Engagement Complications of Adolescents with Borderline Personality Disorder: Navigating Through a Zone of Turbulence

Abstract

Background: Premature treatment discontinuation is a widespread phenomenon in child and adolescent mental health services that impacts treatment benefits and costs of care. Studies of specialized care for adolescents with BPD show that almost 40% of them do not complete treatment. Given that recurrence of suicidal behaviour is one of the main symptoms of BPD, and that the presence of past suicidal attempts is a strong predictor of subsequent attempts in young people, difficulties with treatment engagement in this population needs to be given special consideration. The aim of this study was to describe the process of treatment disengagement and identify warning signs that foreshadow dropouts of adolescents with BPD.Methods: A constructivist grounded theory method was used. Thirty-three interviews with 3 groups of informants (adolescent, parent, clinician) were conducted to document 11 treatment trajectories.Results: Disengagement is preceded by engagement complications, which may sometimes go unnoticed. These will 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, followed by treatment interfering attitudes and openly disengaged behaviours. These engagement complications lead the way towards the development of a “zone of turbulence” which creates a vulnerable and unstable therapeutic process.Conclusion: Engagement complications which arise during therapy illustrate how the initial engagement of adolescents with BPD and of their parents for treatment is neither static nor certain, but subject to fluctuating emotions and perceptions. This implies that engagement can never be taken for granted and must constantly be monitored during the therapeutic process. Maintaining the engagement of adolescents with BPD should be a therapeutic objective akin to reducing symptomatology or improving psychosocial functioning, and should therefore be given the same attention.