Psychotherapy for Borderline Personality Disorder Mentalization Based Treatment

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Edition: 1st
Format: Paperback
Pub. Date: 2004-05-20
Publisher(s): Oxford University Press
List Price: $77.86

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Summary

Borderline Personality disorder is a severe personality dysfunction characterized by behavioural features such as impulsivity, identity disturbance, suicidal behaviour, emptiness, and intense and unstable relationships. Approximately 2% of the population are thought to meet the criteria for BPD. The authors of this volume - Anthony Bateman and Peter Fonagy - have developed a psychoanalytically oriented treatment to BPD known as mentalization treatment. With randomised controlled trials having shown this method to be effective, this book presents the first account of mentalization treatment for BPD. The first section gives an overview of BPD, including discussion of nosology, epidemiology, natural history, and psychosocial aetiology. It additionally summarises the present state of our research knowledge about effective psychotherapeutic treatments and use of medication. The second section outlines the authors' theoretical approach and contrasts it with other well known methods, including DBT, CAT, and CBT. In the extensive final section, the authors outline their clinical approach starting with how treatment is organised. A detailed account of the transferable features of the model is provided along with the main strategies and techniques of treatment. Numerous clinical examples are given to illustrate the core techniques and detailed information provided about how to apply aspects of the mentalization based treatment approach in everyday practice. Aimed at mental health professionals, along with counsellors, psychotherapists, and psychoanalysts, the book will be a valuable tool, providing an effective means of treating those suffering from Borderline Personality Disorder.

Author Biography


Anthony Bateman is Consultant Psychiatrist in Psychotherapy, St. Anns Hospital Peter Fonagy is the Freud Memorial Professor of Psychoanalysis, University College London, and Chief Executive of the Anna Freud Centre. He is the author of 8 other books, including, 'What works for whom? A critical review of psychotherapy research.'

Table of Contents

About the authors xvii
Introduction xix
Aims
xix
Organization of manual
xx
Core component of treatment
xxi
Who is this manual for?
xxii
The authors
xxiii
Chapter 1: Epidemiological and etiological research on borderline personality disorder 1(38)
Definition of the problem
1(2)
Diagnostic procedures
2(1)
Thresholds for diagnosis
2(1)
Epidemiology
3(1)
Clinical picture
3(6)
Phenomenological picture
3(1)
Functional impairment
4(1)
Psychodynamic picture
5(2)
BPO
5(1)
Defence mechanisms
5(1)
Object relations
5(2)
Co-morbidity
7(1)
Dimensional models of BPD
8(1)
The natural history of BPD
9(3)
The stability of the diagnosis over time
9(1)
The course of BPD
10(2)
Studies of mechanisms and aetiological factors
12(7)
Biological considerations
12(7)
Biological markers
12(1)
Genetic studies
12(2)
Neurotransmitter abnormality
14(1)
Candidate genes
14(1)
Cortical localization
15(3)
Attention and self-control
18(1)
Conclusion
19(1)
Psychosocial influences
19(15)
Theoretical considerations
19(2)
Parenting
21(2)
Parental separation or loss
21(1)
Family history
21(1)
Abnormal parenting attitudes
22(1)
Childhood trauma and maltreatment
23(3)
Models of psychosocial aetiology based on neglect and trauma
26(8)
The PTSD model
26(1)
The stress-diathesis model
27(1)
A multiple pathway model
28(1)
Biological pathways of the impact of extreme stress
29(3)
Childhood trauma as a risk factor for adverse brain development
29(1)
Serotonin system
30(1)
Endogenous opiate system
30(1)
HPA axis
30(1)
Anterior cingulate dysfunction
31(1)
Psychological pathways linking BPD to the impact of extreme stress: the role of affect dysregulation
32(2)
Attachment and BPD
34(3)
Theoretical considerations
34(1)
Empirical studies using the AAI
35(1)
Empirical studies using self-report measures of attachment
35(1)
Summary of empirical data
36(1)
Problems with a simple attachment model
37(1)
Conclusions
37(2)
Chapter 2: Therapy research and outcome 39(16)
Psychological treatments
40(10)
Psychoanalytic psychotherapy
40(6)
Empirical evidence for mentalization-based psychoanalytic treatment
43(1)
Results
44(2)
Cognitive analytic therapy
46(1)
Cognitive therapy
46(1)
Dialectical behaviour therapy (DBT)
47(2)
Therapeutic community treatments
49(1)
Drug treatments
50(2)
Antipsychotic drugs
51(1)
Antidepressant drugs
51(1)
Mood stabilizers
51(1)
Problems of outcome research
52(3)
Randomization and personality disorder
52(3)
Chapter 3: Mentalization-based understanding of borderline personality disorder 55(56)
The developmental roots of borderline personality disorder
55(1)
The relevance of the attachment theory perspective
56(1)
Optimal self-development in a secure attachment context
57(25)
Early stages of self-development
59(3)
The infant's sensitivity to social contingency
59(2)
The teleological stance
61(1)
The self as an intentional and representational agent
62(6)
Parental mirroring and the development of mental state concepts
64(4)
Psychic equivalence and the pretend mode
68(2)
Mentalization
70(5)
Reflective function and attachment
75(4)
Neurological basis of mentalization
79(3)
The impact of an insecure base
82(9)
The failure of mirroring
82(1)
Lack of playfulness
83(2)
Enfeebled affect representation and attentional control
85(2)
Disorganization of attachment
87(1)
Establishment of the 'alien self'
88(2)
Controlling IWM
90(1)
The impact of attachment trauma
91(18)
Failure of mentalization
92(2)
Changes to the arousal 'switch'
94(2)
Psychic equivalence, shame, and the teleological stance
96(1)
Failure of mentalization and the exposure of the 'alien self'
97(7)
Interpersonal relating and the transference
99(1)
Self-harm
100(1)
Suicide
101(1)
Impulsive acts of violence
101(2)
Clinical illustration
103(1)
Remembering trauma
104(5)
Conclusion
109(2)
Chapter 4: Current models of treatment for borderline personality disorder 111(34)
Transference-focused psychotherapy (TFP)
112(7)
Evaluation
117(2)
Dialectical behaviour therapy
119(7)
Dialectics
119(2)
Emotional dysregulation
121(1)
Mentalization and mindfulness
122(2)
Practice
124(2)
Cognitive behavioural therapy
126(3)
Cognitive analytic therapy (CAT)
129(3)
Reciprocal roles
129(1)
Reformulation and interpretation
130(2)
Psychodynamic-interpersonal
132(2)
Therapeutic communities
134(1)
Other North American approaches
135(4)
Other European approaches
139(2)
Mentalization: The common theme in psychotherapeutic approaches to borderline personality disorder
141(3)
Conclusion
144(1)
Chapter 5: Treatment organization 145(38)
Introduction
145(1)
Service models
145(3)
One-team model
146(1)
Treatment context
147(1)
Treatment guidelines
147(1)
The treatment programmes
148(2)
Staff
150(6)
The selection of staff
150(2)
Characteristics of training
152(1)
The team
152(1)
The key worker or primary clinician
153(1)
The responsible medical officer
154(2)
Assessment
156(2)
Engagement In treatment
158(17)
Pathway to admission
159(3)
Provision of information
159(2)
Clarification of key problems, as identified by the patient
160(1)
Explanation of the underlying treatment approach and its relevance to the problems
160(1)
Information about individual and group therapy and how it can lead to change
160(1)
An outline of confidentiality
161(1)
Clarification of some basic rules
161(4)
Violence
161(1)
Drugs and alcohol
161(1)
Sexual relationships
162(1)
Stabilizing social aspects of care
162(1)
Assuring the possibility of contact with the patient
162(1)
Clear-agreed goals
163(1)
Defining and agreeing roles of mental health professionals and others involved in the care of the patient
164(1)
History taking
165(2)
Interpersonal behaviour and intimate relationships
165(1)
Previous treatments and their outcome
166(1)
Formation of relational and working alliance
167(2)
Empathy and validation
167(2)
Reliability and readiness to listen
169(1)
Dynamic formulation
169(3)
Example of formulation
170(2)
Expressive therapies
172(2)
General strategic recommendations
173(1)
Organization
173(1)
Specific recommendations
173(1)
Common problems
174(1)
Drop-outs
174(1)
In-patient care
174(1)
Supporting the team
175(4)
Team morale
175(2)
Supervision
177(2)
Care programme approach
179(1)
Adherence
180(1)
Conclusions
181(2)
Chapter 6: Transferable features of the MBT model 183(20)
Structure
183(4)
Principle
183(1)
Rationale
184(2)
Boundary violations
184(2)
Implementation
186(1)
Consistency, constancy, and coherence
187(2)
Principle
187(1)
Rationale
187(1)
Implementation
188(1)
Relationship focus
189(2)
Principle
189(1)
Rationale
189(1)
Implementation
190(1)
Flexibility
191(1)
Principle
191(1)
Rationale
191(1)
Implementation
191(1)
Intensity
192(2)
Principle
192(1)
Rationale
193(1)
Implementation
194(1)
Individual approach to care
194(1)
Principle
194(1)
Rationale
194(1)
Implementation
195(1)
Use of medication
195(5)
Principle
195(1)
Rationale
196(1)
Implementation
196(3)
Summary of guidelines for psychopharmacological treatment
199(1)
Integration of modalities of therapy
200(1)
Conclusions
201(2)
Chapter 7: Strategies of treatment 203(18)
Enhancing mentalization
203(2)
Bridging the gaps
205(2)
Transference
207(3)
Retaining mental closeness
210(2)
Countertransference
211(1)
Working with current mental states
212(2)
Bearing in mind the deficits
214(2)
Real relationships
216(4)
Working with memories
217(1)
Hyperactive mentalization and pretend mode
218(2)
Conclusions
220(1)
Chapter 8: Techniques of treatment 221(48)
Identification and appropriate expression of affect
222(30)
General principles
222(2)
Rationale
222(1)
General strategic recommendations for identification of affects
222(1)
Individual session
222(1)
Group psychotherapy
223(1)
Impulse control
224(9)
General principles
224(9)
Rationale
224(1)
General strategic recommendations for dealing with problems of impulse control
225(1)
Suicide attempts and self-harm
225(1)
Suicide
228(1)
Self-harm
230(1)
Individual therapy
231(1)
Group therapy
232(1)
Other challenging affect states
233(19)
General principles
233(5)
Rationale
233(1)
General strategic recommendations
234(1)
Aggression related to paranoid anxiety
234(2)
Individual session
236(1)
Group therapy
237(1)
Passive aggression
238(2)
Individual session
238(1)
Group therapy
239(1)
Envy
240(2)
Individual session
240(1)
Group therapy
241(1)
Idealization
242(2)
Individual session
242(1)
Group therapy
243(1)
Sexual attraction
244(3)
Individual session
245(1)
Group therapy
246(1)
Hate and contempt
247(3)
Individual session
248(1)
Group therapy
249(1)
Love and attachment
250(2)
Individual session
250(1)
Group therapy
251(1)
Establishment of stable representational systems
252(8)
General principles
252(8)
Rationale
252(1)
General strategic recommendations
253(1)
Individual and group sessions
253(7)
Identifying primary beliefs and linking them to affects
254(2)
Identifying and understanding second-order belief states
256(1)
Exploring wishes, hopes, fears, and other motivational states
257(1)
Individual therapy
258(1)
Group therapy
259(1)
Formation of a coherent sense of self
260(3)
General principles
260(3)
Rationale
260(1)
General strategic recommendations
261(1)
Individual therapy
261(1)
Group therapy
262(1)
Development of a capacity to form secure relationships
263(4)
General principles
263(7)
Rationale
263(2)
General strategic recommendations
265(1)
Individual therapy
265(1)
Group therapy
266(1)
Conclusions
267(2)
Chapter 9: Implementation pathway 269(18)
Step 1: Consider the context in which you work, identify your skills and how you practice, and audit your resources
270(2)
Context
270(1)
Skills
271(1)
Audit of resources
272(1)
Step 2: Apply organizational principles
272(6)
Structure
273(1)
Clarity
274(1)
Consistency
274(1)
Relationship focus
275(1)
Intensity
276(1)
Medication
277(1)
Step 3: Modify the aims and techniques of your current practice
278(3)
Identify iatrogenic aspects of current practice
278(1)
Increase mentalization skill set incrementally to replace current iatrogenic techniques
279(2)
Step 4: Implement procedures for dealing with challenging behaviours
281(1)
Step 5: Constantly evaluate your practice
281(6)
Therapy adherence
281(1)
Systemic adherence
282(1)
Patient experience of treatment
282(5)
Appendix 1: Suicide and self-harm inventory 287(14)
Appendix 2: Training materials 301(12)
Appendix 3: Crisis plan 313(2)
Appendix 4: Rating of MBT adherence and competence 315(4)
Appendix 5: Text of intensive out-patient programme (IOP) leaflet 319(2)
Appendix 6: Admission feedback questionnaire 321(2)
References 323(50)
Index 373

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