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Borderline personality disorder

Therapeutic alliance:
Working with people with borderline personality disorder (BPD) is inherently complex. The chaos and disorder that characterises the internal world of the individual with BPD can impact on attempts of the professionals and agencies involved to engage effectively. Having a diagnosis of BPD should never exclude an individual from receiving other services which are required.

This is well recognised and research suggests that staff should devote effort to achieving adherence to care, treatment and interventions which should:

• be well structured
• have a clear focus
• have a theoretical basis that is coherent to both staff and service users
• be relatively long term (months rather than weeks)
• be well integrated with other services available to the individual, using where appropriate, the Care Programme Approach as a main means of networking, communicating and reviewing plans between different elements of the service where appropriate, and
• involve a clear treatment alliance between staff and service user.

With this group in particular, there is a need for the multidisciplinary team to be supported by the organisations in reducing vulnerability of clinicians and other practitioners in their endeavour to balance risk with sound judgement. This client group are also known to be particularly sensitive to any changes in their environment (including care environment).

Principles of management of people with BPD:

In order to successfully implement ICPs for BPD, there needs to be a generic training programme that promotes empathy, respect and the implementation of the principles of management of people with BPD for all staff who come into contact with service users with this condition.

These principles are applicable to all interactions between service users and staff, with both staff and service users having responsibility to maintain them:

• establish and maintain the therapeutic alliance while managing risk
• maintain flexibility
• establish conditions to make the patient safe
• tolerate intense anger, aggression and hate
• promote reflection
• set necessary limits
• understand the dynamics and monitor relationships between service user and staff thereby reducing the potential for splitting (or conflicting allegiances) between psychotherapy and pharmacotherapy, and between different members of staff
• monitor countertransferance feelings (strong irrational feelings that can be unconsciously evoked in staff) with view to using this to understand the patients communications and difficulties, and
• use a consistent approach.

Role of the community mental health team:

• development of a management plan agreed with the patient
• referral to specialist services if necessary
• risk assessment
• co-ordination of a crisis plan
• identification of a keyworker
• access to acute inpatient care
• family and social support, and
• prescription of medication.

Multi-agency care management goals:

• emotional support
• monitoring and supervision
• intervening in crises
• increasing motivation and compliance
• increasing understanding of difficulties
• building a therapeutic relationship
• avoiding deterioration
• limiting harm
• reducing distress
• treating comorbid Axis I disorders
• treating specific areas (eg anger, self-harm, social skills, offending behaviour), and
• giving practical social support with housing, finance, child care.