What should we do and not
do in treatment of borderline
personality disorder?
Prof Anthony W Bateman
Glasgow 2006
Acknowledgments



St Ann’s Hospital, London
Catherine Freeman
Rory Bolton
Countless other clinicians
University College, London
Prof Peter Fonagy
Dr Mary Target
Dr Liz Allison
Menninger/Baylor Department of Psychiatry
Dr Efrain Bleiberg,
Dr Jon Allen
Therapies for BPD
Supportive Psychotherapy
 Behavioural

Dialectical Behaviour Therapy (DBT)

Cognitive
Manual Assisted Cognitive Therapy (MACT)
Schema Focused Psychotherapy (SFP)

Psychoanalytic
Transference Focused Psychotherapy (TFP)
Mentalization Based Treatment (MBT)
Outcomes (selected) at baseline &12 months in MACT and
TAU groups
Tyrer, P., Tom, B., Byford, S., et al (2004) Differential effects of manual assisted cognitive behaviour therapy in the treatment of recurrent
deliberate self-harm and personality disturbance: the POPMACT study. Journal of Personality Disorders, 18, 102-116.
HADS dep
HADS anx
MACT
TAU
Baseline 12 months
Baseline 12 months
11.3
14.0
7.0 11.2
10.3 14.3
7.1
10.3
Social function 13.3
9.8 13.3
10.3
(n=400)
(n=400)
GAF
symptoms
(n=402)
18.7
61
18.6
62
Summary of clinical findings
Tyrer, P., Tom, B., Byford, S., et al (2004) Differential effects of manual assisted cognitive behaviour therapy in the
treatment of recurrent deliberate self-harm and personality disturbance: the POPMACT study. Journal of Personality
Disorders, 18, 102-116.
Neither self-harm episodes, nor other psychometric
assessment outcomes, showed any convincing
differences between MACT and TAU, either at 6 or 12
months.
Possible that a longer period of treatment or greater
engagement in face-to-face treatment, were this
achievable in routine health care settings, would show
more favourable results.
BPD showed an increase in costs in health service usage
with MACT
Manual-assisted cognitive therapy slightly increases the
likelihood of self harm relative to treatment as usual with
PD patients
Dialectical Behaviour Therapy



Initial improvement
Disappointing in follow-up
Replication in inner city London delivered poor results
 High drop out
 Worse on a number of measures





Level of training required unknown but considered
extensive
Better for self-harm than suicide
Effect on personality function unclear
Poor social-emotional function probably continues
Variable change on depression and hopelessness
Verheul, R., Van Den Bosch, L. M., Koeter, M. W., et al (2003)
Dialectical behaviour therapy for women with borderline personality
disorder: 12-month, randomised clinical trial in The Netherlands. Br J
Psychiatry, 182, 135-140.
Log-transformed LPC Composite Score
8
7
DBT (n=27)
TAU (n=31)
6
5
4
3
2
1
0
baseline
week 22
week 52
Figure 2. Frequency of self-mutilating behaviors in the past 3 months at week 22 and week
52 since the start of treatment by treatment condition. DBT indicates Dialectical Behavior
Therapy; TAU indicates treatment-as-usual.
Verheul, R., Van Den Bosch, L. M., Koeter, M. W., et al (2003) Dialectical
behaviour therapy for women with borderline personality disorder: 12-month,
randomised clinical trial in The Netherlands. Br J Psychiatry, 182, 135-140.
Log-transformed LPC Composite Score
18
16
14
DBT- high-severity group (n=13)
TAU - high severity group (n=16)
DBT - low severity group (n=14)
TAU - low severity group (n=15)
12
10
8
6
4
2
0
week 22
week 52
Figure 4. Frequency of self-mutilating behaviors in the past 3 months at week 22 and week
52 since the start of treatment by treatment condition and baseline severity group. Membership
of severity groups is determined by median split on the lifetime number of self-mutilating acts
(i.e., <14 versus  14). DBT indicates Dialectical Behavior Therapy; TAU indicates treatmentas-usual.
Change in Reflective Function as a
Function of Time and Treatment
4.5
4.3
4.1
3.9
3.7
3.5
3.3
3.1
2.9
2.7
2.5
TFP
DBT
SPT
RF Time 1
RF Time 2
Trial I:
RCT of Psychoanalytic Partial
Hospital Treatment (18 months)
(Bateman & Fonagy, 1999, 2001, 2003)
Attempted Suicide:
Self-Mutilating:
Inpatient Episodes:
Depression:
NNT (18 months)= 2.1
NNT (36 months)= 1.9
NNT (18 months)= 2.1
NNT (36 months)= 2.0
ES(18m)= 1.4
ES(36m)= 1.1
NNT(36m)= 2.1
Limitations
Small sample size
 Control treatments undefined
 Multi-component treatment
 No replication sites yet (no longer true)
 Costly, relative to an outpatient treatment
(at least relative to little service)
 Only for most chaotic and severe
 Length of treatment unclear

Dutch Cohort Study
SCL-90
BDI
IIP
OQ-45
300.0
250.0
243.0
231.8
Effect size:
200.0
190.5
201.8
186.4
184.6
167.6
BDI: 2.2
IIP: 2.2
150.0
104.7
95.0
OQ-45: 2.0
105.9
100.0
72.3
50.0
SCL-90: 1.1
26.1
23.4
27.3
Basislijn
3m
6m
16.8
0.0
Eerste groep MBT-patiënten
12m
Conclusions from treatment trials



RCTs have shown modified psychodynamic
therapies (MBT and TFP) and modified CBT
(DBT, SFT) to be moderately effective
Non-randomised trials show other
implementations of psychodynamic, supportive
and CBT interventions to be somewhat effective
Briefer periods of hospitalisation shown to be
more effective than longer ones
 Hospitalisation motivated by suicidal threat is
ineffective (Paris, 2004)

A range of well-organised and co-ordinated
treatments are effective for BPD
Problems, Problems, Problems
Some efficacy of various treatments which
may bring forward natural improvement
 More limited effects in severe populations
 Questionable generalizability of treatments
 High levels of training required
 Poor penetration of psychiatric services

Re-mapping the course of
borderline personality disorder
Therapeutic Nihilism About BPD

Early follow-up studies
inexorable progression of the ‘disease’
“burnt out” borderlines

Condition resistant to therapeutic help
intensity and incomprehensibility of emotional
pain
dramatic self-mutilation
ambivalence in inter-personal relationships
wilful disruption of any attempt at helping
Remissions and Recurrences
Among 275 Patients with BPD
Percent
Remission
Recurrence
90
80
70
60
50
40
30
20
10
0
2-Years
4-Years
6-Years
Source: Zanarini et al. (2003) Am. J. Psychiat. 160, 274-283
(10-Years)
Time to 12 Month Remission for DIPD
Positive Cases (The CLPS Study)
BPD (n=201)
MDD (n=95)
Proportion not remitting
1
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
0
6
12
18
24
30
36
42
48
Time from intake in months
Remission is defined as 12 months at 2 or fewer criteria for PDs; Grilo et al., (2004)
Remission is defined as 2 months at 2 or fewer criteria for MDD JCCP, 72, 767-75.
Summary of Remission Findings




After six years 75% of patients diagnosed with
BPD severe enough to require hospitalisation,
achieve remission by standardised diagnostic
criteria.
About 50% remission rate has occurred by four
years but the remission is steady (10-15% per
year).
Recurrences are rare, perhaps no more than
10% over 6 years.
Treatment has no (or only negative) relationship
to outcome
Impulsive Features, Affective Instability
and Identity Problems of 290 BPD
Manipulative Suicide
Affective Instability
Self-mutilation
Identity Disturbance
Percent
100
80
60
40
20
0
Baseline
2-Years
4-Years
Source: Zanarini et al. (2003) Am. J. Psychiat. 160, 274-283
6-Years
Interpersonal Features of 290 BPD
Patients Followed Prospectively
Aloneness
Relationship Storms
Abandonment
Dependency
Percent
100
80
60
40
20
0
Baseline
2-Years
4-Years
Source: Zanarini et al. (2003) Am. J. Psychiat. 160, 274-283
6-Years
Affective Features of BPD Followed
Prospectively
Hopelessness
Anger
Anxiety
Depression
Percent
100
80
60
40
20
0
Baseline
2-Years
4-Years
Source: Zanarini et al. (2003) Am. J. Psychiat. 160, 274-283
6-Years
Differential improvement rates of
BPD symptom clusters

Impulsivity and associated self mutilation and
suicidality that show dramatic change
 The dramatic symptoms (self mutilation, suicidality,
quasi-psychotic thoughts) recede

Affective symptoms or deficits of social and
interpersonal function are likely to remain present
in at least half the patients.
 anger,
 sense of emptiness,
 relationship problems,
 vulnerability to depression
Time to GAF 12 Month Remission for DIPD
Positive Cases (The CLPS Study)
BPD (n=201)
MDD (n=95)
Proportion not remitting
1
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
0
6
12
18
24
30
36
42
48
Time from intake in months
Remission is defined as 12 months at 2 or fewer criteria for PDs; Grilo et al., (2004)
JCCP, 72, 767-75.
Remission is defined as 2 months at 2 or fewer for MDD
Determinants of remission

When dramatic improvements occur, they
sometimes occur quickly,
often associated with relief from severely
stressful situations (Gunderson, Bender,
Sanislow, et al, 2003)

Co-morbidities undermine the likelihood of
improvement (Zanarini, Frankenburg,
Hennen, et al, 2004)
Persistence of substance use disorders
Implications of Recent Follow Along
Studies
 Implication of secondary persistence of
social/functioning impairment
Treatments should be directed at social function
o Social skill building, community/groups
o Vocational rehabilitation; testing; training
o Improve adaptive capabilities (as opposed to decreasing
maladaptive behaviours) e.g. recreational or leisure time
activities
GAF is very relevant outcome measure
Need for better measures sensitive to social
functioning in this population (?APFA)
Partial Hospital RCT: Patients at 5 yrs FU
MBT-PH
TAU
90
80
70
60
50
40
30
20
10
0
Meet criteria
(p<.0001)
No longer Subsequent Any suicide
on
treatment
attempt
medication
(p<.02)
(p<.001)
(p<.005)
No self harm
(p<.001)
Partial Hospital RCT: Patients at 5 yrs FU
MBT-PH
TAU
20
18
16
14
12
10
8
6
4
2
0
total
score(p<0.0001)
affective
disturbance
(p<.01)
cognitive
disturbance
(p<.08)
impulsivity score
(p<.001)
disturbed
relationship
(p<.0.0003)
Partial Hospital RCT: % Attempting Suicide
N=44
NNT (18 months)=2.1
NNT (36 months)=1.9
NNT (60 months)=2.1
100
90
80
*
*
70
***
***
60
**
50
**
Day Hospital
Control
40
30
20
10
0
Admission 12 months 24 months 36 months 48 months 60 months
Treatment
Follow -up
* p < .05
** p < .01
*** p < .001
Partial Hospital RCT: Employment
MBT-PH
TAU
80
Percent in Employment
70
60
50
40
30
20
10
0
Baseline
MidTreatment
End
Treatment
1 year FU
2 year FU
3 year FU
Partial Hospital RCT: GAF Scores
65
60
Mean GAF Score
55
50
MBT-PH
TAU
45
40
35
30
Baseline
End
treatment
18m FU
30 m FU
42 m FU
The outcome paradox in BPD
Non-suitability
Het alternatief
The paradox of the outcome of BPD



Many treatments show moderate effectiveness
The disorder has a positive natural progression,
irrespective of treatment
Historically, experts agreed about the treatmentresistant character of the disorder
 97% of patients receive outpatient of care
 average of 6 therapists
 TAU is only marginally effective (Lieb et al, 2004)
The painful conclusion

Some psychosocial treatments impede the
patient’s recovery following
 The natural course of the disorder
 Advantageous social circumstances
Suggestive evidence for the reality
of iatrogenic harm

Classic follow-up of patients treated in the 1960s and 1970s
(Stone, 1990)



One year hospitalisation is significantly less effective than 6
months hospitalisation (Chiesa et al, 2003)


66% recovery only achieved in 20 years
4 times longer than recent studies
The iatrogenic effects of hospitalisation persist at 72 months followup
Brief manual-assisted cognitive therapy slightly increases
the likelihood of self harm relative to treatment as usual with
PD patients (Tyrer et al, 2004)
Suggestive evidence for the reality
of iatrogenic harm

Karterud et al 530 patients high intensity treatment ‘v’ 330
low intensity
 Low intensity better for the BPD-patients.
 lower number of dropouts (27% versus 32%)
 higher number of patients achieving reliable change in GAF which
was maintained at one year follow-up.

Improvements in treatment outcome may be a
consequence of the changing pattern of healthcare in the
US
 reduced the likelihood of iatrogenic deterioration associated with
damaging side effects of lengthy psycho-social treatment
Iatrogenesis, psychotherapy and
BPD



Pharmacological studies assume the possibility
of and test for adverse reactions
Psychotherapy is assumed to be at worse inert
No systematic studies of adverse reactions to
psychotherapy
 No theory of adverse reaction

Adverse reaction must link to mechanisms of
change
How change occurs in therapy with
BPD

Interpersonal mechanism of change
Change occurs not through insight, catharsis,
or negotiation
Change occurs through new emotional
experience in the context of attachment salient
interactions

Not the content of therapy but the process
of treatment
Adverse reactions and ordinary
mechanisms of therapeutic change


Psychotherapies interface with a range of processes
associated with technique (distorted cognitions,
coherence of narrative, expectations of the social
environment, expectations of the self – hope)
A generic factor in common to all these:



Consideration of one’s experience of ones own mental state
alongside that which is presented through therapy (by the
therapist, by the group)
Assumes appreciating the difference between ones
experience of ones own mind and that presented by
another person
We assume that the integration of current experience of
mind with alternative views is foundation of the change
process (Allen and Fonagy, 2002)
Reduced appreciation of mind 
vulnerability to therapy

Individuals with BPD have impoverished model of
mental function



Creates vulnerability to




Emotional storms
Impulsive actions
Problems of behavioural regulation
Consequently unable to compare



Own and others’
Schematic, rigid, extreme ideas about states of mind
A self-generated model
Model presented by ‘mind expert’
Maladaptive consequences


Accept alternatives uncritically, without integration,
(untherapeutic)
Reject them wholesale  drop-out of therapy
The danger of ‘psychotherapies’ for
BPD

The therapist’s general stance may often in itself
be harmful, however well-intentioned
 ‘I think what you are really telling me …..
 It strikes me that what you are really saying…
 I think your expectations of this situation are distorted’

A person who cannot discern the subjective
state associated with anger cannot benefit from
 Being told that they are feeling angry
 And what the underlying reasons for the anger might
be
The fate of assertions about the
inner world of BPD patients


It can only be accepted as true or rejected
outright
Dissonance between patient’s inner
experience and external perspective is not
appreciated  bewilderment  instability
by challenging and undermining the
patient’s own enfeebled representation of
inner experience  more rather than less
mental and behavioural disturbance
The Fonagy & Bateman Principle
A therapeutic treatment will be effective to the
extent that it is able to enhance the patient’s
mentalising capacities without generating too
many iatrogenic effects
Clinical Implications
The Focus of Psychotherapy is
Often on Autobiographical Memory
“You‘re born, you deconstruct your
childhood, and then you die “
Dysregulation of attentional
capacities



With individuals whose attachment relationships
have been disorganized we may anticipate quite
severe problems in affect regulation and
attentional control along with profound
dysfunctions of attachment relationships
Exploratory psychotherapy techniques are likely
to dysregulate the patient’s affect
It is wise to anticipate difficulties in effortful
control
Disorganisation of self

The therapist should be alert to subjective
experiences indicating discontinuities in self
structure (e.g. a sense of having a
wish/belief/feeling which does not ‘feel like their
own’.)

It is inappropriate to see these states of minds as
if they were manifestations of a dynamic
unconscious and as indications of the ‘true’ but
‘disguised’ or ‘repressed’ wish/belief/feeling of the
patient

The discontinuity in the self will have an aversive
aspect to most patients leading to a sense of
discontinuity in identity (identity diffusion)
Projection of alien self

Patients will try to deal with discontinuous
aspects of their experience by externalisation
(generating the feeling within the therapist)

The tendency to do this had been established
early in childhood

It is not going to be reversed simply by bringing
conscious attention to the process – therefore
interpretation of it is mostly futile
That was just a joke
to break the ice.
Now don’t immediately
cry you silly cow!
Doctor, I feel
very depressed
I can understand
with such a sad face
That woman is
clearly not ready
for therapy.
Psychic equivalence




Characterised by conviction of being right that makes
entering into Socratic debates mostly unhelpful
Patients commonly assume that they know what the
therapist is thinking - claiming primacy for introspection
(i.e. saying that one knows one’s own mind better than
the patient) will lead to fruitless debate
Therapist may make ill advised attempt to ‘defend’
position
Grandiosity and idealization are also expectable
consequences of an unquestioning mind
Psychic equivalence



It is not the action itself that carries most meaning
in this mode but deviation from action that is
contingent with the patient’s wishes
Self-harm, suicide attempts and other dramatic
actions tend to bring about contingent change in
the behaviour of most people - patient
experiences a sense of being cared about
Misuse of mentalisation may be linked to such
pseudo-manipulativeness and involve realistic
risk of harm to the patient or interactive partner
Pseudomentalizing



Challenging pseudo-mentalisation in the pretend mode
can provoke extremeȠreactions because of the vacuum it
reveals
Pretend mode pseudo-mentalisation denies the
therapist's own sense of reality and the therapist can be
left feeling excluded and trying harder to connect to the
patient’s discourse
The patient’s experience of lack of meaningful connection
to reality can be the prompt and drive behind the search
for connection but the connections found are often
random, complex, untestable and confusing – exploration
is unproductive
Iatrogenesis




Therapeutic interventions run the risk of exacerbating
rather than reducing the reasons for temporary failures of
mentalising
Non-mentalising interventions tend to place the therapist
in the expert role declaring what is on the patients’ mind
which can be dealt with only by denial or uncritical
acceptance
To enhance mentalising the therapist should state clearly
how he has arrived at a conclusion about what the patient
is thinking or feeling
Exploring the antecedents of mentalisation failure is
sometimes but by no means invariably helpful in restoring
the patient’s ability to think
Therapist Stance

Not-Knowing/Inquisitive
 Neither therapist nor patient experiences interactions other than
impressionistically
 Identify difference – ‘I can see how you get to that but when I
think about it it occurs to me that he may have been preoccupied with something rather than ignoring you’.
 Acceptance of different perspectives
 Active questioning

Monitor you own mistakes
 Model honesty and courage via acknowledgement of your own
mistakes
o Current
o Future
 Suggest that mistakes offer opportunities to re-visit to learn more
about contexts, experiences, and feelings
Therapist/Patient Problem
THERAPY STIMULATES
ATTACHMENT SYSTEM
EXPLORATION
DISCONTINUITY
OF
SELF
ATTEMPT TO STRUCTURE
by
EFFORT TO CONTROL SELF &/OR OTHER
Therapist/Patient Problem
ATTEMPT TO STRUCTURE
by
EFFORT TO CONTROL SELF &/OR OTHER
RIGID SCHEMATIC REPRESENTATION
NON-MENTALIZING
CONCRETE MENTALIZING (PSYCHIC EQUIVALENCE)
PSEUDO MENTALIZING (PRETEND)
MISUSE OF MENTALIZING
FAQ’s about Mentalization Based
Treatment

Do you use validation?
 Yes
o observing and reflection - two aspects of validation are
common to every therapy and are an essential aspect to MBT.
 Direct validation
o DBT - used to confirm the patient’s experience and contingent
response as being understandable in a specific context.
o MBT follows the same principles but the focus is on
exploration and on elaborating a multi-faceted representation
based on current experience particularly with the therapist.
FAQ’s about Mentalization Based
Treatment

Does the mentalizing therapist self-disclose
 Yes. But no more than you would in everyday
interaction.
o Explanation of the reasons for your reaction is useful
especially when challenged by the patient
o Answer appropriate questions prior to exploration in order not
to use fantasy development as part of therapy
 Careful self-disclosure
o Verifies a patient’s accurate perception
o Underscores the reality that you are made to feel things by him
which is an essential aspect of treatment
FAQ’s about Mentalization Based
Treatment

Do you use fantasy development about the
therapist?
No
o Stimulating fantasy about the therapist is likely to be
experienced as fact
o Confirms the patients distorted beliefs or
assumptions
o Borderline patient does not retain an ‘as if’ quality or
‘observing ego’ when operating in psychic
equivalence
Thank you for
mentalizing!
For further information
anthony@abate.org.uk
Trial II:
Outpatient Implementation of
Mentalization Based Therapy for
Borderline Personality Disorder
Design of pilot study of out-patient MBT
Eligible consecutive patients
SCID I&II plus Clarkin Severity
(N=56)
Patients randomised (N=50)
Minimisation for:
Age (18-25, 26-30, >30)
Gender
Antisocial PD
3:2 Experimental – control ratio
Mentalization Based Treatment
Individual and Group
Psychotherapy 18-months
(N=30)
Patients not randomised
due to refusal (N=6)
Naturalistic follow-up
Where consent to research
now or later
Non-manualised therapies:
Individual or group
‘supportive’ psychotherapy
18-months plus normal care
(N=20)
Pilot Study out-patient MBT
Patients in treatment
(N=50)
Mentalization Based Treatment:
Individual and group psychotherapy
18-months (N=30)
3-months: SCL-90, BDI, SpielS&T, IIP, SAS
6-months: Sui & Self-harm Inventory
Hospital Admission
Service Usage e.g.A&E
Drop-out=3
Intention to treat analysis(N=)
18 Months Follow-up (N=?)
Non-manualised therapy group
Individual, group, other psychotherapy
plus normal care
18-months (N=20)
3-months: SCL-90, BDI, SpielS&T, IIP, SAS
6-months: Sui & Self-harm Inventory
Hospital Admission
Service Usage e.g.A&E
Drop-out=7
Intention to treat analysis (N=)
18 Months Follow-up (N=?)
Pilot Study: % Attempted Suicide (NNT=3.8)
100
O/P MBT
(n=29)
90
Control Therapy
(n=20)
80
70
60
50
*
40
30
20
PH outcome
10
0
Admission
6 months
12 months
Trend O/P MBT: W=.45, Chi squared= 38.7, df=3, p<.001
Trend Control: W=.16, Chi squared= 9.33, df=3, p<.05
18 months
* p < .05
** p < .01
*** p < .001
% Self-Mutilating Behavior (NNT=6.7)
90
O/P MBT
(n=30)
80
70
n.s.
Control Therapy
(n=20)
60
50
40
PH outcome
30
20
10
0
Admission
6 months
12 months
Trend O/P MBT: W=.20, Chi squared= 17.5, df=3, p<.001
Trend Control: W=.08, Chi squared= 4.5, df=3, n.s.
18 months
* p < .05
** p < .01
*** p < .001
Self Rated Depression (BDI)
Control
Therapy
(n=15)
O/P MBT
(n=22)
35
30
**
Mean BDI Scores
25
20
PH outcome
15
Pair-wise
comparisons
10
* p<.05
** p<.01
*** p<.001
5
0
Admission
6 months
12 months
18 months
ANOVA: Significance of interaction term: F2.4, 83 = 6.6, p<.01
Some progress but limitations
Bigger sample size
 Control treatments defined
 Two-component treatment
 Replication sites in UK and Netherlands
 Cheaper than most outpatient treatments
 Requires less training of staff team
 BUT

Effective component not yet clear
Measuring mechanisms of change.
Slides
http://www.psychol.ucl.ac.uk/
psychoanalysis/anthony.htm