Research

The effectiveness of the Day Unit programme in the treatment of Borderline Personality Disorder has been the subject of a randomised, controlled study, which has been published in the following papers:

Bateman, A.W. & Fonagy, P. (1999) Effectiveness of Partial Hospitalization in the Treatment of Borderline Personality Disorder: A Randomized Controlled Trial. American Journal of Psychiatry; 156: 1563-1569.

Objective: This study compared the effectiveness of psychoanalytically oriented partial hospitalization with standard psychiatric care for patients with borderline personality disorder. Method: 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. Results: 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. Conclusions: Psychoanalytically oriented partial hsopitalization 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.

Bateman, A.W. & Fonagy, P. (2001) Treatment of Borderline Personality Disorder with Psychoanalytically Oriented Partial Hospitalization: An 18-month Follow-Up. American Journal of Psychiatry; 158: 36-42.

Objective: 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. Method: 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. Results: 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. Conclusions: 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.

The effectiveness of the Intensive Outpatient Programme in the treatment of personality disorder is currently the subject of an ongoing randomised, controlled study.

Further relevant publications are:

Bateman, A.W. (1995) The Treatment of Borderline Patients in a Day Hospital Setting. Psychoanalytic Psychotherapy; 9(1): 3-16.

This paper outlines some of the theoretical principles underpinning the psychotherapeutic treatment of borderline patients in a day hospital setting. The main emphasis is on maintaining a creatively functioning parental couple in different contexts. The parental couple is conceptualised as a balance of appropriate 'doing' and 'being'. The attacks of the borderline patient, through splitting and projective identification, on the creatively functioning parental couple leads to excessive 'doing to' or inappropriate 'being with' on the part of the staff. The different contexts in which the parental couple is attacked are described. The task of the day hospital and the staff group is to hold the parental couple in mind at all times and to function as a cohesive whole. In order to do this the day hospital functions as a transitional space in which 'doing' and 'being' are explored, especially through the understanding of countertransference reactions. The use of a third object to maintain a therapeutic balance is discussed.

Bateman, A.W. (1997) Borderline Personality Disorder and Psychotherapeutic psychiatry: An Integrative Approach. British Journal of Psychotherapy; 13(4): 489-498.

A creative and constructive partnership between different psychotherapies needs to develop if a psychotherapeutic psychiatry is to flourish. The greatest threat to the development of psychotherapeutic psychiatry is the partisan approach of the psychotherapies themselves. Prejudicial attitudes prevent acquisition of useful knowledge and its appropriate assimilation in psychiatric settings. The concepts of the self and borderline personality are used to show how understanding different psychotherapeutic approaches can inform treatment and further the development of a fruitful psychotherapeutic psychiatry which is itself essential for the treatment of severe personality disorder.

Bateman, A.W. (2000) Integration in Psychotherapy: An Evolving Reality in Personality Disorder. British Journal of Psychotherapy; 17(2): 147-156.

Psychotherapy continues to be bedevilled by ideological schisms with practitioners apparently ignoring alternative conceptualisations and potentially superior interventions. However, I argue here that there is evidence of a rapprochement, both in theory and practice, between cognitive therapy and psychoanalytic therapy, especially within the domain of personality disorder, which may lead to the development of integrative psychotherapy. Cognitive therapy has begun to encompass an interpersonal approach within its theoretical base. Similarly, psychoanalytic therapy increasingly uses an interpersonal formulation of the process of therapy. The therapeutic alliance is emphasised equally and process research suggests that interventions, when given by experienced practitioners, are not as dissimilar as 'brand-named' therapies imply. Continued refinement of process psychotherapy research could lead to true integration of efficacious therapeutic interventions. But translating research findings into practice will necessitate psychotherapists opening themselves up to each others' ideas.