Improving access in borderline therapy for difficult-to-engage patients: a clinical description

Debate about suitability or clinicians' low expectations has led to patients with personality disorders being labeled as difficult and being socially excluded from pathways of care. Traditional psychotherapeutic treatments in borderline personality disorder demand too much of these patients' fractured ego structures for meaningful (long-term) therapeutic engagement. However, these patients cause clinicians anxiety and are a burden in health care systems. This article describes the challenge for clinical care teams working in partnership arrangements-psychotherapy and psychiatry services-to provide a containing framework of care. Early access to a pragmatic psychoanalytically oriented group treatment in borderline personality disorder is aimed at offering these patients an opportunity to make transitions in borderline treatment and thus alter the trajectory of their (self-) destructive pathway. A clinical and theoretical case is made for clinicians and health strategists to re-engage in the process of making meaningful early contact with borderline vulnerability. The group-based treatment model in borderline disturbance described in this article has helped forge partnerships between psychotherapy and psychiatric teams in providing in-depth diagnostic and prognostic information early in the patients' journey.