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Under the vast majority of managed care arrangements, the psychotherapy of patients with borderline personality disorder (BPD) is severely limited. In some cases, treatment of such patients is entirely eliminated based on a policy of only reimbursing treatment of Axis-I conditions. Given that approximately 23 percent of inpatients and 11 percent of outpatients suffer from BPD (Widiger and Frances, 1989), this stipulation leaves a great many severely disturbed individuals without adequate treatment.
Other managed care companies may allow anywhere from 6 to 30 psychotherapy sessions for borderline patients. While there are no hard data to support the efficacy of such brief treatments with borderline patients, the limits are generally rationalized based on the notion that patients with BPD are “bottomless pits” who will be in treatment indefinitely if given the opportunity for more extended treatment. This practice of setting arbitrary session limits is a recipe for disaster with many patients. By the very nature of their psychopathology, borderline patients live with an undercurrent of dread that, at any moment, they will be abandoned. This dread is activated in the transference to the therapist, and abandonment after several weeks or months due to third- or fourth-party reimbursement constraints may be experienced