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The Capacity to End: Termination of Mentalization-Based Therapy for Borderline Personality Disorder

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Abstract

Terminating a therapeutic relationship can be a challenging phase with patients suffering from borderline personality disorder. Despite the critical importance of the termination phase, the proportion of psychotherapy literature devoted to the demands and challenges of this phase is small. This paper describes a mentalization-based approach to detect and intervene against such challenges. It is proposed that termination challenges, while operating through overlapping and interactive mechanisms, can be attributed to (1) patient factors, (2) therapist factors, and (3) therapeutic relationship factors. The paper has clinical implications and suggests that the aim of enhancing mentalizing capacities should include mentalizing the often complicated and mixed feelings associated with separation and loss of the therapeutic relationship. To facilitate this process, we propose the use of a “termination formulation”, in which patients’ outcomes and future goals are recapitulated in the termination phase of mentalization-based therapy.

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References

  • American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5®). Washington, DC: American Psychiatric Publishing.

    Book  Google Scholar 

  • Bateman, A. (2011). Commentary on ‘Minding the difficult patient’: Mentalizing and the use of formulation in patients with borderline personality disorder comorbid with antisocial personality disorder. Personality and Mental Health, 5(1), 85–90. https://doi.org/10.1002/pmh.156.

    Article  Google Scholar 

  • Bateman, A., & Fonagy, P. (1999). Effectiveness of partial hospitalization in the treatment of borderline personality disorder: A randomized controlled trial. American Journal of Psychiatry, 156(10), 1563–1569. https://doi.org/10.1176/ajp.156.10.1563.

    Article  CAS  PubMed  Google Scholar 

  • Bateman, A., & Fonagy, P. (2009). Randomized controlled trial of outpatient mentalization-based treatment versus structured clinical management for borderline personality disorder. American Journal of Psychiatry, 166(12), 1355–1364. https://doi.org/10.1176/appi.ajp.2009.09040539.

    Article  PubMed  Google Scholar 

  • Bateman, A., & Fonagy, P. (2016). Mentalization-based treatment for personality disorders: A practical guide. Oxford, United Kingdom: Oxford University Press.

    Book  Google Scholar 

  • Bateman, A., & Fonagy, P. (2019). Handbook of mentalizing in mental health practice (2nd ed.). Washington, DC: American Psychiatric Association Publising.

    Google Scholar 

  • Bateman, A., Kongerslev, M., & Bo Hansen, S. (2019). Mentalization-based treatment group therapy (MBT-G) for adults and adolescents. In A. Bateman & P. Fonagy (Eds.), Handbook of mentalizing in mental health practices. Washington, DC: American Psychiatric Association Publishing.

    Google Scholar 

  • Betan, E., Heim, A. K., Conklin, C. Z., & Westen, D. (2005). Countertransference phenomena personality pathology in clinical practice: An empirical investigation. American Journal of Psychiatry, 162, 890–898.

    Article  PubMed  Google Scholar 

  • Bo, S., Sharp, C., Fonagy, P., & Kongerslev, M. (2017). Hypermentalizing, attachment, and epistemic trust in adolescent BPD: Clinical illustrations. Personality Disorders, 8(2), 172–182. https://doi.org/10.1037/per0000161.

    Article  PubMed  Google Scholar 

  • Bowlby, J. (1972). Attachment and loss: Volume I: Attachment. London: Penguin Books.

    Google Scholar 

  • Bowlby, J. (1973). Attachment and loss: Volume II: Separation, anxiety and anger (pp. 1–429). London: The Hogarth Press and the Institute of Psycho-Analysis.

    Google Scholar 

  • Bowlby, J. (1998). Attachment and loss: Volume III: Loss—sadness and depression. London: Pimlico.

    Google Scholar 

  • Choi-Kain, L. W., Fitzmaurice, G. M., Zanarini, M. C., Laverdière, O., & Gunderson, J. G. (2009). The relationship between self-reported attachment styles, interpersonal dysfunction, and borderline personality disorder. The Journal of Nervous and Mental Disease, 197(11), 816–821.

    Article  PubMed  Google Scholar 

  • Colli, A., Annalisa Tanzilli, A., Dimaggio, G., & Lingiardi, V. (2014). Patient personality and therapist response: An empirical investigation. American Journal of Psychiatry, 171, 102–108.

    Article  PubMed  Google Scholar 

  • De Panfilis, C., Marchesi, C., Cabrino, C., Monici, A., Politi, V., Rossi, M., et al. (2012). Patient factors predicting early dropout from psychiatric outpatient care for borderline personality disorder. Psychiatry Research, 200(2–3), 422–429.

    Article  PubMed  Google Scholar 

  • Folmo, E. J., Karterud, S. W., Kongerslev, M. T., Kvarstein, E. H., & Stänicke, E. (2019). Battles of the comfort zone: Modelling therapeutic strategy, alliance, and epistemic trust—A qualitative study of mentalization-based therapy for borderline personality disorder. Journal of Contemporary Psychotherapy. https://doi.org/10.1007/s10879-018-09414-3.

    Article  Google Scholar 

  • Fonagy, P., & Allison, E. (2014). The role of mentalizing and epistemic trust in the therapeutic relationship. Psychotherapy, 51(3), 372.

    Article  PubMed  Google Scholar 

  • Fonagy, P., Allison, E., & Campbell, C. (2019). Mentalizing, resilience, and epistemic trust. In A. Bateman & P. Fonagy (Eds.), Handbook of mentalizing in mental health practice (2nd ed.). Washington, DC: American Psychiatric Association Publishing.

    Google Scholar 

  • Fonagy, P., & Luyten, P. (2009). A developmental, mentalization-based approach to the understanding and treatment of borderline personality disorder. Development and Psychopathology, 21(4), 1355–1381. https://doi.org/10.1017/S0954579409990198.

    Article  PubMed  Google Scholar 

  • Fonagy, P., Luyten, P., Allison, E., & Campbell, C. (2017a). What we have changed our minds about: Part 1. Borderline personality disorder as a limitation of resilience. Borderline Personality Disorder and Emotion Dysregularity, 4, 11. https://doi.org/10.1186/s40479-017-0061-9.

    Article  Google Scholar 

  • Fonagy, P., Luyten, P., Allison, E., & Campbell, C. (2017b). What we have changed our minds about: Part 2. Borderline personality disorder, epistemic trust and the developmental significance of social communication. Borderline Personality Disorder and Emotion Dysregularity, 4, 9. https://doi.org/10.1186/s40479-017-0062-8.

    Article  Google Scholar 

  • Fonagy, P., Target, M., & Gergely, G. (2000). Attachment and borderline personality disorder: A theory and some evidence. Psychiatric Clinics, 23(1), 103–122.

    CAS  PubMed  Google Scholar 

  • Fraiberg, S. (1969). Libidinal object constancy and mental representation. The Psychoanalytic Study of the Child, 24(1), 9–47.

    Article  CAS  PubMed  Google Scholar 

  • Hartmann, H. (1952). The mutual influences in the development of ego and id. The Psychoanalytic Study of the Child, 7(1), 9–30.

    Article  Google Scholar 

  • Joyce, A. S., Piper, W. E., Ogrodniczuk, J. S., & Klien, R. H. (2007). Termination in psychotherapy: A psychodynamic model of processes and outcomes. Washington, DC: American Psychological Association.

    Book  Google Scholar 

  • Juul, S., Lunn, S., Poulsen, S., Sorensen, P., Salimi, M., Jakobsen, J. C., et al. (2019). Short-term versus long-term mentalization-based therapy for outpatients with subthreshold or diagnosed borderline personality disorder: A protocol for a randomized clinical trial. Trials, 20(1), 196. https://doi.org/10.1186/s13063-019-3306-7.

    Article  PubMed  PubMed Central  Google Scholar 

  • Karterud, S., & Kongerslev, M. T. (2019). Case formulations in mentalization-based treatment (MBT) for patients with borderline personality disorder. In U. Kramer (Ed.), Case formulation for personality disorders (pp. 41–60). London: Elsevier.

    Chapter  Google Scholar 

  • Kernberg, O. F., Yeomans, F. E., Clarkin, J. F., & Levy, K. N. (2008). Transference focused psychotherapy: Overview and update. The International Journal of Psychoanalysis, 89(3), 601–620.

    Article  PubMed  Google Scholar 

  • Kvarstein, E. H., Pedersen, G., Urnes, O., Hummelen, B., Wilberg, T., & Karterud, S. (2015). Changing from a traditional psychodynamic treatment programme to mentalization-based treatment for patients with borderline personality disorder–does it make a difference? Psychology and Psychotherapy, 88(1), 71–86. https://doi.org/10.1111/papt.12036.

    Article  PubMed  Google Scholar 

  • Levy, K. N., Meehan, K. B., Weber, M., Reynoso, J., & Clarkin, J. F. (2005). Attachment and borderline personality disorder: Implications for psychotherapy. Psychopathology, 38(2), 64–74.

    Article  PubMed  Google Scholar 

  • McMurran, M., Huband, N., & Overton, E. (2010). Non-completion of personality disorder treatments: A systematic review of correlates, consequences, and interventions. Clinical Psychology Review, 30(3), 277–287. https://doi.org/10.1016/j.cpr.2009.12.002.

    Article  PubMed  Google Scholar 

  • Möller, C., Karlgren, L., Sandell, A., Falkenstrom, F., & Philips, B. (2016). Mentalization-based therapy adherence and competence stimulates in-session mentalization in psychotherapy for borderline personality disorder with co-morbid substance dependence. Psychotherapy Research. https://doi.org/10.1080/10503307.2016.1158433.

    Article  PubMed  Google Scholar 

  • Norcross, J. C., Zimmerman, B. E., Greenberg, R. P., & Swift, J. K. (2017). Do all therapists do that when saying goodbye? A study of commonalities in termination behaviors. Psychotherapy, 54(1), 66.

    Article  PubMed  Google Scholar 

  • Sharp, C., Ha, C., Carbone, C., Kim, S., Perry, K., Williams, L., et al. (2013). Hypermentalizing in adolescent inpatients: Treatment effects and association with borderline traits. Journal of Personality disorders, 27(1), 3–18.

    Article  PubMed  Google Scholar 

  • Simonsen, S., Nørgaard, N. L., Larsen, K. A., & Bjørnholm, K. I. (2011). Mentalization-inspired case formulation: Minding the difficult patient. Personality and Mental Health, 5(1), 73–79. https://doi.org/10.1002/pmh.154.

    Article  Google Scholar 

  • Smits, M. L., Feenstra, D. J., Eeren, H. V., Bales, D. L., Laurenssen, E. M., Blankers, M., ... Verheul, R. (2019). Day hospital versus intensive out-patient mentalisation-based treatment for borderline personality disorder: Multicentre randomised clinical trial. The British Journal of Psychiatry, 1–6.

  • Soeteman, D. I., Hakkaart-van Roijen, L., Verheul, R., & Busschbach, J. J. V. (2008). The economic burden of personality disorders in mental health care. Journal of Clinical Psychiatry, 69, 259–265.

    Article  PubMed  Google Scholar 

  • Waters, E., Merrick, S., Treboux, D., Crowell, J., & Albersheim, L. (2000). Attachment security in infancy and early adulthood: A twenty-year longitudinal study. Child Development, 71(3), 684–689.

    Article  CAS  PubMed  Google Scholar 

  • Winnicott, D. W. (1960). Ego distortion in terms of true and false self. The maturational process and the facilitating environment: Studies in the theory of emotional development (pp. 140–157). New York: International Universities Press.

    Google Scholar 

  • Winter, D., Elzinga, B., & Schmahl, C. (2014). Emotions and memory in borderline personality disorder. Psychopathology, 47(2), 71–85.

    Article  PubMed  Google Scholar 

  • Wnuk, S., McMain, S., Links, P. S., Habinski, L., Murray, J., & Guimond, T. (2013). Factors related to dropout from treatment in two outpatient treatments for borderline personality disorder. Journal of Personality Disorders, 27(6), 716–726.

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. Stolpegaard Psychotherapy Centre, Mental Health Services in the Capital Region of Denmark, Stolpegårdsvej 20, 2820, Gentofte, Denmark

    Sophie Juul & Sebastian Simonsen

  2. Department of Psychology, University of Copenhagen, Copenhagen, Denmark

    Sophie Juul

  3. Anna Freud Centre, Kantor Centre of Excellence, London, Great Britain

    Anthony Bateman

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  1. Sophie Juul
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  2. Sebastian Simonsen
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  3. Anthony Bateman
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Correspondence to Sophie Juul.

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Juul, S., Simonsen, S. & Bateman, A. The Capacity to End: Termination of Mentalization-Based Therapy for Borderline Personality Disorder. J Contemp Psychother 50, 331–338 (2020). https://doi.org/10.1007/s10879-020-09456-6

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