Authors' reply

We share Dr Mountain's concern that this group of patients is often inadequately managed. Our primary aim in pointing to the iatrogenic consequences of psychotherapy was to illustrate the dangers of intensive interventions or those with poorly defined boundaries. The same concerns for iatrogenic consequences apply to institutional involvement because this is often disrupted by frequent staff changes. Separations and losses of this kind are also iatrogenic. They activate patients’ attachment systems, leading them to make unproductive attempts to restabilise their sense of self. Moreover, interactions with institutions often occur at times of personal crisis when the attachment system is already stimulated. Concerns about the patient's state of panic and about reduced mentalising may lead to hospital admission. However, this can become iatrogenic in itself because emotionally charged interactions with staff and other patients may further destabilise the patient, leading them to self-harm or threaten suicide, prolonging hospital admission. We and others (Paris, 2004) recommend that the level of risk for self-harm of patients admitted to hospital should be assessed and documented daily. If there is no reduction in risk, alternative management of the patient in the community should be implemented.

Although patients may seem to be enacting past experiences in their interactions with clinical teams, in our view it is not useful to consider these as hapless repetition of past patterns or as acts that respond to or compensate for past hurts; rather they should be viewed as the only solution available to restore a sense of integrity, continuity and coherence. The provision of a highly integrated model of psychiatric care in a structured institutional environment that aims to offer consistent, coherent and thoughtful psychological care with a relationship focus, organised in a patient-oriented flexible manner with individualised care plans, is likely to be most helpful. Out-patient treatment, discharge from an in-patient unit or referral following a casualty visit should be considered in this context if services are to present a stable and coherent view of the patient's subjective world that may be adopted (internalised) as part of the self-image of the patient's mind. In our view this is the critical change in the treatment of borderline personality disorder.