Hospitalization of Persons with BPD
Persons with BPD constitute an oversized percentage of persons found in inpatient hospitals. They often end up there after contact with police or through the emergency room, and a suicide attempt or suicidal thoughts. Once there, however, the care they receive is generally not well tailored to their symptoms.
Borderline Personality Disorder (BPD) affects between .7-2% of the population. Research indicates anywhere from 3-10% of persons with BPD will eventually commit suicide. Despite the seriousness of this disorder, most persons with BPD who are receiving mental health treatment are not receiving BPD specific treatment. The result is often poor management of symptoms, high utilization of emergency rooms, and a disproportionate rate of admittance or commitment to inpatient psychiatric hospitals.
Persons with BPD are disproportionately found amongst “high-utilizers” of this system. The American Psychiatric Association’s “Guidelines for the Treatment of Borderline Personality Disorder” suggest a liberal use of hospitalization (Paris, 2004). However, the care such persons tend to receive while in the hospital tends to be quite poor; it is generally non-specific to their symptoms, and tends not to reduce their symptoms. Few hospitals offer comprehensive DBT treatment, for example, for their patients with BPD.
It is clear many persons with BPD enter psychiatric hospitals through the emergency department or through contact with police, after suicide attempts, gestures, or struggling with suicidal ideation. One study (Comtois & Carmel, 2016) investigated the relationship between BPD and hospitalization. Amongst a random sample of psychiatric inpatients, about 10% met criteria for BPD. Amongst “high-utilizers,” persons with a high number of hospitalizations, the figure rose to 42%.
Experiences of Persons with BPD While Hospitalized
This same study also found that the clinical record for such patients did not generally reveal a diagnosis of BPD: this was only discovered during clinical interviews conducted as part of the study. This suggests that persons with BPD, even though they are over-represented in an inpatient sample, are not being treated as BPD patients, nor are they receiving specific BPD treatment.
Katsakou et al. (2012) interviewed persons who had previously been involuntarily committed to investigate their attitudes towards their commitment. Most of the participants agreed that had been “unwell” and “out of control” prior to their commitment. Those who agreed that their commitment was the correct decision were those who believed the process averted further harm that was likely to have occurred. Those who believed their commitment was wrong, and those who were ambivalent, tended to endorse the idea that a lesser level of care would have been sufficient to prevent greater harm.
Is Hospitalization Helpful for Persons with BPD?
Commitment does not appear beneficial for persons with BPD if the reason for admission is suicidal threats, overdoses, or self-mutilation (Paris, 2004). It appears commitment often does not reduce suicidal behavior. It is thought this is because, often, the responses by treatment providers in inpatient units to suicidal behavior serves to actually reinforce the behavior. In addition, commitment does not reduce suicidal ideation, either during or after the commitment has ended. It is likely, however, that involuntary commitment is generally beneficial if a person with BPD is admitted after a psychotic episode, rather than a suicide attempt.
Though many persons who are involuntarily committed have BPD symptoms, the treatments generally provided in such settings are not geared to such patients. For example, psychopharmacology is an important component in inpatient treatment, though such treatments are generally not effective for reducing BPD symptom severity (Oud et al., 2018). While medication (including forced medication) is beneficial for patients with psychotic or manic symptoms (especially when commitment follows a period of medication non-compliance), it does not tend to stabilize persons with BPD in the same manner.
It appears inpatient treatment for persons with BPD, even if all the shortcomings discussed above are addressed, is very cost-ineffective. One study examined an inpatient program specially designed for persons with BPD. The program required three months of inpatient care, followed by 6 months of step down care. Outcomes were only slightly better than for outpatient BPD treatment, while costing about 20 times as much as outpatient treatment.
The Negative Experiences of Hospitalization of Persons with BPD
Persons with BPD are often treated more poorly than other inpatients. In one metareview, Dickens, Lamont, & Gray (2016) examined the attitudes, behaviors, and knowledge of mental health nurses towards and about persons with BPD. They considered forty studies, both qualitative and quantitative. Their overall finding was that mental health nurses often display attitudes and behaviors towards persons with BPD that is counter-therapeutic. In addition, they found that studies of interventions designed to improve the quality of care for persons with BPD were largely ineffective. The authors stress the need for both professional education about BPD, and the development of more “coherent therapeutic frameworks” for how to treat and relate to BPD inpatients. They suggest that more observational research be performed in order to inform and guide the development of these frameworks.
Another study found that psychiatrists and nurses working in inpatient hospitals held more negative attitudes and less empathy towards patients diagnosed with BPD (Bodner et al., 2014). In addition, higher negative attitudes were correlated with higher levels of recent contact with patients diagnosed with BPD. Psychiatrists were found to be especially uninterested in treating, or receiving additional training on how to treat, clients with BPD. Providing BPD specific therapies for BPD in-patients would require additional training, but research indicates that the overall costs would be much lower over time than not providing BPD specific therapies.
Overview
Generally, the use of involuntary commitment for persons with BPD is not supported by the evidence, for many reasons. First, most persons with BPD are not even identified as such after being involuntarily committed. Studies have identified persons with BPD based in clinical interviews after their commitment, and most of those persons were not identified during the admission to the hospital, nor during their time as inpatients.
Second, the quality of care is generally low, and tailored towards a different population. It is rare for persons with BPD to receive BPD specific treatment. In many inpatient hospitals the only treatments provided are milieu therapy, groups, medication, and occasional (often brief) discussions with some kind of mental health provider. While these approaches may help to stabilize acutely and severely mentally ill patients, they often fail to address why persons with BPD tend to end up committed.
Third, this approach not only fails to address and reduce BPD symptoms, but it often reinforces them. Suicidal behavior in particular tends to result in more attention from staff, which can increase the behavior. Even when this contingency is obvious, protocols often require staff to continue (and even increase) this ineffective response.
Fourth, there is evidence that persons with BPD are treated more poorly than other types of inpatients. Staff tends to have less empathy towards persons with BPD, which may result in them receiving poorer care.
Finally, even if quality of care for patients with BPD was high, it appears that the inpatient aspect is unnecessary. In more severe cases it might be slightly beneficial for some period of time, but the costs are so much higher than outpatient care, and the improvement so slight, that a cost-benefit analysis generally does not support commitment for persons with BPD alone.
Here at FRTC, we offer a comprehensive DBT treatment program for persons with BPD. Contact us today to learn more about how a DBT therapist can help you reach your goals.
