Working with clients who have Borderline Personality Disorder, henceforth referred to as BPD, presents its own set of challenges. This article aims to examine these issues and present a guide to training in this area.
Firstly, we will provide an overview of BPD and its symptoms, plus the challenges faced by clinicians in treatment directly relating to these symptoms. Then, we will take a look at the current training options for BPD.
What is BPD?
While it is difficult to reduce a complex psychological disorder to simplistic terms, at its core, BPD is a disorder of mood. It also affects how an individual interacts and forms relationships with others.
Given that a healthy relationship between the therapist and client is vital for successful treatment, it is important to look at these areas, and in this case, it is essential to go into greater detail about emotional instability and unstable relationships.
The difficulties faced by therapists
A common perception is that BPD is problematic, if not impossible, to treat and that patients are challenging. But why is this? Typically, it stems from building a relationship between the client and therapist. Those with BPD can have intense fears of abandonment and commitment and they may take a long time to establish such a relationship.
Once these boundaries have been overcome and a relationship is in place, maintaining this trust may become a battle. Clients may demonstrate behaviours such as calling regularly at unsociable hours or asking for additional appointments which the therapist may not be able to accommodate. The availability of therapists is often outside of the regular 9 to 5, but clients with BPD may take advantage of this to increase contact beyond what a therapist feels is manageable. There is also the potential for some sufferers to engage in disruptive behaviours to test the strength of the therapeutic alliance. These may include deliberately arriving late or missing appointments, to see if the therapist will continue.
What is widely agreed to be beneficial for both the client and therapist is setting clear and firm boundaries at the start of treatment. This may seem standoffish to the client, and in the worst-case scenario as a sign of rejection, but it is the first step in ensuring a healthy working relationship.
Traditionally, treatment for BPD involves psychotherapy delivered by a trained professional. There are different forms that this therapy can take, but two of the most successful are Dialectical Behaviour Therapy (DBT) and Mentalisation-Based Therapy. DBT is intended to tackle the intense emotions felt by those with BPD. The therapy aims to reconcile how two different things that may seem to be opposed can both be true. Clients with BPD can often struggle with this, resulting in intense mood swings between two opposing emotions. An example would be love/hate. These intense emotions can lead to some of the actions previously mentioned, as well as poor impulse control.
MBT focuses more on the ability of clients to mentalise – that is, think about thinking. It takes the stance that clients with BPD do not have the ability to mentalise, and aims to develop this skill. A large part of this is understanding that others have mental states that are different from our own. Therefore, our initial interpretation of others’ actions may not necessarily be correct. This aims to encourage more introspection on whether unpleasant thoughts are helpful and avoid going straight to the worst possible outcome. This can be particularly helpful for issues relating to abandonment as such thoughts can often result in clients seeking constant reassurance to combat the discomfort it causes.
This article provides an overview of some of the challenges faced in treating those with BPD and some of the treatment available. However, as it is such a vast subject, we cannot hope to cover all aspects here.
What is required is thorough Borderline Personality Disorder training that allows for an in-depth examination of this topic. By analysing the underpinnings of BPD, from childhood causes and trauma, courses allow for therapists to gain a well-rounded appreciation of the complexity of issues surrounding BPD. A commitment to continually developing your understanding is key to developing effective treatment plans, and removing the stigma that can surround the disorder.
Overall, many of the reasons BPD is seen as a challenge for therapists are linked to symptoms of disorder of mood and forming relationships. These symptoms require firm boundaries to be set at the outset to ensure the client-therapist relationship remains beneficial. Courses in BPD allow you to arm yourself against some of the common pitfalls of treating a client. Following these steps will help to get a better understanding of treating clients with BPD.