Available online at www.sciencedirect.
com
ScienceDirect
Barriers to care for adolescents with borderline
personality disorder
Kiana Wall, Sophie Kerr and Carla Sharp
Intervention for borderline personality disorder (BPD) in
adolescence is crucial as early onset of the disorder predicts
more severe course, and intervention ‘late’ in the course of the
disorder is associated with more negative outcomes. In spite of
this, access to services is poor. This is because several unique
barriers to accessing care exist for adolescents with BPD. In
this article we highlight key barriers to care for adolescents with
BPD utilizing a conceptual model for understanding health care
access that emphasizes the interaction between patient and
health care system characteristics. We conclude with
proposed recommendations to address these identified
barriers.
Address
University of Houston, United States
Corresponding author: Sharp, Carla (csharp2@uh.edu)
Current Opinion in Psychology 2021, 37:54–60
This review comes from a themed issue on Personality pathology:
developmental aspects
Edited by Carla Sharp, Andrew Chanen and Marialuisa Cavelti
For a complete overview see the Issue and the Editorial
Available online 6th August 2020
https://doi.org/10.1016/j.copsyc.2020.07.028
2352-250X/ã 2020 Published by Elsevier Ltd.
Borderline personality disorder (BPD) often onsets dur-
ing adolescence and contributes to ‘adaptive failure’ in
the areas of school, work, and relationships, and subse-
quent psychosocial debilitation [1,2]. Early intervention
for BPD is crucial because early onset predicts more
severe course, and intervention ‘late’ in the course of
the disorder is associated with more negative outcomes
[1,3]. In spite of this, access to services is poor [4].
Although there are well documented challenges all indi-
viduals face when seeking mental health services [5],
unique hurdles exist for adolescents [6] and individuals
with BPD [7,8]. We argue that these challenges are
compounded at the intersection of adolescence and
BPD. Consistent with the scope of Current Opinion articles
we will not attempt to discuss all literature relevant to this
topic. However, we will endeavor to highlight key barriers
to care for adolescents with BPD utilizing a patient-
centered conceptual model [9] for understanding health
Current Opinion in Psychology 2021, 37:54–60
care access. This model illustrates the interaction
between characteristics of the health care service system
and characteristics or abilities of the population being
served to elucidate barriers to care at each step of the
multilevel, dynamic process of treatment seeking and
completion (Figure 1).
We conclude with proposed recommendations to address
identified barriers. Although we focus on BPD specifically
due to lack of available data on other PDs, the model and
recommendations are applicable to all personality pathol-
ogy in youth.
Health care needs
Patients with BPD have high needs due to high risk for a
variety of poor outcomes. BPD features in teens predict
future self-harm and suicide attempts above and beyond
other psychopathology [10] and adolescents with BPD
more frequently engage in self-injurious behaviors than
adults with BPD [11]. This demonstrates high levels of
burden and distress experienced by teens with BPD,
which extends to family members and caregivers who
also experience immense psychosocial burden [12,13].
Further, BPD in adolescence is an economic burden
largely as a result of crisis admissions and high medication
use, and has been shown to be more costly than other
adolescent psychiatric disorders, and even adult person-
ality pathology [14–16].
Perception of needs and desire for care
To initiate the health care utilization process, patients
must recognize that their symptoms are impairing or
causing distress, and subsequently desire help. Simulta-
neously, the health care system must be approachable, as
indicated by visible and transparent services. These goals
are often accomplished via outreach, screening, and
increased mental health literacy.
Patient ability to perceive
Individuals with BPD may not recognize that they have
mental health concerns related to BPD specifically and
therefore not seek appropriate services, in part because of
poor mental health literacy. BPD is among the most under
recognized psychiatric disorders by the public [17] and
professionals [18]. With sparse knowledge of the disorder,
patients and loved ones may not see their symptoms as
problematic or may rationalize them [19]. Parents of teens
with BPD may have difficulty distinguishing between
typical development and problematic behavior or symp-
toms because adolescents experience normative increases
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 Barriers to care for adolescents with borderline personality disorder Wall, Kerr and Sharp 55

Figure 1

Current Opinion in Psychology

The process of health care utilization for adolescents with borderline personality disorder.
Note. Adapted from Levesque, et al. [9]. As described by Levesque, et al. [9], access to health care is a continual process and is not simply
realized once first contact is made. For those with health care needs, the authors define true health care access as the ability to identify what
ones needs are, then find relevant and available services, then reach or come into contact with those services, then maintain use of the services,
and finally, fully engage with appropriate services (each step in the arrow). Successful access at each step of this process of health care utilization
is a result of the interaction between: 1) characteristics of health systems, organizations and providers, and 2) characteristics and abilities of the
population being served — in this case, adolescents with borderline symptoms and their families. At each step in the health care utilization
process, interactions between these supply (health care system) and demand (patient population) characteristics can create barriers to access.

in risky behaviors which mirror symptoms of BPD, or may
misattribute symptoms to more well-known disorders
such as bipolar disorder or ADHD [20], an issue that
even trained clinicians struggle with [21].
System approachability
Lack of service visibility and informed professionals as a
result of low funding and few clinical trials
In comparison to other severe psychiatric disorders,
BPD and its treatment is greatly under funded and
under researched, leading to a lack of visibility within
the mental health profession and for those seeking
treatment. For example, BPD-focused research has
received less than one-tenth of the NIH funding and
produced far fewer publications than bipolar disorder
research in the past few decades, despite evidence that
BPD is similarly, if not more, prevalent, impairing, and
lethal as bipolar disorder [22]. This may be even more
pronounced in research on youth with BPD. Currently,
there are only eight published RCTs of psychotherapy
interventions with active comparison groups that tar-
geted youth with BPD or subthreshold BPD features
[23], compared to over thirty RCTs with adults with
BPD [24].

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56 Personality pathology: developmental aspects
Lack of visibility and informed professionals as a result of lack
of a unified mental health strategy
The diagnosis of BPD in adolescents is sanctioned by the
DSM-5 [25] and ICD-11 and the treatment of youth with
BPD has been integrated in national guidelines in the UK
(National Collaborating Centre for Mental Health,) and
Australia (National Health Medical Research Council).
However, BPD treatment guidelines in the USA [26]
have not been updated since 2001 and do not include
guidelines for youth. While there are no age-related
caveats for PD diagnosis in the ICD-11, DSM-5 Section
III, or UK, or Australia guidelines, DSM-5 Section II
urges caution, stating that PD should only be diagnosed in
adolescents in ‘relatively unusual instances’ [25; p. 647].
Additionally, BPD is not recognized as a serious mental
illness across US health systems, such as the Substance
Abuse and Mental Health Administration (SAMSA,
which therefore allows treatment access and eligibility
to be decided by state law or insurance companies [8].
Further, available treatment guidelines largely focus on
complex, specialized interventions that are not scalable to
the prevalence of the problem, rather than preventative or
stepped-care models proposed by researchers [3]. With-
out a unified strategy for BPD treatment in youth, the
empirical consensus supporting early intervention and
prevention has not translated to routine clinical care,
and there is a dearth of identifiable services for adoles-
cents with BPD.
Health care seeking
Once patients recognize that they have a health care
need, they must seek services. Successful health care
seeking is the result of an interaction between the
patient’s ability to do so, and the acceptability of the
services they find. Service acceptability refers to the
values, norms, and culture of available services and pro-
viders. Ability to seek services is impacted by cultural and
individual characteristics such as autonomy and gender.
Moreover, cultural and social factors may determine
whether people accept aspects of the service (e.g. the
beliefs associated with the system of medicine). There-
fore, in ensuring access, there is a constant challenge to
meet the needs of different cultural, disadvantaged and
vulnerable populations.
Patient ability to seek
Youth lack the autonomy and capacity to independently
seek treatment as they cannot consent and pay for treat-
ment. As already noted, difficulty in identifying norma-
tive versus problematic behavior by parents may preclude
teens from receiving care if not initiated by the teen.
Regarding gender, while BPD is diagnosed three times
more often in females than males [25], epidemiological
samples do not report such high gender differences [27],
suggesting that males with BPD may face even greater
barriers to reaching treatment.
Current Opinion in Psychology 2021, 37:54–60
System acceptability
Immense discrimination and stigma surrounds BPD
within public and professional realms [28]. Research
shows that clinicians hold more negative attitudes about
patients with personality disorder than depression and
may refuse to treat patients with a BPD diagnosis [7,29].
Individuals with BPD may be particularly vulnerable to
stigma or marginalization given their incoherent sense of
self and tendency to integrate negative features into their
identity, leading to increased self-stigma and decreased
treatment-seeking after stigmatizing experiences [30].
Negative experiences in treatment due to stigma and
invalidating behavior by clinicians create barriers to
future pursuit of care [8]. Further, individuals with
BPD are high users of crisis services and involuntary
admissions, which are often experienced as highly nega-
tive [31], and youth may be even more likely to experi-
ence crisis or involuntary treatment given higher rates of
suicidal behaviors and parental ability to consent. Hyper-
sensitivity to invalidation or negativity bias [32] may
exacerbate this cycle of negative experiences and avoid-
ance, as even neutral or positive service experiences may
feel negative.
Health care reaching
Once health care services are sought and acceptable
services are identified, patients must ‘reach’ services,
meaning they must physically get to services in a timely
fashion. Success in this step is a result of the interaction
between the patient’s ability (determined by resources
such as personal mobility, transportation, occupational
flexibility, and knowledge about health services) and
the availability and accommodation of health care ser-
vices (the physical existence of providers and services
that are sufficient to meet demand).
Patient ability to reach
Resources
Given that BPD is more prevalent in groups of low SES
[33], individuals with BPD may not have the resources for
psychotherapy, which are typically very intensive, long-
term and not necessarily dose appropriate for BPD [23].
Lack of time presents another barrier for parents of
adolescents with mental health problems as they report
that missing work is a major barrier to sustaining treat-
ment [34]. Scheduling appointments is more difficult for
adolescents with BPD, who often require a higher level of
care such as intensive outpatient programs, than adoles-
cents with other disorders.
Social support
Adolescents with BPD present with significant psychoso-
cial impairment and may lack the social support from
family and peers to reach treatment [35]. Further, carers
of family members with BPD report significantly greater
burden than carers of relatives with other serious mental
illnesses [13].
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 Barriers to care for adolescents with borderline personality disorder Wall, Kerr and Sharp 57
Treatment availability and accommodation
Lack of providers
In a recent study of 22 countries, most lacked a sufficient
number of psychotherapists to meet demand for treat-
ment seeking adults with BPD and no country had a
sufficient number of clinicians certified in evidence-
based treatments [36]. In part, this reflects a lack of
sufficient training in the treatment of severe psychopa-
thology, particularly personality pathology [37]. Current
data [38] on 336 APA-accredited clinical/counseling doc-
toral programs indicate that only 47 (14%) currently have
a faculty researcher of PDs, compared to 91 (27%) for
anxiety/panic disorders, and only 49 (14.6%) programs
offer specialty clinical training/practica in PDs, compared
to 109 (32.4%) for anxiety/panic disorders. The rarity of
services is compounded for adolescents due to the adult
focus of most training programs. Without available pro-
viders, adolescents who must wait to obtain high-demand
services often engage in dangerous behaviors in an
attempt to ‘skip the line’ or as their psychopathology
worsens [6]. Therefore, lack of available services is not
only a barrier to care for adolescents but also increases the
likelihood that BPD becomes medically dangerous.
Organizational problems and flexibility
Adults with BPD cite organizational inefficiency as a
barrier to initiating or maintaining services [39]. While
similar data on adolescent BPD programs is not available,
most specialized mental health services for youth cannot
be accessed directly and have complex and inefficient
referral routes, creating a time-consuming barrier to
reaching treatment [6]. Specialized services are also often
characterized by rigidity or inflexibility which is not
accommodating of family schedules [6].
Health care utilization
If patients are able to reach available and accommodating
services, services must be affordable and patients must
have the time and financial resources to maintain
utilization.
Patient ability to pay
Maintaining treatment requires prolonged use of family
resources and is a barrier to care if treatment is not
covered by insurance or not available in settings that
lower income families might frequent – circumstances
which are typical for families managing an adolescent
with BPD [8].
System affordability
Empirically supported treatments for BPD are time con-
suming and expensive [40,41], especially if additional
family therapy or parent skills groups are included.
The cost of evidence-based treatment for BPD, particu-
larly for severe patients, is not adequately covered by
insurance companies in the US. Insurers’ medical neces-
sity guidelines are structured to cover brief treatments for
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acute psychiatric symptoms, such as suicidality, rather
than long-term treatments of the chronic aspects of illness
[42]. Additionally, many insurance companies do not
accept BPD as a billable diagnosis [43]. Further, it is
difficult to find providers that specialize in evidence-
based treatment for BPD who are also reimbursed by
Medicaid or Medicare [7].
Health care consequences
Finally, patients who can afford services experience the
greatest benefits when the treatment is appropriate, and
they are able to fully engage with the services. A service is
considered appropriate when thorough assessment is
utilized to determine the best treatment, the treatment
content is relevant, and there is a high degree of fit
between the provider and the client. Patient ability to
engage refers to capacity and motivation for treatment,
which impacts involvement in treatment decision making
and commitment to its completion.
Patient ability to engage
Treatment engagement and dropout
Patients with BPD may have negative reactions to therapy
content [44]. They may find skills-based psychoeducation
anxiety provoking or have difficulty with treatment jargon
[44]. Many treatments for BPD are often didactic and
content-heavy which could exacerbate treatment dropout
rates that are already high in both adults [45] and adoles-
cents [46]. In adolescents, dropout rates appear to be related
to specific vulnerabilities [46], such as mistrust or competi-
tion between the parent and therapist, fear of stigma, and
previous negative experiences. Younger age in adults has
also been found to predict treatment dropout [45].
Involvement of parents or family
Treating a PD often involves ‘treating families’ or pro-
viding support for caretakers or loved ones [47]. Most
families have a desire to be included in the care plan and
often seek services for themselves but largely find that
these are unavailable [7]. In child and adolescent inter-
ventions generally, perceived irrelevance of treatment,
and poor relations between adolescents, parents and
therapists are associated with premature termination
among families [48].
Disorder characteristics
Characteristics of BPD may interfere with readiness or
motivation to engage in treatment [49]. Some internal
factors such as unhelpful cognitive style, characterized by
mistrust, and impaired interpersonal skills [49] may be
rooted in attachment disruption. In the etiology of BPD,
attachment disruption results in impaired social cognitive
processes, such as mentalizing, which interferes with
building trust in the client-therapist relationship [50].
Trust, which is significantly lacking in BPD [51], is the
foundation of the therapeutic alliance, which in turn is a
key predictor of success in almost all treatments for
Current Opinion in Psychology 2021, 37:54–60
58 Personality pathology: developmental aspects
psychopathology. Epistemic trust, in particular, refers to
the client’s belief that the therapist’s feedback and guid-
ance are in their best interest. If lacking, epistemic trust
may impede an individual’s ability to effectively make
use of psychotherapy and may be even more pronounced
in young people who are developmentally inclined to be
more suspicious of adults’ motivations [52].
Treatment appropriateness
Lack of formal diagnoses
After successfully accessing services, up to 20% of adults may
not receive BPD as their first diagnosis [39]. Among adoles-
cents, Laurenssen, et al. [21] found that although 58% of
providers agreed that PD’s could be diagnosed in adoles-
cents, only 9% would actually diagnose. Clinicians often
refrain from assigning or disclosing BPD diagnoses in an
effort to ‘protect’ the patient from discrimination or because
of the unfounded assumption that BPD is untreatable [28].
However, non-diagnosis is discriminatory because it pre-
cludes patients from disorder-specific treatment, promotes
misdiagnosis and iatrogenic harm, and excludes BPD from
health care policy and implementation [3]. Further, lack of
information about BPD, reluctance to convey the diagnosis,
or withholding the diagnosis is associated with perceived
stigma and rejection by patients, while delivery of a BPD
diagnosis in an empathic, and non-judgmental manner may
increase patient’s perceptions of validity of the diagnosis and
instill hope for the future [53].
Lack of assessment tools and beliefs in myths contribute to
lack of diagnoses
Resistance to assigning appropriate diagnoses and subse-
quent treatment plans for teens with BPD is exacerbated
by myths surrounding BPD and a lack of assessment of
personality pathology in teens. Myths about BPD in teens
and empirical evidence to the contrary have been sum-
marized elsewhere in detail [20]. Although empirically
validated tools for the assessment of BPD in adolescents
exist [54], and providers report a desire for clearer assess-
ment guidelines [55], providers do not use appropriate
tools or do not have access to them. This is an obstacle to
diagnosis, as clinicians have a much better chance of
detecting BPD using formal assessment [18].
All or nothing approach to treatment
The complex, time intensive, and ‘cumbersome’ nature of
treatments for BPD reduce their appropriateness and qual-
ity [56,57]. The efficacy and appropriateness of evidence-
based treatments that have been adapted for adolescents is
also a significantly understudied area [58] suggesting that
as a field we have little information that available services
are of the highest possible effectiveness.
Recommendations
1 Prioritize funding for adolescent BPD research to
increase public and provider mental health literacy
and visibility of services.
Current Opinion in Psychology 2021, 37:54–60
2 Develop unified, comprehensive prevention, early
intervention, and treatment guidelines for adolescent
BPD.
3 Increase the quantity and quality of graduate level
training in PD’s and the amount of post-graduate,
transdisciplinary psychoeducation and training work-
shops available for clinicians to continue to combat
stigma [59,60] and increase BPD literacy among
professionals.
4 Disseminate assessment tools for BPD in youth and
integrate into routine clinical care.
5 Empirically investigate and implement stepped care
or clinical staging models for BPD as scalable, cost
effective alternatives for resource intensive interven-
tions [40,61,62].
6 Investigate telehealth services for adolescents with
BPD, in line with recommendations for patients at
higher risk for suicide [63].
7 Support caregivers of teens with BPD by directing
them to existing advocacy organizations who offer
online psychoeducational and support materials [8].
8 Advocate for treatments such as General Psychiatric
Management for adolescents (GPM-A) for use by ‘the
majority of mental health professionals who will never
receive training in [evidence-based] treatments [for
BPD]’ [57; pg. 4] to expand the number of available
providers and discourage clinicians from refusing
treatment due to perceived lack of competency in
treating BPD.
9 Prevent treatment dropout by assessing dropout vul-
nerabilities at the beginning of treatment [46], devel-
oping risk profiles to aid in treatment personalization
and stepped care [64], and increasing family involve-
ment in treatment, either directly or through referrals
to free services (e.g. Family Connections).
10 In treatment, be cognizant of the adolescents full
social system (e.g. school, medical health, peers)
and collaborate and consult appropriately.
Conflict of interest statement
Nothing declared.
Funding
This research did not receive any specific grant from
funding agencies in the public, commercial, or not-for-
profit sectors.
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