Happiness in practice: How strong boundaries with BPD patients make all the difference

Borderline personality disorder (BPD) is a pattern of instability in mood, behavior, functioning, self-image, and relationships. Clinically, BPD may manifest in frequent self harm or suicide attempts. BPD is estimated to exist in ~ 1.6% of the general population and 20% of the psychiatric inpatient population. 

Setting boundaries when working with individuals with BPD is absolutely essential for you as a prescriber in practice. Individuals with BPD often struggle when boundaries are set because they see boundaries as a form of rejection.  They believe that if you care about them, you will tolerate any behavior on their part to prove you care. A common trait is the need for frequent reassurance that they are cared about and loved by others – this frequently manifests in testing personal boundaries. Pushing boundaries allows for testing of compassion. Unfortunately, this boundary-testing can be frustrating for the prescriber and at times lead to significant deviation from the norm of standard treatment. 

How do you treat borderline personality disorder?

There isn’t any particular FDA-approved medication to treat BPD. Instead, treatment involves therapy, such as Dialectical Behavioral Therapy, which is often led by the patient’s therapist. 

Your role as a prescriber most likely involves addressing other mental health concerns such as co-occurring mental disorders which may include depression, anxiety or bipolar disorder. In fact, individuals with BPD may be more likely to experience symptoms of PTSD, major depression, bipolar disorder, substance use disorders, or eating disorders.

Causes of BPD

The causes of BPD are not fully understood but thought to involve environmental factors, genetics, or brain abnormalities. Environmental factors may include a history of child abuse, neglect, or trauma. Some studies of twins and families suggest that personality disorders may be inherited with other mental disorders among family members. 

Other research has shown changes in certain brain regions that influence emotional regulation and impulsivity which may contribute to the development of BPD. 

Now, how do you provide quality, compassionate care (while also maintaining your own mental health) when providing treatment to this often challenging patient population?

There are many elements you’ll want to have in place when working with individuals with BPD as a prescriber including: establish clear communication, collaborative decision making, frequent follow up, safety planning, psychotherapy integration, support system involvement, and setting boundaries. 

Setting boundaries is one of the key elements of treatment because boundaries can so often be pushed and tested by individuals with BPD. 

Strategies for how to establish and maintain boundaries

Setting boundaries is one of the key elements of treatment because boundaries can so often be pushed and tested by individuals with BPD. Let’s dive into strategies for how to establish and maintain boundaries. 

      1. Clear Communication: Start by clearly communicating the treatment plan, including the roles and responsibilities of both the provider and the patient. Explain that boundaries are in place to ensure their safety and well-being. Communication must be conveyed directly but with compassion because individuals with BPD are often sensitive to rejection. Some language you might use after discussing the treatment plan and establishing boundaries could be: “We’ll have open and honest communication. If you have questions or concerns, please feel free to share them with me. Your voice matters.” This conveys clear communication, empathy, and collaboration – all key elements when treating individuals with BPD.

        1. Consistency: Consistency is key in setting and maintaining boundaries. Ensure that rules and expectations are applied consistently throughout the treatment process. This is important for all patients, but particularly important for individuals with BPD to establish a sense of trust.

          1. Patient Involvement: Involve the patient in discussions about boundaries. Encourage them to express their thoughts and concerns regarding treatment and boundaries. This helps foster a sense of agency and collaboration.

            1. Emergency Protocols: Establish protocols for handling emergencies and crises. Ensure that the patient knows how to access help outside of scheduled appointments when necessary. Individuals with BPD have heightened risk of impulsivity and self-harm, so establishing emergency and safety protocols is key. 

              1. Address manipulative behaviors and document boundaries: Individuals with BPD may exhibit manipulative behaviors as a way to test boundaries. Address these behaviors in sessions, discussing healthier coping strategies. Therapists may be more heavily involved in addressing behaviors and helping patients build skills to develop more appropriate responses for needs to be met. Document discussions about boundaries in the patient’s medical record. This can be valuable in case issues arise in the future.

                1. Self-care: Emphasize the importance of self-care for the patient and for yourself as the provider. As a provider, self-care is something we often disregard, however it’s especially important when treating individuals with BPD for self-preservation and avoiding burnout. Debriefing difficult encounters with your colleagues or seeking counsel from a collaborating physician or through private supervision is an excellent form of self care. Professional mentorship is another incredibly helpful avenue for self care, whether you’re a new or experienced nurse practitioner. 

                  1. Use validation: Validate your patient’s emotions and experiences while still maintaining boundaries. Acknowledge their feelings without necessarily agreeing with their actions or demands.

                Where can I find more information on BPD?

                As a prescriber, there are several resources you can utilize to learn more on BPD and also recommend to your patients and their families.  

                National Education Alliance for Borderline Personality Disorder (NEABPD) has the largest online media library of BPD resources. McLean Hospital’s website has many resources about BPD and treatment methods. 

                Books for family members about BPD and emotion regulation include Loving Someone with BPD by Shari Manning and The High Conflict Couple by Dr. Alan Fruzzetti

                BPD Resource Center is another good resource for learning about BPD resources for patients, families, and healthcare providers. 

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                Remember that setting and maintaining boundaries is a dynamic process. It requires ongoing communication, flexibility, and a commitment to the patient’s well-being while also safeguarding your professional and personal boundaries. Approaching treatment with empathy and patience while also maintaining professional boundaries is a skill that can be learned or strengthened.

                Using these strategies to maintain boundaries you can effectively support your patients while minimizing stress and maintaining a patient-centered approach to care. 

                You will likely encounter many patients, regardless of practice setting, who present with either diagnosed or undiagnosed BPD in addition to other health concerns. Treating this patient population can test you on multiple levels.

                While these skills of navigating BPD are essential, its equally important to know how to skillfully diagnose and treat other potentially co-occurring mental disorders.  If you want a quick 60-minute introduction into a framework for how to diagnose and treat mental disorders, you can sign up for my free Mental Disorders Training

                If you want my most detailed, step-by-step support, you can sign up for my Mental Disorders Crash Course

                Either way, I’m here to support you as you treat your patients with mental health needs!

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