Academic journal article International Journal of Psychoanalysis

A Psychoanalytically Informed Hospitalization-Based Treatment of Personality Disorders

Academic journal article International Journal of Psychoanalysis

A Psychoanalytically Informed Hospitalization-Based Treatment of Personality Disorders

Article excerpt


Most of the data of this paper and a more detailed description of method and data analysis have been published before as separate studies by the same authors (Lowyck et al., 2009, 2015; Vermote et al., 2009, 2010, 2011, 2012). It is however the first time that the study is published as a whole, and this gives us the opportunity not only to bundle the different aspects of the study and the main findings, but it also challenges us to reflect on the study and the process of it. When we started the study, psychoanalytically informed treatment was no longer mentioned in psychiatric manuals as a treatment of choice for PDs (personality disorders). Moreover, a hospitalization is correctly seen as a necessary evil because of the risk of malignant regression. However, a specialised hospitalization-based treatment for PDs, based on a coherent treatment model is different from a psychiatric hospitalization. With the seminal study of Bateman and Fonagy (2001) showing the efficacy of their hospitalization-based psychodynamic treatment for BPD patients, the credibility of psychoanalytically informed treatments for PDs improved, and around the world one could observe a renewed interest in this kind of treatment. It was at that time that we decided1 to empirically investigate in a naturalistic study whether our treatment was effective - the treatment involved a coherent focus on inner psychic life within a psychoanalytic therapeutic and conceptual framework. In addition to this overall question we were also interested in for whom the treatment works best and whether our hypothesized mechanism of change in three dimensions could explain the therapeutic effects.

Based on the major psychoanalytic findings about inner change in severe pathology as developed by Klein,Winnicott, Bion, Kernberg, Fonagy, Akhtar and others, we found three main headings to conceptualise, organise and evaluate the treatment: inner safety, mentalization of experiences and emotions and self-object relations. These three dimensions were elaborated into a coherent model, as this is a necessary condition in treating PDs (NICE, 2009, 2015). We used the model to organize and evaluate a hospitalization-based treatment program for PD patients. We will first describe this model and how we implemented it in the treatment. Then we will describe our attempt to measure inner psychic change in patients during and after a psychoanalytically informed hospitalization-based treatment for PDs, and whether this psychic change is related to outcome at a symptom level, also asking here for whom such a treatment works best and whether the results are sustained over a 5 year follow-up period.

A three-dimensional model about the inner psychic change in personality disorders

The first dimension is a background experience of safety and is seen as a basic, generalized feeling of safety. It is described by Sandler (1960) as:

... a background feeling within the ego, a feeling which can be referred to as one of safety or security. I want to stress the positive character of this feeling (which need not, of course, be conscious). It is a feeling which bears the same relation to anxiety as the positive body state of satiation and contentment bears to instinctual tension. Genetically, this feeling must be a derivative of the earliest experiences of tension and satisfaction. It is a feeling of well-being, a sort of ego-tone. It is more than the mere absence of anxiety, and reflects, I believe, some fundamental quality of living matter which distinguishes it from the inanimate. It is a quality of feeling which we can oppose to the affect of anxiety, representing in a sense its polar opposite.

(Sandler, 1960, p. 352)

This inner feeling of safety is frail and often lacking in PD patients, hence their great sensitivity to even small changes in the therapeutic frame. It gives rise to a subjective feeling of self, 'a place within oneself to retreat and relax' (Winnicott, 1960). …

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