“Developing precise interventions by understanding the mechanisms”

Peter Fonagy and the undermining of old ideas on personality disorder

“At the Madrid conference I intend to come up with a truly convincing case for the diagnosis and treatment of personality disorder in adolescence. I will present a pathway to modifying practice that can ensure we give young people with emergent personality disorder the best possible chance of having not a lifelong problem, but an adolescence-limited problem.”

Peter Fonagy portraitProfessor Peter Fonagy intended to write history. The case study he presented as a keynote speaker at the ESCAP 2015 Congress in Madrid included research outcomes and reports from recent implementation trials. View his Madrid slides, his abstract and Madrid interview on this page.

In accordance with the congress motto – linking expertise to clinical practice – Peter Fonagy concentrated on what has proved to be effective and what can be easily taught. Fonagy: “Those two aspects are equally important: how can we ‘translate’ research outcomes into a practice that is known to work? Many things are known to work, far fewer make the leap into practice.”
In this extensive, in-depth interview the world famous ‘father’ of Mentalization Based Treatment and missionary of evidence-based practice tells us what he is up to now. He talks about his current research focus, the early diagnosis of personality disorder, European scientific collaboration and how to implement guidance. Peter Fonagy speaks out on these subjects without indulging scientists’ and practitioners’ attitudes that might stand in the way of moving forward with improved therapeutic methods.

Borderline Personality Disorder
in adolescence
Peter Fonagy: “My main research focus is currently on emergent borderline personality disorder. It has been known since serious systematic work on personality disorder began that borderline personality disorder normally first presents in adolescence. We also know that good outcomes can be obtained from treating adults with personality disorder, but we also know – since the outcomes are only reasonably good – that there are residual problems which are not dealt with. I am very concerned that we try and identify how we can recognize and treat personality disorder early on. If we do so, I hope that some of the long-term problems of adaptation and functioning that we see in adult personality disorder would not arise.”

What ages are you directing your studies at?
“One large study that I am involved in is focused on adolescents from the ages of fourteen to 25. This is a study in collaboration with Ian Goodyer as well as Ed Bullmore and Peter B. Jones – all based in Cambridge – and Ray Dolan from UCL. This is a Wellcome funded study designed to identify emergent psychopathology in the adolescent years. This study is known as an NSPN – Neuroscience in Psychiatry Network – it is an ambitious project that combines neuroscience with epidemiology to identify emergent problems. The study has recruited about 2,200 people. Its broad aim is to find out if early intervention in personality disorder can be more effective, as it has proven to be in psychosis. We already have earlier studies that look at specific cues in childhood. A major study that we have started at the Menninger Clinic in the United States is an inpatient study that involves adolescents who have failed treatment elsewhere. There we are doing very intensive studies of social cognition as well as attachment, focusing on trying to identify emergent personality disorder.”

Inadequate use
of neuroscience
In some studies, for example in psychosis and schizophrenia, researchers go back much further and study birth and even prenatal indicators.
“In the field of personality disorder we are a little bit behind the curve. Going back to adolescence is an important start, but theoretically future research could indeed go back further, because I must say that – looking at the neuroscience – I firmly believe that mental disorder is a disorder of the brain. Unless you are a dualist, you have to believe that. This does not mean that there are no important psychosocial parameters that demand investigation. But social and psychological impact will always be experienced at the level of the brain. I think some of our failure in psychiatry, particularly in nosology, comes from the inadequate use of neuroscience. We have tried to force phenomenology to fit in with neuroscience – so we have been looking for a neuroscientific or biological basis for phenomenological categories, from a developmental and psychopathological perspective. I am a developmental psychopathologist myself and I still say: this is an unsound principle. There are many roads that lead to Rome and many mechanisms can generate the same pathology. Lumping them all together is probably just an unsound scientific principle. I am very keen to look at lesser nosology and to approach these problems more from an angle of psychological capacities, and try to look much more closely at what has been shown to have a fairly close biological equivalent. My personal interest here is social cognition, as it is one of the areas where strong connections have been made between the neurobiological and the psychological. This is how I would like to try and trace the roots of personality disorder, via the emergence of anomalies at the level of brain function – specifically in the area of social cognition.”

Do you think neuroscientists tend to be over-optimistic?
“It is human nature to be over-optimistic, so why would neuroscience be free of that? We all think that we are of above average intelligence, which of course is an impossibility… We would all like to think we have found the solution, but that would obviously be too easy. I think that neuroscience is part of the answer and it is going contribute to solutions. I am a developer of therapies and where I think we have gone wrong in the development of therapies in the past is this: we develop something, we manualize it, we kind of package it up into something and we end up with a therapy that has some effective components and some less effective components. But the ultimate problem is that we are not focusing, we are not doing keyhole surgery of the mind. We are trying to do too much which creates too many complications and which makes the interventions less effective. So by understanding the mechanisms more, we can become more precise in our interventions.”

More specific than
ever before
Let us look for some good news. What progress have you made in the recent years?
 “I think it is very important that we are discovering that disorders which we previously thought immutable and unresponsive to change – such as personality disorder – turn out to be fairly responsive to treatment. We have had major successes with borderline personality disorder in adults, we are replicating some of that successfully in adolescents, and most importantly we are more specific in what we are trying to address in psychosocial treatment than we ever were before. When we did very broad interventions, the problem was that we created a lot of complications that made it difficult for the patients to benefit properly. I think we have become just a bit more sophisticated – as we are becoming more precise and focused in our work, we are doing better.”

Looking back at your presentation for the ESCAP 2007 Congress in Florence shows that you came a long way. There and then you focused on the basics of evidence-based treatment – which seems to be common practice today.
“Yes it is now generally accepted that evidence-based practice is important. In the UK I have been very fortunate in being able to introduce evidence-based psychological therapies for children and young people nationally.”

Turning the field around
“This initiative has turned the field around. Clinicians used to be very sceptical and hostile, saying: ‘Hold on there, you are trying to undermine our status quo’. Now a new, popular movement presents itself: a wide range of practitioners – from psychoanalytic to behavioural, to family and systemic oriented professionals – embrace the evidence-based way of working. We are using a broad interpretation of what is evidence-based, but we are succeeding in changing hearts and minds and clinicians’ behaviour as well as outcomes for patients.”

And your missionary work still keeps you busy: currently by striving for an increased access to psychological therapy in the UK. How is that in other European countries?
“When it comes to access to specialized mental health care, some countries are better than others. In the Netherlands, for example, there has been a lot of interference from politicians, who have over-interpreted the evidence, which has not been helpful. These politicians have taken over academia, which I think can cause harm. They should empower clinicians rather than use the charade of science at the expense of genuine scientific thinking.”

What would you say to these politicians if they argue that Mentalization Based Treatment – MBT – or psychoanalysis lacks evidence?
“I would say that is untrue. There is no evidence that randomized controlled trials carried out on non-CBT therapies are any less scientific than the ones that are carried out on CBT therapies, or that the studies looking at methodology which compares CBT therapies to non-CBT have shown that they are not equivalent. In 2012, the American Psychoanalytic Association concluded in a formal review that, when looking at comparisons, there is very little evidence to show one intervention to be superior to any other, looking across diagnostic categories. I think that diagnostic categories themselves are part of the problem. I don’t think that psychoanalysis or MBT or CAT or TFB or DBT or any three letter therapy that you choose is better than any other treatment, but I do think that there are particular problems that each of those therapies are better at addressing. For example I would say that DBT is very helpful for individuals with borderline personality disorder who have emotional dysregulation problems, but it is far less effective for individuals whose primary problem is interpersonal.”

Bloom: ‘Everyone is a dualist’
What could be the root of this ‘unreasonable’ opposition to psychological therapies?
“There are several levels of explanation for that. The first level is represented by Paul Bloom who wrote a beautiful book about a decade ago, called Descartes’ Baby. He showed that we are all fundamentally dualist. We do not believe in the mind as such. Unless you have a very strong government initiative behind psychological therapies, I think there is a natural popular scepticism about psychological therapies: the mind cannot change the mind. In child psychiatry, however, pharmacological interventions have shown – other than for attention deficit and hyperactivity disorder – limited effectiveness. So we do need the therapies that people don’t seem to want.”
Peter Fonagy.“In the end: reason rules. Ultimately we will persuade people. In the UK it works: improved access to psychological therapies is becoming a very popular initiative. With digital technology going hand in hand with therapies, I think the problem of access and the availability of trained professionals will become less urgent. In my view there is much to be learned from our computer scientist friends.”

What works
for whom?
Could you confront politicians with a hard evidence base, specifically for the treatment of children?
“Yes. We have just reviewed the evidence base for child and adolescent mental disorders in the second edition of our book ‘What works for whom?’. It has some 4,000 citations in it. So there is a strong evidence base specifically for children and adolescents. A lot has improved during the last decade; there is a lot more data now, but research needs to become more sophisticated. Diagnostic categories are not necessarily the best moderating variable. Where we probably failed in the ‘What works for whom’ question, is that we haven’t looked at emerging neuroscientific findings in relation to specific capacities and component capacities that are dysfunctional in mental disorder and could be directly addressed by more sophisticated psychological as well as physical interventions. Again we need more focus and we need to learn a lot more about young people’s psychopathology.”

NICE guidance
You have contributed many times to the development of the NICE guidelines. Would you think these British guidelines are applicable all over Europe?
“I am a strong believer in NICE guidelines. Around the table are people who have done the research, very high-level clinicians, and people who are actually receiving services. The combination of these three groups helps, in a kind of a steel casing of systematic review methodology, to document, understand and adjudicate on variations in clinical practice.”

Professor Minderaa, the president of ESCAP, has said “Implementation of knowledge is the issue now. Let’s use what we know.”
“I would entirely agree with that. I think implementation science has also progressed. Part of what we try to do in the improved access to psychological therapies initiative for children and young people in England, is to use the findings of implementation science to create a national program. So we do not simply want to say ‘This is what you should do’, but to try and design an implementation protocol using knowledge about how things work on the ground. I will give you one example: in introducing evidence-based therapies we do not stop at saying ‘This is the therapy you should use’, but we try and train practitioners in evidence-based therapy. We also train supervisors who work with the mental health workers putting evidence-based therapies into practice. And finally we train the managers who oversee services where evidence-based therapy is implemented.”

Integration of
national guidelines
NICE guidelines have now reached 60 per cent of British child and adolescent mental health services. The Dutch Knowledge Centre’s protocols for diagnostics and treatment are now being used by 70 per cent of Dutch practitioners, and the Swedish and German associations for child and adolescent psychiatry seem to have similar national successes. When can we finally expect cross border collaboration in the field of guidelines?
“My entire career has been devoted to collaboration. I would love nothing more than a Europe-wide collaboration on integrating national guidelines. If ESCAP could undertake such a collaboration on developing standard European guidelines for major childhood disorders, I would pay my own fares and my own hotel to be part of it.”

“Publishing of guidance
will do nothing”
“ESCAP could popularize and translate – breaking down the language barriers – to make guidelines available to all practitioners. But watch out: implementation science tells us that publishing guidance in itself will do nothing. In countries where implementation is not very strong yet, you have to help develop protocols for implementing the guidelines, as well as publishing it and popularising it. So ESCAP should take chapters out of implementation science text books and set up protocols for getting evidence-based practice going in Italy, France and Spain and Greece and so on.”
“ESCAP is a marvellous society. The origin of ESCAP is the dissemination of the science underpinning child and adolescent psychiatry. I am very proud to have contributed to it in very minor ways to it, and I think guidance on a European level could well become a core activity of ESCAP.”

Motivating
the network
What should be the first steps? Couldn’t we simply embrace NICE?
“No. ESCAP should modify NICE and integrate it with other European guidelines and develop its own integrated guidelines. That is not an insuperable challenge: it would be a matter of six meetings involving the relevant professionals. But what is a major challenge, once you have the European guidelines written down, is, again, implementation. And that is where ESCAP could make the difference: to train opinion leaders in the networks who can motivate everyone at conferences and each of those ‘notes’ or ‘hubs’ in the network should become local leaders, developing teams around them.”

Changing psychiatric practice
in Europe
“For ESCAP’s Madrid conference I have got together a group of like-minded professionals who feel we can intervene effectively in personality disorder in adolescents. What I would like to do is to change psychiatric practice in Europe so that you can diagnose personality disorder in adolescents.”
“Today we are really underserving young patients by our reluctance to diagnose. Still, 63 per cent of British child psychiatrists think that borderline personality disorder is not a valid diagnosis for adolescents, while 82 per cent of them think it is valid for adults. They are just wrong. They are scientifically wrong, immunologically wrong, in every way it is wrong. It is clinically outrageous! And we can shift that, so that people are going to be able to diagnose borderline personality disorder, treat it appropriately and start serving young people far better than we are doing at the moment.”

Outdated ideas
“It is time for clinicians to stop hanging on to outdated ideas about the alleged impossibility of diagnostics, saying that the diagnosis may be iatrogenic, that the disorder is ‘only a life phase’ that ‘they will grow out’ or that there is insufficient data. These are all unsubstantiated concerns that do not work in the interest of young patients.”
“The problem could partly be a generational one. I meet many young clinicians who do have an open mind towards scientific research, but in some European countries the system is very hierarchical, making it difficult for them to have much influence. Many clinicians are eager to learn though: they come to congresses, like ESCAP’s, which has always been a scientifically based platform. I think it is possible to reach them by being relevant, by coming up with things that make their work more effective. Some older scientists are far too complacent: they do not work with clinicians, they talk down to them and alienate them. I feel that if you are a scientist-practitioner, you have to know the daily problems that practitioners face and help them address those problems. We have to be collaborative, rather pronouncing from on high and telling them what to do.”