster a therapeutic alliance by helping patients understand a central aim of treatment, namely, fostering mentalizing, the awareness of mental states in self and others. The educational material is based on research in the Menninger Child and Family Program. The educational sessions are conducted like seminars in which the leaders and patients collaborate in understanding these concepts and their application to treatment. Patients in the program are provided with this article as background material for the seminar. Many persons with serious psychiatric disorders require intensive treatment. Medication or individual psychotherapy alone—or even their combination—won't always do. Patients who have not benefited sufficiently from less intensive outpatient treatment may require inpatient treatment that provides for comprehensive assessment and combines a wide range of interventions—not just medication and individual psychotherapy, but also group therapy, family work, educational groups, therapeutic activities and a specialized milieu. Crucial to such treatment is a social environment that provides support, a feeling of belonging and ample formal and informal opportunities to confide in peers and learn from them. Such a rich array of therapeutic interventions confronts us with a problem: How does it all work? It is no small challenge to understand how medications work or to understand how individual psychotherapy helps. Researchers have been studying these interventions for decades. When we combine these standard interventions with many other therapies, understanding the basis of our treatment's effectiveness becomes even more challenging. We all subscribe to the "bio-psycho-social" model of treatment, believing that we must integrate the biological, psychological and social domains, as well as the spiritual domain. But this is a vast territory to cover.
Presents a theoretical analysis of the representational mechanism underlying a child's ability to pretend. This mechanism extends the power of the infant's existing capacity for (primary) representation, creating a capacity for "metarepresentation." It is this, developing toward the end of infancy, that underlies the child's new abilities to pretend and to understand pretense in others. There is a striking isomorphism between the 3 fundamental forms of pretend play and 3 crucial logical properties of mental state expressions in language. This isomorphism points to a common underlying form of internal representation that is here called metarepresentation. A performance model, the "decoupler," is outlined embodying ideas about how an infant might compute the complex function postulated to underlie pretend play. This model also reveals pretense as an early manifestation of the ability to understand mental states. Aspects of later preschool development, both normal and abnormal, are discussed in the light of the new model. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
This study explores the stability of attachment security and representations from infancy to early adulthood in a sample chosen originally for poverty and high risk for poor developmental outcomes. Participants for this study were 57 young adults who are part of an ongoing prospective study of development and adaptation in a high-risk sample. Attachment was assessed during infancy by using the Ainsworth Strange Situation (Ainsworth & Wittig) and at age 19 by using the Berkeley Adult Attachment Interview (George, Kaplan, & Main). Possible correlates of continuity and discontinuity in attachment were drawn from assessments of the participants and their mothers over the course of the study. Results provided no evidence for significant continuity between infant and adult attachment in this sample, with many participants transitioning to insecurity. The evidence, however, indicated that there might be lawful discontinuity. Analyses of correlates of continuity and discontinuity in attachment classification from infancy to adulthood indicated that the continuous and discontinuous groups were differentiated on the basis of child maltreatment, maternal depression, and family functioning in early adolescence. These results provide evidence that although attachment has been found to be stable over time in other samples, attachment representations are vulnerable to difficult and chaotic life experiences.
To determine the prevalence rate of personality disorder among a consecutive sample of UK primary care attenders. Associations between a diagnosis of personality disorder, sociodemographic background and common mental disorder were examined.
Three hundred and three consecutive primary care attenders were examined for the presence of ICD-10 and DSM-4 personality disorders using an informant-based interview.
Personality disorder was diagnosed in 24% (95% CI: 19-29) of the sample. Personality-disordered subjects were more likely to have psychiatric morbidity as indicated by GHQ-12, to report previous psychological morbidity, to be single and to attend the surgery on an emergency basis. 'Cluster B' personality disorders were particularly associated with psychiatric morbidity.
There is a high prevalence rate of personality disorders among primary care attenders. These disorders are associated with the presence of common mental disorder and unplanned surgery attendance. Personality disorders may represent a significant source of burden in primary care.
Convergence of PDQ-R- and SIDP-R-derived personality disorder diagnoses was studied in a sample of 85 forensic psychiatric patients. For categorical diagnoses, the mean kappa was .34, but on a dimensional level convergence was somewhat higher. Paranoid, antisocial and borderline personality disorders had prevalence rates around 40%; the other personality disorders occurred with much lower frequency. The PDQ-R yielded more diagnoses, except for antisocial, histrionic, narcissistic, and sadistic personality disorder. Because the latter disorders are among the most prevalent in forensic settings, and because they have important risk and treatment implications, the PDQ-R is not suitable as a screening device in forensic populations. Semistructured interviews that make use of collateral information are recommended for diagnosing personality disorders in forensic subjects.
We consider whether disruption of a specific neural circuit related to self-regulation is an underlying biological deficit in borderline personality disorder (BPD). Because patients with BPD exhibit a poor ability to regulate negative affect, we hypothesized that brain mechanisms thought to be involved in such self-regulation would function abnormally even in situations that seem remote from the symptoms exhibited by these patients. To test this idea, we compared the efficiency of attentional networks in BPD patients with controls who were matched to the patients in having very low self-reported effortful control and very high negative emotionality and controls who were average in these two temperamental dimensions. We found that the patients exhibited significantly greater difficulty in their ability to resolve conflict among stimulus dimensions in a purely cognitive task than did average controls but displayed no deficit in overall reaction time, errors, or other attentional networks. The temperamentally matched group did not differ significantly from either group. A significant correlation was found between measures of the ability to control conflict in the reaction-time task and self-reported effortful control.
Borderline personality disorder (BPD) is a highly prevalent, chronic, and debilitating psychiatric problem characterized by a pattern of chaotic and self-defeating interpersonal relationships, emotional lability, poor impulse control, angry outbursts, frequent suicidality, and self-mutilation. Recently, psychopathology researchers and theorists have begun to understand fundamental aspects of BPD such as unstable, intense interpersonal relationships, feelings of emptiness, bursts of rage, chronic fears of abandonment and intolerance for aloneness, and lack of a stable sense of self as stemming from impairments in the underlying attachment organization. These investigators have noted that the impulsivity, affective lability, and self-damaging actions that are the hallmark of borderline personality occur in an interpersonal context and are often precipitated by real or imagined events in relationships. This article reviews attachment theory and research as a means of providing a developmental psychopathology perspective on BPD. Following a brief review of Bowlby's theory of attachment, and an overview of the evidence with respect to the major claims of attachment theory, I discuss individual differences, the evidence that these differences are rooted in patterns of interaction with caregivers, and how these patterns have important implications for evolving adaptations and development. Following this discussion, I present recent work linking attachment theory and BPD, focusing on the implications for understanding the etiology and treatment of BPD. In conclusion, I address some of the salient issues that point to the direction for future research efforts.
To examine adaptive functioning and psychopathology in adolescents with DSM-IV borderline personality disorder.
177 psychiatric outpatients (derived from 2 samples collected between March 1998 and July 1999 and between November 2000 and September 2002) aged 15 to 18 years were assessed using a structured interview for personality disorder diagnoses. Three groups, namely (1) those with a borderline personality disorder, (2) those with a personality disorder other than borderline personality disorder ("other personality disorder"), and (3) those without any personality disorder ("no personality disorder"), were compared on measures of psychiatric symptoms and psychosocial functioning. Primary outcome measures were Axis I diagnoses, Youth Self-Report, Young Adult Self-Report, Health of the Nation Outcome Scales for Children and Adolescents, Social and Occupational Functioning Assessment Scale, and sociodemographic variables.
The borderline personality disorder group (N = 46) had the most severe psychiatric symptoms and functional impairment across a broad range of domains, followed by the other personality disorder (N = 88) and no personality disorder (N = 43) groups, respectively. Borderline personality disorder was a significant predictor over and above Axis I disorders and other personality disorder diagnoses for psychopathology, general functioning, peer relationships, self-care, and family and relationship functioning.
The borderline personality disorder diagnosis should not be ignored or substituted by Axis I diagnoses in adolescent clinical practice, and early intervention strategies need to be developed for this disorder.
There is a lack of psychological autopsy studies assessing the influence of axis II disorders on other risk factors for suicide. Therefore, we investigated if the estimated suicide risk for axis I disorders and socio-demographic factors was modified by personality disorders. Psychiatric disorders were evaluated by a semi-structured interview including the Structured Clinical Interview for DSM-IV Axis I (SCID-I) and Personality Disorders (SCID-II) by psychological autopsy method in 163 completed suicides and by personal interview in 396 population-based control persons. Personality disorders modify suicide risk, differently for affective disorders, substance use disorders, smoking, life events during the last three months, and socio-demographic factors such as being single. Estimated suicide risk for socio-demographic factors and life events is not substantially altered following adjustment for affective disorders or substance use disorders. These findings suggest that treatment of personality disorders is essential for suicide prevention.
The authors use a new diagnostic algorithm derived from the Diagnostic Interview Schedule (the DIS/Borderline Index) to identify a borderline personality disorder among 19- to 55-year-olds at the Duke site of the Epidemiologic Catchment Area project. A criterion score of 11 or more symptoms from the 24-item DIS/Borderline Index identifies 1.8% of the sample. The borderline diagnosis is significantly higher among females, the widowed, and the unmarried; and there is a trend toward the diagnosis in younger, non-White, urban, and poorer respondents. Extensive psychiatric comorbidity and high use of mental health services are found in the borderline group.
Frequencies of personality disorder categories as defined by the Millon Clinical Multiaxial Inventory were determined in a sample of male mentally disordered offenders detained in a maximum security hospital (N = 115). Sixtyeight per cent of the sample met criteria for at least one personality disorder, and only 12 per cent displayed an absence of deviant personality traits. Most prominent were dependent, avoidant, schizoid, and histrionic and passive-aggressive disorders, while compulsive, borderline and antisocial disorders had a low frequency While patients in the Mental Health Act category of psychopathic disorder were more likely to show passive-aggressive disorder, and to exhibit a higher frequency of some features of antisocial personality disorder than those categorized as mentally ill, the frequency of personality disorders in these two categories was otherwise not significantly different. The results suggest that the medico-legal categorization is not a useful guide to the long-term psychological problems and treatment needs of this population.
This randomized controlled trial tested the effectiveness of an 18-month mentalization-based treatment (MBT) approach in an outpatient context against a structured clinical management (SCM) outpatient approach for treatment of borderline personality disorder.
Patients (N=134) consecutively referred to a specialist personality disorder treatment center and meeting selection criteria were randomly allocated to MBT or SCM. Eleven mental health professionals equal in years of experience and training served as therapists. Independent evaluators blind to treatment allocation conducted assessments every 6 months. The primary outcome was the occurrence of crisis events, a composite of suicidal and severe self-injurious behaviors and hospitalization. Secondary outcomes included social and interpersonal functioning and self-reported symptoms. Outcome measures, assessed at 6-month intervals, were analyzed using mixed effects logistic regressions for binary data, Poisson regression models for count data, and mixed effects linear growth curve models for self-report variables.
Substantial improvements were observed in both conditions across all outcome variables. Patients randomly assigned to MBT showed a steeper decline of both self-reported and clinically significant problems, including suicide attempts and hospitalization.
Structured treatments improve outcomes for individuals with borderline personality disorder. A focus on specific psychological processes brings additional benefits to structured clinical support. Mentalization-based treatment is relatively undemanding in terms of training so it may be useful for implementation into general mental health services. Further evaluations by independent research groups are now required.
This study compared the effectiveness of psychoanalytically oriented partial hospitalization with standard psychiatric care for patients with borderline personality disorder.
Thirty-eight patients with borderline personality disorder, diagnosed according to standardized criteria, were allocated either to a partially hospitalized group or to a standard psychiatric care (control) group in a randomized controlled design. Treatment, which included individual and group psychoanalytic psychotherapy, was for a maximum of 18 months. Outcome measures included the frequency of suicide attempts and acts of self-harm, the number and duration of inpatient admissions, the use of psychotropic medication, and self-report measures of depression, anxiety, general symptom distress, interpersonal function, and social adjustment. Data analysis used repeated measures analysis of covariance and nonparametric tests of trend.
Patients who were partially hospitalized showed a statistically significant decrease on all measures in contrast to the control group, which showed limited change or deterioration over the same period. An improvement in depressive symptoms, a decrease in suicidal and self-mutilatory acts, reduced inpatient days, and better social and interpersonal function began at 6 months and continued until the end of treatment at 18 months.
Psychoanalytically oriented partial hospitalization is superior to standard psychiatric care for patients with borderline personality disorder. Replication is needed with larger groups, but these results suggest that partial hospitalization may offer an alternative to inpatient treatment.
The aim of this study was to determine whether the substantial gains made by patients with borderline personality disorder following completion of a psychoanalytically oriented partial hospitalization program, in comparison to patients treated with standard psychiatric care, were maintained over an 18-month follow-up period.
Forty-four patients who participated in the original study were assessed every 3 months after completion of the treatment phase. Outcome measures included frequency of suicide attempts and acts of self-harm, number and duration of inpatient admissions, service utilization, and self-reported measures of depression, anxiety, general symptom distress, interpersonal functioning, and social adjustment.
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 the patients treated with standard psychiatric care, who showed only limited change during the same period.
The superiority of psychoanalytically oriented partial hospitalization over standard psychiatric treatment found in a previous randomized, controlled trial was maintained over an 18-month follow-up period. Continued improvement in social and interpersonal functioning suggests that longer-term changes were stimulated.
Borderline personality disorder (BPD) is a complex and serious mental disorder associated with severe functional impairment, substantial treatment utilization, and a high rate of mortality by suicide. Recently, BPD has become a focus of intensifying study. In Part I of this three-part article meant to provide a foundation to researchers on the current status of the borderline diagnosis and prospects for its future development, we examine the psychopathology, comorbidity, and personality structure of BPD. Although the descriptive characteristics of BPD are well-represented by DSM-IV diagnostic criteria, other important aspects of BPD psychopathology are not included. The descriptive criteria in conjunction with semistructured interviews have, however, increased the ability of investigators to diagnose BPD as reliably as many Axis I disorders. Frequent comorbidity of BPD with Axis I disorders necessitates a broad assessment of psychopathology to help account for clinical heterogeneity. Because of the absence of evidence of the validity of the diagnostic threshold for a categorical diagnosis of BPD, and because of the heterogeneity within the diagnosis, investigators should also supplement their DSM-IV diagnoses with assessments of underlying personality trait structures. Although there are a number of competing models of personality structure, they have remarkable convergence on a set of three to five basic personality dimensions.
The authors assessed health care costs associated with psychoanalytically oriented partial hospital treatment for borderline personality disorder compared with treatment as usual within general psychiatric services.
Health care utilization of all borderline personality disorder patients who participated in a previous trial of partial hospital treatment compared with treatment as usual was assessed by using information from case notes and service providers. Costs were compared for the 6 months before treatment, 18 months of treatment, and an 18-month follow-up period.
There were no cost differences between the groups during pretreatment or treatment. Costs of partial hospital treatment were offset by less psychiatric inpatient care and reduced emergency room treatment. The trend for costs to decrease in the partial hospitalization group during the follow-up period was not apparent in the treatment-as-usual group.
Specialist partial hospital treatment for borderline personality disorder is no more expensive than treatment as usual and shows considerable cost savings after treatment.
There is evidence that psychopathology in mothers may be associated with dysfunctional mother-infant interactions.
To investigate mother-infant relations when mothers have borderline personality disorder.
Eight mothers with borderline personality disorder and twelve mothers without psychiatric disorder were videotaped interacting with their 2-month-old infants in three successive phases of interaction: face-to-face play; an episode when the mother adopted a 'still face' and was unreactive; and a period when play interactions were resumed. The videotapes were rated by judges blind to the diagnostic group of the mother.
The mothers with borderline personality disorder were more intrusively insensitive towards their infants. During the still-face period, their infants showed increased looking away and dazed looks. Following this, mother-infant interactions were less satisfying and their infants showed dazed looks and lowering of affect.
The diagnosis of borderline personality disorder is associated with a particular pattern of mother-infant interaction. The infants' responses to the still-face challenge might suggest dysfunctional self-regulation, but the developmental significance remains to be assessed.
Adverse childhood experiences such as abuse and neglect are frequently implicated in the development of personality disorders (PDs); however, research on the childhood histories of most PD groups remains limited. In this multisite investigation, we assessed self-reported history of abuse and neglect experiences among 600 patients diagnosed with either a PD (borderline, schizotypal, avoidant, or obsessive-compulsive) or major depressive disorder without PD. Results indicate that rates of childhood maltreatment among individuals with PDs are generally high (73% reporting abuse; 82% reporting neglect). As expected, borderline PD was more consistently associated with childhood abuse and neglect than other PD diagnoses. However, even when controlling for the effect of borderline PD, other PD diagnoses were associated with specific types of maltreatment.
In a recent meta-analysis, only 53% of disorganized infants were predicted by parental Unresolved states of mind on the Adult Attachment Interview (AAI). The goal of this study was to identify additional predictors of infant disorganization on the AAI by developing and validating an interview-wide coding system for Hostile/Helpless (H/H) parental states of mind with respect to attachment. Maternal AAls were collected from 45 low-income mothers with high rates of childhood trauma when their children were age 7; Strange Situation assessments had been collected at 18 months of age. AAIs were independently coded using both the Main and Goldwyn coding system and newly developed codes for H/H states of mind. Results indicated that the H/H coding system displayed discriminant validity in that it did not overlap substantially with the Unresolved, Cannot Classify, or Fearfully Preoccupied by Traumatic Events categories in the Main and Goldwyn coding system. Second, H/H states of mind accounted for variance in disorganized infant behavior not associated with the Unresolved classification. Third, H/H states of mind were significantly related to maternal disrupted affective communication as coded by the Atypical Maternal Behavior Instrument for Assessment and Classification coding system, and maternal disrupted communication mediated the relations between H/H states of mind and infant disorganization.
We outline recent evidence suggesting that the natural course of borderline personality disorder is more benign than formerly believed. We explore possible reasons for the change in findings which include both the iatrogenic effects of earlier treatment models and the recent availability of effective interventions. Clinicians should be optimistic about improvement and long-term outcomes.
This paper presents a new outline for psychotherapy with persons with anorexia nervosa. 'Model on mentalisation' is the intellectual and empirical framework for this contribution. Mentalisation is defined as the ability to understand feelings, cognitions, intentions and meaning in oneself and in others. The capacity to understand oneself and others is a key determinant of self-organisation and affect regulation, and is acquired in early attachment relationships. Impaired mentalisation is documented and described as a central psychopathological feature in anorexia nervosa. Psychotherapeutic enterprise with individuals with compromised mentalising capacity should be an activity that is specifically focused on the rehabilitation of this function, with special emphasis on how the body is representing mental states. The paper describes psychotherapeutic goals, stances and techniques. It is intended that this outline will be further developed into manuals as a basis for therapy, training and research.
This study evaluated the effect of mentalization-based treatment by partial hospitalization compared to treatment as usual for borderline personality disorder 8 years after entry into a randomized, controlled trial and 5 years after all mentalization-based treatment was complete.
Interviewing was by research psychologists blind to original group allocation and structured review of medical notes of 41 patients from the original trial. Multivariate analysis of variance, chi-square, univariate analysis of variance, and nonparametric Mann-Whitney statistics were used to contrast the two groups depending on the distribution of the data.
Five years after discharge from mentalization-based treatment, the mentalization-based treatment by partial hospitalization group continued to show clinical and statistical superiority to treatment as usual on suicidality (23% versus 74%), diagnostic status (13% versus 87%), service use (2 years versus 3.5 years of psychiatric outpatient treatment), use of medication (0.02 versus 1.90 years taking three or more medications), global function above 60 (45% versus 10%), and vocational status (employed or in education 3.2 years versus 1.2 years).
Patients with 18 months of mentalization-based treatment by partial hospitalization followed by 18 months of maintenance mentalizing group therapy remain better than those receiving treatment as usual, but their general social function remains impaired.
Traumatic relationships and serious mental disorders
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The development of the person: the Minnesota study of risk and adaptation from birth to adulthood
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