Avances en Salud Mental Relacional

http://hdl. handle. net/10401/6114

Avances en Salud Mental Relacional
Advances in Relational Mental Health
ISSN 1579-3516 - Vol. 11 - Núm. 3 - Diciembre 2012
Órgano de expresión de la Fundación OMIE y AMSA Avances Médicos
Revista Internacional On-line / An Internacional On-line Journal

BRIEF INTENSIVE DYNAMIC GROUP PSYCHOTHERAPY IN
PATIENTS WITH BORDERLNE PERSONALITY DISORDER:
EVALUATION OF AN 8 YEARS PROGRAM

José Guimón, Claudio Maruottolo, Aizpea Boyra, Andrés Mascaró, Wendy Dávila (Avances Médicos
AMSA, Bilbao, España)
jose. guimon@ehu. es

SUMMARY
Over the last 35 years we have developed a number of group therapy programs with an orientation
toward community therapy. In the last 20, even though at certain centres we have maintained a milieu
of therapeutic focuses, the programs have become less psychodynamic and less democratic ­ somewhat
`decaffeinated'(1, 2) (2, 3). In view of the promising results we consider that the "Intensive Dynamic
Brief Group Psychotherapy" (IDBGT) approach (1, 4, 5) that we use on our day unit short-stay programs,
is highly advisable to patients with borderline personality disorder (BPD).
Key words: Group Psychotherapy. Milieu Therapy. Borderline Personality Disorder.

RESUMEN
A lo largo de los últimos 35 años hemos desarrollado una serie de programas de terapia grupal
orientados hacia la comunidad terapéutica. En los últimas dos decadas, aunque en determinados
centros hemos mantenido enfoques terapéuticos variados, los programas se han tornado menos
psicodinámicos y más democráticos, por decirlo de algun modo- "descafeinados". A la vista de los
prometedores resultados consideramos que la psicoterapia intensiva grupodinámica breve, utilizada en
nuestras unidades de día de corta estancia, es altamente recomendable para pacientes con trastorno
límite de la personalidad (TLP).
Palabras clave: psicoterapia de grupo. Entorno terapéutico. trastorno límite de la personalidad.

© 2012 CORE Academic, Instituto de Psicoterapia

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1. THE OVERALL MANAGEMENT OF PATIENTS WITH BORDERLINE PERSONALITY DISORDER
Personality disorders involve maladjusted, invasive, and permanent behaviours, deeply
ingrained, and which are not due to any physical illness or cultural alterationi. A borderline personality
refers to impulsiveness, disordered hostility, self-destructive acts, mood swings, and splitting. The term
remains inadequate and is full of confusion, which makes the validity of the concept questionable. For
one thing, it defines symptoms, not traits. On the other hand, in spite of some reliable
neurophysiological findings, biological research on the subject continues to be weak. Different
aetiological hypotheses have been proposed to explain this disorder, ranging from constitutional factors
(difficulty in regulating affect) to family and psychodynamic factors: perturbations in the establishment
of object relations and inadequate processes of identification during early infancyii.
Kernberg is one of the many others that traces the pathology of personality back to inadequate
processes that take place in childhood (3, 7) (3, 7, 8). This author relates BPD to early defence
mechanisms against sexual and aggressive drives, and refers to a pathology of the super-ego, an
alteration in ego organisation, difficulties in internalised object relations, and a pathological
development of narcissistic functions. He highlights the role played by dysfunctions in object relations
established during early infancy. The patient sets into motion pathological defence mechanisms,
systematically using dissociation, acting out, projective identification etc. . . which are going to create
relational difficulties in adult life. Later studies contend that most core symptoms of the disorder such as
the diffuse sense of self, bursts of rage, unstable interpersonal relationships, feelings of emptiness and
abandonment, chronic fears of and intolerance for aloneness have their roots in an impairment in the
underlying attachment organization (in Bowlby's sense). KN Levy et als (9) underline that individual
differences in adult attachment are rooted in patterns of interaction with caregivers, and these patterns
have important implications for understanding the aetiology and treatment of borderline personality
disorderiii.
It is very common for patients in a crisis suffering from BPD to go to the emergency services of
the general hospitals. There, they receive momentary help, frequently only medication, and then return
home. Some fairly specific treatments have been used, including serotonine reuptake inhibitors, mood
stabilizers, and neuroleptics at a low dose level. On other occasions they are hospitalized, although
many of them do not remain long enough in order to obtain the desirable benefit.
The American Psychiatric Association (APA) 2001 Practice Guideline for the Treatment of
Patients with Borderline Personality Disorder (5) advises brief hospitalisation when patients present an
imminent danger to others, lose control of suicidal impulses or make a serious suicide attempt, have
transient psychotic episodes, and have symptoms of sufficient severity to interfere with functioning.
Pascual contends that if the APA guidelines recommendations were applied, most patients with
borderline personality disorder who visit psychiatric emergency services would require hospital
admission. In reality, very few patients are actually hospitalized. On the other hand, some authors
believe that hospitalization can be regressive, harmful, and counter therapeutic (10).

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2. DYNAMIC PSYCHOTHERAPY OF PATIENTS WITH BORDERLINE PERSONALITY DISORDER
Patients with BPD are difficult to manage in individual analytical psychotherapy, due to their
instability, which is frequently related to a loss of self-esteem and identity confusion. The course of
therapy tends to be disturbed by intense transferences and various acts, such as suicide attempts,
attacks of rage, and self-mutilation caused by suicidal thoughts. Years ago, Kernberg (3, 11)
recommended confronting these patients and interpreting their negative transference early on,
whereas other authors (12) advise therapists to limit themselves to acting as a holding environment for
the patient and avoid interpretations. A high percentage of drop-out in treatment is characteristic of
these patients.
Several studies, of variable methodological quality, show favourable results in borderline
patients with group dynamic approaches based on the experiences of therapeutic communities.

2. 1. Group therapy approaches in the treatment of borderline personality disorders
Group therapy, traditionally used in BPD patients when they are hospitalized, is currently
considered of particular interest for out-patients. Springer and Silk (13, 14) designed an efficient short
program and discussed, particularly, the advantages and disadvantages of Linehan's dialectical
behaviour therapy. Dawson (15-17) proposes a program with the aim of « managing emotions » in
which therapists show themselves as permissive even if they forbid acting out. Regular attendance at
meetings is not obligatory, which means that only 30% of regular presence that forms the nucleus of
patients is more or less constant. In addition, there is a greater cloud of patients who show up at the
group from time to time searching for occasional help.
Indeed, group therapy offers the advantage of being less expensive, making transference easier
to manage, producing an improvement in ego functioning (18) and interpersonal functioning, and
decreasing the patient's regressive tendencies. Moreover, these patients are more likely to take advice
or have confrontations with other patients than with the therapist, and they have the possibility to
relate with them on an equal level.
The therapeutic groups tend to be heterogenous in composition although the present most
popular programs (Linnehan´s, Kernberg´s and Bateman´s) are homogeneous. The orientation of groups
tends to be eclectic, and although open psychodynamic groups are the most frequent, others (19, 20)
focus on aspects such as the acting out, the splitting, the countertransference and the eroticization of
relationships.
On the other hand, group therapy is frequently part of a multidimensional program, including
medication and different types of psychotherapy. In these cases, because of the risks of acting out, the
therapist must be able to count on a support system offering more holding for these kinds of patients,
i. e. a hospital unit (which should be avoided as much as possible in order to not embark on a prolonged
and counterproductive relationship with the institution) or a day hospital. For example, Bateman and
Fonagy (21, 22) have shown favorable results with treatment based on dynamic psychotherapy in a day
hospital.

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Some therapeutic community-oriented hospitals offer still specific and efficient programs for
these patients. Dolan et al. (23-25)) noted a significantly greater improvement in those treated in their
program in positive correlation with the length of treatment. Similarly, Hafner and Holme (26) showed
positive results in a therapeutic community with borderline personality disorders.
This type of approach should be an antidote to the trend toward managed care. In practice,
some borderline patients with serious symptoms (incompetence, suicidality, dependency) who suffer
from a feeling of profound insecurity will continue to need long-term, intensive therapy and we should
display some reticence when faced with attempts to reduce or dilute the services we offer(27, 28). A
training process which corresponds to therapeutic community principles should encourage the growth
and differentiation of patients and, as Campling and Haigh (27, 28) warn, avoid the indoctrination and
infantilization typical of both medical and psychoanalytical training.
As we already pointed out the hospital-based therapeutic community will continue to justify
itself. It combines socio-therapeutic treatment, psychotherapeutic treatment and the advantages of a
hospital context (29). Moreover, it has shown to be useful in the treatment of BPD and the rehabilitation
of certain delinquents.
However, the philosophy of therapeutic communities has become especially widespread over
the last few years in half-way institutions. The following section describes the brief-intensive dynamic
group therapy which is the main focus of our programs in our institution in Bilbao.

2. 2. "Decaffeinated therapeutic communities"
Over the last decades we have created, both in Spain and in Switzerland (30-33), a dozen
different care units (short-stay units in general hospitals, rehabilitation units, day hospitals) conceived as
integrative programs with an orientation towards community therapy. The programs of these units
include, at the minimum, a daily medium-sized group bringing together patients and staff and a "small"
group of patients, with a dynamic orientation but with occasional cognitive-behavioral tendencies as
well as specified group activities (« group work » in Foulkes' sense).

2. 3. 1. AMSA day unit programs
In this paper we discuss the outcome of BPD patients in the holistic emergency program we
have been developing in Bilbao since 2003. It provides a "call center", 1 outpatient crisis unit, a 25 beds
short-term hospitalization unit (with a 14-day average stay), and 4 short-term stay programs at day
centers that make up the outpatient clinic. This is a private network serving 325. 000 people from the
area of Bilbao and its province (1. 100. 000 inhabitants).
The sample for the work we are presenting today includes ¿? 800 hospitalized patients (5% (20)
BPD and the rest non BPD) and 106 (64, 2 % BPD and 35, 8% nonBPD) attending four intensive programs
which are psychodynamically oriented.
Simultaneously we treated a maximum of 24 patients, with mean stay of 58onths) in the
program that runs five days a week for four hours a day.

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The four therapeutic teams included psychiatrists, psychologists, social workers, occupational
therapists and psychomotor therapists, trained in individual dynamic therapy and group and family
therapy.
The work day included: medication prescription and control; three small verbal therapy groups
(staff-patients once a week, dynamic 5 days a week, cognitive 5 days a week) and several group
activities (artistic expression 2 days a week, body movement 2 days a week, relaxation once a week,
daily activities 5 days a week). The multifamily group met once a week. This group conceived according
to the principles of the psychoanalytic therapeutic community based on a multiple family structure,
developed in Buenos Aires by Jorge García Badaracco in 1972 (34) which is nowadays basic in our
therapeutic program.

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Table 1. Day Unit Schedule
Monday

Tuesday

Wednesday

Thursday

Friday

9. 30 - 9. 45

Reception

Reception

Reception

Reception

Reception

9. 45 - 10. 45

Dynamic Group

Dynamic Group

Dynamic Group

Dynamic Group

Dynamic Group

10. 45 - 11. 15

Break 1

Break 1

Break 1

Break 1

Break 1

11. 15 - 12. 15

Relaxation
Tecniques

Art Therapy

Dance and
Movement
Therapy

Art Therapy

Dance and
Movement
Therapy

12. 15 - 12. 30

Break 2

Break 2

Break 2

Break 2

Break 2

12. 30 - 13. 30

Discussion Group

Conflict focused
Group

DiscussionGroup

Psychoeducationa
DiscussionGroupl
l Workshop

3. METHODOLOGY FOR THE EVALUATION OF OUR PROGRAMS
In order to evaluate the effectiveness of different therapies developed in the Department of
Psychiatry at the University of Geneva, the outcomes of different treatment methods were assessed by
means of the so called "Bel-Air Battery" including instruments on several levels: in a global assessment
of therapeutic outcomes by patients and therapists and a more differentiated assessment of changes
(pre-post treatment) in patient responses to questionnaires, screening symptoms and aspects of social
roles. An overview of instruments is given in Table 1.

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Table 2: Conceptual levels and methodological implementation of an evaluation program for different
psychiatric disorders (University of Geneva core battery)
Level of assessment

Variables

Instruments

Symptoms

- Complaints/ psychopathology Brief Symptom Inventory (BSI, 35, 36)
(self-report)
DSM-IV (American Psychiatric Association, 1994)
- Diagnosis (clinician ratings)
- Personal relationships (self- Evaluation of Relationships Questionnaire (ERA,
report)
Fredenrich & Zinetti, 2000)

Social roles

- Social functioning (clinician Global Assessment of Functioning (DSM-IV-Axis
ratings)
V, American Psychiatric Association, 1994)
- Social functioning (self-report)

Social Functions Questionnaire (QFS, 37)

The tests were the following: on the clinical side the SCID (Structured Clinical Interview for DSM
IV-TR), the BDI (Borderline Diagnostic Inventory, Gunderson, 1992), the BSI (Brief Symptoms Inventory,
Lipman and Derogatis), the STAI (State-Trait Anxiety Inventory), the BDI (Beck´s Depression Inventory).
On the psychosocial side, the ERA( Questionnaire d`évaluation des relations avec les autre, Zinetti et al.
2004)iv, the QFS (39)v and an adaptation of Sherer & Sherrer´s Coping Index (40)
All scales outlined here constitute a basic core of outcome measures for various psychiatric
populations. During the last decade, disorder specific approaches gained more attention.
In addition, the degree of severity of many of the patients was evaluated in some of the studies
using the Spanish version of the scale for the Severity of Psychiatric Illness (SPI)vi. We have also
evaluated the severity of the BPD patients with the scale of Asnani [13] that counts the number of DSM
IV items present in the patients and then classifies them in 4 groups, (group 1 fulfils up to five DSM
diagnostic criteria; group 2 fulfills up to 6 criteria, group 3 fulfills up to seven criteria and group 4 fulfills
up to eight/nine criteria of the diagnostic manual).

4. RESULTS
As we have mentioned, in Bilbao, in 2003, we organized a day unit program for a maximum of
27 patients (41) and we reported our first promising clinical results. Further on, in another study
(42)with a sample of 109 patients (64, 2 % borderline and 35, 8% non-borderline) we described the
evolution of certain socio-demographic and clinical variables during the year preceding treatment
admission, after being discharged from the program and a year later.
There were some significant differences between the BPD group and the 35, 8% that made up
the non-BPD group (5, 7% psychoses, 47, 2% anxious/depressive, 18. 9%)viisubstance abuse, 23, 6% other

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personality disorders). There was an overall significantly important improvement of the symptoms
without statistical differences between BPD and non-BPD. On the other hand, some social variables
significantly affected certain symptoms: depression improved more in those with higher socioeconomical status and higher educational level. Suicidal ideation improved more in those who were
university students.
BPD patients showed a non-expected good attendance rate to the program, in contrast to the
data found in literature. We found no difference in type of discharge and length of stay between BPD
and non-BPD, contradicting our initial hypotheses that BPD would have a more irregular attendance. In
fact, the drop-out rate during the treatment was smaller in BPD than in non-BPD (p= 0. 499).
In the one year follow up we continued to observe, in those who accepted to come for
evaluation, a similar improvement as seen at the discharge of the program (42) both in BPD and NonBPD patients. However, an important number (24%) of the patients entering the program were not
attainable at one year follow-up and could not be evaluated, so only a few data were obtained thru
contact with their relatives. A significantly smaller percentage of BPD patients (39% vs. 61%) were
attainable and their higher number of DSM IV inclusion criteria indicated a higher severity than those
who were attainable. Among other characteristics of those who were not attainable there was a higher
presence of males, and of those with higher symptoms severity and with history of substance abuse.

Regarding the psychosocial functioningviii, half of the patients who were previously unemployed
had a job after one year (0, 05). There was an improvement in the QFS items Global Social Functioning (
p= 0. 001), frequency of relations (p= 0. 001), and satisfaction in the activities (p= 0, 003). In the ERA
questionnaire there was a positive correlation between symptom improvement in the BSI and the items
"Openness to others" (p= 0. 073) , relational distance (p= 0, 000), "personal insight" (p= 0. 035) and
"pleasure in relations" (p= 0. 139) and "global activities" (p= 0. 031)
Existing studies around this
subject have shown variable and contrasting results. For instance, Chanen et al. (43) found that
borderline personality disorder was a significant predictor of the presence of Axis I disorders and other
personality disorder diagnoses for psychopathology, general functioning, peer relationships, self-care,
and family and relationship functioning. Skodol et al. (44) found that the impairment in social
relationships appeared frequently in patients with personality disorder. and that patients with BPD
showed no improvement in their overall functioning over time. Ansell et al. (45) ixfound that BPD is a
source of considerable psychological distress equivalent to, and at times exceeding, the distress found in
mood and anxiety disorders and that the BPD group was characterized by significantly greater
psychiatric and non-psychiatric treatment utilization . In the same way Chanen et al. (43) examined
adaptive functioning and psychopathology in adolescents with DSM-IV borderline personality disorder
and found that had they presented more severe psychiatric symptoms and functional impairment than
a control group across a broad range of domains.
Other studies show more uplifting results. Jovev & Jackson (46) had documented an enduring
poor social functioning associated with borderline personality disorder (BPD) but found that many
patients with BPD who experienced change in personality psychopathology did show some
improvement in social functioning. A research from Ullrich (47)suggest that although most personality
disorders are associated with impaired psychosocial functioning and life-failure, some personality
disorder traits (even if considered as pathological) can contribute positively to one important aspect of

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life-success: status and wealth. Venturini & Andreoli (2011) contend they have obtained good clinical
and social results in a large number of BPD with a variety of techniques. Lastly, a recent study shows a
better compliance to treatment and good clinical evolution in patients with dual diagnosis (48).
The results shown in this paper are in line with these last studies. In our sample clinical
symptoms improved overall: those who had had psychiatric hospitalizations were not hospitalized the
following year; half of the patients who were substance abusers at the beginning of the treatment had
ceased to use substancesx; AND moderately severe BPD patients improved in the area of social
functioning relatively independent to their clinical changes. These favourable dataxi can of course be
questioned on the terms of a milder clinical and social severity in those patients who were attainable in
the follow up xii.

5. THE THERAPEUTIC MECHANISMS INVOLVED

5. 1. Environmental factors
The majority of severely affected borderline patients have a fragmented internal world, with a
disorganized identity and a disorganized mental process. In this way, disorganized institutions threaten
to increase disorganization in their members who, in turn, will disturb the institution. Patients will
project their difficulties onto the community that surrounds them and introject elements of the
organization of that community. The concept of "internalization of object relations" is essential in the
dynamic treatment of borderline patients even if it is being recently criticized (Coderch, 2012).
Historically two factors were recognized as characteristic of the course of treatment in a
therapeutic community: "containment" (in Bion's sense ) furnishes a feeling of security in the face of the
infantile pain, the rage and the despair frequently re-experienced in the therapeutic community, and
the "structuring the environment" reduces uncertainty and enables modifications of ill-adapted
behavior in the patient (49-53).
Other elements important to the efficiency of a therapeutic milieu are: the "support" given by
foster patients'; the personal investment of each patient in their treatment plan; accepting the
expression of their pathology ("validation") which allows patients to assume their individuality; and
"implication", the mechanism through which patients are encouraged to interact with their
environment, to escape from passiveness and collaborate.
These different mechanisms act in a specific fashion for different patients. Thus, containment
can be necessary for borderline patients in an acute phase, confused and impulsive, but can have a
negative effect later. Support can be very useful for depressed or frightened patients, but may be
harmful for borderline patients. And validation can be very useful for paranoid and borderline patients
but can be dangerous if they have a suicidal risk.

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5. 2. Psychoanalytical ingredients
From a psychoanalytical point of view, certain ingredients derived from theories object relation,
of the ego psychology and of group analysis represent the quintessence of therapeutic communities and
explain their therapeutic effect with borderline patients.
Following a developmental sequence (54-56), we can describe several therapeutic ingredients
starting with "attachment"xiii. The therapeutic community creates a culture in which belonging is highly
prized and where the members themselves are validated, which is reassuring for the patient. But, for an
individual to develop, he or she must be able to confront other complex experiences, of love, hate,
anger, frustration, sadness, attack, defense, comfort, etc. , facilitating the disillusion of the fantasy of
symbiotic fusion and early attachment and rendering the patient capable of « growing up and leaving
home ». In this sense, the therapeutic community offers experiences of "inclusion" (a process of
acceptance and evaluation) and of departure (rituals of farewell, etc. ).
Another fundamental therapeutic factor of development (55) is of course the already mentioned
concept of "containment , which relates to the « mothering element » of these institutions. But there
also exists a « paternal element » extremely important for borderline patients that consists in
establishing limits and rules, in reinforcing boundaries, which contradicts in a certain fashion the notion
of « permissiveness » demanded in a therapeutic community.
Once the therapeutic community has mastered primitive preverbal work with a patient, a
fundamental challenge consists in establishing "communication", in the form of contacts with other
patients and care-givers, which allows them to build mutual understanding through the use of "symbolic
representations" and the process of "identification". For this, there must exist a "communal
identity"(57) which consists in a set of intimate relationships forged through the participation of all the
members in therapeutic, social and informal activities within a « culture of enquiry ». Stable, protected
groups with well-defined boundaries implement this process.
Another factor specific to therapeutic communities is represented by the compromise obliging
patients to accept that all interpersonal interaction belongs to all the members of the community.
Everything that goes on in the community can be utilized from a therapeutic point of view, leading to an
inseparable union between « living and learning » (58).
On the other hand, there exists, in therapeutic communities, a basic belief according to which
the patient's unconscious is a better judge than the analyst's of the direction therapy should take,
thereby bringing into play the notion that the most important therapeutic effect is brought into being by
the patient, not by the therapist. The lack of symmetry between the therapist and the patient is
accepted, but the automatic assumption of the therapist's superiority is rejected by most borderline
patients. This attitude fosters accountability in patients who assume responsibility for their own
therapeutic process, which allows improvement but can be a source of ambivalence, for example
engendering feelings of guilt.
Bender, D. (59) discusses some other issues, especially "splitting", that arise in the alliance when
patients with personality disorders are treated in inpatient psychiatric hospital settings.
Concerning the therapeutic communities approaches in the hospital milieu, (and also in half-way
institutions), treatment is carried out in settings where several care-givers interact. Adshead (60-62), in

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light of the theory of attachment, reported that the hospital setting provides security only if care-givers
are capable of tolerating both the external demands of the system and the internal demands of
patients. He pointed out that therapeutic relationships between staff and patients are only repetitions
and recreations of internal object relations and that reaction to splitting and to projective identification
from the team can sometimes be negative. A certain number of negative reactions can be detected
through the patronizing and contemptuous way in which the care-giver may sometimes express him- or
herself to the patient. An example of this can be the excessive reinforcements of the regulation of
services, like the inappropriate use of restrictions. Adshead also remarks how the conflict between
therapist and patient comes to be added to the new organization of "cost containment", particularly, in
the managed-care system, the interference of insurance companies. Finally, he underlines that
problems in the organization the unit, such as inadequate accounting practices, lack of leadership,
difficulties in communication and violation of boundaries, can seriously aggravate the condition of
patients.

5. 3. Intensive dynamic brief group therapy in our experiences in Bilbao
In Intensive dynamic brief group therapy (IDBGT) medication and different kinds of
psychotherapy are combined. This procedure is frequently called «combined pharmacological and
psychotherapeutic treatment». In our programs combined psychotherapy is seldom carried out by the
same clinician. On most cases a "collaborative treatment" model is used among two or three different
clinicians. In fact, the triangle is a well-known situation for containing conflict and anxiety as has been
shown by couple and family therapists. It is, however, well known that transference and countertransference issues can seriously deteriorate collaborative treatmen . Apart from the type of profession,
intergenerational differences can add to the difficulties. In these circumstances, patients can be
transformed into narcissistic objects. If triangular relations are usually difficult, the collaborative group
psychotherapy and pharmacological treatment create additional problems because they tend to elicit
rivalry among some members, stigmatization of some others and other group phenomena.
From our IDBGT work frame several therapeutic factors must be noted. As in therapeutic
communities, in our units we emphasize the role played by `containment'. Also a particular emphasis is
made on the `here and now' and on inter-member cohesiveness. This has shown itself to be, in our
experience, a useful stabilizing `buffer' tool. It fosters involvement and supports and allows a controlled
expression of anger and aggressiveness. The patient-staff group is the key holding element of our
program, due to its basic contribution to creating a `container' for the anxieties arising in the ward. It is
also of invaluable help because of the information it provides concerning each patient. The other groups
also provide the patient with orientation and emotional support and, within the staff, tensions among
the therapeutic team are reduced and incoming nursing personnel notice how their previous fears and
apprehensions diminish.
"Attachment" is of very low quality in many of our patients and can be improved through these
therapeutic experiences. In our units, a «multiple treatment setting» is the rule, with a great variety of
professionals being involved in different activities. «The multiple treatment setting» has many
advantages. The therapeutic relationship between staff and severely pathological patients makes for a
potentially positive ambiance where reenactments of internal object relations can be interpreted. The
therapeutic team offers itself as an alternative family able to provide a corrective emotional experience

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which can help the patient, as was conceptualized by Adshead (61, 62) in terms of attachment theory .
However, therapeutic teams do not always behave as an ideal family. Certain manifestations signal
negative counter-transference reaction.
The IDBGT offers `support' to fight against patients' passiveness and promotes accepting the
expression of their pathology, (`validation'). In this way their `implication' is more assured. Said
implication and compromise with the treatment enables the patients to interact with their environment
and to escape from passiveness.
.
A continuous challenge is to improve "communication", in the form of contacts with other
patients and therapists through the use of `symbolic representations' and the process of `identification'.
For this to occur, a `communal identity' should ideally be achieved. This is forged through the
participation of all the members in therapeutic, social, and informal activities. Stable, protected groups
with well-defined boundaries can support this process.
In our we try to underline the trend of the traditional `democratic' therapeutic communities
(which arose from the experiments conducted by Foulkes at Northfield) to give patients co-responsibility
for their treatment. However, we do not allow the community to take important decisions such as
patient admittance and discharge. On the same line the "equality" between different members of the
staff is more a desire than a reality.

5. 4. The impact of these experiences in the mental health systems
From the standpoint of the creation of a positive atmosphere in the ward that we have tried to
create and measure (63)xiv, the patients­staff group is the key element, through the information it
provides to patients. The other groups also give the patient orientation and emotional support. All this
has enabled us to decrease the dosages of medication required and to create an agreeable atmosphere
in the sessions, as well as lowered the number of incidents (e. g. aggression, suicide attempts and
runaways). The tensions in the therapeutic teams have also diminished. These different groups
constitute a network for group analysis, which is favourable to the harmonious communication between
the different services. This systemic vision of the mental health system is conducive to easier, quicker
detection of problems and conflicts inside the institutions. All of these elements furnish the input which
feeds `healthy anticipatory paranoia' (64, 65), which is so indispensable to managing these
organizations.
Our impression is that the experiences in Bilbao have brought about greater integration among
health professionals in the various teams, by providing them with a meeting place and a common
theoretical frame of reference, highly useful to all.
To the best of our knowledge, one of the dangers facing dynamic therapy programs not strictly
based on evidence of their effectiveness is that they are subject to modifications arising from the
medical hierarchy at the institution. Thus, when the leadership changes, the programs very likely
disappear altogether or are weakened, as has happened in many of the units created in Geneva. Even in
our experiences in Bilbao, certain units have lost some of their freshness in favor of more traditional and
less personally engaging biological interventions. This is why the process must be carefully observed so
as not to lose sight of the basic concepts of the therapeutic program. It has been very important to

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maintain the group training programs we started organizing 35 years ago for the personnel in Bilbao,
Barcelona, and Geneva. They constitute a kind of `didactic communities'(66, 67), assuring, in some way,
the maintenance of the therapeutic ideology among the professionals. Interpersonal problems among
the members of the staff are also taken up. This makes for a better understanding of the ward
atmosphere, and a more comprehensive approach to the patient. Interpersonal difficulties and
interprofessional competitiveness are often dealt with under the guise of theoretical disagreement, and
become manifest at times in the form of lateness, absence or rationalizations. This environment fosters
the transparency and directness of both patients and the therapeutic team.
Resistance arising in the patients, such as fears of criticizing others or being punished, tends to
disappear soon. Irregular attendance on the part of the professionals arises during certain periods,
under the pretext of overwork, but in reality reflecting a devaluation of the group approach, which can
spread to the rest of the team. This is often encouraged by the institution itself, which is reluctant to
have its assisting personnel involved in these kinds of `specialized' activities. These problems are best
worked out through the participation of the staff in the post group meeting created for this purpose. At
the end, the maintenance of these kind of programs depends in a large proportion on the attitude of the
ward leader toward group or milieu therapy.
Finally, we stress both in the training of the professionals as in the evaluation of the results of
our interventions, the need to take into account the `evidence-based' movement that has appeared in
medicine and in psychiatry as a regulative idea and a research method. It is, however, also a powerful
socio-political endeavour (68) and we discussed it briefly in the following section. This trend has
important ethical implications (69) since moral neutrality is a myth when referring to the incompatible
ethical positions inherent in clinical and research practices (70).

5. 4. Evidence based results of psychotherapy in these patients: results and limitations
A meta-analytic review by McRoberts, Burlingame, and Hoag (71) encompassed 23 studies which
directly compared the effectiveness of the individual and group therapy formats. Like the majority of
previous meta-analytic reviews, the results of this analysis indicated that there is little difference in
efficiency between individual and group therapy.
Buchkremer et al. plead to add in evaluation studies some criteria deried from mental health
policy and economics (72). In this sense, Barlow (73) offers a way to overcome the problems of rigid
manuals as well as those associated with forcing clinicians to adhere to theories and practices that are
outside of their interest, experience, and expertise.
A Cochrane review(74) identified seven studies involving 262 people, and five separate
comparisons. When psychoanalytically oriented partial hospitalization was compared with general
psychiatric care the former tended to come off best. People who received treatment in a
psychoanalytic orientated day hospital were less likely to be admitted into inpatient care when
measured at different time points. Fewer people in psychoanalytically oriented partial hospitalization
needed day hospital intervention in the 18 months after discharge. More people in the control group
took psychotropic medication by the 30 to 36th month of follow-up than those receiving
psychoanalytic treatment. Anxiety and depression scores were generally lower in the

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psychoanalytically oriented partial hospitalization group, as were global severity scores. People
receiving psychoanalytic care in a day hospital had better social improvement in social adjustment
using the SAS-SR at 6 to 12 months compared with people in general psychiatric care. Rates of attrition
were the same
The authors suggest that some of the problems frequently encountered by people with
borderline personality disorder may be amenable to talking/behavioural treatments but all therapies
remain experimental and the studies are too few and small to inspire full confidence in their results.
These findings require replication in larger 'real-world' studies.
Many psychiatrists have reservations . about the "evidence-based' approach because of
perceived limitations in methodology (75), gaps in interpreting the available evidence and neglect of
individual patient uniqueness in quantitative research through annualised treatment procedures (76).
Concerning BPD the settings of the psychotherapy randomised controlled trials are highly
artificial. Naturalistic studies should be implemented and efficiency studies should be undertaken in the
whole health care system. Finally, empirically supported BPD psychological treatments (Kernbergs TFP,
Linnehans and Bateman´. s)have not been effectively disseminated among the mental health
professionals and thus are not readily available to the public who requires them (73) (77).
Therapists complain that research on BPD has only a remote resemblance to what goes on in
actual clinical practice. . There is a need of training of staff to implement new psychological treatments,
addressing professional barriers that may limit uptake, and investigations of the `minimum effective
dose' or the key active ingredients of the interventions.
New models of research have also been proposed. Margison (78) supports a model of
professional self-management 'practice-based evidence', as a complementary paradigm to improve
clinical effectiveness in routine practice via the infrastructure of "Practice Research Networks". For the
prediction of courses of treatment response Lutz et al (79) combines a dose-response model with
growth curve modelling to determine dose-response relations for well-being, symptoms, and
functioning. Barkham (80) argues for a core outcome measure (the "Clinical Outcomes in Routine
Evaluation-Outcome Measure") to provide practice-based evidence for the psychological therapies to
complement the evidence-based practice paradigm. Kendall et al (81) proposes "normative
comparisons", a procedure for evaluating the clinical significance of therapeutic interventions,
consisting of comparing data on treated individuals with that of normative individuals. Mundt and
Backenstrass emphasize the importance of more detailed psychopathology (through data that can be
expected from neurosciences) that can then be matched to specific psychotherapeutiv tools (75) .

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NOTES IN TEXT:
i

Borderline personality disorder is prevalent (2% in the general population, 20% among psychiatry inpatients) and has a major impact on health facilities even if these patients make a poor use of the
attempts to help them.

ii

From an anamenesic point of view, in women there seems to be a relationship with childhood abuse
and incest. A developing model of borderline personality disorder based upon the study of normal
attention, individual differences in temperament, self definition and attachment organization, can relate
the symptoms to more enduring temperamental aspects of the patients. With the potential to
illuminate the psychology and psychobiology of the disorder and to contribute to psychotherapeutic
intervention. The goal, say the authors, will be to "understand the development of neural networks that
underlie the abnormalities of adults, and eventually work out the interaction between temperament,
genes, and experience that produce the disorder, and potentially inform intervention".
iii

Factor analysis of ninety-nine outpatients reliably diagnosed with BPD and completing a number of
attachment measures revealed six factors that clustered into three groups corresponding to an avoidant
attachment pattern, a preoccupied attachment pattern, and a fearfully preoccupied pattern. The
preoccupied pattern showed more concern and behavioral reaction to real or imagined abandonments,
whereas the avoidant group had higher ratings of inappropriate anger. The fearfully preoccupied group
had higher ratings on identity disturbance, although only at the trend level.
iv

The Evaluation of Relationships Questionnaire (French: ERA, Fredenrich & Zinetti, 2000) is a self-report
measure intended to be equally appropriate for different psychiatric and psychotherapeutic disorders
(e. g. , schizophrenia, depressive

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