This section contains resources and links to further sources of information on people who have a diagnosis of personality disorder.
Taken from Homelesss Link’s Multiple Needs Good Practice Briefing (2002), p. 39 – 40. Based on the research of Dr Anthony Bateman and Peter Fonaghy at the Halliwick Day Unit in London
Personality disorders have been a rubbish bin diagnosis for years, with psychiatrists saying that they cannot be cured and therefore they will not intervene. Homeless people suffering under this problem and diagnosis have had little hope of receiving appropriate treatment or support from mainstream services. If the medical profession had applied the same criteria to cancer there would be a national outcry!
Findings of this new study show that psychotherapeutic intervention can help people. The research looked at patients with borderline personality disorder who had completed a specially devised psychoanalytically orientated day hospital programme (DHP).
In the first study, 44 patients were assigned either to the specialist treatment in the DHP or received their standard psychiatric care as part of a control group for 18 months. Individual and group psychoanalytical psychotherapy and some expressive therapy in the DHP focused on enhancing the patient's resilience to stress over the long-term by helping them understand their relationship problems better. This kind of treatment compared to a focus on symptom reduction within the standard psychiatric service for the control group. Use of medication was maintained for both groups.
The aim of the study was first to determine whether the patients made gains on the programme and second to see if they were maintained and/or improved over an 18-month follow-up period.
Patients who completed the day hospital programme responded favourably on symptomatic and clinical measures. For example, some of their crippling symptoms of anxiety and depression improved and their clinical need for in-patient psychiatric care was lowered, especially because they become less suicidal when compared to patients who continued in their usual treatment of out-patient and community support, psychiatric day hospital care, and medication. Because borderline personality disorder is chronically cyclic by nature long-term follow-up was called for, and a further 18-month follow-up of all patients was undertaken.
At the end of the treatment significantly more borderline personality disorder patients who completed the day hospital programme had refrained from self-mutilation in the preceding six months than control group patients. In addition, after 24 and 30 months more day hospital patients reported not self-harming than those from the control group. 90.9% of DHP patients reported not engaging in self-mutilation after 24 months as opposed to 36.8% of control group patients. After 30 months, 81.8% DHP patients were still not self-mutilating versus 31.6% of the control group who were not.
A similar pattern emerged for suicide attempts. At the end of treatment, significantly fewer patients who completed the DHP than control group patients had attempted suicide in the preceding six months. The same was true at 24 months (9.1% versus 36.8 per cent), and at 36 months (18.2 per cent and 63.2 per cent).
This research showed not only that the substantial gains made in symptom improvement, (e.g. anxiety and depression), and clinical gains, (e.g. less hospitalisation, suicide attempts and Casualty department visits), during treatment were maintained but also that additional improvement was made. The continuing decline in these areas, and the associated low admission rates and minimal acts of self-harm throughout the follow-up period suggest that the DHP patients developed the psychological capacities necessary to withstand the normal stresses and strains of everyday life.
While there is no detailed data on cost-effectiveness, the gains made during and after treatment are important from a health care service perspective. The control group used more of all types of services monitored in this study. Borderline patients dominate psychiatric referrals in A&E departments, particularly following impulsive acts of self-harm. Reducing episodes of self-harm and suicide attempts and low rates of admission to both medical and psychiatric wards for borderline personality disorder patients reduced the need for costly emergency treatment and expensive inpatient care. This suggests considerable savings following treatment.
Bateman, A. and P. Fonagy (1999). ‘The effectiveness of partial hospitalization in the treatment of borderline personality disorder - a randomised controlled trial’. American Journal of Psychiatry 156: 1563-1569.
Bateman, A. W. and P. Fonagy (2001). ‘Treatment of borderline personality disorder with psychoanalytically oriented partial hospitalisation: an 18-month follow-up’. American Journal of Psychiatry 158: 36-42.
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