In total 18 patients were interviewed in order to ensure data saturation of themes and a sufficiently diverse set of perspectives. We attempted to ensure we had patients with varied therapy exposure and different characteristics (age, gender, history of treatment and exposure to different therapy models). The number of therapists patients had engaged with varied. Almost half (44.4%) of the patients had engaged with one to three therapists, while one patient had 19 therapists across her treatment history. The sample ranged in age from 19 to 46, there was a mix of genders and there were differences in vocational and employment characteristics. All patients met lifetime criteria for BPD and 17 (94.4%) currently met criteria. All clinical and demographic data can be seen in Table 1. All identified with the view that recovery was a journey and were able to discuss both challenges and success in their treatment course. At the time of the interview, 12 of the 18 (66%) patients felt they were responding well to treatment despite current challenges, and four felt they had not yet reached a recovery phase. There were no demographic or clinical differences between these two groups of responders and so all were analysed as a single sample as representing a range of views.
Table 1. Demographics, Diagnosis and Treatment Information
|
|
N (%)
|
M (SD)
|
Range
|
Total N
|
18
|
|
|
Non-Binary People
|
2 (11.1)
|
|
|
Females
|
13 (72.2)
|
|
|
Males
|
3 (16.7)
|
|
|
Age
|
|
29.4 (8.0)
|
19 - 46
|
Occupation
|
|
|
|
|
Full Time Employment
|
4 (22.2)
|
|
|
|
Part Time Employment
|
6 (33.3)
|
|
|
|
Unemployment Benefit
|
3 (16.7)
|
|
|
|
Student Allowance
|
2 (11.1)
|
|
|
|
Pension
|
3 (16.7)
|
|
|
Currently studying
|
18 (100)
|
|
|
Currently in a relationship
|
9 (50)
|
|
|
Currently taking psychotropic medication
|
8 (44.4)
|
|
|
Currently in treatment
|
12 (66.7)
|
|
|
Primary Therapist
|
|
|
|
|
Psychologist
|
11 (61.1)
|
|
|
|
Counsellor
|
1 (5.6)
|
|
|
|
Social Worker
|
1 (5.6)
|
|
|
|
No longer in treatment
|
5 (27.8)
|
|
|
Months in treatment with current therapist
|
|
15.3 (9.7)
|
2 - 36
|
Number of therapists engaged with
|
|
|
|
|
1 - 3
|
8 (44.4)
|
|
|
|
4 - 7
|
5 (27.8)
|
|
|
|
8 - 11
|
4 (22.2)
|
|
|
|
12 - 19
|
1 (5.6)
|
|
|
No. BPD criteria currently endorsed (out of 9)
|
|
5.6 (2.7)
|
0 - 9
|
No. BPD lifetime criteria (out of 9)
|
|
7.5 (1.5)
|
5 - 9
|
Patients currently meeting criteria for BPD
|
17 (94.4)
|
|
|
Patients who previously met criteria for BPD
|
18 (100)
|
|
|
Lifetime comorbid diagnoses
|
|
|
|
|
Depression
|
17 (94.4)
|
|
|
|
Anxiety
|
16 (88.9)
|
|
|
|
Obsessive Compulsive Disorder
|
2 (11.1)
|
|
|
|
Bipolar Disorder
|
7 (38.9)
|
|
|
|
Phobias
|
3 (16.7)
|
|
|
|
Attention Deficit-Hyperactivity Disorder
|
3 (16.7)
|
|
|
|
Post Traumatic Stress Disorder
|
10 (55.6)
|
|
|
|
Complex Post Traumatic Stress Disorder
|
6 (33.3)
|
|
|
|
Eating Disorder
|
2 (11.1)
|
|
|
Four broad overarching domains consisting of twelve themes were constructed from the insights patients shared on non-response to psychotherapy for BPD. Domains and themes are depicted in Figure 1.
Domain 1: Community Non-Response Factors
Domain 1 captured the common recognition among patients that certain broader environmental, social, and service provider pre-conditions must first be met before psychotherapy can commence and be effective.
Theme 1: Safety and stabilisation. ‘Therapy only works if you are safe, stable and supported’.
Theme 1 was generated from discussions regarding the necessity of having stability across multiple life domains before one can engage consistently in therapy. The required factors were to be free from living in active trauma, to have a safe and stable environment with minimal chaos and a supportive social network. Patient – ‘…where before I was in this chaotic position, I was really struggling in a lot of aspects of my life. Very – you know, struggling to maintain jobs and really struggling with living circumstances and, particular hard life events that were happening. Whereas I’m in a much better position now. If something bad does happen I can cope with it because I’m settled. I’m not in the constant chaotic mess.’ Patients also described the necessity of having people in their lives that understood the validity of mental health problems and supported them to get professional help, instead of holding stigmatised attitudes about mental illness. Encountering unhelpful attitudes in patient’s social environments were described as shame inducing, which acted as a barrier for them to be able to seek and engage consistently in therapy. Patients explained that without first reaching a level of safety and stability in their external environments, they could not reach a level of psychological stability and safety required to truly engage in and benefit from therapy. Patient – ‘Like I feel like the person really needs to be in a safe place for therapy to kind of work effectively, because it is requiring so much vulnerability, it's hard to imagine someone whose been living in active trauma to like, get benefit from something like talk therapy, unless they're obviously being empowered to leave that abusive situation. But it's just like, I feel like the vulnerability required for it to be super effective and efficient and really life-changing requires like a foundation of some kind of safety for the person so that they can kind of, you know, undress and strip down and figure out what's going on.’
Theme 2: Accessibility. ‘Therapy only works if you can get it’.
Patients noted that for therapy to be effective you must first be able to access it. While patients discussed the lack of information available regarding how to access therapy, the main concern was the lack of therapists available. Patients described encountering long waiting lists and long periods between appointments as barriers to engagement. Some patients reported services to be so overburdened that consistent appointments with the same therapist were often unobtainable. Patients viewed this situation as unacceptable, especially when people experience acute crises and need immediate and frequent care. Patient – ‘… especially when people – I know that people who suffer from this borderline personality or people who are, um in this intense kind of crisis mindset, it’s really immediate attention that they need, with regular appointments, and I know that I’ve gone to my doctor at times and said, “I am here because I don’t know what to do. My appointment is not for another two months because I couldn’t get in and I really need to talk to someone now, I need to do something now.’ Patients also expressed exasperation about discussing past trauma in session, only to be left alone with open emotional wounds because the next available appointment was not for many weeks. Another frequently cited barrier to obtaining therapy was affordability. It was consistently recognised that the public healthcare system may be inaccessible due to being overburdened, while private psychologists, who also have long wait lists, are too expensive even after accounting for government subsidies. Patient – ‘… there’s just not enough, you know, spaces, appointments, especially in the public health system. And Medicare [governmental subsidies for private psychological treatment] doesn’t cover the full fee. I had – I had to cancel appointments when I was younger because I just couldn’t afford it at the time.’
Domain 2: Patient Non-Response Factors
Domain 2 was informed by retrospective insights about what patients considered they were doing to contribute to their non-response.
Theme 3: Denial. ‘Therapy didn’t work when I was stuck in denial that I needed and deserved help’.
This theme is drawn from the recognition of patients that, in hindsight, being stuck in denial had impeded their ability to effectively engage in therapy. Patients described how in the past they were in denial about how unacceptable their living situation was, how toxic or abusive their relationships were, and how poor their mental health was. Patient – ‘… I found that there was a few things that I was lying to myself about. And not admitting to how badly some things were affecting me. Some external factors, like how people treated me, and how much I actually took that on myself, and how much that played on my schemas of feeling inferior and feeling worthless. Because I would tell myself that, you know, that's, that's just how it is, I'm used to it now. It's okay.’ Patients described this as a stage of denial that had to be progressed through before they could take the initial step of admitting that there was a problem and that they needed help. Patient – ‘So obviously it sunk me down into more darkness first, but I think you have to hit rock bottom before you can be out of that denial stage, it needs to kind of hit you like a tonne of bricks.’ Furthermore, patients noted that progressing through their denial phase was contingent on developing enough self-worth and the resolve that they deserved for things to be different. Patient – ‘ I just think that I needed to realise that I did matter because I didn't really see myself as an important or that it would make a difference whether I was here or not.’ Patients acknowledged the need to be brave enough to embrace the vulnerability that came with letting go of defences, of letting the therapist in, and of baring the whole truth, so the therapist could provide suitable help. Patient – ‘So I was dishonest in therapy and I was kind of like beating around the bush trying to get help without being completely honest, because I was scared of being honest.’
Theme 4: Responsibility. ‘Therapy didn’t work when I was unwilling to accept responsibility for my role in contributing to my problems’.
Patients understood that after they resolved their denial, and accepted they needed help, they also needed to accept that that their behaviours were perpetuating their mental health problems. Patient – ‘… possibly not willing to look intensely at their own behaviours that sort of contribute to the issues they may be having in their life… and kind of scrutinising your behaviours and your thought processes’. Patients acknowledged that this process can be very painful, yet necessary. Patient – ‘Oh, like, well, it’s never going to be comfortable to admit that maybe you’re doing something wrong or that maybe you’re the problem in situations.’ This process was said to help patients move past using therapy solely as a space to vent (pour out problems without taking action to resolve them). Patient – ‘Because if you're just going to go into your sessions, and just want to whinge and moan about how hard your life is, and how the world’s against you, and how horrible things are, then if you're not delving into the actual reasons why you feel that way, then I just don't think you've got any, any platform to work on.’ Patients spoke of the importance of no longer using therapy to vent, and instead as a place to take full accountability, which requires an ability to tolerate high levels of discomfort. Patient – ‘Like, if you can’t take responsibility for or understand that your experience in the world is all based on perspective, as opposed to it all just happening to you, I think that that’s when people might find it really tricky.’ Acceptance of responsibility was described as letting go of old coping strategies that were no longer functional. Patient – ‘Um, I think I just reached a point where I became very aware that the coping mechanisms that I had developed from a very young age were no longer serving me, or benefiting me in any way. I had to become very willing to let go of that and learn new strategies, but that can almost be quite difficult in itself because it’s like these defence mechanisms and coping strategies, they’re almost like a dysfunctional old close friend in a way.’
Theme 5: Commitment. ‘Therapy didn’t work when I was unwilling to do the hard work, inside and outside of sessions, required for change’.
Patients recognised that they must accept that they need help, then accept that they are contributing to their problems, and finally that they need to commit to exerting consistent effort inside and outside of sessions to make lasting change. The recognition that they had some power to change was described as the first step. Patient – ‘… instead of sitting there just freaking out. Like I said, it’s hard to get out of that freak-out stage but there needs to be something like a trigger there that goes, ‘hey, hang on a second, you can do something about this.’’ This was followed by the realisation that change, although hard, is the responsibility of the patient. Patient – ‘I feel, actively choosing is probably the best way, because look, I’ve been in a place where you feel like you can’t, and you don’t want to, like, it’s all too hard and you think you’ve got no one else can help you and, well I can’t – it comes down to yourself’. Patients described how the realisation of how much continual work they had to do as overwhelming, but it was exactly what was required. Patient – ‘but you know, their victim mentality can sort of come into play a bit; not wanting to take responsibility for the effort that they have to put in because therapy is more than just talking for an hour once a week or once a fortnight. It’s a lot of work that consumes every day.’
Domain 3: Therapeutic Alliance Non-Response Factors
Domain 3 was created from the insights patients shared about a perceived lack of safety in the therapeutic alliance, and what therapists do to contribute to non-response.
Theme 6: Effective therapy depends on an early alliance. ‘Therapy only works if you click with your therapist’.
The majority of patients asserted that the effectiveness of psychotherapy was contingent on an immediate, safe and secure therapeutic alliance. Patient – ‘I think one of the biggest and most important things is having a therapist that you feel safe with and you can trust and you just click with.’ Patients used many words including ‘click’, ‘vibe’, gel’, ‘symbiosis’, ‘connection’, ‘bond’, to discuss the therapeutic alliance. Although the click was a difficult phenomenon to articulate, and patients were at times unsure of what ‘it’ was, all patients were confidently sure of whether it was or was not present, and of its profound importance. Patient – ‘ I imagine that that gel is what a lot of people would talk about because it's very there or not there. And — and yet it's not tangible.’ Patients felt that the click happened almost immediately, instinctively and below conscious awareness. Patient – ‘… you can pick it when you start interacting with someone if you are down with them. I think it’s just a human instinct. Like, an instinctual thing.’ Patient - Oh it’s definitely not conscious’.
Patients noted that you could not force the ‘click’; it was reported to either happen naturally or not at all. Patient – ‘…it's just like the connection that you feel, like a natural connection.’ Patient – ‘I think it's like falling in love with someone, right? Not that you fall in love with them. But when you've got chemistry with someone — you either know if it's there and you can build on that or you don't …’ Accordingly, the patients’ advice was invariably to keep trying different therapists until one was found that could be ‘clicked’ with. Patient – ‘They’d just have to keep trying different people until they connect with someone.’ There was also a recognition that searching for a therapist you can connect with is a difficult and costly task. Patient – ‘…the problem itself … that we’re talking about at the moment is an extremely hard one to solve without trial and error. So from a 10-session perspective, unless you get that connection you're going to lose 20% of your, um, healthcare plan [governmental subsidies for private psychological treatment]’.
Theme 7: Therapist disengagement creates disengagement. ‘Therapy doesn’t work when therapists don’t genuinely care about me’.
This theme was created from patient observations of therapist behaviours that indicated a lack of motivation and investment in the therapeutic relationship or genuine care in the patient and their recovery. Patient – ‘And it just kind of felt like they were going through a workbook, essentially, like, I’ve got to do step one and then step two...’ Patients asserted that therapy does not work when therapists did not listen or take their concerns seriously, then sent them home with handouts or advised that meditation apps would make things better. Other therapist behaviours perceived to indicate disengagement and lack of care were not maintaining common courtesies and not holding the therapeutic frame, i.e., being late, answering calls and typing in session. Patient – ‘… it felt dismissive because she would just keep giving me paperwork on breathing techniques and, like, here’s some recent studies on anxiety and depression. Go home and study up about your own mental health. And her phone would be going off and she’d be like, ‘Oh sorry, it’s just my daughter’. And she’d be typing on the laptop as I was talking, asking me to repeat things.’ Inattention, lack of genuine care, and the sense of being dismissed lead to patients also disengaging from therapy. Patient – ‘… like, looking out the window or their phone. I’m, like, well, I’m here, spilling out my guts and they’re not paying full attention to me so why would I bother’
Theme 8: Ruptured relationships. ‘Therapy doesn’t work when therapists make me feel unsafe’.
This theme is created from patient’s perspectives on the behaviours therapists can exhibit to rupture a safe therapeutic alliance, which in turn, contribute to non-response. One of the frequently reported, highly valued elements of psychotherapy was being able to speak freely without needing to worry about judgement, consequences or the emotional impact on the listener. Maintaining the safety for patients to openly express themselves appeared to be delicate – even subtle misattunements and communication mistakes were described as enough to fracture the safety of the holding environment. When therapists were seen to break confidentiality, anonymity or neutrality by penetrating this space with their own displays of emotion or personal opinions, it was experienced as intrusive and was reported to influence patients to become defensive and careful with what they spoke about. Patient – ‘…rather than let me voice it… she had a very big personality that she brought to the room, and it was very domineering, So I did struggle to open up to her. Because I was just cautious of how I am going to word this so that she lets me finish my sentence. And I think that's counterproductive. I just don't think that you should have to worry about your wording and things like that’. This type of therapist behaviour was often cited to be what lead to patients terminating therapy. Patient – ‘I feel like you're judging my life choices and my morals… I don't subscribe to a particular religion, and they definitely did. Like, there are a few comments made, like "If you're a feminist, you're not going to like what I have to say next”… I could have been really quite sensitive about it. But it was enough to… I just didn't book another appointment and I'd been talking to that person for five years.’
Patients discussed therapist behaviours that were experienced as highly distressing, such as being condescending, threatening and shaming. These overt displays of unmanaged countertransference contaminated the safety of the holding environment, breached the patient’s sense of trust, and essentially prevented therapy from being effective. Patient – ‘And so she threatened ‘If you come back in here next week with fresh harm scars, I’m going to phone the ambulance and they’re going to come and they’re going to pick you up in front of all of these people in the waiting room and they’re going to take you to the hospital’ and I never went back there again.’
Domain 4: Foundational Factors for Mitigating Non-Response
Domain 4 is comprised of the insights patients shared about which factors to focus on as a way to address non-response.
Theme 9: Prioritising safety. ‘Therapy could work better if the therapist prioritised helping me feel comfortable and accepted’.
This theme emphasises the importance of a safe relationship as the foundation of effective psychotherapy. Patients described a therapist’s ability to be attuned and responsive to the patient’s emotions as the predominant factor that supported the development of safety in the relationship. Patient – ‘She puts her mood to suit our mood. Like, she makes her mood, very calming, makes us feel comfortable… I can’t even explain it.’ Patients asserted that active listening, demonstrated by holding patients in mind, showed that the therapist was interested, invested and genuinely cared about the patient. Therapists who were warm, compassionate and non-judgemental supported patients to feel safe to express themselves freely and remain their authentic selves. Patient – ‘Well, I think one of the biggest and most important things is having a therapist that you feel safe with and you can trust and you just click with. You’re able to just interact with them well, not kind of have to change how you talk to suit their style of doing things. Being able to remain authentic.’ Patients identified that being available, reliable and relatable by demonstrating lived experience also facilitated the development of a safe therapeutic relationship. Patient – ‘Just in my own personal experience I was able to click and gravitate more towards those with lived experience.’
Theme 10: Acceptance and change. ‘Therapy could work better if the therapist understood and accepted that my behaviours and emotions can be a result of my situation, while still gently pushing me to change’.
This theme was created from the discussions around the importance of their behaviours and emotional responses being understood as originating from trauma or context. Patients wished for therapists to develop a nuanced and comprehensive understanding of each individual as unique, by knowing their specific circumstances and history. Patients believed that this would require therapists to let go of preconceived notions and assumptions based on patient’s diagnoses of BPD. Patient – ‘…generally there’s a bit of dismissal, there’s a shift in tone, a shift in decorum from the clinician. So yeah, I think a little bit more flexibility and working with a person, rather than working with a diagnosis.’ Patients asserted that this holistic understanding of a person’s behaviours and emotional responses in context helped the therapist to provide genuine validation, and that receiving such validation was highly valued. Patient – ‘I found it really useful when my therapist put himself in my shoes, and sat back was like, ‘Wow, no wonder you’re as low as you are.’’ Patients emphasised that contextual understanding of patients is also essential for the delivery of effective therapy. Such knowledge was seen to allow for the therapy to be adjusted to individual needs and to move responsively between supportive and expressive stances as needed. Patient – ‘I think it’s important in a way for the patient to get challenged at times. And I think it has to be gentle, you know, that kind of push for change and trying to encourage a perspective shift. It definitely has to be gentle.’
Theme 11: Collaboration and clear diagnosis. ‘Therapy could work better if the therapist gave me a clear diagnosis and worked with me to help me get better’.
This theme is created from the perspective shared among patients that they highly valued therapists who were transparent, provided rationales for interventions and offered them choices and opportunities to have input into their own treatment. This demonstrated respect, equality and nurtured the development of shared goals that could be worked towards as a team. Patient – ‘The most important one to me that I think worked was feeling like it was a team effort. Like I wasn’t going to therapy and receiving help, I was going to therapy and working through my problems with the therapist’. A collaborative approach was described to empower the patient to gain control over their own life. Patient – ‘To have that open discussion, to let me be part of my own treatment path, as opposed to just saying ‘This is what we're going to do, this is how we're going to tackle it’. For it to be an actual discussion so that I feel like I have some control. Because essentially, it is my life.’ Patients also described how being supported to develop a more sophisticated understanding of their internal world was the foundation for change. Patient – ‘I think for me, my first real indication that I was on that path was just a bit more insight. Say I’d act in like a certain way and then I’d think to myself, ‘Okay, like, that’s old behaviour, that’s not how I want to engage anymore’. So, it really started with heightening awareness.’ Lastly patients discussed the necessity of receiving a stable diagnosis of personality disorder because being given many varied and inconstant diagnoses was frustrating and confusing. Many patients described how being given a well-considered diagnosis can be liberating, and a relief to know it is a diagnosable condition that is treatable. Patient – ‘That diagnosis was really powerful for me, because it took a lot of self-blame away, because I wasn't the screw-up. It wasn't my fault that I responded to things abnormally. And it wasn't until someone gave me a diagnosis and said, ‘It's not your fault that you're wrong - that you're responding to these abnormally’. And when someone was able to say, ‘This is what's wrong. And the thing is, we can now help you fix it.’’
Theme 12: Focus on functionality and connection. ‘Therapy could work better if the therapy was practical and helped me make real life changes’.
This theme is built on the recognition that not only does therapy need to focus on the traditional therapeutic goals of symptom reduction, but it also needs to focus on supporting people to set practical and actionable goals that support progress towards social and occupational function. It was recognised that being encouraged to envision a better life facilitated such progress. Patient – ‘I was in a place where I was able to see change. I was able to envision change. I was in a position where me and my therapist, we took small steps. We worked on getting my licence and we worked on getting me into university and then we kept working on getting a better job and things like that. And because I was able to envision things that I could do in the future, we – I was able to do so.’ Patients discussed the value of being connected with social support via support groups, group therapy, or including chosen and important people in the therapy. Patient – ‘Because I feel like when you're going through something like mental health you always feel alone. You think you're crazy. You feel like you're insane. But being exposed to other women going through the same thing, or who were also having mental health issues, was already healing in itself.’