Improving Treatment Outcomes for Adolescents with Borderline Personality Disorder Through a Socioecological Approach

Abstract

Background: There is a dearth of studies evaluating treatment efficacy for adolescents diagnosed with borderline personality disorder. The few available randomized controlled trials that have been conducted show modest results and treatments appear to have equivalent effects. The current paper draws on (a) the lessons learnt from the last 50 years of psychotherapy research in general and (b) recent advances in mentalization-based understanding of why treatment works, which together point to the importance of following a socioecological approach in the treatment of personality problems in adolescence – a developmental period that insists on a treatment approach that goes beyond the therapist-client dyad. Case presentation: Here, we describe such an approach, and offer a clinical case example with a young 17-year old girl diagnosed with borderline personality disorder, to illustrate what a shift toward a more socioecological approach would entail. Conclusions: The clinical impact of the socioecological approach and the potential benefits as illustrated in the current case illustration, offers a framework that justifies and allows for the expansion of service delivery for youth with borderline personality disorder beyond dyadic therapist-client work.

Development and Validation of the Certainty About Mental States Questionnaire (CAMSQ): A Self-Report Measure of Mentalizing Oneself and Others

“…MASC scores distinguish between hypomentalizing and hypermentalizing and are associated with psychopathology (e.g., Fossati et al, 2017Fossati et al, , 2018; for a meta-analysis, see McLaren et al, 2021) but the administration of the MASC is also rather time-consuming and limited to the mentalizing of others. In addition, maladaptive forms of mentalizing may primarily manifest themselves in the context of interpersonal relationships (Bo et al, 2017) and might thus not be optimally measured under laboratory conditions when interpreting the mental states of actors with no possibility to interact.…”

“…In our view, a self-report measure of mentalizing should first and foremost cover a core definition of the construct as, for example, provided by Fonagy et al (2016, p. 1), where mentalizing is described as "the capacity to interpret both the self and others in terms of internal mental states, such as feelings, wishes, goals, desires, and attitudes." A shared feature of existing mentalizing questionnaires (see Supplemental Table S1 for an interpretation of the item content from the authors' point of view), however, is that their item content might conflate the given definition with assumed psychopathological consequences of mentalizing impairments such as problems in interpersonal relationships, impulsive behavior, or emotion dysregulation (e.g., Bo et al, 2017;Müller et al, 2021). This issue impedes investigating the associations between mentalizing and psychopathology because correlation coefficients may be inflated merely due to shared item content.…”

“…It might thus be important to also examine different configurations of Self-and Other-Certainty by exploring their unique associations with psychopathology. Although not explicitly stated in mentalizing theory, one could surmise that hypermentalizing is primarily salient in inferring others' mental states because it is often portrayed in this way in case vignettes that are based on clinical experience (e.g., Bateman & Fonagy, 2019;Bo et al, 2017). Considering some of the more general descriptions of PDs in DSM-5 (i.e., unstable self-image vs. suspiciousness toward others; APA, 2013), it is conceivable that hypermentalizing could also be reflected in having greater certainty about knowing others than about knowing oneself.…”

“…Individuals prone to hypermentalizing tend to overinterpret mental states (Sharp et al, 2011;Sharp & Vanwoerden, 2015), perceive themselves as exceptionally capable in mentalizing, and engage in lengthy narratives about their own or others' mental states that lack connection to reality (e.g., Bateman & Fonagy, 2019). Such individuals might exhibit socially inadequate behaviors by jumping to rash and ill-advised conclusions about others, for example, by misinterpreting their motives as malignant (Bo et al, 2017). In this vein, hypermentalizers can be experienced as intrusive or offensive which might harm interpersonal relationships or prevent their formation.…”