Written evidence submitted by Shereen Hussain (PhD Candidate at City St George’s University of London) (CMH0071)

Community Mental Health Services Inquiry

Improving services for people with Borderline Personality Disorder

Shereen Hussain

Summary

This brief focuses on improving community mental health services for adults with Borderline Personality Disorder, a severe mental health condition affecting 1-2% of the UK population over their life course.

It will draw on evidence from a research project interviewing people with BPD about their experiences of accessing mental health care (1).

This brief is authored by Shereen Hussain, a PhD candidate at City St George’s University of London, specialising in Population Health, with a focus on mental health.

What does high quality care look like for adults with severe mental illness?

This brief will focus on care for people with Borderline Personality Disorder (BPD) only. BPD is also referred to as Emotionally Unstable Personality Disorder (EUPD).

5 different talking therapies are effective in treating BPD:

• Dialectical behaviour therapy (DBT)
• Mentalisation-based treatment (MBT)
• Schema-focused therapy
• Transference-focused psychotherapy
• Systems training for emotional predictability and problem solving

Both DBT and MBT are offered on the NHS. They have been shown to be effective when implemented according to the intended guidelines (2). They should be 12 months or longer – longer-term interventions are more likely to prevent relapse (3). However, a lack of healthcare providers in the NHS who are appropriately trained to carry out BPD treatments can prevent these services from being implemented equitably across the UK (4).

The current evidence base shows that people with BPD face stigma and discrimination from healthcare staff (5,6). Participants from the research project interviews recalled experiences of being dismissed and facing judgement from healthcare staff. They also felt that staff did not understand BPD very well. This resulted in subsequent difficulties accessing appropriate care (1).

Recommendations:

• Introducing staff training and creating resources to increase awareness of conscious and subconscious biases around mental health conditions.
• Revisiting the term ‘personality disorder’ to reduce stigma (7).
• Giving patients who use BPD treatments greater choice over their treatment and treatment provider.

How could the service user journey be improved in community mental health services?

The NICE guidelines outline a pathway to access treatment for BPD on the NHS, as shown in the diagram below.

However, in reality, the service user journey to access appropriate treatment for BPD on the NHS does not follow this pathway. The evidence base and interviews from the linked research project (1) show that pathways to accessing BPD treatment are often unclear and disjointed (8).

Barriers experienced throughout the patient journey included:

• Being inappropriately discharged from the Community Mental Health Team (CMHT)
• Not receiving referrals or appropriate follow-ups to enable access to the specialist services
• Having to present with very severe symptoms in order to be able to access appropriate care (‘symptom thresholds’).

Symptom thresholds present a significant issue to patient outcomes. Due to limitations in resources, these ‘thresholds’ have been introduced to determine patient eligibility for the limited services available (9-11). However, this often results in people with BPD being discharged from intermediary services (the CMHT) and/or rejected from specialist services, unless they present in suicidal crisis or following self-harming. This can result in distressing experiences for people with BPD and can worsen their mental health outcomes (1, 10).

A lack of staff continuity can affect the quality of care that service users receive. This can result in patients’ having to provide histories multiple times or re-do their assessments with different staff members, which can hinder progress through the treatment pathway and increase patient disillusionment (1).

Recommendations:

• Creating an accessible care framework (12) and making this available to the general public. This will help to make service pathways clearer and more accessible for people with BPD.
• Creating treatment pathway guidelines for clinicians to use, and ensuring these are implemented in health services.
• Introducing staff training around personality disorders, so people with BPD can be referred to appropriate services more efficiently.
• Increasing staff continuity in community mental health services.

How could access be improved across the country?

NHS DBT and MBT services are inequitably distributed across the UK, often referred to as a ‘postcode lottery’. They are more concentrated in urban areas, and are often not available through the NHS in rural areas (4). These geographical and financial barriers may widen health inequalities (13).

Recommendations:

• Increasing availability of specialist services around the country.
• Innovative methods to increase service capacity for BPD treatments include:
• Making services available online (i.e. offering virtual appointments for specialised therapy)
• Integrating digital and e-health apps (14,15)
• Delivering an adapted version of DBT/MBT in non-specialist settings.

References

1. Hussain, S (2024). “It’s just exhausting”: A qualitative study investigating experiences of access to treatment for Borderline Personality Disorder in the UK. Master’s dissertation. The London School of Hygiene and Tropical Medicine.
2. Hernandez-Bustamante et al, 2024. Efficacy of Dialectical Behaviour Therapy in the Treatment of Borderline Personality Disorder: A systematic review of randomised controlled trials. Iran J Psychiatry. 2024 Jan;19(1): 119-129.
3. Beatson J. Making psychological treatments for borderline personality disorder available. Australas Psychiatry. 2019;27(6):545-6.
4. National Collaborating Centre for Mental Health (UK). Borderline Personality Disorder: Treatment and Management. The British Psychological Society and The Royal College of Psychiatrists. 2018.
5. Lawn S, McMahon J. Experiences of care by Australians with a diagnosis of borderline personality disorder. J Psychiatr Ment Health Nurs. 2015;22(7):510-21.
6. Carrotte E, Hartup M, Blanchard M. “It's very hard for me to say anything positive”: A qualitative investigation into borderline personality disorder treatment experiences in the Australian context. Australian Psychologist. 2019;54(6):526-35.
7. Motala Z, Price O. ‘Commanded to be ill, accused of being well’ a lived-experience-led, qualitative investigation of service user perspectives on the impact of emotionally unstable personality disorder diagnosis on self-concept. Journal of Mental Health. 2024;33(1):22-30.
8. Proctor JM, Lawn S, McMahon J. Consumer perspective from people with a diagnosis of Borderline Personality Disorder (BPD) on BPD management-How are the Australian NHMRC BPD guidelines faring in practice? J Psychiatr Ment Health Nurs. 2021;28(4):670-81.
9. Dixon-Woods M, Cavers D, Agarwal S, Annandale E, Arthur A, Harvey J, et al. Conducting a critical interpretive synthesis of the literature on access to healthcare by vulnerable groups. BMC Med Res Methodol. 2006;6:35.
10. Ware A, Preston A, Draycott S. “It doesn’t get taken seriously until it gets bad”: experiences of risk management from people diagnosed with a borderline personality disorder. Mental Health Review Journal. 2022;27(3):333-47.
11. Wehbe-Alamah H, Wolgamott S. Uncovering the mask of borderline personality disorder: Knowledge to empower primary care providers. Journal of the American Association of Nurse Practitioners. 2014;26(6)
12. Cailhol L, Ragonnet C. Besoins ressentis des patients et des soignants quant à la prise en charge des troubles de personnalité limite. Annales Médico-psychologiques, revue psychiatrique. 2013;171(2):100-3.
13. Broadbear JH, Rotella JA, Lorenze D, Rao S. Emergency department utilisation by patients with a diagnosis of borderline personality disorder: An acute response to a chronic disorder. Emerg Med Australas. 2022;34(5):731-7.
14. Schiffler T, Seiler-Ramadas R, Stefanac S, Haider S, Mues HM, Grabovac I. Implementation of a Mobile DBT App and Its Impact on Suicidality in Transitional Age Youth with Borderline Personality Disorder: A Qualitative Study. Int J Environ Res Public Health. 2022;19(2).
15. Xie Q, Torous J, Goldberg SB. E-Mental Health for People with Personality Disorders: A Systematic Review. Curr Psychiatry Rep. 2022;24(10):541-52

February 2025