18c
Peter Fonagy, Anthony Bateman, Patrick Luyten, Elizabeth Allison, and Chloe Campbell
We are delighted to have two expert and enlightening commentaries on our chapter and we broadly concur with both in the issues raised. Given space limitations, this rejoinder takes up a few key issues raised for further development, including (a) the full range of available psychodynamic treatments, (b) the added value of a dimensional approach, and (c) the role of transference.
The Full Range of Available Psychodynamic Treatments
As Levy (this volume) points out, we did not cover the full range of psychodynamic treatments available for personality disorder, such as Dynamic Deconstructive Psychotherapy, Psychodynamic Supportive Therapy, and Good Psychiatric Management (GPM). Psychodynamic understanding and relational processes form a central part of GPM for BPD, which is now manualized (Gunderson & Links, 2014). GPM is a structured treatment based on supportive dynamic psychotherapy. The underlying theory is that interpersonal sensitivity is at the core of the disorder. As a result, considerable emphasis is placed on forming a working and relational therapeutic alliance and focusing on interpersonal sensitivities of the patient. Management of self-destructive behaviors and impulsivity, and help with emotional regulation is undertaken pragmatically using medication, reassurance, psychoeducation, and crisis management. An RCT comparing GPM with dialectical behavior therapy (DBT) showed no differences between treatments on any outcomes at the end of treatment or at two-year follow-up (McMain, Guimond, Streiner, Cardish, & Links, 2012; McMain et al., 2009).
The value of giving a full account of the range of possible treatments for BPD is underscored by the findings of Cristea and colleagues’ meta-analysis, which found roughly equal treatment effect sizes for all bona fide psychotherapeutic interventions (Cristea et al., 2017). The fact there is now a variety of approaches that are effective in the treatment of BPD – not many years ago regarded as a condition that was almost impossible to treat – is, as Salsman and Katz (this volume) remark, a state of affairs to be celebrated. Some interventions will be more acceptable and/or effective than others for different individuals. Embracing a heterodoxy of approaches and thinking about intervention choices in a way that is tailored to best meet the needs of the patient is an issue that is gaining increasing traction as a result of growing challenges to the categorical diagnostic approach to psychopathology. It is being compellingly argued that problems such as comorbidity (Copeland, Shanahan, Erkanli, Costello, & Angold, 2013; Kessler, Chiu, Demler, Merikangas, & Walters, 2005; Merikangas et al., 2010) and lack of clarity around severity and what this might mean for disease boundaries (Zimmermann, Morgan, & Stanton, 2018) reflect the distinct possibility that existing categories lack validity. These issues – of comorbidity and severity – are, of course, of particular clinical relevance in the treatment of PD.
Added Value of a Dimensional Approach
A dimensional approach to psychopathology is being increasingly considered more clinically useful as well as more conceptually and empirically valid (Beauchaine & Cicchetti, 2016; Forbes, Tackett, Markon, & Krueger, 2016). The emerging body of evidence on the general psychopathology factor (the “p” factor) also supports the empirical validity of the dimensional approach (Caspi & Moffitt, 2018). As suggested by Levy, more could have been said in our original text on the key topical research area of the p factor. We have written extensively about this elsewhere (Fonagy, Luyten, Allison, & Campbell, 2017a, 2017b). Recent research indeed points to a general vulnerability for persistent distressing conditions characterized by a lack of emotional stability running the gamut of diagnostic conditions not fully accounted for by associations at the spectral level (Sharp et al., 2015).
One of the significant benefits of a dimensional approach to psychopathology is that it supports and advances the case for a more flexible and tailored approach to psychopathology by undermining the tendency to regard a patient as a mere manifestation of a diagnostic category. As Salsman and Katz elegantly point out, flexibility in thinking about treatment according to individual needs is essential if we are to hope that patients do not withdraw “from engaging effectively and genuinely in the therapeutic process.”
There are many additional valuable points that we would like to follow up in the rich and thoughtful commentaries provided by Levy and Salsman and Katz; unfortunately space does not allow us to do so. However, we would particularly like to acknowledge Levy’s point about the use of jargon. The chapter could indeed have benefited from a more restrained use of psychoanalytic language, and we regard this comment as a well-placed reminder of this occupational hazard/indulgence of the psychoanalytic world.
The Role of Transference
A further point we would like to mention is the role of transference, as discussed by Levy. The concept of transference is problematic and multi-layered, and restricting it to unconscious experiences is a controversial issue even within the psychoanalytic world. Our position has always been that transference is key to mentalizing relationships, most particularly the one in the here-and-now with the therapist, which is likely to be critical to achieving significant therapeutic gain. Implicitly all therapeutic approaches address the issue, in terms of aspects of relational processes that interfere with therapy, as in DBT, or as something that informs about childhood experience and its current representation in the patient’s mind, as in classical psychoanalysis. In all these contexts, addressing and working with the therapeutic relationship serves to increase the psychosocial literacy of the patient in terms of learning about other minds as well as their own. In that sense, we would suggest that all psychodynamic therapeutic modalities focus on the clinician–patient relationship in the hope that doing so will contribute to the patient’s well-being. While patterns of relationships – whether in therapy, from childhood, or outside therapy – might be pointed to, a difference between the more classical psychodynamic approach and MBT-informed approaches is that the purpose of this relationship focus is not primarily to provide insight or explanation to the patient. Rather, it is in the service of stimulating and strengthening mentalizing, and of adopting a thoughtful, inquisitive stance in relation to mental states in self and others.
References
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Caspi, A., & Moffitt, T. E. (2018). All for one and one for all: Mental disorders in one dimension. American Journal of Psychiatry, 175(9), 831–844.
Copeland, W. E., Shanahan, L., Erkanli, A., Costello, E. J., & Angold, A. (2013). Indirect comorbidity in childhood and adolescence. Frontiers in Psychiatry, 4, 144.
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