Barriers and facilitators to employment in borderline personality disorder: A qualitative study among patients, mental health practitioners and insurance physicians

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Abstract

Background

Borderline personality disorder (BPD) is associated with unemployment and impaired functioning. However, a comprehensive understanding of barriers and facilitators to employment from a multidisciplinary perspective is currently lacking. Therefore, the aim of this qualitative study was to explore barriers and facilitators in gaining and maintaining employment in BPD from the perspectives of patients, mental health practitioners (MHPs) and insurance physicians (IPs).

Methods

Fifteen semi-structured interviews were conducted in patients with BPD and two focus groups were carried out among MHPs (n = 7) and IPs (n = 6) following a thematic content analysis approach.

Results

All participants described barriers and facilitators relating to three overall themes: characteristics of BPD, stigma, and support to employment. Barriers to employment mainly related to characteristics of BPD, such as low self-image, difficulty posing personal boundaries, difficulty regulating emotions, and lack of structure. MHPs and IPs additionally mentioned externalization and overestimation of competencies on the part of patients. Enhancing emotion regulation and self-reflection by successful treatment was suggested as a facilitator to enhance employment. Increasing collaboration between mental health and vocational rehabilitation services, and increasing knowledge about BPD, were suggested to increase sustainable employment and decrease stigma.

Conclusions

The present findings revealed that both facilitators and barriers are important in gaining and maintaining employment in BPD in which diminishing symptoms, examining stigma and increasing support to employment are key. As a next step, supported employment strategies that follow patient preferences and integrate employment and mental health services, should be studied in the context of BPD.

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Most cited references 59

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Developing and implementing a triangulation protocol for qualitative health research.

Tracy Farmer, Kerry Robinson, Susan J. Elliott … (2006)

In this article, the authors present an empirical example of triangulation in qualitative health research. The Canadian Heart Health Dissemination Project (CHHDP) involves a national examination of capacity building and dissemination undertaken within a series of provincial dissemination projects. The Project's focus is on the context, processes, and impacts of health promotion capacity building and dissemination. The authors collected qualitative data within a parallel-case study design using key informant interviews as well as document analysis. Given the range of qualitative data sets used, it is essential to triangulate the data to address completeness, convergence, and dissonance of key themes. Although one finds no shortage of admonitions in the literature that it must be done, there is little guidance with respect to operationalizing a triangulation process. Consequently, the authors are feeling their way through the process, using this opportunity to develop, implement, and reflect on a triangulation protocol.

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Ten-year course of borderline personality disorder: psychopathology and function from the Collaborative Longitudinal Personality Disorders study.

John Markowitz, B. Ansell, T H McGlashan … (2011)

Borderline personality disorder (BPD) is traditionally considered chronic and intractable. To compare the course of BPD's psychopathology and social function with that of other personality disorders and with major depressive disorder (MDD) over 10 years. A collaborative study of treatment-seeking, 18- to 45-year-old patients followed up with standardized, reliable, and repeated measures of diagnostic remission and relapse and of both global social functioning and subtypes of social functioning. Nineteen clinical settings (hospital and outpatient) in 4 northeastern US cities. Three study groups, including 175 patients with BPD, 312 with cluster C personality disorders, and 95 with MDD but no personality disorder. The Diagnostic Interview for DSM-IV Personality Disorders and its follow-along version (the Diagnostic Interview for DSM-IV Personality Disorders-Follow-Along Version) were used to diagnose personality disorders and assess changes in them. The Structured Clinical Interview for DSM-IV Axis I Disorders and the Longitudinal Interval Follow-up Evaluation were used to diagnose MDD and assess changes in MDD and in social function. Eighty-five percent of patients with BPD remitted. Remission of BPD was slower than for MDD (P < .001) and minimally slower than for other personality disorders (P < .03). Twelve percent of patients with BPD relapsed, a rate less frequent and slower than for patients with MDD (P < .001) and other personality disorders (P = .008). All BPD criteria declined at similar rates. Social function scores showed severe impairment with only modest albeit statistically significant improvement; patients with BPD remained persistently more dysfunctional than the other 2 groups (P < .001). Reductions in criteria predicted subsequent improvements in DSM-IV Axis V Global Assessment of Functioning scores (P < .001). The 10-year course of BPD is characterized by high rates of remission, low rates of relapse, and severe and persistent impairment in social functioning. These results inform expectations of patients, families, and clinicians and document the severe public health burden of this disorder.

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The effectiveness of supported employment for people with severe mental illness: a randomised controlled trial.

Tom Burns, Jocelyn Catty, Thomas Becker … (2007)

The value of the individual placement and support (IPS) programme in helping people with severe mental illness gain open employment is unknown in Europe. Our aim was to assess the effectiveness of IPS, and to examine whether its effect is modified by local labour markets and welfare systems. 312 patients with severe mental illness were randomly assigned in six European centres to receive IPS (n=156) or vocational services (n=156). Patients were followed up for 18 months. The primary outcome was the difference between the proportions of people entering competitive employment in the two groups. The heterogeneity of IPS effectiveness was explored with prospective meta-analyses to establish the effect of local welfare systems and labour markets. Analysis was by intention to treat. This study is registered with ClinicalTrials.gov, with the number NCT00461318. IPS was more effective than vocational services for every vocational outcome, with 85 (55%) patients assigned to IPS working for at least 1 day compared with 43 (28%) patients assigned to vocational services (difference 26.9%, 95% CI 16.4-37.4). Patients assigned to vocational services were significantly more likely to drop out of the service and to be readmitted to hospital than were those assigned to IPS (drop-out 70 [45%] vs 20 [13%]; difference -32.1% [95% CI -41.5 to -22.7]; readmission 42 [31%] vs 28 [20%]; difference -11.2% [-21.5 to -0.90]). Local unemployment rates accounted for a substantial amount of the heterogeneity in IPS effectiveness. Our demonstration of the effectiveness of IPS in widely differing labour market and welfare contexts confirms this service to be an effective approach for vocational rehabilitation in mental health that deserves investment and further investigation.

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Author and article information

Contributors

Trees T. Juurlink:

ORCID: http://orcid.org/0000-0003-1801-4067

Role: ConceptualizationRole: Data curationRole: Formal analysisRole: InvestigationRole: MethodologyRole: Project administrationRole: ResourcesRole: SoftwareRole: ValidationRole: VisualizationRole: Writing – original draft

Miljana Vukadin: Role: ConceptualizationRole: Formal analysisRole: ValidationRole: Writing – original draftRole: Writing – review & editing

Barbara Stringer: Role: ConceptualizationRole: Data curationRole: Formal analysisRole: InvestigationRole: SupervisionRole: ValidationRole: Writing – original draftRole: Writing – review & editing

Marjan J. Westerman: Role: ConceptualizationRole: MethodologyRole: Writing – review & editing

Femke Lamers: Role: SupervisionRole: Writing – review & editing

Johannes R. Anema: Role: SupervisionRole: Writing – review & editing

Aartjan T. F. Beekman: Role: SupervisionRole: Writing – review & editing

Hein J. F. van Marle: Role: InvestigationRole: ResourcesRole: SupervisionRole: ValidationRole: Writing – review & editing

Peter G. van der Velden: Role: Editor

Journal

Journal ID (nlm-ta): PLoS One

Journal ID (iso-abbrev): PLoS ONE

Journal ID (publisher-id): plos

Journal ID (pmc): plosone

Title: PLoS ONE

Publisher: Public Library of Science (San Francisco, CA USA )

ISSN (Electronic): 1932-6203

Publication date (Electronic): 23 July 2019

Publication date Collection: 2019

Volume: 14

Issue: 7

Electronic Location Identifier: e0220233

Affiliations

[1 ] Department of Psychiatry, Division of GGZ inGeest Specialized Mental Health Care, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands

[2 ] Department of Social Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands

[3 ] Centre for Consultation and Expertise (CCE), Utrecht, The Netherlands

[4 ] Department of Health Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands

CentERdata, NETHERLANDS

Author notes

Competing Interests: The authors have declared that no competing interests exist.

* E-mail: t.juurlink@ 123456ggzingeest.nl

Author information

Trees T. Juurlink http://orcid.org/0000-0003-1801-4067

Article

Publisher ID: PONE-D-18-34606

DOI: 10.1371/journal.pone.0220233

PMC ID: 6650068

PubMed ID: 31335909

SO-VID: 4a3b4b7d-7afa-47f5-8174-8c4f9da44f19

License:

This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

History

Date received : 3 December 2018

Date accepted : 11 July 2019

Page count

Figures: 0, Tables: 3, Pages: 18

Funding

The authors received no specific funding for this work.

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Data Availability According to European law (GDPR) data containing potentially identifying or sensitive patient information are restricted; our data involving clinical participants that did not consent to make their full transcripts publicly available are not freely available in public repository. Excerpts of the raw data (quotes from interviews) are available within the text of this paper. However, data requests can be send to our data management department: datamanagement@ 123456ggzingeest.nl .

Barriers and facilitators to employment in borderline personality disorder: A qualitative study among patients, mental health practitioners and insurance physicians

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Most cited references 59

Developing and implementing a triangulation protocol for qualitative health research.

Ten-year course of borderline personality disorder: psychopathology and function from the Collaborative Longitudinal Personality Disorders study.

The effectiveness of supported employment for people with severe mental illness: a randomised controlled trial.

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