Clinical management of common presentations of patients diagnosed with BPD during the COVID-19 pandemic: the contribution of the MBT framework

ABSTRACT

The coronavirus (COVID-19) pandemic has both a profound effect on mental health and affects how psychosocial interventions are delivered. In this paper, we outline particular difficulties patients with Borderline Personality Disorder (BPD) may encounter as a result of the pandemic. We also consider changes in the provision of treatment, specifically the transition from face to face encounters to remotely delivered sessions. Building on a mentalization-based developmental framework, we use clinical vignettes to chart some of these challenges for patients, clinicians and teams. We then make practical recommendations for adaptations to work during the pandemic via the phone or video-link with BPD patients and other groups characterized by a vulnerability to unstable and imbalanced mentalizing. We conclude that the response to these challenges benefits from an existing treatment context that aims at fostering mentalizing and resilience, in which practitioners address the hierarchy of patient needs and their individual responses to the experience of remote treatment during the COVID-19 pandemic.

KEYWORDS:

• COVID-19
• borderline personality disorder
• mentalization
• epistemic trust
• remote therapy

Acknowledgments

The authors would like to thank the clinical teams at the Halliwick Personality Disorder Service, St Ann’s Hospital London and DeanCross Personality Disorder Service, ELFT for their discussion of their clinical work, and Catherine Sunderland, Kate Ambler, Joost Hutsebaut, Robert Klotins and Stephan Gingelmaier for their very helpful comments on an earlier draft of the manuscript.

Disclosure statement

P. Fonagy and A. Bateman have been involved in the training and dissemination of mentalization-based treatments and hold research grants on mentalizing.

Correction Statement

This article has been republished with minor changes. These changes do not impact the academic content of the article.

Notes

1. All vignettes are composites of several clinical manifestations and therefore do not reflect an individual’s material to ensure confidentiality.

2. Multidisciplinary professional meeting, that includes the child (where age-appropriate) and their family, with the aim of identifying the child’s needs and agree on the most effective multi-agency plan to meet those needs with measurable outcomes and within stated timescales.

Additional information

Funding

This work was is in part supported by the NIHR Applied Health Research Collaboration (ARC) North Thames at Barts Health NHS Trust. The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care.

Notes on contributors

Tamara Ventura Wurman

Tamara Ventura Wurman trained as a General Adult Psychiatrist in Chile. She has completed MSc in Theoretical Psychoanalysis and PhD in Psychoanalysis in UCL. Her research interest lies in using quantitative and qualitative approaches to studying psychodynamic psychotherapy process and its association to clinical outcomes. Currently, she works in the NHS as a Specialist Registrar in Medical Psychotherapy.

Tennyson Lee

Tennyson Lee is a Consultant Psychiatrist in Psychotherapy and General Adult Psychiatry. He is presently clinical lead at a Personality Disorder Service in East London. He trained in Public Health before training in psychiatry. He has over 25 peer reviewed papers.

Anthony Bateman

Anthony W Bateman is Consultant Psychiatrist and Psychotherapist and MBT co-ordinator, Anna Freud National Centre for Children and Families; Visiting Professor University College, London; Honorary Professor in Psychotherapy University of Copenhagen.He developed mentalization based treatment with Peter Fonagy for borderline personality disorder and studied its effectiveness in research trials. Adapted versions are now being used in multi-centre trials for antisocial personality disorder, eating disorders, and drug addiction. He was an expert member of National Institute for Clinical Excellence (NICE) development group for treatment guidelines for Borderline Personality Disorder in UK. His NHS clinical services are recognised by the Department of Health as a national demonstration site for the treatment of personality disorder. He was President of the European Society for the Study of Personality Disorders (ESSPD) from 2012-2015.He received a senior scientist award from British and Irish group for the Study of Personality Disorder in 2012 and in 2015 the annual award for “Achievement in the Field of Severe Personality Disorders” from the BPDRC in the USA.He has authored numerous books, book chapters, and over 120 peer reviewed research articles on personality disorder and the use of psychotherapy in psychiatric practice. 

Peter Fonagy

Peter Fonagy is Head of the Division of Psychology and Language Sciences at UCL; Chief Executive of the Anna Freud National Centre for Children and Families, London; Consultant to the Child and Family Programme at the Menninger Department of Psychiatry and Behavioural Sciences at Baylor College of Medicine; and holds visiting professorships at Yale and Harvard Medical Schools.  He has occupied a number of key national leadership positions including Chair of the Outcomes Measurement Reference Group at the Department of Health, Chair of two NICE Guideline Development Groups, Chair of the Strategy Group for National Occupational Standards for Psychological Therapies and co-chaired the Department of Health's Expert Reference Group on Vulnerable Children. His clinical interests centre on issues of early attachment relationships, social cognition, borderline personality disorder and violence. He has published over 500 scientific papers, 260 chapters and has authored or co-authored 19 books. He is a Fellow of the British Academy, the Academy of Medical Sciences, the Academy of Social Sciences and the American Association for Psychological Science, and was elected to Honorary Fellowship by the American College of Psychiatrists. He has received Lifetime Achievement Awards from several national and international professional associations including the British Psychological Society, the International Society for the Study of Personality Disorder, the British and Irish Group for the Study of Personality Disorder, the World Association for Infant Mental Health and was in 2015 the first UK recipient of the Wiley Prize of the British Academy for Outstanding Achievements in Psychology by an international scholar.

Tobias Nolte

Tobias Nolte studied medicine in Göttingen, Germany and obtained an MSc in Psychodynamic Developmental Neuroscience from UCL in a combined programme with the Yale Child Study Center. He is currently working as a clinical research fellow at the Wellcome Trust Centre for Neuroimaging, UCL and as a Senior Researcher at The Anna Freud Centre, London.