Ongoing management
If you are in a position in which you may work with a person with BPD, it is important to remember that intention and outcome are often unrelated. It is critical that you establish the following ground rules from the start to maintain consistency and client expectations. By aiming for a nonjudgmental stance, you will be better able to provide more effective care, help the individual to a greater degree and reduce your own burnout.
Environment
- Ask if there is a current relationship that is violent in nature and use local services to assist with this.
- Maintaining education, social, family, work life is critical for the individual to have a fulfilling life.
Relationships
- Refer the individuals to a psychologist to help them understand how and why they sabotage useful relationship or develop harmful ones.
- Therapist to set aside regular longer appointments to engage in psychotherapy.
- Although development of secure attachment to therapist is required for psychotherapy to have positive results, this may not occur easily for those with BPD given their intense needs and fears about committing to relationships.
Consistency and structure
ANTONIA NEW – Strategies for maintaining recovery
- Consistency allows for setting firm boundaries as it important for individuals with BPD who may try booking more frequent appointments or bargain for more because “you are the only one who understands”.
- Boundaries must be clear to the client from the beginning to allow for increased sense of safety and trust between the individuals and service provider, and increased empowerment for the individuals to meet their own needs and take care of themselves.
- Aim of the psychotherapy is to contain the anxiety and rage. It is essential that if you are a therapist, you show that you can deal with whatever it is that is being experienced by your client. Maintaining a structured approach will relay to the client that their emotional and mental experiences do not have the power to influence their environment and those around them and therefore the client will learn to be in control of their emotions.
- Be consistent by keeping to the regular, longer appointments and provide sufficient notice of your holiday or leave.
- Set up weekly psychotherapy appointments at a time that will not be impacted by other emergency patients and do not get distracted during sessions
Therapies
MARSHA LINEHAN – The need for a relationship of equality between therapist and client
To see more BPD interview footage see Borderliner Notes.
- Therapies should only be conducted by trained therapists with previous experience with BPD.
- Dialectical Behaviour Therapy (DBT) is most effective for severe dysregulation, high risk, multiple diagnoses and is based on Cognitive Behaviour Therapy (CBT) with an emphasis on psychosocial aspects of treatment:
- Synthesis of acceptance with change
- Principle-based integration of evidence-based treatments (EBTs)
- Focus on in-session behaviours
- Stages targeting by severity and threat
- Suicide risk and assessment protocol
- Skill-based on EBTs + mindfulness skills
- Definition of team as part of therapy
- Therapist self-disclosure
- DBT is based on the theory that people with BPD react in a more intense and prolonged way towards emotional situations, especially in relationships. DBT teaches skills that will help with accepting and coping with these emotional surges.
- DBT teaches patients to identify their strengths and build on them so they can feel better about themselves and their life
- The CBT basis allows patients to identify thoughts, beliefs and assumptions that make life harder.
- DBT involves completing weekly homework assignments, role-play new ways of interactions, and to practise skills such as self-soothing when upset.
- Individual weekly psychotherapy sessions emphasise on problem-solving the past week’s difficulties in the patient’s life.
- Deliberate suicidal and self-harm behaviours are prioritised before behaviours
- Possible discussion on quality of life and working toward improving
- Individual session focussing on enhancing self-respect and self-image
Read Is DBT the right fit for your patient (access to article will require free registration).
Push-Pull or Love/Hate dynamic
- Be aware of patients’ potential to “test” the commitment and honesty of relationships, including patient-doctor relationship
- Sometimes there will be evidence of patient deliberately provoking or sabotaging their relationships to test whether they will stay or not
- BPD patients also have a fear or abandonment and these actions are driven by a mixture of poor self-esteem with desperation for care and nurture.
- BPD patients may test the doctor by being late or not attending sessions or trying to provoke anger verbally or deliberate self-harm
- which may cause further harm to the recovery as the patient may try to “pull” the doctor back in by overblown apologies and promises, and threaten self-harm.
- It is important to explain this complex dynamic to the patient and discuss when such responses have occurred.
Managing trauma/rage
- Mindfulness allows patients to become more aware of and reflect on the unhelpfulness of some thoughts. It is does not involve changing way of thinking.
- It is recommended to practise mindfulness therapy when patient is in a non-crisis periods to eventually minimise rage and related responses.
For more information
Medscape – BPD treatment and management
Emotion-focused principles for working with borderline personality disorder
Managing borderline personality disorder and substance use
Training and resources
Practice Guideline for the Treatment of Patients with BPD
Click onto QCOSS Community Door eTraining – Strengthening Non-Governmental Organisations to find free self-paced training modules.
The Mental Health Professionals’ Network (MHPN), in partnership with the Australian BPD Foundation and Spectrum Personality Disorder Service for Victoria is producing a free webinar series to increase clinicians’ expertise and ability to provide high quality, responsive, evidence-based treatment, care and support for people with BPD. To view the first of the six-part webinar click here. To view more webinars from MHPN click here.
Look out for local BPD training workshops conducted by BPD Awareness ACT.
Source
Emotion-focused principles for working with borderline personality disorder
Managing borderline personality disorder and substance use
