Support Promote Advocate

for Borderline Personality Disorder

Strategies for clinicians working with someone with BPD

• 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