Letters to the Editor
Re: Recent Advances in the Treatment of Borderline Personality Disorder
Dear Editor: In his recent article on borderline personality disorder (BPD), Joel Paris comments on a study of the treatment of BPD that is underway in Sydney, Australia (1). These remarks warrant a response.
Attitudes toward BPD have recently changed. The pessimism formerly associated with such a diagnosis has been mitigated by evidence from prospective and controlled studies. Early studies were conducted in Seattle, Washington, and Sydney, Australia (2–4). Of the Sydney study, Paris writes that the 30 patients received 2 years of treatment. In fact, they received 1 year of treatment. They were followed up 1 year after treatment. Paris then describes the control group, whose members received treatment as usual, as untreated while on a waiting list. Our published description states, that
during the waiting period, they had their usual treatments, which were various (e.g. supportive psychotherapy, crisis intervention only, cognitive therapy, pharmacotherapy). Some patients were hospitalised. There was no typical course of
treatment (2).
Paris describes our treatment as self-psychology. It is actually guided by the conversational model (5), the main aim of which is to foster the emergence of reflective consciousness that William James called self
consciousness (6,7). A principal tenet of this approach is that this form of consciousness, discovered through a particular form of conversation, reflects a specific kind of relatedness. The nearest North American equivalent to this approach comes from Kohut and his followers.
Paris remarks, that since there was a low attrition rate in our sample, the patients were unlikely to be “representative of a clinical population” (1). Our dropout rate was 16%, the same as that of the Seattle study. In terms of severity, our published report notes “57% of the cohort showed all eight DSM-III criteria, compared with 7% in Stone’s large series.”
Paris also notes that these early studies should be properly followed up. Our cohort has been followed up: all patients were traced to the 5-year mark. They maintained their improvements (4).
I appreciate the opportunity to make these clarifications.
References
1. Paris J. Recent advances in the treatment of borderline personality disorder. Can J Psychiatry 2005;50:435–41.
2. Stevenson J, Meares R. An outcome study of psychotherapy for patients with borderline personality disorder. Am J Psychiatry 1992;149:358–62.
3. Meares R, Stevenson J, Comerford A. Psychotherapy with borderline patients: a comparison between treated and untreated cohorts. Aust N Z J Psychiatry 1999;33:467–72.
4. Stevenson J, Meares R, D’Angelo R. Five-year outcome of outpatient psychotherapy with borderline patients. Psychol Med 2005;35:79–87.
5. Hobson RF. Forms of feeling. London (UK): Tavistock; 1985.
6. Meares R. Intimacy and alienation. London (UK): Routledge; 2000.
7. Meares R. The metaphor of play. London (UK): Routledge; 2005.
Russell Meares, MD
Parramatta, Australia
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