Engagement complications of adolescents with borderline personality disorder: navigating through a zone of turbulence

Abstract

Objective: Premature treatment discontinuation is a widespread phenomenon in child and adolescent mental health services that impacts treatment benefits and costs of care. Adolescents with borderline personality disorder (BPD) are heavy users of health care services and notoriously difficult to engage in treatment. However, there is hardly any data regarding this phenomenon with these youths. Considering that BPD treatment is associated with intense and chaotic therapeutic processes, exploring barriers emerging in the course of treatment could be relevant. Thus, conceptualizing treatment dropout as a process evolving from engagement to progressive disengagement, and ultimately to dropout, could highlight the mechanisms involved. The aim of this study was to describe the process of treatment disengagement and identify warning signs that foreshadow dropouts of adolescents with BPD. Method: A constructivist grounded theory method was used. This method has been favoured based on the assumption that the behaviours and decisions leading to disengagement may be better informed by the subjective experience of treatment. Thirty-three interviews were conducted to document 11 treatment trajectories with 3 groups of informants (9 adolescents with BPD 13-17 of age, 11 parents, and 13 clinicians). Results: Well before dropout occurs, different phenomena identified as "engagement complications" characterize the disengagement process. These unfold according to a three-step sequence starting with negative emotions associated with the appropriateness of treatment, the therapeutic relationship or the vicissitudes of treatment. These emotions will then generate treatment interfering attitudes that eventually evolve into openly disengaged behaviours. These complications, which may sometimes go unnoticed, punctuate the progression from treatment engagement to disengagement leading the way towards the development of a "zone of turbulence" which creates a vulnerable and unstable therapeutic process presenting risk for late dropout.

Dissatisfied dropout from school‐based humanistic counselling: A theory‐building case series

“…The findings from the present study go further than previous research, in which the proposed therapy can trigger painful feelings that adolescents may want to avoid (e.g., Desrosiers et al., 2020). The present study suggests some overwhelming negative thoughts and feelings about the counselling may appear after the counselling when adolescents may reflect on the session, which then may lead to dissatisfied dropout.…”

“…According to previous research, a therapist may not address an issue because they may miss indirect signs, such as the adolescent disengaging with therapy, or the client giving the therapist a false impression about therapy progress (Desrosiers et al., 2020; O'Keeffe et al., 2020). However, the present study suggests that young people may also have a delayed response to an issue with counselling.…”

“…against the wishes of the young person, or they may fail to sufficiently discuss the limits of confidentiality at the beginning of therapy (Desrosiers et al, 2020;O'Keeffe et al, 2020). There may also be a lack of shared involvement in the therapeutic process between the young person and the therapist (Desrosiers et al, 2015;Mirabito, 2006).…”

“…There may also be a lack of shared involvement in the therapeutic process between the young person and the therapist (Desrosiers et al, 2015;Mirabito, 2006). The responses of the young person to the actions of the therapist may include signs of overt and/or covert detachment from therapy, like becoming confrontational or missing sessions (Desrosiers et al, 2020;Fredum et al, 2021;O'Keeffe et al, 2018O'Keeffe et al, , 2020O'Keeffe, Martin, Target, et al, 2019).…”

“…For instance, the therapist may persist with an unwanted therapeutic activity, such as giving psychodynamic interpretations that adolescents disagree with, not facilitating speech and reflection, therapist silence, or passivity (Fredum et al., 2021; O'Keeffe et al., 2020). They might also break confidentiality against the wishes of the young person, or they may fail to sufficiently discuss the limits of confidentiality at the beginning of therapy (Desrosiers et al., 2020; O'Keeffe et al., 2020). There may also be a lack of shared involvement in the therapeutic process between the young person and the therapist (Desrosiers et al., 2015; Mirabito, 2006).…”