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Borderline Personality Disorder: The Role of the Agency and the System

Mardoche Sidor, MD and Karen Dubin, PhD, LCSW

“Sometimes I feel like her dumping ground. Two nights ago, I was out for dinner and she called, but I did not pick up. Emma left a voicemail, stating she was suicidal. When I called back, she was screaming and crying on the phone, explaining how Joel, her boyfriend, had not shown up for dinner and was not returning her calls or text messages, and she thought he had just left her. She then went on and on until the text messages from Joel started again, and she ended the call with me. I feel drained.” Leila articulated these words to Rodis, the consultant to the HOPE Clinic. She was sharing about Emma, who suffered from Borderline Personality Disorder and has been a challenge to her and the rest of the team.

A lack of purpose and direction in treatment has been one of the factors contributing to feeling drained when working with patients and clients suffering from Borderline Personality Disorder. This draining propensity is rather common; it adds to negative countertransference and leads to clinician resistance to working with these patients and clients.

“However, it does not need to be this way. There are well established skills for working effectively with this population and we will learn them, together,” added Rodis.

There are, indeed, well-established skills for working effectively with patients and clients suffering from Borderline Personality Disorder. The factors related to patient and clients, and to clinicians have been explored. It is now time to look from the perspective of the agency and the system, in preparation for us to delve into The How of working with this population. (For the perspectives of the patient and client and of the clinician, see the two previous articles entitled, Borderline Personality Disorder: What Is Needed, and Borderline Personality Disorder: The Clinician’s Perspective, respectively).

Agency and System perspective

Burnout prevention

“I feel drained…” uttered Leila.  In a series of articles on Burnout Prevention and Self Care for Clinicians and Advocates, I spoke about the reasons why it is crucial to address burnout and promote self-care for staff. I also explained the essential role of the agency and system in this endeavor (see Preventing Burn Out-From the Agency Perspective: 2 More Reasons Why; and Preventing Burnout: From a System Perspective: 4 Reasons Why, for further reading).

As Leila confessed, working with patients and clients suffering from Borderline Personality Disorder is draining, taxing, and can ultimately lead to burnout.

“However, it does not need to be this way. There are well established skills for working effectively with this population and we will learn them, together,” echoed Rodis. I often refer to empowering tools and skills as an effective resource to help prevent burnout, which in turn is a main reason why agencies and the system as a whole ought to help prepare and arm clinicians with effective skills for working with patients and clients suffering from Borderline Personality Disorder.

Successful integration of care

“Two nights ago, I was out for dinner, she called, I did not pick up, and she left a voicemail, stating she was suicidal…” explained Leila to Rodis, in a drained and distressed voice.

Self-injurious behaviors are present in up to 80% of patients and clients affected with Borderline Personality Disorder and up to 10% of them will attempt suicide. At least 75% of them have a comorbid mood disorder or anxiety disorder and over 70% of them also have a substance use disorder. Post-Traumatic Stress Disorder (PTSD) is also present in at least 40% of those affected by Borderline Personality Disorder, and other cited comorbidities include Attention Deficit and Hyperactivity Disorder (ADHD), Panic Disorder, and Obsessive-Compulsive Disorder (OCD). Borderline Personality Disorder is a highly prevalent condition, with high comorbidities, with a highly stigmatized patient population. Effective skills for working with patients and clients with Borderline Personality Disorder are crucial, if we are to be successful at care integration, care coordination, and at reducing fragmented care.

Waste containment

Waste containment is closely associated with implementing care integration, care coordination, and reducing fragmented care.

Borderline Personality Disorder has been shown to be associated with a high economic burden, a result of both medical costs and loss in productivity. Further, 911 calls, ER visits, and inpatient hospitalizations have been correlated with the type of treatment, especially that relative to the attention and medical care given to comorbidities. With over three trillion dollars allocated to healthcare, 85% of this cost is accounted for by chronic illnesses, like Borderline Personality Disorder and several associated comorbidities. The cost is also high in European countries. A paper published in European Psychiatry reports a cost per patient of over sixteen thousand Euros. Decreasing waste in healthcare brings with it the hope that resources can be rightly reallocated towards addressing such need as the social determinants of health, for example. In so doing, since social determinants account for 90% of the burden for wellness, we can begin to relieve waste and debt, as actual medical care influences only about 10% of a cost burden.

“Sometimes I feel like her dumping ground. Two nights ago, I was out for dinner, she called, I did not pick up, and she left a voicemail, stating she was suicidal. When I called back, she was screaming and crying on the phone, explaining how Joel, her boyfriend, had not shown up for dinner and was not returning her calls or text messages. Emma thought he had just left her. She then went on and on until the text messages from Joel started again, and she ended the call with me. I feel drained.” Leila articulated these words to Rodis, the consultant to the HOPE Clinic. She was sharing about Emma, who, suffered from Borderline Personality Disorder and has been a challenge to her and the rest of the team.

A lack of purpose and direction in treatment has been one of the factors contributing to feeling drained when working with patients and clients suffering from Borderline Personality Disorder. This draining propensity is rather common; it adds to negative countertransference and leads to clinician resistance to working with these patients and clients. “However, it does not need to be this way. There are well established skills for working effectively with this population and we will learn them, together,” said Rodis.

Prior to delving into the skills for working with patients and clients affected by Borderline Personality Disorder, we have been exploring the reasons why it is crucial to possess these skills. We have looked at them from the perspective of the patient and client, from that of the clinician, and in this current article we have looked at them from the perspective of the agency and system, with this rationale: Burnout prevention; Successful integration of care; and Waste containment. As supported by resources from the NIH, Borderline Personality Disorder is highly prevalent; it is a challenge to all of us, but there are effective skills to use to arm our clinicians to help our patients and clients towards recovery.

References

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  4. Meissner WW: Treatment of Patients in the Borderline Spectrum. Northvale, NJ, Jason Aronson, 1988.

  5. McGlashan TH: The Chestnut Lodge follow-up study, III: Long-term outcome of border- line personalities. Arch Gen Psychiatry 1986; 43:20–30.

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  7. Stone MH: Abnormalities of Personality: Within and Beyond the Realm of Treatment. New York, WW Norton, 1993.

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  10. Gunderson JG, Phillips KA: A current view of the interface between borderline personality disorder and depression. Am J Psychiatry 1991; 148:967–975.

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