Understanding the Experiences of Social Workers Who Provide Care to People Living with Borderline Personality Disorder: A Critical Realist Qualitative Study

Background and Purpose: Borderline Personality Disorder (BPD) is a serious mental illness characterized by instability in interpersonal relationships and self-image, emotional and behavioral deregulation stemming from past trauma and/or biological aetiologies, with high morbidity and mortality. This presentation explores how social workers describe their experiences of providing care to people living with BPD across the continuum of care from community mental health to hospital in-patient settings.

Methods: Data were collected using in-depth semi-structured interviews with social workers recruited in the Canadian province of Ontario. Interviews were conducted between April 2020 and January 2021 and lasted between 50 and 60 minutes. Interviews were audio recorded and professionally transcribed verbatim and imported into NVivo 12 qualitative data management software. The transcribed data were coded, and major themes were identified using a Critical Realist Analysis. Standard research ethics protocols were followed, and participants were provided with a $25 CAD honorarium.

Results: We recruited N=41 social workers (CisFemale 33, CisMale 7, Gender Queer = 1) employed across the continuum of care. Years in practice ranged from 1 to 44, with an average of 11 years post accreditation. The age of participants ranged from 27 to 72 years old; with the average age being 39 years old. All interviews were conducted remotely due to COVID-19; 39 of the 41 interviews were conducted on the phone and two took place over Microsoft Teams. Participants were recruited using snowball sampling, and email recruitment; we attached the recruitment flyer and sent a mass email through the school of social work at a university.

Key themes which emerged in the data are: 1) structural barriers when trying to provide equitable access to evidence-based treatment programs for people living with BPD (e.g., social workers do not feel they have received enough clinical training to support people living with BPD and evidence-based treatment modalities are not available or accessible to people who need them), 2) Professional and intra-professional provider-based stigma (e.g., every participant interviewed had witnessed stigma leading to negative treatment towards those diagnosed with BPD in the workplace), 3) The impact of class and racial disparities on treatment access and care outcomes (e.g., people who are incarcerated and experience comorbid mental illness cannot access any treatment until they are out of prison which creates a very challenging dynamic to support individuals living with BPD) and 4) Advocate Clinician (e.g., seeing patients as worthy of excellent care, using “work arounds” to make this happen, going above and beyond to support clients).

Conclusions: Social workers are uniquely positioned to support and advocate for the inclusion of people living with BPD across their many practice roles. Findings from this study will support the development of education materials for social work education and inform policies to improve access to care at partner sites in Ontario with implications for social workers practicing in other contexts.