The prescription

To the Editor

‘When my previous therapist took out his prescription pad, I knew I could never tell him anything important’ (Gutheil, 1982).

There is a change in the wind, with an increasing focus on the biological differences between people who have and who do not have borderline personality disorder. Given the unsatisfactory response to current psychotropic medications, the changing paradigm that postulates a central role for the neuropeptides offers new treatment possibilities. However, prescribing as an intervention, whether for medication, case manager allocation or hospitalisation, remains a complex interaction involving the nature of often unspoken meanings, expectations and relationships (Gutheil, 1982; Swoskin, 2001; Winer and Andriukaitis, 1989).

For some patients, the fantasy of the perfect treatment does exist. It is an intervention that is immediate and specific in its effectiveness and is without side effects. Thus, to not prescribe may be perceived as withholding and a lack of caring, reminiscent of earlier life experiences. However, the same withholding may be experienced as a refusal to be distracted from seeing the patient as a person, as highlighted in the opening quotation. Prescribing is similarly vexed. Treatment choices, adjustments and augmentation strategies may serve to distract both clinician and patient from a psychological understanding of their difficulties. This runs the risk of strengthening a person’s defences against change as they continue to hope that the solution is external to him or herself. If symptoms have become a person’s armour, their removal is frightening. Finally, side effects may serve both to confirm the patient’s unloveability and wound the prescriber – ‘Telling a doctor his pills aren’t working is like telling a mother her baby is ugly’ (Gutheil, 1982).

Our understanding of the borderline experience will continue to change. The inherent dilemma of prescribing can be approached by an open and shared inclusion of the patient in developing time-limited, testable assertions – ‘By making the patient a partner in treatment, the doctor emphasises and reinforces the patient’s strengths as a person instead of his weakness in a dependent, sick role, thus opening up the door for more flexible, appropriate, responsive and responsible drug therapy’ (Gutheil, 1982). Changes in treatment approaches can thus be embraced rather than feared.