New thesis calls compulsory care of people with borderline personality disorder into question

How do caregivers reason when deciding to treat patients with borderline personality disorder (BPD) under compulsory care? Is compulsory care ethically defensible? A new thesis by psychiatrist Antoinette Lundahl tries to answer these questions and concludes that there is much to indicate that compulsory care does not help patients with BPD and can even increase the risk of suicide.

In her thesis, Antoinette Lundahl demonstrates that the inclination to order compulsory care for patients with BPD varies from one clinician to the next, which can lead to unequal care. Compulsory care as a suicide-preventive measure is common, even though such care has been associated with several harms for the patients—including increased suicide risk.

Antoinette Lundahl is a psychiatric consultant and works with patients with BPD in inpatient care.

"I've heard how my colleagues reason and noticed that their opinions are contradictory," she says. "It's strange. We have so much experience showing that compulsory care doesn't work for these patients and yet there's such resistance to changing practices."

Locked up in a ward

Detention through compulsory care means being locked up in a psychiatric inpatient ward.

"Imagine not knowing how long you're going to be locked up for and being forced to take drugs under restraint. For such a huge violation of personal liberty to be made, the medical reasons should be so strong that the benefits outweigh the harm."

Lundahl stresses that she is not opposed to compulsory care per se, which she believes to be justifiable if, for example, such care is of great help to the patient and cannot be provided by other means.

"From a medico-ethical perspective, compulsory care should only be used when the patient lacks the capacity to make their own decisions about the care they receive, due, for instance, to a psychosis that distorts their perception of reality."

Patients with BPD normally do not fall within this category, she continues, but at the same time, the clinical guidelines for patients with BPD and a risk of suicide are vague.

"Intuitively, the locking up and monitoring of suicidal patients seems the safest bet, but it's very possible that the compulsory care of patients with BPD rather increases than decreases suicide risk."

The collected body of experience and research suggests that suicide risk can increase from such care, or, at least, compulsory care fails to decrease suicide risk for these patients.

Lundahl's thesis shows that there can be other motives than medical ones for ordering compulsory care for patients with BPD. For example, doctors are afraid of being reported if they discharge a suicidal patient, which can have the opposite effect. In one of her studies, health care staff say that their patients' self-harming behavior increases after only a few days in compulsory care.

"There seems to be something toxic about compulsory care," she says. "Perhaps because it deprives patients of their autonomy, which can be perceived as ending up at rock bottom."

Philosophical argumentation

The psychiatrists who decide on compulsory care are, of course, in an ethical dilemma, so Lundahl decided to include philosophical reasoning in her thesis. One question is whether it can be considered ethically justified to compulsorily detain BPD patients as a life-saving measure. She concludes that it is not.

"The respect for the patient's autonomy is an important medico-ethical principle," she says. "In other words, a patient should be entitled to refuse care as long as they are capable of making their own decisions—and these patients usually are. Another important principle is that the treatment should do more good than harm. I've seen nothing that suggests that this is the case when it comes to compulsory care of patients with BPD."

Alternatives to compulsory care

She believes that the reason many caregivers still routinely opt for compulsory care for this group of patients can be explained by tradition and the idea that it is the only possible option when a patient displays suicidal behavior.

"Some clinics in Sweden work with short voluntary hospital admissions followed by outpatient psychotherapy, in which patients learn to handle their emotions in a crisis. This has shown to be very effective."