Adolescent behavior or characteristics of borderline? When it comes to a personality disorder, it is important not to delay the diagnosis for too long. This is often not without consequences, argues clinical psychologist Joost Hutsebaut. Tilburg University recently appointed him professor by special appointment of ‘Prevention and early intervention of personality pathology’. A good reason to talk to him about his research and ambitions: “Puberty is the crucial period in which you can intervene successfully and this time flies by”.
In his work as a clinical psychologist at the Viersprong – a national organization specialized in the treatment of problems in personality, behavior and family – he often encounters them: young people with an incipient (borderline) personality disorder. They come into conflict with teachers, get stuck in school, have few friends or self-harm. In most cases, these young people are not treated for this. If they are treated, they rarely get the right treatment program. And that while an early diagnosis and correct treatment are essential steps towards a stable future, according to Hutsebaut.
Why is it important to have a personality disorder already in puberty to diagnose and treat?
“Puberty is an important period of development. That’s when a person lays their social and professional foundations. Think of building a social network, making friendships and following an education. In addition, during puberty you learn certain lifestyle habits that you will fall back on throughout your life, such as exercising, eating, sleeping, smoking, drinking or using narcotics. It is important that young people teach themselves good habits during this period and lay a solid foundation.
“Negative behaviors and patterns are difficult to reverse later in life. It is much easier to intervene when they are not yet chronic. But then therapists must diagnose young people with a personality disorder as such and focus the treatment on this.”
‘A personality disorder is wrongly attributed to undesirable characteristics’
Nevertheless, practitioners are often hesitant to diagnose a personality disorder in puberty. Where does that reluctance come from?
“I think this has to do with the name of the diagnosis. Undesirable characteristics are wrongly attributed to a personality disorder. For example, the name ‘personality disorder’ suggests that there is something wrong with someone’s personality, you don’t want to ‘just’ stick that label on someone. In addition, adolescents are very changeable in their behavior. This may also be a reason why practitioners are hesitant to make such a ‘heavy’ diagnosis. They prefer to push it forward.”
In your inaugural lecture, you explain that typical features of a borderline personality disorder – such as fluctuating emotions and moods, impulsiveness, changing self-image, confusion of identity and hypersensitivity – resemble adolescent behaviour. How do you prevent that not every rebellious teenager is wrongly diagnosed?
“That is actually the crucial question. Personality pathology in children and adolescents is a relatively young field of research. That makes it difficult. But if you can draw one conclusion from the research of the last twenty years, it is that young people with characteristics of a (borderline) personality disorder run an increased risk of serious problems, such as dropping out of school, addictions and suicidal thoughts. It is simply not the case that ‘certain behaviour’ will ‘go away’ because you are an adolescent. On the contrary: that behavior seems to predict the outcomes of someone’s mental health in the long term.
“That does not mean that every adolescent with these symptoms will necessarily experience negative consequences in the long term. The same goes for smoking: some people smoke a pack of cigarettes a day and escape the dance. Contrary to expectations, they do not develop lung cancer. But an individual exception does not disprove the overall expectation.
“However, we do not only focus on the characteristics of a personality disorder. But also, for example, on someone’s risk profile. If that is low, we can more often let natural psychological development take its course. If, on the other hand, it is high, then we must intervene appropriately.”
What does ‘appropriate intervention’ mean?
“That refers to two things. On the one hand, the help – the intervention – must match the stage of the problem. A simple comparison: when someone has a suspicious skin spot that has not spread, the doctor removes that spot. In that case, chemotherapy is not necessary. The same applies to a personality disorder: if someone self-harms (for example, cuts themselves) but still goes to school and lives at home, appropriate care is different than if this person does not go to school and lives at home.
“On the other hand, the care must fit someone’s personality problem. People with personality disorders are generally wary of the intentions of others. This can lead to a break in contact with the practitioner when they think they see something of ‘falsehood’. For example, when a practitioner sticks too tightly to a protocol. That is why it is important as a therapist to always actively monitor and discuss the treatment relationship. They must be given frameworks and tools for this so that they know how best to respond to young people with a personality disorder.”
To what extent are there enough practitioners to provide everyone with the right care?
“I think there is unfortunately a huge shortage of practitioners and treatment programs. One of the chair’s ambitions is therefore to make these types of treatment programs more readily available in practice. Experience tells us that many young people with a personality disorder are treated unsuccessfully. Puberty is the crucial period when you can successfully intervene and this time flies by. By training many good practitioners, you can prevent failed treatments.
“That does not mean that all these practitioners have to be hyper-specialized. It is especially important that therapists have frameworks with which young people can get a lot further with ‘slightly adapted treatment’: in many cases ‘good enough’ is also ‘good’.”
‘Health care is so expensive because intervention is often too late’
How do you reconcile this need for treatment programs and the right practitioners with the years of cutbacks in healthcare?
“Healthcare is so expensive because interventions are often made too late. If someone has not worked for twenty years, has no social network to fall back on and constantly needs new treatments, the costs can add up. If you can prevent someone from ending up in that position by intervening in time, the care at the bottom of the line will be much cheaper.
“Partnerships with schools and municipalities contribute to this. The teacher also has an important role in this: they know students well and quickly see who is left out in the class. In this way, teachers can recognize children with a possible personality disorder at an early stage.
“It is also important that children with a personality disorder continue to attend school during their treatment process and are not pulled out of ‘normal life’. They benefit from education and contact with peers. That requires a lot from teachers because these children need extra attention.”
In addition to health care, education has also been cut back enormously. Teachers face ‘popular classes’ and experience a high workload. How do you see this plan successfully succeeding if they also have to take on this task?
“In Scandinavia you see that governments invest huge sums in education. School classes are much smaller there. In the long run, this will pay off more. Unfortunately, the choices of the Dutch government are different and the policy differs greatly from the Scandinavian model. But within this policy you have to look at how teachers can give more tools so that they can keep as many young people on board as possible.
“At the moment, systems work too isolated from each other: mental health care treats a child, but then there is no contact with schools. The cooperation with municipalities can also be improved: on 1 January 2015, the Youth Act came into force and municipalities are responsible for providing the full range of youth assistance. In addition to teachers, youth professionals who work for the municipalities can therefore also play a crucial role in the early identification of personality disorders. Together with parents and young people, they decide on appropriate help. That is why it is important that they also have the right knowledge so that they can refer these children appropriately.”
