Patient perspectives on non-response to psychotherapy for borderline personality disorder: a qualitative study

Abstract

Background Despite increasing evidence for the effectiveness of psychotherapy for Borderline Personality Disorder (BPD), estimates show that approximately half of those in treatment do not clinically improve or reach reliable change criteria. There are limited qualitative descriptions of treatment factors associated with non-response from the perspectives of those struggling to improve. Method Eighteen people (72.2% female, mean age 29.4 (SD = 8)) with experience of receiving psychotherapeutic treatment for BPD were interviewed to obtain their perspectives on hindering factors in treatment and what may be helpful to reduce non-response. The data in this qualitative study was analysed thematically. Results Four domains were created from the insights patients shared on non-response and what may be needed to mitigate it. The focus of Domain 1 was that therapy cannot be effective until two factors are in place. First, the patient needs sufficient safety and stability in their environment in order to face the challenges of therapy. Second, they need to be able to access therapy. Domain 2 described factors the patients themselves contribute. The themes in this domain were described as phases that need to be progressed through before therapy can be effective. These phases were ceasing denial that help is warranted and deserved, taking responsibility for behaviours that contribute to unwellness, and committing to the hard work that is required for change. Domain 3 described how the lack of a safe alliance and ruptures in the safety of the relationship with the therapist can contribute to non-response. Domain 4 was comprised of factors that patients identified as supportive of moving through the barriers to response. The first theme in this domain was prioritising the safety of the therapy relationship. The second theme was giving a clear diagnosis and taking a collaborative approach in sessions. The final theme described the importance of focusing on practical goals with the patient to create tangible life changes. Conclusion This study found that non-response is complex and multifaceted. First, it is clear that systems need to be in place to support access to adequate care and foster life stability. Second, considerable effort may be needed at the engagement phase of therapy to clarify expectations. Third, attention to specific interpersonal challenges between patients and therapists is an important focus. Finally, structured work to improve relationships and vocational outcomes is indicated.

Diagnosing borderline personality disorder: Reports and recommendations from people with lived experience

“…Interviews with participants were conducted by two researchers, one of whom was a clinical psychologist. Following estimates of data saturation from qualitative research studies (Crouch & McKenzie, 2006;Guest et al, 2006), the final sample for this project was 15 participants, consistent with research employing a similar methodology (e.g., Miller et al, 2021;Woodbridge et al, 2023).…”

Towards an informed research agenda for the field of personality disorders by experts with lived and living experience and researchers

“…Recently, a growing body of research involving EE has emerged. Here, a distinction should be made between research that seeks to explore the experiences and perspectives of EE (e.g., [ 3 , 48 ]), and research that is planned and conducted in collaboration with EE (e.g., [ 14 ], see below). While the former reinforces the patient – practitioner dichotomy, the latter creates the potential for new forms of equal partnership.…”

The significance of connectedness: avoidant personality disorder patients’ subjective experiences of change after attending a specialized treatment program

“…It is important to note that although existing psychotherapy studies achieve significant relief for many AvPD patients, research also shows varying outcomes and even little or no progression for some with a more severe pathology, despite them receiving long-term psychotherapy ( Kvarstein and Karterud, 2012 ). The potential of getting worse in therapy is generally present for psychotherapy patients (e.g., Curran et al, 2019 ; Strauss, 2021 ; Woodbridge et al, 2022 ), and this is probably also the case for people diagnosed with AvPD. Studies on the effectiveness of psychotherapy are important to evaluate whether positive changes likely correlate with the therapy in question.…”