Jeremy Holmes

Borderline Personality Disorder and the Search for Meaning: An Attachment Perspective:

Objective: To explore the links between the attachment theory-derived concept of disorganized attachment, and the psychiatric diagnosis of borderline personality disorder (BPD). Method: Literature search for characteristics of disorganized attachment. Clinical case material from psychotherapeutic work with patients suffering from BPD. Results: Disorganized attachment can be understood in terms of an approach-avoidance dilemma for infants for whom stressed or traumatized/traumatizing caregivers are simultaneously a source of threat and a secure base. Interpersonal relationships in BPD including those with caregivers is similarly seen in terms of an approach-avoidance dilemma, which manifests itself in disturbed transference/countertransference interactions between therapists and BPD sufferers. Borderline personality disorder sufferers lack meaning in their lives because they are unable to play ‘language games’ with their potential intimates, resorting to actions rather than words to express feelings. Conclusions: Possible ways of handling these phenomena are suggested, based on Mains (1995) notion of ‘meta-cognitive monitoring’, in the hope of re-instating meaning and more stable self-structures, in these patients’ lives.

Narrative in psychiatry and psychotherapy: the evidence?

Psychiatry is perhaps the most “narrative” of all medical specialties, but here as elsewhere clinical skills are in danger of being lost as evidence-based medicine becomes the dominant paradigm in medical culture. Psychotherapy is a quintessentially narrative discipline. Starting from an “attachment” perspective, the uses of narrative in psychotherapy are outlined. These include the importance of metaphor, story-telling, the search for event-scripts, and the role of “narrative competence” as a mark of psychological health. Life history research, the “adult attachment interview” and other research approaches to narrative in psychiatry and psychotherapy are described. The paper calls for an integration of narrative and evidence-based medicine.

Attachment theory - a secure theoretical base for counselling?

Abstract Attachment theory emerged from the cross-fertilization of object relations psychoanalysis and the science of ethology. It offers a useful theoretical framework for psychodynamic counselling. It is clear, comprehensible, and susceptible to experimental testing. Longitudinal studies of children classified as secure or insecure at one year have linked non-verbal interactional patterns of infancy with the emergence of ‘autobiographical competence’ in later life. Counselling and psychotherapy can be conceived as being based on the movement from insecure to secure attachment. The importance of a secure therapeutic base, of coherent narrative, the attunement of the counsellor, the processing of affect especially anger, and the emergence of self-exploration within the security of the counselling relationship are described as essential ingredients of psychodynamic counselling.

Psychotherapy and general practice: Evidence, narrative and the ‘new deal’ in mental health

SUMMARY I take as my starting-point the themes of the recently published NHS Framework for Mental Health, which could boost the psychological therapies in a number of ways, particularly by its acknowledgement of the effectiveness of psychotherapy. I go on to draw comparisons between the role of the psychotherapist and that of the GP, showing how, although primary-care practitioners should not seek to turn into psychotherapists, they could usefully rely more on language, narrative and metaphor in their everyday work.

Ethics and Values in Psychotherapy

Ever since Thomas Szasz announced that mental illness was a myth and that psychiatric disorders were in fact moral dilemmas hiding beneath the shirt-tails of medicalisation, psychiatric ethics has been hotly debated, a debate given poignancy in the 1970s by the revelations of the abuse of psychiatry in Soviet Russia. However, discussion of ethical aspects of psychotherapy has lagged behind its psychiatric cousin, and it is mainly the emergence in the past decade or so of psychotherapy as a profession in its own right—and with it the need to develop professional codes of ethics—that has stimulated practitioners and their critics to take psychotherapeutic ethics seriously. This book is one of the few devoted exclusively to the subject, and …

The Burden of Personality Disorder: a District-Based Survey

Patients with a clinical diagnosis of personality disorder (PD) often suffer prolonged distress. They are a considerable burden on psychiatric services and they are experienced as difficult to manage by their keyworkers. This paper describes the creation of a community-based case register of patients suffering from PD. It explores the relationship between psychological distress, personality dysfunction, service utilisation and keyworker stress. Mental Health workers were asked to identify those patients on their caseload whose primary problem was PD. This list provided the basis for the case register. Patients completed the revised Personality Diagnostic Questionnaire IV (PDQ 4); the General Health Questionnaire (GHQ); and the Beck Depression Inventory - 21 item (BDI). A brief, semi-structured interview was conducted by Community Psychiatric Nurses to estimate service utilisation and keyworker stress. The mean GHQ was 14.58; the mean BDI score was 28.22. The mean number of PDs per patient was 4.5. One quarter of patients (21/80) had been admitted at least once to a psychiatric ward in the previous year and 17% (13/80) had presented to casualty at least once in the previous two months. 57% of the patients had weekly or more contacts with a helping agency. The number of PD diagnoses per patient as measured by the PDQ 4 was not found to be predictive of stress experienced by CPNs, whereas high BDI and GHQ scores were strongly correlated. Similarly, the number of admissions to a psychiatric ward was associated with high BDI and GHQ scores but not with number of PDs per patient. It is feasible to establish a case register of all patients in the district with PD. There are high levels of depression and distress amorsgst patients with PD being treated as outpatients. Service utilisation and keyworker stress are not predicted by number of PDs per patient but are strongly associated with distress as measured by the GHQ and BDI, The implications of these findings are discussed.

Psychiatry without walls: Some psychotherapeutic reflections

SUMMARY Community care, despite its many benefits, can result in fragmentation and confusion. Bions and Bowlbys notions of containment and attachment are applied to the difficulties inherent in trying to practise psychotherapeutic psychiatry in a community setting. The treatment of a ‘difficult’ patient, which ended in suicide, is described. The implications for psychotherapy of the new arrangements in the National Health Service are discussed. Psychotherapeutic supervision for all mental health workers is essential if community care is to become effective, and this needs to be recognised by the development of adequately funded psychotherapy services.