Borderline therapy: Miss Understanding in the spotlight

7. October 2013

Borderline patients can empathise well with others – but it often happens that they misunderstand people. This paradox is related to their capacity to mentalise. Mentalisation-based therapy can help them, according to a study.

“Mentalising” is understood among psychologists as the ability to assess the desires, fantasies, thoughts and intentions of other people. Whoever can mentalise has the ability to reflect on themselves and others. The so-called “mental states” – such as desires and intentions – can be derived from gestures, facial expressions and actions.

Research has shown that mentalisation capacity is impaired in patients with borderline personality disorder. Psychoanalysts Peter Fonagy and Anthony Bateman have developed a therapy that improves the mentalisation capacity: mentalisation-based psychotherapy (MBT). This psychodynamic therapy method is a module that can be incorporated into various forms of therapy. Here, the therapist gives the patient space to contemplate their own mental states and the states of other people. Fonagy and Bateman present MBT in their book “Psychotherapy of Borderline Personality Disorder” (2008) extensively.

Good long-term results

Now, the authors present the long-term results of a randomised controlled study on MBT. They evaluated the data of 41 patients who were undergoing semi-hospitalised treatment because of borderline personality disorder. Patients were randomly assigned to an MBT group or a standard therapy group. The participants in the MBT group received 18 months of mentalisation-based therapy and for another 18 months after discharge maintained visits to a MBT group. The control group received standard psychiatric therapy. 8 years after the start of the study, or 5 years after completion of mentalisation-based therapy, it was shown that patients in the MBT group had significantly benefited more from therapy than patients in the standard treatment group.

While “only” 23% of the MBT group were still suicidal, the proportion of suicidal patients in the standard group sat at 74%. Also, the use of medication was significantly lower in the MBT group than in the standard group: The MBT patients took three or more medications for time periods adding up to 0.02 years, while for patients in the standard group this figure was 1.9 years. 45% of the MBT group and 10% of the standard therapy group showed a value of about 60 in the GAF scale (Global Assessment of Functioning Scale). Whereas the MBT patients were working or in training for about 3.2 years, the average work/education-training period among the patients of the standard group was 1.2 years.

Hypermentalisation is treatable too

A particular problem of many borderline patients is “hypermentalisation”. Because of trauma in their past, patients are constantly in a “wary state” so to speak, and over-interpret the actions and intentions of others. For example: A patient invites a girlfriend to a birthday. This friend declines because she already has an important appointment on that day. The patient derives from this the fact that the friend generally rejects her.

Whether patients tend to hypermentalise can be determined for instance by using the “Movie for the Assessment of Social Cognition” (MASC). Here the patient will be played 15-minute films. After various scenes, the patient is asked how he or she interprets these sequences. The researchers can determine whether the patient does not mentalise (eg take everything literally), or is under the average level, is adequate in this faculty or mentalises too much (ie. over-interprets behaviours).

Carla Sharp and colleagues at the University of Houston, Texas, USA, investigated whether hypermentalisation is a characteristic feature of borderline patients and whether this kind of mentalisation can be reduced during stationary psychodynamic therapy.

From among 164 adolescent study participants, 68 (41%) demonstrated a borderline personality disorder. Hypermentalisation appeared independently of exhibited internal and external problems. Compared to patients with other conditions, hypermentalisation was particularly frequently observable among borderline patients. The more strongly the hypermentalisation was pronounced at the time of admission to the hospital, the greater the borderline patients also suffered from their symptoms.

The researchers established among these respective patients a significant reduction in hypermentalisation between the date of admission to the hospital and date of discharge (F = 76.11, p < 0.01). The reduction in hypermentalisation was highly significantly statistically associated with the reduction of borderline symptoms (r = -0.25, p = 0.005). All patients received interpersonal-psychodynamic therapy, which was targeted at among other things improving the mentalisation capacity of the patients.

The frequently encountered assumption that borderline patients cannot or only weakly mentalise therefore have to be looked at critically. Rather, many borderline patients are characterised by the fact that they mentalise “too strongly”. Mentalising is thus very often an ability available to them, although in disturbed form. Using psychodynamic mentalisation-based therapy, it can be reset to normal.

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Medicine, Psychiatry

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