Strategies for clinicians working with someone with BPD

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•Believe that people with BPD have a genuine mental illness. It is not “just a behaviour” (NHMRC clinical practice guidelines for BPD refers to BPD as a mental illness).

• BPD is a condition of the brain and the mind and it is not the person’s fault, weakness or a failing on their part.

• Patients with BPD have a hyperactive and hyper-responsive emotional system (Amygdala). The cortical control over Amygdala is inadequate.

• Take a developmental perspective and understand the patient’s illness from a theoretical perspective.

• While working with patients with BPD, if you make mistakes, apologise. Be transparent and totally honest with patients with BPD. They have very sensitive interpersonal radar and see through defensiveness.

• Develop a treatment plan and a crisis management plan along with the patient. Encourage patients to author the development of such plans under clinicians’ guidance.

• Have a clear structure and boundaries to your treatment plan.

• Be aware of emotions in the therapeutic relationship (yours and patients) and manage them with care.

• People with BPD are frequently chronically suicidal. Learn to differentiate chronic risks from acute risks.

• Teach patients skills to manage their painful emotions, interpersonal relationships and self-harm and suicidal urges.

• Remain calm when patients are in crisis. A crisis may not always mean imminent suicide risk.

• Take a long term perspective. Patient’s illness may fluctuate in the short term.

• People with BPD get well. Clinical remission is the norm, not an exception. Many people with BPD achieve recovery and very few people require lifelong treatment.

• It is not always necessarily to have specialist BPD-specific psychotherapy (e.g. DBT, MBT) training and skills. Knowledge of common psychotherapeutic factors and principles may be sufficient to treat very many patients.

• Clinicians who are active, enthusiastic, interested, hopeful, validating and willing to treat seem to be able to get good results with BPD patients.

• Seek supervision or at least informal discussions with your peers or colleagues.

• Take second opinions.

• Keep medication prescriptions to a minimum. Do not admit them frequently. 

A/Prof Sathya Rao