McLean Hospital / Harvard Medical School

Background

Borderline personality disorder (BPD) is a common and series psychiatric disorder.  Our group has followed for 24 years a large cohort of men and women who were initially inpatients at McLean Hospital.  We found that 77% has a remission that lasted for at least 12 years. This information led us to the conclusion that BPD has the best symptomatic outcome of all of the major psychiatric disorders. 

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However, the McLean Studt of Adult Development (MSAD) also found that only 60% achieved a recovery from BPD.  This was defined as at least a two-year remission of BPD, having at least one emotionally supportive relationship, and being able to work or go to school full-time for two years or more.

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First Study of Flourishing and Mechanisms of Change (three virtues)

The Mclean Mentalization-Based-Treatment (MBT) Clinic has been the home to this now completed study undertaken to assess the concept of flourishing and the associated mechanisms of change (forgiveness, gratitude, and humility) in a randomized controlled clinical trial of Standard MBT vs. MBT Plus Flourishing in the treatment of outpatients with BPD.  It was found that both treatment groups taken together had a substantially greater increase in their level of flourishing than a decrease in the severity of their BPD psychopathology.  It was also found that the level of forgiveness and gratitude were mediating the level of flourishing.

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Training in First Study

Subjects were well trained in the underlying concepts of MBT by Brandon Unruh, MD, the clinic’s director and the study’s CO-I and well trained in understanding the concept of flourishing and its attendant mechanisms of change by Mary C. Zanarini, EdD, the study’s PI.  However, we realized as the study was nearing its end (one year of group treatment involving 14 groups), the group leaders needed more information about each patient’s flourishing goals and reasons for using or not using the study’s mechanisms of change. 

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Additional Training for Second Study

In response to this deficit in clinicians’ knowledge about their group members, Dr. Zanarini developed two self-report measures that dealt with 1) flourishing goals and 2) current use of the three virtues and possible reasons for not using them.  We believe that this type of information is an important addition to the treatment of those with BPD as it makes it very plain that there are goals beyond symptom reduction (e.g., making a friend, getting a job, taking care of one’s physical health).  All subjects will fill out these self-report measures before their group begins.  All group leaders will review this material before each of their groups begin.

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All subjects will be in six months of MBT Plus Flourishing group treatment.  Half of our group leaders will be randomized to standard training and the other half of our group leaders will be randomized to enhanced training. 

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We also believe that group leaders randomized to enhanced training need practical training in the types of interventions that are most effective in facilitating group interactions concerning flourishing and the mechanisms of change.  We are in the process of developing two sets of training videos that will be overseen by Dr. Unruh.  The first type of enhanced training will be watching videos of Dr. Unruh interacting with a group of non-MBT clinicians acting as study group members. Our “treatment group members” would then take turns engaging in role playing a patient or a group leader, under Dr. Unruh’s supervision.