Bridging the Gap – from Basic Science to Treatment Implementation: a summary of the 4th World Congress for Borderline Personality Disorder

Following the 4th World Congress for Borderline Personality Disorder, Lisa Lyssenko summarises the key messages that emerged.

More than 750 scientists and clinicians from 43 countries all over the world met in Vienna at the European Society for the 4th International Borderline Congress to present and discuss ongoing research and therapeutic concepts on Borderline Personality Disorder (BPD).

Prof.  Martin Bohus, president of the European Society for the Study of Personality Disorders (ESSPD), Editor-in-Chief of Borderline Personality Disorder and Emotion Dysregulation and organizer of the congress, states in his opening address:

“We have made great progress in the study of Borderline Personality Disorder over the past few years: We have begun to understand the core pathogenic mechanisms of this disorder; we have started to tailor treatment approaches to specific domains of pathology; we can demonstrate efficacy and effectiveness of these programs; we are in the process of understanding the moderators and mediators of treatment response.

Borderline Personality Disorder has lost its ability as a diagnosis to scare clinicians; the erstwhile psychiatric Cinderella has morphed into an appreciated and reputable clinical and research discipline.

What made this happen so rapidly? The first important step was to leave the world of theoretical concepts and instead to define research questions based on operationalized clinical phenomenology. This enabled us to establish empirical and experimental research questions. The second step is a natural consequence: Once we had reliable data, we could leave the world of school based therapeutic identities and start to communicate.

The ESSPD and the biannual International Congress for Borderline Personality Disorder has been founded to create an energetic and pulsating platform for this communication – bridging the gap between researchers and clinicians and bridging the gap between clinicians of different therapeutic schools.

However, all these efforts would be fruitless and sterile if we were not eager to transfer the new evidence based therapeutic concepts to our daily clinical practice – bridging the gap from basic science to treatment implementation. This is the challenge for the next 10 years and this is the theme of the fourth international congress on BPD.”

Treatment Implementation

Dr. Shannon Dorsey (University of Washington) presented in her plenary talk on “Implementation Science the “How” of integrating evidence-based psychotherapies into usual care settings” a simple, but striking number to the congress: evidence-based mental health treatments need an average of 17 years to be implemented in clinical practice – an incredible waste of resources. To study the factors which are hindering and promoting implementation therefore seems of utmost importance.

Two other plenary speakers reported on larger scale implementation projects. Firstly, Dr. David Clark (University of Oxford) presented striking data on the “Improving Access to Psychological Therapies (IAPT)” project in England which was designed to implement a stepped care program for people suffering from depression and anxiety disorders, and reached more than 1 million people in the first three years.

Secondly, Dr.  Arnoud Arntz, Amsterdam spoke about the implementation of schema therapy in the Netherlands. Several smaller scale projects illustrated their experiences in symposia.

Taken together, one major promoting factor seems to be the support of the new treatment, not only by therapists and professional organizations, but also by insurance companies and other funding agencies as well as by patient interest groups.

In addition: every single stakeholder group needs some kind of benefit for investing time and other resources on the implementation of the new treatment, be it cost-efficiency, better outcomes or a positive media coverage to enhance the individual reputation.

One major hindering factor seems to be the complexity of treatments. First, lengthy and complex treatments may not be feasible in many settings due to limited resources (which not only applies to low- and middle-income countries). Second, many evidence-based therapeutic treatments (including those for BPD) consist of manualized protocols and/or require intensive training.

Recent surveys show, that clinicians tend to adapt the trained protocols according to their own interests, organizational constraints or subjectively perceived client needs. Challenges for the future in the treatment of mental disorders seem therefore to further study pathogenic mechanisms in order to compose simplified treatments which target the core features, as well as to help therapists to find out how to adapt while keeping effectiveness.

Integrative perspective

Last but not least the congress considered the perspective of patients, their families and partners – which is of increasing importance in the field of mental disorders, as data shows that the psychosocial surrounding is crucial for recovery trajectories. Martin Bohus presented data from qualitative interviews undertaken 20 years after their DBT treatment asking them which problems they consider the most important to be treated in BPD.

Most patients named gaining control over emotions, mood swings and negative thoughts, followed by reduction of suicidality, self-harm and other destructive behavior and improving self-acceptance and self-confidence. However, improving relationships and improvement of social participation, social competence and job situation has been mentioned as important.

The cultural highlight of Friday afternoon was the presentation of Michel Negropontes autobiographic documentary of a former BPD patient, which was discussed with the filmmaker. After the film, Michel Negroponte moved on stage and reported about his complex personal involvement during the 5 years of work and opened a highly emotional debate with the professional audience.

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