COGNITIVE-ANALYTIC THERAPY FOR BORDERLINE PERSONALITY DISORDER IN THE CONTEXT OF A COMMUNITY MENTAL HEALTH TEAM: INDIVIDUAL AND ORGANIZATIONAL PSYCHODYNAMIC IMPLICATIONS

ABSTRACT Given that borderline personality disorder (BPD) is increasingly managed by community mental health teams (CMHTs), an exploration of the effectiveness of the cognitive-analytic model (Ryle 1997a) was undertaken in this context. A young man with a primary diagnosis of BPD was offered a course of cognitive-analytic therapy (CAT) by a member of the CMHT. Therapy was only partially successful, due apparently to the severity of the disorder but also, critically, to the absence of a shared understanding of the disorder by team members as well as other agencies involved. However, the CAT model, involving explicit reformulation, helped educate key members of the team about the disorder and the part they might play in it and to contain the splitting and anxiety provoked by such a patient. In addition, CAT created a reasonably robust therapeutic alliance, with more regular contact and no re-admission during the period of therapy. An extended'contextual' reformulation can also offer a means of understanding the difficulties encountered in working with such patients, classically described by Main in'The ailment' (1957), and provide the conceptual containment required to work with such'difficult' patients.