Should “Good enough” healthcare network management be considered as a key element of borderline personality disorder treatment?

Abstract

The onset of generalist treatments for patients with borderline personality disorder (BPD), such as John Gunderson’s "Good Psychiatric Management" (GPM), enabled sharing of simple and accessible therapeutic principles designed for a majority of clinicians and a majority of patients. In addition, BPD is often associated with other comorbidities, both psychiatric and somatic (addictions, psychosomatic presentation, obesity, etc.). This correlation explains why BDP patients tend to be high care consumers or “frequent flyers”. Moreover, BPD greatly affects social and vocational functioning. Indeed, this population of patients has significant difficulties in finding a fulfilling place in society. The impact of BDP on patients’ social life even became a prognosis factor. Over the last two decades, models of integrated care have been implemented in Europe. These developments allowed a clear connection between care coordination and care efficacy to be established. This conclusion proved to be relevant for the medical field in general, as well as for psychiatry. Given the wide impact of BPD on patients’ lives, treaters often find it impossible to address all dimensions of their patients’ problems on their own. Consequently, an adapted and effective treatment often requires the construction of a multidisciplinary network of professionals working in a synergistic manner. This teamwork appears both as a genuine component of the sociotherapy patients need and an invaluable tool for patients’ rehabilitation. This article aims to illustrate how GPM is an effective tool for building and managing a healthcare network for BPD patients. However, these team settings require a significant investment of time and energy from the professionals. They also are expensive. For these reasons, we think that the effectiveness of these team settings justifies proper training to ensure their best use.

Introduction

Patients with borderline personality disorder (BPD) represent 20% of both outpatient and inpatient populations in psychiatry. The prevalence of this specific personality disorder is 2% in the general population [1]. These patients are well known among clinicians for their stormy clinical presentation. They display intense symptoms in four psychological fields: emotion regulation, relationship handling, impulse control and identity [2]. The complexity of the clinical presentation, characterised by emotional outbursts and impulsive behaviours, has contributed to the notorious reputation and stigmatisation of these patients among healthcare providers [3]. Moreover, BDP is often associated with other mental health syndromes [4] as well as with somatic comorbidities. In addition, BPD frequently affects patients’ social and vocational functioning. This impairment tends to persist over time unlike symptoms intensity [5,6]. This can easily make patients vulnerable in various ways.

As a result, healthcare providers may need to refer their patients to an extended healthcare network [7]. Thanks to coherent cooperation, the members of a professional team aim to improve the quality and effectiveness of health care. To achieve this, healthcare networks often consider two criteria: (1) defining care according to a diagnosis; (2) defining care according to the patient's needs and resources. This is the common conclusion reached by integrated care models implemented in Europe over the past 30 years [8. 9]. This integrated approach also enables a wider range of patients’ problems to be rapidly addressed [10]. According to the specific situation, this network may include social workers, general practitioners, patients’ legal representatives, lawyers, etc. This stresses the importance of both team building and team leading in a coherent way adapted to the patient’s needs.

Before the emergence around 30 years ago of specific manualised treatment, such as dialectic behavioural therapy (DBT) [11], BPD was considered untreatable. During the following decade, evidence-based manualised psychotherapies (mainly DBT, transference focused psychotherapy and mentalisation-based psychotherapy) became the therapeutic gold standard for the treatment of BPD. However, these treatments required a lot of training and few therapists were available [12]. In order to provide “good enough” care to this patient population and “good enough” training for practitioners, John Gunderson developed a generalist treatment based upon his practice: good psychiatric management for BPD patients (GPM). The notion of “good enough” care is a reference to D. Winnicott’s work [13]. The “good enough” mother or parent provides the child with what is necessary without letting them either become helpless or overwhelming them. Correspondingly, GPM does not try to be a perfect treatment. It only seeks to be adapted and well-balanced.

It is “good enough” to treat patients and to allow them to feel cared for. On the other hand, it provides treaters with “good enough” tools to face a vast majority of situations. It is not perfect, but allow therapists to feel well equipped. Against expectations, recent studies (2009 and 2018) showed that generalist treatments such as GPM or structured clinical management (SCM) were as effective as gold standard treatment [14,15].

In Switzerland [16], these generalist approaches are now recommended treatments for patients with BPD. This is also the case in countries such as the USA, Canada and Australia [17]. Nevertheless, J. Gunderson and his successors believe that clinicians must extend the implementation of generalist treatments for BPD patients [18]. The GPM design aims to make it accessible and useful to a majority of clinicians and a majority of patients. It is flexible and looks to build a stepped care treatment. To do so, GPM considers the available resources for treatment and the severity of the clinical presentation [18]. In a collaborative way, therapists help their patients in actively developing useful strategies adapted to their situation and needs via core principles. Interpersonal hypersensitivity [19] is the core concept that binds GPM principles together. It prompts therapists to be active. It expects patients to involve themselves actively in the treatment. It expects patients to focus on their lives outside of treatment. As a result, it supports patients in moving on in their lives and prevents them from identifying themselves merely as sick people [20].

In this paper, we will describe the construction and the function of the healthcare network in the treatment of BPD patients, adapted to the Swiss public health setting. This aspect of the treatment generally lacks description but turns out to be crucial for patients displaying intense symptoms and a complex social situation. We based the content of this paper on our long-term clinical experience in the frame of a specialised programme dedicated to patients with BPD [21,22] and the latest updates of generalist approaches for BPD.

A summary of the GPM concept and recommendations regarding BDP

Psychopathology – the interpersonal hypersensitivity concept

Interpersonal hypersensitivity is at the core of BPD psychopathology according to GPM:

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It states that Interpersonal stress factors trigger the vast majority clinical manifestations of BPD.

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Consequently, BPD phenomenology shifts drastically in response to patients' interpersonal context.

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Supportive behaviours tend to calm patients.

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Angry reactions or withdrawal tend to activate distressed behaviors and more dangerous reactions from patients.

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The GPM interventions are founded upon the interpersonal hypersensitivity concept.

Therapeutic principles

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Offer psychoeducation about BPD to patients and relatives.

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Be active (responsive and curious), not reactive: it is the most effective way to show support. The patient’s life matters, is unique and deserves interest.

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Be thoughtful: cautious, reflective and uncertain. You contain the patient's anxiety and become a role model for "thinking before acting".

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The relationship with the therapist is both real and professional.

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Accountability: change is expected. Expect patients to be active within treatment and to move on in their lives.

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Focus on life situations: vocation and relationships. Maintain focus on life outside treatment.

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Be flexible, pragmatic and eclectic.

Adapted from: Gunderson JG: Borderline Personality disorder, a clinical guide, Washington, DC, American Psychiatric Press; 1984 [1] and Choi Kaïn, et al. Evidence-based treatments for BPD: implementation, integration, and stepped care. Harv Rev Psychiatry. 2016; 24(5 :342–56 [12p. 352].

Detailed investigation of the situation and psychoeducation to enable the building of the appropriate team

GPM was developed as a “good enough” treatment for the vast majority of patients with BPD [1]. It considers it a priority to disseminate all valid knowledge about BPD, its aetiology, course and treatment to treaters, patients and families in order to define realistic objectives in the face of a well-defined problem [23]. The current situation in Switzerland led us to consider that the dissemination process of GPM is also a priority among the extended healthcare network to increase the coherence, consistency and effectiveness of the treatment. A disorganised or uncoordinated intervention may prolong the treatment or, in the worst case, make it ineffective [23].

Consequently, the GPM approach advocates the thorough assessment of every patient’s situation to define the nature of the difficulties at hand as clearly as possible (clinical, social, financial, professional, family, etc.). Mapping the situation enables patients and therapists to agree on a priority order of intervention [24]. After this identification process, according to patients’ needs and the quality of their surroundings, treaters ought to gather the right professionals with the necessary skills. It might indeed be difficult to develop strategies adapted to symptoms if social, economic or administrative stress factors have not been addressed in a straightforward and relevant way.

However, in order to allow every protagonist to work in good conditions, it is crucial for them to understand the phenomenology of BPD. GPM helps to find a common language between therapists from different therapeutic approaches [24]. It is our experience that it also helps to develop a common language between different but complementary professions: psychiatrists, psychotherapists, general practitioners (GPs), nurses, pharmacists, social workers, educators, legal representative, job coach, etc. The key idea is to share with them not only the knowledge we have about the disorder but also the principles of treatment described in the previous section [12].

Sharing the GPM concepts with other professionals aims to develop a synergy in the care process of the whole situation of the patient. For this purpose, patients and professionals must have a clear view of the network and be able to identify everyone’s roles and limits. It will first allow realistic objectives in every dimension of the patient’s situation to be set. Secondly, it enables coordination of available skills. Consequently, it is essential that a member of the network assumes the leadership of the group. The leader’s tasks are monitoring patients’ objectives and their realisation, coordinating everyone’s interventions, organising network meetings and ensuring a good level of communication both within the group and between the group of professionals and the patient [23]. Patients must be granted the chance to experience both the plurality and unity of the network. At times a source of frustration, this organisation of the network also induces a noticeable reduction of the symptoms.

The choice of the team leader can seem a tricky job. The psychiatrist or mental health professional of the group is often the most effective and coherent choice. It is not a rule though. Other choices can be relevant if the treater is familiar enough with the GPM model. For instance, a paediatrician with an adolescent patient can be a reasonable choice. Remember that the team leader must be available for group appointments and feel at ease with leading them.

Take-home messages of the section

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Define patients’ problems and prioritise them.

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Select appropriate and coordinated network members and choose a leader.

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Check and update GPM knowledge among network members.

Coordination and communication between network members

Once the network is established, its main therapeutic tool is its capacity to communicate actively and efficiently [8]. It is very important that every protagonist remains up-todate regarding the global evolution of the patient. The onset of a common mailing list and regular meetings, every 3 months for example, are very useful in achieving this objective. They will ensure the building of the team and the creation of a coherent message to the patient.

The network becomes an entity in itself with its own life, relationships and growth. As such, it must be taken care of to ensure its continuous dedication to the patient’s situation. Its members must keep on exchanging and thinking independently of the evolution of the patients and even in their absence. The significant amount of time the professionals dedicate to communication about the patient is an underground work, often ignored, time-consuming and invisible, but crucial. It allows the shaping of an accurate and realistic representation of the patients and of their functioning [23]. The network meetings are also places where treaters can speak about the difficulties they face, their needs and their limits.

This dynamic and plural setting becomes a therapeutic area centred on clinical observation to allow the common elaboration of integrated interventions. It enables quick detection and containment of clinical crises, in-coming stress factors or splitting behaviours [25] from the patients. The pro-active communication of the professionals allows them to refer the patient to the right colleague if they receive misplaced demands from the patient.

As a result, it is fundamental to monitor steadily the evolution of the patient and the care process. A poor course or the signs of treatment failure must trigger reflection and adaptation of the professionals’ work and methods [26].

Take-home messages of the section

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The leader manages the mailing list and ensures periodic meetings (e.g., every 3 months).

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Ensure good communication among members and between the patient and the team.

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Professionals must be proactive and share their views of the situation.

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Monitor patient and network evolution.

Importance of social and occupational aspects

BPD is associated with a great impact on social and vocational functioning [27]. Moreover, work is a key aspect of life. It participates in the shaping of an individual’s identity and is a core component in the development of the feeling of being useful, dependable and responsible [27]. For these reasons, we can easily see how this aspect of patients’ lives is directly related to their prognosis. This is why we believe that this matter must be addressed with patients directly. We aim to assess their ability to work, or at least to remain active through an occupational activity, in order to shake the often-strong idea that reintegration and change is impossible or out of their hands [24]. This kind of belief could prompt patients to remain passive. If this were the case, it would be fundamental to question the disposition of the patient to avoid an active involvement in society. It could be, for example, a clinical expression of avoidance or exploitative tendencies, which should not be ignored.

Swiss social services often have the reputation for being quite demanding of their beneficiaries, whom they do not hesitate to refer to medical professionals, especially GPs and psychiatrists, to investigate a medical or psychological condition that could interfere with the rehabilitation or reintegration process. The discovery of such a condition often results in a more passive stance of the social service.

Because of the clinical, social and vocational odds at stake, the outpatient clinic staff are frequently in contact with social services professionals to help them better understand the situation of their beneficiaries. The goal is to turn social services into an ally, who will also encourage and sustain patients’ motivation to reintegration. As Gunderson and Links early stated, the therapeutic modalities that target social impairment and vocational rehabilitation (sociotherapy) should become more central and more available [28]. GPM is an integrated approach. The patient’s whole life matters. We think it is unique, interesting and deserves care [28]. In other words, we could say that progressively finding a place in society is part of the treatment and not a consequence of a successful treatment.

Take-home messages of the section

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Assess the patient’s ability and motivation to work or to be occupied.

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Shake the belief that one has to get better to get a life. Getting a life helps getting better.

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Include social services in the network to find reintegration pathways.

The GPM recommended stance for professionals

Seeking skills outside of the medical field is an embodiment of the “real and professional relationship” GPM prompts therapists to develop with their patients [24]. It is an acknowledgment of the patient’s range of issues and, as such, represents a way to be true to them and resolve any confusion regarding the motivation of the therapist to offer assistance. At the same time, this attitude shows that the therapist, and consequently every member of the network, renounces the idea that a “clairvoyant or omnipotent” [29] individual could solve every problem. From this perspective, GPM is consistent with Kernberg’s early statement that BPD patients tend to develop relationships based upon extreme idealisation and devaluation [30]. Network members act as “representatives of reality” who can progressively recognise and in parallel question the feasibility and effectiveness of patients’ longing for an omniscient and exclusive relationship [12]. This more realistic disposition of the professional network allows the progressive development of a constructive answer to patients’ desire for change. This arrangement may also allow patients to feel increasingly connected and cared for in their relationship [19]. Over time, these feelings of connection and security could lead patients to build a new relational referential [31], as Winnicott advocated, which they will be able to use in their day-to-day lives.

The purpose of this approach and teamwork is to enhance social and vocational rehabilitation of patients with BPD. It seems obvious that, for such a task, the key member of the team is the patient. This is why patients’ active collaboration is fundamental. They are not responsible for their suffering, but they are the main actor in their changing through their resolution to take action [24].

However, this approach can be effective only if every member of the network assumes it. This explains why it is so important to explain the GPM understanding of the disorder among professionals, as we have already stated. It also justifies the amount of time dedicated to communication [8]. Indeed, the effectiveness of the stance relies on coherence between the different interventions of the cotreaters [23]. Unfortunately, professionals may fail to work together. A dysfunctional partnership is harmful to the patient and has to be addressed [23]. If a solution appears impossible to find, the network leader may have to ask the co-treater who does not stay within the framework to leave the team [23]. Keep in mind that this event may put the patient before a choice: “Whom shall I follow and why?”

Take-home messages of the section

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Patients with BPD have a tendency to develop idealised relationships.

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Offer “a real and professional relationship” and expose professionals’ main limit: neither “omnipotent” nor “clairvoyant”. It will help patients to feel connected and cared for in the end.

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The patient is the main actor in his/her changing and cannot rely exclusively on treaters.

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The network must monitor every intervention to ensure that it is coherent and that no treater is operating alone.

Interacting with a multidisciplinary network: a potentially deep and mixed relational experience for patients

The interactions between patients and the group of professionals appear as a reduced-scale society where patients re-enact their usual relational patterns and mechanisms. Consequently, from the patient point of view, the establishment of an adapted healthcare network often induces mixed feelings and reactions. The GPM core psychopathological concept – interpersonal hypersensitivity [19] – allows us to understand these reactions. We previously mentioned it in table 1. It states that BPD phenomenology shifts drastically in response to patients' interpersonal context. As such, clinical manifestations should urge therapists to look for interpersonal stress factors in their patients [24].

Patients who understand that professionals try to help them in a global way beyond psychological suffering alone often experience a relief. They feel cared for and hopeful that change is possible. What is more, the coherent message and active stance of the healthcare team bring them a feeling of content, which frequently induces less intense clinical presentations. As a result, it regulates impulsive behaviours which effectively soothe patients psychologically, but which also are harmful and dysfunctional [19]. This clinical evolution brings the possibility for patients to accept some help and opens the door to taking more time to think before acting. According to interpersonal hypersensitivity, this clinical contentment is an illustration that patients feel understood, supported and cared for by their surroundings and treaters. As long as this attitude persists, symptoms shall decrease and remain low [24].

The efforts of the team of professionals to prompt patients to develop an active involvement in the treatment may unveil contradictory attitudes. A common example of this manifestation is a clear desire for help from the patient associated with an actively passive outlook limiting the possibility to receive any assistance. Statements such as “When I’m doing better I shall deal with the issues in my life” or “I can be active again but someone must find me a suitable job or occupation” represent well this attitude. Early in treatment, professionals should question these contradictory expectations and express their doubts and “skepticism” regarding patients’ motivation for their passive stance and “level of dependency to the relationship” [12]. The combined efforts of every protagonist in the professional network should help the patient renounce passivity and instead take action progressively . In the optic of “a stepped care” [12] treatment, if the patient shows lasting difficulties in being active in achieving common objectives, treaters should suggest redefining more realistic objectives. Less ambitious but accessible is often a more efficient way to move on.

The intervention of a team of specialised medical and social staff may also induce negative reactions from patients who consider the team worthless and even hostile [25] at some point. According to interpersonal hypersensitivity, patients with BPD tend to feel insecure, disconnected and even threatened from a relational point of view when interpersonal stress factors show up [19]. For instance, patients may display devaluation and hostility because they feel abandoned or controlled by some professionals within the team or forced into directions they deem too demanding. Disagreements with treaters may also trigger a symptomatic outburst.

At this point, patients with BPD exposed to interpersonal stress factors tend to classify people into “good” or “bad” people. This is the “splitting” phenomenon developed by Melanie Klein [32]. Under stress, the patient fails to keep an integrated representation of people around them. It means that treaters or relatives do not have qualities and shortcomings any more. They are only “good” or only “bad”. We could also say that patients can only feel that people around are “with them” or “against them”. This classification only represents how patients can perceive themselves, either “good” or “bad”, but not integrated [32]. Interpersonal hypersensitivity allows us to understand that splitting is a defence mechanism that is psychologically efficient but very dysfunctional at the same time [24]. Its purpose is to decrease anxiety. To do so, it seeks to destroy the interpersonal stress factor. This disposition often induces relationships based upon a struggle for domination [30]. In this context, attempts to divide professionals is only a way to seize back control over the situation and the group by discarding members the patient deems “bad” [32]. This manifestation can concern all the professionals or only some of them. Ultimately, it exposes the patient to the risk of ending up alone and isolated if professionals are not able to contain these manifestations [24]. However, this process often impedes the course of the treatment, as if the patient chose in a time of confusion to battle health professionals rather than the symptoms.

Therapists should seize the opportunity to lean in and understand patients’ manifestations of hostility or aggression towards both themselves and others. This clinical feature is a core dimension in severe personality disorder and must be addressed to bring change. The GPM model of interpersonal hypersensitivity [19] is an efficient tool for talking about these aspects and showing patients that their reaction is likely due to a feeling of threat and disconnection instead of a sense of confidence and a feeling of support from the network. Coming back to the coherent and common message of the professionals and the objectives agreed on with the patient can help to overcome this kind of crisis and bring him or her back to a connected state [19].

Take-home messages of the section

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Assess patients’ reactions to the interactions with the team: relief, contradictory attitudes, threat, aggressivity, etc.

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Address these reactions and help patients consider their consequences.

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Rely on the interpersonal hypersensitivity model to help patients explore and regulate these reactions.

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“Splitting” is a common clinical manifestation among patients with BPD. It effectively soothes patients from a psychological point of view. However, it is very dysfunctional at the same time.

The healthcare network: an evolving therapeutic tool with a beginning and an end

A professional healthcare network evolves along with the patient’s situation. In many situations, our experience is that the network becomes silent at some point. This occurs when every member knows what to do and how to do it. Simultaneously, it reflects the fact that the patient is able to rely actively and appropriately on this extended offer of care. The result is often decreased clinical intensity and the achievement of objective life changes (picking up an activity, training or a job, finding a suitable living place, less conflict in relationship, less isolation, etc.).

As a component of sociotherapy, the network should always question how relevant its presence or range is. Indeed, professionals should steadily monitor how useful their combined efforts are and whether they are adapted to the patient’s situation. For a time, patients need to depend on others’ skills to move on. However, at some point, we wish them to acquire some of these skills to move on in their lives in a more autonomous way [33].

There is no predefined course for a professional network. Patients only know from the beginning that the treatment is not meant to last forever [24]. Members may join and leave the team depending on the situation, patients’ needs and professionals’ point of view. The evolution of the professional network becomes an illustration of the possible evolution of a social group in the real life.

Being able to define with the patient when members of the team have achieved their purpose or that the network should be dismissed is also part of the treatment. This aspect is essential for BPD patients because of their difficulties in facing interpersonal stress factors and espacially separation. The evolution of the network allows patients to test the evolution of their relational skills in a secure setting. It also enables them to develop resilience in a secure environment, a skill indispensable in reaching recovery and rehabilitation [36]. Indeed, resilience is fundamental to building vocational competence and to deal with hard-to-handle features of temperament.

Take-home messages of the section

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The network illustrates the evolution of a real social group in real life.

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Interacting with the network and its evolution helps the patient develop resilience and social skills.

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Patients are expected to draw on the professionals’ skills to develop skills of their own.

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At some point, the professional network shall be dismissed.

A clinical situation

We would like now to share with the reader a clinical situation in order to illustrate our point. It shall be found in the appendix: “Start low, go slow, but steadily”.

Conclusion

Our experience with BPD patients led us to consider that the establishment of an individualised and adapted professional network is essential to addressing the wide range of issues this specific population faces. Beyond clinical content, the most significant impact of a specialised team of multi-disciplinary professionals is the capacity to alter and if possible treat the impact of BPD on patients’ vocational and social functioning. The involvement of social workers, for example, may enable patients to access specific reintegration pathways that therapists alone might never have been able to open.

Because of the effect of social and vocational factors on BDP patients’ prognosis, we consider that the deployment of an adapted multi-disciplinary professional network is a necessity worth the cost [27]. What is more, intervention late along the patient’s trajectory only increases the level of challenge they will have to face alongside their therapists. Thus, we consider that an adapted, early and extensive intervention for BPD patients is a “good enough” investment from a public health point of view.

Creating an appropriate setting of sociotherapy for patients with BPD through the building of an adapted and dynamic multidisciplinary network is a therapeutic field that requires more investigation in order to validate the clinical results we observed. It would be valuable to assess more accurately its impact on patients’ trajectories and would allow the definition of recommendations based on the clinical and social features of the patients. From this perspective, it would be interesting to take into consideration the unique position of patients’ relatives. At the crossroads between healthcare beneficiaries and those who provide assistance, their capacity to get involved in a beneficial and well thought-out manner, their limits, their needs and their specific interactions with both patients and professional teams should be integrated into further investigation.

Take-home messages

The reader shall find below all the key messages that emerged chronologically throughout the article, section after section. They should help build and then manage a healthcare network for patients with BPD. It is most useful to navigate back and forth from one section to another during therapy to check that nothing important has been overlooked. The case vignette in the appendix of the article uses these take-home messages as milestones to illustrate the therapeutic process.

Investigation

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Define patients’ problems and hierarchize them.

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Select adapted and coherent network members and choose a leader.

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Check and update GPM knowledge among network members.

Coordination and communication

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The leader manages the mailing list and ensures periodic meetings (e.g. every 3 months).

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Ensure a good communication among members and between the patient and the team.

–

Professionals must be pro-active and share comprehension of the situation.

–

Monitor patient and network evolution.

Social and occupational aspects

–

Assess patient’s ability and motivation to work or to be occupied.

–

Shake the belief that one has to get better to get a life. Getting a life helps getting better.

–

Include social services in the network to find reinsertion pathways.

The GPM recommended stance

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Patients with BPD have a tendency to develop idealized relationships.

–

Offer “a real and professional relationship” and expose professionals’ main limit: neither “omnipotent” nor “clairvoyant”. It will help patients feel connected and cared for in the end.

–

The patient is the main actor of his/her changing and cannot rely exclusively on treaters.

–

The network must monitor that every intervention is coherent and that no treater is riding alone.

Clinical reactions

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Assess patients’ reactions to the interactions with the team: relief, contradictory dispositions, threat, agressivity, etc.

–

Address these reactions and help patients consider their consequences.

–

Rely on the interpersonal hypersensitivity model to help patients explore and regulate these reactions.

–

“Splitting” is a common clinical manifestation among patients with BPD. It is effective to soothe patients from a psychological point of view. However, it is very dysfunctional at the same time.

An adapting tool

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The network illustrates the evolution of real social group in real life.

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Interacting with the network and its evolution helps the patient develop resilience and social skills.

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Patients are expected to draw on the professionals’ skills to develop skills of their own.

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At some point, the professional network shall be dismissed.