Understanding and Managing Borderline Personality Disorder

1
Understanding and Managing Borderline Personality
Disorder

• Petti Tsoudis
• Dr. Priscilla Yardley
• Psychologists, Primary Mental Health Service
• Peninsula Health. VIC

2
What is Borderline Personality Disorder (BPD)?
3
Diagnostic Statistical Manual for Mental
Disorders (DSM-IV) Criteria for BPD

• Frantic efforts to avoid abandonment
• Uncertainty in the reliability of others leading
  to unstable relationships (devaluation/idealisatio
  n)
• Lack of predictable sense of self or separateness
• Poorly modulated affect
• Poorly modulated impulse control
• Suicidal threats or behaviour, self-harm
• Chronic feelings of emptiness
• Inappropriate anger
• Transient paranoia

4
Background to BPD

• BPD occurs in the context of the development of
  an enduring, pervasive, inflexible pattern of
  inner experience and behaviour that leads to
  distress or impairment.

5
Background to BPD

• Up to 95 have an abuse history (sexual,
  physical, emotional abuse)
• have background of difficulty with attachments
  with others (particularly with early care givers)
• History of emotional turbulence (easily
  distressed, remain distressed for longer periods,
  higher intensity of distress than others)
• Leads to feeling overwhelmed in response to even
  minor stressors.
• Early invalidating environment

6
How does this presentation manifest in clients?
7
How does this presentation manifest in clients?

• Feeling vulnerable, unlovable, HELPLESS
• Strong sense of ABANDONMENT
• Lack of trust
• Self-harm, suicidal behaviours
• SELF HATRED
• Unrealistic expectations, blaming others
• Angry, hostile, demanding, PUNISHING
• Pushing boundaries
• Inconsistency in presentation, CHAOTIC

8
Splitting

• Idealisation vs devaluation
• (e.g. New worker is the best worker, old worker
  is worst worker)

9
What feelings are evoked within us when
working with clients with BPD?
10
What feelings are evoked within us when
working with clients with BPD?

• Feel isolated
• Question, doubt ourselves
• Helpless, hopeless, vulnerable
• Feeling unqualified
• Fearful
• Burnt-out, exhausted
• Feeling defensive, angry, resentful
• Withdrawing or shut-down
• Doing too much for the client, rescuing

11
Working Styles

• Enmeshed
• Withholding
• Nurturing/limit setting

12
Enmeshed Style

• Being over-involved
• Attempt to rescue and save
• Going beyond the boundaries of the work
• Aligning with the client against other workers or
  services
• Solving problems for client

13
Impact of Enmeshed Style

• Reinforces helplessness distress
• Encourages dependency
• Inhibits autonomy and responsibility
• Discourages problem solving
• Not in best interest of client in longer term

14
Withholding Style

• Punitive approach
• Can lead to condescending attitude
• Sarcastic, angry, hostile response
• Judgmental
• Assumes client is creating too many problems for
  the worker or service

15
Impact of Withholding Style

• Worker or services withdrawn
• Reinforces invalidating experience
• Can lead clients to escalate their behaviours and
  responses to get help (e.g. self-harm attempts,
  aggression)

16
Nurturing and Limit Setting Style

• Containment (validation, empathy)
• Compassion
• Constancy
• Consistency
• Calming
• Consequences

17
Impact of Nurturing and Limit-setting Style

• Most constructive response style
• Validates distress
• Recognises peoples ability to learn and change
  and enhance existing strengths
• Teaching, coaching, assisting and strengthening
  people to help themselves
• Provision of clear boundaries (appropriate
  limit-setting)
• Puts order into an emotionally chaotic inner
  world

18
Suggestions for Working with this Client Group
19
Strategies for Worker

• Just listen!!
• Identify and validate peoples feelings
• (e.g. It seems youre feeling really
  disappointed at the moment)
• Take a problem solving approach (ie identify the
  current problem, explore possible solutions
  together)
• Consult, consult, consult
• Refer all suicidal presentations to local
  Psychiatric Hospital/Service

20
Strategies for Client

• Distraction (e.g. go for a walk)
• Self-soothing (have a bath)
• Grounding (here and now, name 5 things you can
  see, hear and feel)
• Mindfulness (Observing breath, sounds, sights)

21
Managing the System

• Be explicit about roles
• Minimise blaming and splitting
• Consult, consult, consult

22
Managing Yourself

• Stress Management
• Seek support
• Debriefing
• Supervision

23
In Summary

• Care, but not too much
• Get close, but dont get enmeshed
• Empathise, but protect your own boundaries
• Hear about trauma, but dont lose optimism
• Witness intense emotion, but maintain focus