From Clinical Practice to System Change: A Critical Realist Qualitative Study of Social Workers' Perspectives on Borderline Personality Disorder Care Delivery in Ontario
Bibliographic record
Abstract
This manuscript-based dissertation examines how social workers in Ontario experience and understand providing care to people living with Borderline Personality Disorder (PLBPD), with particular attention to structural barriers and systemic challenges in care delivery. Through 41 in-depth interviews with social workers across diverse practice settings, this research illuminates the complex intersections between individual care experiences, professional practice, and broader systemic factors that shape BPD care provision. The dissertation consists of four manuscripts that progressively build upon each other: The first manuscript details innovative methodological approaches to conducting qualitative research during the COVID-19 pandemic, highlighting the opportunities and challenges of remote data collection. The second manuscript demonstrates the application of Critical Realism (CR) methodology in social work research, providing a detailed framework for examining complex social phenomena. The third manuscript analyzes how provider-based stigma and interprofessional dynamics impact care delivery for PLBPD, revealing both individual and structural barriers to effective care. The fourth manuscript examines structural barriers within Ontario's healthcare system, identifying how system fragmentation, resource constraints, and social determinants of health create compounding challenges in BPD care delivery. Key findings reveal that while social workers recognize BPD as a complex diagnosis requiring comprehensive support, they face significant challenges in providing effective care due to limited resources, inadequate training, and systemic barriers. The research identifies four interconnected themes across the manuscripts: (1) the impact of healthcare system fragmentation on care coordination; (2) the persistence of provider-based stigma despite increasing awareness; (3) the intersection of social determinants of health with care access; and (4) the need for collaborative, integrated approaches to care delivery. This dissertation makes several significant contributions to the field. Methodologically, it provides a detailed example of applying critical realist analysis to complex healthcare phenomena. Empirically, it offers new insights into how structural mechanisms shape both individual care experiences and systemic outcomes in BPD care delivery. Practically, it identifies specific opportunities for healthcare system reform while highlighting the crucial role of social workers in addressing both immediate care needs and broader systemic barriers. Findings indicate that addressing BPD care requires moving beyond individual clinical interventions toward coordinated system-level responses, including integrated care pathways, anti-stigma initiatives at institutional levels, and enhanced workforce development. Keywords: Borderline Personality Disorder, healthcare systems, structural stigma, social work, critical realism, qualitative research
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.015 | 0.023 |
| Meta-epidemiology (narrow) | 0.001 | 0.001 |
| Meta-epidemiology (broad) | 0.001 | 0.001 |
| Bibliometrics | 0.002 | 0.003 |
| Science and technology studies | 0.033 | 0.033 |
| Scholarly communication | 0.008 | 0.004 |
| Open science | 0.003 | 0.009 |
| Research integrity | 0.003 | 0.004 |
| Insufficient payload (model declined to judge) | 0.003 | 0.000 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".