Interview with Dr Visintini, one of the founders of the GET method for the treatment of borderline personality disorders.

What is Borderline Personality Disorder?

Borderline personality disorder is mainly determined by a portion of the brain that fails to function properly: the amygdala (part of the brain that handles emotions) is overdeveloped and prevents the development of the prefrontal areas (area involved in planning complex cognitive behaviour, personality expression, decision-making and moderation of social behaviour).

The subject is therefore unable to decipher emotions because he only recognises two basic ones: anger and sadness. Moreover, he always knows them in an exclusive way (with the impulsive outburst) and never with a recognition of his own state of mind and thus with the ability to “mentalize” them.

The patient therefore does not have the tools that enable him to cope with the situations of everyday life and consequently make him feel alienated from the rest of the world: he does not feel he has the dignity of being among others and constantly fears abandonment. This leads the subject to avoid situations that might dysregulate him, he automatically never has any real experience of building his emotional world at a young age because he avoids situations rather than ending up in them.

What does the GET Method consist of, who is it aimed at and why has there been a need for such treatment in recent years?

Over the last 15 years, the caseload has shrunk a lot in terms of the average age once between 25 – 30 and now between 16 – 25. These data have led us to study a treatment that not only deals with dysfunctional behaviour but also takes care of the personality of the subject. Behaviour is nothing but the expression of personality and if we do not also dynamically treat the personality of the subject, we will only have given an answer on behaviour but nothing else will have changed.

The GET’s thinking was: let’s start addressing the behavioural part until the patient structures his own ability to mentalise, to grasp his own and others’ moods, to understand why he is sick and what is dysregulating him emotionally. Once he has the tools to recognise emotions and manage them, he will begin to do so in a more dynamic sense within groups with other people so that he then experiences human relationships where he becomes an expert in emotions like the others.

The GET experiential groups are places of emotional experience, four groups in the first phase and four in the second, where the patient is not taught something as in other types of treatment, but it is he who constructs together with his group mates his own experience, his own idea of joy, anxiety, sadness and anger.

He begins to get to know it by beginning to be able to describe it in a phenomenological sense (what goes on in my head ed.) and through the experience in a group where everyone talks about, for example, sadness, how the crisis happened, or how to plan the crisis to avoid it.

The central theme of the GET method is the group. Why is the group so important for this type of patient?

In the world they are excluded there are included. The vast majority of therapy for borderlines is done in groups, the difference is between group and in-group therapy. Group therapy means that I go into the group, do the things I have to do and get out (individualistic position). Group therapy, on the other hand, is a team concept: we all work together on what is happening (e.g. in the crisis group, everyone brings in their own crisis that they have had during the week, but then the group chooses by voting on a crisis and everyone deals with it).

This is very useful for self-esteem because we listen and value everything the patient is feeling: the group helps each other to express the phenomena happening in the subject’s mind and thus to order them, as opposed to their feeling of isolation and emotional chaos.

The method is structured in three different phases. How do the phases and the patients evolve during the phases? In your view, is there a common phase in which patients start to ‘heal’?

From admission and every 3 months, the patient takes self-administered tests that are translated into diagrams. In this way, every 3 months the patient has the opportunity to compare the quarters together with their tutor.

It is also a way to combat their pessimism, these individuals never have the feeling that they are really changing, but in front of the data they realise it. We see the first changes in the first 3-6 months when suicidal ideation, self-harm and dysfunctional behaviour drop significantly.

Normally after about 3 months they move from phase 0 to phase 1 (i.e. the subject can describe a crisis and planning). Between 9-12 months they move from phase 1 to phase 2 (final phase) in which they have finally acquired an ability to mentalise and no longer have crises.

We often speak of individuals with Borderline Disorder precisely because this borderline (borderline) is what separates individuals from a ‘normal’ life in society from inclusion. Does such a clear borderline really exist?

It is the patient above all who feels detached, who feels abnormal, unfit for the world, unworthy. He always has to hide how he is with shame because he fears that if others know how he thinks, what he does and how he thinks, he will be thrown out.

Borderline individuals live as pseudo-normal knowing that they are not. Everything happens in their head but what happens is true, because if they talked about their cuts, their sexuality, their substance use people would not understand their suffering: the vast majority of friends and family think it is a problem of willpower.

They are people who are slaves to judgement, of themselves and of others. They are people who already have predisposing genetics, they are hypersensitive. They are children who demand a kind of attention that others unfortunately cannot always respond to, and as a result the environment becomes worse for them.

Precisely because the disorder shares aspects with other psychiatric disorders (comorbidity), how can it be identified with certainty?

In life The subject is configured in a certain way due to his hypersensitivity to the environment etc. during his life, a subject sensitive to separation, fear, very sensitive to human relationships.

The behavioural expression may be of a different type (e.g. histrionic, narcissistic…) but those are behavioural expressions of the disorder, of the organisation that are classified as disorders by the DSM.

Personality organisation, on the other hand, is expressed in various behaviours that can be: panic attacks, in some cases bipolar and eating disorders.

The difference is that in borderline patients the comorbidity depends very much on the environment. A borderline patient for example has mood swings that can be traced back to bipolar disorder, the difference being that in a patient with a borderline configuration the swings are influenced by external events (good news, bad news) whereas for a bipolar patient, the process occurs independently of the environment.

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