Evidence-based psychological interventions for borderline personality disorder in the United Kingdom—who falls through the gaps?

Over the past fifteen years, access to evidence-based psychological interventions (EBPIs) for borderline personality disorder has dramatically increased in the United Kingdom. However, some patients continue to fall through the gaps. This article presents a novel analysis of evidence on patients who are currently unable to benefit from EBPIs and explores possible solutions, with particular reference to dialectical behaviour therapy and mentalization-based therapy. At one end of the spectrum, patients with less severe difficulties often do not meet the threshold for receiving EBPIs in dedicated personality disorder services. The nascent evidence base for a possible solution—implementation of streamlined versions of EBPIs in generic mental health or even primary care services—is reviewed. At the other end, a sizeable minority of patients receiving long-term EBPIs discontinue treatment prematurely and/or experience poor outcomes. This is a highly distressing experience with potential for iatrogenesis—yet the evidence base for what to do next is non-existent and follow-on treatment pathways in services are unclear. Difficulties in the therapeutic alliance, a failure to overcome epistemic hypervigilance, and therapist non-adherence to the model are reviewed as possible contributing factors. The importance of understanding the patient perspective on what happened, considering the role of both patient and therapist in contributing to difficulties, and offering patients a choice in specifying their onward treatment, is discussed. Finally, increasing access to trauma-focused EBPIs for post-traumatic stress disorder is recommended as an avenue for the future.

"And whatever you say, you say nothing" Establishing epistemic trust in The Lighthouse MBT-parenting programme: a case study

Mentalization-based treatment (MBT), developed by Anthony Bateman and Peter Fonagy for treatment of borderline personality disorder (BPD), is explicit in seeking to establish epistemic trust in the therapeutic relationship and has as a goal its generalisation to other relationships and social connections/opportunities (Fonagy et al., 2017a, 2017b). MBT adaptations have shown some promising results with parents with histories of disrupted/disorganised attachments and abuse in childhood, and who themselves have maltreated their children (Byrne et al., 2018). These parents rarely seek referral for treatment but are coerced into the therapeutic space by a court order or child protection plan, effectively; by the threat of removal of their children from their care if they do not attend. This article outlines the research context including a summary of what we know about the childhood experiences and attachment histories of those parents with BPD who have been identified as at risk of maltreating their children and the recent research on MBT informed parenting interventions. It describes the climate of epistemic mistrust within which a specialist treatment service attempts to engage these parents and the challenges to the establishment of epistemic trust. Clinical examples are used to illustrate the journey from epistemic mistrust and hypervigilance to trust in the facilitators and the group.

The pragmatic application of attachment theory in medical decision making regarding emotionally unstable personality disorder presentations to healthcare settings

A hypothesis is formulated whereby individuals with adverse childhood experiences can come to have a disrupted attachment system and this can impact the manner in which individuals engage in healthcare. Maslow's hierarchy of needs suggests a motivation for safety and it is proposed that the healthcare system can come to represent the secure base. Behaviours that lead an individual into the healthcare setting can thus be positively reinforced by satisfying such a dynamic need. Prescribing behaviours are examined relating to this notion. The spectrum of intention-to-die type presentations in an acute healthcare setting are considered. The contribution of the concept of risk and uncertainty to decision makers is examined as a possible component to the propagation of unhelpful care pathways, where risk averse decision making leads to interventions of limited clinical utility for an individual. An introduction to the notion of a "corrupted capacity assessment" is made, which refers to the process of a doctor concluding that an individual lacks capacity without considering that this may be the outcome desired by a patient with capacity. Pragmatic strategies are suggested as a way to minimise iatrogenic harms and maximise therapeutic potential at clinical encounters where risk is a facet. Longitudinal assessments with an acknowledgement of the harms in preceding compulsory care pathways are promoted as well as an articulation of the clinician's anxiety for the purposes of reflection, in order to arrive at a clinical decision that is solely in the patient's best interest. It is suggested that ambivalence over the patient's perception of value to life is explicitly validated at such junctures. Personal responsibility and capacity for individuals presenting should be therapeutic goals if an individual has come to, or is doubting, their own autonomy and wishing to invest such factors in compulsory care pathways.

Borderline personality disorders: from the developmental theory of the "self" and mentalizing to "systems"

In the last fifty years the thinking around borderline personality disorder (BPD) shifted from an intra-psychic to a psychoanalytically oriented relational model. The latter described the difficulties associated with this presentation as arising from a disorganisation of the "self" structure in the context of an early caregiving relationship. The concept of inaccurate, or inconsistent "social biofeedback parental affect mirroring" has been pivotal to explain the characteristic failure to mentalize and the interpersonal difficulties associated with a diagnosis of BPD. Nevertheless, far from being the result of a sole linear relationship, these difficulties appear linked to communicative and emotional feedback loops that are reminiscent of cybernetic principles. Furthermore, recent claims have suggested that the communication feedback loops characteristic of the carer–child attachment style represent nothing less that the communication styles of the wider social environment in which the dyad is located. These claims have recently prompted a further shift from mentalizing to epistemic trust and epistemic vigilance, hence departing from a relational model towards a more systemic one. The difficulties associated with BPD are now suggested to be linked to a disorder of social learning, impacted by the rigid nature of the person's information-processing systems. This article reviews this journey.

What you see is not what you get: multiple states and dialogues in borderline presentations

The recently revised NICE guidelines on treatment and management of borderline personality disorder (BPD) (NICE, 2018) presents new evidence on psychological therapies being effective treatments for patients diagnosed with BPD. This article will describe some of the challenges we face as clinicians working with complex co-morbid presentations in a healthcare setting. It will briefly discuss the different modalities as suggested by NICE guidelines and expand on the implications of this guidance in relation to service development and constant restructuring, often acted out as an organisational procedure to avoid the harsh reality of limited resources within the NHS. The impact of this on patient care, organisational dynamics, the need for joined-up thinking, and contextual formulations will be discussed using case scenarios. Clinical examples will be used to highlight that pseudo hallucinations, core thoughts, self-to-self dialogues, which trigger "state shifts", can be understood and formulated using dialogic sequence analysis (Leiman, 1998) and concepts from cognitive analytic therapy (CAT). This article will offer some pointers as to how we as clinicians can build resilience, survive the powerful projections and countertransference reactions, recognise the importance of self-care, supervision, and personal therapy in order to be effective, minimise harm, and develop compassion for our patients.

The relationship to caregiving: how psychological therapies can support carers of people with a diagnosis of emotionally unstable (borderline) personality disorder

This article reviews empirical studies of psychological interventions that have been offered to (informal) carers for people with a diagnosis of emotionally unstable (borderline) personality disorder (EUPD). A search of electronic databases, and subsequent reference searching, was performed in October 2019 to identify empirical studies in this area. In total, sixteen articles were included in this review. The quality of each paper was formally reviewed, alongside their findings. Three main theoretical approaches were apparent: mentalization-based treatment (MBT), dialectical behaviour therapy (DBT), and other psycho-education or miscellaneous intervention. Intervention outcome measures included scales for burden, grief, depression, and anxiety, many of which saw improvements, including clinically significant changes. Among high-quality papers, there was no clearly superior approach to interventions for carers. This review emphasised the need for plurality in psychological approaches for supporting carers, and for more work in this developing area of research.

Freud, sex, and the soul: does Freud’s focus on sex obscure his relevance to the twenty-first century soul-searcher?

This article explores what the work of Sigmund Freud has to offer those searching for a more spiritual and philosophical exploration of the human experience. At the early stages of my psychotherapy training, I shared with many peers an aversion to Freud’s work, driven by a perception of a mechanistic, clinical approach to the human psyche and of a persistent psychosexual focus. This article traces my own attempt to grapple with his work and to push through this resistance. Bettelheim’s (1991) treatise that Freud was searching for man’s soul provides a more sympathetic lens through which to explore Freud’s writing, one which enabled me to discover a rich depth which had not previously been obscured. This article is an account of my journey to a new appreciation of Freud’s work. It identifies a number of challenges to Bettelheim’s argument, whilst also indicating how his revised translation allowed a new understanding of the relevance of Freud’s work to the modern reader. This account may be of interest to those exploring classical psychotherapeutic literature as well as those guiding them through that process.

An inevitable crisis? From first to second year in counsellor training

In a seminal 1973 paper, Robert Clark described the very different “cultures” of the first and second year students in a four year clinical psychology PhD programme. The author applies Clark’s template to his own experiences as trainee or trainer in five different counsellor education programmes, one in the US and four in Australia. Each of the programmes, to varying degrees, demonstrates key features of the pattern identified by Clark, where the first year is “therapeutic” and other-oriented, the second is “professional” and self-focused. The author concludes that all the surveyed programmes exhibited some level of “second year crisis”, in which a significant number of students felt abandoned, dissatisfied, or rebellious. The author extends and refines Clark’s developmental analogy (first year = childhood; second year = adolescence) to reflect recent neurological research, in particular, the shift from a right hemisphere-dominant first year of life, prioritising affiliative needs, to a left hemisphere-dominant second year, prioritising autonomy and control. This shift is paralleled later by a more gradual move from a protective, supportive childhood to necessary, but sometimes conflictual, individuation in adolescence. The first two years of a counsellor training programme broadly echo this process, a process exacerbated by the second year internship/placement, in which students must “leave home” and adjust to unfamiliar, potentially less nurturing, authority figures. Finally, the author suggests introducing more rigorous “academic holding” into the first year, and greater attention to “therapeutic holding” of dissident students in the second, hopefully decreasing student dropout, and achieving a better balanced training experience.

Learning to stay still: reflective practice in the context of supervision—integrating the personal and the professional

Clinical supervision plays a crucial role for professional development and is mandatory for trainees and qualified psychologists and psychotherapists alike. Its function and style can vary significantly and range from case management to the depth of reflexive supervision characteristic of counselling psychology and psychotherapy. While the literature has thoroughly described the purpose and the characteristics of helpful and unhelpful supervision, the relationship between the personal and the professional elements of supervision is largely ignored. Trainees often embark on their professional journey with an unclear and, at times, fearful sense of integrating the clinical and the personal. Yet, the two cannot be separated. This article aims to reflect on a personal journey in supervision and to bridge the gap between the professional and the personal. The reader can expect a very personal style of writing as I recount some episodes of my own learning and transformation, and I use the theory to make sense of that journey. Given that it’s in the intersection between the different selves that transformational learning is created, the profession ought to encourage and foster more transparent, reflexive dialogues.