Borderline Personality Disorder. Acparian THE. Self-harm. Complexities and challenges. Integrative model of care. Attachment and parenting

Transcription

1 A C PA THE AUSTRALIAN CLINICAL PSYCHOLOGY ASSOCIATION THE Acparian The e-journal of the Australian Clinical Psychology Association ISSUE 9: JUL 2014 THE ACPARIAN ISSUE 9: JUL 2014 Borderline Personality Disorder Complexities and challenges Attachment and parenting Psychological Interventions Self-harm Integrative model of care Medication considerations

2 EDITORIAL Kaye Horley, PhD Editor 1 Borderline Personality Disorder (BPD) is a complex, pervasive disorder, its heterogeneous range of behaviours resulting in conceptual classification, assessment, and treatment difficulties. As clinicians, we need all our skills of empathic understanding to recognise and treat those who are so extremely sensitive in their interpersonal relationships. To provide an initial understanding of the lived experience of this distressing disorder, our first paper, the voice of BPD, depicts a client s cry for help over many years. The challenges and difficulties presented by these distressed individuals are exemplified by Brin Grenyer in providing an encompassing overview of the associated complexities in responding to those with this condition. He outlines implementation of a comprehensive step-down approach of care that has far-reaching treatment implications. Although systematic reviews of BPD interventions appear limited, there are a range of structured psychological treatments considered to have value in treating symptomatology. Some of these are examined here. Dialectical Behaviour Therapy, with strategies developed from cognitive-behavioural therapy, is one of the most widely recognised psychological treatments for BPD. A description of this therapy, and its treatment modes, is provided by Simone Jaques, and its employment in a community setting is described. Another therapy, also developed from a cognitive perspective, is that of schemafocused therapy, focusing upon maladaptive schemas. The key stages of this therapy in responding to behavioural difficulties and guiding treatment are overviewed by Louise Sharpe. The links between psychodynamic interpersonal therapies and cognitive therapies are explored by Simon Boag and two major psychodynamic therapies briefly outlined, transference therapy and mentalisation-based therapy. Focus upon attachment needs and relationships and attaining a sense of identity is considered central in providing an explanatory understanding of BPD deficits. In accordance with this theory, Louise Newman discusses models of transgenerational transmission of attachment patterns, and the difficulties those with BPD experience in parenting. Emphasis is placed upon relational approaches of care. Mentalisation-based therapy is described more fully by Margie Stuchbery. As cognitive difficulties in making sense of self and others are considered the core deficit in BPD, the focus is upon mental states. Self-harm is a behaviour that is often associated with BPD. The differing types of self-harm, aetiology and functions, and diagnostic criteria for BPD, are delineated by Marc Wilson and colleagues. Eve Hermansson-Webb outlines research providing grounds for considering nonsuicidal self-injury as a behaviour that can be distinct from BPD, and the consequent advantages of such a conceptualisation. Apart from the provision of structured psychological therapies, individuals with BPD are frequently prescribed medication. Graham Wong, in reviewing BPD treatment guidelines, provides a considered response as to whether or not this is good practice. In the final paper, a family member writes of the emotional rollercoaster, the love and the pain, of having a sister with BPD, a seminal reminder that care and support of significant others needs be inherent in our care for the individual with BPD. We are grateful to the many contributors to the ACPARIAN. Since its inception, it has continued to publish quality papers of clinical relevance to the readership. The Editorial Board is please to announce that, following this addition it will have a new title, Australian Clinical Psychologist, reflective of its evolution as a professional journal. 1 Correspondence to: editor@acpa.org.au The ACPARIAN: ISSUE 9: July 2014 Australian Clinical Psychology Association

3 CONTENTS 2 Editorial Kaye Horley 4 From the President Judy Hyde 6 The Voice of Borderline Personality Disorder Client Perspective 8 An Integrative Relational Step-Down Model of Care: The Project Air Strategy for Personality Disorders Brin F. S. Grenyer 16 Dialectical Behaviour Therapy in Community Mental Health Teams Simone Jaques 21 Schema-focused Therapy for Borderline Personality Disorder: An Overview Louise Sharpe 25 Psychodynamic Approaches to Borderline Personality Disorder Simon Boag 30 Parenting and Borderline Personality Disorder: Working with Transgenerational Trauma Louise Newman 34 Mentalisation-Based Treatment for Borderline Personality Disorder Margie Stuchbery 38 Prevalence, Correlates, and Functions of Deliberate Self- Harm and Non-Suicidal Self-Injury: Self-Harm and Borderline Personality Disorder Marc Stewart Wilson, Jessica Garisch, Robyn Langlands, Lynne Russell, Angelique O'Connell, Emma-Jayne Brown, Tahlia Kingi, Madeleine Judge, and Kealagh Robinson 43 Non-Suicidal Self-Injury: A Diagnosis Independent of Borderline Personality Disorder? Eve Hermansson-Webb 46 Borderline Personality Disorder and Psychotropic Medications Graham Wong 49 Riding the Rollercoaster Over the Maelstrom: A Perspective Mel's sister The ACPARIAN: ISSUE 9: July 2014 Australian Clinical Psychology Association

4 From the President Judy Hyde, PhD This has been a very busy quarter for ACPA with submissions made to the Psychology Board of Australia on Registration Standards, Continuing Professional Development, and Recency of Practice, and to the Australian Psychology Accreditation Council (APAC) on Standards for training in psychology. The latter was a second round of consultations that again proposed to significantly undermine the current Standards for training in clinical psychology and continued to fall well short of all international standards for professional psychology in the Western world. It appears APAC is not able to meet the challenge of protecting the public through adequate training standards for the profession at this point in time. It is hoped the new structure of the APAC Board, that includes as stakeholders Heads of Departments and Schools of Psychology and strong representation for Psychology Board of Australia, will be able to provide better input to ACAP to develop adequate Standards for the future of the profession and protection of the public. While the Australian Psychological Society remains a main stakeholder with three places on the APAC Board, Associate Professors Hunt and Bretherton have taken up positions on this Board as representatives of the Psychology Board of Australia. Dr Bretherton also remains on the ACPA Board. We are most grateful for her ongoing contributions to the profession. The 5 th Annual ACPA Conference was held in April in Christchurch, New Zealand with the New Zealand College of Clinical Psychologists (NZCCP). This event was well attended by ACPA members, many of whom presented papers. This was a stimulating conference that strengthened and enriched the bonds between ACPA and NZCCP. ACPA presented our host organisation with a plaque made from New Zealand KAHIKATEA timber, which reflected the conference theme of mutual support and was featured in the conference brochure. This plaque featured an Australian opal stone with the ACPA colours of blue and green running through it. The issue of specialist recognition continues as the Minister for Health in Victoria announced at the College of Clinical Psychologists that this would not be as rigid as the plan proposed by NOVA as advisories to the Australian Health Ministers Advisory Council and the decision will be in the hands of the Psychology Board of Australia. ACPA awaits the release of the guidelines to make application to the Psychology Board for the recognition of qualified clinical psychologists as specialists. This has the support of the medical profession as they are currently unable to determine who has qualifications in clinical psychology via endorsement. At the conference an inaugural President s Citation was awarded to our much valued Editor of the ACPARIAN, Dr Kaye Horley. This was in recognition of the work Dr Horley has undertaken in establishing the ACPARIAN and holding it, along with the Editorial Board, to such a high standard. The change of name for the ACPARIAN reflects the level of professionalism that Dr Horley and her Board have brought to this publication. The gratitude of ACPA members for this clinically relevant and enhancing publication is boundless. The 6 th Annual ACPA conference will be held in Hobart on 13/14 November, The venue is to be announced. The theme will be related to the treatment of complex trauma. Please save the date. The Annual General Meeting (AGM) for ACPA will be held on 21 November in Sydney at a venue to be determined. Please save this date also. The theme of the clinical presentations preceding the meeting will be Psychopathy across the Lifespan. We look forward to sharing this day with as many of you who can attend. At the AGM it is hoped we will be able to have a membership vote on the proposed constitution. The current committee has been working hard to consult with interested members and the lawyers, Thomas and Co., to develop a constitution that supports the egalitarian ethos of ACPA, while providing structures to ensure members have a voice locally and through their specific interests. It is ACPA policy that all sectors of clinical psychology are represented on committees that represent a spread of members, such as those in private practice, public health, academic areas, training, research, etc. This ensures that issues related to all sectors are addressed and managed at all levels, and no sector is disadvantaged or overlooked. I would like to take this opportunity to announce a new benefit for Associate members of ACPA (Registrars). Insurance House Group has offered free insurance to these members, on condition that they are undertaking a Psychology Board of Australia approved Registrar program and are being supervised by a clinical psychologist with an accredited post-graduate degree in clinical psychology. This offer is exclusive to ACPA Registrar (Associate) members and is available through completion of a short form in the Member Section of the website (at acpa.org.au). Coupled The ACPARIAN: ISSUE 9: July 2014 Australian Clinical Psychology Association

5 with free student membership and free upgrades of memberships, this offers substantial savings to new members of the profession based on recognition of the value of their training in clinical psychology. New Sections of ACPA are being established in Queensland and NSW and members local to these states will be contacted with details of inaugural meetings. A Student Section is also about to be launched, arising out of the University of Sydney student body. These Sections will provide networking, Continuing Professional Development, and representation of specific interests. Sections will liaise with the Board. The new constitution will allow for mechanisms for this to occur. ACPA continues to grow and develop and this enables us to represent clinical psychology strongly and clearly. We face many challenges, but we have a strong voice and we are listened to; we thrive because of the commitment and dedication of our members, particularly those who continue to contribute to ACPA in substantial ways via the Finance Committee, Membership Committee, Editorial Board, Medicare taskforce, ATAPS Committee, Constitutional Committee, Events Committee, Mentoring Committee, CPD Committee, State Sections (including the Malcolm Macmillan Prize Committee), and National Board. The strength of ACPA arises from the members for whom we share our passion. Thank you to each and every one of you! Notification of Change of Journal Name As of the October 2014 issue, The ACPARIAN will be called Australian Clinical Psychologist Our name change reflects our growth and evolution as a journal. We hope our valued readers continue to enjoy high quality clinical papers. The Editorial Board The ACPARIAN: ISSUE 9: July 2014 Australian Clinical Psychology Association

6 2 I The Voice of Borderline Personality Disorder My Personal Experience with Having Borderline Personality Disorder 1 Client Perspective suffered from severe BPD for the past ten years of my life. I had been in and out of the public mental health system for about eight years. To me, in order to survive BPD in Australia means courage, thick skin and plenty of luck. I have very scattered memory for the past ten to fifteen years of my life. I remembered I moved to Sydney from Melbourne in 2004 to attend University, and I remember I had a mental break down. I was in out of the hospital emergency almost every week for about a few years, I called myself the "Frequent Flyer". I remembered I was relieved to be formally diagnosed with BPD and did not understand the implications, and the stigma attached with it especially from the health professionals. I remembered I begged help from the local mental health team numerous times for about a year, again and again, they kept telling me, "You just have depression, don't you? We have a lot more people who have far more severe conditions than you are, such as schizophrenia. We can't help you here." I remembered I called someone and end up being on the ambulance, an officer asked me, "So, have you done anything yet tonight?" I replied no. He then told me to stay home. I then asked him, "If I have done something to myself, is that mean I can go to the hospital?" He replied in a casual tone, "Yes." I remember I used to fancy about being institutionalised, however, mental institutions are no longer existed in Australia. I felt safe when I was in the hospital. I used to dream about committing a crime so I could be intuition in a jail, where I would be watched all the time so I won't end up killing myself. I remember a friendly head nurse at the hospital warned me, "Don't tell all the nurses about your diagnose in the psychiatric ward, you are a very friendly person. People don't take this diagnose well." I remember my local hospital refused to admit me, because they claimed, " You don't live in our zone. You need to go to hospital R." I remembered hospital R also refused to admit me and gave me the same reason. I used to live on a street where it was the border between two suburbs. I felt I was like a ball being kicked around between different health departments and hospitals. I remembered I finally had enough I took a mixture of medications, alcohol and jumped off a bridge. I 2 1 Client Perspective is unedited woke up in the emergency ward, I opened my eyes, the light was bright and shiny, something was securing my neck and I couldn't move, there was a doctor wearing a very neat light pink shirt, he said, "Don't move, you might have spinal cord injury." He asked where I live, and I also asked where he lived, he replied, "Kings Cross!" I whispered, "No wonder." I had the assumption that he must be gay. I remember I finally got an offer from the local mental health team after numerous request, begging, four years and the drastic suicide attempt. I remember I knocked the door of the local hospital at mid night, because I felt extremely unsafe. Someone from the ward told me, "You've been here too many times. If you want to come here, the procedure is, go home and call your local mental health team, and let them organise the admission. "He kicked me out of the hospital, and locked the door. I no longer felt shocked by such treatment, but my heart bleed, my spirit was shattered and fortunately my soul was still intact. I WANTED TO LIVE. I did not have my mobile phone with me at the time. I was extremely agitated and I was fearful of my own life. I was broke and the only number I could call without costing me a cent was 000. I walked 15 minutes to find a telephone booth, called 000 and got myself admitted again. I remembered I tried numerous of medications and all failed, and my doctor used to give me very strong medications to sedate me so I could sleep throughout the days without harming myself. I remembered I wasted a few years of my life bed bounded because I was overly sedated, and finally decided to tell my doctor, "I don't want to be a living zombie, I want life, and I want to find a job, I want to have friends, I want to function! "I realised medication was not the only solution for me in the long term, going 'herbal'; therapy might be the long-term solution for me. There was a "better access" scheme, where I could see a psychologist for 12 times. There were not enough sessions for me, and the public system did not offered any therapy. It took me days to weight out 'getting treatment' and food on the table, as I was relying solely on Centrelink because I could not work. I no longer wanted to be in hibernation, I needed therapy. I started exploring different psychological treatment options. I had seen a school psychologist before but she was never helpful to me. I remembered I asked her how much students under her care committed suicide, she counted her fingers, and said, "not too many, 6 or 7." I was extremely unwell, and was never referred to other specialist by her. This time round, I decided to be cautious with whom I select. There were many therapists and psychologist out there. I have found there was no clear line between what each can do. I have seen a few, and found most of them very unhelpful to me. Some were even harmful, as I was given advices such as "Perhaps medication is not for you." Those were clearly The ACPARIAN: ISSUE 9: July 2014 Australian Clinical Psychology Association

7 stepped outside their role. By the time I found a suitable candidate, my sessions were exhausted from Medicare. In 2008, I found "Spectrum" from the Internet. It is the only government-funded clinic in Australia where it specialised in treating Borderline Personality Disorder. I viewed it as my last hope and decided to move back to Melbourne, as it was also the criteria to be admitted to Spectrum. I remembered a guy from Spectrum interviewed me at the local mental health clinic. He told me "There might be two years wait." Their website clearly state, "For people who are at risk from serious self-harm or suicide." I wondered, "If those are classified as terminally ill, can they really wait for two years?" Fortunately I was admitted after three months. Spectrum only offered two years of support, and I was fortune enough to have three years with them. It was still not enough. I need someone to support me in the long term. I remember I was fully discharged from the local mental health team two years ago. It was a milestone for me. I indulged in excitement for a few weeks until I received a letter from my previous local mental health team, a discharge letter, with four pages detail medical history including my days at the local mental hospital, my diagnoses, the words I said, the stories I told I thought I was cured, I thought I have deleted all nasty memories in the past, I never expected my history would haunt me with those four pages of medical record. My soul was shattered. I thought it was a mistake. I wrote a complain letter, called the hospital and only been told, "It is a standard procedure, that we send all medical records to the patients who have been discharged. Most people would found it helpful." I have never demand nor to have request to have my medical record to send to me, no apology was given. I have a few recommendations for our government and policy makers: All mental health workers should be trained about BPD. There is no place of discrimination in our society, the same to BPD sufferers. We are mentally unwell but we are not stupid. We deserve better treatment. The treatment I received (and many in similar situation) from the public health sector were beyond believed and disgrace. We are suffering, and please do not scarred us further during our process of seeking help and recovery. I welcome The Clinical Practice Guideline for the Management of Borderline Personality Disorder, but where is the funding to implement the recommendations? I believe many of us don't want to use up the public health scarce resources by attending emergency frequently to solve our crisis. Prevention is the way to go, the only way to prevent a crisis is longterm therapy. Not many psychiatrist are trained in There should be a board or qualification to clear-cut the role of clinical psychologist, psychologist and therapist. At the present moment the line between each category is too blurry. The public is not clear informed, and bad practices are everywhere in Australia. People's lives are at risk. We all know that we don't seek help from a podiatrist if we have a heart condition, although they are all called DOCTORS. Privacy Law should be reviewed in the public sector. I know we all have the right to request our medical record to be released to us. How about in a situation where knowing your medical history will post a significant harm to your mental health? I never request my own medical record to send to me, it was not send to me by mistake, but rather a standard procedure. NDIS, does it include mental illness? Many of us know how to bath and eat but at the same time cripple by our mental condition. I could not work, I could not function, and I end up in hospital emergency almost once every two weeks in a year. I tried to kill myself many times and end up in intensive care a few times. I was not alone, and I met many from my time spending at the hospital that was in similar situations, living in constant crisis, and poverty. I am sure there are better ways for our government to spend the taxpayer's money. We want to live, and the only way to achieve this, is to have a choice of our treating team. Where will be stability, and that is very crucial for our recovery. Changes are needed urgently and many people are dying unnecessarily. I am now working full time, and have been working for the past one-year. I have my own private treating team, a psychiatrist, a clinical psychologist and a psychologist. I see my clinical psychologist weekly and have close contact with two other helpers. I have finally found the right medication with the help from my psychiatrist. I have my own private insurance and no longer rely on the public health system. I work and pay tax and I spend most of my salary on medical expenses, it is money well spent as now I have a life. I am fortunate that I have a team of loving care helpers who always have my best interest at heart. I am fortunate that I have a family who have finally accepted me for who I am, I am fortunate that all the harms I did to myself in the past did not result in any serious medical consequences, I am fortunate that I can work just like everybody else. I consider myself very lucky. The ACPARIAN: ISSUE 9: July 2014 Australian Clinical Psychology Association

8 34 Globally, An Integrative Relational Step-Down Model of Care: The Project Air Strategy for Personality Disorders Brin F. S. Grenyer, PhD Illawarra Health and Medical Research Institute, University of Wollongong, Australia Abstract Personality disorders, particularly borderline disorders, represent a significant treatment challenge for mental health services, in part because of the severity of the disorder, but also because of the high prevalence. Approximately one quarter of emergency mental health presentations and inpatient admissions are people with personality disorders. Evidence-based treatment for Borderline Personality Disorder is psychological therapy based on clinical guidelines, yet the prevalence of the disorder presents a challenge to specialist intervention programs that typically are unable to meet the high clinical demand. Similarly, the particular nature of the disorder can challenge the capacity of teams to maintain compassion towards clients, given the particular features of the disorder that can induce negative countertransference responses. An integrative step-down whole of service approach, based on a relational model, is described; this focuses on both the intrapsychic difficulties of the individual and broader interpersonal conflicts that can challenge treatment teams, families and carers, and the broader community. The model includes the whole system supporting the client in the strategy. The Project Air Strategy for Personality Disorders outlines approaches to clinical leadership and service redesign, targeted training, the provision of brief and longer term treatments, rapid access to psychological assistance, support for families and carers, and better access to information and clinical resources to provide a more hopeful and integrated treatment. the treatment of personality disorders, particularly Borderline Personality Disorder (BPD), in mental health services is under significant pressure due to their high prevalence and the cost and burden of treatment. People with personality disorders present in significant numbers to Emergency Departments as well as to Mental Health and Drug and Alcohol services. An analysis of data from one large mental health service that are reasonably representative of the State of New South Wales (NSW), Australia, demonstrates that 26% of emergency presentations and 25% of inpatient admissions to mental health beds were for patients classified, using ICD-10, as having personality disorders and related conditions, as shown in Figure 1. Figure 1. Percentage of all mental health emergency department presentations (Fig A) and inpatient admissions (Fig B) based on ICD- 10 classification of diseases coding (affective disorders, psychotic disorders, personality disorders, drug and substance use disorders, and other disorders). Data are for four years from Nov 2008 Nov 2012, Illawarra Shoalhaven Local Health District (total sample N = 6338). Acknowledgment: The author would like to acknowledge the support of NSW Health and the Project Air Strategy team. Corresponding author: grenyer@uow.edu.au Generally, treatment as usual involves health services providing crisis management that may include short-term admission for safety and de-escalation of distress. Longer-term service involvement has traditionally been regarded as counterproductive due to mental health clinicians' concerns about reinforcing helplessness and escalating help-seeking behaviour through actions (e.g., increased self-harm). This has resulted, in some cases, in a stigmatised response from mental health services and unconscious negative responses (countertransference) from health professionals. Prevalence data for the disorder vary between countries and based on method. The best prevalence data in Australia suggest that 6.5% of the Australian population has a personality disorder (Jackson & Burgess, 2000), whilst North American data report a median prevalence rate of 10.56% (Lenzenweger, 2008). Further, an estimated 40 50% of psychiatric patients have a comorbid or primary personality disorder, including an estimated 22% of psychiatric outpatients who specifically meet the criteria for BPD (Korzekwa, Dell, Links, Thabane, & Webb, 2008). Similarly, 31.4% of patients with a general mental health disorder (such as anxiety or depression) have been found to also be diagnosed with a personality disorder (Zimmerman, Rothschild, & Chelminski, 2005). The prevalence of personality disorders is the same in both men and women, although their pattern of presentation to services can vary. The Burden of Providing Appropriate Services Along with the high prevalence is the high severity of problems, which put considerable strain on mental health services. People with a personality disorder are at increased risk of suicide and self-harm, and frequently have contact with, and pose difficult management issues for, a number of agencies, including Health, Police, Corrections, and Housing. This client group have not always had consistent or helpful responses from the health service and other agencies; hence, there have been difficulties in providing the best The ACPARIAN: ISSUE 9: July 2014 Australian Clinical Psychology Association

9 treatment responses, and with clients accepting these when offered. Health service inconsistencies have in some cases led to greater escalation in help seeking and a greater ambivalence towards help provided. These difficulties extend beyond just mental health and also involve justice, health and corrections. People in correctional settings have higher rates of personality disorder than people in the general community; 43.1% of adult prisoners in NSW reception centres meet criteria for a personality disorder, compared with 9.2% of a community sample (Butler et al., 2006). The presence of personality disorder symptoms in adolescents has also been linked to violent offending and rate of recidivism during adolescence and early adulthood (Johnson et al., 2000; Steiner, Cauffman & Duxbury, 1999). Due to the wellestablished relationship between personality disorder and violent offending, a diagnosed personality disorder is considered a risk factor in a number of tools used to assess risk of violence (e.g., HCR-20). Offending is often related to symptoms of personality disorder, such as impulsivity, emotion dysregulation, and associated substance abuse. Notably, risk of re-offending among those with a mental illness, including a personality disorder, is increased significantly when a comorbid substance abuse disorder is present (Davison & Janca, 2012; Smith & Trimboli, 2010). By treating personality disorders in the broader community, we will likely reduce criminal offending associated with the disorder in two ways: (1) by lowering the incidence of substance abuse among people with personality disorder, and (2) by helping people with personality disorder reintegrate into society from prison and abstain from criminal offending. People with personality disorders who seek treatment (e.g., present to Emergency Departments, require outpatient and inpatient care) pose a high economic burden on society, a burden substantially higher than that found for other mental illnesses such as depression and generalised anxiety. A study conducted in the Netherlands (N = 1740) found that the direct medical costs per patient with a personality disorder were AUD$10,760 ( 7,398) per year (Soeteman, Roijen, Verheul, & Busschback, 2008), while the indirect cost per patient with a personality disorder and a paying job was an additional AUD$10,309 ( 7,088) per year. The total days lost because of absence from work or inefficiency at work was found to be 47.6 per patient per year. BPD was associated with increased direct and indirect costs. According to the Australian National Survey of Mental Health and Well-Being, 4.8% of the Australian full-time workforce has a personality disorder, with a personality disorder being predictive of work impairment (Lim, Sanderson, & Andrews, 2000). A current mental illness was associated with an average of one lost day from work, and three days of reduced performance in the month prior to the survey. Lost work productivity due to mental disorders, such as personality disorders and substance-related disorders, contributes a loss of AUD$2.7 billion each year. The high societal costs of personality disorders suggest the importance of prioritising the development and implementation of effective personality disorder treatments. Research undertaken in Australia has established a significant cost benefit of implementing appropriate psychosocial treatments for people with BPD (Stevenson & Meares, 1999). One year of psychotherapy was associated with an average decrease in inpatient costs of AUD$21,431 per patient with BPD. Findings suggest a suitable psychotherapy treatment course for BPD will save health services at least AUD$8,000 per patient a year following therapy. What Is Evidence-Based Practice for BPD? Clinical guidelines and systematic reviews based on over 25 randomised controlled trials support structured psychological therapy as the treatment of choice for BPD (Grenyer, 2013; Leichsenring, Leibing, Kruse, New, & Leweke, 2011). Recently, the National Health and Medical Research Council (NHMRC; 2012) issued clinical guidelines for the treatment of personality disorders, with some core recommendations in Table 1. Table 1 Selected key recommendations from the Clinical practice guidelines for the management of borderline personality disorder (NHMRC, 2012). 1. BPD is legitimate diagnosis for healthcare service. 2. Structured psychological therapies should be provided. 3. Medicines should not be used as primary therapy. 4. Treatment should occur mostly in the community. 5. Adolescents should get structured psychological therapies. 6. Consumers should be offered a choice of psychological therapies. 7. Families and carers should be offered support. 8. Young people with emerging symptoms should be assessed for possible BPD. Of the structured psychotherapies, there is evidence from controlled trials for a number of approaches, including cognitive-behavioural (such as dialectical behaviour therapy and schema focussed therapy), and dynamic interpersonal therapies (such as mentalisationbased therapy, transference-focused psychotherapy, cognitive analytic therapy, and general psychiatric therapy). Because there are few or no differences in efficacy among the different treatments evaluated (Leichsenring et al., 2011), clinical guidelines and researchers have proposed core components of therapy shared by all approaches as the essential ingredients of structured psychological therapy. These include: (1) a focus on the treatment relationship; (2) an active therapist stance towards the client; (3) specific attention on affect; and (4) the use of exploratory changeoriented interventions (Weinberg, Ronningstam, Goldblatt, Schechter, & Maltsberger, 2011). The synthesis of these core principles leads to a certain set of attitudes and key principles, as shown in Table 2. The ACPARIAN: ISSUE 9: July 2014 Australian Clinical Psychology Association

10 Table 2 Key principles for the treatment of personality disorders (Project Air Strategy for Personality Disorders, 2011). Key Principles for Working with People with Personality! Demonstrate empathy. Disorders! Listen to the person's current experience.! Validate the person's current emotional state.! Take the person's experience seriously, noting verbal and non-verbal communications.! Maintain a non-judgemental approach.! Stay calm.! Remain respectful.! Remain caring.! Engage in open communication.! Be human and be prepared to acknowledge both the serious and funny side of life where appropriate.! Foster trust to allow strong emotions to be freely expressed.! Be clear, consistent, and reliable.! Remember aspects of challenging behaviours have survival value given past experiences.! Convey encouragement and hope about the person's capacity for change while validating their current emotional experience. The Need for Step-Down Service Re-Design, Balancing Intensive with Brief Psychological Interventions The mental health intake and emergency department data from a hospital system servicing a population of approximately 250,000 people are shown in Figure 1. Within this population, about 16,250 are estimated to have had diagnosable personality disorders based on population prevalence. Of the 6,338 inpatients of mental health services who presented at some time within a 4 year period, 1,584 unique people presented with a personality disorder. This represents 396 people per year (approximately one each day) who were admitted. It is important to then ask: how do you treat 396 people per year using guidelines-based psychological therapy with finite resources? Currently, a service this size usually offers around two group plus individual therapy personality disorder programs with places for about 40 clients a year, with each of the eight specialist staff taking about five clients each for psychological therapy. To meet the demands for the other 356 clients, and to avoid care that is not supported by clinical guidelines (such as long-term inpatient care or offlabel pharmacotherapy), step-down approaches based on brief structured psychological therapy are required. These briefer interventions can specifically intervene when clients are in crisis and presenting to services, thus creating an opportunity to divert BPD clients from inpatient and emergency departments into rapid follow-up psychological care. Using a model adapted from St Vincent's Hospital Sydney (Wilhelm et al., 2007), we have developed a brief psychological intervention focused specifically on BPD clients in crisis. This aims to help overcome the crisis and develop a care plan to assist the client to be actively involved in their recovery. With 16 multidisciplinary staff offering brief intervention sessions over three locations, 450 places are made available each year so that all clients can be offered an appointment within 1 3 days to discuss their difficulties using a psychological approach supported by evidence-based clinical guidelines. Significantly, these sessions include one session that is set aside to connect with carers, family, and partners of the identified client; this is based on our research showing that these carers typically suffer significant burden, stigma, and distress that can be addressed through psychoeducation and carer planning that also have benefits for the client (Bailey & Grenyer, 2014). Re-thinking BPD: The Project Air Strategy Given the high prevalence of the disorder, the challenges of providing sufficient resources to meet clinical need, the stigma and burden for those involved, and the cost-benefit of intervening effectively, led the NSW Government in 2009 to recognise the need to re-think treatment approaches. The Project Air Strategy for Personality Disorders (2011) is a collaboration between NSW Health and the Illawarra Health and Medical Research Institute. It was awarded a competitive tender in 2010 to improve the capacity of mainstream mental health services to manage and treat personality disorder and to expand specialist treatment options, including improved referral pathways between generic and specialist treatment. The strategy aims to enhance treatment options for people with personality disorder and their families and carers. A close association with similar groups providing services in the area of personality disorders, including the Spectrum Personality Disorder Service for Victoria and Orygen Youth Health, has provided essential peer review and opportunities for collaboration. The strategy adopted a relational model based on the understanding that personality disorders have been described as disorders of relationship, with three key relationships of particular focus: (1) the relationship between the client and themself, which in BPD is frequently characterised by extreme self-criticism and low self-esteem. A factor analysis of the nine BPD diagnostic criteria described three over-arching themes as 'affect dysregulation' (describing the mood and anger impulsivity), 'rejection sensitivity' (describing the interpersonal hypersensitivity including abandonment, anxiety, and emptiness), and 'mentalisation failure' (describing the identity disturbance and transient psychotic symptoms) (Lewis, Caputi, & Grenyer, 2012); the relationship between the client and health professionals, which is known to be both a key to success and conflictual and difficult to manage, incorporates hostile, narcissistic, compliant, anxious, and sexualised dimensions (Bourke & Grenyer, 2013); and (3) the relationship between the client and the The ACPARIAN: ISSUE 9: July 2014 Australian Clinical Psychology Association

11 broader environment, including families, education, health, and community services, which can be characterised by ambivalence in the capacity and willingness to provide adequate support (NIMHE, 2003). All evidence-based treatments work to target the first relationship component, some incorporate strategies to assist with the second, but few address the third component including the broader context. The field needs to move beyond an exclusive focus on the individual's intrapsychic difficulties to an interpersonal focus that includes health professionals, families, educators, employers, and communities within a recovery framework. Supporting the relationship model is the technology of the Core Conflictual Relationship Theme, which describes the interaction among client needs, wishes, and goals, the responses of others (including the therapist, partners, and family), and the response of self within an interpersonal dynamic (Bourke & Grenyer 2010; Grenyer, 2012). Using such a relationship model allows a broader understanding of what has been described as the dialectic between support and change, which applies to both the client's difficulties and the clinical and social environment. At the commencement of the Project Air Strategy, the team undertook a series of research and evaluation studies to determine the shape of the implementation plan. These included collecting data from front-line clinical staff involved in the treatment of personality disorders (McCarthy, Carter, & Grenyer, 2013), conducting focus groups on the need for change (Fanaian, Lewis, & Grenyer, 2013), reviewing the literature (Bailey & Grenyer, 2013), seeking the views of experts on the advisory committee, obtaining peer review from an international audience (Grenyer & Carter, 2011), and ensuring the proposals met national and international guidelines (Grenyer, 2013). In addition, key findings from implementation science studies were incorporated, including the need for working with managers, involving key 'champion' clinicians, and ensuring that consumers played a role in reviewing the proposals. A whole of service approach was chosen. Training all mental health staff was designed to reduce stigma and therapeutic nihilism surrounding this client group and to facilitate the adoption of more hopeful and evidence-based attitudes towards treatments. Therefore, working with managers was also important to ensure support for the project within a relational model. Including families, carers, and consumers in the service redesign, and offering specific education, provided an opportunity to overcome previous barriers to support. Developing easy to learn brief interventions also worked to help health services manage the large volumes of clinical demand from this client group. At the commencement of the project, specialist longer-term treatments in the implementation sites were struggling with waiting lists of one to two years length, with little prospect of effectively meeting the demands of the large numbers of this treatment seeking group. Step-down services with rapid follow-up that provided diversion from emergency and inpatient units was a key innovation of the model developed. The central role of assessment and care planning provided individuals with a sense of direction and purpose that integrated the large number of community options available to them both from government and nongovernment service providers, including the mental health service. The project has delivered education and supervision programs in addition to the provision of expert interventions, treatment guidelines, and complex care reviews for a small number of high needs complex clients. Figure 2 shows the six key strategies as redesigning services, upgrading mental health staff skills, evaluating outcomes, connecting with families, carers, and consumers, improving awareness and information, and enhancing the quality of clinical services. Figure 2. Six components of the Project Air Strategy for personality disorders. The project model has been operationalised through clinical guidelines which describe the pathway of a client through the health service, from assessment and care planning, brief and longer term therapies, the role of inpatient and community care, interaction with general practitioners, involving families and carers, and systemic issues for services (Project Air Strategy, 2011). The operationalisation of the strategy involves a combination of senior management leadership, training and support, clinical leadership within services by experienced staff, and the design of service models to enhance clinical pathways using guidelines-based treatment to match client need. Core to the strategy is the role of clinical psychologists who act as the pivot point to coordinate the flow of clients into brief and more intensive treatments, and who lead the local consultation team. Essential to the strategy is collaborative care planning to assist in the coordination and integration of services, including a core leadership role for clinical psychologists assisting physicians, public and private psychiatrists, community services, emergency departments, non-government agencies, community housing, and other relevant services, based on a collaborative assessment of needs. Brief interventions, and family and carer sessions and workshops, complement more traditional extended group and individual therapies. The needs of children of persons with a personality disorder are one example of how the model focuses on the broader social context of care through enhanced parenting interventions. The ACPARIAN: ISSUE 9: July 2014 Australian Clinical Psychology Association

12 Conclusion The challenge for the field is no longer whether psychological treatments work. There is now a variety of models and methods which, for the right clients, can sustain their improvement and retain them in meaningful treatment, sometimes for up to three years (Grenyer, 2007). The next challenge is how to ensure models are available that allow step-down care, with both short and longer term options, to meet client need and the capacity of health services to respond. The sobering conclusion of a recent systematic review into BPD stated "there is evidence that psychotherapy is beneficial with respect to some clinically relevant problems of patients with borderline personality disorder. However, the available forms of psychotherapy do not yet lead to remission of borderline personality disorder for most patients" (Leichsenring et al., 2011, p. 80). High drop-out rates remain a challenge for the field, with a large number of clients unable or unwilling to commit to the established longer forms of treatment. Nevertheless, research on the treatment careers of psychotherapy clients typically shows that at least 90% presenting for help come with histories of previous treatment that accumulatively has benefited them (see, for example, Grenyer, Deane, & Lewis 2008). Every treatment interaction, however brief, is an opportunity to reinforce skills and to challenge beliefs about a client's capacity to be helped. It has been known for a long time that teams can be easily fractured and split into groups of clinicians who like and want to help, and groups who dislike and are unwilling to help, borderline clients (Main, 1957). The challenge before us is to both treat a patient's intrapsychic problems, and simultaneously support teams and the broader social and emotional environment, to maintain hope and compassion. The Project Air Strategy is one comprehensive relational approach that integrates both individual consultation with broader social and emotional engagement with services, families, carers, and the community to promote needed whole of service guidelinesbased care. References Bailey, R. C., & Grenyer, B. F. S. (2013). Burden and support needs of carers of persons with personality disorder: A systematic review. Harvard Review of Psychiatry, 21(5), Bailey, R. C., & Grenyer, B. F. S. (in press). Supporting a person with personality disorder: A study of carer burden and wellbeing. Journal of Personality Disorders. e-view Ahead of Print. doi: /pedi_2014_28_136 Bourke, M., & Grenyer, B. F. S. (2013). Therapists' accounts of psychotherapy process associated with treating borderline personality disorder. Journal of Personality Disorders, 27(6), doi: / pedi_2013_27_108 Bourke, M. E., & Grenyer, B. F. S. (2010). Psychotherapists' response to borderline personality disorder: A core conflictual relationship theme analysis. Psychotherapy Research, 20(6), Butler, T., Andrews, G., Allnutt, S., Sakashita, C., Smith, N. E., & Basson, J. (2006). Mental disorders in Australian prisoners: A comparison with a community sample. Australian and New Zealand Journal of Psychiatry, 40(3), Davison, S., & Janca, A. (2012). Personality disorder and criminal behaviour: What is the nature of the relationship? Current Opinion in Psychiatry, 25(1), Fanaian, M., Lewis, K., & Grenyer, B. F. S. (2013). Improving services for people with personality disorders: The views of experienced clinicians. International Journal of Mental Health Nursing, 22(5), Grenyer, B. F. S. (2007). Hope for sustaining a positive three-year therapeutic relationship with borderline patients. Archives of General Psychiatry, 64, 609. Grenyer, B. F. S. (2012). The clinician's dilemma: Core conflictual relationship themes in personality disorders. ACPARIAN, 4, Grenyer, B. F. S. (2013). Improved prognosis for borderline personality disorder: New treatment guidelines outline specific communication strategies that work. Medical Journal of Australia, 198(9), Grenyer, B. F. S., & Carter, P. (2011). Psychotherapy for borderline personality disorder: Where to start, when to finish? Journal of Personality Disorders, 25(Suppl 1), Grenyer, B. F. S., Deane, F. P., & Lewis, K. (2008). Treatment history and its relationship to outcome in psychotherapy for depression. Counselling and Psychotherapy Research, 8, Jackson, H. J., & Burgess, P. M. (2000). Personality disorders in the community: A report from the Australian National Survey of Mental Health and Wellbeing. Social Psychiatry and Psychiatric Epidemiology, 35(12), Johnson, J. G., Cohen, P., Smailes, E., Kasen, S., Oldham, J. M., Skodol, A. E., & Brook, J. S. (2000). Adolescent personality disorders associated with violence and criminal behavior during adolescence and early adulthood. American Journal of Psychiatry, 157(9), Korzekwa, M. I., Dell, P. F., Links, P. S., Thabane, L., & Webb, S. P. (2008). Estimating the prevalence of borderline personality disorder in psychiatric outpatients using a twophase procedure. Comprehensive Psychiatry, 49(4), Leichsenring, F., Leibing, E., Kruse, J., New, A. S., & Leweke, F. (2011). Borderline personality disorder. Lancet, 377, Lenzenweger, M. F. (2008). Epidemiology of personality disorders. Psychiatric Clinics of North America, 31, Lewis, K., Caputi, P., & Grenyer, B. F. S. (2012). Borderline personality disorder subtypes: A factor analysis of the DSM-IV criteria. Personality and Mental Health, 6, DOI /pmh.1183 Lim, D., Sanderson, K., & Andrews, G. (2000). Lost productivity among full-time workers with mental illness. Journal of Mental Health and Policy Economics, 3, Main, T. F. (1957). The ailment. British Journal of Medical Psychology, 30, McCarthy, K. L., Carter, P. E., & Grenyer, B. F. S. (2013). Challenges to getting evidence into practice: expert clinician perspectives on psychotherapy for personality disorders. Journal of Mental Health, 22(6), National Health and Medical Research Council. (2012). Clinical practice guideline for the management of borderline personality disorder. Melbourne, Australia: Author. Project Air Strategy for Personality Disorders. (2011). Treatment guidelines for personality disorders. Sydney, Australia: NSW Health and Illawarra Health and Medical The ACPARIAN: ISSUE 9: July 2014 Australian Clinical Psychology Association

13 Research Institute. Retrieved from Smith, N., & Trimboli, L. (2010). Comorbid substance and non-substance mental health disorders and re-offending among NSW prisoners. Crime and Justice Bulletin, no. 140, pp Retrieved from documents/pdf/cjb140.pdf Soeteman, D. I., Roijen, L., Verheul, R., & Busschback, J. J. (2008). The economic burden of personality disorders in mental health care. Journal of Clinical Psychiatry, 69(2), Steiner, H., Cauffman, E., & Duxbury, E. (1999). Personality traits in juvenile delinquents: Relation to criminal behavior and recidivism. Journal of the American Academy of Child & Adolescent Psychiatry, 38(3), Stevenson, J., & Meares, R. (1999). Psychotherapy with borderline patients: II. A preliminary cost benefit study. Australian and New Zealand Journal of Psychiatry, 33(4), Weinberg, I., Ronningstam, E., Goldblatt, M. J., Schechter, M., & Maltsberger, J. T. (2011) Common factors in empirically supported treatments of borderline personality disorder. Current Psychiatry Reports, 13(1), Wilhelm, K., Finch, A., Kotze, B., Arnold, K., McDonald, G., Sternhell, & Hudson, B. (2007). The Green Card clinic: Overview of a brief patient-centred intervention following deliberate self-harm. Australasian Psychiatry, 15(1), Zimmerman, M., Rothschild, L., & Chelminski, I. (2005). The prevalence of DSM-IV personality disorders in psychiatric outpatients. American Journal of Psychiatry, 162(10), Erratum Fitzgerald, J. (2014). Emotionally focused therapy for couples: A brief overview. The ACPARIAN, 8, 4 6. The third sentence of the third paragraph should read: As the therapist respectfully reaches behind the masks of reactive angry pursuit and fearful withdrawal, the typical patterns of conflict and alienation, a distressed couple is helped to understand their distress more deeply. They are not coached to behave or talk in a certain way The ACPARIAN: ISSUE 9: July 2014 Australian Clinical Psychology Association

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16 Dialectical Behaviour Therapy in Community Mental Health Teams Simone Jaques, MPsych(Clin) Lower North Shore Community Mental Health & Bankstown Community Mental Health, Sydney, Australia Abstract Dialectical Behaviour Therapy (DBT) is an evidence-based intervention for symptoms of Borderline Personality Disorder (BPD). Increasingly, Community Mental Health (CMH) teams are providing this therapy for patients with BPD. It is frequently both an appealing and a challenging intervention for CMH teams to provide. This paper provides an overview of DBT, outlines its evidence base, and discusses the appeal and challenges of using the therapy in CMH teams. Factors to consider in developing a DBT program within a CMH team, as well as strategies to assist CMH teams in successfully implementing and maintaining the program, are discussed. 5 Community Mental Health Teams The New South Wales (NSW) public health system in Australia is divided into 15 Local Health Districts. Each Local Health District includes multiple Community Mental Health (CMH) teams. These teams are geographically based, with clients accessing mental health care from the CMH team allocated to their residential address. The CMH team is responsible for providing mental health assessment, care planning, and treatment, usually via ambulatory care services (including psychiatry, case management, psychological therapies, medication clinics, and rehabilitation) and afterhours services where necessary. There are no consistent CMH team structures or functions across NSW, with service models developed according to local need and resources (NSW Department of Health, 2008). Furthermore, there are no standardised criteria for receiving mental health services via each CMH team, with specific inclusion criteria varying from service to service. Generally, CMH teams provide services for individuals with severe mental health disorders, including but not limited to, schizophrenia, bipolar disorder, depression, and borderline personality disorder (BPD). Borderline Personality Disorder BPD is characterised by a range of symptoms, including intense fear of abandonment, unstable relationships, unstable identity, impulsivity, suicidal/parasuicidal behaviour, affective instability, chronic feelings of emptiness, anger, and paranoia or dissociation (American Psychiatric Association, 2013). Linehan (1993a) conceptualises pervasive emotion dysregulation to be at the core of the disorder; the diagnostic criteria for BPD are seen as reflections of the dysregulated emotional response system (McMain, Korman, & Dimeff, 2001). Clients with BPD present particular difficulties for individual clinicians and services involved in providing their treatment and care. The hallmark symptoms of BPD, such as intense emotional reactivity, anger, impulsive behaviour, and suicidal and parasuicidal behaviours, frequently contribute to compassion fatigue, burnout, and hopelessness in clinicians and services alike. Clinicians and services often have difficulty in sustaining the effort required to provide effective treatment (Swenson, Torrey, & Koerner, 2002). The nature of CMH work results in CMH teams often bearing the brunt of the difficulties associated with caring for clients with BPD. The core work of the CMH team includes providing care to clients following emergency department and psychiatric inpatient admissions, as well as assessment and treatment of clients who frequently present as suicidal and in crisis. Therefore, CMH teams are well placed to provide evidence-based treatment to clients with BPD. Overview Dialectical Behaviour Therapy Dialectical behaviour therapy (DBT) is an evidencebased treatment for the symptoms of BPD (Linehan, 1993a; Verheul et al., 2003), and is recommended by the National Health and Medical Research Council (2012) in their Australian Clinical practice guidelines for the management of Borderline Personality Disorder. Furthermore, a Cochrane Review in 2012 concluded that DBT and DBT-related treatments provide "the most solid (but not sufficiently robust) evidence of efficacy relative to all other treatments [for BPD] that have been investigated so far" (Stoffers et al., 2012, p. 73). DBT is a comprehensive treatment, based on dialectical philosophy, that blends cognitive-behavioural strategies with acceptance-based strategies. The fundamental dialectic employed in DBT is the therapeutic focus on behaviour change, balanced with acceptance, compassion, and validation of the client (Linehan, 1993a; McMain et al., 2001; Swenson et al., 2002). 5 Corresponding author: simone.jaques@sswahs.nsw.gov.au The ACPARIAN: ISSUE 9: July 2014 Australian Clinical Psychology Association

17 The Biosocial Theory DBT is based on a biosocial theory, which posits that BPD develops from the combination of genetic vulnerabilities and invalidation (when the environment trivialises, ignores, dismisses, and/or punishes the expression of internal experience). Environmental invalidation can be extreme, as seen in cases of sexual abuse, but can also be less prominent, as seen in cases where the individual's genetic vulnerability is more pronounced (McMain et al., 2001). Emotion dysregulation is then maintained by the ongoing transaction between the individual's own emotional vulnerability and their experience of pervasive invalidation (Linehan, 1993a; Swenson et al., 2002), resulting in the symptoms seen in BPD. The Three Stages of DBT DBT is a structured intervention that is separated into three stages (Linehan, 1993a). The purpose of the first stage of treatment is to achieve behavioural stabilisation and to master skills. The second stage of treatment focuses on resolving post-traumatic stress disorder, and the third on addressing self-respect and individual goals. Generally, the first year of treatment focuses on stage 1, with some clients also beginning stage 2 if they have achieved behavioural stability within the first year. Most published literature regarding DBT refers to stage 1. stages 2 and 3 are more variable and are not described or manualised by Linehan (1993a, 1993b). Once behavioural stabilisation has been achieved (stage 1), clients are able to engage in other evidence-based therapies (e.g., EMDR, exposure therapy) to address stages 2 and 3. DBT Modes of Treatment The first year of standard comprehensive DBT is comprised of four modes of treatment: weekly individual psychotherapy sessions, weekly skills training groups, weekly clinician consultation team meetings, and telephone coaching as needed by the clients (Linehan, 1993a; McMain et al., 2001). Individual psychotherapy sessions. Individual therapy provides structure to overwhelming crises by utilising a therapeutic hierarchy to determine the behavioural targets to be addressed. Life interfering behaviours are prioritised, followed respectively by therapy interfering behaviour, quality of life-interfering behaviour, and increasing coping skills (Linehan, 1993a; McMain et al., 2001). The theoretical underpinnings of the hierarchy are logical and pragmatic; treatment of quality of life-interfering behaviours (e.g., substance use, interpersonal difficulties) is unlikely to be effective if the client is engaging in behaviour that renders the therapy ineffective (e.g., missing sessions, attending sessions intoxicated). The individual therapy sessions use a chain analysis to examine problem behaviours. A solution analysis follows the chain analysis, allowing for generalisation of the skills learnt in the skills training group. Skills training group. The skills training group explicitly teaches skills in four areas: core mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness. The skills training group teaches the skills in a didactic manner and requires the clients to strengthen the concepts by completing, and then reviewing, weekly homework tasks (Linehan, 1993b). Clinician consultation meeting. The clinicians involved in providing the individual therapy and the group skills training meet weekly. The clinicians' consultation meeting assists therapists in maintaining and enhancing their own motivation and capability to provide effective treatment (McMain et al., 2001) and in managing burnout and reducing drift from the DBT model (Linehan, 1993a). Telephone coaching. In standard DBT, clients are able to access their individual therapist 24 hours per day for telephone coaching. The purpose of telephone coaching is threefold. Firstly, it provides an opportunity for the client to ask effectively for help. Secondly, telephone coaching assists the client to generalise their skill acquisition by providing them with coaching in skill use in real time, as the crisis is unfolding. Finally, telephone coaching allows the client opportunities, between sessions, to repair the therapeutic relationship (Linehan, 1993a). Evidence for DBT: A Brief Review DBT has repeatedly been established as an effective treatment for symptoms of BPD in a variety of randomised controlled trials, some conducted by the developer of DBT, Marsha Linehan (e.g., Linehan, Armstrong, Suarez, Allmon, & Heard, 1991) and others by independent research teams (e.g., McMain et al., 2009; Verheul et al., 2003). Furthermore, a review of randomised controlled trials for treatment of BPD found DBT is the most studied of therapies for BPD and that DBT is a treatment supported by the current evidence (Stoffers et al., 2012). Blennerhassett and O'Raghallaigh (2005) have observed that published research tends to find that standard outpatient DBT reduces the rate of suicidal behaviour compared with treatment as usual, with further positive effects on rates of psychiatric hospitalisation and retention in therapy. Studies have also shown that DBT is an effective treatment in CMH settings where the clients included in the research were more similar to those encountered by CMH teams (e.g., are not excluded for comorbid diagnoses), and the clinicians providing the treatment were more akin to the clinicians providing services in CMH teams (e.g., variety of professional backgrounds, levels of academic qualification). These studies have been conducted in CMH teams in a variety of countries, including the United States (Ben-Porath, Peterson, & Smee, 2004; Comtois, Elwood, Holdcraft, Smith, & Simpson, 2007), Australia (Pasieczny & Connor, 2011; Williams, Hartstone, & Denson, 2010), Canada (McMain et al., 2009), and New Zealand (Brassington & Krawitz, 2006), and have reported a variety of positive clinical outcomes. Together, these studies demonstrate DBT is an effective treatment that can be successfully conducted in real-world CMH settings. The Appeal of DBT in CMH Teams DBT is an appealing intervention for CMH teams as it provides the framework, resources, and support required for clinicians to work effectively with extremely distressed, The ACPARIAN: ISSUE 9: July 2014 Australian Clinical Psychology Association

18 emotionally dysregulated, and suicidal clients. Furthermore, CMH teams are well placed to provide DBT as they are structured to provide acute mental health care to suicidal individuals, and clinical management is more easily streamlined across inpatient, emergency, and acute care services. Clinicians in CMH teams who are providing a DBT intervention are not only supported by their DBT consultation team, but also can be more readily supported by the mental health team as a whole, both in and out of hours, therefore further reducing the anxiety and trepidation frequently experienced when providing clinical services to clients with BPD. Furthermore, DBT is compatible with recovery principles, which provide the current theoretical underpinnings for many CMH teams (NSW Department of Health, 2008; Swenson et al., 2002). DBT is also an appealing intervention for the CMH team as it is a manualised intervention (Blennerhassett & O'Raghallaigh, 2005) that is feasible and effective (Swenson et al., 2002). Also, DBT appeals to the variety of clinicians employed in CMH teams as it is simple enough to be understood by newer clinicians and complex enough to appeal to those clinicians with more experience (Swenson et al., 2002). Frequently, clinicians in the CMH team are employed into generalist 'mental health worker' positions and are required to provide broad ranging case management services as the core of their work. DBT provides an opportunity for therapeutically trained clinicians to utilise their skills and deliver a psychological intervention, which for clinicians in many DBT programs (e.g., Bankstown Mental Health, Lower North Shore Mental Health) appears to increase job satisfaction. Furthermore, clinicians in CMH teams are trained in a variety of disciplines (e.g., psychology, psychiatry, nursing, social work, occupational therapy), and the different skill mix is frequently an asset to the DBT consultation meeting and to the clients who are receiving the DBT intervention. Further appeal of DBT to CMH teams is that it has been shown to be a cost effective intervention compared to treatment as usual (Comtois et al., 2007; Pasieczny & Connor, 2011), resulting in cost savings to administrators. Furthermore, the length of DBT (usually approximately 12 months for stage 1) means it is often inaccessible to clients without private health cover as publically funded alternative therapy via Medicare is generally limited to 10 sessions per calendar year. While CMH teams are subject to limited budgets, they are not restricted to a funding model that stipulates the number of sessions clients are funded to receive. Therefore, CMH teams are one of the few services able to provide DBT at no cost to clients who have limited financial resources. Challenges Facing DBT in CMH Teams Clinician resources. The time commitment required from individual therapists is frequently greater than the time allocated to other clients of CMH teams. This is especially the case once the time allocated to the clinician consultation and facilitating the skills training group is taken into account. Furthermore, basic training in DBT requires clinicians to be absent from their general duties for a minimum of 4 days, resulting in a temporary reduction in productivity. Demand. DBT programs in CMH teams are frequently in high demand. Clients typically take 12 months to complete Stage 1 DBT, resulting in slow turnover. Typically, the demand is greater than the number of available places. Many DBT programs in CMH teams have waiting lists of up to 12 months, or prioritise the most severe cases, limiting access to clients with more moderate symptoms, who then need to access alternative treatment in the community. Funding. Although DBT has been demonstrated to provide cost savings to mental health services, frequently the bulk of cost savings is related to a reduction in costs to inpatient services and not to the CMH team. This results in a reduction in the use of inpatient resources and a greater use of community resources, without a corresponding realignment of budgets. This presents a significant challenge to CMH teams, which are frequently operating under limited funding. Training. Accessing suitable DBT training is another challenge facing DBT programs in CMH teams. The training and nurturing required for clinicians new to DBT represents a significant investment for CMH teams. Frequently, clinicians are well trained when a DBT program is being set up, as service administrators are willing to fund, and sometimes arrange, DBT training for this purpose. However, staff turnover and attrition can reduce the expertise a CMH team has in DBT, with new clinicians likely to have had little or no DBT training and clinical experience (Herschell, Kogan, Celedonia, Gavin, & Stein, 2009). In order for the DBT programs to continue, it is often necessary for clinicians to begin to provide DBT therapy before they have received appropriate training. Furthermore, ongoing training for experienced DBT therapists is often not prioritised, and commonly clinicians must be self-motivated and self-funding to achieve suitable levels of training. Ongoing awareness of the need for DBT. It is noted that there is a tendency for the need for DBT in CMH teams to be highlighted when DBT is not available for clients who have severe BPD and who consume CMH team resources intensely over many years. Such clients can prompt services to develop DBT programs in order to contain and reduce service usage. However, once DBT programs are well established and clients with BPD are offered DBT relatively early, the clinical need for DBT is not as apparent, as the clients are receiving appropriate treatment and use crisis and inpatient services more sparingly. This can result in a gradual reduction of support for DBT from service administrators, as the apparent need for DBT is less pronounced. Factors to Consider When Developing a DBT Program in CMH Teams Modification of the DBT protocol. CMH teams are often subject to staffing and budget constraints. As a result, they frequently modify DBT to fit their available resources. For example, studies conducting DBT in CMH teams have The ACPARIAN: ISSUE 9: July 2014 Australian Clinical Psychology Association

19 frequently adapted the standard treatment protocol described by Linehan (1993a; 1993b). Some studies have reduced the length of the treatment to 6 months (e.g., Ben- Porath et al., 2004; Brassington & Krawitz, 2006; Pasieczny & Connor, 2011; Williams et al., 2010) or have reduced the requirement for DBT individual therapy (Williams et al., 2010). Other studies have reduced or eliminated the availability of the individual therapist to provide telephone coaching, with adaptations such as using after-hours mental health clinicians to perform telephone coaching outside business hours (Comtois et al., 2007; Williams et al., 2010). These adaptations to Linehan's treatment protocol are likely reflections of the real-world constraints CMH clinicians and services face in providing such an intensive treatment. However, significant adaptations may also represent drift from the DBT model (Swenson et al., 2002) and CMH teams must be careful that the treatment being offered still resembles and functions in line with Linehan's model, especially when the intervention being offered is labelled as DBT. In NSW there are multiple examples of DBT programs in CMH teams that provide stage 1 DBT in a manner that is close to Linehan's protocol, with only minor modifications. These programs offer all four modes of treatment (individual therapy, group skills training, telephone coaching, and clinician consultation) over approximately 12 months. Anecdotally, the most common modification appears to be an adjustment to the telephone coaching protocol, with clients accessing the after-hours CMH clinicians instead of their individual therapist. Therefore, clinicians who are initiating and developing DBT programs in CMH teams should feel confident that major modifications to the DBT protocol are not necessary for stage 1 DBT to be offered by CMH teams. Obtaining and sustaining motivation for DBT DBT programs in CMH teams require significant motivation from both service administrators who make strategic decisions and manage the budget for the service, and from the clinicians who work directly with clients with BPD. DBT programs that do not have support and motivation from both managerial and clinical staff are unlikely to thrive. Comtois et al. (2007) and Herschell et al. (2009) both noted that administrative support is essential for DBT programs to survive in CMH teams. CMH administrative support is crucial in the initial phase of a DBT program as administrators are able to directly influence factors that may impede the successful implementation of DBT. Administrators are able to address policy, provide funding for training, and adjust critical structural barriers such as a reliance on traditional clinical case management models and requirements for caseload size (Comtois et al., 2007). Furthermore, ongoing administrative support is also crucial for DBT programs after they are well established, to maintain the gains already achieved in the start-up phase and to allow the program to grow. In particular, ongoing administrative support is required for continuing training and supervision for clinicians, and to assist the DBT program to withstand the pressures faced by CMH teams, such as staff turnover, differing models of care, and increasing requirements for high caseloads. In addition to administrative support, successful DBT programs in CMH teams also require significant motivation and commitment from the clinicians who work directly in the DBT programs. DBT clinicians must be willing to work with a population of clients who are frequently challenging. When the CMH team suffers from staffing shortages, DBT clinicians are likely to be required to take on work above and beyond their colleagues who are not involved in the DBT program. Furthermore, they must be willing to commit to continued employment in the CMH team for a minimum of 12 months, in order to provide consistent individual therapy for their clients. Finally, clinicians involved in DBT in CMH teams are frequently required to be motivated for, and to fund their own, professional development in DBT. Strategies to Develop and Maintain Motivation for DBT There are several strategies that administrators and clinicians can employ to develop and maintain motivation and enthusiasm for DBT programs in CMH teams. Administrators and clinicians should meet regularly to discuss both the progress and outcomes of DBT programs and any requirements for ongoing implementation and success. To assist this process, DBT clinicians should develop and implement some form of evaluation of their DBT program. Such outcomes are likely to include direct measures of clinical effectiveness (e.g., measurement of symptoms such as suicide attempts, self-harm, emotional distress, depression) as well as measures directly related to CMH team administrators (e.g., service usage, emergency department presentations, psychiatric inpatient bed days). Such evaluations improve clinicians' levels of motivation as they are able to see the outcomes of their efforts, and administrators are able to use the data to justify their ongoing support for the DBT program. Additionally, CMH teams should consider allocating a DBT co-ordinator, either through a dedicated position or as dedicated time within an existing position on the team. Allocating a DBT coordinator allows CMH team DBT programs to have an 'in-house' clinician who can evaluate the program and provide initial training and supervision for novice DBT therapists. This provides a degree of confidence, and close supervision, for clinicians who would otherwise start providing DBT before they are formally trained. Furthermore, a dedicated DBT coordinator provides some consistency for the DBT program, allowing it to weather staff turnover more effectively. Finally, allocation of a DBT coordinator provides a physical and practical representation of administrators' support for DBT. Conclusion DBT is a structured evidence-based intervention that clinicians working in CMH teams are able to offer clients presenting with symptoms of BPD. CMH teams are well suited to provide DBT; however, they also face challenges in developing and sustaining such a resource intense The ACPARIAN: ISSUE 9: July 2014 Australian Clinical Psychology Association

20 intervention. Ongoing provision of DBT in CMH teams is reliant on proactive strategies to ensure that both mental health administrators and the clinicians providing DBT are able to manage and overcome the challenges they face, so they are able to continue to provide evidence-based care to clients with BPD. References American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5 th ed.). Arlington, VA: American Psychiatric Publishing. Ben-Porath, D. D., Peterson, G. A., & Smee, J. (2004). Treatment of individuals with borderline personality disorder using dialectical behavior therapy in a community mental health setting: Clinical application and a preliminary investigation. Cognitive and Behavioral Practice, 11, Blennerhassett, R. C., & O'Raghallaigh, J. W. (2005). Dialectical behaviour therapy in the treatment of borderline personality disorder. The British Journal of Psychiatry, 186, Brassington, J., & Krawitz, R. (2006). Australasian dialectical behaviour therapy pilot outcome study: Effectiveness, utility and feasibility. Australasian Psychiatry, 14(3), Comtois, K. A., Elwood, L., Holdcraft, L. C., Smith, W. R., & Simpson, T. L. (2007). Effectiveness of dialectical behavior therapy in a community mental health center. Cognitive and Behavioral Practice, 11, Herschell, A. D., Kogan, J. N., Celedonia, K. L., Gavin, J. G., & Stein, B. S. (2009). Understanding community mental health administrators' perspectives on dialectical behavior therapy implementation. Psychiatric Services, 60(7), Linehan, M. M. (1993a). Cognitive behavioral treatment of borderline personality disorder. New York, NY: Guilford Press. Linehan, M. M. (1993b). Skills training manual for treating borderline personality disorder. New York, NY: Guilford Press. Linehan, M. M., Armstrong, H. E., Suarez, A., Allmon, D., & Heard, H. L. (1991). Cognitive-behavioral treatment of chronically parasuicidal borderline patients. Archives of General Psychiatry, 14, McMain, S., Korman, L. M., & Dimeff, L. (2001). Dialectical behavior therapy and the treatment of emotion dysregulation. Journal of Clinical Psychology, 57(2), McMain, S. F., Links, P. S., Gnam, W. H., Guimond, T., Cardish, R. J., Korman. L., & Streiner, D. L. (2009). A randomized trial of dialectical behaviour therapy versus general psychiatric management for borderline personality disorder. American Journal of Psychiatry, 166, National Health and Medical Research Council. (2012). Clinical practice guideline for the management of borderline personality disorder. Melbourne, Australia: Author. NSW Department of Health. (2008). NSW Community Mental Health Strategy Retrieved from mental_health_strategy.pdf Pasieczny, N., & Connor, J. (2011). The effectiveness of dialectical behaviour therapy in routine public mental health settings: An Australian controlled trial. Behaviour Research and Therapy, 49, Stoffers, J. M., Völlm, B. A., Bücker, G., Timmer, A., Huband, N., & Lieb, K. (2012). Psychological therapies for people with borderline personality disorder. Cochrane Database of Systematic Reviews, 8, Art. No. CD DOI: / CD pub2 Swenson, C. R., Torrey, W. C., & Koerner, K. (2002). Implementing dialectical behavior therapy. Psychiatric Services, 53(2), Verheul, R., Van Den Bosch, L. M. C., Koeter, M. W. J., de Riddler, M. A. J., Stijnen, T., & Van Den Brink, W. (2003). Dialectical behaviour therapy for women with borderline personality disorder. The British Journal of Psychiatry, 182, Williams, S. E., Harstone, M. D., & Denson, L. A. (2010). Dialectical behavioural therapy and borderline personality disorder: Effects on service utilisation and self-reported symptoms. Behaviour Change, 27(4), The ACPARIAN: ISSUE 9: July 2014 Australian Clinical Psychology Association

21 Schema-focused Therapy for Borderline Personality Disorder: An Overview Louise Sharpe, PhD School of Psychology, University of Sydney, Australia Abstract Schema-focused therapy (SFT) was first advanced in the early 1990s as a treatment for patients who had failed to benefit from traditional cognitive therapy. Despite the fact that there are, as yet, only a handful of studies that demonstrate the efficacy of SFT, the effect sizes are very large, and there is now sufficient evidence to conclude that SFT is definitely efficacious for the treatment of Borderline Personality Disorder. This article will briefly outline the major mechanisms that are used in SFT, review the evidence for its efficacy, and discuss the challenges of using SFT in the Australian context. 6 What is Schema Therapy? Schema-focused therapy (SFT)_developed predominantly from a cognitive therapy perspective in the early 1990s for patients who had failed to respond to traditional cognitive therapy (Young, 1994). However, its early iterations focused on patients who had experienced a negative childhood environment characterised by neglect and/or abuse and the first specific conceptualisations were for Borderline Personality Disorder (BPD; Arntz & van Genderen, 2009; Young, Klosko, & Weishaar, 2003). SFT is more integrative than traditional forms of cognitive therapy, involving strategies that have their origin in psychodynamic models, gestalt therapy, and emotion-focused and attachment-based models. Key Stages of Schema Therapy SFT has three key stages. Initially, therapists must focus on bonding with the patient and helping the patient to achieve success in emotional regulation. The second phase focuses on schema mode change. Because this phase relies heavily on the use of experiential techniques, it is very important that the patient has established a strong therapeutic alliance with the therapist in the first phase, and that any high risk behaviours (such as self-harm) have been stabilised before progressing to this second phase. The final phase of therapy encourages the patient to develop more autonomy, and challenges patients to develop new behavioural repertoires. To achieve these outcomes, SFT has four key mechanisms: (1) limited re-parenting; (2) schema mode change using experiential strategies; (3) cognitive therapy; and (4) behavioural pattern breaking (Kellogg & Young, 2006). Therapeutic Relationship A major focus in SFT is on the therapeutic relationship. In traditional cognitive therapy, there is emphasis on the importance of a collaborative relationship 6 Corresponding author: louise.sharpe@sydney.edu.au with the patient. However, in schema therapy, the assumption is that patients with complex difficulties, such as borderline personality disorder, have typically had aversive parenting experiences (which have become internalised in the dysfunctional parent modes); hence, the therapeutic relationship is seen as particularly important in providing a limited opportunity for re-parenting. As such, the relationship becomes a vehicle for change within which the therapist is able to model appropriate behaviours, such as nurturing the abused child mode and setting boundaries for the impulsive child mode. Throughout therapy, the relationship acts to provide disconfirmatory evidence to the patient of key schema, such as abandonment, defectiveness/ shame, and mistrust/abuse. SFT revolves around two central concepts: early maladaptive schemas and schema modes. Young (1994) and Young et al. (2003) described early maladaptive schema which were central to the development of the kinds of generalised problems typically seen in patients with personality disorders. Early maladaptive schemas are the rigid and self-defeating patterns that patients learned from early negative and aversive childhood experiences. They differ from beliefs that characterise more straightforward presentations in that they are more rigid and are elicited from more varied triggers. Moreover, schemas are comprised not simply of cognitive content, but also emotions, associated memories, and impulses, to behave in a habitual way. Young et al. (2003) have produced a list of common early maladaptive schemas, the most common of which in BPD are abandonment, mistrust/abuse, and defectiveness/shame. Importantly, individuals try to cope with their schemas in a variety of ways (described next); however, these coping strategies typically reinforce the underlying schema and, as such, evidence that might disconfirm a schema is typically not forthcoming. Schema Modes The second important construct in SFT is schema modes. Schema modes are internalised scripts that are enacted when early maladaptive schemas are activated and The ACPARIAN: ISSUE 9: July 2014 Australian Clinical Psychology Association

22 produce strong negative emotions, such as anger, shame, or guilt. These modes prompt the individual's habitual behaviour in situations where schemas have been activated in an attempt to try and minimise the negative emotions that are experienced as overwhelming. Young et al. (2003) described four categories of modes: dysfunctional child modes, dysfunctional parenting modes, dysfunctional coping modes, and healthy modes. While schema modes can be applied to patients with a range of difficulties, the best conceptualisations are available for BPD (Arntz & van Genderen, 2009). The primary dysfunctional child modes seen in borderline personality are the abandoned/abused child and the angry/impulsive child. Hence, the emotional experiences of someone with BPD are seen to be explained by the activation and vacillation of these two modes, which lead to the extreme sadness associated with the abandoned/abused child mode and the anger and impulsivity associated with the angry/impulsive child. In BPD, the punitive parent mode results in the individual devaluing themselves in the way they experienced in childhood, and can be associated with the impulses to self-harm that are characteristic of this disorder. Further, the predominance of the detached protector mode drives an avoidant style of coping with the intense and overwhelming emotions that they experience, resulting in dissociation, social withdrawal, and the use of substances (or self-harm) aimed at numbing the intense emotional pain. In severe presentations of BPD, the healthy child and adult modes are typically weak. Essentially, the aim of SFT is to weaken the dysfunctional modes whilst strengthening these healthy modes. SFT is guided by the mode conceptualisation, which is explained to patients and linked to their early learning experiences (see Sempértegui, Karreman, Arntz, & Bekker, 2013 for a comprehensive review). Early stages of therapy need to be able to teach patients other ways in which they might cope with their overwhelming negative emotions in order to reduce the patient's reliance on selfdefeating coping mechanisms which interfere with the client's safety (e.g., self-harm), their quality of life (e.g., substance abuse) and/or their ability to experience the negative emotions of the abused and angry child modes. Once stabilised, the phase of therapy thought to be primary to the treatment of BPD is the treatment of the dysfunctional child modes. In schema therapy, these modes are treated predominantly through the use of experiential strategies, such as imaginal re-scripting (Arntz & Weertman, 1999; Holmes, Arntz, & Smucker, 2007; Smucker & Dancu, 1999; Weertman & Arntz, 2007) or other forms of dialogue work (Kellogg & Young, 2006). In imaginal rescripting, important early memories of abuse are identified, and patients are asked to revisit these memories. Through imaginal dialogue, patients are encouraged to rescript these incidents to allow the child to learn different messages from the experience. There is evidence to support the efficacy of imaginal rescripting (Weertman & Arntz, 2007). In the most structured approach to imagery rescripting, Smucker and Dancu (1999) outline three phases of imagery rescripting. The first phase is imaginal exposure, known to be a highly efficacious treatment for post-traumatic stress disorder (Powers, Halpern, Ferenschak, Gillihan, & Foa, 2010). The second phase is the mastery phase, although this terminology is not shared with the patient because it is important to reduce the demand characteristics and allow patients to process the emotions they experience within the image. In this phase, at the point of perpetration, the patient is asked to imagine their adult self entering the image as they watch the perpetrator abusing the child. The adult is invited to do or say whatever they wish to. The aim of this phase is to allow the patient to resolve the issue of powerlessness, by allowing their adult self to intervene in a way in which the child was unable to do. Many patients are able, through the rage and anger they experience, to address and remove the perpetrator from the scene. This is seen as a good prognostic indicator. However, the more severely disturbed patients may be angry at the child, and it is important to allow patients to resolve these issues by using Socratic dialogue to increase the adult's empathy with the child and their experience. The final phase involves the adult-nurturing child. In this phase, the therapist asks the patient where the adult is in relation to the child. The adult is then encouraged to talk to the child based on their feelings. According to Smucker and Dancu's (1999) protocol, imagery re-scripting should be repeated on four occasions, after which the therapy focuses exclusively on the final phase of the adult nurturing the child for an additional four sessions. Experiential strategies are also used to address the dysfunctional parent modes. Again, imagery or other forms of chair dialogue are used to get the patient to express their rage or anger towards important parental figures, whose criticisms have become internalised (Kellogg & Young, 2006). In some instances, patients need support from the therapist to address these dysfunctional parenting modes during the experiential sessions; however, it is important that they learn to adopt the more adaptive and compassionate approaches over time. Breaking behavioural patterns As patients progress and are able to gain more control over their dysfunctional modes, the focus in therapy shifts again to try and help patients to behave in more constructive ways in order that their interactions will bring a further source of disconfirmatory evidence about key early maladaptive schema. Importantly, whereas in cognitive therapy, the cognitions are specified and challenged with a view of changing emotions, in schema therapy, behaviour is primarily used to effect change in the underlying schema. Hence, when the patient is able to resist a previous impulse to engage in a dysfunctional coping mode, patients are encouraged to review the outcome and use the results to update their underlying schema, gradually modifying the content of their early maladaptive schema. However, it is also important to ensure that the patient has enough information to challenge their schema effectively and so it can be appropriate for therapists to engage in psychoeducation about important and relevant topics, such as sexual abuse education, parenting, or trust differentiation skills. Evidence for the Efficacy of SFT Although SFT was first described in the 1990s (Young, 1993), the first randomised controlled trial was not published until 2006 (Giesen-Bloo et al., 2006). In this The ACPARIAN: ISSUE 9: July 2014 Australian Clinical Psychology Association

23 exemplary trial, 88 patients with BPD were randomised to receive either twice-weekly sessions of SFT (n = 45) or transference focused therapy (n = 43). The treatment period was three years, and patients were independently assessed to determine whether or not they met criteria for BPD at three monthly intervals. A one year follow-up was also reported. Retention rates in therapy were significantly better in the schema-focused arm, with 33/45 patients continuing therapy throughout the three years in comparison to only 21/43 in the transference focused group. In terms of outcome, more patients in the SFT group were reliably changed over time, and more patients were recovered (no longer meeting criteria for BPD) than those in the transference-focused therapy condition. Further, differences emerged, favouring the schema therapy group within one year of treatment, including for quality of life and for six of the nine symptom domains on the Borderline Personality Disorder Severity Index. A recent review and meta-analysis of SFT for BPD confirmed that these effects were consistent with the other four studies that were identified (Jacob & Arntz, 2013). The median effect size of available studies (including one case series, two open trials, and two randomised controlled trials) was large (Cohen's D = 2.38). Similarly, across trials, low dropout rates were observed, a result consistent with Giesen-Bloo et al's (2006) trial (average drop-out rate = 10%), although there was some suggestion that the group format used in one trial had slightly higher drop-out rates (33%) (Jacob & Arntz, 2013). Importantly, they observed a significant correlation between therapy dose (number of sessions) and outcomes. Trials with fewer than 30 therapy sessions, and conducted over only 18 months, had smaller effect sizes than those trials where therapy continued between 18 months and 3 years (Jacob & Arntz, 2013). Although the evidence for SFT is still scant, emerging evidence suggests that it is a very effective approach for treating BPD. Further, based upon the success of SFT with BPD, trials are underway to examine its efficacy across a broader range of personality disorders (Bamelis, Evers, & Arntz, 2012). However, the fact that schema therapy is not a short-term intervention presents challenges for its use within the Australian context. Schema Therapy in the Australian Context In the Australian context, few clinical psychologists are able to see patients for hundreds of sessions over years of therapy. However, it is worthwhile noting that an economic evaluation of this form of intensive schema therapy has found that the high cost of treatment is offset by savings in health care utilisation, such as hospital admissions (van Asselt et al., 2008). Nonetheless, there is emerging evidence that schema-therapy can be effectively administered in a group setting (Farrell, Shaw, & Webber, 2009), although the dropout rate may be slightly higher (Jacob & Arntz, 2013), which may be an option in some services. Further, there are some lessons from a schema-focused approach that can be applied in the course of more traditional cognitive therapy practice. Firstly, many patients presenting with psychological disorders have experienced invalidating environments during their childhood. The focus on the therapeutic relationship as a vehicle for change that forms an important mechanism of SFT can also be applied in routine care of patients. Importantly, Spinhoven, Giesen-Bloo, van Dyck, Kooiman, & Arntz, (2007) showed that the therapeutic alliance was a strong predictor of retention of patients in SFT and therapy outcome. Hence, paying particular attention to the therapeutic relationship is likely to enhance therapy outcomes. Secondly, the schema mode conceptualisation model is a helpful way in which to comprehensively formulate clients' problems. The model is usually well received by patients and is a straightforward way of helping them to understand behaviours that are often difficult for patients to understand. The self-help book written by Jeffrey Young and colleagues, Reinventing Your Life, is particularly useful for patients and can support ongoing therapy (Young & Klosko, 1993). Thirdly, many of the unhelpful beliefs reported by patients have their origins in early life experiences. It is a common myth that cognitive therapy does not address childhood origin of beliefs, and many cognitive therapists already challenge beliefs in an historical context. However, it is also very common for patients to be able to logically challenge their beliefs and yet still feel as though the original belief was true. The focus on experiential strategies in schema therapy is a very effective way to help patients to make the shift from knowing something is true to believing it. From a theoretical point of view, it makes sense that in order to optimally challenge beliefs, the affect associated with the development of the belief needs to be activated. Indeed, there has been recognition in cognitive therapy generally about the importance of imagery in both the maintenance and alleviation of emotional disorders (Holmes & Mathews, 2010). Further, recent evidence suggests that adding experiential components in the form of imaginal exposure facilitates the outcome of dialectical behaviour therapy (Harned, Korslund, & Linehan, 2014). Hence, evidence is emerging that experiential strategies may be important in optimising outcomes across a range of available treatments. Conclusions The evidence is that SFT is definitely efficacious for the treatment of BPD. Other treatments, such as psychodynamic psychotherapy and cognitive therapy (Leichsenring & Leibing, 2003), dialectical behaviour therapy (Kliem, Kröger & Kosfelder, 2010), and mental visualisation (e.g., Bateman & Fonaghy, 2008), have also been found to be effective in this population. However, SFT outperformed transference-focused psychotherapy and the effect sizes compare favourably to other treatments, according to the relevant meta-analyses (Jacob & Arntz, 2013; Kliem, Kroger & Kosfelder, 2010; Leichsenring & Leibling, 2003). Hence, longterm SFT is a viable and cost-effective option for the treatment of BPD (van Asselt et al., 2008). The Australian context does produce particular challenges in implementation. Nonetheless, the focus on the therapeutic relationship and on experiential techniques can be used within more traditional forms of cognitive therapy to enhance the therapeutic outcomes for particular patients. 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24 References Arntz, A., & Van Genderen, H. (2009). Schema therapy for borderline personality disorder. Chichester, England: John Wiley & Sons. Arntz, A., & Weertman, A. (1999). Treatment of childhood memories: Theory and practice. Behaviour Research and Therapy, 37(8), Bamelis, L. L., Evers, S. M., & Arntz, A. (2012). Design of a multicentered randomized controlled trial on the clinical and cost effectiveness of schema therapy for personality disorders. BMC Public Health, 12(1), 75. Bateman, A., & Fonagy, P. (2008). 8-year follow-up of patients treated for borderline personality disorder: Mentalization-based treatment versus treatment as usual. American Journal of Psychiatry, 165(5), Farrell, J. M., Shaw, I. A., & Webber, M. A. (2009). A schemafocused approach to group psychotherapy for outpatients with borderline personality disorder: A randomized controlled trial. Journal of Behavior Therapy and Experimental Psychiatry, 40(2), Giesen-Bloo, J., Van Dyck, R., Spinhoven, P., Van Tilburg, W., Dirksen, C., Van Asselt, T.,... & Arntz, A. (2006). Outpatient psychotherapy for borderline personality disorder: Randomized trial of schema-focused therapy vs transference-focused psychotherapy. Archives of General Psychiatry, 63(6), Harned, M. S., Korslund, K. E., & Linehan, M. M. (2014). A pilot randomized controlled trial of dialectical behavior therapy with and without the dialectical behavior therapy prolonged exposure protocol for suicidal and self-injuring women with borderline personality disorder and PTSD. Behaviour Research and Therapy, 55, Holmes, E. A., Arntz, A., & Smucker, M. R. (2007). Imagery rescripting in cognitive behaviour therapy: Images, treatment techniques and outcomes. Journal of Behavior Therapy and Experimental Psychiatry, 38(4), Holmes, E. A., & Mathews, A. (2010). Mental imagery in emotion and emotional disorders. Clinical Psychology Review, 30(3), Jacob, G. A., & Arntz, A. (2013). Schema therapy for personality disorders - A review. International Journal of Cognitive Therapy, 6(2), Kellogg, S. H., & Young, J. E. (2006). Schema therapy for borderline personality disorder. Journal of Clinical Psychology, 62(4), Kliem, S., Kröger, C., & Kosfelder, J. (2010). Dialectical behavior therapy for borderline personality disorder: A metaanalysis using mixed-effects modeling. Journal of Consulting and Clinical Psychology, 78(6), 936. Leichsenring, F., & Leibing, E. (2003). The effectiveness of psychodynamic therapy and cognitive behavior therapy in the treatment of personality disorders: A meta-analysis. American Journal of Psychiatry, 160(7), Powers, M. B., Halpern, J. M., Ferenschak, M. P., Gillihan, S. J., & Foa, E. B. (2010). A meta-analytic review of prolonged exposure for posttraumatic stress disorder. Clinical Psychology Review, 30(6), Sempértegui, G. A., Karreman, A., Arntz, A., & Bekker, M. H. (2013). Schema therapy for borderline personality disorder: A comprehensive review of its empirical foundations, effectiveness and implementation possibilities. Clinical Psychology Review, 33(3), Spinhoven, P., Giesen-Bloo, J., van Dyck, R., Kooiman, K., & Arntz, A. (2007). The therapeutic alliance in schemafocused therapy and transference-focused psychotherapy for borderline personality disorder. Journal of Consulting and Clinical Psychology, 75(1), Van Asselt, A. D., Dirksen, C. D., Arntz, A., Giesen-Bloo, J. H., Van Dyck, R., Spinhoven, P.,... & Severens, J. L. (2008). Out-patient psychotherapy for borderline personality disorder: Cost-effectiveness of schema-focused therapy v. transference-focused psychotherapy. The British Journal of Psychiatry, 192(6), Weertman, A., & Arntz, A. (2007). Effectiveness of treatment of childhood memories in cognitive therapy for personality disorders: A controlled study contrasting methods focusing on the present and methods focusing on childhood memories. Behaviour Research and Therapy, 45(9), Young, J. E., & Klosko, J. S. (1993). Reinventing your life: How to break free from negative life patterns. New York, NY: Dutton. Young, J. E., Klosko, J. S., & Weishaar, M. E. (2003). Schema therapy: A practitioner's guide. New York, NY: Guilford Press. The ACPARIAN: ISSUE 9: July 2014 Australian Clinical Psychology Association

25 Psychodynamic Approaches to Borderline Personality Disorder Simon Boag, PhD Department of Psychology, Macquarie University, Australia Abstract Psychodynamic approaches to Borderline Personality Disorder (BPD) are particularly relevant to understanding the aetiology, treatment, and even prevention of BPD. Psychodynamic approaches contribute an understanding of the core deficits surrounding identity, object relations (self and other relationships), and emotion dysregulation in terms of personality organisation, motivational processes (e.g., attachment needs), affects, conflict, and defences. Psychodynamic approaches complement non-psychodynamic approaches to BPD. There are two major psychodynamic approaches to treating BPD: Transference-Focused Psychotherapy and Mentalisation-based Treatments. Both have demonstrated clinical utility and share common features with respect to the development of self- and other-reflection. Both the conceptualisation and classification of personality disorders have received longstanding criticism for various reasons, including comorbidity and poor reliability of assessment. Nevertheless, the view that personality (however conceptualised) can be disordered is generally accepted, and psychodynamic approaches have a long history of contributing to both our description and understanding of 'character pathology'. Furthermore, psychodynamic accounts are particularly well-suited to understanding and guiding the treatment of personality disorders. 7 Borderline Personality Disorder 8 DSM-IV provided for up to 256 different ways of diagnosing Borderline Personality Disorder (BPD) (American Psychiatric Association [APA], 2000; see Schmeck, Schlüter- Müller, Foelsch, & Doering, 2013). While this heterogeneity suggests that no one-size-fits-all account will be sufficient (Clarkin et al., 2007), there are nevertheless core features of BPD found across both DSM-IV and DSM-5 that strongly implicate a psychodynamic approach to both understanding and treatment. These features include frantic efforts to avoid real or imagined abandonment, and unstable and conflicted interpersonal relationships characterised by alternating between extremes of idealisation and devaluation ('splitting'), identity disturbances (unstable self-image), impulsivity, affective instability (including intense anxiety and anger), and other dissociative phenomena such as depersonalisation (APA, 2013). The term 'borderline' first emerged in the psychoanalytic writings of Adolph Stern (1938) where it described individuals on the borderline of neurosis and psychosis. Borderline individuals generally retain both intact reality testing and (albeit neurotic) functioning which, nevertheless, breaks down under severe stress (see Bradley and Westen, 2005 for a historical review of BPD). One of the first clear references to BPD as a personality disorder is from Kernberg (1967) who restricted the use of 'borderline' to 'borderline personality organisation'. This personality organisation entailed a "pathological ego structure" rather than "a transitory state fluctuating between neurosis and psychosis" (pp ). Pathology entails ego-deficits (including failures to synthesise various object-relations) as well as specific defensive manoeuvres such as 'splitting' (idealisation and devaluation). While borderline personality organisation is a broader concept than BPD, in several 8 Corresponding author: simon.boag@mq.edu.au respects Kernberg's initial account provides a basis for psychodynamic approaches to BPD discussed today. Psychodynamic Approaches to BPD Although psychodynamic approaches are, of course, diverse (Wallerstein, 1995), they generally contribute both a descriptive and explanatory framework that encompasses both normal and pathological behaviour. These frameworks address personality structures, motivation, affects, and beliefs, as well as the vicissitudes of conflict and defence (Boag, 2012). In terms of description, Bornstein (2006) noted that there are three inter-related psychodynamic constructs relevant to describing and understanding personality disorders: (i) ego strength; (ii) defence style; and (iii) mental representations of self and others. Ego strength ("the degree to which the ego carries out reality testing functions and deals effectively with impulses", p. 341) develops through experience, particularly within relationship contexts. Defence styles ("a characteristic way of managing anxiety and coping with external threat", p. 342) exist along a continuum ranging from primitive/immature defences to mature defence/coping styles. Mental representation of self and others involves instances where the child "[e]arly in life internalizes mental representations of self and significant others (e.g., parents, siblings)" (p. 343). Such 'introjects' are affectively-charged internal objects that shape responses to threat and stress. Where internalised introjects are malevolent and entail conflict, individuals are likely to have difficulty with affective control and interpersonal relations (Bornstein, 2006). By way of explanation, psychodynamic perspectives contribute an understanding of the core BPD deficits surrounding identity, object-relations (self and other relationships), and emotion dysregulation in terms of personality organisation, motivational processes (e.g., attachment needs), affects, conflict, and defences. This The ACPARIAN: ISSUE 9: July 2014 Australian Clinical Psychology Association

26 approach to understanding personality, healthy or otherwise, provides an integrative account that addresses motivation and affects, and their relation to cognition (what a person both desires and believes, either consciously or unconsciously). As Bradley and Westen (2005) indicate, such an approach allows formulating specific questions to help understand BPD: 1. What are the individual's desires ('wishes') and beliefs, including fears and conflicts? 2. What are the individual's coping resources (egostrengths) for dealing with conflicts and affects, including defences and coping mechanisms? 3. What are the individual's object-relations, both to internal and external objects, as well as to oneself as object (selfconcept)? In terms of addressing these questions, a psychodynamic framework views the development of psychopathology in terms of a relational context (objectrelations) and the attachment needs of the individual (and conflicts surrounding them) (Bradley & Westen, 2005; Fonagy & Target, 2008) (see Maze, 1993 for a discussion of the relationship between drives and object-relations). Attachment processes appear particularly relevant to understanding BPD, and there is a large literature indicating the developmental significance of attachment for both intraand inter-personal functioning and the ensuing conflicts and defences that arise when attachment needs are not adequately met (e.g., Bradley & Westen, 2005; Fonagy & Target, 2008; Shaver & Mikulincer, 2002, 2005). Some propose that BPD reflects caregiving styles associated with severe insecurity and 'disorganised' attachment (Fonagy & Bateman, 2008; Holmes, 2004). Disorganised attachment has been associated with approach avoidance conflict, whereby the caregiver is both a source of security and threat (Holmes, 2004). This conflict creates an intolerable situation: the child can neither develop a consistent behavioural and affective response pattern to threat nor rely on internal objects (internalised beliefs of comforting caregivers) when distressed. The primitive defensive manoeuvres dealing with this include dissociation, projection, and splitting, which distort the child's understanding of relationships with both themselves and others. While not entirely static, childhood attachment patterns generally persist throughout life and the BPD individual presents these attachment-oriented fears and conflicts (e.g., fears of abandonment accompanied by rejecting significant others), and ensuing emotional dysregulation and impulsivity. In many respects, psychodynamic approaches can be seen as complementary rather than antagonistic towards other approaches to BPD, including ostensibly more straightforward cognitive approaches which propose that "dysfunctional beliefs stem from negative learning experiences in childhood that inhibit the development of flexible information processing" (Wenzel, Chapman, Newman, Beck, & Brown, 2006, p. 504). However, rather than isolating one aspect of functioning (such as 'cognition' or 'schemas'), the psychodynamic theoretician will generally attempt to see how cognition relates to motivation and affects within the overall functioning of the individual. For instance, an individual is likely to only ever react behaviourally and emotionally to a belief (e.g., schema) if that belief actually matters to them (i.e., is relevant to his or her desires and fears) (Mackay, 1996, 2003). Furthermore, as Bornstein (2006) observes, cognitive models also necessitate psychodynamic ideas. The construct of 'dichotomous thinking', for instance, found in Beck's cognitive approach (Wenzel et al., 2006) appears to be synonymous with the long-standing psychodynamic conceptualisation of 'splitting' (viz., idealisation/devaluation). Terminological issues aside, given that shifts of splitting "often reflect disillusionment with a caregiver whose nurturing qualities had been idealized or whose rejection or abandonment is expected" (APA, 2013, p. 664), a psychodynamic perspective addressing the motivational and affective components complements the cognitive account. It is also precisely dissociative processes, such as splitting, in BPD that require a sophisticated and necessarily psychodynamic account to address the nature of psychological conflict and explain what 'inhibits the development of flexible information processing' (i.e., explain how one side of the dichotomy is prevented from appearing when the other is present (Boag, 2007, 2012; Maze & Henry, 1996). Clinical Implications Bradley and Westen (2005) note that all psychodynamic treatments for BPD tend to share three goals: (i) to identify and alter relationship factors and patterns (particularly based in primary attachment relationships), such as fears of abandonment; (ii) to identify and integrate split object-relations and increase coherence of self- and otherobject-relations; and (iii) to identify and alter pathological modes of emotion regulation. Psychodynamic perspectives also contribute the essential clinical consideration of the transference/countertransference, which is particularly important within the BPD therapeutic setting (Gabbard, 2001). In the therapeutic context, transference and countertransference refer to "the constellations of thoughts, feelings, motives, and behaviors of the patient and the therapist, respectively" (Bradley & Westen, 2005, p. 947). Classically, what is transferred are desires and feelings towards significant others from childhood onto the current therapeutic relationship. The critical relevance of transference/countertransference for BPD therapeutic contexts is recognised by psychodynamic and nonpsychodynamic approaches alike (e.g., Freeman, 2004). There are two major psychodynamic directions in treating BPD. One of these approaches, Transference- Focused Psychotherapy (TFP), is based on Kernberg's objectrelations model (Clarkin et al., 2007; Kernberg, Diamond, Yeomans, Clarkin, & Levy, 2008). As the name indicates, TFP focuses upon the transference to address the predominating object-relations, with the core tasks being "to establish a stable relational context, to identify the patient's predominant internal object-relations dyads, and to help him or her observe, modulate, and integrate the split sectors of experience into unified coherent representations of self and other" (Kernberg et al., 2008, p. 176). On the other hand, Mentalisation-Based Treatments (MBT) focus on increasing the capacity of mentalisation for BPD individuals. Mentalisation involves "the process of interpreting (the behaviour of) oneself and others in terms of The ACPARIAN: ISSUE 9: July 2014 Australian Clinical Psychology Association

27 mental states" (Jurist, Slade & Bergner, 2008, p. 2) and develops both cognitively and affectively in the infantcaregiver relationship. The caregiver's own mentalisation skills and 'mirroring' and 'marking' of emotional signals are said to impact directly upon the infant's relationship to its own mental states and personality development. MBT acts to increase mentalisation through the therapist adopting a 'mentalising stance' towards the thoughts and feelings of both the therapist and patient in the current situation: "The objective is for the patient to find out more about how he thinks and feels about himself and others, how this dictates his responses, and how "errors" in his understanding of himself and others lead to actions that are attempts to retain stability and to make sense of incomprehensible feelings" (Fonagy & Bateman, 2008, p. 153). Both TFP and MBT demonstrate some therapeutic success with BPD (Fonagy & Bateman, 2008; Kernberg et al., 2008; Levy et al., 2006) and there are several commonalities between TFP and MBT: both emphasise the role of cognition in terms of improving the capacity for mentalisation, and both appreciate the wider psychodynamic significance of motives and affects; both also focus on the here-and-now patient-therapist relationship and avoid historical ('archaeological') interpretation (for a discussion, however, of critical differences between TFP and MBT, see Kernberg et al., 2008). In some respects, at the heart of all of these therapies is making the unconscious conscious (Boag, 2012), and this is similarly so for 'cognitive therapy'. For instance, 'belief identification' in cognitive therapy involves making 'latent' beliefs known (i.e., conscious). Interpretation of what is unconscious is also employed in cognitive therapy with respect to 'hypothesising' what a BPD individual unconsciously believes (Wenzel et al., 2006, p. 511). This is perhaps not unsurprising since we have, after all, known since Freud that psychopathology is often a reflection of unconscious beliefs (Freud, 1915) (or what some might refer to as unconscious schemas; e.g., Mairet, Boag, & Warburton, 2014). However, as psychodynamic thinking appreciates, it is through addressing the wider constellation of desires, affects, and thinking that entails therapeutic success. References American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4 th ed., text rev.). Washington, DC: Author. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5 th ed.). Arlington, VA: American Psychiatric Publishing. Boag, S. (2007). Realism, self-deception and the logical paradox of repression. Theory & Psychology, 17, Boag, S. (2012). Freudian repression, the unconscious, and the dynamics of inhibition. London, England: Karnac. Bornstein, R. F. (2006). A Freudian construct lost and reclaimed: The psychodynamics of personality pathology. Psychoanalytic Psychology, 23, Bradley, R., & Westen, D. (2005). The psychodynamics of borderline personality disorder: A view from developmental psychopathology. Development and psychopathology, 17, Clark, L. A. (2007). Assessment and diagnosis of personality disorder: Perennial issues and an emerging reconceptualisation. Annual Review of Psychology, 58, Clarkin, J. F., Lenzenweger, M. F., Yeomans, F., Levy, K. N., & Kernberg, O. F. (2007). An object relations model of borderline pathology. Journal of Personality Disorders, 21, Fonagy, P. & Bateman, A. (2008). Mentalization-based treatment of borderline personality disorder. In E. L. Jurist, A. Slade, & S. Bergner (Eds.), Mind to mind: Infant research, neuroscience, and psychoanalysis (pp ). New York, NY: Other Press. Fonagy, P. & Target, M. (2008). Attachment, trauma, and psychoanalysis. In E. L. Jurist, A. Slade, & S. Bergner (Eds.), Mind to mind: Infant research, neuroscience, and psychoanalysis (pp ). New York, NY: Other Press. Freeman, A. (2004). Cognitive therapy with borderline personality disorder. Psychiatric Annals, 34, Gabbard, G. O. (2001). Psychodynamic psychotherapy of borderline personality disorder: A contemporary approach. Bulletin of the Menninger Clinic, 65, Holmes, J. (2004). Disorganized attachment and borderline personality disorder: A clinical perspective. Attachment & Human Development, 6, Jurist, E. L., Slade, A., & Bergner, S. (Eds.). (2008). Mind to mind: Infant research, neuroscience, and psychoanalysis. New York, NY: Other Press. Kernberg, O. (1967). Borderline personality organization. Journal of the American Psychoanalytic Association, 15, Kernberg, O., Diamond, D., Yeomans, F. E., Clarkin, J. F., & Levy, K. N. (2008). Mentalization and attachment in borderline patients in transference focused psychotherapy. In E. L. Jurist, A. Slade, & S. Bergner (Eds.), Mind to mind: Infant research, neuroscience, and psychoanalysis (pp ). New York, NY: Other Press. Levy, K. N., Clarkin, J. F., Yeomans, F. E., Scott, L. N., Wasserman, R. H., & Kernberg, O. F. (2006). The mechanisms of change in the treatment of borderline personality disorder with transference focused psychotherapy. Journal of Clinical Psychology, 62, Mackay, N. (1996). The place of motivation in psychoanalysis. Modern Psychoanalysis, 21, Mackay, N. (2003). Psychotherapy and the idea of meaning. Theory & Psychology, 13, Mairet, K., Boag, S., & Warburton, W. (2014). How important is temperament? The relationship between coping styles, early maladaptive schemas, and social anxiety. International Journal of Psychology and Psychological Therapy, 14, Maze, J. R. (1993). The complementarity of object-relations and instinct theory. International Journal of Psychoanalysis, 74, Maze, J. R., & Henry, R. M. (1996). Problems in the concept of repression and proposals for their resolution. International Journal of Psychoanalysis, 77, Schmeck, K., Schlüter-Müller, S., Foelsch, P. A., & Doering, S. (2013). The role of identity in the DSM-5 classification of personality disorders. Child and Adolescent Psychiatry and Mental Health, 7, 27. The ACPARIAN: ISSUE 9: July 2014 Australian Clinical Psychology Association

28 Shaver, P. R., & Mikulincer, M. (2002). Attachment-related psychodynamics. Attachment & Human Development, 4, Shaver, P. R., & Mikulincer, M. (2005). Attachment theory and research: Resurrection of the psychodynamic approach to personality. Journal of Research in Personality, 39, Stern, A. (1938). Psychoanalytic investigation of and therapy in the borderline group of neuroses. Psychoanalytic Quarterly, 7, Wallerstein, R. S. (1995). The talking cures: The psychoanalyses and the psychotherapies. New Haven, CT: Yale University Press. Wenzel, A., Chapman, J. E., Newman, C. F., Beck, A. T., & Brown, G. K. (2006). Hypothesized mechanisms of change in cognitive therapy for borderline personality disorder. Journal of Clinical Psychology, 62, Expressions of Interest Associate Editor, The ACPARIAN The Editorial Board of The ACPARIAN invites expressions of interest from members to add to our dynamic team. Availability and commitment to share in the task of resourcing the latest in clinical practice for our readership are primary requirements. Assisted by annual face-to-face meetings, Associate Editors work co-operatively under the leadership of the Editor, and have specific responsibilities associated with the production of each journal. PhD desirable, but not essential. Please send expressions of interest with a brief CV to the Editor, Dr Kaye Horley editor@acpa.org.au The ACPARIAN: ISSUE 9: July 2014 Australian Clinical Psychology Association

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30 Parenting and Borderline Personality Disorder: Working with Transgenerational Trauma Louise Newman, MBBS(Hons), PhD Centre for Developmental Psychiatry & Psychology, Monash University, Australia Abstract Severe Borderline Personality Disorder (BPD) impacts functioning in interpersonal relationships and attachment. Many parents with BPD have early experiences of attachment-related trauma which shapes both their capacity to be a consistent attachment figure and their ability to understand their child's psychological needs. Interventions need to focus on improving the parents' reflective capacity, and understanding of their own, and their child's, emotional needs. 9 Defining Borderline Personality Disorder Borderline Personality Disorder (BPD) remains a controversial diagnostic category, largely as a result of misuse, pejorative use, and failure to acknowledge the condition as a complex response to trauma and disrupted early attachments (Allen, Fonagy, & Bateman, 2008). Others argue that it is a severe mental disorder, with implications for social functioning, that has been neglected from both a clinical and research perspective. Whilst both sides of the debate make valid points, there still remains the need to respond to often distressed and traumatised individuals by providing psychological interventions to assist them with the core issues of affect regulation, interpersonal functioning, and self-regulation. Individuals with BPD frequently experience difficulties in managing close relationships; whilst seeking connection with others, they find this anxiety provoking. Maintaining relationships and finding a balance between intimacy and distancing can be a major challenge (Holmes, 2003). The DSM diagnostic criteria include a variety of 'symptoms' of BPD, which may be seen as interpersonal or attachment difficulties of self-experience and attempts to maintain a sense of identity and connectedness. This paper outlines the impact of these issues on parenting relationships, and an approach to parent-child intervention. Personality disorders are seen increasingly as core difficulties in both self-regulation and relational functioning. Individuals with personality disorders have deficits in identity and self-concept, poor affect regulation, and limited understanding of interpersonal functioning. Many have deficits in mentalisation or the capacity to understand self and others in terms of mental states and psychological factors (Fonagy, Gergely, Jurist, & Target, 2004). All relationships may be impacted by lack of empathic understanding, and this has a direct impact on the ability to negotiate and resolve interpersonal conflicts and competing 9 Corresponding author: louise.newman@monash.edu needs. From this perspective, the individual with personality disorder may be seen as struggling to communicate emotional and attachment needs whilst having limited capacity to reflect on their impact on others in relationships. Relationships, including the relationship with a child, are complex and frequently characterised by instability, conflict, and lack of empathic understanding of the needs of the relational partner. The individual with personality disorder may have difficulty understanding and communicating their own emotional and attachment needs, and resort to maladaptive behaviours and patterns of relating in attempts to have these met. The other, or child, may become a player or object in these attempts to maintain connection with others. Relational dynamics of need, control, and ambivalence are typical in families impacted by parental personality disorder (Newman, Stevenson, Bergman, & Boyce, 2007). Parenting is a relational construct, and, on this level, involves core functions of provision of an organised attachment relationship and regulation of child affect. Parenting is organised around support for individuation and child development, balanced with nurture and protection. The good enough parent develops a psychological model of the child which acknowledges the child's separateness and individual psychological needs, and which allows the parent to hypothesise about the inner world of the child. In healthy early relationships, the parent has the capacity to engage with the child, prioritise the child's developmental needs, and adapt to the role of nurturing and being an attachment figure. This capacity to think about the inner world of the child, or parental reflective capacity, underlies emotionally attuned early interactions and supports the child's sense of validation of their emotional communication (Grienenberger, Kelly, & Slade, 2005). The concept of parental reflective capacity is an important one as it focuses on the parents' understanding of themselves as an attachment figure; this is mediated by the parents' own early attachment experiences, and models of interpersonal functioning, shaped in the family of origin. The models of transgenerational transmission of patterns of attachment and relating is central to understanding parenting difficulties and challenges for parents with histories of early maltreatment and parenting disturbance. The ACPARIAN: ISSUE 9: July 2014 Australian Clinical Psychology Association

31 The DSM-5 defines personality disorders as patterns of inner experience and behaviour that are pervasive and inflexible over time. Cluster A personality disorders (paranoid, schizoid, and schizotypal) share marked interpersonal deficits, ranging from withdrawal or discomfort in relationships to suspiciousness of others. Cluster B personality disorders (antisocial, borderline, histrionic, and narcissistic) focus on distortions of perceptions of others and disturbances of relating. In this cluster, the partner in the relationship serves a function for the individual, including meeting emotional needs and shoring up a core sense of identity. Cluster C personality disorders (avoidant, dependent, and obsessive compulsive) may also be seen as focussed on fundamental difficulties, with maintaining and regulating attachment distance resulting in attempts to control attachment-related anxiety by avoidance, clinging, and control of the other. Whilst there are clearly issues of diagnosis and overlap of diagnostic categories, a broad framework looking at relational patterns is useful when looking at functional implications of personality disorder. Focus on the parenting relationship from this perspective allows a review of the implications of parental personality disorder on attachment and child development. Early Attachment Relationships The quality of early care and interactions with the infant has long been seen as central to infant development and later socioemotional functioning. Following Freud, Bowlby (1969) described the relationship with the primary caregiver as shaping the child's development of a sense of self, other, and relationships with evolving models or representations of relational functioning. These models emerge from experiences of emotional interaction and communication with the carer and, in turn, reflect the carer's capacity to "read", process, and respond to the child's emotional signals and indicators of need. Inner models of relationships are seen as core components of personality functioning; they influence perception, cognition, and affect about relationships, and form the basis for ongoing patterns of relating or attachment. Attachment theory has developed a classification of attachment organisation in adults which emphasises the organisation of thinking, feeling, and memory around attachment issues and the ways in which different attachment styles represent adaptational or defensive strategies to manage anxieties around significant attachment relationships. Within this framework, parenting style, and the quality of interaction between parent and child, will reflect the parent's attachment status and attachment history. Parents will recapitulate or re-enact early attachment experiences with their own child and, in some cases, attempt to rework or resolve their own attachmentrelated trauma in their parenting relationship. The concept of transgenerational transmission of attachment themes is central to understanding parents with personality disorder (Newman, 2008). A significant body of research has outlined the manner in which parental "state of mind", with respect to attachment and representation or model of the relationship with the child, is predictive of child attachment status. Similarly, the parent's own history of being parented and their attachment relationships influences emotional interaction and communication with the child. Whilst there is support for these broad associations, there are ongoing discussions about continuity from childhood attachment to adult attachment status, and around the concept of change in attachment status and resolution of attachment-related trauma. Clinical attention has focussed on the category of attachment disorganisation, where infants experience confusion and fear in the relationship with the carer and develop conflict about approach and avoidance. Predominately found in high-risk samples, disorganised infants exhibit breakdown or failure to develop a coherent strategy to regulate anxiety and emotional behaviour with the caregiver (Lyons-Ruth, Repacholi, McLeod, & Silva, 1991). The infant may experience the carer as both frightening and frightened, or avoidant, and these experiences are both unresolvable and anxiety provoking, and have significant effects on the emerging capacity to understand emotions in the self and other and on self-organisation and representation. In terms of parenting, the parents of disorganised infants are more likely to have histories of maltreatment and abuse, depression, current relational trauma, and substance abuse. Diagnosis of BPD is common, and relationships with the child may be centred around repetition of early trauma. The parent may themselves display contradictory caregiving strategies and show both need to position the child as carer and avoidance, or even active rejection, of the child. In these situations, the child experiences high levels of attachment anxiety and confusion about the operation of relationships, and expression of emotional need in an interpersonal context. This impacts broad relational functioning and is a component of the concept of attachment disorder where patterns of attachment disturbance in primary relationships generalise to all social functioning. The issues of overlap between ideas of attachment disorganisation, attachment disorder, and personality disorder remain unclear (Newman & Mares, 2007), but taking a developmental approach and looking at the child's emerging understanding of self and relationships is a helpful approach. Early disturbances of parenting behaviour are associated with parental risk factors, child attachment disorganisation, and subsequent impact on self-concept and relational functioning. The prevailing theoretical model of the 'disorganising' parent remains that originally described, where the parent with unresolved loss or trauma transmits this to the child via specific interactional patterns characterised by insensitivity, misreading, or frightening interaction. Patterns of parent child interaction, however, also reflect the parent's current level of stress and social context, sense of parenting confidence and self-efficacy, and representation of the child. The parent's capacity to reflect on the child and to conceptualise the child as having individuality, mental states, and an internal world is increasingly recognised as fundamental to shaping the child's attachment organisation and inner representation of relationships. An Integrative Model of BPD and Attachment Fonagy and Target's Mentalisation Hypothesis Fonagy and Target (1998) have developed an aetiological model of BPD and severe personality disorder that integrates attachment, cognitive, and psychoanalytic developmental models. This has contributed in a major way The ACPARIAN: ISSUE 9: July 2014 Australian Clinical Psychology Association

32 to pulling together disparate theoretical traditions and research models, and has generated considerable research efforts (Fonagy, Steele, Steele, Moran, & Higgit, 1996). Fonagy and Target's account is arguably the major development in contemporary psychoanalytic theory, challenging psychoanalysis to incorporate cognitive developmental models of the emergence of the representation of self and other and to examine their role in psychoanalytic treatment. Fonagy and Target's model is informed by the understanding of the role of trauma in the aetiology of BPD, and provides an account of the way in which child maltreatment disrupts the development of mental processes needed to understand and regulate socioemotional interactions. The origins of this capacity of 'mentalisation' are located in the attachment relationship and the parents' inner working models of attachment. Fonagy and Target argue that the quality of infant attachment to the parent involves not just sensitivity and 'attunement' but a crucial process whereby the parent acknowledges the infant as having mental states, such as desires, feelings, and intentions, and communicates their understanding of the 'intentional stance' to the infant. The parent needs to reflect upon the inner world of the infant and communicate back to the infant their 'reading' or understanding of the infant's mental state along with an alternate emotional communication that contains the infant's anxiety. Infants of parents with limited reflective capacity are more likely to be insecurely attached, whilst, at the most extreme point, infants who are maltreated or abused by attachment figures fail to develop their own reflective capacity, which in turn disrupts the development of representational capacities needed to regulate self and affective states. Parenting and BPD BPD is characterised by significant difficulties in maintaining stable attachment relationships and in the regulation of affect, self-image, and impulses. The DSM classification system describes the interpersonal relationships of individuals with borderline disorder as swinging between poles of idealisation and devaluation, stressing the individual's often unrealistic expectations of the other in a relationship, and coexisting anxieties in closer interactions. Melges and Swartz (1989) describe this as a pattern of 'oscillating' attachments with the individual experiencing difficulties in maintaining an appropriate 'distance' in relationships. These characteristics of BPD will presumably also operate for the parent with BPD and will influence perception and expectations of the child as well as parenting behaviour. As previously discussed, traumatic attachment issues in the parent's past will also affect the parenting relationship and quality of early interaction. Despite the clinical and theoretical importance of BPD in parenting and the relevance of this to child protection and mental health outcome, minimal research exists in this area. Most research effort has focussed on the implications for parenting of mental illness, such as schizophrenia and maternal major depression, and has developed multifactorial models of child outcome. Ironically, Rutter and Quinton (1984) noted that the presence of parental personality disorder was more strongly associated with poor child outcome than was parental depression. Personality disorders are, by definition, chronic conditions, impacting in an ongoing way on relationship quality. This is in sharp distinction to an episode of disorder and the time limited nature of those mental disorders with intervening periods of appropriate parenting. Children of parents with BPD are likely to have been exposed to inappropriate and insensitive care, as well as a variety of other developmental risk factors such as parental relationship breakdown, domestic violence, parental substance abuse, socioeconomic adversity, and instability of housing and social supports. Given the clustering of risk factors, it is clearly difficult to isolate the direct impact of parental personality dysfunction on child outcome. Nevertheless, a body of work describing the impact of parenting practices on child outcome has emerged over the past 20 years (Laulik, Chou, Browne, & Allam, 2013). Most authors highlight the interaction of factors within the parent (personality), factors within the child, and the sociocultural context of parenting, in influencing child outcome. Parents with BPD typically have vulnerability in neuroregulatory, psychological, and social domains, experience multiple stressors, and have few external supports. Similarly, their children experience multiple developmental risk factors on several levels, including biological, psychological, and environmental, creating an extremely high risk developmental climate. Attachment Focussed Interventions Working with parents with BPD necessarily involves an understanding of the parents' own attachment history and the way in which this impacts the current relationship with the child. The parents' representation of the child, and the capacity to understand the child as a separate individual with their own needs and desires, are crucial areas of initial assessment. Parents with histories of attachment-related trauma may variously see the child as reminiscent of their own early experiences or as the embodiment of their anxieties and fears. The parent may have difficulty in empathic functioning and in processing the child's emotional communication. Interventions aim to improve the parent's capacity to see the child as communicating and to see the self as an attachment figure. Programs based on attachment theory provide the parent with core information about the role of parent as a secure base and the child's need for security (e.g., Circle of Security). However, parents with trauma backgrounds may be less able initially to use this framework and need an engaged clinician who can help support the anxious parent in a way which acknowledges their motivation to nurture and also the difficulties associated with this. Allowing the parent to express ambivalence towards the child, and to tolerate confusion about the parental role, is important. For parents of infants it may be important to focus on 'reading' the child's cues, 'learning' how the infant communicates, and building on sensitivity. Approaches may The ACPARIAN: ISSUE 9: July 2014 Australian Clinical Psychology Association

33 involve 'coaching' of interactional responses, with the parent encouraged to watch or observe the child and build on their hypothesising, or 'wondering' about the child's emotional communication (Muir, Lojkasek, & Cohen, 1999). These relational approaches support the development of parental reflective capacity and mentalisation (Newman & Mares, 2007). The parent is supported in better understanding their own emotional responses to parenting and the emotional and mental states underlying the child's behaviour. Clinicians maintain a 'wondering' or mentalising stance, modelling an understanding of psychological processes. Sample models of the infant as a communicating subject "look at your baby and think about what they might be telling you" can be used as the beginnings of a relational understanding. For many parents with BPD the new relationship with a child represents an opportunity for relational repair and a coming to terms with their own early experiences. The challenges for clinicians are to maintain a reflective stance and to deal with complex emotional responses. Training and supervision help manage the often anxiety provoking interactions and need to focus on child safety. References Allen, J. G., Fonagy, P., & Bateman, A. W. (2008). Mentalizing in clinical practice. Washington, DC: American Psychiatric Publishing. Bowlby, J. (1969). Attachment and loss: Attachment. New York, NY: Basic Books. Fonagy, P., Gergely, G., Jurist, E., & Target, M. (2004). Affect regulation, mentalization and the development of the self. London, England: Karnac. Fonagy, P., Steele, M., Steele, H., Moran, G., & Higgit, A. (1996). Ghosts in the nursery: An empirical study of the repercussions of parents' mental representations on the security of attachment. La Psychiatrie de l'enfant, 39(1), Fonagy, P., and Target, M. (1998). Mentalization and the changing aims of child psychoanalysis. Psychoanalytic Dialogues: The International Journal of Relational Perspectives, 8(1), Grienenberger, J., Kelly, K., & Slade, A. (2005). Maternal reflective functioning, mother-infant affective communication, and infant attachment: Exploring the link between mental states and observed caregiving behavior in the intergenerational transmission of attachment. Attachment & Human Development, 7(3), doi: / Holmes, J. (2003). Borderline personality disorder and the search for meaning: An attachment perspective. Australian and New Zealand Journal of Psychiatry, 37(5), Laulik, S., Chou, S., Browne, K. D., & Allam, J. (2013). The link between personality disorder and parenting behaviors: A systematic review. Aggression and Violent Behavior, 18(6), doi: /j.avb Lyons-Ruth, K., Repacholi, B., McLeod, S., & Silva, E. (1991). Disorganized attachment behavior in infancy: Shortterm stability, maternal and infant correlates, and riskrelated subtypes. Development and Psychopathology, 3(04), Melges, F. T., & Swartz, M. S. (1989). Oscillations of attachment in borderline personality disorder. The American Journal of Psychiatry, 146(9), Muir, E., Lojkasek, M., & Cohen, N. J. (1999). Watch, wait and wonder. A manual describing a dyadic infant-led approach to problems in infancy and early childhood. Ontario, Canada: Hincks-Dellcrest Institute. Newman, L. (2008). Attachment theory and personality disorder: Approaches to high-risk families. Communities, Children and Families Australia, 3(2), 4. Newman, L., & Mares, S. (2007). Recent advances in the theories of and interventions with attachment disorders. Current Opinion in Psychiatry, 20(4), Newman, L. K., Stevenson, C. S., Bergman, L. R., & Boyce, P. (2007). Borderline personality disorder, mother-infant interaction and parenting perceptions: Preliminary findings. Australian and New Zealand Journal of Psychiatry, 41(7), doi: / Rutter, M., & Quinton, D. (1984). Parental psychiatric disorder: Effects on children. Psychological Medicine, 14(4), doi: S The ACPARIAN: ISSUE 9: July 2014 Australian Clinical Psychology Association

34 10 The Mentalisation-Based Treatment for Borderline Personality Disorder Margie Stuchbery, MPsych Karitane, Sydney, Australia Abstract Mentalising is the process by which we make sense of each other and of ourselves. The capacity to understand behaviour in terms of underlying mental states and processes is fundamental to social relationships and to self-regulation. It is, therefore, unsurprising that deficits in this crucial intrapsychic and social capacity underlie many psychopathologies; however, a mentalising approach has particular utility in the treatment of Borderline Personality Disorder (BPD). The mentalising capacity of patients with BPD is vulnerable to being lost, particularly in the context of interpersonal interactions, leading to difficulties managing impulsivity and problems with affect regulation. In fact, the phenomenology of BPD can be explained by temporary losses of mentalising. It is, therefore, heuristically valid to treat this serious and common psychiatric disorder by focussing on the development of mentalising capacity, as Mentalisation-Based Treatment (MBT) does. This structured, time limited therapy has been found to be an effective treatment for BPD in clinical trials when delivered by mental health professionals with some additional training and supervision. As such, MBT is an accessible treatment approach for both public and private mental health service delivery. complex and serious nature of Borderline Personality Disorder (BPD) has challenged clinicians and theorists to develop a coherent model to explain the origins and symptomatology of this not infrequent disorder, and to devise a treatment that addresses the underlying intrapsychic deficits that produce the borderline pathology. The phenomenology of BPD affective dysregulation, impulsivity and aggression, instability of relationships, and sense of self can be explained by temporary failures of the capacity for mentalising. Bateman and Fonagy (2013) envisage mentalising as "the process by which we make sense of each other and ourselves, implicitly and explicitly, in terms of subjective states and mental processes" (p. 595). It is not a fixed property of mind, but rather is influenced by emotional states, perceptions, and beliefs. Mentalisation- Based Treatment (MBT) for BPD is founded on the premises that vulnerability to temporary loss of mentalising underlies the presenting symptomatology of BPD and that mentalising is a skill which can be developed or improved in therapy. Mentalising The capacity for mentalising about ourselves and others underlies human social interaction. Individual mentalising capacity varies depending on the context, and temporary lapses are both necessary and normal to human functioning. We all drift in and out of mentalising, but the ability to retain the capacity to think about feelings and thoughts under intense stress or emotion demonstrates robust mentalising. Flexibility of thought, curiosity about the mind, the ability to generate multiple perspectives, and awareness of the different states of mind in self and the other are all features of good mentalising. Sometimes mentalising is automatic or implicit and at other times it is effortful and explicit. Robust mentalising enables the individual to retain a sense of themselves in the face of interpersonal challenge, to regulate intense affect, and to maintain close attachment relationships (Fonagy, Gergely, Jurist, Elliot, & Target, 2002). 10 Corresponding author: margie@maternalconnections.com.au Individuals with high levels of mentalisation are more able to be resilient, and even derive benefit from adversity (Fonagy, Steele, Steele, Higgit, & Target, 1994). They demonstrate good capacities both to attach to caring others (Hauser, Allen, & Golden, 2006) and to ask for and receive assistance (Grossman et al., 1999). High levels of mentalisation are, therefore, understandably associated with the formation of secure attachment relationships and a secure state of mind with regard to attachment (Bouchard et al., 2008). The capacity to mentalise well is associated with a number of measures of healthy social and mental functioning. Mentalising is a fundamental psychological process and profoundly social. It is, therefore, unsurprising that impairments in this elemental psychological process are associated with psychopathology. Impulsive acts, frantic efforts to avoid abandonment, self-harming behaviours, and the instability of self in patients with BPD are theorised to arise from a temporary loss of the capacity to mentalise both the patient's own experience and that of the other. For individuals with BPD, interpersonal interactions are a particular source of vulnerability to heightened arousal and associated loss of mentalising. A Developmental Construct Bateman and Fonagy (2012) have argued that the mentalising capacity is a developmental achievement rather than an entirely constitutional one. Moreover, its development is supported by secure attachment relationships, particularly those with early caregivers. The experience of being 'held in mind' by a trusted other and having one's subjective experience adequately 'mirrored' and 'marked' leads to the development of an internalised coherent sense of self and the capacity to mentalise. Fonagy and colleagues (2002) have drawn on empirical research from neurobiology, attachment studies, and infant and child psychology, to articulate the elegant sequence of events and experiences necessary for this important developmental pathway. The ACPARIAN: ISSUE 9: July 2014 Australian Clinical Psychology Association

35 It is hypothesised that, prior to the development of mentalisation, children demonstrate three pre-mentalising modes of thinking: pretend, teleological, and psychic equivalence. In adults whose mentalising is temporarily lost we often see a return to these pre-mentalising modes of thinking which is problematic for relationships, including the therapeutic relationship. Therapists will recognise these modes of thinking from their clinical encounters and perhaps recall the struggles introduced into the therapy when these pre-mentalising modes of thinking were active. Pretend mode. In the pretend mode, the external world is shut out and the mind occupies an exclusive imaginary space. Young children create these imaginary worlds which are maintained completely separate from physical reality. In patients, the parallel to this is the capacity to retreat to thinking about experiences without any connection to the correlating effect of that experience. The hallmark of this mode of thinking is the dissociation from affect, which the therapist may experience as the patient not 'being real'. Therapists typically feel quite bored and may function themselves on 'autopilot' when confronted with pretend mode. Lengthy monologues, or even dialogues, may ensue, apparently about internal experience with which the patient has no connection, and nothing new is learned. Teleological thinking. When thinking teleologically, an individual understands the physical actions of another as directly representing mind states. The emphasis is on the physical realm as evidence of feelings, intentions, and desires, but it is an associative link rather than a perception of the mind driving the behaviour 'if this, then that'. Young children make sense of their world this way without much awareness of hopes, drives, and wishes in the caregiver's mind. The very young child 'knows' that throwing dinner on the floor will make her mother appear angry, but, beyond that association, has little understanding of her mother's mind. The patient who insists on immediate text responses from her boyfriend as proof of his caring for her may also be unable to think deeply about his mind. When encountering the teleological mode, the therapist may find themselves wishing to do something and may feel inclined to offer strategies and give practical advice. Psychic equivalence mode. In the psychic equivalence mode, an individual experiences what is in their mind as real and absolutely true. Thoughts assume terrifying proportions as there is no awareness that the mind is representing something that has no existence in reality. The capacity for symbolic thought appears absent and there is a rigidity and concreteness to the subjective experience. A child's fears of monsters hiding in the bedroom, or the patient's belief that their medication is causing them harm, can be experienced as absolutely true, with an accompanying sense of panic and consequent avoidance. Clinicians may find themselves feeling puzzled and confused, or even angry, when faced with a patient in psychic equivalence, not knowing what to say and perhaps resorting to excessive nodding. Clinicians sometimes end up arguing with the patient as their stated belief has so many inconsistencies. For the therapist, the significance of recognising these three modes of thinking in the patient is crucial to supporting and maintaining the patient's mentalising. Nonmentalising in the patient has at least two important implications for the therapy. First, as described above, it tends to lead to non-mentalising in the therapist. Second, attempting psychotherapy with patients who are not mentalising can be fruitless, at best, and may lead to therapeutic enactments and a potential worsening of the patient's mental state. Mentalising Up and Down As mentioned earlier, mentalising is not a static capacity; it varies not only between individuals, but within individuals. There is an observable relationship between stress and arousal, neurobiological functioning, and shifts from automatic and implicit mentalising to more explicit and controlled mentalising. Understanding this relationship and the processes involved is important to understanding some psychopathologies, particularly BPD. Based on Arnsten's (1998) dual-process model, it has been proposed that there is a threshold of stress arousal that results in a neurobiological switch from cortical, prefrontal systems to posterior, subcortical systems, with a corresponding switch from controlled to automatic mentalising (Bateman & Fonagy, 2012). There is now considerable evidence from neuroimaging, behavioural, and physiological studies to support not only the existence of such a switch, but its close relationship to activation of the attachment system (Fonagy & Luyten, 2009). Once the switch to posterior cortex and subcortical regions is activated, the disengagement of the prefrontal cortex means that executive functions and conscious control of the mind are inhibited, and the mind is functioning in a much more automatic and reactive way. After this point, the capacity for an individual to exercise any conscious control over either their mind or their behaviour is severely limited. BPD and Interruptions to Mentalising The close links between the neurobiology of the switch from controlled to automatic mentalising and the arousal of the attachment system is a problem for individuals with BPD. Studies of attachment styles in BPD reveal a preponderance of insecure and disorganised styles, with the anxious preoccupied pattern predominating (Levy et al., 2006). Individuals with an anxious preoccupied attachment style will typically use hyperactivating strategies in an attempt to re-establish connection with the attachment figure and consequent emotional and self-equilibrium. Hyperactivation strategies involve fearful amplification of distress with an accompanying heightened sense of attentional focus on the attachment figure and relationship (Mikulincer & Shaver, 2007). Unfortunately, for individuals with BPD, this heightened arousal around attachment undermines their mentalising capacity in interpersonal relationships. The hyperarousal of the attachment system in BPD increases the likelihood of a switch to automatic or prementalising modes of thinking about internal states. When the pre-mentalising modes of thinking are activated, patients experience distortions of their subjectivity, often accompanied by intense psychic pain that feels unbearably real. The challenge for the therapist is to achieve enough activation of the attachment system to have influence, yet not so much that it undermines the patient's capacity to The ACPARIAN: ISSUE 9: July 2014 Australian Clinical Psychology Association

36 mentalise. This requires continuous monitoring of the patient's tolerance for closeness to, and distance from, the therapist and close observance of any activation of their switch to pre-mentalising modes of thinking. To do this, the therapist must work to sustain their own mentalising. MBT Many psychological treatments involve mentalising interventions; MBT is not unique in this regard. The difference with MBT is that the patient's mind, and attempts to understand it as it is experienced by the patient, are at the heart of the therapy. The focus on the patient's internal mental process aims to develop the capacity for introspection and an aptitude for exploration of both their internal world and that of others. Of course, this necessitates that the therapist relinquish any claim to 'knowing' and to expert status. Assessment of Mentalising At the heart of the (mentalising) work of the MBT therapist is the ability to recognise when the patient is mentalising and when prementalising modes are dominating. Distinguishing pretend mode and pseudomentalising, teleological mode, and psychic equivalence from genuine mentalising is a continuous task of the therapist. Noticing the contexts in which a loss of mentalising occurs provides crucial clues to the therapist about where the difficulties lie in the patient's mind. Ultimately, identifying and exploring these moments where mentalising is lost becomes a focus of exploration by the therapist and the patient. The therapist works to maintain mentalising in the patient, to recover it when lost, and eventually to explore the internal processes that lead to disruptions in mentalising. Therapist Stance As mentioned previously, the position of the therapist is of curiosity about the patient's mind, and this necessitates that the therapist eschew any expert, knowing status. A sense of humility and not-knowing underlies the MBT therapist's stance. Having the patience to take time to identify different perspectives, and legitimising and accepting the existence of these, promote the patient's exploration of their internal world. The MBT therapist is also very active, frequently asking for more detail about internal experience and sometimes pursuing this in a rather persistent manner. The MBT therapist is not so interested in historical or post hoc explanations of 'why' and recognises that such conversations frequently represent a pretend mode of thinking or even pseudomentalising. Structure of MBT Like all well designed treatments for BPD, MBT is a structured intervention (Bateman & Fonagy, 2012). The structure of MBT has been designed with an awareness of the specific conditions necessary to advance a patient's mentalising capacity. MBT structure straddles the balance between having enough influence to induce change in the BPD patient's mentalising capacity without undermining this through overactivation of the attachment system. Bateman and Fonagy have suggested that MBT interventions be structured around a series of therapeutic steps: 1. Demonstrating empathy with the patient's current subjective state; 2. Exploring, clarifying, and, if appropriate, challenging; 3. Identifying affect and establishing an affect focus; and 4. Mentalising the relationship. Evidence for MBT Evidence for this psychological intervention comes from at least two sources - one from the evidence for the theory that underpins the development of the approach, the other from the outcome of clinical trials. There have been only two clinical trials of MBT for the treatment of BPD, with both of these conducted by the developers of MBT. The first study evaluated the use of MBT in a day hospital context. The sample size was small (N = 44); however, the treatment group made significantly greater gains in reducing self-harm, suicidality, and depression in comparison to the control group receiving general psychiatric care (Bateman & Fonagy, 1999). These gains, observed at 18 months, were maintained at 36 months (Bateman & Fonagy, 2003). Frequency of suicide attempts and hospitalisation were reduced, and social functioning improved, in the treatment group at 8-year follow-up (Bateman & Fonagy, 2008). The second, larger well-designed trial was based on an outpatient program of MBT compared to structured clinical management. One hundred and thirty-four BPD patients were randomised to either condition and assessments conducted at 6, 12, and 18 months. The MBT group had significantly fewer self-harm or hospitalisation episodes as well as improved scores on a range of measures of social and interpersonal functioning (Bateman & Fonagy, 2009). A study of the use of outpatient MBT for BPD outside the United Kingdom found significant improvements in measures of interpersonal functioning and personality pathology as well as reduction in episodes of self-harm and suicidality; however, this study did not employ a control group (Bales et al., 2012). Nor did it exclude individuals with comorbid diagnoses of substance use disorder, and other indicators of severe pathology that are excluded from most studies of BPD treatments. A Danish study compared intensive MBT for BPD to supportive group therapy, and found both treatments produced self-reported symptomatic relief for the duration of the study. The effect sizes for both arms of treatment were substantial and similar to those obtained in DBT and transference-focussed therapy (Clarkin, Levy, Lenzenweger, & Kernberg, 2007). Therapist ratings of Global Assessment of Functioning were significantly higher for the MBT group, and there was a trend toward greater improvement across all measures for the MBT group; however, this did not reach significance. Follow-up studies are being conducted to determine whether MBT produces more lasting structural change. A strength of the MBT approach to the treatment of BPD is its strong theoretical grounding in the mechanisms of psychopathology that underlie the formation of symptoms. The ACPARIAN: ISSUE 9: July 2014 Australian Clinical Psychology Association

37 The concept of reflective function, of which mentalising is the operational arm, arose from findings from prospective studies of attachment. The subsequent elaboration of the model has drawn on research from cognitive psychology, infant behaviour, trauma studies, and neuropsychiatry. Neuroimaging studies have been particularly helpful in confirming the relationship between arousal, attachment, and the switch to sub-cortical brain functioning. Conclusion MBT is an approach that has been developed gradually in response to research findings from diverse fields as neurobiology, attachment theory, cognitive science, and studies of infant behaviour. The developers continue to adapt the model as the knowledge base for the mechanisms of psychopathology, and change, in BPD expands. While the accumulation of evidence for the efficacy of MBT for BPD is in its early stages, the underlying science for MBT is fundamentally sound. Early clinical trials are yielding promising results, even with severe presentations of BPD. References Arnsten, A. (1998). The biology of being frazzled. Science, 280, Bales, D., van Beek, N., Smits, M., Willemsen, S., Busschbach, J., Verheul, R., & Andrea, H. (2012). Treatment outcome of 18 month, day hospital mentalization-based treatment in patients with severe borderline personality disorder in the Netherlands. Journal of Personality Disorders, 26, Bateman, A., & Fonagy, P. (1999) The effectiveness of partial hospitalisation in the treatment of borderline personality disorder - A randomised controlled trial. American Journal of Psychiatry, 156, Bateman, A., & Fonagy, P. (2003). Health service utilisation costs for borderline personality disorder patients treated with psychoanalytically oriented partial hospitalization versus general psychiatric care. American Journal of Psychiatry, 160, Bateman, A., & Fonagy, P. (2008). 8-year follow-up of patients treated for borderline personality disorder. Mentalization based treatment versus treatment as usual. American Journal of Psychiatry, 165, Bateman, A., & Fonagy, P. (2009). Randomised controlled trial of outpatient mentalization-based treatment versus structured clinical management for borderline personality disorder. American Journal of Psychiatry, 166(12), Bateman, A., & Fonagy, P. (2012). Handbook of mentalizing in mental health practice. Washington, DC: American Psychiatric Publishing. Bateman, A., & Fonagy, P. (2013). Mentalization based treatment. Psychoanalytic Inquiry: A Topical Journal for Mental Health professionals, 33, Bouchard, M., Target, M., Lecours, S., Fonagy, P., Tremblay, L., Schachter, A., & Stein, H. (2008). Mentalization in adult attachment narratives: Reflective functioning, mental states, and affect elaboration compared. Psychoanalytic Psychology, 25, Clarkin, J., Levy, K., Lenzenweger, M., & Kernberg, O. (2007). Evaluating three treatments for borderline personality disorder: A multiwave study. American Journal of Psychiatry, 164, Fonagy, P., Gergely, G., Jurist, E., Elliot, L., & Target, M. (2002). Affect regulation, mentalisation and the development of the self. London, England: The Other Press. Fonagy, P., & Luyten, P. (2009). A developmental, mentalisation-based approach to the understanding and treatment of borderline personality disorder. Developmental Psychopathology, 21, Fonagy, P., Steele, M., Steele, H., Higgit, A., & Target, M. (1994). Theory and practice of resilience. Journal of Child Psychology and Psychiatry and Allied Disciplines, 35, Grossman, K. E., Grossman, K., & Zimmerman, P. (1999). A wider view of attachment and exploration. In J. Cassidy & P. Shaver (Eds.), Handbook of attachment theory and research and clinical applications (pp ). New York, NY: Guilford Press. Hauser, S., Allen, J., & Golden, E. (2006). Out of the woods: Tales of resilient teens. Cambridge, MA: Harvard University Press. Levy, K., Meehan, K., Kelly, K., Reynoso, J., Weber, M., Clarkin, J., & Kernberg, O. (2006). Change in attachment patterns and reflective function in a randomized control trial of transference-focused psychotherapy for borderline personality disorder. Journal of Consulting and Clinical Psychology, 74, Mikulincer, M., & Shaver, P. (2007). Attachment in adulthood: Structure, dynamics, change. New York, NY: Guilford Press. The ACPARIAN: ISSUE 9: July 2014 Australian Clinical Psychology Association

38 11 Given Prevalence, Correlates, and Functions of Deliberate Self-Harm and Non-Suicidal Self-Injury: Self-Harm and Borderline Personality Disorder Marc Stewart Wilson, PhD 1, Jessica Garisch, PhD 1, Robyn Langlands, PhD 1, Lynne Russell, PhD 2, Angelique O'Connell, PGDipClinPsyc 3, Emma-Jayne Brown, BSc(Hons) 1, Tahlia Kingi, BSc(Hons) 1, Madeleine Judge, BSc(Hons) 1, and Kealagh Robinson, BSc 1 1 School of Psychology, Victoria University of Wellington, New Zealand 2 Health Services Research Centre, Victoria University of Wellington, New Zealand 3 Child and Adolescent Mental Health Service, Capitol and Coast District Health Board, New Zealand Abstract In this brief commentary, we discuss self-harming behaviour in the context of both clinical and community populations. As well as drawing a distinction between Non-Suicidal Self-Injury (NSSI; behaviours that cause tissue damage, but without suicidal intent) and Deliberate Self-Harm (DSH; behaviours that cause psychological, emotional, or physical harm, potentially with suicidal intent), we discuss self-harm as a diagnostic criterion for Borderline Personality Disorder (BPD) and summarise DSM-5-related changes both to the assessment for BPD and the proposal for further investigation of NSSI as a behaviour of interest in its own right. Finally, we discuss the functions that self-injurious behaviours may serve for clinical and community populations. the lengths that humans (and other organisms) go to in order to avoid harm, it is paradoxical that anecdote, clinical experience, and research suggest that a significant minority of humans (but few other organisms) deliberately harm themselves (see Jacobson & Gould, 2007; Nock, 2010, for reviews). Indeed, clinical populations tend to be more likely to report a history of self-harm. For example, Sansone and Levitt (2002) found that more than a quarter of eating disordered in- and out-patients had self-harmed. Fortune, Seymour, and Lambie (2005) reported that approximately 50% of adolescent clients of Child and Adolescent Mental Health services had engaged in self-harm, though self-harm was not necessarily the reason for referral. Until relatively recently, research has traditionally failed to distinguish between self-injury with and without suicidal intent (Muehlenkamp & Gutierrez, 2007). Lumping non-suicidal self-injury (NSSI) with non-fatal suicide attempts behaviours often referred to by the less specific term Deliberate Self-Harm (DSH) has hindered efforts to understand factors that lead to, and maintain, non-suicidal self-injurious behaviours, and develop effective interventions. However, increasing evidence supports a distinction between non-suicidal and suicidal forms of selfinjury (Brausch & Gutierrez, 2010; Muehlenkamp & Gutierrez, 2007), and researchers increasingly use the term NSSI to refer to Non-Suicidal Self-Injury behaviours. NSSI is "intentional, self-effected, low-lethality bodily harm of a socially 11 Acknowledgement: The work this manuscript summarises has been assisted by Victoria University Senior Scholarships to Jessica Garisch, a Bright Futures Top Scholar Award to Robyn Langlands, and Funding from the Health Research Council of New Zealand. Corresponding author: marc.wilson@vuw.ac.nz unacceptable nature" (Walsh, 2006, p. 3), consistent with the evidence-based perspective that many people engage in self-injury to cope, rather than as an attempt to end their lives, and includes behaviours such as cutting and burning oneself without suicidal intent. Thus, NSSI refers to nonsuicidal self-injurious behaviours, while the term DSH refers to a more inclusive group of behaviours where suicidal intent is unclear. For the purposes of this review, self-harm will be used where suicidal intent is included, or where it is unclear if suicidality is excluded when assessing behaviours. While self-harm is not uncommon among clinical populations, until DSM-5 (American Psychiatric Association [APA], 2013) it had typically been seen as a diagnostic criterion for particular diagnoses rather than a focal clinical issue in its own right. That is to say, self-harm has long been a criterion associated particularly with diagnosis of Borderline Personality Disorder (BPD; APA, 2000). According to DSM-IV- TR, BPD is characterised by instability in interpersonal relationships, view of self, affect, and decision-making; we refer later to newer DSM-5 criteria. It typically 'develops' in late adolescence/early adulthood. A diagnosis may be based on evidence of five (or more) of several criteria, one of which explicitly refers to self-harm (recurrent behaviours that appear to be suicidal or self-mutilatory in nature; criterion 5). A second criterion includes impulsive behaviours that are potentially harmful (such as risky sexual behaviour, dangerous drinking or driving; criterion 4). Additionally, the presence of behaviours directed at avoiding abandonment are diagnostically relevant, but clinicians are directed to avoid inclusion of self-harming behaviour that such efforts might involve, indicating that self-harm might function as a means to manage relationships. Unsurprisingly, rates of selfinjury are high among people who receive a diagnosis of The ACPARIAN: ISSUE 9: July 2014 Australian Clinical Psychology Association

39 BPD. For example, Zanarini, Frankenberg, Hennen, Reich, and Silk (2005) reported that 81% of a sample meeting BPD criteria had harmed themselves in the previous two years. Importantly, for reasons we'll return to, other criteria for BPD diagnosis allude to difficulties in managing emotions and distress, including unstable and highly reactive mood (criterion 6), issues around managing anger (criterion 8), and paranoia or dissociation related to stress (criterion 9). At the same time, self-harm isn't limited to clinical populations. Briere and Gil (1998) reported that 4% of a large adult community sample had engaged in self-harm at some point in their lifetime. Also, just as clinical adolescent populations tend to report more self-injury (e.g., Fortune et al., 2005), so too do adolescents in general. In fact, typical age of onset of self-harm is early to middle adolescence (Nixon, Cloutier, & Aggarwal, 2002; Nock, Holmberg, Photos, & Michel, 2007). Up to 50% of adolescents will deliberately hurt themselves, without suicidal intent, before they reach schoolleaving age (Garisch, 2010; Lundh, Karim, & Quilisch, 2007). In a review of 52 studies of adolescent samples, Muehlenkamp, Claes, Havertape, and Plener (2012), found average rates of self-injury and self-harm of 18% and 16.1%, respectively, with Australian samples reporting prevalence rates of between 14.1% (Hasking et al., 2010) and 33.3% (Martin, Swannell, Hazell, Harrison, & Taylor, 2010). Not only are there immediate economic and social costs when adolescents require treatment for self-injury, but also long-term costs when self-injury becomes part of an ongoing pattern of behaviour. What do We Know about Self-Harm? Research investigating NSSI can be grouped into two broad areas: NSSI risk factors and correlates (Garisch & Wilson, 2010), and functions of NSSI (i.e., purposes that the behaviour fulfils) (Klonsky & Glenn, 2009; Nock & Prinstein, 2005; Walsh, 2006). This reflects attempts to answer two fundamental questions: What leads people to deliberately injure themselves; and why do people continue to do so? Given the lack of local research into NSSI, we focus on international publications, and research we have been involved in, to provide an overview of the NSSI evidence base. Correlates of Self-Harm There is no one-size-fits-all reason for NSSI, and research implicates a range of intrapersonal, interpersonal, and sociocultural factors. Repeated NSSI has been associated with adolescent disordered eating, depression, anxiety, low self-esteem, and substance use (Bjärehed & Lundh, 2008; Briere & Gil, 1998; Jacobson & Gould, 2007; Jacobson & Luik, 2014). Our research indicates that, for adolescents, intrapersonal risk factors associated with self-injury include alexithymia (i.e., deficits in identifying, describing, and dealing with emotions), anxiety, depression, impulsivity, and concerns over sexuality, while self-esteem and resilience (i.e., the ability to deal with life's stressors) appear to be protective factors (Garisch, 2010; Garisch & Wilson, 2010). Interpersonal factors associated with, or predictive of, NSSI include peer victimisation (i.e., physical, verbal, and electronic bullying), attachment to significant others (Wilson, 2005), and the selfinjury profile of one's social network (e.g., whether one's friends or family have self-injured, family support) (Tuiskuet al., 2009). Sociocultural factors also play a critical role in the development of NSSI. Adolescents who self-injure are more likely to know peers who have engaged in NSSI, prompting speculation that adolescents may model self-injury to friends, or that adolescents who self-injure are drawn to each other, which may socially validate NSSI as a coping mechanism (Claes, Houben, Vandereycken, Bijttebier, & Muehlenkamp, 2010). Indeed, researchers have investigated the concept of 'contagion' in self-injury, where an environment in which selfinjury is salient is implicated in the start of self-injury 'epidemics' (Rosen & Walsh, 1989). That self-harm is relatively common, indeed much more common than the conditions with which it co-occurs, is a problem for researchers and clinicians alike. Firstly, that it is associated with pathologies of eating, mood, and personality does not really help us understand it - to say that one problematic thing is associated with psychiatric diagnosis describes the phenomenon of interest, but does not (on its own) assist in understanding or treating it. Secondly, if up to 50% of young people self-harm at some point, and 10 15% do so in any one year (Muehlenkamp et al., 2012), it seems unreasonable that all of these young people will receive a BPD (or other self-harm-related) diagnosis. Functions of Self-Harm In the research literature, the dominant models of NSSI are behavioural in nature - at its core, people hurt themselves because it serves some function, and their behaviour is reinforced. For example, the Experiential Avoidance Model (Chapman, Gratz, & Brown, 2006) proposes that stressors (that can usually be linked back to occurrences in the environment) cause intense emotional experiences for which individuals may be poorly equipped (e.g., because they have poorly developed faculties for identifying, understanding, and describing their own emotions) (Garisch & Wilson, 2010). Some individuals hurt themselves to avoid the intensity of these emotional experiences, resulting in temporary relief that reinforces their behaviour so, over time, self-injury can become an automatic conditioned response to stressors or the emotions they elicit. Of course, not everyone avoids emotional experiences in this way, either because they engage in other types of avoidance (e.g., drinking themselves insensible) or because they cope with the experience without avoidance (e.g., using other emotion regulation strategies). In our research, we have used the Functional Assessment of Self-Mutilation (Lloyd-Richardson, Perrine, Dierker, & Kelly, 2007) and the Inventory of Statements About Self-injury (Klonsky & Glenn, 2009) to investigate the functions that self-injury serves in a variety of different (nonpsychiatric) populations. Currently, we use exclusively the Inventory of Statements About Self-injury, which asks respondents to indicate the relevance of 39 statements potentially describing their self-injury. Following a stem statement "When I self-harm, I am ", example items include "punishing myself", "calming myself down", "causing pain so I will stop feeling numb", and "avoiding the impulse to The ACPARIAN: ISSUE 9: July 2014 Australian Clinical Psychology Association

40 attempt suicide". Klonsky and Glenn have suggested these 39 items represent 13 subscales that account for different functions self-injury can serve. These include affect regulation, self-punishment, anti-dissociation/feelinggeneration, interpersonal influence, and autonomy. In short, people can hurt themselves to achieve various different outcomes, and not necessarily to serve only a single function. Indeed, people who self-injure commonly report more than one function for their behaviour. For that reason, higher-order analysis of these subscales suggests that these 13 functions can be further differentiated in terms of interpersonal (including maintaining interpersonal boundaries, peer-bonding, and interpersonal influence functions) and intrapersonal functions (including affect regulation, self-punishment, and anti-suicide functions) (see Figure 1; Langlands, 2011). Intrapersonal functions are more strongly endorsed than interpersonal functions, and affect regulation is typically the most common function endorsed. There is reason to think that people who self-injure primarily for interpersonal reasons engage (on average) in more forms of self-injury, and are at greater risk for other negative psychological outcomes. the presence of interpersonal difficulties, negative cognitions and feelings, and premeditation of, and/or rumination about, self-injury. Self-injury that is socially or subculturally sanctioned is excluded. Meanwhile, in DSM-5, self-harming, and potentially self-harming, behaviours are collected together under criterion 2 (disinhibition) with other impulsive and risk-taking activities. In anticipation of recognition of NSSI as a disorder in DSM-5, Glenn and Klonsky (2013) reported analysis of the overlap in NSSI and BPD diagnosis in several hundred adolescents recruited from adolescent psychiatric inpatient, and some outpatient, services in the United States. The sample was classified into BPD-only, NSSI-only, NSSI and BPD, and neither groups. Unsurprisingly, there was an overlap, with 52% of adolescents meeting criteria for NSSI also meeting BPD indicators, while 78% of those with a tentative BPD diagnosis also satisfied the criteria for NSSI. However, comorbidity between NSSI and BPD was no greater than comorbidity between BPD and other disorders. For example, Glenn and Klonsky reported that 84% of BPD diagnoses cooccurred with an anxiety disorder, and more than three quarters with a mood disorder. The take-home message is that while BPD and NSSI are associated, it is not clear that this is an important piece of information, excepting that the sorts of functions that research identifies as underlying NSSI are common among individuals experiencing the things that go along with BPD. Conclusion Figure 1: Cluster analysis of functions of episodes of NSSI in a sample of 152 community adults with a history of NSSI (from Langlands, 2011). NSSI as a Potential Diagnosis Consideration of functions of self-injury brings us back to diagnosis. Recall that several criteria for DSM-IV-TR BPD alluded to borderline pathology around managing emotions (criteria 6 and 8) and dissociative experiences (criterion 9), and that these are clearly consistent with functions identified in the literature of self-injury among non- BPD populations. It may not be just people with BPD who self-regulate through self-injury. Given that NSSI is rather common, is non-specific in terms of comorbidity, and occurs for a variety of functions, but isn't fully understood, it isn't surprising to find NSSI included in DSM-5 not as a 'formal' disorder but as a "condition requiring further study". Criteria for NSSI include: five or more days of intentional self-inflicted damage to the surface of the body; an expectation of gaining relief from negative cognitive or affective states, inducing a positive affective state, and/or relieving interpersonal problems; and, In sum, prevalence of self-harming behaviours varies between 4% and almost 50% depending on the nature of community samples (e.g., Briere & Gil, 1998; Muehlenkamp et al., 2012); it is common among psychiatric samples (Nock, Joiner, Gordon, Lloyd-Richardson, & Prinstein, 2006), most notably among adolescent clinical samples and those diagnosed with BPD (Glenn & Klonsky, 2013; Nock et al., 2006). Numerous factors place people at risk of engaging in NSSI and are associated with the ongoing use of NSSI as a coping mechanism. Knowledge of these factors is important for understanding what leads people to self-injure; also, it can inform treatment. Research has indicated that adolescent (and adult) NSSI fulfils a range of functions, which include regulating negative emotions, communicating distress, seeking to influence others' behaviour, and self-punishment (Klonsky & Glenn, 2009; Nock et al., 2006). In our work on functions of NSSI in a predominantly adult sample, NSSI most commonly functioned as emotion regulation and selfpunishment (e.g., Langlands, 2011; Wilson & Langlands, 2011). However, self-injury is a fairly promiscuous partner for other diagnoses and it shouldn't be assumed that, in spite of its importance as an historical criterion for BPD, it occurs solely in the context of that disorder. References American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4 th ed., text rev.). Washington, DC: Author. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5 th ed.). Arlington, VA: American Psychiatric Publishing. The ACPARIAN: ISSUE 9: July 2014 Australian Clinical Psychology Association

41 Bjärehed, J., & Lundh, L. (2008). Deliberate self-harm in 14- year-old adolescents: How frequent is it, and how is it associated with psychopathology, relationship variables, and styles of emotional regulation? Cognitive Behaviour Therapy, 37, Brausch, A. M., & Gutierrez, P. M. (2010). Differences in nonsuicidal self-injury and suicide attempts in adolescents. Journal of Youth and Adolescence, 39, Briere, J., & Gil, E. (1998). Self-mutilation in clinical and general population samples: Prevalence, correlates, and functions. American Journal of Orthopsychiatry, 68, Chapman, A. L., Gratz, K. L., & Brown, M. Z. (2006). Solving the puzzle of deliberate self-harm: The experiential avoidance model. Behaviour Research and Therapy, 44, Claes, L., Houben, A., Vandereycken, W., Bijttebier, P., & Muehlenkamp, J. (2010). Brief report: The association between non-suicidal self-injury, self-concept and acquaintance with self-injurious peers in a sample of adolescents. Journal of Adolescence, 33, Fortune, S., Seymour, F., & Lambie, I. (2005). Suicide behaviour in a clinical sample of children and adolescents in New Zealand. New Zealand Journal of Psychology, 34, Garisch, J. (2010). Youth deliberate self-harm: Interpersonal and intrapersonal vulnerability factors, and constructions and attitudes within the social environment. Unpublished doctoral dissertation, Victoria University of Wellington, New Zealand. Garisch, J., & Wilson, M. S. (2010). Vulnerabilities to deliberate self-harm among adolescents: The role of alexithymia and victimisation. British Journal of Clinical Psychology, 49, Glenn, C. R., & Klonsky, E. D. (2013). Nonsuicidal self-injury disorder: An empirical investigation in adolescent psychiatric patients. Journal of Clinical Child & Adolescent Psychology, 42, Hasking, P. A., Coric, S. J., Swannell, S., Martin, G., Thompson, H. K., & Frost, A. D. J. (2010). Brief report: Emotion regulation and coping as moderators in the relationship between personality and self-injury. Journal of Adolescence, 33, Jacobson, C. M., & Gould, M. (2007). The epidemiology and phenomenology of non-suicidal self-injurious behavior among adolescents: A critical review of the literature. Archives of Suicide Research, 11, Jacobson, C. M., & Luik, C. C. (2014). Epidemiology and sociocultural aspects of non-suicidal self-injury and eating disorders. In L. Claes & J. J. Muehlenkamp (Eds.), Non-suicidal self-injury in eating disorders (pp ). Berlin, Germany: Springer-Verlag. Klonsky, E. D., & Glenn, C. G. (2009). Assessing the functions of non-suicidal self-injury: Psychometric properties of the Inventory of Statements About Self-injury (ISAS). Journal of Psychopathology and Behavioral Assessment, 31, Langlands, R. L. (2011). Does non-suicidal self-injury function as a form of experiential avoidance? Unpublished doctoral dissertation, Victoria University of Wellington, New Zealand. Lloyd-Richardson, E. E., Perrine, N., Dierker, L., & Kelley, M. L. (2007). Characteristics and functions of non-suicidal self-injury in a community sample of adolescents. Psychological Medicine, 37, Lundh, L. G., Karim, J., & Quilisch, E. (2007). Deliberate selfharm in 15-year-old adolescents: A pilot study with a modified version of the Deliberate Self-Harm Inventory. Scandinavian Journal of Psychology, 48, Martin, G., Swannell, S. V., Hazell, P. L., Harrison, J. E., & Taylor, A. W. (2010). Self-injury in Australia: A community survey. Medical Journal of Australia, 193, Muehlenkamp, J. J., Claes, L., Havertape, L., & Plener, P. L. (2012). International prevalence of adolescent nonsuicidal self-injury and deliberate self-harm. Child and Adolescent Psychiatry and Mental Health, 6, 1 9. Muehlenkamp, J. J., & Gutierrez, P. M. (2007). Risk for suicide attempts among adolescents who engage in nonsuicidal self-injury. Archives of Suicide Research, 11, Nixon, M. K., Cloutier, P. F., & Aggarwal, S. (2002). Affect regulation and addictive aspects of repetitive selfinjury in hospitalized adolescents. Journal of the American Academy of Child & Adolescent Psychiatry, 41, Nock, M. K. (2010). Self-Injury. Annual Review of Clinical Psychology, 6, Nock, M. K., Holmberg, E. B., Photos, V. I., & Michel, B. D. (2007). The self-injurious thoughts and behaviors interview: Development, reliability, and validity in an adolescent sample. Psychological Assessment, 19, Nock, M. K., Joiner, T. E., Gordon, K. H., Lloyd-Richardson, E., & Prinstein, M. J. (2006). Non-suicidal self-injury among adolescents: Diagnostic correlates and relation to suicide attempts. Psychiatry Research, 114, Nock, M. K., & Prinstein, M. J. (2005). Contextual features and behavioral functions of self-mutilation among adolescents. Journal of Abnormal Psychology, 114, Rosen, P. M., & Walsh, B. W. (1989). Patterns of contagion in self-mutilation epidemics. American Journal of Psychiatry, 146, Sansone R. A., & Levitt, J. L. (2002). Self-harm behaviors among those with eating disorders: An overview. Eating Disorders, 10, Tuisku, V., Pelkonen, M., Kiviruusu, O., Karlsson, L., Ruuttu, T., & Marttunen, M. (2009). Factors associated with deliberate self-harm behaviour among depressed adolescent outpatients. Journal of Adolescence, 32, Walsh, B. W. (2006). Treating self-injury: A practical guide. New York, NY: Guilford Press. Wilson, M.S. (2005, September). Attachment and psychopathology. Paper presented at the Child and Adolescent Mental Health Study Day, Kenepuru, New Zealand. Wilson, M. S., & Langlands, R. (2011, June). Evidence for interpersonal and intra-personal dimensions of the functions of non-suicidal self-injury. Annual Conference of the International Society for the Study of Self- Injury. New York, NY. 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42 Zanarini, M. C., Frankenburg, F. R., Hennen, J., Reich, B., & Silk, K. R. (2005). The McLean study of human development (MSAD): Overview and implications of the first six years of prospective follow-up. Journal of Personality Disorders, 19, POST-GRADUATE STUDENTS Expressions of interest The Editorial Board is establishing a panel of Assistants to the Copy Editor The purpose of this role is to ensure that all referencing conforms with the Publication Manual of the American Psychological Association (6th ed.). It also involves checking the accuracy of referencing within the text and the reference list, and ensuring consistency between in-text citations and reference listings. If you would like to volunteer some of your time and have the following skills, the Editorial Board would welcome an expression of interest from you: Familiarity with the Publication Manual of the American Psychological Association (6th ed.) and the ability to ensure manuscript compliance with it A meticulous approach to work A keen eye for detail To submit an expression of interest the editor, Kaye Horley, editor@acpa.org.au. Please include a brief CV. The ACPARIAN: ISSUE 9: July 2014 Australian Clinical Psychology Association

43 1213 In Non-Suicidal Self-Injury: A Diagnosis Independent of Borderline Personality Disorder? Eve Hermansson-Webb, PhD Department of Psychology, University of Otago, New Zealand Abstract Non-suicidal self-injury (NSSI) is a pathological behaviour that is not exclusive to Borderline Personality Disorder, as was once thought. However, this observation was only recently recognised formally by the medical and psychiatric communities in the newly released Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). This article details some of the research that supports this distinction, reports some of the benefits that would emerge from generating a separate diagnostic category for NSSI, and outlines the primary theory behind NSSI behaviour which may make it common to various psychiatric disorders. Research pertaining to adolescents, a population amongst whom NSSI appears to be disproportionately widespread, is discussed, and directions for future research are presented. the past, non-suicidal self-injury (NSSI) was considered as predominantly a behaviour pathognomonic of Borderline Personality Disorder (BPD). Indeed, the previous edition of the Diagnostic and Statistical Manual of Mental Disorders (4 th ed., text rev.; DSM-IV-TR; American Psychiatric Association [APA], 2000) mentioned NSSI only once, as a symptom of BPD. However, systematic surveys amongst both adult and adolescent inpatients and outpatients have shown that many individuals who engage in NSSI do not meet the DSM-IV-TR criteria for BPD (Shaffer & Jacobsen, 2009), that self-injury co-occurs with a variety of diagnoses, and that the behaviour is also prevalent in nonclinical and highfunctioning populations (Klonsky, 2007). Amongst adolescents, the behaviour has been described as occurring at a rate of 'epidemic' proportions (Muehlenkamp, 2012). Whilst BPD is estimated to occur in approximately 1% of the general population (Jackson & Burgess, 2000), NSSI has a much higher prevalence rate. In studies that have been conducted using nonclinical adolescents' self-reports, results suggest that approximately 14% to 39% of this population engage in NSSI (Lloyd, 1998; Ross & Heath, 2002). In a 7-country collaborative study, conducted by Madge and colleagues (2008) and involving over 30,000 adolescents, a NSSI prevalence of between 5.7% and 17.0% amongst female adolescents was documented, with Australia having both the highest lifetime and previous year incidence rates. Proposals to classify NSSI as a distinct disorder with its own diagnostic criteria have led to its inclusion in Section III of the Diagnostic and Statistical Manual of Mental Disorders (5 th ed.; DSM-5; APA, 2013), for those conditions requiring further research. This is an important step, as previously a lack of consensus as to how NSSI should be defined confounded attempts to establish a "solid empirical research base to guide future research" (Laye-Gindhu & Schonert- Reichel, 2004, p. 447), with professionals in contention over how best to conceptualise and operationalise NSSI. A failure 13 Corresponding author: evehermansson@hotmail.com to adopt consistent terminology has also contributed to the 'dilution' of research findings; counts have identified over 33 different labels for NSSI (Favazza, 1996; Ross & McKay, 1979), including self-mutilation, deliberate self-harm and, less commonly, parasuicide, each term having a somewhat different definition of self-injury. By referring to the criteria for NSSI proposed in DSM-5, researchers may henceforth generate studies that reliably add to the emerging knowledge base and produce generalisable findings. Although practising clinicians may not yet use NSSI diagnostically, it may be of use for them to refer to these criteria also, particularly when working with clients who engage in NSSI but do not meet the criteria for BPD. A number of advantages would emerge from establishing NSSI as a diagnosable disorder independent of other psychiatric diagnoses (Cohen, 2014). It would facilitate the development of empirically-based treatments targeted specifically towards self-injury, could potentially enable mental health funding to be offered to clients who fail to meet criteria for other psychiatric diagnoses, would enhance inter-professional and therapist-client communication about the behaviour, would increase the visibility and public awareness of self-injury, and would separate NSSI from the stigma that typically surrounds BPD and suicidal behaviour. Thus, there is clear clinical utility to featuring NSSI as its own diagnostic category. Alternatively, current and future research may indicate that NSSI is best classified as a specifier or subtype of various other psychiatric diagnoses. Various practitioners petitioned for NSSI to be identified in the DSM-5 as a specifier due to the identification of NSSI across diagnoses (McCracken & McCracken, 2013). According to this suggestion, diagnoses such as 'Depression with NSSI' or 'Social anxiety with NSSI' might be given, similar to such diagnoses currently in practice, such as 'Depression with psychotic features' or 'Bipolar I with catatonic features'. Although less clear cut than featuring NSSI as a discrete disorder, there would be similar advantages to this taxonomic approach. The ACPARIAN: ISSUE 9: July 2014 Australian Clinical Psychology Association

44 Essentially, NSSI may be common to various disorders because of the particular functions that the behaviour appears to serve, as outlined by Nock and Prinstein (2004) in their influential and widely-endorsed four function behavioural model of NSSI. This theory draws on empirical knowledge of operant conditioning processes, and posits that self-injury is activated and maintained by four primary functional processes: automatic negative reinforcement, automatic positive reinforcement, social negative reinforcement, and social positive reinforcement. In this model, automatic negative reinforcement refers to the use of NSSI to reduce or escape from an undesired intrapersonal emotional state, such as anxiety or tension, whereas automatic positive reinforcement refers to the use of NSSI to achieve a desired physiological state, such as relaxation or euphoria. The social negative reinforcement function of NSSI refers to its use by an individual to avoid or escape unpleasant interpersonal experiences, such as criticism from a teacher or being asked to complete an aversive task; in contrast, the social positive reinforcement function involves eliciting a desired response from others, such as attention from parents or acceptance from peers. These functions are reflected in criterion B of the DSM-5 proposed criteria for NSSI, which states that the individual engages in the behaviour with the expectation of obtaining relief from a negative emotional or cognitive state, inducing a positive emotional state, or resolving an interpersonal difficulty (APA, 2013). Fundamentally, this theory presents NSSI as a maladaptive coping strategy used by individuals (who may or may not meet the criteria for other psychiatric disorders) with certain pre-existing risk factors to deal with social or emotional distress, dysregulation, or disconnection. As intrapersonal and interpersonal problems are prominent features of numerous mental health problems, this may explain why NSSI is 'transdiagnostic'. In this manner, NSSI may be compared to substance abuse or binge eating, both of which may emerge as a maladaptive coping strategy secondary to another disorder, but which also exist in the DSM-5 as independent diagnoses in and of themselves. Nock (2009) proposed that individuals who have certain preexisting risk factors may be subject to selecting NSSI from their repertoire of potential 'coping strategies'. He proffered an integrated theoretical model that described various distal, proximal, and acute risk factors for self-injury These included genetic predisposition for emotional reactivity, childhood abuse, poor distress tolerance, poor social problem-solving, stressful event triggers, and social learning of the behaviour; the resulting NSSI served to effectively regulate the individual's affective experience or influence their social environment, thus reinforcing the behaviour and the likelihood of the individual engaging in the behaviour again. Regardless of whether or not NSSI is recognised in the DSM nomenclature, it is important for clinicians to be educated about the reinforcement processes that can perpetuate the behaviour, to consider these when conducting psychological assessment there are some psychometric measures that may be of use in this regard (e.g., the Inventory of Statements About Self-injury, Klonsky & Glenn, 2009; the Ottawa Self-Injury Inventory, Martin et al., 2013) and to feature the relevant functions of the behaviour in any clinical formulations of NSSI. Treatments may be targeted towards educating the client about their personal behaviour and what drives it, and towards teaching skills (e.g., problem-solving, relaxation training) that the client may utilise as an alternative to self-injury to achieve the same intrapersonal or interpersonal goals. Similarly, any predisposing risk factors should be considered, as these may need to be addressed in treatment and may explain the presence or emergence of any other pathological behaviour. Future research should focus on confirming and supplementing the details of NSSI already provided in the DSM-5 with regard to diagnostic features, development and course, and risk and prognostic factors. Further differentiation of the behaviour from BPD, the newly proposed 'Suicidal Behavior Disorder', and stereotypic selfinjury as occurs in the context of developmental disorders, would be of use, as would further evidence for NSSI being present amongst nonclinical populations and/or comorbid with other less pervasive diagnoses. In addition to confirmatory research, more exploratory investigation is also warranted. Research is breaking new ground with regard to establishing the mechanisms by which NSSI may develop, such as via social 'contagion' (e.g., Hermansson-Webb, 2013), with previous research having already determined such an effect for associated issues such as depression (e.g., Rosenquist, Fowler, & Christakis, 2011) and suicide (e.g., Brent et al., 1989; Phillips & Carstensen, 1986). Theories as to why adolescents may be particularly susceptible to NSSI should also be elaborated upon and empirical evidence sought (e.g., poorer emotion regulation skills amongst adolescents, Nock, Wedig, Holmberg, & Hooley, 2008; poorer impulse control, Nock & Prinstein, 2005). As NSSI has been identified by some as the most distressing client behaviour encountered in clinical practice, and the behaviour that is most traumatising to professionals (Gamble, Pearlman, Lucca, & Allen, 1994, as cited in Deiter & Pearlman, 1998), it is important for researchers to disseminate clear and practical knowledge about self-injury to clinicians. This may help to instil in clinicians a sense of confidence that they can apply established psychological theory to make sense of the behaviour and that they have the requisite tools with which to address it in practice. In conclusion, the recognition of NSSI as distinct from BPD is a positive step towards representing NSSI more accurately in disseminated texts, towards de-stigmatising both conditions, and towards developing targeted psychological treatments that focus specifically on the variables maintaining problematic self-injury. Further empirical research will allow the field to better understand NSSI and will inform decisions about placement of the behaviour in subsequent editions of the DSM. For now, clinicians should exercise their clinical expertise as scientistpractitioners to best serve their clients who engage in NSSI and to work within the profession towards identifying the behaviour's distinctive characteristics and its most appropriate categorisation within the DSM, the major diagnostic and treatment classification resource. The ACPARIAN: ISSUE 9: July 2014 Australian Clinical Psychology Association

45 References American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4 th ed., text rev.). Washington, DC: Author. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5 th ed.). Arlington, VA: American Psychiatric Publishing. Brent, D. A., Kerr, M. M., Goldstein, C., Bozigar, J., Wartella, M., & Allan, M. J. (1989). An outbreak of suicide and suicidal behaviour in a high school. Journal of the American Academy of Child & Adolescent Psychiatry, 28, Cohen, L. (2014). Stepping out of the shadows: Non-suicidal self-injury as its own diagnostic category. Columbia Social Work Review, Vol. V, pp Deiter, P. J., & Pearlman, L. A. (1998). Responding to selfinjurious behaviour. In R. M. Kleespies (Ed.), Emergencies in mental health practice: Evaluation and management (pp ). New York, NY: Guilford. Favazza, A. R. (1996). Bodies under siege: Self-mutilation and body modification in culture and psychiatry (2 nd ed.). Baltimore, MD: John Hopkins University Press. Hermansson-Webb, E. B. (2013). 'With friends like these ': The social contagion of non-suicidal self-injury amongst adolescent females (Unpublished doctoral thesis). University of Otago, New Zealand. Jackson, H., & Burgess, P. M. (2000). Personality disorders in the community: A report from the Australian National Survey of Mental Health and Wellbeing. Social Psychiatry & Psychiatric Epidemiology, 35(12), Klonsky, E. D. (2007). Non-suicidal self-injury: An introduction. Journal of Clinical Psychology, 63(11), Klonsky, E. D., & Glenn, C. R. (2009). Assessing the functions of non-suicidal self-injury: Psychometric properties of the Inventory of Statements About Self-Injury (ISAS). Journal of Psychopathology and Behavioral Assessment, 31(3), Laye-Gindhu, A., & Schonert-Reichl, K. A. (2004). Nonsuicidal self-harm amongst community adolescents: Understanding the "whats" and "whys" of self-harm. Journal of Youth and Adolescence, 34(5), Lloyd, E. E. (1998). Self-mutilation in a community sample of adolescents (Doctoral dissertation, Louisiana State University, 1998). Dissertation Abstracts International: Section B, The Sciences and Engineering, 58, Madge, N., Hewitt, A., Hawton, K., Jan de Wilde, E., Corcoran, P., Fekete, S., Ystgaard, M. (2008). Deliberate selfharm within an international community sample of young people: Comparative findings from the Child and Adolescent Self-Harm in Europe (CASE) study. Journal of Child Psychology & Psychiatry, 49(6), Martin, J., Cloutier, P. F., Levesque, C., Bureau, J. F., Lafontaine, M. F., & Nixon, M. K. (2013). Psychometric properties of the functions and addictive features scales of the Ottawa Self-Injury Inventory: A preliminary investigation using a university sample. Psychological Assessment. Advance online publication. doi: /a McCracken, S., & McCracken, S. (2013, October 28). DSM-5 update: Transitioning to the fifth edition. PowerPoint presentation at the National Association of Social Workers Illinois Statewide Conference. Muehlenkamp, J. (2012). Non-suicidal self-injury. In R. Levesque (Ed.), Encyclopedia of adolescence (pp ). Berlin, Germany: Springer. Nock, M. K. (2009). Why do people hurt themselves? New insights into the nature and function of self-injury. Current Directions in Psychological Science, 18, Nock, M. K., & Prinstein, M. J. (2004). A functional approach to the assessment of self-mutilative behavior. Journal of Consulting and Clinical Psychology, 72, Nock, M. K., & Prinstein, M. J. (2005). Contextual features and behavioral functions of self-mutilation among adolescents. Journal of Abnormal Psychology, 114(1), Nock, M. K., Wedig, M. M., Holmberg, E. B., & Hooley, J. M. (2008). The Emotional Reactivity Scale: Development, evaluation, and relation to self-injurious thoughts and behaviours. Behavior Therapy, 39(2), Phillips, D. P., & Carstensen, L. L. (1986). Clustering of teenage suicides after television news stories about suicide. The New England Journal of Medicine, 315, Rosenquist, J. N., Fowler, J. H., & Christakis, N. A. (2011). Social network determinants of depression. Molecular Psychiatry, 16, Ross, S., & Heath, N. (2002). A study of the frequency of selfmutilation in a community sample of adolescents. Journal of Youth and Adolescence, 31(1), Ross, R. R., & McKay, H. R. (1979). Self-mutilation. Lexington, MA: Lexington Books. Shaffer, D., & Jacobson, C. (2009). Proposal to the DSM-V childhood disorder and mood disorder work groups to include non-suicidal self-injury (NSSI) as a DSM-V disorder. Washington, DC: American Psychiatric Association. The ACPARIAN: ISSUE 9: July 2014 Australian Clinical Psychology Association

46 14 Treatment Borderline Personality Disorder and Psychotropic Medications Graham Wong, MBBS, MMed(Psychiatry) Epworth Clinic, Camberwell, Australia Abstract This article outlines the approach of one psychiatrist when considering the use of biological treatments (medications and neurostimulation modalities such as electroconvulsive therapy) when managing the patient with Borderline Personality Disorder (BPD). Therapeutic guidelines have been published which summarise and outline all treatments according to the current evidence base. The psychologist has significant roles within the medication management of BPD. Well devised management plans remain the backbone of effective BPD management. Considering issues of suicide risk, understanding medication limitations, and recognising comorbid conditions are fundamental. of Borderline Personality Disorder (BPD) can be a complicated and difficult endeavour. There is a strong evidence base for the use of specific psychotherapeutic and psychosocial interventions. There is very little substantive evidence for the use of biological treatments. Even psychotropic guidelines de-emphasise the role of medication in BPD (Therapeutic Guidelines, 2013). However, I suspect there would be very few people with BPD who have not been prescribed a psychotropic medication at some stage. The absence of a single, effective treatment, and the powerful presence of self-harm and suicide risk which demands "treatment", is but one dialectic that leads to great angst within an individual therapist. We are all too aware of the potential for splitting when, as is almost always the case, multiple agencies are involved. As a general adult psychiatrist, working in both the public and private sectors, I hope to share some of my experiences and principles that I try to adopt when considering prescribing medications to a person with BPD. A shared knowledge of these principles can help all involved clinicians assist in maintaining appropriate use of medications in BPD. Guidelines In Australia, a recent Federal Government sponsored guideline, namely the National Health and Medical Research Council's Clinical practice guideline for the management of borderline personality disorder (NHMRC; 2012), thoroughly reviewed the evidence for understanding, diagnosing, and managing people with BPD (see pp for an excellent summary of psychotropic medication considerations). A significant point to note regarding medications in BPD is that "BPD is not listed as an approved indication for any medicine licensed in Australia by the Therapeutic Goods Administration, nor is any medicine reimbursed by the Pharmaceutical Benefits Scheme specifically for the treatment of BPD" (NHMRC, 2012, p. 65). Whenever one is 14 Corresponding author: graham.wong@epworth.org.au prescribing in BPD, one is technically treating comorbid conditions such as Major Depressive Disorder or associated symptoms, not the condition itself. There is no evidence base supporting the use of psychotropic medications as a specific efficacious treatment for BPD itself. Communication It is challenging to work with a person with BPD. Most patients also recognise the dilemmas others face when dealing with their erratic selves. Once a psychiatrist becomes involved, the medical model seems to dictate that the "doctor" assume ultimate psychiatric responsibility for the patient, whereas clinical psychologists (and other mental health clinicians who have undergone specialist BPD training) are well recognised generally as having a far greater therapeutic role in managing BPD and may well have a greater knowledge of the therapies required. I fear that many psychiatrists flounder within this medical model, and many psychologists defer to the psychiatrist. Psychologists can provide very helpful feedback regarding the effectiveness or otherwise of the introduction or cessation of a medication. Knowledge of the patient's adherence to, and misuse of, medication, as well as level of substance use, is important information that a psychiatrist may overlook. Similarly, recognition of worsening comorbid conditions can help encourage a psychiatrist to consider trialling a medication. I would encourage frequent and meaningful communication amongst clinicians. Management Plans Current management guidelines emphasise the use of well devised management plans. These should also include medication types, doses, and durations of use, particularly during acute crises (NHMRC, 2012). It can be helpful for someone to inquire of the psychiatrist what particular plans are thought appropriate with a new medication. It is not uncommon for medications to be used for longer than agreed. This may be an oversight and can lead to the inadvertent development of dependence on, for instance, benzodiazepines. One should encourage patients The ACPARIAN: ISSUE 9: July 2014 Australian Clinical Psychology Association

47 to be mindful of their medication use and remind them about any plans in place to limit use of particular medications. Risk Management How does one manage the inherent conflict between suicidality and the use of medications that can be the very means of self-harm and suicide? Again, careful collaboration, communication, documentation, and reasonable adherence to the established management plan is both therapeutically progressive and medico-legally protective. Introducing contingency plans for medication access to be limited in times of crises is an important consideration. Similarly, the use of substances is commonplace in BPD. Significant drug interactions, and increased risk with overdose and misuse, should always be considered. Harm minimisation is a useful therapeutic tool in minimising substance misuse with prescribed medications. Limitations of Medications and Biological Treatments Psychotropics have significant limitations at the best of times. A patient's (or medical practitioner's) inappropriate focus on medications can lead to therapeutic standstill and increased frustration in patient and therapists alike. Patients should be aware of the balance of benefits and drawbacks of medications. Side effects, such as oversedation, weight gain, metabolic syndromes (e.g., diabetes, hypercholesterolaemia, hypertension), hormonal elevation (e.g., hyperprolactinaemia), and potentially irreversible neurological side effects, require careful consideration and monitoring. The use of electroconvulsive therapy is certainly not an indicated treatment for BPD, but can be used appropriately to manage an evident comorbid Major Depressive Disorder. Improvement in a depressive condition may only lead to a return to baseline emotional instability and dysthymia inherent in BPD. The use of standardised rating scales, such as the Hamilton Depression Rating Scale (Hamilton, 1967), to measure response can assist in differentiating the changes due to a biological treatment, whilst BPD symptoms persist. Having said this, BPD distress often skews and artificially elevates the scores of severity on these rating scales. I would consider medications for treating comorbid disorders and associated symptoms as a means of reducing distress to enable a person to better engage in the fundamental psychotherapy. Comorbid Disorders Revealed Whilst there are concerns that a focus on medications is inappropriate in BPD, the reverse also warrants consideration. I find BPD and the Bipolar Disorder spectrum seem to coexist frequently. If a person's mood becomes increasingly unstable, or elevated, with antidepressants, then a diagnosis of a Bipolar Disorder should be seriously considered. As such, adherence to specific medication guidelines, such as avoiding antidepressants, may be needed. On a similar note, characteristic BPD features can become inflamed during relapses in psychiatric disorders, and hence respond to optimal medication management of these conditions. Conclusion These are a few considerations and principles that I believe important when considering medications in the management of BPD. As is evident, the dangers of competing pressures, such as treating suicidality with medications that can be a means of suicide, often make navigating the path of BPD management very difficult. Clear management plans that incorporate the considered views of each person, including the patient, along with constant and constructive communication, are fundamental elements in the medication management of BPD. References Hamilton M. (1967). Development of a rating scale for primary depressive illness. British Journal of Social Clinical Psychology, 6, National Health and Medical Research Council. (2012). Clinical practice guideline for the management of borderline personality disorder. Melbourne, Australia: Author. Retrieved from guidelines/ publications/mh25 Therapeutic Guidelines. (2013). Psychotropic version 7. Melbourne, Australia: Author. Retrieved from org.au/index.php?sectionid=71 The ACPARIAN: ISSUE 9: July 2014 Australian Clinical Psychology Association

48 Practice Guidelines for the Assessment and Treatment of Borderline Personality Disorder National clinical practice guidelines on Borderline Personality Disorder (BPD) assessment in Australia (National Health and Medical Research Council [NHMRC], 2012) have been adapted from pre-existing guidelines, particularly current BPD guidelines in the United Kingdom (National Collaborating Centre for Mental Health, 2009). These were further developed by the BPD Guideline Development Committee (NHMRC, 2012) with guidelines derived from evidence-based systematic review findings and expert consensus recommendations. The United Kingdom BPD guidelines for psychometric diagnostic assessment were based on an Australian study by Chanen et al. (2008). Assessment of BPD DSM-5 diagnostic criteria for BPD (American Psychiatric Association, 2013). Clinical presentation, current functioning, coping, risk factors. Co-morbidity. An expert second opinion if diagnosis is unclear. Helpful adjunct psychometric tests: i) Borderline Personality Questionnaire (BPQ) (Poreh et al., 2006). ii) McLean Screening Instrument for Borderline Personality Disorder (MSI-BPD) (Zaranini et al., 2003). iii) Structured Clinical Interview for DSM-IV Axis II Personality Disorders (SCID-II) (First, Gibbon, Spitzer, & Williams, 1997). iv) International Personality Disorder Examination (IPDE) (Loranger, Sartorius, & Janca, 1996). Treatment of BPD 1. Formulation of a management plan, including crisis management, with client. 2. Application of common principles of care. 3. Referral to a specialised BPD centre for group, and individualised treatment for those needing complex care. 4. Co-ordinated care. 5. Support services for partners, families, and carers. 6. Structured psychological therapies explicitly designed for BPD from specialist BPD clinicians. Structured psychological therapies considered to have benefit in reducing various symptomatology include: References American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5 th ed.). Arlington, VA: American Psychiatric Publishing. Chanen, A. M., Jovev, M., Djaja, D., McDougall, E., Yuen, H. P., Rawlings, D., & Jackson, H. J. (2008). Screening for borderline personality disorder in outpatient youth. Journal of Personality Disorder, 22, First, M. B., Gibbon, M., Spitzer, R. L., & Williams, J. B. W. (1997). The Structured Clinical Interview for DSM- IV Axis II Personality Disorders (SCID-II). Washington, DC: American Psychiatric Press. Loranger, A. W., Sartorius, N., & Janca, A. (1996). Assessment and diagnosis of personality disorders: The International Personality Disorder Examination (IPDE). New York, NY: Cambridge University Press. National Collaborating Centre for Mental Health. (2009). Borderline personality disorder: The NICE guideline on treatment and management (Clinical guideline no. 78). Leicester: British Psychological Society & Royal College of Psychiatrists. National Health and Medical Research Council. (2012). Clinical Practice Guideline for the Management of Borderline Personality Disorder. Melbourne, Australia: Author. Poreh, A. M., Rawlings, D., Claridge, G., Freeman, J. L., Faulkner, C., & Shelton, C. (2006). The BPQ: A scale for the assessment of borderline personality based on DSM-IV criteria. Journal of Personality Disorder, 20, Zanarini, M. C., Vujanovic, A. A., Parachini, E. A., Boulanger, J. L., Frankenburg, F. R., & Hennen, J. (2003). A screening measure for BPD: The McLean Screening Instrument for Borderline Personality Disorder (MSI-BPD). Journal of Personality Disorder, 17, Kaye Horley Editor i) Dialectical behavioural therapy (DBT) ii) Mentalisation-based treatment (MBT) iii) Emotion-regulation training (ERT) iv) Schema-focused psychotherapy (SFT) v) Systems training for emotional predictability and problem-solving (STEPPS) vi) Manual assisted cognitive therapy (MACT) vii) Cognitive-behavioural therapy (CBT) viii) Interpersonal psychotherapy (IPP) ix) Transference-focused therapy (TFT) x) Motive-oriented therapeutic relationship (MOTR) The ACPARIAN: ISSUE 9: July 2014 Australian Clinical Psychology Association

49 Riding the Rollercoaster over the Maelstrom: A Perspective Mel's sister A policeman will tell you that three different people will give you five different interpretations of a particular event. As the media daily demonstrates, 'truth' is a dangerous word and what we see and feel is filtered through our age, experiences, and personal biases. People, and our relationships with them, are much the same. This is my perspective on having a sister with Borderline Personality Disorder (BPD). Others will see her and our relationship differently. Intelligent. Beautiful. Compassionate. Kind. Loving. Friendly. Funny. Intuitive. Generous. Imaginative. Creative. Musical. Sensitive. Difficult. Unstable. Impulsive. Depressed. Angry. Unreasonable. Irrational. Self-doubting. Temperamental. Melodramatic. These are all words that described my beloved sister, Mel. She had BPD. Two years, eleven months, and twenty-four days ago, at time of writing, she lost her fight for stability and took her own life. And things have changed forever, and my heart is forever broken. I'm the youngest in my family, six years younger than Mel, who was the next one up. Looking back with the impeccable vision of hindsight, it seems that my sister's abnormal behaviours began in very early childhood but I never knew a time without her. Whatever she did was just her. When I was eleven, I had a bicycle accident. I knocked out one front tooth, cracked the other, split my tongue, and ended up with mild concussion. Mel ran like the wind to get to her little sister, to reassure me, say that Mum was coming, it was okay. I was away from school for a week, taken to doctors and dentists, the centre of a small fuss. The following week, Mel (17) went to school one day and didn't come home. She phoned to say she'd gone to live with a bloke she'd met on a train. Amidst all the argument, grief, and chaos that followed, I was sure it was my fault that she'd left. I'd been getting too much attention. It wasn't until she came home alone, pregnant, three years later, that I finally accepted that it was more complicated than that. The maelstrom of emotions and drama returned with her. It wasn't that she was unwelcome. We were all hugely relieved to have her back, to be able to see, touch, hug her. It was just that Mel brought her own particular worldview with her. She wanted well, it was never quite clear what she wanted. Except that it wasn't things the way they were. Or the types of relationships that existed within our family. Like most families, we got on each other's nerves at times but for the most part we got along. Our parents worked hard and encouraged us to do likewise; education was valued; ethical behaviour was expected. Conservative values, yes, but not the type that lead to the banishment or cutting dead of someone who is a little different. Returning home did come with the condition that Mel went to counselling. It was then that, looking back, a pattern became evident. Mel would attend counselling for a period of time months, sometimes as long as a year and then she would stop. Often, stopping involved physically leaving the area, usually triggering another rollercoaster of crises, arguments, accusations. I've lost count of the number of times Mel moved but that time, after she'd had her daughter (adopted out), she left home again and moved interstate. With a bloke she met at the Easter Show. There was almost always a bloke involved. And he always turned out to be abusive in some way. She didn't drink but he was usually an alcoholic. Mostly she seemed to run away from the counselling because it invariably led her in a direction she didn't want to go to an understanding that it wasn't always somebody else's fault; that she made poor choices and had to face how that made her feel; and that she could learn to make better choices but that it would be hard. There was no silver bullet, no magic fix, no pill that would enable her to live a healthy, happy life. That it was going to be a daily fight, that she would have to aim for 'stable' rather than 'well'. That it wasn't a lack of faith on her part that withheld the miracle of good mental health. Moving running away, really always isolated her from her family; put significant physical distance between us, making any kind of emotional or practical support well-nigh impossible, although she always resented its absence. And each time I would listen to the arguments between my parents, often involving other family members, feel the conflicting loyalties in myself, and watch as, present or absent, my sister's behaviour what we only later knew to be her illness drove wedges between us. As a child, I simply couldn't understand why. As a teenager, I came to realise that Mel was a different person to each of us and, intentionally or unintentionally on her part, loyalty to our perception of her and her needs, and our need to 'rescue' her, led to conflict between us. And between us and friends who also knew her or thought they did. When Mel returned home that first time, when I was fourteen, she befriended the mothers and older sisters of my school friends. And I found myself being lectured at school about 'my poor sister' and how unfair my parents were being to her. They could never quite tell me what it was that my parents were doing that was so terrible and wicked but they knew they and their parents were right and we, her family, was wrong. It was a pattern I came to know all too well. I watched as Mum's friends criticised her as the The ACPARIAN: ISSUE 9: July 2014 Australian Clinical Psychology Association

50 mother, it must be her fault that her daughter was 'troubled'; right? And Mel was so intelligent, charming, kind, funny Nobody except her family really spent enough time with her to see anything else. So it had to be some mishandling on Mum's part. After all, the mother, in those days, did most of the parenting. If Mum had been more affectionate, less affectionate, stricter, less strict, more tolerant, not so easy going It's a terrifying thought, you see: to realise that no matter how careful the parenting, sometimes there are things that love cannot fix. Aunts, uncles, grandparents, cousins, siblings - everybody had their opinion about what my parents were 'doing wrong'. The fact that, at twenty-one, my sister was fully in charge of her own life and listening to no one apparently wasn't a factor in their reasoning. Whether Mel was there or not, family gatherings became strained with the unsaid. The elephants in the room were carefully painted over to match the walls, and everyone performed bizarre and uncomfortable social dances that ducked over, under, and around the Great Unsaid. Like anything else, if you haven't known life any other way, the weirdness doesn't really register. All my life Mel was moody, often swinging from excited and happy to snappy and sulky in the blink of an eye. It was bewildering at times but over the years I learned to adapt. To tread more carefully. To watch for 'the signs'. To work harder at getting along with everybody, not just her, in case something I (or they) say or do causes the 'snap' in her mood. Like many children, my sister often avoided doing her 'jobs' around the house, or somehow disappeared when she was needed. She was often late home from school without explanation. Or she would drag her feet in the morning so that she missed her train and Mum had to drive her across the city to high school. The constant tension caused by that lack of organisation and responsibility had an impact on me. I didn't like raised voices or seeing my parents upset or annoyed. So, at the age of about eight, by deliberate choice, I made myself the opposite. I was compliant. Organised. Helpful. I was quiet. I was independent and reliable. I didn't argue (most of the time) and tried to be polite. I watched. And listened. No harm in that, right? But compliance can be dangerous as one gets older. A fear of being rude or upsetting people can make it impossible to set boundaries. A compulsion to be helpful and friendly and understanding can lead to an overdeveloped sense of responsibility and a tendency to allow people to take advantage of one's good nature. It meant saying, 'yes, of course, that's fine' whenever anything I'd planned, or even thought of planning, was sidelined by other people's plans, needs, ideas. And all of it left me as someone who had virtually no sense of who I was. Me. I'm still, with a supportive psychologist, working on that. All of which makes it sound as if I resented my sister. I did, at times, being human. But I loved her to bits. In between the mood swings and the temperaments and the behaviours that interrupted plans and damaged family relationships, she was magical. We both loved music, writing, reading, animals, children, older folk and each other. As her need to run away from problems led her from place to place, man to man, we wrote. I hear her voice in those old letters. Hear her laughter, her love. Looking back on twenty years' worth of her letters to me, I find that even then I was apparently trying to look after her. Send her things for her children, for her. Keep her up to date (and therefore connected, I hoped) with the events in the immediate and extended family. I didn't know what else to do. Most of her letters to me were equally newsy. In 2002 there was a stinker, though. A raging torrent of words designed to cut to the soul, sent after I had cut short a similar rant by phone a call that she staged the week my mother was in hospital recovering from hip surgery. The week after the letter arrived, Mel, children in tow, turned up without warning on the doorstep because, from her point of view, it was over. It took me, on the other hand, 18 months, and hard work with my psychologist, to get to the point where I didn't shake like a leaf in a high wind and bolt for the bathroom every time I heard her voice. Those in the family who'd never been on the receiving end of such scalding attacks could never understand the pain of those who had and would often reprimand us for not being sufficiently forgiving, compassionate, understanding. We were supposed to move closer, so we could be hit again. Build a bridge, so she could burn it down. Which we did because you can't give up, right? You can't watch someone heading towards disaster and not reach out to stop them. And she always regretted hurting people. And she meant it. Years later she told me those rages were like tsunamis of emotion that caught her up and she would wake up on a beach with destruction all around her and ask herself, "What the hell just happened?" When, towards the end, Mel's illness ate her alive and she stopped writing, even in her endless journals, we talked on the phone instead. For the last two and half years of her life we spoke between fifteen minutes and three hours every day, although eventually (thanks to my psychologist) I grew strong enough to set time limits in order to reclaim my day. I read everything I could about BPD. I learnt SET UP communication skills: support, empathy, truth, understanding, persistence. I had a folder beside the phone with useful 'starters' for sentences to remind me how to phrase things in a way that made her feel more supported and encouraged but allowed me to be as honest as I could. I had a sign that read "neutral = negative" because my psychologist helped me understand that for a person with BPD anything that is not positive or supportive is heard as criticism or judgement; a neutral tone is heard as icy; tiredness is boredom and rejection. I listened to the daily cycles of self-hatred, self-doubt, resentment of the healthy, and despair. She told me more than I ever wanted to know about what had been done to her by her abusers and what she had done to herself. I bore witness to her struggle to reposition her views, to understand the pattern of her illness, her unrelenting grief for what and who she had lost along the way. Together we revisited painful incidents in family history, and compared our different perspectives and opinions. The ACPARIAN: ISSUE 9: July 2014 Australian Clinical Psychology Association

51 I became very good at asking blunt questions when needed because, when Mel was spiralling into suicidal ideation and making plans, she would lie except if you asked the right question. What did you eat for breakfast? Did you take your antidepressants this morning? Are you stockpiling pills again? I built up enough trust to ask the hard questions about any new bloke she starting seeing: How much does he drink? Does he use drugs? Does he have a job? Does he hit you? Why did I do it? Because I loved her and she needed a lifeline and I was one of those available whom she'd learned to trust. She was losing any sense of her true self, drowning in her own pain sometimes because of a refusal to swim, sometimes because she wasn't even aware the water was there. Mel was trying to do the hardest thing a person with BPD can do: she was trying to find herself within and behind the illness; she was trying to find her balance. I couldn't give up. Her children, even those alienated from her, needed her alive if only so that they could be angry with her. Anger is a form of love. If you don't love, you can't feel anger. "But how can you love me?" Mel would ask. "What's to love?" "You're my sister", I said. "There doesn't have to be a reason." And then I'd tell her anyway. The ACPARIAN: ISSUE 9: July 2014 Australian Clinical Psychology Association

52 LookfortheACPAMemberlogo TheAustralianClinicalPsychologyAssociation(ACPA) POBox1242BROADWAY,NSW,2581 Doesyour psychologisthave accreditedquali cationsin clinicalpsychology? TheAustralianClinicalPsychologyAsociation (ACPA)representsonlyclinicalpsychologistswho haveobtainedtheaccreditedquali cationsset downbythepsychologyboardofaustraliafor recognitionasaclinicalpsychologist. Theseare: AnaccreditedMasters(twoyear)orDoctoral(threeyear) degreeinclinicalpsychology; and Apost-degreeperiodofsupervisiontobringthetotalof post-graduatetrainingtofouryears. InchoosinganACPAMemberyouareensuringthatyour clinicalpsychologisthascompletedthisestablishedstandard oftraining. AccreditedMastersandDoctoral-leveltraininginclinical psychology: Providesthehighestlevelsoftrainingcurentlyoffered withinthepsychologyprofessioninaustralia Facilitatesthedevelopmentofhigh-level,specialisedskils inmentalhealthassessment,diagnosis,andevidencebasedtreatmentplanningandimplementation Notalpsychologistswhoarepermitedtousetheterm clinicalpsychologistinaustraliahavecompletedthislevelof training.indeed,somehavenotcompletedanypost-graduate quali cationsinclinicalpsychology. Internationalstandardsrequirepost-graduatequali cationsin clinicalpsychologyforalclinicalpsychologists. Askthepsychologistprovidingyourmental healthtreatmentwhataccreditedpost-graduate quali cationstheyhaveinclinicalpsychology. To ndaclinicalpsychologistwhoisamemberof theaustralianclinicalpsychologyasociationgoto: Clinicalpsychologistsarespecialistsinthe asesmentandevidence-basedtreatmentof awiderangeofmentalhealthproblems, including: Addictions AtentionDe citandhyperactivitydisorders AutisticSpectrum Disorders BipolarDisorder Depresion&MoodDifficulties Drug&AlcoholAbuse EatingDisorders Emotional&BehaviouralProblemsinChildren Fears,Phobias,Anxiety&PanicAtacks Grief,Los&Bereavement Obsesions&CompulsiveBehaviour PainandSomaticSymptoms PersonalityDisorders Post-traumaticStresDisorder PsychoticIlneses Recoveryfrom ChildhoodTrauma Schizophrenia SeparationAnxiety SocialAnxiety SleepDisorders