Fonagy & Bateman (Reference Fonagy and Bateman2006) hypothesise that a more benign course of borderline personality disorder may partially result from a reduction in iatrogenic harm. They describe people with borderline personality disorder as having ‘hyperactive attachment systems’ which interfere with the therapeutic relationship and treatment. They describe ‘treatment’ as being psychosocial treatment or psychotherapy, and attachment figures as therapists.

Many people with borderline personality disorder do not receive psychotherapy but do have contact with psychiatric services – casualty assessments, out-patient contact with generic services, brief crisis admissions and sometimes even prolonged admissions. I am curious as to Fonagy & Bateman's view on the nature of attachments that people with borderline personality disorder have with psychiatric institutions, especially when contact with individual workers may be inconsistent. Fonagy & Batemen give advice about how to encourage ‘mentalisation’ in the context of psychotherapy in order to avoid potential iatrogenic damage but give no advice for other clinical settings.

Clinical teams are well aware of how people with borderline personality disorder may unconsciously ‘engineer’ situations to re-enact disturbed early life experiences. Now Fonagy & Bateman suggest that although teams are aware of this situation further damage may be done. A ‘helpful’ intervention may deprive the patient of using or developing other more useful strategies. Fonagy & Bateman suggest that an ‘inquisitive and flexible’ approach may be useful. The challenge is therefore how this approach should be applied to how clinical teams within institutions respond to people with borderline personality disorder.