‘A personality disorder? Diagnose and intervene in time’
Adolescent behavior or characteristics of borderline? If it is a personality disorder, it is important not to delay the diagnosis for too long. After all, it is often not without consequences, argues clinical psychologist Joost Hutsebaut. Tilburg University recently appointed him as an endowed professor of Prevention and Early Intervention of Personality Pathology. A great occasion to talk to him about his research and ambitions: “Puberty is the crucial period when you can successfully intervene, and this time just flies by.”
In his work as a clinical psychologist at the Viersprong—a national organization specializing in the treatment of personality, behavior, and family problems—he often encounters them: young people with incipient (borderline) personality disorder. They come into conflict with teachers, get stuck at school, have few friends, or inflict physical injuries on themselves. In most cases, these young people are not treated for this. When they do receive treatment, they rarely get the right treatment program. And yet, according to Hutsebaut, early diagnosis and proper treatment are essential steps toward a stable future.
Why is it important to diagnose and treat a personality disorder as early as adolescence?
“Adolescence is an important developmental period. It is the time when a person lays his social and professional foundations, such as building a social network, making friends, and getting an education. In addition, during puberty you learn certain lifestyle habits that you fall back on throughout your life, such as in the areas of exercise, eating, sleeping, smoking, drinking, or using narcotics. It is important during this period that young people teach themselves good habits and build a solid foundation.
‘Undesirable traits are unjustly attributed to personality disorder’
“Negative behaviors and patterns are difficult to reverse later in life. It is much easier to intervene when they are not chronic yet. But then treatment providers must diagnose adolescents with personality disorders as such and target treatment accordingly.”
Yet practitioners often hesitate to diagnose a personality disorder as early as adolescence. Where does this reluctance come from?
“I think this has to do with the name of the diagnosis. Undesirable traits (in Dutch) are unjustly 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 stick that label on someone ‘just like that.’ In addition, adolescents are very changeable in their behavior. This too can be a reason that practitioners hesitate to make such a ‘heavy’ diagnosis. They prefer to delay it.”
You explain in your oration that typical features of borderline personality disorder—such as fluctuating emotions and moods, impulsivity, changing self-image, identity confusion, and hypersensitivity—resemble adolescent behavior. How do you prevent every rebellious adolescent from being unjustly diagnosed with this?
“That’s actually the crucial question. Personality pathology in children and adolescents is a relatively young field of research. That makes it tricky. But if you can draw one conclusion from the research of the last twenty years, it is that adolescents with characteristics of a (borderline) personality disorder are at an increased risk of serious problems, such as dropping out of school, addictions, and suicidal thoughts. Just because you are an adolescent does not mean that ‘certain behaviors’ will simply ‘go away.’ On the contrary, those behaviors seem to predict the outcomes of one’s long-term mental health.
“This is not to say that every adolescent with these symptoms necessarily suffers long-term negative consequences from it. The same goes for smoking: some people smoke a pack of cigarettes a day and have a lucky escape. They—contrary to expectation—do not get lung cancer. But an individual exception does not disprove the overall expectation.
“Yet, we don’t just focus on the characteristics of a personality disorder. But also, for example, on a person’s risk profile. If it is low, we can more often let natural psychological development take its course. If, on the contrary, it is high: then we have to intervene appropriately.”
What does “appropriate intervention” mean?
“That relates to two things. On the one hand, the help—the intervention—must be in line with the stage of the problem. A simple comparison: when someone has a suspicious skin spot that has not metastasized, the doctor removes that spot. Chemotherapy is not necessary in that case. The same goes for a personality disorder: if someone injures him/herself (e.g. cuts him/herself) 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, care must be in line with a person’s personality disorder. People with personality disorders are generally wary of the others’ intentions. This can lead to a breakdown in contact with the practitioner when they think they see something of ‘falsehood.’ For example, when a practitioner sticks to a protocol too tightly. This is why it is important for practitioners to always actively monitor and discuss the treatment relationship. They should be given frameworks and tools for this, so that they know how best to respond to young people with personality disorders.”
To what extent are there enough practitioners to give everyone the right care?
“I think there is, unfortunately, a huge shortage of practitioners and treatment programs. So one of the ambitions of this chair is to make these types of treatment programs more available in practice. Experience tells us that many adolescents with personality disorders are treated unsuccessfully. Adolescence is the crucial period when you can successfully intervene, and this time just flies by. By training many good practitioners, you can avoid treatment failures.
‘Health care is so expensive because intervention is often too late’
“That is not to say that all these practitioners have to be hyper-specialized. It is especially important that practitioners have frameworks that allow young people with ‘slightly modified treatment’ to get a lot further: in many cases, ‘good enough’ is also ‘good.'”
How do you reconcile this need for treatment programs and right practitioners with years of cuts in health care?
“Health care is so expensive because intervention is often done too late. If someone hasn’t worked for 20 years, has no social network to fall back on, and constantly needs new treatments, the costs add up quite a bit. If you can prevent someone from ending up in that position by intervening in time, care is much cheaper in the end.
“Collaborations with schools and municipalities contribute to this. The teacher also has an important role in this: they know pupils well and can quickly see who is out of place in the class. Teachers can recognize children with a possible personality disorder early on in this way.
“In addition, it is important that children with personality disorder continue to attend school as usual during their treatment journey and are not pulled out of ‘normal life.’ They benefit from being educated and having contact with peers. This does require a lot from teachers because these children need extra attention.”
In addition to health care, there have been huge cuts in education. Teachers are facing ‘huge classes’ and experiencing a high workload. How do you see this plan succeeding if they also have to take on this task?
“In Scandinavia, you see governments investing huge amounts of money in education (in Dutch). School classes there are much smaller. In the long run, that yields 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 to give teachers more tools so that they keep as many young people as possible on board.
“Currently, systems work in too much isolation from each other: the GGZ treats a child, but then there is no contact with schools. Cooperation with municipalities could also be even better: on Jan. 1, 2015, the Youth Act came into effect and municipalities are responsible for providing the full range of youth aid. Thus, in addition to teachers, youth professionals working for municipalities can also play a crucial role in the early detection of personality disorders. They decide on appropriate help together with parents and youngsters. Therefore, it is important that they too have the right knowledge so that they can refer these children appropriately.”
Translated by Language Center, Riet Bettonviel