Three main results emerged from this study: 1) the branch of the study including specific MHS team supervision in addition to treatment-as-usual (STM) showed an improvement in the symptoms and functioning compared to baseline, even though a structured psychotherapy was not applied; 2) the improvement was found to be stable over time; 3) a time-limited psychodynamic psychotherapy focused on patients' level of personality functioning (SB-APP) was more effective than STM with respect to some core psychopathological characteristics of BPD (disturbed relationships, impulsivity, suicidality/self-damaging behaviors, and chronic feelings of emptiness) and working alliance.
With regard to the first point, both patients and raters reported that one year of treatment as usual, comprehending specific MHS team training and supervision, improved in both psychopathological expression and substantial reduction of heavy use of MHS. These data provide support to design a randomized controlled trial to demonstrate that the addition of team training may have a role in obtaining these effect. The whole group of patients reported a significant improvement in general psychopathology and in anger control during treatment and at the first-year follow-up. STM effectiveness is even more extensively confirmed by hetero-administered scales, showing a significant improvement in all CGI scores.
These results are in line with previous studies and are interesting because a better management of anger is an important target when treating BPD patients [27
]. This may be consequent to a greater consistence of MHS team management and/or to a reduction of counter-transferal reactions by therapeutic team which could elicit BPD patients' anger [28
]. Indeed, anger reactions are often explosive and prolonged, constituting indeed major risks factors for suicidality [29
An overall improvement in clinical severity (CGI), global functioning (GAF), and all nine psychopathological domains included in the diagnosis of BPD (CGI-M items 1-9) were reported by blind, trained researchers. The overall improvement in global functioning (GAF) after one year is particularly important because personality disturbances lead to social dysfunction to a greater extent than the majority of other pathologies and patients quality of life may remain poor even after well-designed therapeutic interventions (i.e. Cognitive Behavioral Therapy for Personality Disorders - CBT-PD) [30
]. Besides, poor social adjustment is a risk factor for suicide attempts among patients with BPD [29
]. Moreover, individuals who did not reach a sufficient GAF level remained heavy users of MHS at T24.
The improvement of anger control in our sample could have a role on reduction in self-damaging behaviors and hospitalization rates during the year after psychotherapeutic treatment. Further studies are necessary to confirm this causal hypothesis.
Finally, the significant improvement of the main outcome measure of this study, i.e. recurrence of high use of psychiatric service at the two-year follow-up, showed that the interventions were effective on this core problem afflicting both patients and service. These results are consistent with literature findings. Among medium-term interventions ranging from 12 to 18 months, one year of DBT was superior both to treatment-as-usual (TAU) and treatment by community experts with regard to self-harm, suicidality, hospitalization and psychiatric emergency visits reduction [9
]. Also eighteen months of Mentalization Based Treatment (MBT) showed better results than TAU concerning a steeper decline of both self-reported and clinically significant problems, including suicide attempts and hospitalizations [31
]. Similarly, Transference Focused Psychotherapy (TFP) [32
] was more effective than treatment by experts in reducing suicidality and in inpatient psychiatric treatment, but not in self-harming behaviors. Finally, there is evidence of benefit from adding CBT-PD to TAU on suicidal attempts, state anxiety and dysfunctional beliefs [33
]. Among brief treatments, a shorter form of DBT (DBT-B; 6 months of duration) lead to significant decreases in self-injure, suicide ideation and overall patients subjective distress, but not to a reduction of hospitalizations and emergency visits [34
BPD patients are high users of MHS because they need several repeated treatments, including urgent interventions either in community settings or in emergency departments [2
]. The reduction of dramatic occurrences and unscheduled interventions in both groups of patients underlines that a significant component of borderline malfunction can be reduced correcting therapeutic behaviors that worsen symptoms [28
] by a specific MHS team training. Working with a precise theoretical framework and being supported by a specialist supervision which addresses relational dynamics of the therapeutic team is useful with BPD, a disorder which heavily challenges consistence and coherence of operators [5
]. Data showed in this study strongly encourage MHS teams to adopt similar supervision procedures.
As regards the second finding of this study, our data analysis of the scores at the second-year follow-up did not show any significant change in psychopathology or clinical scores and no significant differences at the between-group analysis were found. Nevertheless, the evaluation of heavy use status underscores that at the two-year follow-up the majority of BPD patients are no more heavy MHS users. This sustains a stability of improvement one year after the beginning of the intervention. This stability has been supported by the persistence of the STM with team supervision in the follow-up period. Nevertheless, this suggests that: 1. improvement from the initial therapeutic approach (without team supervision) to the therapeutic approach with team supervision (STM) leads to an enduring better functioning of BPD patients; 2. STM with supervision alone is not able to significantly further improve patients' functioning after one year of treatment; 3. improvement of BPD functioning reached with a better clinical management is sufficient to significantly reduce the heavy use of the service at two-year follow-up; 4. more specific treatments (possibly SB-APP) are needed to further improve BPD psychopathology beyond the functioning level obtained in first year of both treatments. In fact, the high non-homogeneity of BDP diagnoses require tailored treatments based on specific clinical, psychopathological and functioning (PLF) characteristics [13
These data have to be confirmed by longer follow-up periods. BPD patients treated with CBT-PD showed a stable improvement after 6 years [30
] and patients treated with MBT after 8 years [36
As concerns the third finding of this study, one of the major aims was to compare two different therapeutic techniques: STM with and without a structured cycle of SB-APP. Research supports that BPD treatment may benefit from a structured approach to psychotherapy [31
], since patients are often chaotic in their lives and relationships and have a deficient psychic structure [8
]. The effectiveness of well structured treatments might widely relate to common factors such as stable framework, active and empathic therapist, attention to countertransference and progressive patients' awareness connecting feelings, thoughts and behaviours [37
] and not to specific techniques [8
]. Nevertheless, focusing on specific psychopathological processes could add benefits to structured clinical support [40
SB-APP is a time-limited psychopathology-based intensive-supportive psychotherapy derived from B-APP, a 15-session time-limited treatment that has been used with good results [19
], either alone or in combination with medication, for treating outpatients with mood and anxiety disorders [40
] or eating disorders [41
], also in comorbidity with personality disorders. The SB-APP was conceived because of the BPD individuals relationship disturbances, fears of abandonment and severe difficulties with building a stable therapeutic alliance [20
Several treatments [9
] are useful to address specific disruptive behaviors of severe BPD, but are less effective in reducing heavy MHS use related to intolerance of aloneness and conflicts over dependency [10
] or the tendency of "pushing the limits" in building therapeutic alliance which produce a high rate of MHS use and great problems in BPD management [11
Since the same therapists of the team performed both kind of interventions with different patients SB-APP, superiority to STM was not related to therapists' subjective skills but possibly to the specific setting and technique of the structured treatment with respect to the unstructured psychological support. In order to treat acting out and impulsivity (CGI-M, item 4) and self-damaging behaviors (CGI-M, item 5), an accurate identification of patients' cognitive and emotional patterns and defense mechanisms [15
] is required: this represents the SB-APP specific focus. Distorted relationships and acting out (CGI-M, item 2) could also benefit from a well structured treatment setting. Moreover, patients feelings of emptiness (CGI-M, item 7) are very persistent and have different psychopathological features during evolution of BPD [21
]. Consequently, SB-APP therapists address patients emptiness with either promoting mentalization [42
] (PFL 1) or decreasing splitting defenses (PFLs 2 and 3) and increasing tolerance for ambivalence (PFL 4).
Considering remaining CGI-M items: dysphoria and anxiety (CGI-M, item 6), rage (CGI-M, item 8), as well as paranoid ideation (CGI-M, item 9) are likely to be decreased by pharmacological therapy. Increasing better skills to cope novelty with risk, as in unstructured psychological support, and providing empathic validation and encouragement to elaboration, as in SB-APP, are likewise useful to reduce affective and cognitive symptoms. Furthermore, treatment of fear of abandon (CGI-M, item 1) might benefit from implicit aspects of therapeutic relationship
Patients' identity instability (CGI-M, item 3) may be reduced by identification with therapists, irrespectively from their technique [43
The client-rated quality of therapeutic alliance was rated only at the end of follow-up because of the difficulties in alliance-building and early termination of treatment [44
]. Structured psychotherapy was more effective in building a good and stable therapeutic relationship. In fact, individuals treated with SB-APP described their therapist as more empathic and confident and rated a better working alliance than did those in the STM group.
A detailed cost-effectiveness analysis considering the savings due to the reduction of high MHS use (repeated hospitalizations, unscheduled sessions, at home interventions, loss of working days, etc.) was not performed in the present study to support the opportunity of SB-APP. SB-APP costs are represented by specific training to therapists and by the need of performing 40 structured weekly sessions with the psychotherapists. In our study, the total number of T0-T12 sessions was the same in the two treatment branches. Nevertheless, at T12 and T24follow-up SB-APP allowed to avoid the weekly psychological support which was carried on in the STM group saving about 40 weekly sessions (about 4.000, 00 $/participant).