The Dilemma of People Experiencing Borderline Personality Disorder (BPD) on Assertive Community Treatment (ACT) Teams—A Scoping Literature Review: Can ACT help people with BPD?

Publication: Canadian Journal of Community Mental Health
3 May 2024

Abstract

People with borderline personality disorder (BPD) are typically excluded from assertive community treatment (ACT) teams, the intensive model that typically serves people with serious psychotic and mood disorders. Nevertheless, many people with BPD are on ACT teams for clinical comorbidity or other reasons. Suitability and ability of ACT to provide their care is understudied. Our scoping literature review shows a limited body of research, with strong but mixed opinions on this dilemma, but notable incorporation of training and skills (e.g., dialectical behavioral therapy) into ACT may improve care for this population whose presence on ACT teams is a clinical reality.

Résumé

Les personnes atteintes d’un trouble de personnalité limite (TPL) sont souvent exclues du suivi intensif dans le milieu (SIM), le programme généralement offert aux personnes atteintes de troubles psychotiques et de l’humeur graves. Néanmoins, de nombreuses personnes atteintes de TPL font partie d’équipes SIM pour une comorbidité clinique ou d’autres raisons. L’aptitude et la capacité du SIM à leur fournir des soins sont sous-étudiées. Notre revue de la portée de la littérature fait d’une part état d’un nombre limité de recherches avec des opinions fortes, mais mitigées sur ce dilemme, et d’autre part constate que l’intégration notable de la formation et des compétences (p. ex. la thérapie comportementale dialectique) dans le SIM peut améliorer les soins pour cette population dont la présence dans les équipes SIM est une réalité clinique.

Get full access to this article

View all available purchase options and get full access to this article.

References

Aviram R. B., Brodsky B. S., and Stanley B. 2006 Borderline personality disorder, stigma, and treatment implications Harvard Review of Psychiatry 14 5 249 -256 https://journals.lww.com/hrpjournal/abstract/2006/09000/borderline_personality_disorder,_stigma,_and.3.aspx
Basevitz, P., & Aubry, T. (2002). Providing services to individuals with borderline personality disorder in the context of ACT: Research base and recommendations. Centre for Research on Community Services, Faculty of Social Sciences, University of Ottawa, Ottawa, Ontario. https://www.researchgate.net/profile/Tim-Aubry/publication/252363910_Providing_services_to_individuals_with_Borderline_Personality_disorder_in_the_context_of_ACT_Research_base_and_recommendations/links/0046352b496ff66346000000/Providing-services-toindividuals-with-Borderline-Personality-disorder-in-the-context-of-ACT-Research-base-and-recommendations.pdf
Bateman A. and Fonagy P. 2009 Randomized controlled trial of outpatient mentalization-based treatment versus structured clinical management for borderline personality disorder American Journal of Psychiatry 166 12 1355 -1364 https://doi.org/10.1176/appi.ajp.2009.09040539
Bateman Anthony and Fonagy P. 1999 Effectiveness of partial hospitalization in the treatment of borderline personality disorder: a randomized controlled trial American Journal of Psychiatry 156 10 https://doi.org/10.1176/ajp.156.10.1563
Ben-Porath D. D., Wisniewski L., and Warren M. 2009 Differential treatment response for eating disordered patients with and without a comorbid borderline personality diagnosis using a dialectical behavior therapy (DBT)-informed approach Eating Disorders 17 3 225 -241 https://doi.org/10.1080/10640260902848576
Black D. W., Blum N., Pfohl B., and Hale N. 2004 Suicidal behavior in borderline personality disorder: prevalence, risk factors, prediction, and prevention Journal of Personality Disorders 18 3 226 -239 https://doi.org/10.1521/pedi.18.3.226.35445
Blum N. and Black D. W. 2008 Systems training for emotional predictability and problem solving (STEPPS) for the treatment of BPD Social Work in Mental Health 6 1–2 171 -186 https://doi.org/10.1300/J200v06n01_14
Bond G. R., Drake R. E., Mueser K. T., and Latimer E. 2001 Assertive community treatment for people with severe mental illness Disease Management and Health Outcomes 9 3 141 -159 https://doi.org/10.2165/00115677-200109030-00003
Bond G. R., Witheridge T. F., Dincin J., Wasmer D., Webb J., and De Graaf-Kaser R. 1990 Assertive community treatment for frequent users of psychiatric hospitals in a large city: A controlled study American Journal of Community Psychology 18 6 865 -891 https://doi.org/10.1007/BF00938068
Braun V. and Clarke V. 2006 Using thematic analysis in psychology Qualitative Research in Psychology 3 2 77 -101 https://doi.org/10.1191/1478088706qp063oa
Burroughs T. and Somerville J. 2013 Utilization of evidenced based dialectical behavioral therapy in assertive community treatment: examining feasibility and challenges Community Mental Health Journal 49 1 25 -32 https://doi.org/10.1007/s10597-012-9485-2
Cattane N., Rossi R., Lanfredi M., and Cattaneo A. 2017 Borderline personality disorder and childhood trauma: Exploring the affected biological systems and mechanisms BMC Psychiatry 17 1 221 https://doi.org/10.1186/s12888-017-1383-2
Catty J., Burns T., Knapp M., Watt H., Wright C., Henderson J., and Healey A. 2002 Home treatment for mental health problems: A systematic review Psychological Medicine 32 3 383 -401 https://doi.org/10.1017/S0033291702005299
Chanen A. M., Jackson H. J., McCutcheon L. K., Jovev M., Dudgeon P., Yuen H. P., Germano D., Nistico H., McDougall E., Weinstein C., Clarkson V., and McGorry P. D. 2008 Early intervention for adolescents with borderline personality disorder using cognitive analytic therapy: Randomised controlled trial British Journal of Psychiatry 193 6 477 -484 https://doi.org/10.1192/bjp.bp.107.048934
Chanen A. M., Mccutcheon L. K., Germano D., Nistico H., Jackson H. J., and Mcgorry P. D. 2009 The HYPE Clinic: An early intervention service for borderline personality disorder Journal of Psychiatric Practice 15 3 163 -172 https://doi.org/10.1097/01.pra.0000351876.51098.f0
Choi-Kain L. W., Albert E. B., and Gunderson J. G. 2016 Evidence-based treatments for borderline personality disorder: Implementation, integration, and stepped care Harvard Review of Psychiatry 24 5 342 -356 https://doi.org/10.1097/HRP.0000000000000113
Choi-Kain L. W., Finch E. F., Masland S. R., Jenkins J. A., and Unruh B. T. 2017 What works in the treatment of borderline personality disorder Current Behavioral Neuroscience Reports 4 1 21 -30 https://doi.org/10.1007/s40473-017-0103-z
Clarkin J. F., Levy K. N., Lenzenweger M. F., and Kernberg O. F. 2007 Evaluating three treatments for borderline personality disorder: A multiwave study American Journal of Psychiatry 164 6 922 -928 https://doi.org/10.1176/ajp.2007.164.6.922
Crowell S. E., Beauchaine T. P., and Linehan M. M. 2009 A biosocial developmental model of borderline personality: Elaborating and extending Linehan’s theory Psychological Bulletin 135 3 495 -510 https://doi.org/10.1037/a0015616
Cunningham K., Wolbert R., and Lillie B. 2004 It’s about me solving my problems: Clients’ assessments of dialectical behavior therapy Cognitive and Behavioral Practice 11 2 248–256 https://doi.org/10.1016/S1077-7229(04 80036-1
Dale O., Sethi F., Stanton C., Evans S., Barnicot K., Sedgwick R., Goldsack S., Doran M., Shoolbred L., Samele C., Urquia N., Haigh R., and Moran P. 2017 Personality disorder services in England: Findings from a national survey BJPsych Bulletin 41 5 247 -253 https://doi.org/10.1192/pb.bp.116.055251
Dieterich M., Irving C. B., Bergman H., Khokhar M. A., Park B., and Marshall M. 2017 Intensive case management for severe mental illness Schizophrenia Bulletin 43 4 698 -700 https://doi.org/10.1093/schbul/sbx061
Dixon L. 2000 Assertive community treatment: Twenty-five years of gold Psychiatric Services (Washington, D.C 51 6 759 -765 https://doi.org/10.1176/appi.ps.51.6.759
Drake R. E. 1998 Brief history, current status, and future place of assertive community treatment American Journal of Orthopsychiatry 68 2 172 -175 https://doi.org/10.1037/h0085086
Drake R. E., Goldman H. H., Lehman A. F., Dixon L., Mueser K.T., and Torrey W. C. 2001 Implementing evidence-based practices in routine mental health services settings Psychiatric Servcies 52 179 -182
Ellison W. D., Rosenstein L. K., Morgan T. A., and Zimmerman M. 2018 Community and clinical epidemiology of borderline personality disorder Psychiatric Clinics of North America 41 4 561 -573 https://doi.org/10.1016/j.psc.2018.07.008
Freije, H. (2016). STEPPS in The Netherlands. In D. W. Black & N. Blum (Eds.), Systems training for emotional predictability and problem solving for borderline personality disorder (pp. 51–67). Oxford University Press. https://doi.org/10.1093/med:psych/9780199384426.003.0003
Frisman L. K., Mueser K. T., Covell N. H., Lin H.-J., Crocker A., Drake R. E., and Essock S. M. 2009 Use of Integrated Dual Disorder Treatment Via Assertive Community Treatment Versus Clinical Case Management for Persons With Co-Occurring Disorders and Antisocial Personality Disorder Journal of Nervous & Mental Disease 197 11 822 -828 https://doi.org/10.1097/NMD.0b013e3181beac52
George L., Kidd S., Wong M., Harvey R., and Browne G. 2010 ACT fidelity in Ontario: Measuring adherence to the model Canadian Journal of Community Mental Health 29 S5 87 -96
Giesen-Bloo J., van Dyck R., Spinhoven P., van Tilburg W., Dirksen C., van Asselt T., Kremers I., Nadort M., and Arntz A. 2006 Outpatient psychotherapy for borderline personality disorder Archives of General Psychiatry 63 6 649 https://doi.org/10.1001/archpsyc.63.6.649
Giourou E., Skokou M., Andrew S. P., Alexopoulou K., Gourzis P., and Jelastopulu E. 2018 Complex posttraumatic stress disorder: The need to consolidate a distinct clinical syndrome or to reevaluate features of psychiatric disorders following interpersonal trauma? World Journal of Psychiatry 8 1 12 -19 https://doi.org/10.5498/wjp.v8.i1.12
Grant B. F., Chou S. P., Goldstein R. B., Huang B., Stinson F. S., Saha T. D., Smith S. M., Dawson D. A., Pulay A. J., Pickering R. P., and Ruan W. J. 2008 Prevalence, correlates, disability, and comorbidity of DSM-IV borderline personality disorder: Results from the Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions The Journal of Clinical Psychiatry 69 4 533 -545 https://doi.org/10.4088/jcp.v69n0404
Gunderson, J., Weinberg, I., & Choi-Kain, L. (2014). Borderline personality disorder. In Gabbard’s Treatments of Psychiatric Disorders. American Psychiatric Publishing. https://doi.org/10.1176/appi.books.9781585625048.gg70
Haigh R. 2007 The 16 personality disorder pilot projects Mental Health Review Journal 12 4 29 -39 https://doi.org/10.1108/13619322200700036
Horvitz-Lennon M., Reynolds S., Wolbert R., and Witheridge T. F. 2009 The role of assertive community treatment in the treatment of people with borderline personality disorder American Journal of Psychiatric Rehabilitation 12 3 261 -277 https://doi.org/10.1080/15487760903066446
Iliakis E. A., Sonley A. K. I., Ilagan G. S., and Choi-Kain L. W. 2019 Treatment of borderline personality disorder: Is supply adequate to meet public health needs? Psychiatric Services 70 9 772 -781 https://doi.org/10.1176/appi.ps.201900073
Iineh Research on dialectical behavior therapy for patients with borderline personality disorder Psychiatric Clinics of North America 23 1 151 -167
Koons C. R., Robins C. J., Lindsey Tweed J., Lynch T. R., Gonzalez A. M., Morse J. Q., Bishop G. K., Butterfield M. I., and Bastian L. A. 2001 Efficacy of dialectical behavior therapy in women veterans with borderline personality disorder Behavior Therapy 32 2 371–390 https://doi.org/10.1016/S0005-7894(01 80009-5
Lamont E. and Dickens G. L. 2019 Mental health services, care provision, and professional support for people diagnosed with borderline personality disorder: Systematic review of service-user, family, and carer perspectives Journal of Mental Health 1 -15 https://doi.org/10.1080/09638237.2019.1608923
Lawn S. and McMahon J. 2015 Experiences of care by Australians with a diagnosis of borderline personality disorder Journal of Psychiatric and Mental Health Nursing 22 7 510 -521 https://doi.org/10.1111/jpm.12226
Lefave H. G., de Souza H. R., and Geber G. J. 1996 Assertive community treatment of severe mental illness: A Canadian experience Psychiatric Services 47 757 -759
Leichsenring F., Leibing E., Kruse J., New A. S., and Leweke F. 2011 Borderline personality disorder The Lancet 377 9759 74–84 https://doi.org/10.1016/S0140-6736(10 61422-5
Lieb K., Zanarini M. C., Schmahl C., Linehan M. M., and Bohus M. 2004 Borderline personality disorder The Lancet 364 9432 453–461 https://doi.org/10.1016/S0140-6736(04 16770-6
Linehan, Marsha M. (1993). Skills training manual for treating borderline personality disorder. Guilford Press.
Linehan M. M., Armstrong H. E., Suarez A., Allmon D., and Heard H. L. 1991 Cognitive-behavioral treatment of chronically parasuicidal borderline patients Archives of General Psychiatry 48 12 1060 -1064 https://doi.org/10.1001/archpsyc.1991.01810360024003
Linehan M. M., Heard H. L., and Armstrong H. E. 1993 Naturalistic follow-up of a behavioral treatment for chronically parasuicidal borderline patients Archives of General Psychiatry 50 12 971 -974 https://doi.org/10.1001/archpsyc.1993.01820240055007
Linehan Marsha M., Korslund K. E., Harned M. S., Gallop R. J., Lungu A., Neacsiu A. D., McDavid J., Comtois K. A., and Murray-Gregory A. M. 2015 Dialectical behavior therapy for high suicide risk in individuals with borderline personality disorder JAMA Psychiatry 72 5 475 https://doi.org/10.1001/jamapsychiatry.2014.3039
Links P. S. 1998 Developing effective services for patients with personality disorders The Canadian Journal of Psychiatry 43 3 251 -259 https://doi.org/10.1177/070674379804300303
Marshall M. and Lockwood A. 2000 Assertive community treatment for people with severe mental disorders Cochrane Database of Systematic Reviews https://doi.org/10.1002/14651858.CD001089
McFarlane W. R. 1997 Fact: Integrating family psychoeducation and assertive community treatment Administration and Policy in Mental Health 25 2 191 -198 https://doi.org/10.1023/a:1022291022270
McHugo G. J. Drake R. E. Whitley R. Bond G. R. Campbell K. Rapp C. A … Finnerty M. T. 2007 Fidelity outcomes in the national implementing evidence-based practices project Psychiatric Services 58 10 1279 -1284
McLaughlin, J. J. (2013). Assertive community treatment: An evidence-based practice and its continuing evolution. In J. Rosenberg & S. Rosenberg (Eds.), Community mental health: Challenges for the 21st century., 2nd ed. (Vol. 53, Issue 9, pp. 197–214). Routledge/Taylor & Francis Group.
McMain S. F. Chapman A. L. Kuo J. R. Guimond T. Streiner D. L. Dixon-Gordon K. L. … Hoch J. S. 2018 The effectiveness of 6 versus 12-months of dialectical behaviour therapy for borderline personality disorder: The feasibility of a shorter treatment and evaluating responses (FASTER) trial protocol BMC Psychiatry 18 1 1 -16
McMain S. F., Links P. S., Gnam W. H., Guimond T., Cardish R. J., Korman L., and Streiner D. L. 2009 A randomized trial of dialectical behavior therapy versus general psychiatric management for borderline personality disorder American Journal of Psychiatry 166 12 1365 -1374 https://doi.org/10.1176/appi.ajp.2009.09010039
Moher D. 2009 Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement Annals of Internal Medicine 151 4 264 https://doi.org/10.7326/0003-4819-151-4-200908180-00135
Mueser K. T., Bond G. R., Drake R. E., and Resnick S. G. 1998 Models of community care for severe mental illness: A review of research on case management Schizophrenia Bulletin 24 1 37 -74 https://doi.org/10.1093/oxfordjournals.schbul.a033314
Nakhost A., Law S. F., Francombe Pridham K. M., and Stergiopoulos V. 2017 Addressing complexity and improving access in community mental health services: An inner-city adaptation of flexible ACT Psychiatric Services 68 9 867 -869 https://doi.org/10.1176/appi.ps.201700195
Nehls N. 1998 Borderline personality disorder: Gender stereotypes, stigma, and limited system of care Issues in Mental Health Nursing 19 2 97 -112 https://doi.org/10.1080/016128498249105
Ranger M., Methuen C., Rutter D., Rao B., and Tyrer P. 2004 Prevalence of personality disorder in the case-load of an inner-city assertive outreach team Psychiatric Bulletin 28 12 441 -443 https://doi.org/10.1192/pb.28.12.441
Reynolds, S., Wolbert, R., Abney-Cunningham, G., & Patterson, K. (2007). Dialectical behavior therapy for assertive community treatment teams. In L. Dimeff & K. Koerner (Eds.), Dialectical behavior therapy in clinical practice applications across disorders and settings (pp. 298–325). Guilford Press.
Rosen A., Mueser K. T., and Teesson M. 2007 Assertive community treatment issues from scientific and clinical literature with implications for practice The Journal of Rehabilitation Research and Development 44 6 813 https://doi.org/10.1682/JRRD.2006.09.0110
Sansone R. A. and Sansone L. A. 2013 Responses of mental health clinicians to patients with borderline personality disorder Innovations in Clinical Neuroscience 10 5–6 39 -43 https://pubmed.ncbi.nlm.nih.gov/23882440/
Sansone R. A., Sellbom M., and Songer D. A. 2018 Borderline personality disorder and mental health care utilization: The role of self-harm Personality Disorders: Theory, Research, and Treatment 9 2 188 -191 https://doi.org/10.1037/per0000245
Sealy P. and Whitehead P. C. 2004 Forty years of deinstitutionalization of psychiatric services in Canada: An empirical assessment The Canadian Journal of Psychiatry 49 4 249 -257 https://doi.org/10.1177/070674370404900405
Shah A. A. 2020 Is borderline personality disorder serious enough to be called serious mental illness? Psychiatric Annals 50 1 5 -6 https://doi.org/10.3928/00485713-20191202-02
Silverman M. M., Berman A. L., Sanddal N. D., O’Carroll P. W., and Joiner T. E. 2007 Rebuilding the Tower of Babel: A revised nomenclature for the study of suicide and suicidal behaviors part 2: Suicide-related ideations, communications, and behaviors Suicide and Life-Threatening Behavior 37 3 264 -277 https://doi.org/10.1521/suli.2007.37.3.264
Skodol A. E., Gunderson J. G., McGlashan T. H., Dyck I. R., Stout R. L., Bender D. S., Grilo C. M., Shea M. T., Zanarini M. C., Morey L. C., Sanislow C. A., and Oldham J. M. 2002 Functional impairment in patients with schizotypal, borderline, avoidant, or obsessive-compulsive personality disorder American Journal of Psychiatry 159 2 276 -283 https://doi.org/10.1176/appi.ajp.159.2.276
Spivak S., Cullen B. A., Green C., Firth T., Sater H., and Mojtabai R. 2019 Availability of assertive community treatment in the United States: 2010 to 2016 Psychiatric Services 70 10 948 -951
Stein L. I., Test M. A., and Marx A. J. 1975 Alternative to the hospital: A controlled study American Journal of Psychiatry 132 5 517 -522 https://doi.org/10.1176/ajp.132.5.517
Sulzer S. H. 2015 Does “difficult patient” status contribute to de facto demedicalization? The case of borderline personality disorder Social Science & Medicine 142 82 -89 https://doi.org/10.1016/j.socscimed.2015.08.008
Temes C. M., Frankenburg F. R., Fitzmaurice G. M., and Zanarini M. C. 2019 Deaths by suicide and other causes among patients with borderline personality disorder and personality-disordered comparison subjects over 24 years of prospective follow-up The Journal of Clinical Psychiatry 80 1 https://doi.org/10.4088/JCP.18m12436
Torgersen S., Kringlen E., and Cramer V. 2001 The prevalence of personality disorders in a community sample Archives of General Psychiatry 58 6 590 https://doi.org/10.1001/archpsyc.58.6.590
Tricco A. C. Lillie E. Zarin W. O’Brien K. K. Colquhoun H. Levac D. Moher D. Peters M. D. J. Horsley T. Weeks L. Hempel S. Akl E. A. Chang C. McGowan J. Stewart L. Hartling L. Aldcroft A. Wilson M. G. Garritty C. … Straus S. E. 2018 PRISMA extension for scoping reviews (PRISMA-ScR): Checklist and explanation Annals of Internal Medicine 169 7 467 -473 https://doi.org/10.7326/M18-0850
Urben S., Mantzouranis G., Baier V., Halfon O., Villard E., and Holzer L. 2016 Timing of clinical improvement in assertive community treatment for adolescents: A pilot naturalistic observational study Archives of Psychiatric Nursing 30 5 645 -646 https://doi.org/10.1016/j.apnu.2016.04.015
Verheul R., Van Den Bosch L. M. C., Koeter M. W. J., De Ridder M. A. J., Stijnen T., and Van Den Brink W. 2003 Dialectical behaviour therapy for women with borderline personality disorder British Journal of Psychiatry 182 2 135 -140 https://doi.org/10.1192/bjp.182.2.135
Watson H., Harrop D., Walton E., Young A., and Soltani H. 2019 A systematic review of ethnic minority women’s experiences of perinatal mental health conditions and services in Europe PLOS ONE 14 1 e0210587 https://doi.org/10.1371/journal.pone.0210587
Weijers J., Ten Kate C., Viechtbauer W., Rampaart L. J. A., Eurelings E. H. M., and Selten J. P. 2020 Mentalizationbased treatment for psychotic disorder: A rater-blinded, multi-center, randomized controlled trial Psychological Medicine 1 -10 https://doi.org/10.1017/S0033291720001506
Weisbrod B. A. 1983 A guide to benefit-cost analysis, as seen through a controlled experiment in treating the mentally ill Journal of Health Politics, Policy and Law 7 4 808 -845 https://doi.org/10.1215/03616878-7-4-808
Whitbeck L. B., Armenta B. E., and Welch-Lazoritz M. L. 2015 Borderline personality disorder and Axis I psychiatric and substance use disorders among women experiencing homelessness in three US cities Social Psychiatry and Psychiatric Epidemiology 50 8 1285 -1291 https://doi.org/10.1007/s00127-015-1026-1

Information & Authors

Information

Published In

cover image Canadian Journal of Community Mental Health
Canadian Journal of Community Mental Health
Volume 43Number 1March 2024
Pages: 37 - 54

History

Version of record online: 3 May 2024

Key Words

  1. assertive community treatment team
  2. borderline personality disorder
  3. dialectical behavioural therapy
  4. program improvement

Mots-clés

  1. équipe de suivi intensif dans le milieu
  2. trouble de personnalité limite
  3. thérapie comportementale dialectique
  4. amélioration de programme

Authors

Affiliations

Josiah Osagie
Yvonne Bergmans
Toronto Metropolitan University
Aly Kassam
St. Michael’s Hospital, Unity Health Toronto
Michaela Beder
Madeleine Ritts
Juveria Zaheer
Centre for Addiction and Mental Health
Kate Wren
George Brown College, Toronto
Melissa Button
Centre for Addictions and Mental Health, Toronto
Nicole Kirwan
St. Michael’s Hospital, Unity Health Toronto
Matthew Levy

Metrics & Citations

Metrics

Other Metrics

Citations

Cite As

Export Citations

If you have the appropriate software installed, you can download article citation data to the citation manager of your choice. Simply select your manager software from the list below and click Download.

There are no citations for this item

View Options

Login options

Check if you access through your login credentials or your institution to get full access on this article.

Subscribe

Click on the button below to subscribe to Canadian Journal of Community Mental Health

Purchase options

Purchase this article to get full access to it.

Restore your content access

Enter your email address to restore your content access:

Note: This functionality works only for purchases done as a guest. If you already have an account, log in to access the content to which you are entitled.

View options

PDF

View PDF

Media

Media

Other

Tables

Share Options

Share

Share the article link

Share on social media