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CAMH Stories Centre for Addiction
and Mental Health

Tackling a treatment crisis

CAMH team advances awareness and treatment options for people with Borderline Personality Disorder (BPD)

Lisa Walter recalls a “choking hopelessness” resulting from the mood instability she experienced from Borderline Personality Disorder (BPD).

The Toronto-based visual artist and educator says treatment at CAMH helped her become more aware of her thoughts, and manage anger and frustration.

“Treatment was integral for me,” Lisa says.   “It has helped me to lay a foundation of distress-tolerance skills so that I can be more aware of my thoughts as just thoughts.”

Lisa Walker
Lisa Walter 

BPD is a serious psychiatric disorder characterized by features including unstable emotion and behavior. More than 80 per cent of people with BPD have intentionally injured themselves, and many attempt suicide. The lifetime suicide rate is estimated to be 10 per cent, on par with other serious mental illness such as schizophrenia, and about 60 times higher than average for the general population in Canada.

Symptoms and stigma

Dr. Robert Cardish, a Psychiatrist with CAMH’s BPD Clinic and Assistant Professor at the University of Toronto, notes that the diagnosis of BPD is relatively new compared to other forms of mental illness -- it was first included in the Diagnostic and Statistical Manual of Mental Disorders (DSM) in 1980. “But the clients are not new -- they’ve always been there and have faced serious illness.”

Moreover, because of the unstable nature of the condition, BPD clients may be perceived as ‘difficult’ or ‘not trying hard enough,’ he says.  “The instability of emotion is much shorter in duration than depression, for example. So the client may be in Emergency one day in acute distress, and chatting happily on day two.”

As a result there may be suspicion and stigma around BPD on the part of friends, family and health care providers. “What gets lost is how much the clients are suffering.”

In addition to unstable emotions, features of BPD include unstable relationships, impulsive behavior, fear of abandonment, outbursts of anger, an unstable sense of self, and feelings of emptiness.

Lisa Walter started cutting herself in her teens – at that time it made her feel balanced and in control. Dialectical Behaviour Therapy (DBT) helped her understand her thoughts and behaviours. Moreover, she says, it opened a door to allow her to get treatment for a co-existing condition of Obsessive Compulsive Disorder (OCD).

Taking steps forward with treatment

Standard DBT treatment is delivered over one year and includes individual therapy, skills training, client phone calls with the therapist, and consultation among therapists.

“It’s the small steps that are the key to moving forward,” Lisa says. “Thinking about what you want to do, who you are as a person, not just an illness. Are you a person who is passionate, who has a great sense of wanting to contribute to the world? Let that define who you are.  Let your work pull you forward, and then hope comes.”

Dr. Robert Cardish
Dr. Robert Cardish

In Ontario, there are few clinics offering specialized treatment for BPD. And specialized programs for BPD often have long wait lists. The clinic at CAMH, which treats approximately 100 BPD clients each year, is currently closed to new referrals due to volume, but is examining ways to be more responsive within limited resources.

In one step to tackle the treatment crisis, a new CAMH study will analyze the impact of a shorter course of standard treatment – aimed at reducing wait times in existing programs and making BPD treatment more broadly accessible. The research will also assess the potential to reduce related emergency and hospital care costs.

“We’ve come a long way over the past 20 years, with multiple trials showing the effectiveness of specialized treatments for BPD,” says lead investigator Dr. Shelley McMain, Clinic Head, CAMH BPD Clinic.

The DBT treatment offered at CAMH, and several other clinics across Canada, has been shown to reduce self-harm and improve quality of life in clients with BPD, she says.

“The biggest crisis now with BPD is the problem of accessing treatment. We want to determine whether we can effectively deliver standard treatment in a shorter time frame.”

Dr. Shelley McMain
Dr. Shelley McMain

The two-year study, launched in February 2015, will assess 240 clients at two treatment sites – CAMH’s Toronto BPD clinic, and a Vancouver site affiliated with Simon Fraser University. Clients will be randomly assigned either to the standard one-year treatment program or a condensed six-month program.

Clinical research tracks client outcomes and health costs

Dr. McMain and fellow researchers will closely monitor clients’ outcomes, including frequency and severity of self-harm, symptoms such as anger and substance use, as well as other aspects of their lives including school and work.

The study will also track clients’ health-care utilization. That includes emergency room visits, inpatient admissions, and days in hospital. Cost data will be accessed through the Ontario Health Insurance Plan, Population Data B.C. and the Canadian Institute for Health Information.

Finally, the study will assess if treatment is more effective for certain clients based on characteristics including symptom severity and concurrence with other mental illness. Clients will receive a total of nine assessments over two years during the treatment study, funded by the Canadian Institutes of Health Research.

“The answer may not be as simple as ‘Shorter treatment is just as effective,’” says Dr. McMain. “We expect to learn more about the variability of treatment responses, and this may point to more tailoring of treatment options for clients.” She is teaming up on the study with co-principal investigators Dr. Janice Kuo, Assistant Professor, Department of Psychology, Ryerson University, and Dr. Alexander Chapman, Associate Professor, Department of Psychology, Simon Fraser University.

Building awareness and capacity in the health system

In addition to advancing treatment options, CAMH also promotes awareness of BPD, counters stigma and delivers training locally and across Canada aimed at building treatment capacity in the healthcare system.

On May 27, 2015, BPD clients, friends, family, health/service providers, researchers and other interested groups will attend the BPD forum hosted by CAMH.

This year’s guest speaker is Dr. Anthony Ruocco, Assistant Professor of Psychology, University of Toronto. As an Associate Scientist at CAMH, he has been investigating patterns of brain activity in clients with BPD. The forum will be moderated by Dr. Cardish, with updates from Dr. McMain and perspectives from several BPD clients, family members and a peer support worker.

Training practitioners -- with the objective of building capacity for BPD treatment in different parts of the health care system -- is an important goal for the CAMH clinic.  Throughout the year, the clinic offers DBT training to medical staff, social workers and psychology students. “We had more than 20 trainees at the clinic this year,” says Manager Brenda Finlayson. In addition, clinic staff deliver training sessions at many CAMH programs, locally and across the country at diverse venues including community mental health centres, mental health services in community hospitals, corrections settings and inpatient units. Since 2009, clinic staff have been the primary instructors for the DBT Certificate Program offered by the Faculty of Medicine at the University of Toronto. “The aim is to continue to enhance the capacity to treat clients with BPD in the broader health system and to develop better treatments,” Brenda says.

Turning a corner

Treatment and a commitment to BPD advocacy helped Lisa turn a corner. She counts herself as fortunate, given that many other people with the same diagnosis continue to “bounce around” the health system without receiving specialized treatment.  As an advocate, she has spoken at BPD forums organized by CAMH, and shared her personal journey in newspaper articles.

With an artistic style described by the Globe and Mail as “delicate and unsparing,” Lisa has been exhibiting her visual art since 2010, including two works for Toronto’s Nuit Blanche festival. She participated as a visual and media artist with Rendezvous with Madness Film Festival in 2010 and 2011. Starting in 2014, Lisa has been the Visual Artist in Residence at Workman Arts, an arts and mental health company known internationally for its artistic collaborations, presentations, knowledge exchange, best practices and research. The company focuses on the “impact of the arts on the quality of life of people living with mental illness and addiction.”

With the right treatment and support, “the future is in your hands,” Lisa tells others who struggle with BPD.

And hope will come through the hard work of treatment: “If you persist, if you want it badly enough, that change will happen.”

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