Ethical Challenges in the Treatment of Personality Disorders

No therapy is comfortable, because it involves dealing with pain. But there’s one comfortable thought: that two people sharing pain can bear it easier than one.

—Elvin Semrad (1)

Personality disorders are pervasive and carry significant treatment implications for patients in psychiatric and correctional facilities. Personality disorders are defined as enduring traits and behaviors that deviate from cultural and societal norms; they may have an impact on cognition, affect, interpersonal functioning, and impulse control (2). Personality disorders are divided into three broad clusters based on distinctive features: cluster A (paranoid, schizoid, schizotypal); cluster B (antisocial, borderline, histrionic, narcissistic); and cluster C (avoidant, dependent, obsessive-compulsive). This article focuses on borderline personality disorder.

According to a recent meta-analysis (3), the global prevalence of personality disorders is 7.8%, with cluster B disorders accounting for an estimated total of 2.8%. The National Institute of Mental Health suggests a higher frequency: 9.1% for all personality disorders and 1.4% for borderline personality disorder (4). It is estimated that about 20% of psychiatric inpatients meet criteria for borderline personality disorder (2).

Despite a wealth of research regarding therapeutics, borderline personality disorder remains one of the most challenging disorders to treat. Unique challenges in the treatment of the disorder also give rise to various ethical concerns that physicians will confront in practice.

This article explores a clinical case as a window into the ethical challenges that early career psychiatrists (ECPs) face when treating patients diagnosed as having borderline personality disorder.

Case 1, Part 1

Ms. A is a 29-year-old woman who presented to Dr. Smith’s outpatient psychiatry practice with a chief complaint of relationship difficulties, suicidal thoughts, and self-cutting behavior. Ms. A’s previous psychiatrist, Dr. M, referred her to Dr. Smith because Dr. Smith is experienced in treating personality disorders and specializes in transference-focused psychotherapy. When Ms. A was 22 years old, a previous therapist had diagnosed her as having borderline personality disorder. Ms. A reported to Dr. Smith that she has felt depressed “all [her] life,” and has had intermittent suicidal thoughts since entering high school. Although suicidal thoughts are “always around,” she has no current thoughts or future plans to end her life.

Ms. A reported difficulty maintaining relationships, specifically friends, romantic partners, and family members. Almost all her relationships have been marked by intense emotions that “would flip back and forth between great and awful.” Ms. A described constant worries that her friends and romantic partners were always on the verge of abandoning her. She reported that all her relationships ended because she “pushed them away . . . [she] was always too much to handle.”

On review of Ms. A’s treatment history, she reported having been treated by at least 15 psychiatrists. Like her other relationships, Ms. A reported having difficulty remaining in treatment with one therapist for longer than a few months to a year. However, she reported that her relationship with Dr. M was “different” than her relationships with other psychiatrists. She had felt very secure in her treatment with Dr. M, had been in treatment with him for more than 3 years, and had felt confused when he referred her to a new psychiatrist.

Ms. A was never psychiatrically hospitalized and said she had never attempted suicide. Regarding self-harm behaviors, she reported that she has been cutting herself since high school as a way to “feel better.”

• 1.1. At this point in Dr. Smith’s assessment, what would be the most appropriate next step?

  • A. Ask permission to speak to Dr. M for collateral information.

  • B. Prescribe a psychotropic medication to address Ms. A’s suicidal thoughts.

  • C. Admit the patient to an inpatient psychiatric unit.

  • D. Ask Ms. A’s family members to join the session for further information.

• 1.2. In general, what two ethical principles conflict with each other when a physician involuntarily hospitalizes a patient?

  • A. Beneficence versus nonmaleficence

  • B. Autonomy versus beneficence

  • C. Justice versus autonomy

  • D. Autonomy versus nonmaleficence

Case 1, Part 2

Ms. A agrees to sign a consent form for Dr. M to speak with Dr. Smith. Dr. M reported that he first started treating Ms. A when he was a third-year psychiatry resident working in a clinic specializing in the treatment of personality disorders. Dr. M characterized the case as one of his most challenging. He described very strong transference and countertransference reactions that required intensive supervision during his residency. Dr. M recalled persistent concerns about Ms. A’s suicide risk and self-harming behaviors.

Nevertheless, Dr. M reported that Ms. A had made significant progress in terms of decreased suicidal thoughts, higher level of functioning (obtaining stable employment), and reduced cutting behavior. After Dr. M graduated residency, he continued to treat Ms. A in his newly established private practice. He soon noticed that the treatment began to hit roadblocks, which caused him to feel that Ms. A’s clinical status was regressing. He recalled that Ms. A began to arrive late or to miss appointments. She would often forget to pay Dr. M for her treatment or would make late payments, causing her to be consistently in arrears. Dr. M eventually became frustrated with the case and thought a new therapist with more experience might be more helpful to Ms. A.

• 1.3. Which of the following is a common challenge for ECPs like Dr. M?

  • A. Formation of a new payment arrangement

  • B. New office location

  • C. New supervisory requirements

  • D. Self-care and mentorship

  • E. All of the above

Discussion: Supervision as a Matter of Ethics

Supervision in Undergraduate and Graduate Medical Education.

Physicians value knowledge and expertise. Medical education begins primarily with coursework in medical school, then transitions to clinical rotations, which emphasize patient interactions with clinical supervision. Formal supervision continues as a mandatory component of medical school, psychiatry residency programs, and psychiatry fellowships. In order for psychiatric residents to safely treat patients in a training environment, “they are supervised, supported, and directed by highly trained and experienced physicians” (5).

The ethics of supervision come to the foreground as soon as a resident physician begins treating a patient. From a legal perspective, “disclosure of information to those who are assisting the primary caregiver’s efforts is not considered a breach of confidentiality and is included under the ‘treatment’ exception to HIPAA’s requirement for patient authorization” (6). However, from an ethical perspective, the patient has a right to know their physician’s level of training and must be informed that a resident physician has a supervisor who will be involved in the patient’s care. Part of the informed consent process involves the patient’s understanding that a resident physician will, as a matter of course, discuss the case with a more experienced supervisor. In addition to supervision being an essential aspect of learning for resident physicians, the physician acting as supervisor is legally responsible for the care of the patient under the legal doctrine known as “respondeat superior—‘let the master reply’” (6).

Supervision Beyond Training.

All members of the American Psychiatric Association (APA) are bound by ethical guidelines (7). These guidelines state the following regarding professional education:

A physician shall continue to study, apply, and advance scientific knowledge, maintain a commitment to medical education, make relevant information available to patients, colleagues, and the public, obtain consultation, and use the talents of other health professionals when indicated.

Regarding psychiatrists in particular, the guidelines state: “Psychiatrists are responsible for their own continuing education and should be mindful of the fact that theirs must be a lifetime of learning” (7). In this regard, the pursuit of lifelong learning is a guiding ethical principle.

Although many continuing medical education programs exist to promote knowledge, how often do psychiatrists continue clinical supervision after completing formal training? We are unaware of data that speak to the percentage of graduating residents who continue to be supervised. In the recent past, the practice of psychiatrists retaining a more senior supervisor for educational purposes was commonplace. This practice was likely influenced by the psychoanalytic model of training and supervision under the guidance of a more experienced psychiatrist in the community.

This column addresses the treatment of personality disorders, which can present challenges to even the most experienced psychiatrist. Continued clinical supervision with those having traversed similar waters can be immensely helpful both to the treating psychiatrist and to the patient. Supervision allows a widening of emotional containment, experience, and confidence that is often necessary for safe and successful treatment.

Case 1, Part 3

Dr. Smith empathized with Dr. M’s concerns about continued treatment with Ms. A, but highlighted her treatment progress and the strength of the therapeutic alliance. Dr. Smith asked Dr. M if he might be interested in continuing to treat Ms. A if Dr. Smith provided clinical supervision. Dr. M decided that he would be interested in such an arrangement. After speaking with Ms. A about the issue, and obtaining informed consent for continued treatment, Dr. M resumed seeing Ms. A for weekly psychotherapy and medication management.

• 1.4. The most helpful option for Dr. M in terms of Ms. A’s care and his own lifelong learning includes which of the following?

  • A. Informing Ms. A that he will only prescribe her medications and will transfer her psychotherapy to a psychiatric social worker

  • B. Treating Ms. A while receiving supervision from Dr. Smith

  • C. Joining an ECP group

  • D. B and C only

• 1.5. As an ECP, Dr. M will likely encounter which challenges?

  • A. Reimbursement policies that devalue psychotherapy

  • B. Handling taxes, billing, and electronic records

  • C. Self-care and achieving optimal work-life balance

  • D. All of the above

Discussion: Challenges of ECPs

It has long been observed that the first 3–5 years after training can be stressful and chaotic for psychiatrists. Not only must they establish a secure clinical identity, but they must also navigate “the business side of having an office, getting insurance, handling taxes, billing, and electronic records” (8). Some challenges for ECPs will depend on their choice of work and location; however, common themes include networking, relationships with colleagues, obtaining mentors, self-care, and achieving appropriate levels of clinical confidence (9).

Fortunately, there are now reliable resources for the ECP, including mentorship, various associations for ECPs, as well as virtual study groups and peer supervision. The APA dedicates specific sessions to ECPs and has formed an “Assembly Committee on Early Career Psychiatrists” to promote ECP professional development (10). Joining such associations can offer invaluable resources and decrease professional isolation. Clemens (8) has observed that “challenges in the early career stage . . . may have lasting or career-defining impact.” Thus, the ways in which these challenges are met and supported become a crucial part of the ECP’s development. Particularly for those ECPs who seek to practice both psychopharmacology and psychotherapy, ongoing professional study groups may provide a wealth of benefits, including peer support, supervision, networking, and lifelong learning.

Answers

• 1.1. The answer is A. Obtaining collateral information from the referring psychiatrist would be the next appropriate step clinically. As Ms. A’s most recent therapist, Dr. M would be in a good position to inform Dr. Smith of the patient’s recent history and experience in treatment. A conversation with the prior therapist allows Dr. Smith to understand the general nature of the treatment relationship, including the difficulties that ultimately led to the referral to a new therapist. Although certain medications may be helpful for suicidal thoughts, prescribing medication (choice B) would not be clinically wise prior to completing a full evaluation, negotiating a treatment frame, and obtaining informed consent for treatment. Given the limited information obtained thus far, inpatient hospitalization would not be warranted (choice C). Involving family members (choice D) in session may be beneficial in certain cases once treatment has commenced, but not prior to completing a full consultation and establishing a treatment alliance.

• 1.2. The answer is B. When a psychiatric patient is involuntarily hospitalized, there is a potential conflict between the desire of the patient to remain out of the hospital and what the physician deems necessary to protect the patient from harm. Autonomy refers to the patient’s liberty, wishes, and ability to make decisions for themselves. Beneficence refers to the duty of a physician to protect the patient’s welfare and interests and, in some cases, to “prevent or remove harm” (5). Justice is a core ethical principle that is generally interpreted to mean fair and equitable treatment for all persons (11). Nonmaleficence refers to the obligation to not harm the patient, which encompasses several rules: “do not kill, do not cause pain or suffering, do not incapacitate, do not cause offense, and do not deprive others of the goods of life” (11).

• 1.3. The answer is E. It is not uncommon for resident psychiatrists to continue treating certain patients after residency graduation. It is important to recognize that, although the physician and patient remain the same people before and after the resident becomes an attending physician, certain aspects of treatment will inevitably change. All the issues mentioned above (fee arrangement, location of treatment, supervisory presence, and self-care and mentorship) are elements of the treatment framework that must be agreed on by both physician and patient. First and foremost, the treatment framework is designed to protect the patient and therapist. The framework also serves as a vehicle through which the psychotherapy can unfold. Any deviations from the framework should be noticed by the therapist and processed as potential data emerging from the treatment. Dr. M mentioned several apparent deviations from the framework, such as frequent lateness to appointments or payment. The complicating issue was that the shift from the resident clinic to the new private practice fundamentally altered the existing framework. A renegotiation of the framework must take place to ensure the patient is consenting to the treatment in the new setting, including the new agreements on fees, location of treatment, timing of treatment, and lack of supervisory presence.

• 1.4. The answer is D. In focusing on what is most helpful for Ms. A, as well as for Dr. M’s career development, referring Ms. A to an outside therapist is the least helpful of all the options. It neither coordinates Ms. A’s continuing care, nor develops Dr. M’s experience and confidence. As an ECP who is interested in maintaining his psychotherapy skills and practice, supervision by Dr. Smith and support from an ECP group are more productive options for Dr. M.

• 1.5. The answer is D. As an ECP, Dr. M is very likely to encounter all the challenges listed. Seeking supervision, participating in peer study groups, joining an ECP association, and self-care and achieving optimal work-life balance are likely to provide a wealth of helpful information as Dr. M negotiates the difficulties of transition to real-world psychiatric practice.