Borderline Personality Disorder
OPTIMAL OUTCOME OF TREATMENT:
The client attains the skills to develop and maintain stability in work, relationships and self-image, particularly through the stormy ages from 20 through 40, avoiding institutionalization, substance abuse, suicide and harm to others.
ASSESSMENT PRINCIPLES: (See Assessment Guidelines for Adults)
1. Assessment of Borderline Personality Disorder requires an alertness to overlapping Axis I and Axis II conditions. DSM-IV criteria must be fully met to make the diagnosis of Borderline Personality Disorder. The diagnosis of Borderline Personality Disorder should be made when the criteria are met. Consultation is often helpful in establishing the diagnosis.
2. The clinician should be alert to the existence of co-morbid Axis I disorders, especially substance abuse and depression. Appropriate treatment should be provided or arranged for these problems. Transient co-morbid symptoms (e.g., psychotic) should be distinguished from those that meet DSM-IV criteria.
TREATMENT PRINCIPLES: (See Treatment Guidelines for Adults)
1. The therapist should have a well-articulated model of treatment for the person with Borderline Personality Disorder which directs treatment beyond a crisis orientation. The therapeutic relationship must model consistent, clear boundaries, and clear explicit goals set in a collaborative manner.
2. Providing education about their disorder empowers clients to better participate in treatments. Over the course of treatment, therapists should educate the client about his/her disorder, including its chronicity, aspects of self-care which affect the course of the disorder, and the prognosis for improvement later in life.
3. With the client, therapists should identify specific short-term goals for each episode of treatment within the course of the chronic disorder. A clear, specific contract should be negotiated with the client.
4. Collaboration is vital to treatment:
4.1 With team: The intensity of the therapeutic work with this type of client often makes clinical consultation a necessity. The boundaries of the therapeutic relationship should extend beyond the dyad to the treatment team. Neutral, third party clinicians may have the best perspective on recommending changes in the course of treatment.
In some cases, it will be necessary to accept consultation that the therapist has not sought, and to offer consultation when it has not been requested.
The role of the team is to provide support to the treating clinician to assist him/her in dealing with the intensity of feelings according to clinical description rather than reactively or pejoratively (Linehan).
4.2 With other providers: Coordination with other agencies/providers may be critical to an effective treatment plan. Therapists should discuss the importance of this collaboration with the client and collaborate when release of information is given. The degree of involvement of significant others in the treatment process needs to be discussed with the client.
4.3 With support staff: During certain phases of the disorder, it may be important to communicate the treatment contract to support staff, including the crisis team and office staff.
5. Treatment needs to encourage optimal functioning. Therapists should not encourage regression, purposefully induce dissociation or revivification of trauma. Exceptions to this guideline should be reviewed with the clinical team.
6. Hospitalization is indicated when there is: 1) imminent danger, 2) lack of available social support, and 3) a history of good response to hospitalization or expected positive response to hospitalization;
--Or--
A history of behavior high in lethal potential with no expectation of rescue or
intervention (as opposed to gestures, minor self-injurious behavior or verbal threats).
7. Because hospitalization may encourage decompensation, in general, hospitalization should be as brief as possible to minimize therapeutic dependency and decompensation.
8. Therapists working with borderline clients should emotionally join without enmeshing or over containing the client. This may be evidenced by maintaining similar boundaries as with other clients. The therapist should review exceptions with the clinical supervisor (e.g.: home visits, differences in the amount or frequency of contact, phone calls at home).
9. Therapists working with clients with Borderline Personality Disorder should provide psychoeducation about managing affect (Linehan's Dialectical Behavioral Therapy is a good source, Guilford Press, 1993). Supportive therapy sessions includes assisting the client to manage their affect and therapy disrupting behaviors, e.g., inappropriate anger.
10. Therapists deciding whether to make outreach calls after the client has failed an appointment should consider the following factors: Is the client an active suicide risk? Is there reason to believe their alliance with the therapist has been threatened? Is there any disruption in their primary relationship(s)? These factors may increase risk of harm.
11. Medications may be helpful in targeting specific symptoms.
THESE GUIDELINES
HAVE BEEN DEVELOPED BY:
THE UTAH PREFERRED PRACTICE CONSENSUS PANEL
UNDER THE AUSPICES OF THE UTAH
DIVISION OF MENTAL HEALTH
APPROVED DECEMBER 13, 1996