This paper discusses the main ndings of a prospective study based at the Cassel hospital, a centre dedicated to the psychoanalytically informed residential treatment of severe personality disorders. The authors present the clinical and psychodynamic implications of the study results based on an understanding of the internal and interpersonal mode of functioning of borderline patients.
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Original Title
When Less is More- An Exploration of Psychoanalytically Hospital
This paper discusses the main ndings of a prospective study based at the Cassel hospital, a centre dedicated to the psychoanalytically informed residential treatment of severe personality disorders. The authors present the clinical and psychodynamic implications of the study results based on an understanding of the internal and interpersonal mode of functioning of borderline patients.
This paper discusses the main ndings of a prospective study based at the Cassel hospital, a centre dedicated to the psychoanalytically informed residential treatment of severe personality disorders. The authors present the clinical and psychodynamic implications of the study results based on an understanding of the internal and interpersonal mode of functioning of borderline patients.
An exploration of psychoanalytically oriented hospital-based
treatment for severe personality disorder 1 a Marco Chiesa, b Peter Fonagy and c Jeremy Holmes a The Cassel Hospital, Richmond TW10 7JF, UK m.chiesa@ucl.ac.uk; b Sub-department of Clinical Psychology, University College London, UK p.fonagy@ucl.ac.uk; c North Devon Healthcare NHS Trust, Barnstaple, UK J.A.Holmes@btinternet.com (Final version accepted 23 October 2002) This paper discusses the main ndings of a prospective study based at the Cassel Hospital, a centre dedicated to the psychoanalytically informed residential treatment of severe personality disorders. The resultsshowing that signicantly greater improvements on a number of outcome indicators were found in patients exposed to the psychoanalytically informed treatment programmes compared to a general psychiatric approach based on management and pharmacotherapy aloneunderscores the importance and the centrality of the psychoanalytic input in the treatment of severe personality disorders. However, the results of the study also suggestedthat some features of long-termhospital treatment might carry the risk of iatrogenic and anti-therapeutic effects for a sub-group of patients with severe borderline core pathology. The authors present the clinical and psychodynamic implications of the study results based on an understanding of the internal and interpersonal mode of functioningof borderline patients. Keywords: psychoanalyticoutcome research, controlled-prospective study, psycho- therapeutic residential treatment, severe personalitydisorder, psychosocial treatment programme, claustro-agorophobic object relationships In-patient psychoanalytically oriented psychotherapy was developed in a handful of pioneering centres in the USA and in Europe in the rst decades of the last century. The theoretical and conceptual background that sustained treatment practices in these centres was in stark contrast with the institutionalising and dehumanising culture present in the traditional psychiatric hospital (Barton, 1959; Goffman, 1961) and hence represented a radical and alternative answer to the treatment of a range of psychiatric disorders. Patients admitted to these centres for long-term treatment were suffering from severe psychopathology not deemed to be amenable to classic ambulatory psychoanalytic treatment. The nature and frequency of acting-out behaviour, which included serious self-mutilations and suicide attempts, required adequate controls to protect the patient and the treatment setting. Patients with a borderline and psychotic personality structure were regarded as unable to form a stable therapeutic alliance without the external support of hospital structures, and their insufcient ego-strength to tolerate the stress that psychodynamic therapy provokes would make them prone to acute psychotic episodes. In addition, it was felt that for these patients in the poor prognosis spectrum the comprehensive range of treatment modalities provided by 1 This is a revised and expanded version of the paper that won one of the three IPA Biannual Psychoanalytic Research Exceptional ContributionAwards in the year 2000. Int J Psychoanal 2003;84:637650 #2003 Institute of Psychoanalysis these residential settings enhanced nal outcome (Main, 1958; Horwitz, 1974; Kernberg, 1984). At the outset the main form of treatment consisted of four to ve times weekly individual psychoanalysis delivered by experienced analysts, with the hospital setting function- ing as a physical container to safeguard the patients life and the integrity of the analytic setting. Over time, sophisticated forms of social rehabilitation programmes, which used the living-together opportunities as treatment tools, enriched the hospital milieu. Thus daily interactions within the structured daily programme allowed the unfolding of pathological way of relating, that could be claried and confronted in small- and large-group situations. In addition the investigation of the impact of institutional dynamics on the treatment process (Stanton and Schwartz, 1954) led to the formation of integrated therapeutic strategies, which included focus on three main dimensions: (a) individual psychodynamics, (b) interactional processes and (c) large-group and institutional dynamics. In recent years, a diversication of treatment approach has occurred, to include partial hospitalisation (Karterud et al., 1992; Bateman and Fonagy, 1999) and specialist out-patient programmes (Najavitis and Gunderson, 1995; Clarkin et al., 1999). The overall effectiveness of psychoanalytically informed hospital-based treatment was documented by a series of studies (McGlashan, 1986; Wallerstein, 1986; Rosser et al., 1987; Tucker et al., 1987; Stone, 1990; Dolan et al., 1997; Gabbard et al., 1999). But, in the absence of control groups, no denite evidence existed that these psychoanalytically informed treatment programmes led to a better outcome compared to general psychiatric management and pharmacotherapy alone. A primary aim of the present study has been to provide such evidence. In the pharmacology literature evidence of effectiveness is relatively easy to obtain. Patients are administered unmarked capsules containing either active preparations or inert placebo. Neither the patient nor the physician is aware which condition the patient is in. The lack of information introduces a sense of hoped for objectivity into drug trials, since it is believed that expectation biases cannot inuence the apparent effectiveness of the treatments. However, this is not often the case. Patients detect whether they are on active treatments from side-effects of the medication and this knowledge biases their reporting. Indeed, it is commonly found that psychotropic drug effects compared to active placebos (which replicate some of the side- effects of the medication) reduce effectiveness to about 50 per cent of those observed when the comparison is with inert placebo treatments (Fisher and Greenberg, 1997). In psychotherapy trials we cannot hope for blindness either in the patient or in the assessor. There is no credible placebo treatment that would compare to four or ve times per week psychoanalysis. The appropriate comparison is with what might happen with a patient if they do not have access to in-patient psychotherapy. This is not controlling for ingredients of the treatment (such as all the hope that can be generated by an expensive medical procedure) but has the function of providing a baseline against which an expensive treatment such as hospitalisation could be judged. What would happen to a patient like the one receiving in- patient treatment if the hospital service were not available? This kind of comparison is helpful administratively, for example, in order to assess the extent of benet that we might expect from a treatment programme but it cannot demonstrate whether it was the treatment under scrutiny (in this case in-patient treatment) that was responsible for the change in the treated group. In order to establish a causal connection between the active treatment and the improvements observed in the treated group, drug studies have a second device which is more appropriate for studies of psychological therapies: establishing a so-called doseeffect relationship. It is argued that if the drug is the causal agent of change than increasing the dose should be associated with increasing effects (up to a certain point). The same logic has been applied to 638 Marco Chiesa, Peter Fonagy andJeremy Holmes psychotherapy research where increasing the dose (the number of sessions offered) has been repeatedly shown to be associated with greater likelihood of clinical improvement (Howard et al., 1986, 1993; Howard et al., 1989). Building on this logic it could be argued that decreasing the length of hospitalisation should lead to inferior outcome as less opportunity was available for patients to address pathological processes in the context of the containing environment of admission. In the case of in-patient treatment it could be argued that longer treatments should lead to superior outcomes. This argument of course does not take account of intrapsychic constellations when less may be more, that is, when long-term intensive therapy is contra-indicated. Those committed to a psychoanalytic approach too readily assume that the doseresponse metaphor holds for psychological therapy. In general, lengths of treatment, including in-patient admissions are rarely varied systematically in order to identify what the ideal length of treatment might be. Further, it is assumed that the same length of treatment would best serve all diagnoses meriting in-patient treatment. In addition to exploring the effectiveness of in-patient therapy in comparison to psychiatric treatments these patients routinely receive in the UK, the present study attempted to explore whether relatively short (twenty-four-week) or long (one-year) admissions were more appropriate for severe personality disordered patients, and retrospectively to study differences in the diagnostic group best suited for each of these forms service delivery. Summary of the Cassel/North Devon study The study took place at the Cassel Hospital, a fully state-funded centre that has treated severe neurotic conditions and personality disorders since 1919. The treatment approach is based on a broad psychoanalytical understanding of the patients psychopathology and of its expression and interaction with the various aspects of the therapeutic milieu. A structured psychosocial programme consisting of small- and large-group meetings, and workgroups, denes the daily sociotherapeutic programme. Patients are given a degree of responsibility in the day-to-day running of the hospital and play a role in the planning of meals and domestic chores. Trained therapists who have no contact with the patients outside the sessions provide formal psychoanalytically oriented individual and small-group psychotherapy. Patients attend daily unit meetings, where an understanding of the patients state of mind and of institutional dynamics informs the patients overall management (Main, 1989). Traditionally, the length of hospital stay varied between twelve and eighteen months, and the patients were discharged back to the larger community with no provision for follow-up treatment. More recently, a phased treatment programme was introduced, comprising a twenty-four-week hospital stay followed by an out-patient stage of treatment consisting of twice-weekly group psychotherapy (Chiesa, 1997). Patients selected for specialist treatment suffer from diagnosable psychiatric disorders (anxiety, mood, eating and substance-use disorders) as well as personality disorders such as borderline, paranoid, histrionic, dependent and avoidant, alone or in combination. Patients with severe anti-social personalities are excluded, and are referred to other specialist forensic settings like the Henderson group of therapeutic communities (Norton, 1992). Other exclusion criteria are a history of schizophrenia, paranoid psychosis and current severe addiction to alcohol or drugs. More detailed, technical descriptions of the study are available in other publications (Chiesa, 2000; Chiesa and Fonagy, 2000; Chiesa et al., 2003a). Here we will only report the main features and results. Three groups of patients were naturalistically selected between 1993 and 1997 and allocated to three different treatment conditions. The rst group included patients WHEN LESS IS MORE 639 who were referred from outside the London area, and were offered treatment for a year in the in-patient psychosocial therapy programme of the hospital with no subsequent out-patient treatment (purely residential treatment). The second group comprised patients who resided within the geographical boundaries of Greater London; the treatment consisted of six months in-patient psychosocial treatment at the Cassel Hospital, followed by eighteen months out- patient twice weekly psychoanalytically oriented psychotherapy and six months of concurrent psychosocial outreach nursing in the external community (two-phase treatment). The third group comprised a matched sample of personality disorder patients who were not exposed to psychotherapeutic treatment, but received standard psychiatric care from their local services within the North Devon District, UK (general psychiatric treatment). 2 Comprehensive data was collected and analysed for 141 patients, evenly divided amongst the three groups. Patients were evaluated at intake, 6 months, 12 months and 24 months on a number of clinically meaningful dimensions to ascertain their progress into treatment and at follow-up. In outline, several dimensions of functioning were assessed through the use of standardised instruments and systematic collection of clinical outcome variables in the areas of symptom distress, social adaptation, global functioning, health service utilisation patterns and attachment status. As would be expected, patients were on average in their early thirties, two-thirds female, mostly single. A high proportion of these patients reported having suffered from traumatic events and disturbing experiences, sometimes in combination, in their infancy and/or childhood, such as maternal deprivation, early loss, sexual abuse and molestation, and physical abuse and neglect by caregivers. Over the same period, more than half had self-harmed or attempted suicide, or both, at least once. The majority presented a long psychiatric history including repeated admissions to psychiatric services and extensive use of psychotropic medication over the years. The demands made on mental and medical health services before admission had been high, as shown by frequent visits to General Practitioners, emergency rooms and general psychiatric services. The average annual cost of these patients to the National Health Service in the year prior to treatment was estimated as 9,509 in health service use only (Chiesa et al., 2002b). Early discontinuation of treatment within twelve weeks from admission to the Cassel Hospital was found to be signicantly higher in the purely residential treatment group, which reduced the expected length of in-patient stay in that group to an average of nine months. In contrast, the combined in-patient and out-patient length of treatment in the two-phase programme patients was sixteen months. The two groups of patients exposed to psychoanalytically informed treatment showed highly signicant improvement over the two-year period from intake in the dimensions of symptom distress, social adaptation and global assessment of mental health, while the general psychiatric group remained substantially unchanged by the time of the two-year follow-up. There were signicant group differences on all three outcome dimensions in favour of the two specialist treatment groups at the end of treatment and one-year follow-up. However, while the two-phase treatment group continued symptomatic improvement in the interval from twelve to twenty- four months, the purely residential treatment group patients tended to retain the gains they made over the period of hospitalisation but showed no further improvement; the difference between the two groups in terms of symptom distress at twenty-four months was signicant. Signicant differences were also found at twelve and twenty-four months concerning social adaptation and at twelve months in global functioning, in favour of the two-phase treatment. 2 North Devon was selected because of the relative paucity of specialist psychotherapeutic facilities available in the area, which would allow for more valid comparison with expectable outcome of a general psychiatric approach. 640 Marco Chiesa, Peter Fonagy andJeremy Holmes The ratio of reliable change 3 on the same measures indicated that 45 per cent to 65 per cent in the Cassel samples were substantially improved, compared with only 10 per cent to 30 per cent in the general psychiatric sample. Further, if we dene improvement as the presence of reliable change in two out of the three dimensions of functioning, 48 per cent of patients in the two- phase treatment were improved, compared with 37 per cent in purely residential treatment and only 5 per cent in the general psychiatric treatment (Figure 1). A signicant reduction in acute psychiatric morbidity was found in the two-phase treatment patients by twenty-four months. The percentage of patients who self-harmed was reduced by half, the incidence of attempted suicides fell from 56 per cent to 16 per cent and only one in ten was readmitted to hospital by twenty-four months. Changes in the same variables were more modest in the other two groups (Table 1). Concerning levels of service utilisation both psychoanalytically informed treatment samples reduced their reliance on out-patient psychia- tric visits, while we found that patients in the general psychiatric treatment had a marked increase in visits to psychiatrists. Psychoanalytic implications of results This study shows that signicant improvement occurs over time (twenty-four months after admission) in the dimensions of symptom distress, social adjustment and global assessment of outcome in a group of severely personality disordered patients treated with psychoanalytically informed interventions. These improvements compare favourably with those obtained by a matched group of patients treated without psychotherapy but with adequate pharmacological and social support treatments in a general psychiatric setting. The latter group remained 3 Reliable change refers to improvement that is not ascribable to measurement errors, a degree of which is always present in standardised instruments. A statistical formula allows calculation of Reliable Change Indexes (Jacobson and Truax, 1991). 48 37 5 Two-phase Residential Psychiatric 60 50 40 30 20 10 0 % Figure 1 Rates of Reliable Improvement in at leas t one out of three s tandardis ed outcome meas ures in the three groups by 24 months WHEN LESS IS MORE 641 substantially unchanged over the two-year period of the study. These results conrm previous ndings that a psychoanalytical approach based on dynamic understanding, confrontation and emotional containment of the various psychopathological aspects of personality disorder is helpful in achieving sustained and substantial improvements of painful and distressing symptomatology, of adaptation to ones societal environment and overall degree of mental health is to be achieved (Kernberg, 1984; Wallerstein, 1986; Bateman and Fonagy, 1999). In addition, the speed of the improvements made in the specialist treatment groups was greater than expected from previous studies, which had shown that up to nine years after admission were necessary before marked improvement became apparent (McGlashan, 1986). It should be noted that the psychoanalytic treatment model offered in these earlier retrospective studies differed considerably from the model used at the Cassel Hospital. Case 1 Ms A presented with a fteen-year history of severe eating disorder developed in her late teens, characterised by periods of abstinence and binge-eating followed by vomiting and using hot water inserted into her rectum as a laxative, but also as part of self-mutilation. Her life was dominated by her preoccupation with weight and food, and she chose an avoidant lifestyle that led to social isolation. Ms As mother was diagnosed with paranoid psychosis when Ms Awas 7 years old, having developed a delusion the Ms As (non-existent) twin sister had been kidnapped, and a delusional preoccupation with sex and fear of being poisoned. Ms A was repeatedly accused by her mother of working as a prostitute, and every boyfriend she had was seen as her pimp. Ms A became very frightened of her mothers unpredictable behaviour. Ms A had painful memories of the way her initially beloved father constantly put her down and did not reciprocate her feelings of affection for him; hence she developed strong hatred towards him. Following initial difculties in adapting to the life of the therapeutic milieu, Ms A showed remarkable receptiveness to a psychoanalytic approach. During the rst months of individual treatment it was possible to understand that the onset of her bulimarexia, triggered by a feeling Table 1 Clinical outcomes in the three samples (gures represent values the year prior to intake, at expected discharge and over the year after expected discharge) Pure ly res idential N 47 Two-phas e N 45 Gene ral ps ychiatric N 49 Variable N % N % N % Self-harm, yes Intake 23 48.9 25 55.6 24 49.0 Discharge 31 66.0 14 31.0 18 36.7 24 months follow-up 23 48.9 12 26.7 20 40.8 Attempted s uicide, yes Intake 21 44.7 25 55.6 20 40.8 Discharge 19 40.4 6 13.3 18 36.7 24 months follow-up 13 27.7 7 15.6 15 30.6 Hospital admiss ion, yes Intake 24 51.1 24 53.3 28 57.1 24 months follow-up 21 44.7 5 11.1 16 32.7 642 Marco Chiesa, Peter Fonagy andJeremy Holmes that she was becoming plump, represented her fear of identication with her fat/mad mother. Fear of being invaded by her mothers madness was evident in the conict-avoidant and counter-phobic posture she adopted in hospital life, where she either kept other people at arms length or related to them in a compliant, placating and controlling fashion. This was repeatedly made explicit in both unit and community meetings by staff and other patients. Ms As phantasy of living in a bubble, a cocooned state of mind in which awareness of time, conict, pain and persecution simply dropped away and could be replaced by smiles, comfort and sweetness was gently but persistently confronted. As her eating disorder markedly improved, her preoccupation shifted to her relationship with other people and men in particular. Ms As daily diary of her eating habits was replaced by a dairy of her emotions and thoughts, which she communicated with increasing ease in therapy and to her key nurse. Understanding in her individual sessions that her experience of what was available to her had been a simple choice between an engulng and abusive relationship or no relationship at all within her bubble, helped her to recognise her intense fear of intimacy. She could then start a sexual relationship for the rst time in many years and perhaps the rst ever where she had not allowed herself to be maltreated. As she came close to discharge from treatment Ms A became very anxious that she was going to be left completely alone and that there would be no one to turn to. Her fear of inner emptiness coincided with a temporary return of mild bulimic symptoms. Five years after the end of treatment Ms As eating disorder had ceased and her quality of life was very much improved. After attending further education, she held a full-time job and was engaged in a long-term relationship. Her attitude to the interviewer was less ingratiating and more direct, and investigation showed that she was more assertive and able to sustain open conict with other people, rather than tting with what she thought they required from her. In contrast to a psychoanalytic approach, a general psychiatric model based purely on a biological approach, on management and social control may achieve some stability in psychopathological uctuations, and lead to a decrease of acute admissions, but has only a marginal impact on the quality of life of these patients, as the following case vignette illustrates. Case 2 Having spent the rst two years of her life in childrens homes, Bella was nally adopted at the age of 2. Her adoptive parents had two older boys of their own, but decided to adopt a girl so as not to increase the number of unwanted children in the world. Bella was subjected to a strict regime, and expected to be grateful. When Bella was 13 her mother had a stroke and became bedridden. Bella did the cooking and was reportedly sexually abused by her adoptive father and her older brothers. She escaped at 17 by getting pregnant by the rst boy she met, and was promptly thrown out of the house by her parents. Her partner turned out to be a feckless drug addict. She took her rst overdose when her child was taken into care after being on the at risk register. There followed a series of psychiatric hospital admissions, often compulsory, usually after episodes of deliberate self-harm, which she would invariably threaten to repeat if not admitted to hospital. The ward staff were divided between those who saw her as vulnerable and in need of protection, and those who saw her as manipulative and controlling. The more sympathetic staff tried to explore her abuse with her. She would either refuse to talk, or this sympathetic enquiry would trigger outbursts of rage, leading to being secluded on the ward and heavily sedated. By her mid-twenties she had become involved with an older man, himself a user of the mental health services, who was protective of her and tolerated her sporadic bouts of indelity, invariably followed by remorse and further episodes of self-harm. Through a case WHEN LESS IS MORE 643 discussion involving all her carers, she was offered a hot line admission to hospital when necessary for no more than one week per two months. Compulsory admission was to be avoided. The situation stabilised and her average number of days spent in hospital and self- harm episodes decreased. She remained childishly dependent on her partner, and from time to time had outbursts of uncontrollable rage and misery, usually triggered by thoughts about her separation from her daughter. She continued to say that she wanted to die, but agreed not to harm herself because you lot wont let me do it. She was referred for once-weekly psychoanalytic psychotherapy, but never really engaged, saying that the therapist was a wanker, so this track was eventually abandoned. The quality of her relationship with her partnerasexual, apparently highly dependentappeared highly pathological. She was chronically unhappy, taking large amounts of psychotropic medication, but she remained alive, her relationship survived and, as the years went by, her prole within the mental health care system gradually decreased. The study also demonstrated that a combination of in-patient and out-patient treatment was consistently more effective, and that longer in-patient treatment was only marginally better than general psychiatric treatment on some clinical outcome indicators. The two-phase treatment patients received less in-patient therapy but had overall longer (in-patient and out- patient) treatment exposure than purely residential treatment patients. This seems to point to the importance of longer (if less intensive in terms of therapeutic input) treatment to obtain positive outcome. Patients in the two-phase treatment tended to carry over conicts and dynamics that had emerged during in-patient treatment into their community-based treatment programme. Case 3 Ms C, a 29-year-old single woman, was admitted to the Cassel two-phase treatment programme following three brief admissions to the local psychiatric unit, where she exhibited suicidal and manipulative behaviour and was diagnosed with depression and borderline personality disorder. Her stepfather reportedly sexually abused her from the age of 13 for several years, with her mothers alleged complicity. Ms C also reported physical and emotional abuse from her mother who locked her up in dark rooms for days, leaving her with only a bedpan and bringing her food and water. Soon after admission to the Cassel she cut herself, and self-harm continued for several weeks. Her relationship with other patients and staff became quite strained and she was at the edge of therapeutic community life, nding it difcult to tolerate the intensity and demands of the milieu. Individual psychodynamic therapy exposed the presence of a narcissistic pathological organisation of the personality (Steiner, 1993), which found expression in Ms Cs inability to sustain feelings of vulnerability and dependence vis-a`- vis her therapist; these feelings were disowned and projected into other patients. As part of that pathological conguration she identied with an abusive and cruel mother, and often resorted to acts of cruelty and sadism. This helped her cope with her deep sense of humiliation and the shame she felt in relation to needing help and feeling abandoned by her therapist. Therapeutic work on these issues was ongoing both in individual treatment and in small and large groups at the time of her discharge from the therapeutic community. She continued addressing these issues in the out-patient stage of treatment, which lasted two years. In this phase she gained further insight into her considerable difculties with trusting other people, as the possibility of betrayal always lurked in her mind. If she developed emotional ties to her group therapist and the psychosocial nurse. However these relationships were not conict-free. She felt that both carers were not inviting her, but seducing her to form an attachment, and that they then would 644 Marco Chiesa, Peter Fonagy andJeremy Holmes sadistically exploit her dependence and cruelly abandon her. In the group she recognised her tendency to project her vulnerable infantile self into others and experience the sense of being cared about through her charges as a nanny, through her clients as a carer for battered women or through starving children as a relief worker in Africa. Despite the serious difculties in establishing a trusting working relationship with her therapist, Ms C functioned increasingly well in her outside life. She stopped self-harming, her depressive and phobic symptoms decreased in intensity, she gained a place at university, furnished a new at, became involved with friends and, just before ending treatment, she was engaged to be married. One year after the end of therapy she remained well and was trying to have a baby. The results compel us to re-examine the psychoanalytic rationale for long-term in-patient psychotherapy. In the light of the present empirical ndings we believe that earlier assertions concerning the value of providing intensive psychoanalytic therapeutic experiences to personality-disordered patients must be qualied. In particular, results concerning levels of early drop-out, self-harm, parasuicide and psychiatric readmission rates in the purely residential treatment group are inconsistent with the notion of greater containment, safety and facilitation offered in an in-patient setting (Horwitz, 1974). This study conrms previous clinical and empirical ndings, which suggested that a proportion of severe personality disordered patients, particularly those with a borderline core psychopathology, may react unfavourably to the treatment conditions provided in long-term hospital settings (Rosser et al., 1987; Main, 1989). In an astonishingly candid paper Tom Main, one of the original founders of the psychoanalytically oriented therapeutic community, conveyed his view that for patients needing psychotherapy, [long-term] hospitalisation usually carries more dangers than benets and the request for hospitalisation is itself a symptom (1958, pp. 12). He felt that the dangers of regression inherent in long-term hospital treatment couldnt be outweighed, even by the most vigorous psychosocial programme. Main pointed out that it was the scarcity of specialist out-patient psychotherapy units with enough skilled staff in the UK that compelled him to admit so many patients at the Cassel Hospital. Case 4 Ms D was a 19-year-old single girl, the eldest of three children, when she was admitted to the Cassel purely residential treatment programme. For the previous two years Ms D had engaged in substance abuse, outbursts of aggressive behaviour, episodes of self-harm, and had struggled with thoughts of suicide. She had two short admissions to the local psychiatric unit, had attended the day hospital and had once-weekly supportive psychotherapy. Ms D had a highly ambivalent attitude to her own family, consciously feeling that she needed to protect her parental objects, both internally and externally, but more deeply resenting and hating them. From the age of 10 she became progressively involved in sexually abusive relationships with older teenagers, from which she emerged with profound sexual identity problems, in which there was a poor differentiation between sexuality and aggression and violence. Ms D found admission to the Cassel very difcult. She had serious problems with opening up in group situations, and her vagueness and silences elicited exasperated responses and erce challenges, to which she reacted by feeling persecuted. Ms D conveyed great fear of being in psychotherapy sessions with her therapist, which resulted in long silences or mindless talk. The chaotic material often referred to rape, which was understood as Ms Ds experience of the therapists attempt to intrude and penetrate her mind in a way that she found disgusting and abhorrent. Ms D would often act out after sessions by getting drunk or cutting herself. Self- harm and other self-destructive behaviour became frequent and, when confronted by other WHEN LESS IS MORE 645 patients or staff, she reacted explosively, on one occasion smashing a piece of furniture. During her stay she experienced psychotic symptoms such as hallucinations and thought disorder, which necessitated prescription of neuroleptics and two transfers to the local general psychiatric unit. Her treatment seemed to lurch from crisis to crisis, in which it became increasingly difcult for the staff team to think constructively and have a treatment plan based on the understanding of the patients state of mind. Ms D left the hospital prematurely after ten months, two months before her planned leaving date. Over the two years since discharge Ms D remained a psychiatric in-patient or day-patient for most of the time, and one attempt to help her to live in a sheltered hostel failed. She continued to self-harm at regular intervals and was maintained on a high dose of anti-psychotic medication. On reecting on Ms Ds negative therapeutic outcome, the hospital team belatedly recognised that she became terried by the intensity of the therapeutic relationships offered by the one-year programme. Far from being reassured by the length of time available for her treatment, like Ms C, Ms D perceived the in-patient admission as a seduction followed by cruel abandonment. She could never allow herself to properly engage with the programme because she perceived little in what was offered except for the ultimate rejection. Conclusions The observed patterns of results may also be examined in the light of psychoanalytic theories of borderline disorders. The group of patients in the purely in-patient programme are admitted to an intense and emotionally charged therapeutic-community-style milieu, and are expected to stay for one year in the hospital where they develop intense, if ambivalent, relationships with other patients and treating professionals; they are then discharged back to the external community without any further planned treatment or support. The dependence on the treating institution and the attachments developed during a long residential treatment are severed at discharge. Patients often experience the discharge as a forcible expulsion, a rejection and abandonment to their own fate. Patients have to negotiate unsupported the transition between hospital and external community life, and they often face an uncertain future concerning their employment, accommodation and social relations. Gunderson (1996) poignantly described the sense of aloneness and intolerance to sudden and traumatic separation as an essential feature of borderline psychopathology. We know that common characteristics of patients presenting with a borderline organisation of the personality are: (a) extreme sensitivity to real or imaginary experience of separation and abandonment, to which they may react with extreme disturbance; (b) engagement in emotionally draining, chaotic and turbulent relationships; (c) identity disturbance and (d) impulsiveness and low frustration tolerance (Kernberg, 1975; American Psychiatric Association, 1995). These overt features represent the externalisation of internal object relationships of a claustrophobic and agoraphobic type as brilliantly described by Rey (1979) and others. When the patient is admitted to the complex milieu of the in-patient setting, the multiplicity of inputs and expectations of functioning as a constructive member of the community may be experienced by him/her as a bombardment of unbearable demands. Thus the hospital setting may be experienced as an engulng, rigid and persecutory object (claustrophobic reaction). This may in part explain the high rate of discontinuation of treatment in the rst twelve weeks from admission and the increase of self-harm in the purely residential treatment patients, as shown by Ms D, in the year after admission. The signicantly lower rate of early drop-out and of self-harm episodes in the two-phase treatment suggests that shortening the in-patient stay may be a protective factor, lowering the intensity of persecutory and regressive reactions by dampening the initial claustrophobic anxiety. At the end of treatment, 646 Marco Chiesa, Peter Fonagy andJeremy Holmes purely residential treatment patients are faced with a discharge from long-term hospitalisation and are faced with the daunting task of re-establishing their relational and occupational lives. Many of them still live in precarious accommodation and feel lonely and unsupported. The hospital discourages further contact as a way to challenge the patients dependency on the hospital, in an attempt to steer him/her towards outside reality. In fact, many patients experience discharge as a cruel rejection, and feel pushed away and unwanted. The continuation therapy programme offered in the two-phase treatment model provides a containing framework for the working through of these anxieties and dynamics, leading to greater adaptation and improvement, as the case of Ms C clearly showed. In our study the longer, but less intensive, two-phase programme had a better outcome than a more expensive, more intensive but briefer purely residential programme. This nding is consistent with previous investigations of doseresponse effects in psychoanalytic therapy. For example a similar positive relationship between length of treatment and outcome was shown by the Heidelberg study in which a positive association was found between good and stable results with duration of treatment in patients with psychosomatic disorders (Kordy et al., 1989; Rad et al., 1998). However it is worth noting that Kachele et al. (2001) did not nd a doseeffect relationship in a hospital-based psychoanalytically informed treatment programme in a large sample of eating disordered patients, as part of a national multi-centre study. It is possible that the absence of a readily demonstrable relationship in the Kachele et al. evaluation might be linked to the conation of in-patient and out-patient treatments. It is possible that some of the shorter in-patient treatments in the German study were followed by out-patient therapy, as in the two-phase model described here, while other longer in-patient stay may not have been. In particular, for a group of patients with severe personality disorder, the intense feelings of abandonment revive early traumatic experiences of emotional and physical deprivation so common in the childhood of these patients (Links et al., 1988). The consequent intense hostility felt against the abandoning and depriving object interfere with positive introjective processes (Klein, 1957) and the hospital is then carried inside as a bad and cruel object. Elsewhere we have argued (Fonagy, 2000) that non-reective internal working models are triggered within the context of emotionally charged attachment relationships, as they inevitably occur when the patient is admitted to the psychotherapy hospital. The acutely disorganised behaviour that may follow is often inadequately responded to by staff, who unwittingly re- enact dysfunctional parental responses (frightened or frightening behaviour), experienced by the patients as abandonment. The non-reectiveness of internal working models reveals developmentally primitive modes of experiencing psychic reality that forces patients to experience the world in a predominantly concrete way, making it even more arousing and apparently uncontrollable than before (Fonagy and Target, 2000). This in turn generates dissociative responses on the part of the patient (the pretend mode of psychic reality), with an increase of interpersonal disturbance, as in the case of Ms D. This bad sequence, if not understood and reversed with corrective measures, may lead to serious acting out and interruption of treatment (Ploye`, 1977). It is our contention that the structural set-up of the purely residential treatment model may aggravate this state of affairs by not providing an adequate framework to contain the borderline patients severe separation anxieties, based on disturbed attachment patterns, awed internal object-relationships and decits in reective functioning. Indeed, we hope that the results from the (still ongoing) analysis of the Adult Attachment Interviews will shed further light on these complex processes. These conclusions have received additional support from two systematic studies of patients perceptions of, and satisfaction with, various aspects of hospital life (Chiesa et al., 2000, 2003). After discharge, patients in the purely residential treatment expressed on average more WHEN LESS IS MORE 647 critical views about the treatment received than patients in the two-phase model. For example, 80 per cent of the former were dissatised with discharge arrangements in contrast to only 20 per cent of the latter. The continuing presence of resentment, dissatisfaction and grievances reects the unresolved internal relationship with a mean, ungiving and abandoning object, not sufciently balanced with positive internal experiences, which leaves borderline patients more vulnerable to resorting to a previous pathological way of functioning. This inevitably leads to acute psychotic and depressive decompensation, as shown by the high post-discharge acute psychiatric readmission rates in the purely residential treatment group. In contrast, patients in the phased model feel supported and held in the outreach stage of the programme to negotiate the transition between discharge and resuming life in the wider community. The continuing psychodynamic input and the provision of a new emotional experience gives opportunity for containment and working through of often severe anxieties to do with separation, abandonment and hopelessness, making possible a further growth of ego functions, which allows patients rst to survive the transition and then to progress to a less dysfunctional life, as shown by the marked reduction in self-harm, parasuicide and readmission to psychiatric services. These ndings suggest that a residential programme for patients with borderline core pathology needs to modulate the intensity of therapeutic input to prevent the onset of acute claustrophobic reactions, which may lead to premature discontinuation of treatment. A low- to medium-intensity programme seems more suited to enable the creation of a greater external and internal space within which the safe emergence of the engulng and persecutory internal object can take place place; this object can then become more available for interpretation and working through, rather than enactment. In addition the programme should be phased and contain an in-built out-patient component for a gradual and long-term working through of chronic and entrenched psychopathology. This study shows the effectiveness of a psychoanalytically based approach for the treatment of personality disorder compared to a general psychiatric approach. We have also found that a phased hospital and community-based psychoanalytically informed approach produces better results than either prolonged in-patient psychoanalytic therapy or standard psychiatric care. The possible underlying psychodynamic factors that may account for these results have been presented and discussed. Acknowledgments: The study was supported over the years by grants from the Sir Jules Thorn Charitable Trust, the Welton Foundation and the International Psychoanalytic Association. Translations of summary Wenn mehr weniger ist: eine Explorierung von psychoanalytisch orientierter stationarer Behandlung fur schwere Personlichkeitsstorungen. Dieser Artikel diskutiert die Hauptergebnisse einer prospektiven Studie an der Cassel Klinik, einem Zentrum, das sich der psychoanalytisch informierten stationa ren Behandlung von schweren Personlichkeitssto rungen widmet. Die Ergebnisse, die zeigen, dass signikant grossere Verbesserungen bei der Anzahl von outcome-Indikatoren in Patienten gefunden wurden, die den psychoanalytischinformierten Behandlungsprogrammen ausgesetzt waren, im Vergleich zu einem allgemein- en psychiatrischen Ansatz, der auf Management und Pharmakotherapie allein beruhte, untermauert die Bedeutung und die Zentralitat von psychoanalytischemInput in der Behandlungvon schweren Personlichkeits- storungen. Jedoch legten die Ergebnisse der Studie auch nahe, dass einige der Merkmale von langzeitiger Krankenhausbehandlung das Risiko von iatrogenen und anti-therapeutischen Auswirkungen fur eine Untergruppe von Patienten mit schwerer Borderline Grundpathologie mit sich bringen. Die Autoren prasentieren die klinischen und psychodynamischen Implikationen der Studienergebnisse, die auf einem Verstehen der inneren und interpersonalenArt des Funktionierens von Borderline Patienten basieren. 648 Marco Chiesa, Peter Fonagy andJeremy Holmes Cuando mas es menos: una exploracion del tratamiento orientado psicoanal ticamente en hospital para el desorden de la personalidad severo. Este art culo discute los numerosos hallazgos de un estudio prospectivo basado en el Cassel Hospital, un centro dedicado al tratamiento residencial psicoanal ticamente informado de los desordenes de la personalidad severos. Los resultados muestran que se registraron mejoras signicativamente mayores, en un numero de indicadores de resultado, en pacientes expuestos a los programas de tratamiento psicoanal ticamente informados, comparado con el enfoque general psiquiatrico basado solo en el manejo y la farmacoterapia. Estos resultados subrayan la importancia y la centralidad de la contribucio n psicoanal tica en el tratamiento de los desordenes de la personalidad severos. Sin embargo, los resultados del estudio tambien sugieren que algunas caracter sticas del tratamiento en hospital de largo plazo, conllevar an algun riesgo de efectos iatrogenos y antiterape uticos para un sub-grupo de pacientes con una patolog a central de tipo lim trofe severo. Los autores presentan las implicaciones cl nicas y psicodina micas de los reusltados del estudio, con base en una comprensio n del modo de funcionamientointerno e interpersonal de los pacientes fronterizos. Lorsque plus est moins : une exploration du traitement intrahospitalier dinspiration psychanalytique de troubles graves de la personnalite. Larticle discute les principales donnees issues dune etude prospective effectue e a` partir du Cassel Hospital, un centre consacre au traitement intrahospitalier dinspiration psychanalytique des troubles graves de la personnalite . Les resultatsqui montrent que, sur une serie dindicateurs concernant lissue therapeutique, les patients ayant suivi un traitement dinspiration psychanaly- tique presentent une amelioration signicativement superieure a` celle de patients ayant benecie du seul suivi psychiatre avec chimiotherapiesouligne limportance et le caracte`re central de lapproche psychanalytique dans le traitement des troubles graves de la personnalite . Toutefois, les resultats de letude sugge`rent egalement que certains aspects du traitement intrahospitalier au long cours pourraient entra ner un risque deffets iatroge`nes et anti-the rapeutiques pour un sous-groupe de patients presentant un noyau de pathologieetat-limite seve`re. Les auteurs presentent les implications cliniques et psychodynamiques des resultats de letude en sappuyant sur la comprehension des modalites de fonctionnement interne et interpersonnel des patients etats- limite. Quando di piu` e` di meno. Un esame del trattamento ospedaliero con orientamento psicoanaliticodi gravi disturbi della personalita`. Questo lavoro discute le principali scoperte di uno studio in corso nel Cassel Hospital, un centro dedicato al trattamento residenziale a orientamento psicoanalitico di gravi disturbi della personalita `. I risultati, che mostrano come si siano trovati miglioramenti signicativamente maggiori di un certo numero di indicatori di esto in pazienti sottoposti a programmi di trattamento con orientamento psicoanalitico rispetto a un approccio psichiatrico generico basato unicamente sulla gestione e la farm- acoterapia, sottolinea limportanza e la centralita ` dellinput psicoanalitico nel trattamento di gravi disturbi della personalita `. 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