New Study on Telehealth as Borderline Personality Disorder Treatment

Despite treatment for borderline personality disorder (BPD) being difficult to access, no published study had examined the efficacy and safety of telehealth treatment for borderline personality disorder (BPD). The current studies that do evaluate telehealth focus on outpatient settings in people without BPD.

Given the complexity and intensity of the symptoms (e.g., self-injury, suicidal ideation, rapid fluctuating emotions, impulsivity, frantic
efforts to avoid abandonment), efficacy and safety considerations have to be made to best adapt telehealth treatment for people with borderline personality disorder. These considerations are especially true for partial hospitalization programs, where people with BPD may be at risk for suicidal and aggressive ideation, may be transitioning from inpatient hospitalization or may need a higher level of care.

A new study published in November 2021 from the Rhode Island Methods to Improve Diagnostic Assessment and Services project adapted telehealth partial hospitalization treatment and found that it was just as effective as their in-person partial hospitalization treatment in treating people with BPD. Full access to the study can be found here. The Rhode Island Hospital Adult partial hospital program transitioned to a virtual format when the COVID-19 pandemic began.

Patients in the virtual and in-person partial hospitalization program were compared on effectiveness, satisfaction and safety. Both treatment modalities remained similar in their structure and content. Specifically, the study found that patients in both groups reported significant improvement in functioning, coping ability/stress tolerance, positive mental health and general well-being.

By program completion, more than 95 percent of patients in both the virtual and in-person program reported they were very or extremely satisfied with their treatment. Likewise, more than 95 percent indicated they would recommend the treatment to a family member or friend.

Given the risk mitigation strategies in the virtual program, which can be perceived as burdensome or intrusive, the high levels of patient satisfaction in both groups warrants considerable attention. The safety strategies included daily check-ins, daily updates and information on patient location/physical address, on-call clinicians for emergencies and an emergency contact person.

The researchers followed a transdiagnostic approach, meaning they used a treatment and measure that targeted the above mentioned areas of improvement (functioning, coping ability/stress tolerance, positive mental health, and general well-being) more broadly. Some patients in the study were also assigned to the borderline personality disorder specialty track. Thus, one limitation of the study is the lack of a BPD outcome measure. Still, the study highlights transdiagnostic improvements that can be made in BPD.

Program completion and attendance were also assessed. The study demonstrated that the virtual program attained a higher attendance rate. This result may attest to the accessibility of a virtual format. The authors described that some of the patients in the program had medical conditions that made in-person treatment attendance more difficult to manage. Notably, several patients who were treated in the virtual program described that even in the absence of a pandemic, they would not have presented to in-person treatment. Limited transportation options and parenting were two other accessibility concerns.

This study highlights several key factors those of us with borderline personality disorder encounter in our treatment. We often encounter considerable difficulty accessing quality treatment given the shortage of BPD practitioners, stigma, location and other barriers (e.g., financial). BPD may require a combination of treatment approaches and multidisciplinary teams, such individual therapy, group therapy, or intensive outpatient programs.

Potential comorbidities can further complicate treatment. BPD is known to present with considerable comorbidity, including psychological conditions such as depression, physical health symptoms, and other disabilities.

For example, one study found greater BPD symptom severity was associated higher rates of later physical health problems, such as headaches, dizziness, stomach aches, back pain, bruises, muscular problems, colds and coughs, even when controlling for depression and anxiety. Another study indicated that while BPD is present in about 1-2 percent of the population, the rate was
around 30 percent for chronic pain patients (e.g., fibromyalgia, chronic back pain). The presence of BPD appeared to intensify pain scores.

In my experience with treatment, accessibility issues were an unbearable predicament that overshadowed my decision to drop out and stop pursing treatment. If I did experience a benefit, such as learning a new skill, the potential progress was significantly reduced due to numerous accessibility issues, and progress did not remain over time.

I started treatment at 10 years old and was treated by approximately seven different mental health specialists by the time I was 22. Accessibility issues in treatment fostered feelings of shame, hopelessness, mistrust and being misunderstood.

For example, my severe sleep disorder and depression that accompanies borderline personality disorder increased further complications. One of my psychologists usually scheduled me for morning appointments, despite my opposition, to which I would arrive 20 minutes late with only an hour or two of sleep that night. The fact that treatment decreased my sleep and compelled me to drive for long periods of time while sleep deprived produced a negative impact on my well-being. I frequently cancelled appointments and dropped out with little to no improvement.

I also live with many other disabilities, including postural orthostatic tachycardia syndrome (POTS). This condition can limit my mobility at times or prevent me from driving. During periods of increased symptoms, along with depression, it may not always be possible to attend treatment, get out of bed or leave the house. It seemed the reasons I needed treatment prevented me from receiving it, and no one cared.

People who need virtual or hybrid options for treatment have been advocating to receive it long before COVID-19. We were often denied services that were suddenly created during the pandemic. One significant barrier to this progress is insurance approval/reimbursement, which can hinder attempts to increase accessibility unless appropriate policies are made.

It is crucial that virtual options remain post-pandemic, and studies such as these remain an important part to advocate for that change.